Abstract

Introduction: The optimal method for reconstructing the proximal humerus in patients with
tumors is controversial. Amputation or a complete flail limb both give poor functional results.
The limb-salvage procedure with joint reconstruction preserves function in the elbow and hand,
thereby improving the quality of remaining life for patient. There is, however, limited data
regarding the shoulder reconstruction for metastatic bone disease of proximal humerus.

Methods: We present male subject, 60 years old with Metastatic bone disease of left proximal
humerus from primary thyroid cancer who performed the procedure of limb salvage surgery with
shoulder resection type I and shoulder arthrodesis using reconstruction plate, pedicle rods and
screw. We choose this procedure due to the probability of fixation failure and the risk of
infection, beside of the simplicity of this procedure.

Results: Our subject was experienced a quite stable fixation and and the movement of the elbow
as expected. After the prochedure, our subject could still performed his daily activities as
usually. This subject had a good outcome of hand movement (70%) according to MSTS scoring
system.

Conclusion: The most important aspect of limb-salvage surgery is to preserve elbow and hand
function after excision of tumours of the proximal humerus, even although the shoulder may
remain flail with a limited active range of movement.

Keywords: proximal humerus tumor, shoulder reconstruction, shoulder arthrodesis, limb

salvage, MSTS
Introduction

The proximal humerus is a relatively common location for primary and metastatic tumors of
bone.1-3 It was the second most common site of all osseous sarcomas and the third most common
site for osteosarcoma. Although osteosarcomas and Ewings sarcomas occur characteristically in
teenagers and young adults, chondrosarcomas occur in older individuals.2

The increasing and often unpredictable longevity of patients with metastatic disease
coupled with higher-than-expected failure rates after internal fixation with or without
intralesional treatment and radiotherapy has led to renewed interest in more aggressive local
control efforts through proximal humeral resection and reconstruction. 1 Reconstruction of the
shoulder after resection of a malignant or a benign locally aggressive primary bone tumor of the
proximal humerus poses the challenging problem of associated bone loss.2 In addition, an
adequate tumor margin implies partial resection of the deltoid musculature and joint capsule and
occasionally the rotator cuff, axillary nerve, glenoid, or the scapula.2

To provide a platform for elbow and hand function, reconstructive limb-preserving

procedures have been proposed for the proximal humerus. Moreover, patient acceptance has been
described as higher for limb-preserving treatments. Therefore, amputation of the shoulder girdle
is avoided if possible. In limb salvage procedures, large bone defects may result after resection of
the proximal humerus.4

There is no consensus regarding the best reconstructive technique after proximal humerus
resection. Principal treatment approaches in use today include arthroplasty prostheses,
osteoarticular allografts, and allograft-prosthesis composites.1,2 Moreover, several autologous
grafts (fibula, scapular crest, or clavicle) have been described. 2 Because autologous grafts often
are used in conjunction with a shoulder arthrodesis, prostheses, osteoarticular allografts, and
allograft-prosthesis composites are the only reconstructions allowing for a mobile glenohumeral
joint. Alternative techniques include allograft arthrodesis, Tikhoff-Linberg resection and
modifications, claviculo pro humero, vascularized fibula transfers, and concomitant scapular
replacement.2 Although all of these approaches are in use, and there are some situations where
only one approach might be appropriate for a particular patient, there are many scenarios in
which all are potential options.2
 In the present report, we presented a sixty-year-old male patient with metastatic bone
disease of proximal humerus which originally spread from thyroid cancer. Pasien have been
performed Limb Salvage surgery procedures include resection Shoulder type I and Shoulder
arthrodesis using reconstruction plate, pedicle screw and rod. And, at a short term follow-up
patients showed an improvement of elbow and hand function.

Case Illustration

The patient felt pain on his left shoulder since 7 years ago. The pain was intermittent, dull, and
non radiating. There was no numbness or tingling. The pain was felt especially when he was
rubbing his back. The pain often disturbed his sleep making him wake up at night. Four years
ago, the patient fell on his left shoulder from his bed while sleeping. He felt the pain was more
intense. He sought treatment to Mitra Bekasi Hospital and underwent x-ray. He was said to have
a fracture, he was splinted and went home with analgesics.

Two years ago, a lump appeared on his left upper arm. It was the size of a tennis ball. He went
back to Mitra Bekasi hospital and referred to Cipto Mangunkususumo Hospital (RSCM). The
patient came to RSCM on March 2015, he underwent x-ray, laboratory and MRI examinations.
The patient also underwent core biopsy and the result was a tumor spread from thyroid gland. He
was consulted to oncologic surgery and underwent a total thyroidectomy on August 2015.

From physical examination we found a mass in the proximal humerus with distal edema. The
mass with a diameter of 47 cm, firm, tenderness with Visual Analogue Scale (VAS) Scored 2-3,
fixated, smooth surface, ill-defined margins with Capillary refil time (CRT) less than 2 second
and normal distal sensory.

On admission, Erythrocyte Sedimentation rate is at 35 and Lactate dehydrogenase at 1.05, were

both markedly elevated. All tumor markers were negative, and there were no abnormal findings
on other tests.

On radiographs of left shoulder and humerus obtained at the last examination, MBD of left
humerus was noted as a destructive osteolytic lesions with pathologic fracture at the left
proximal humerus metadiafisis and surrounding soft tissue thickening. On Magnetic Resonance
Imaging (MRI), a solid mass morphology of malignant cystic dominant in the head until the
proximal diaphysis of the left humerus was observed, infiltrated the glenohumeral ligament,
deltoid, coracobrachialis, biceps brachii, and pectoralis major muscle and involves neurovascular
bundle. From Computed Tomography (CT) Angiography, found hypervascular lesion who gets
feeding from a branch of multiple left axillary artery with draining vein into the superficial veins
in the left axilla and then to the left axillary vein into the left subclavian vein. On pathological
examination, seen a metastatic bone disease, was thought likely to come from the thyroid; based
on these findings, a metastatic bone disease of left proximal humerus from primary thyroid
carcinoma was diagnosed.

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