Elbow Reconstruction Edit 01

ELBOW RECONSTRUCTION FOR DISTAL HUMERUS OSTEOSARCOMA BY USING EXTRACORPOREAL IRRADIATION AUTOGRAFT (TWO CASE REPORTS) By Yanuarso, A Fauzi K, Errol Untung Hutagalung Division of Orthopaedic and Traumatology Faculty of Medicine University of Indonesia Introduction Malignant bone tumors are rare lesions : - RSCM →1,3% of all the cancer load (Errol UH, unpublished data, 2006) - Mayo Clinic → 1-2% Osteosarcoma → the 2nd common malignant bone tumors after multiple myeloma → 19% (Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-95)

Before 1970s → the routine management was amputations or disarticulation → survival rate 10-20% Limb salvage surgery → combination of : - Effective chemotherapies - Precision imaging techniques → designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result J Am Acad Orthop Surg 2003;11:25-37

Local status Mass : - 26 cm in circumferential length (20 cm in the health tissue) - Firm, tenderness, fixed with ill-defined margin

Laboratory - CBC : normal - ESR : 29mm/h - SAP : 161 u/l (40 – 150) - LDH : 303 u/m (230–460)

Left elbow AP and lateral X-ray (January 2006) : - Blastic and lytic lesions in the left distal humerus - Periosteal reaction and soft tissue swelling

After neoadjuvant chemotherapy → tumor became more sclerotic & solid

Chest X-Ray : no evidence of metastatic feature Bone scintigraphy : increased uptake only at the left elbow → Neither showed no evidence of metastatic disease

CT scan : - Lytic-sclerotic lesion with irregular margin - Thickening of cortex and periosteal - New bone formation and good medullary cavity

Cytology examination : Spindle cells, pleomorphic with osteoid positif Photo 11 Clinico Pathological Conference (CPC) - Diagnosed as conventional osteosarcoma → neoadjuvant chemotherapy - Planned for limb salvage surgery using an extracorporeal irradiation of distal humerus First Stage : - Resection of the half distal humerus that contain tumor mass → Pathology Anatomy Department - Osteotomy of olecranon - Conservation of n.radial, n.ulnar & muscle groups, except the part of the triceps & brachialis attached to the tumor mass - The resected humerus was sent to BATAN for irradiation with dose 30,000 rads

Second Stage : - Reconstruction of the half distal humerus with plate and screw - Olecranon fixation with TBW - Sutured common flexor & extensor origins to the original sites

- Histological examination of the surgical specimen: So much residual viable tumor cells and the tumor classified as unresponder to the induction chemotherapeutic agents (HUVOS 1) - After surgery → patient was planned to received adjuvant chemotherapy consisting of another agents

SECOND CASE

Local Status : Mass : - 32 cm in circumferential length (23 cm in the health tissue) - Firm, tenderness, fixed with ill-defined margin - No venectation Laboratory - CBC : normal - ESR 30 mm/h

- SAP 192 u/l (40–150) - LDH : 165 u/m (230–460)

X-ray of left elbow AP and lateral views (May 2006) : → heavily mineralized mass attached by broad base to the posterior aspect of left distal humerus and soft tissue swelling

- Chest X-Ray : no evidence of metastatic feature - Bone scintigraphy : inceased uptake only at the left elbow → No evidence of metastatic disease

Review slide from first operation : Spindle cells, minimal cytologic atypia and rare mitotic figure, osteoid positif -

Clinico Pathological Conference (CPC) Diagnosed as reccurrent parosteal osteosarcoma Planned to limb salvage procedure using extra corporeal irradiation autograft Death : Nov 2007

First Stage : - Resection of the half distal humerus and excision of the tumor mass → sent to Pathology Anatomy Dep. - Resected humerus → BATAN for irradiation 30,000 rads

Second Stage : - Reconstruction of the half distal humerus and elbow by fixed them into the proximal shaft with plate and screw - Olecranon was fixed with the tension band wire - Common flexor and extensor origins were sutered again to the original sites - Radiohumeral joint was fixed with the K wire for temporary

Post-operative X rays : Humeral shaft fixed with plate and screw and olecranon fixed with TBW

Discussion - Primary malignant bone tumors → rare lesions - Before 1970s → routine management was consisted of transbone amputations or disarticulation → dismal survival rate 10-20% Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-95. J Am Acad Orthop Surg 2003;11:25-37. hal. 24

Development of : - Effective chemotherapeutic agents - CT and MRI - Allow precise visualization of the anatomic location of tumor and surrounding structures - Better patient selection for spesific treatment of limb salvage procedure JAm Acad Orthop Surg 2003;11:25-37.

Consideration of Limb Salvage Procedure : 1. An upper extremity tumor → needs resection of the articular portion of the distal humerus or proximal ulna 2. Disfunction of the elbow, wrist, and hand → due to abundant of neurovascular structures in this location 3. Psychological problem associated with tradition and aesthetic J Bone Joint Surg [Br] 1996;78-B:652-57 hal 26

Conclusion - The management of malignant bone tumors still presents many challenge - Advances in imaging, chemotherapy and reconstructive surgery can offered limb sparing surgery - Functional outcome and patient satisfaction appear to be at least as good, and probably better after reconstruction than after ablation