Where Are We Now?
Reconstruction after resection of proximal humerus bone sarcomas in children poses a unique challenge for orthopaedic surgeons. In most cases, the rotator cuff, axillary nerve, and portions of the deltoid must be removed. Instability, even with a reverse shoulder arthroplasty configuration, is also a major concern.
Despite these challenges, our goal should be a durable reconstruction, ideally one that lasts for the lifetime of the patient. While we can cure most patients with bone sarcomas in the proximal humerus, restoring function can be a trying process. Any reconstruction should provide joint stability as well as the ability to position the hand from forehead to buttocks, permitting grooming, eating, and personal hygiene. Reconstruction might also allow patients to return to competitive non-overhead sports.
Alternative treatment options include allografts, allograft-prosthetic composites, endoprosthetics, and free vascularized fibulae. Each has its advantages and disadvantages, and all are associated with real risks of complications. As far as we can tell, the ROM a patient might achieve after surgery seems more dependent upon the extent of the resection than on the particular reconstruction itself.
The clavicula pro humero technique is an attractive alternative surgical option that enables the use of native anatomy to produce a stable, and potentially durable, shoulder reconstruction. This approach is certainly not without its complications, with nonunion, fracture, and pseudarthrosis being most common. The clavicula pro humero technique is performed more commonly in less-developed countries; my first exposure to this procedure was during a visit to a hospital ward in Limpopo, South Africa in 2005 where dozens of abandoned children who had survived their sarcoma resections were participating in aggressive-but-friendly basketball games and soccer matches. Even so, patients in countries where all reconstructive options are available have started to appreciate this procedure’s advantages. I attribute some of the procedure’s newfound (and appropriate) popularity to social media. Patients and their parents considering this approach now can easily communicate with patients who have gone through it.
Where Do We Need To Go?
When to augment a clavicula pro humero reconstruction with a vascularized free fibula remains unanswered. Obviously, when the clavicle is not long enough to approximate the native length of the arm, then some sort of intercalary autograft is necessary. Should this be vascularized? Some surgeons invariably bridge the junction with a vascularized fibula, even when an intercalary segment is not needed. Is this necessary? Surgeons should attempt to better define variables where they would consider this option. Another concern is the amount of fixation needed for the transported clavicle. When the operation is performed properly, the blood supply, which enters from the thoracoacromial branch of the axillary artery, is preserved. Because this blood supply is fragile, a dysvascular insult may arise causing delayed nonunion, bony resorption, and fracture. Even if these complications do not occur, the clavicle in small children may be as weak as a pencil. Accordingly, surgeons should consider plate fixation all the way up the clavicle to the AC joint. While fractures of the clavicle tend to heal, these reconstructions still benefit from internal fixation. Additionally, if the proximal blood supply mentioned above is tenuous, a vascularized free fibula may help minimize the likelihood of nonunion.
How Do We Get There?
Because the problem is so uncommon, and the presentations so heterogeneous, it will be next to impossible to perform a study that will establish a clearly superior reconstructive method. Likewise, the numbers are too small to provide definitive answers to comparative questions about different elements of clavicula pro humero technique reconstructions, like whether to use free fibular grafts, whether they should be vascularized or not, and how much internal fixation is best. An international registry of orthopaedic oncologic reconstruction modalities might help. In the United States, the Musculoskeletal Tumor Society is attempting to engineer such a database. Our European colleagues are also investigating a similar initiative. I strongly encourage surgeons to collaborate to centrally report their individual experiences with this procedure, carefully addressing the variables mentioned above. We can better scrutinize our individual results to improve outcomes through a combined effort. We must remember that these young patients are likely to outlive their cancer diagnoses, but could be burdened by their acquired orthopaedic disease.
Footnotes
This CORR Insights® is a commentary on the article “Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children?” by Barbier and colleagues available at: DOI: 10.1007/s11999-017-5438-y.
The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or The Association of Bone and Joint Surgeons®.
This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-017-5438-y.