Shoulder
Complications and survival after surgical treatment of 214 metastatic lesions of the humerus

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Background

The humerus is the second most common long-bone site of metastatic bone disease. We report complications, risk factors for failure, and survival of a large series of patients operated on for skeletal metastases of the humerus.

Materials and methods

This study was based on 208 patients treated surgically for 214 metastatic lesions of the humerus. Reconstructions were achieved by intramedullary nails in 148, endoprostheses in 35, plate fixation in 21, and by other methods in 10.

Results

The median age at surgery was 67 years (range, 29-87 years). Breast cancer was the primary tumor in 31%. The overall failure rate of the surgical reconstructions was 9%. The reoperation rate was 7% in the proximal humerus, 8% in the diaphysis, and 33% in the distal part of the bone. Among 36 operations involving an endoprosthesis, 2 were failures (6%) compared with 18 of 178 osteosynthetic devices (10%). In the osteosynthesis group, intramedullary nails failed in 7% and plate fixation failed in 22%. Multivariate Cox regression analysis showed that prostate cancer was associated with an increased risk of failure after surgery (hazard ratio, 7; P < 0.033). The cumulative survival after surgery was 40% (95% confidence interval [CI] 34-47) at 1 year, 21% (95% CI, 15-26) at 2 years, and 16% (95% CI, 12-19) at 3 years.

Conclusions

Our method of choice is the cemented hemiprosthesis for pathologic proximal humeral fractures and interlocked intramedullary nail for lesions in the diaphysis. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate.

Section snippets

Data source

The Scandinavian Sarcoma Group Skeletal Metastasis Register was initiated in 1999 as a multicenter database for quality control and scientific research. Data are prospectively collected in a blinded manner on patients surgically treated for pathologic fractures in the long bones and pelvis in the orthopedic tumor centers.10

Patients

This study includes a consecutive series of patients surgically treated for pathologic humeral fractures from 1999 to 2006 were included. Only patients who had their primary

Failures and complications

The surgical procedure in 20 of the 214 cases ended in a failure of the reconstruction, corresponding to a failure rate of 9% (Table II). The median follow-up time from fracture surgery until failure was 8 months (range, 0-97 months). The cumulative survival after surgery was 40% (95% CI 34-47) at 1 year, 21% (95% CI 15-26) at 2 years, and 16% (95% CI 12-19) at 3 years (Fig. 2).

Of the 20 failures, 7 were attributable to nonunion, 4 to deep infection, 4 to stress fracture, 3 to poor initial

Surgical procedures

In 48% of the patients, the operative strategy was stabilization without local tumor treatment. This method was mainly used with intramedullary nails. Stabilization with intralesional curettage and augmentation with bone cement (45%) was most commonly used in combination with internal fixation or prosthetic reconstruction, or both.

Hemiarthroplasty was most commonly performed for proximal humeral fractures. Diaphyseal fractures were mainly treated with intramedullary nails and distal humeral

Discussion

Our main findings were that patients undergoing surgery for skeletal metastases of the humerus had a 1-year survival rate of 40%. As expected, the Cox regression analysis showed that a primary tumor in the lung, a poor and moderate Karnofsky score, multiple skeletal metastases, and the presence of visceral metastases were factors associated with a poor prognosis after surgery (Table III). The failure rate of the surgical reconstructions was 9%. Prostate cancer and distal humeral fractures

Conclusion

A cemented hemiprosthesis is our method of choice in proximal humeral fractures, and the interlocked intramedullary nail is preferred in treating destruction of the diaphysis. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate.

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    Good outcomes have been report with the use of plate stabilization for the treatment of metastatic shaft fractures.17,20,24 When comparing intramedullary stabilization and plate/screw stabilization for shaft lesions alone, intramedullary stabilization have demonstrated to have a lower re-operation and implant failure rates compared to plate/screw stabilization.17,24,26 Failure rates are even lower for when intramedullary stabilization is augmented with bone cement.27

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This study is based on data from the Scandinavian Sarcoma Group Skeletal Metastasis Register and approval from the local Ethics Committee is not required.

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