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Pre-operative radiograph of a pathological fracture involving the proximal humerus. The patient was diagnosed with multiple myeloma. A large lytic lesion is seen replacing the surgical neck, with extension to the articular surface.
Source publication
Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphys...
Contexts in source publication
Context 1
... of the patients with a pathological fracture had pain following a low-impact injury. Mechanisms of injury included opening a jar, lifting a suitcase, closing a door and pushing up from a seated position. Needle biopsies were performed on 12 of 14 patients with impending fractures. An open biopsy was carried out on all patients with dis- placed fractures. A frozen section was performed at the time of surgery in all displaced fractures to confirm the diagnosis, and in two of the 14 impending fractures. The two lesions suspected to be cartilaginous had an open biopsy at the time of surgery to confirm that cartilage was present and to exclude a high-grade sarcoma. Post-operative radiograph of the patient from Figure 1 two years after surgery. The patient has returned to full activities, with no restrictions and no pain. The reconstruction remains stable, without evidence of recurrence. Intra-operative photograph demonstrating multiple locking screws placed in the bone defect just prior to cementation. The locking screws will act as a reinforcing bar to enhance stability. Cement will be placed through this bone ...
Context 2
... medical records were reviewed for demographic data, the medical history, the histological diagnosis, imag- ing reports and peri-operative complications. Wound heal- ing was assessed at two-or four-weeks when the presence or absence of dehiscence, drainage and/or swelling was recorded. All patients had anteroposterior scapular, trans- scapular lateral, and axillary lateral radiographs taken before operation and at each follow-up visit. Radiographs were analysed to determine post-operative alignment, the position of the plate and recurrence of the tumour (Fig. 1). Pre-operative imaging included radiographs in all patients, MRI in 26, bone scans in 16 and CT in six. Each imaging study was reviewed pre-operatively by a musculoskeletal radiologist and an orthopaedic oncologist (HS, RL). The revised Musculoskeletal Tumor Society (MSTS) functional outcomes score was completed for all patients. 15 The decision to operate on impending fractures was based on the criteria of Mirels. 16 Impending or non- displaced fractures were present in 18 patients and 14 had a displaced fracture. Proximal Humeral Internal Locking Systems (Synthes, West Chester, Pennsylvania) and Simplex cement (Stryker, Mahwah, New Jersey) were used in all the patients. A proximal humeral endoprosthesis was available in case adequate stability could not be obtained with the locking plate or if there was significant loss of articular cartilage that was not appreciated during pre-operative planning. Surgical procedure. The operation was performed with the patient under general anaesthesia, and all received prophy- lactic intravenous antibiotics prior to and for 24 hours after the procedure. The patients were positioned supine on a radiolucent operating table, and the adequacy of antero- posterior and axillary lateral fluoroscopic imaging was confirmed before ...
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Citations
... Osteosynthesis with lateral locking plates with or without adjunct poly-methyl-methacrylate (PMMA) bone cement is well studied, with optimal outcomes found in patients with metaphyseal lesions and sufficient epiphyseal bone stock [12,15]. This can be utilized for impending or pathologic fractures of the proximal humerus. ...
Metastasis to the bone is a known risk of breast cancer, with the humerus being the most common upper extremity site of metastases, with most lesions located at the humeral diaphysis. We present a unique case of proximal humeral metastasis involving the epiphysis secondary to primary invasive ductal carcinoma in a middle-aged Caucasian female. It is important to have a high degree of suspicion for metastasis when musculoskeletal pain occurs in breast cancer patients, as it may be masked by common, degenerative conditions about the shoulder girdle. When humeral metastases involve the epiphysis, treatment options are complicated by its location, which jeopardizes the integrity of articular cartilage and the function of the shoulder girdle. External beam irradiation provides pain control in a non-invasive manner, sans surgical risks. Surgical intervention will vary depending on the characteristics of the bony lesion, but the use of endoprosthetics has emerged as the most effective option for restoring range of motion and pain control with acceptable rates of implant survival.
... However, dysfunction is a problem owing to the rotator cuff sacrificing stability for mobility, inserting the greater tuberosity of the humerus [4]. Plate fixation with cement augmentation has been successfully used in treating proximal metaphysis-contained lesions [5]. Choi et al. reported using intramedullary nailing in the proximal humerus pathological fracture [6]. ...
... Plate fixation has shown good outcomes in previous studies for stabilizing impending or complete pathological fractures in the humerus [5,[16][17][18]. Depending on the configuration, plating can be used in any humerus region. ...
... Kapur et al. reported that reverse shoulder arthroplasty provides good outcomes in treating proximal humeral metastatic diseases, including pain relief, restoration function, and no need to consider rotator cuff musculature [19]. Studies reveal that both nailing and plating have better functional recovery, pain relief, and no or few postoperative complications compared with conventional endoprothesis in treating pathological fractures of the proximal humerus [5,6,[20][21][22][23] ( Table 3). Taking the findings of the present study together, intramedullary nailing is more strongly recommended than locking plate because of greater pain relief, low blood loss, and shorter hospital stay, even while functional status and complication rates remain comparable. ...
Background
Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus.
Methods
This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications.
Results
Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60–200) versus 500 (350–600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6–8) versus 6 (5–7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27–29) versus 27 (26.5–28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery.
Conclusions
Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients.
Level of evidence Level II.
Trial registration statement Not applicable.
... Shoulder pain and bone damage due to pathological fractures of the proximal humerus caused by MM can be treated using either the simple bone cement technique or percutaneous microwave ablation and cementoplasty [33]. ...
Background:
Multiple myeloma (MM) bone disease is indicative of MM, and reduces patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM is an essential treatment within the framework of supportive therapy measures and involves orthopedic tumor surgery. Nevertheless, there are few reports on intramedullary (IM) nailing in the treatment of MM-induced proximal humeral fracture to prevent fixation loss. We here describe a case of pathological fracture of the proximal humerus caused by MM successfully treated with IM nailing without removal of tumors and a review of the current literature.
Case summary:
A 64-year-old male patient complaining of serious left shoulder pain and limited movement was admitted. The patient was finally diagnosed with MM (IgAλ, IIIA/II). After treatment of the pathological fracture with IM nailing, the patient's function recovered and his pain was rapidly relieved. Histopathological examination demonstrated plasma cell myeloma. The patient received chemotherapy in the Hematology Department. The humeral fracture displayed good union during the 40-mo follow-up, with complete healing of the fracture, and the clinical outcome was satisfactory. At the most recent follow-up, the patient's function was assessed using the Musculoskeletal Tumor Society score, which was 29.
Conclusion:
Early surgery should be performed for the fracture of the proximal humerus caused by MM. IM nailing can be used without removal of tumors. Bone cement augmentation for bone defects and local adjuvant therapy can also be employed.
... The role of cement augmentation in pathological fractures of the extremity is well documented; it is thought to prevent implant failure and increase stability. [13][14][15] The PMMA is still a valid alternative for augmentation with its low cost, although ceramic bone substitutes may be potentially more effective. There is undoubtedly need for clinical studies to establish the role of augmentation as a routine practice. ...
Objectives:
This study aims to evaluate the outcomes of proximal humeral fracture (PHF) fixation with a polyaxial locking plate (PLP) osteosynthesis alone versus cement-augmented PLP (PLP-CA) in an elderly population.
Patients and methods:
Between May 2015 and June 2018, a total of 101 patients (17 males, 84 females; mean age: 74.5±8.1 years; range, 60 to 94 years) aged ≥60 years with an acute PHF who underwent osteosynthesis with PLP or PLP-CA were retrospectively analyzed. The patients were divided into two groups as the PLP (n=53) and PLP-CA (n=48). Clinical outcomes, Constant-Murley Scores (CMS), Disabilities of the Arm, Shoulder and Hand (DASH) scores, and Short Form-12 (SF-12) scores were compared between the groups.
Results:
The overall mean follow-up was 28.1±11.1 months. No clinically relevant differences in the mean duration of surgery, mean intraoperative X-ray image intensifier time or postoperative in-hospital stay were found between the groups. A higher complication rate was observed in the PLP group (20.8% in PLP vs. 10.4% in PLP-CA; p<0.05). There was no statistically significant difference for this (t-test, p=0.08848). The CMS for the operated side did not show any significant differences between the groups. Also, no statically significant difference was seen in the SF-12. A slightly improved DASH score was found for the PLP group (p=0.02908).
Conclusion:
During follow-up PLP-CA osteosynthesis yielded nearly similar functional outcomes to PLP fracture fixation, despite with an overall lower rate of complication regarding secondary loss of reduction and screw cut-out. The polymethylmethacrylate cement augmentation can decrease morbidity in this patient group.
... Prosthesis can be a good way to relieve pain and x the fracture, but it has poor functional recovery than other treatments. [6,[29][30][31] Besides, more tendons and muscles are sacri ced during resection, which inevitably impair the function. [30] At the same time, plate xation is associated with numerous drawbacks, like short protection length, massive soft tissue stripping, and risk of nerve injury. ...
... [8,32,33] Beside, local relapse may give rise to xation loss or the need of a second operation. [29,34] As a result, plates are restricted in treating metastasis. ...
... IM nailing is suggested to be unsuitable to treat proximal humeral fracture because of the bone defect and thin cortex following curettage. [29] Therefore, at present, IM nailing is restricted to treating diaphyseal fractures. [5] Our results reveal that IM nailing can serve as an e cient and robust way to treat proximal humeral fracture. ...
Background: Multiple myeloma bone disease(MMBD) is indicative of multiple myeloma (MM), and it will reduce patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM represents an essential treatment pillar within the framework of supportive therapy measures and is the task of orthopedic tumor surgery. Nevertheless, there are few reports about applying intramedullary (IM) nailing in treating MM-induced proximal humeral fracture to prevent fixation loss. This paper aims to describe a case of pathological fracture of the proximal humerus caused by multiple myeloma effectively treated with IM nailing without removal of tumors and review the current literature.
Case presentation: This study reported a 64-year-old male patient complaining of serious left shoulder pain and limited movement. X-ray films showed left proximal humeral fracture accompanying with osteoporosis and bone destruction. During the preoperative examinations, tumor markers, whole-body bone imaging and bone marrow biopsy were performed. The patient was finally diagnosed with multiple myeloma (IgAλ, IIIA/II). After the treatment of pathological fracture with IM nailing, the patient's function recovered and the pain was relieved rapidly. The visual analogue scale (VAS) reduced by 7 points to 2 points postoperatively compared with that preoperatively. Histopathological examination results presented plasma cell myeloma. Next, the patient received chemotherapy in the hematology department. Humeral fracture displayed good union in the 40-month follow-up, with complete healing of fracture, and the clinical outcome was still satisfactory.
Conclusion: The pathological fracture of proximal humerus caused by multiple myeloma should be treated by surgery early. IM nail can be used for this kind of fracture without removal of tumors, bone cement augmentation for bone defect or local adjuvant therapy was also employed. Under the combined treatment, the proximal humerus fracture can eventually heal.
... Prosthesis can be a good way to relieve pain and x the fracture, but it has poor functional recovery than other treatments. [6,[29][30][31] Besides, more tendons and muscles are sacri ced during resection, which inevitably impair the function. [30] At the same time, plate xation is associated with numerous drawbacks, like short protection length, massive soft tissue stripping, and risk of nerve injury. ...
... [8,32,33] Beside, local relapse may give rise to xation loss or the need of a second operation. [29,34] As a result, plates are restricted in treating metastasis. ...
... IM nailing is suggested to be unsuitable to treat proximal humeral fracture because of the bone defect and thin cortex following curettage. [29] Therefore, at present, IM nailing is restricted to treating diaphyseal fractures. [5] Our results reveal that IM nailing can serve as an e cient and robust way to treat proximal humeral fracture. ...
Background
Multiple myeloma bone disease(MMBD) is indicative of multiple myeloma (MM), and it will reduce patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM represents an essential treatment pillar within the framework of supportive therapy measures and is the task of orthopedic tumor surgery. Nevertheless, there are few reports about applying intramedullary (IM) nailing in treating MM-induced proximal humeral fracture to prevent fixation loss. This paper aims to describe a case of pathological fracture of the proximal humerus caused by multiple myeloma effectively treated with IM nailing without removal of tumors and review the current literature.Case presentationThis study reported a 64-year-old male patient complaining of serious left shoulder pain and limited movement. X-ray films showed left proximal humeral fracture accompanying with osteoporosis and bone destruction. During the preoperative examinations, tumor markers, whole-body bone imaging and bone marrow biopsy were performed. The patient was finally diagnosed with multiple myeloma (IgAλ, IIIA/II). After the treatment of pathological fracture with IM nailing, the patient's function recovered and the pain was relieved rapidly. The visual analogue scale (VAS) reduced by 7 points to 2 points postoperatively compared with that preoperatively. Histopathological examination results presented plasma cell myeloma. Next, the patient received chemotherapy in the hematology department. Humeral fracture displayed good union in the 40-month follow-up, with complete healing of fracture, and the clinical outcome was still satisfactory.Conclusion
The pathological fracture of proximal humerus caused by multiple myeloma should be treated by surgery early. IM nail can be used for this kind of fracture without removal of tumors, bone cement augmentation for bone defect or local adjuvant therapy was also employed. Under the combined treatment, the proximal humerus fracture can eventually heal.
... 4,8,9 Despite surgical advances, both prospective and established pathological humeral fractures continue to be a surgical challenge. 10 The aims of stabilising such fractures are to provide good pain relief and immediate rigidity of the humerus to achieve unrestricted restoration of shoulder function. 10e12 The surgical construct should last for the remainder of the patient's life, without the need for further surgery. ...
... The method of fixation of the fracture depends on several factors including the location, size, and the quality of the surrounding bone. 1 Humeral bone loss from pathological fracture poses a surgical challenge which will affect the reconstructive technique used and the potential outcome. 10 The glenohumeral joint is principally a non-weight-bearing joint and is the most mobile in the body. 10,25 As a result, the proximal humerus is subject to extremes of bending and rotational forces from its various muscle insertions. 1 Preserving the function of the rotator cuff as much as reasonably possible helps to maximise post-operative function. ...
... 10 The glenohumeral joint is principally a non-weight-bearing joint and is the most mobile in the body. 10,25 As a result, the proximal humerus is subject to extremes of bending and rotational forces from its various muscle insertions. 1 Preserving the function of the rotator cuff as much as reasonably possible helps to maximise post-operative function. 1 Since the shoulder is not primarily subject to weight bearing, using a loadbearing construct such an intramedullary nail is not as important as in the femur for example. ...
The humerus is the second most common long bone for metastatic tumours. These lesions result in weakened bone architecture and increased fracture risk with patients suffering pain, loss of function and diminished quality of life, often when life expectancy is short. Fractures or impending fractures require surgical stabilisation to relieve pain and restore function for the remainder of the patient’s life without the need for further surgery. Conventional management of these lesions in the humerus is intramedullary nailing, however there are issues with this technique, particularly regarding rigidity of fixation. Advances in contoured locking plates have led to the development of different stabilisation techniques. The preferred technique in our regional oncology unit is curettage of the tumour and plating, augmented with cement to fill the defect and restore the structural morphology. In this case series we evaluate the survivorship of the construct and the clinical outcomes in patients who had an established or prospective pathological humeral fracture treated with curettage and cement augmented plating, since 2010. We identified 19 patients; 17 had metastasis and 2 myeloma of whom 15 had established fractures and four impending. The mean age at surgery was 69 years (51–86), and mean time since surgery 3.2 years. Overall mean follow up time was 20 months with 14 patients deceased and 5 surviving. There was 100% survivorship of the construct with no mechanical failures and no re-operations. There were no post-operative wound complications. Excellent early pain control was achieved in 18 patients with one experiencing pain controlled by analgesia. Function was assessed using Toronto Extremity Salvage Score (TESS) and was satisfactory; mean 79/100 (range 72–85). Cement augmented plating for pathological humerus fractures is a suitable alternative to intramedullary nailing and addresses several of the concerns with that technique. It provides immediate rigidity and allows early unrestricted function.
... (iii) We excluded studies with less than 10 patients within surgical approaches. Additionally, authors were contacted if studies within indiscernible reported outcomes or unclear regions of metastatic lesion were published after the year 1985 [8][9][10][11][12]. The qualities of these included researches by predetermined standards-prospective design publicity, bias of loss to follow-up, study of outcomes, basic line, appropriateness standards for selecting patients, comparing treatment arms were independently assessed by two reviewers (FHL, WJ). ...
Background: As for treating metastatic humerus, open reduction with internal fixation (ORIF), intramedullary nail fixation as well as reconstruction of endoprosthesis act as the approaches with highest frequency in surgeries. In the current study, the postoperative complications and functional outcomes were compared after 3 operating treatments for metastatic humerus by performing a meta-analysis. Methods: An electronic search of relevant studies was done on December 29, 2015 and rigorously screened them according to inclusion and exclusion criteria. The summary results of the included studies were pooled using a random-effects mode. Results: A total of 21 studies were included for analysis. we evaluated the functional outcome according to the MSTS score, found that the upper limb function apparently returned after surgery. For local complications, the overall reoperation rate after endoprosthetic reconstruction (95%CI 0.06-0.11) ranged from 0-14%, 0-9% after intramedullary nailing (95%CI 0.04-0.08), and 0-8% after ORIF (95%CI 0.05- 0.24). The rate of re-operation for failed fixations ranged from zero to 10% after reconstruction of endoprosthesis (95%CI 0.03-0.07), 0-6% after intramedullary nailing (95%CI 0.01-0.04), and was 0-19% in all studies after ORIF (95%CI 0.02-0.19), while that for dislocations ranged from 0% to 8% after reconstruction of endoprosthesis (95%CI 0.02-0.05), and 0-5% after intramedullary nailing (95%CI 0.01- 0.04). Conclusions: Compared with the high rate of reoperation due to ORIF, those of intramedullary nail fixation and endoprosthetic construction are of comparability. The findings in the current study is applicable for aiding to make appropriately surgical decision to improve the living quality of patients in the remainder of their lives.
... In these cases, augmented osteosynthesis can enable patients to perform full weight bearing of the lower extremity [24][25][26] or help to restore the function of the upper extremity (Fig. 1C). [27][28][29] ...
The number of fragility fractures is rising, and treatment is a challenge for orthopaedic trauma surgeons. Various augmentation options have been developed to prevent mechanical failure. Different composites can be used based on the fracture type, patient needs, and biomechanical needs. Indications for augmentation are not limited to osteoporotic fractures but can also be performed as a salvage procedure or in pathologic fractures. Biomechanical studies have shown advantages for augmented implants in the spine, proximal femur, and humerus. Clinical studies are preliminary but promising, showing good clinical results after augmentation with reduced mechanical failure and minimal complications.
... This option will be indicated for patients with a sufficiently long vital prognosis, especially in the case of single metastasis. Stabilization of the pathologic fracture by PMMA-reinforced locked plate provides adequate local tumor control, good mechanical stabilization and satisfactory preservation of function [5,6]. Centromedullary nailing makes it possible to treat the majority of diaphyseal metastases, possibly reinforced by PMMA. ...
Kahler's disease or multiple myeloma is a malignant hematological pathology, characterized by the malignant proliferation of plasma cells. Reportin g a case of a humeral shaft fracture in a non - traumatic context that revealed Kahler's disease during paraclinical investigations. Management involves histological confirmation of the pathology, osteosynthesis of the fracture by static centromedullary nail ing, with medical treatment made of biphosphonate combined with a chemotherapy protocol targeting the disease. The management of a pathological fracture is a diagnostic emergency, but never an operating emergency. A diagnosis of certainty must be made befo re any intervention.
