constrained total scapula reconstruction after resection

CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 397, pp. 143–155© 2002 Lippincott Williams & Wilkins, Inc.

143

Patients with high-grade sarcomas arising fromthe scapula or periscapular soft tissues tradi-tionally have been treated with either a totalscapulectomy or a wide, en bloc, extraarticularscapular resection, termed the Tikhoff-Linbergresection. The major challenge after such resec-tions is to restore shoulder girdle stability whilepreserving a functional hand and elbow. Thecurrent authors describe three patients who hadan extraarticular, total scapula resection (mod-ified Tikhoff-Linberg) for a high-grade sar-coma. Each patient had reconstruction witha constrained (rotator cuff-substituting) totalscapula prosthesis in an effort to optimally re-store the normal muscle force couples of bothglenohumeral and scapulothoracic mechanisms.At latest followup, the Musculoskeletal TumorSociety functional score was 24 to 27 of 30(80%–90%). All patients had a stable, painlessshoulder and functional hand and elbow. For-ward flexion and abduction ranged from 25� to40�. Glenohumeral rotation (internal rotation,T6; external rotation �10�) below shoulder level,shoulder extension, and adduction were pre-served. Protraction, retraction, elevation, andabduction of the scapula were restored and con-

tributed to shoulder motion and upper extrem-ity stabilization. There were no complications.Total scapula reconstruction with a constrainedtotal scapula prosthesis is a safe and reliablemethod for reconstructing the shoulder girdleafter resection of select high-grade sarcomas.The authors emphasize the clinical indications,prosthetic design, surgical technique, and earlyfunctional results.

Patients with high-grade scapula and periscapu-lar sarcomas often are treated with either an ex-traarticular scapula resection, termed a Tikhoff-Linberg resection or an intraarticular totalscapulectomy.1–3,7,8,10–15 The major goals aftersuch resections are to restore shoulder girdlestability, preserve a functional hand and elbow,and prevent traction neurapraxia associatedwith a flail, hanging extremity. Early methodsof reconstruction could be summarized as anonanatomic approach to achieve stability ofthe upper extremity.2,3,5,7–9,12–15 These meth-ods ignored the functional importance of theperiscapular muscles that often were sparedfrom resection. Neither the glenohumeral norscapulothoracic mechanisms were restored. Theproximal humerus or remaining humeral shaftsimply was stabilized with sutures or wires tothe clavicle or a rib, either directly or indirectlythrough an interposed intramedullary rod orfunctional spacer. Active shoulder motion wasabsent. Instability was a problem and cosmesis

Constrained Total Scapula ReconstructionAfter Resection of a High-Grade Sarcoma

James C. Wittig, MD*; Jacob Bickels, MD**; Felasfa Wodajo, MD**;Kristen L. Kellar-Graney, BS**; and Martin M. Malawer, MD**

From the *Department of Orthopedic Surgery, New YorkUniversity Medical Center and the Hospital for Joint Dis-eases, New York, NY; and the **Department of Ortho-pedic Oncology, Washington Cancer Institute at theWashington Hospital Center, Washington, DC.Reprint Requests to Martin M. Malawer, MD, Depart-ment of Orthopedic Oncology, Suite C-2173, 110 IrvingStreet N.W., Washington, DC 20010.

was poor. Complications and failures occurredfrequently.

To improve shoulder girdle stability andmotion and upper extremity function, the se-nior author uses an anatomic approach to re-construction, an approach that replaces the re-sected bony structures with a metallic totalscapular prosthesis and that restores the normalmuscle force couples of scapulothoracic andglenohumeral mechanisms.10 This approachwas made possible as a result of increasing ex-perience with induction chemotherapy andlimb salvage surgery, advances in prostheticdesign, and the realization that the deltoid,latissimus dorsi, trapezius, levator scapulae,rhomboids, serratus anterior, and axillary nerveusually can be spared from resection and usedto stabilize and power a prosthesis.

Traditionally, the senior author reconstruct-ed the shoulder girdle with separate, noncon-strained scapula and proximal humerus pros-theses. A Goretex aortic graft (WL Gore andAssociates, Flagstaff, AZ) was used to recon-struct the capsule to prevent glenohumeraldissociation. The remaining periscapular mus-cles were tenodesed to predrilled holes in thescapular prosthesis allowing them to partici-pate in scapulothoracic motion and stabiliza-tion of the entire construct. The deltoid andtrapezius also were tenodesed to each other,providing active motion at the glenohumeraljoint. Therefore, all remaining muscle forcecouples were restored. Although meticulouscapsular reconstruction was done, the Goretexgraft did not seem to be an optimal substitutefor the rotator cuff and glenohumeral capsulebecause of the elasticity inherent to the mate-rial. Also, failure of the Goretex graft occa-sionally occurred, resulting in instability.

Recently, a constrained scapular prosthesiswas developed to improve glenohumeral sta-bility by passively restoring rotator cuff andglenohumeral capsular function. It consists ofa constrained glenoid into which a proximalhumeral prosthesis can be locked withoutcompromising rotation (analogous to a bipolarhemiarthroplasty). The locking mechanismtheoretically substitutes for the resected rota-

tor cuff during active glenohumeral motion bypreventing upward humeral migration withdeltoid contraction. Three patients who had ananatomic shoulder girdle reconstruction usinga constrained total scapular prosthesis after anextraarticular total scapular resection for ahigh-grade sarcoma are described. Emphasisis given to the clinical indications, prostheticdesign, surgical technique, and early func-tional results.

MATERIALS AND METHODS

Three patients (all males) were treated with a mod-ified Tikhoff-Linberg resection (extraarticular totalscapula resection) for a high-grade sarcoma arisingfrom the scapula or rotator cuff muscles. All threepatients had reconstruction with a constrained totalscapular prosthesis and modular proximal humeralprosthesis. The ages of the patients were 13 years,17 years, and 26 years. Diagnoses included recurrenthigh-grade osteosarcoma along the inferior scapularneck, Ewing’s sarcoma of the scapula, and large un-differentiated sarcoma arising from the subscapu-laris muscle. All patients were treated with chemo-therapy before resection (neoadjuvant and inductionchemotherapy). The followup ranged from 7months to 2 years (one patient died 7 months post-operatively). Functional outcome was assessed atlatest followup according to the MusculoskeletalTumor Society Upper Extremity Functional Evalu-ation System6 (Table 1).

Clinical IndicationsThe procedure described here is suitable for se-lected patients with low- or high-grade sarcomasof the scapula or rotator cuff muscles and forlarge metastatic lesions that cause significant bonedestruction.

The deltoid, trapezius, rhomboids, serratus an-terior, and latissimus dorsi muscles, and the axil-lary nerve must be preserved at surgery. Thesemuscles provide the important force couples neededto stabilize and motor the prosthesis. They all arerequired for sufficient soft tissue coverage andprosthetic suspension. The serratus anterior alsoprotects the chest wall from scapular abrasion.Contraindications to this procedure include grossneurovascular (brachial plexus and axillary ves-sels) invasion, extension of tumor to involve thechest wall, and inability to spare the required mus-

Clinical Orthopaedics144 Wittig et al and Related Research

cles and axillary nerve. The authors recommendthat the final decision regarding the ability to use aprosthesis for reconstruction be made intraopera-tively after exploring the tumor and determining itstrue local extent; it often is difficult to precisely de-termine tumor involvement of the required musclesbased only on preoperative imaging studies.

Prosthetic DesignThe body of the constrained scapular prosthesis(Howmedica-Osteonics, Allendale, NJ) is con-structed from CoCr in the shape of a normalscapula (Fig 1). The lateral border, which may lieclose to the neurovascular bundle, is curved androunded. The glenoid is modeled after a bipolarproximal femoral replacement. It consists of a cap-tured polyethylene liner into which the prosthetichumeral head (22 mm) can be snapped into placemanually with a locking mechanism. The devicesare manufactured in two sizes, adult and pediatric.Both sizes are smaller in comparison with normalscapulas in adults or children to facilitate musclecoverage. The scapular body has a large vacant areain the center for free communication between theanterior and posterior aspects of the prosthesis.Therefore, the muscles attached to the anterior andposterior aspects of the prosthesis can scar to eachother, which helps suspend the prosthesis. There

are several holes along the axillary and vertebralborders of the prosthesis for suturing muscles di-rectly to it.

Surgical TechniqueResectionAnterior exploration and mobilization of the axillarysheath are required for most patients with scapulartumors because they frequently present with a largeanterior component. Therefore, in most instances, ananterior approach is used and exploration of thebrachial plexus is done initially. Resectability is de-termined. Once the tumor has been deemed re-sectable, the axillary, musculocutaneous, and radialnerves are identified and preserved. The anterior andposterior humeral circumflex vessels are identifiedand ligated. Patients with large anterior masses alsorequire ligation of the upper and lower subscapularnerves, thoracodorsal nerve, and subscapular artery.This step enables mobilization of the plexus and ves-sels from the scapula, proximal humerus, and tumor.A posterior approach then is done. The incision ex-tends along the lateral border of the scapula andcurves medially at its tip. A large, posterior, medially-based fasciocutaneous flap is developed. The tumoris explored and its extent is determined. The requi-site muscles must not be involved by tumor. All

Number 397April, 2002 Constrained Total Scapula Prosthesis 145

TABLE 1. Preliminary Results of the Three Patients

Adjuvant Followup Age Gender Diagnosis Treatment (months) Complications Function

17 M Ewing’s Chemotherapy: 18 None Shoulder: abduction and sarcoma Induction, forward flexion, 30�–40�;

Adjuvant internal rotation, T6Hand and elbow: normalScapula: � protraction and

retraction, elevation26 M Undifferentiated- Chemotherapy: 7 None Shoulder: abduction and

sarcoma Induction, forward flexion, 35�–45�; arising from Adjuvant internal rotation, T6subscapularis Hand and elbow: normal

Scapula: �protraction and retraction, elevation

13 M Recurrent Chemotherapy: 24 None Shoulder: abduction and osteosarcoma Induction, forward flexion, 25�;

Adjuvant internal rotation, T6Hand and elbow: normalScapula: � pro/retraction,

elevation

� � intact

periscapular muscles are sequentially identified andreleased. The deltoid, trapezius, rhomboids, levatorscapulae, latissimus dorsi, and serratus anterior arepreserved for later reconstruction. Clavicular andhumeral osteotomies are done. The tumor is re-moved en bloc with the scapula, rotator cuff, proxi-mal humerus, and distal 1⁄3 of clavicle.

Scapular ReconstructionThe scapular prosthesis is placed in a pocket be-tween the serratus anterior and the rhomboids. Su-periorly, the trapezius muscle is tenodesed to thedeltoid muscle. The distal 2⁄3 of the prosthesis is cov-ered by the latissimus muscle (Fig 2). The latis-simus is mobilized and rotated superiorly to ensuresufficient coverage of the prosthesis. It is extremelyimportant to position the prosthesis close to thespine, within 1 to 2 cm of the midline, at the samelevel as the contralateral scapula. This facilitatescomplete soft tissue coverage and prevents anteriorgliding of the prosthesis, thus protecting the neuro-vascular bundle and improving cosmesis. The sur-rounding musculature is reattached to the holes inthe prosthesis with 3-mm nonabsorbable tapes. Therhomboids are sutured to holes along the vertebralborder; the trapezius and deltoid are sutured to thesuperior border; and the latissimus dorsi is sutured

to the axillary border of the prosthesis. Theperiscapular muscles then are tenodesed to eachother with Number 0 braided, nonabsorbable suture.A modular proximal humerus is cemented into theremaining distal humerus; its length can be adjustedeasily. The humeral length usually is chosen to al-low shortening of the extremity by 1 to 2 cm, whichrelieves tension on nerves and vessels and eases del-toid and trapezius attachment and wound closure. Inthe three cases reported here, it was decided to con-tinue using a Goretex aortic graft because it facili-tates muscular attachment to the proximal humerusand for extra protection against glenohumeral dis-sociation should the constrained glenoid fail. Theaortic graft is sutured to holes around the glenoidneck and passed over the head of the humerus andsutured through holes in the humeral neck. Musclesare reattached to cover the entire proximal humerus(pectoralis to the prosthesis and to the deltoid andtrapezius). Tenodesis of the biceps tendon to thepectoralis major is done with the elbow in 45� flex-ion and the hand fully supinated.

Patient 1This case exemplifies constrained total scapular re-construction after Tikhoff-Linberg resection of thescapula for Ewing’s sarcoma. The patient was a 17-


Fig 1A–B. The constrained total scapula pros-thetic design is shown. (A) Constrained totalscapular prosthesis shows free abduction of thehumeral component. Holes are manufactured inthe perimeter of the prosthesis for myodesis ofthe periscapular muscles. The vacant areas inthe center of the prosthesis allow scarring of theserratus anterior to the rhomboids. (B) A close-up view shows the snap-fit mechanism of theconstrained polyethylene glenoid component.A

B

year-old boy who presented with pain and swellingof the right shoulder. Physical examination showeda large mass surrounding the scapula. The right up-per extremity was neurovascularly intact. Plain ra-diographs revealed a permeative lesion of the rightscapula. Magnetic resonance imaging (MRI) scans

and computed tomography (CT) scans confirmed alarge mass protruding anteriorly and posteriorlyfrom the scapula. Biopsy revealed a Ewing’s sar-coma. Induction chemotherapy was administeredand caused a dramatic reduction in the size of theextraosseous component (Fig 3). Repeat CT scans


Fig 2A–D. Scapular reconstruction is shown. (A) The scapular prosthesis is positioned in a pocket be-tween the serratus anterior and the rhomboids. It is crucial that the scapular prosthesis be positioned asclose to midline as possible (1 to 2 cm from the spine). (B) The rhomboids and the serratus anterior aretenodesed to the posterior and anterior aspects of the prosthesis, respectively. The trapezius, deltoid,and levator scapulae are tenodesed to the prosthesis and to each other. The latissimus dorsi is mobi-lized to close any remaining soft tissue defect. (C) The entire prosthesis is covered with muscle. (D) Thisintraoperative photograph shows mobilization of the latissimus dorsi and rhomboids for soft tissue cov-erage and suspension of the prosthesis. 2A-C reprinted with permission from Malawer M, Wittig J, Ru-bert C: Scapulectomy. In Malawer MM, Sugarbaker P (eds.). Musculoskeletal Cancer Surgery: Treat-ment of Sarcomas and Allied Diseases. Norwell, MA, Kluwer Academic Publishers, 2001. p. 553–568.

A B

C

D

showed complete regression of the extraosseouscomponent. It now was possible to salvage severalmuscles needed for prosthetic reconstruction. Thepatient had a modified Tikhoff-Linberg resectionand reconstruction with the constrained total scapu-lar prosthesis. There were no intraoperative or post-operative complications.

At 1.5 years postoperatively, the patient has a sta-ble, painless shoulder. Active shoulder abductionand flexion is 30� to 40�, internal rotation is normal,and external rotation is to neutral. Passive motion isnormal. Shoulder abduction strength is Grade 3.Shoulder elevation strength (shrugs) is Grade 5. Pro-traction and retraction of the scapula remain intact.The periscapular muscles contract when the patientcarries objects. Elbow range of motion (ROM) isnormal, and biceps and triceps strength are Grade 5.Hand sensation and motor function are normal. Thepatient can do push-ups. The patient had pulmonarymetastases develop 14 months after surgery and cur-rently is alive with evidence of disease and is re-ceiving additional chemotherapy.

Patient 2This case shows a modified Tikhoff-Linberg resec-tion in lieu of a forequarter amputation for a large,

primary, undifferentiated sarcoma arising from thesubscapularis muscle and invading the scapula. Aconstrained total scapula and a modular proximalhumerus prosthesis were used for reconstruction.This patient, a 26-year-old man, presented with a 9 �7 � 11-cm mass arising from the anterior surfaceof the right scapula (Fig 4). Computed tomographyscans of his chest revealed multiple bilateral pul-monary nodules. He had restricted ROM of theshoulder and paresthesias in his right hand. Biopsyshowed a high-grade undifferentiated sarcoma. Onthe basis of these clinical findings, a forequarteramputation ordinarily would have been recom-mended; however, induction chemotherapy wasused to kill the tumor with the hope that a limb-sparing procedure could be done. An institutionalhigh-risk chemotherapy protocol that includes vin-cristine, cyclophosphamide, doxorubicin, etoposide,and ifosfamide was initiated. After three cycles ofchemotherapy, the patient reported softening of themass and diminished paresthesias in his hand. Stag-ing studies were repeated. Angiography and venog-raphy confirmed patency of the axillary vessels.After the fourth cycle of chemotherapy and 5 monthsafter initial presentation, the patient had an extraar-ticular total scapula resection. Initial exploration


Fig 3A–B. One patient had a large Ewing’s sar-coma from the right scapula and was treated withinduction chemotherapy followed by limb-sparingsurgical resection (A) A CT scan taken at presen-tation shows a large Ewing’s sarcoma arising fromthe right scapula. Arrows delineate the extensivesoft tissue component of the tumor. A repeat CTscan of the same lesion taken after induction che-motherapy showed complete regression of thesoft tissue component of the tumor improving theability to preserve the muscles necessary for pros-thetic reconstruction. (B) An anteroposterior radio-graph of the same patient was obtained after re-construction with the constrained total scapulaand modular proximal humerus prostheses.

A

B

showed that the brachial plexus was free of tumor.The deltoid, trapezius, remaining periscapular mus-cles, and the axillary nerve were preserved. Recon-struction was accomplished with a constrained to-tal scapula and a proximal humeral prosthesis.Pathologically, all surgical margins were negativeand there was 40% tumor necrosis. There were nointraoperative or postoperative complications.

Followup up 7 months postoperatively showeda stable, painless shoulder. There was no evidenceof local recurrence. Active shoulder ROM was 45�abduction, 45� forward flexion, external rotation toneutral, and full internal rotation. Active scapularmotion was restored. The elbow and hand retainednormal function. The patient’s pulmonary diseasecontinued to progress and he died 7 months post-operatively.

Patient 3This case shows revision of an intraarticular prox-imal humerus resection to an extraarticular, totalscapular resection for recurrent osteosarcoma. Thepatient was a 13-year-old boy with telangiectacticosteosarcoma of the proximal humerus. Initially,he presented with a pathologic fracture through a6- � 8-cm osteolytic lesion of the right proximalhumerus. An intraarticular resection of the proxi-mal humerus was done by surgeons in another in-stitution (Fig 5). The defect was reconstructed byfixing a free, nonvascularized, autogenous fibula tothe remaining humerus with an intramedullary metal-

lic pin. Two to 3 months postoperatively, the pinbegan protruding through the skin.

The family sought a second opinion. By that time,local recurrence had developed along the inferior gle-noid and scapular neck. Restaging studies were done.The patient had three cycles of neoadjuvant chemo-therapy consisting of doxorubicin and cisplatin. Ascapulectomy was done and the old construct was re-moved en bloc, which converted the initial intraartic-ular resection to a modified, Tikhoff-Linberg resec-tion. Reconstruction of the scapula and proximalhumerus was accomplished with constrained totalscapular and modular proximal humeral prostheses.There were no intraoperative complications. The pa-tient’s shoulder was placed in a sling for 2 weeks andthen a gentle physical therapy program was started.All skin flaps healed.

At 2 years postoperatively (Fig 5), the patienthas a stable, painless shoulder. His shoulder has 25�active abduction and flexion, internal rotation toT6, and external rotation to �10�. Passive shouldermotion is normal. Active elbow motion rangesfrom 0� to 130�. Shoulder abduction and forwardflexion are Grade 3. Internal rotation, adduction,and extension strength are Grade 5. Elbow flexionand extension strength are Grade 5. The patient canactively protract, retract, elevate, and depress hisscapula. When lifting heavy objects, his periscapu-lar muscles actively contract to stabilize his scapulaand upper extremity. Hand sensation and motorfunction are normal. The patient is free of local andsystemic disease.

RESULTS

Function for all three patients, as evaluated ac-cording to the Musculoskeletal Tumor SocietyUpper Extremity Functional Evaluation Sys-tem,6 was 24 to 27 of 30 (80%–90%). The fol-lowing grades were assigned to each categoryassessed by the Musculoskeletal Tumor Soci-ety system: pain, 5; hand dexterity, 5; emo-tional acceptance, 5; lifting ability, 3 to 4;hand positioning, 3 to 4; function and activi-ties, 3 to 4. In all three patients, a painless, sta-ble shoulder girdle was restored. All patientsretained a functional hand and elbow. No pa-tient required a forequarter amputation. Rota-tion below the shoulder level, which is re-quired for most activities of daily living andpersonal hygiene, was preserved (range, �10�


Fig 4. A CT scan shows a large primary undif-ferentiated sarcoma arising from the right sub-scapularis muscle (arrows). This scan was takenafter a protocol of induction chemotherapy.


Fig 5A–D. Conversion of an intraarticular proximal humerus resection and reconstruction to a Type VIresection for recurrent osteosarcoma are shown. (A) A radiograph of a 13-year-old boy who presented 3months after an intraarticular resection for a telangiectatic osteosarcoma of the proximal humerus isshown. At presentation, in addition to the rod protruding through the skin, a local recurrence was detectedalong the inferolateral border of the scapula. (B) A clinical photograph taken 6 months after the proce-dure shows that elbow flexion strength is almost normal. The periscapular muscles contract to help sta-bilize the upper extremity. (C) The periscapular muscles, trapezius, and rhomboids contract to stabilizethe upper extremity when the patient carries a heavy load. (D) The patient can place his hand aboveshoulder level for activities of daily living. A video is available on CORRONLINE (www.corronline.com).

A B

CD

external rotation to T6 for internal rotation).Internal rotation, adduction, and extensionstrength were Grade 5. Active shoulder ab-duction and forward flexion (combined gleno-humeral and scapulothoracic motion) rangedfrom 25� to 45� and were Grade 3 motorstrength. Each patient was capable of scapularprotraction, retraction, and elevation and theperiscapular muscles contracted when carry-ing objects, thus assisting in upper extremitystabilization. Elbow flexion and extensionstrength were Grade 5. Hand sensation anddexterity were normal and grip strength wasGrade 5 for each patient.

All three patients could reach the top of theirhead, opposite shoulder and armpit, and per-ineal area with their hand. There were no limi-tations in activities of daily living includingfeeding, dressing, and personal hygiene. Liftingability was normal with the arm at the patient’sside. Cosmesis was acceptable to all three pa-tients. The only limitations were in recreational(high intensity athletics) and other activitiesthat required raising the extremity above shoul-der level. There were no intraoperative or post-operative complications. No patient had a trac-tion neurapraxia develop. One patient died ofdisease 7 months postoperatively.

DISCUSSION

This is the first report of a constrained totalscapula prosthesis used for reconstructing theshoulder girdle after resection of a high-gradescapula or periscapular sarcoma. Based on pre-liminary results, this method of reconstructionseems to be a safe and reliable option for limb-sparing surgery after total scapulectomy or anextraarticular scapular resection for selected tu-mors. It provides an anatomic method of recon-struction that restores glenohumeral and scapu-lothoracic mechanisms by recreating the normalmuscle force couples around the shoulder gir-dle. The constrained glenoid was designed topassively restore the dynamic stability nor-mally provided by the rotator cuff, preventglenohumeral dissociation and ease surgical re-construction. Similar to the rotator cuff, it pro-

vides a strong restraint against superior humeralmigration with deltoid contraction without re-stricting rotation. This may translate into bet-ter shoulder abduction, flexion, and stabilitycompared with earlier, nonconstrained ver-sions of total scapular prostheses that usedGoretex aortic graft for reconstructing theglenohumeral joint capsule, which was moreelastic in nature (Fig 6).

The preliminary functional results of theupper extremity and active shoulder ROMachieved in the three patients reported in thecurrent study are at least equivalent to many ofthe long-term results obtained with earliernonconstrained designs.1 The Musculoskele-tal Tumor Society functional rating for thesepatients was 24 to 27 of a maximal score of 30points or 80% to 90%. All three patients re-ceived the best possible score (5 points) in theareas of pain, hand dexterity, and emotionalacceptance. Patients lost points in the areas offunction, hand positioning, and lifting ability.The scoring of these areas was subjective;therefore a range of 3 to 4 was assigned to eachof these areas. All patients had some restric-tions in activities, mostly high level athletics,although all were capable of some recreationalactivities. Hand positioning was not unlimitedbut all patients could place their hand aboveshoulder level, touch the back of their head,and feed themselves. Lifting ability was nor-mal with the arm adjacent to the body; how-ever, none of the patients could lift objects sig-nificantly above shoulder level. These resultsare comparable with the functional results re-ported by Asavamongkolkul et al1 who re-ported an average Musculoskeletal Tumor So-ciety score of 74% for 14 patients who hadreconstruction with a nonconstrained (Goretex-stabilized) total scapula prosthesis after resec-tion of a tumor between 1980 and 1997. Thestudy by Aasavamongkolkul et al1 is the onlyother report in the literature describing totalscapula prosthetic reconstruction after tumorresection.

Additional followup of the current patientsis necessary to determine whether active shoul-der motion, specifically abduction and for-


ward flexion, and strength will be improvedand the risk of glenohumeral instability mini-mized with the new, constrained component.It is anticipated that active shoulder motionand strength will continue to improve with re-habilitation in the two living patients. Basedon the experience of the senior author with

nonconstrained scapula replacements, func-tion improves gradually during the first 2 yearspostoperatively.

Before 1970, most patients with high-gradesarcomas arising from the scapula were treatedwith a forequarter amputation. The first limb-sparing surgeries for high-grade sarcomas aris-


Fig 6. Muscle force vectors across the glenohumeral joint are shown. Under normal conditions, the ro-tator cuff provides a medially and inferiorly directed force vector on the humeral head that stabilizesit against the glenoid. Contraction of the deltoid is converted efficiently into angular acceleration of theglenohumeral joint (large arrow) that results in abduction. When a Goretex aortic graft is used to stabilizeseparate total scapular and proximal humerus components, the inherent elasticity in the Goretex permitsupward humeral migration with deltoid contraction. Deltoid contraction is not converted efficiently into an-gular acceleration of the glenohumeral joint (small arrow). The constrained glenoid mechanically ensuresstability and theoretically restores rotator cuff function. It stabilizes the humeral head within the glenoidand prevents upward humeral migration Deltoid contraction can be converted efficiently into angular ac-celeration (abduction) of the glenohumeral joint. (Reprinted with permission from Malawer M, Wittig J, Ru-bert C: Scapulectomy. In Malawer MM, Sugarbaker P (eds). Musculoskeletal Cancer Surgery: Treatmentof Sarcomas and Allied Diseases. Norwell, MA, Kluwer Academic Publishers 553–568, 2001.)

ing from the shoulder girdle were reported byMarcove et al12 in 1977.12 They reported theTikhoff-Linberg resection achieved local tu-mor control and survival similar to thatachieved with a forequarter amputation. Mostimportantly, a functional hand and elbow werepreserved. Limb-sparing surgery for patientswith high-grade sarcomas in this location soonbecome standard treatment.2–4,11,13,14–16

In the earliest experience with limb-sparingsurgery for tumors of the scapula, there was noeffort to reconstruct the shoulder girdle afterresection.2,7,10,12–14 Shoulders were left flailand the extremity was left dangling by the skinand neurovascular bundle. There was no ac-tive shoulder motion. This combined withshoulder instability led to difficulty with car-rying objects and placing the hand into a func-tional position necessary for activities of dailyliving. Cosmesis was poor and traction neu-rapraxia frequently developed, which led tochronic pain and motor and sensory deficits.Many patients required an external orthosisfor support.

Surgeons attempted to circumvent many ofthese problems by either stabilizing the prox-imal humerus or remaining humeral shaft di-rectly to the clavicle or a rib with heavy su-tures or wires.2,4,8,9,12,13 They also attemptedplacing an intramedullary rod or other typeof functional spacer into the remaininghumeral shaft and stabilizing its proximalend. Shoulder motion was not improved andshoulder instability still was a problem.Complications and failures were frequent andincluded sutures and wires rupturing, androds eroding through the overlying skin andabrading the chest wall. Patients eventuallyended up with a flail, painful shoulder or anamputation.

These early methods of reconstruction arereferred to as nonanatomic methods becausethey made no attempt to reconstruct the bonystructures that were resected nor restore thenormal muscle force couples responsible forscapulothoracic and glenohumeral motion.The periscapular muscles (rhomboids, deltoid,trapezius, serratus anterior) were deemed to be

of no functional value and either were resectedroutinely, or, if preserved, not used for recon-struction. O’Connor et al13 reported on thefunctional results of eight patients who weretreated with a total scapulectomy or Tikhoff-Linberg resection. The shoulders in three pa-tients were left flail (no reconstruction). Theaverage Musculoskeletal Tumor Society scorewas 44%. Five patients had reconstructionwith a functional spacer. The average Muscu-loskeletal Tumor Society score for this groupwas 49%. These patients received unsatisfac-tory scores (� 3) in the areas of function, handpositioning, and lifting ability. These resultsare inferior to the results reported in the cur-rent study and those reported by Asava-mongkolkul et al,1 as cited previously.

Damron et al5 also reported on the func-tional outcome of 14 patients treated with amodified or classic Tikhoff-Linberg proce-dure who had reconstruction with a functionalspacer. Active shoulder motion was reportedas a percentage of the uninvolved side as fol-lows: abduction, 5% to 15%; internal rotation,5% to 10%; external rotation, 0% to 5%;shoulder flexion, 5% to 20%; and shoulder ex-tension, 35% to 45%. These results also seemto compare inferiorly with the preliminary re-sults reported in the current study. In the threepatients reported in the current study, internalrotation is almost normal, shoulder abductionand flexion are approximately 20% to 25% ofthe uninvolved side, and extension is the sameas the uninvolved side. In addition, scapularprotraction, retraction, elevation and depres-sion, that were lacking in the group reportedby Damron et al,5 all were functioning in thepatients in the current study.

Reconstruction with a constrained totalscapula prosthesis is preferred by the currentauthors because it restores most of the bony ar-chitecture necessary for reconstructing the nor-mal muscle force couples of the scapulotho-racic and glenohumeral mechanisms, both ofwhich are important for optimal shoulder girdleabduction and upper extremity stabilization16

(Table 2). Usually during resection of mostscapular sarcomas and sarcomas arising from


the rotator cuff, most of the muscles necessaryfor reconstructing scapulothoracic and gleno-humeral mechanisms can be preserved, namelythe deltoid, trapezius, rhomboids, latissimus,and serratus anterior muscles. The rotator cuff,however, an essential component of the gleno-humeral mechanism, usually is resected and itsfunction must be restored during the recon-struction. The humeral head usually is stabi-lized actively in the glenoid by the rotator cuffthat converts the glenohumeral joint into a fixedfulcrum and enables angular acceleration of thejoint, powered by the deltoid muscle. The con-strained glenoid, by providing a fixed fulcrum,attempts to passively restore the normal inferiorand medial force provided by the rotator cuffthat prevents superior humeral translation withdeltoid contraction. Therefore, the superiorly di-rected force vector of the deltoid may be moreefficiently converted into an angular accelera-tion (abduction) of the glenohumeral joint (Fig6). An improvement in abduction and stabilityof the glenohumeral joint combined with activescapulothoracic motion enhances global shoul-der girdle abduction, strength, and stability.

The current authors describe a new, con-strained total scapular prosthesis and surgicaltechnique termed anatomic reconstruction aftermodified, Tikhoff-Linberg shoulder girdle re-section. The locking mechanism provides a se-cure attachment for the proximal humerus pros-thesis and partially substitutes for the resectedrotator cuff muscles and glenohumeral jointcapsule. This system, which uses all remainingperiscapular muscles, restores glenohumeraland scapulothoracic mechanisms, and poten-

tially improves active glenohumeral motion,shoulder girdle stability, and strength for opti-mal upper extremity function. The locking de-sign also facilitates intraoperative attachmentof the proximal humerus to the scapula, therebyeasing surgical reconstruction and reducing therisk of future dissociation. However, the resultspresented in the current study are preliminary,and additional followup is warranted. With theincreasing use of induction chemotherapy, it islikely that more high-grade sarcomas involvingthe scapula will be resectable with preservationof the necessary musculature to facilitate re-construction with this anatomic approach.

References1. Asavamongkolkul A, Eckardt JJ, Eilber FR, et al:

Endoprosthetic reconstruction for malignant upperextremity tumors. Clin Orthop 360:207–220, 1999.

2. Badhwar R: Reconstruction following limb-sparingen bloc resection of the shoulder girdle- Tikhoff-Lin-berg procedure. Ind J Cancer 27:31–37, 1990.

3. Biagini R, Capanna R, Van Horn JR, et al: Scapulec-tomy: Report on the results of 28 patients. Acta Or-thop Belg 42:732–742, 1986.

4. Capanna R, Van Horn JR, Biagini R, et al: TheTikhoff-Linberg procedure for bone tumors of theproximal humerus: The classical “extensive” tech-nique versus a modified “transglenoid” resection.Arch Orthop Trauma Surg 109:63–57, 1990.

5. Damron TA, Rock MG, O’Connor MI, et al: Func-tional laboratory assessment after oncologic shoul-der joint resections. Clin Orthop 348:124–134, 1998.

6. Enneking WF, Dunham W, Gebhardt MC, et al: Asystem for the functional evaluation of reconstructiveprocedures after surgical treatment of tumors of themusculoskeletal system. Clin Orthop 286:241–246,1993.

7. Francis KC, Worcester JN: Radical resection for tu-mors of the shoulder with preservation of a func-tional extremity. J Bone Joint Surg 44A:1423–1430,1962.


TABLE 2. Comparison of Nonanatomic and Anatomic Reconstructions

Outcome Nonanatomic Anatomic

Stability Poor Good to excellentCosmesis Poor GoodExternal rotation None Neutral to �10�

Abduction 0�–10� 35�–60�

Upper extremity strength Poor GoodComplications (hardware failure, infection, skin erosion, Substantial Few

traction neurapraxia)


8. Ham SJ, Hoekstra HJ, Eisma WH, Koops HS, Old-hoff J: The Tikhoff-Linberg procedure in the treat-ment of sarcomas of the shoulder girdle. J Surg On-col 53:71–77, 1993.

9. Kumar VP, Satku SK, Mitra AK, Pho RWH: Func-tion following limb-salvage for primary tumors ofthe shoulder girdle. Acta Orthop Scand 65:55–61,1994.

10. Lindberg BE: Interscapulo-thoracic resection formalignant tumors of the shoulder girdle region. JBone Joint Surg 10:344–349, 1928.

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humeral interscapulo-thoracic resection. Clin Or-thop 124:219–228, 1977.

13. O’Connor MI, Sim FH, Chao EY: Limb salvage forneoplasms of the shoulder girdle: Intermediate re-constructive and functional results. J Bone Joint Surg78A:1872–1888, 1996.

14. Papaioannou AN, Francis KC: Scapulectomy for thetreatment of primary malignant tumors of thescapula. Clin Orthop 41:125–132, 1965.

15. Voggenreiter G, Assenmacher S, Schmit-Neuren-burg KP: Tikhoff-Linberg procedure for bone andsoft tissue tumors of the shoulder girdle. Arch Surg134:252–257, 1999.

16. Ward B, McGarvey C, Loetz M: Excellent shoulderfunction is attainable after partial or total scapulec-tomy. Arch Surg 125:537–542, 1990.

constrained total scapula reconstruction after resection

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