Clinical Orthopaedics and Related Research®

, Volume 468, Issue 11, pp 2896–2903

Proximal and Total Humerus Reconstruction With the Use of an Aortograft Mesh

  • German A. Marulanda
  • Eric Henderson
  • David Cheong
  • G. Douglas Letson
Symposium: Highlights of the ISOLS/MSTS 2009 Meeting



The shoulder is commonly affected by primary and metastatic tumors. Current surgical techniques for complex shoulder reconstruction frequently result in functional deficits and instability. A synthetic mesh used in vascular surgery has the biological properties to provide mechanical constraint and improve stability after tumor related shoulder reconstruction.


We describe (1) surgical technique using a synthetic mesh during humerus reconstructions; (2) functional level defined as shoulder ROM of patients undergoing the procedure; (3) incidence of postoperative dislocation and shoulder instability; and (4) complications associated with the use of the device.


We retrospectively reviewed 16 patients with proximal humerus replacements reconstructed with a synthetic mesh from February 2006 to July 2008. Patients were followed clinically and radiographically for a minimum of 13 months (mean, 26 months; range, 13–43 months).


There were no shoulder dislocations at the latest followup. The mean shoulder flexion was 43° (range, 15°–170°) and mean shoulder abduction of 38 (range, 15°–110°). The mean operative time was 121 minutes (range, 80–170 minutes) and the mean blood loss was 220 mL (range, 50–750 mL). One patient had a superficial wound infection and none a deep infection requiring removal of the graft or prosthesis.


The data suggest the use of a synthetic vascular mesh for proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment and reconstruction after tumor resection.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Amadi HO, Hansen UN, Bull AM. A numerical tool for the reconstruction of the physiological kinematics of the glenohumeral joint. Proc Inst Mech Eng H. 2009;223:833–837.CrossRefPubMedGoogle Scholar
  2. 2.
    Amin SN, Ebeid WA. Shoulder reconstruction after tumor resection by pedicled scapular crest graft. Clin Orthop Relat Res. 2002;397:133–142.CrossRefPubMedGoogle Scholar
  3. 3.
    Bacci G, Ferrari S, Lari S, Mercuri M, Donati D, Longhi A, Forni C, Bertoni F, Versari M, Pignotti E. Osteosarcoma of the limb. Amputation or limb salvage in patients treated by neoadjuvant chemotherapy. J Bone Joint Surg Br. 2002;84:88–92.CrossRefPubMedGoogle Scholar
  4. 4.
    Bickels J, Wittig JC, Kollender Y, Kellar-Graney K, Meller I, Malawer MM. Limb-sparing resections of the shoulder girdle. J Am Coll Surg. 2002;194:422–435.CrossRefPubMedGoogle Scholar
  5. 5.
    Bos G, Sim F, Pritchard D, Shives T, Rock M, Askew L, Chao E. Prosthetic replacement of the proximal humerus. Clin Orthop Relat Res. 1987;224:178–191.PubMedGoogle Scholar
  6. 6.
    Bruck JC, Weber U. Tumor-related arthrodesis. Reconstruction of the shoulder contour using a free TRAM (Transverse Rectus Abdominis Musculocutaneous) flap [in German]. Orthopade. 1998;27:441–444.CrossRefPubMedGoogle Scholar
  7. 7.
    Camnasio F, Scotti C, Peretti GM, Fontana F, Fraschini G. Prosthetic joint replacement for long bone metastases: analysis of 154 cases. Arch Orthop Trauma Surg. 2008;128:787–793.CrossRefPubMedGoogle Scholar
  8. 8.
    Cheng EY, Gebhardt MC. Allograft reconstructions of the shoulder after bone tumor resections. Orthop Clin North Am. 1991;22:37–48.PubMedGoogle Scholar
  9. 9.
    Dal Monte A, Manes E. Osteosarcoma of the proximal femur and humerus in children treated by resection, endoprosthesis and complementary chemotherapy. Ital J Orthop Traumatol. 1983;9:151–156.PubMedGoogle Scholar
  10. 10.
    Deutsch M, Meinhart J, Zilla P, Howanietz N, Gorlitzer M, Froeschl A, Stuempflen A, Bezuidenhout D, Grabenwoeger M. Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts. J Vasc Surg. 2009;49:352–362; discussion 362.CrossRefPubMedGoogle Scholar
  11. 11.
    De Wilde LF, Plasschaert FS, Audenaert EA, Verdonk RC. Functional recovery after a reverse prosthesis for reconstruction of the proximal humerus in tumor surgery. Clin Orthop Relat Res. 2005;430:156-162.CrossRefPubMedGoogle Scholar
  12. 12.
    Doble M, Makadia N, Pavithran S, Kumar RS. Analysis of explanted ePTFE cardiovascular grafts (modified BT shunt). Biomed Mater. 2008;3:034118.CrossRefPubMedGoogle Scholar
  13. 13.
    Eggers IM, Mennen U. The EFFUL (Evaluation of Function in the Flail Upper Limb) system. A ranking score system to measure improvement achieved by surgical reconstruction and rehabilitation. J Hand Surg Br. 1997;22:388–394.CrossRefPubMedGoogle Scholar
  14. 14.
    Fernie GR, Kostuik JP, Lobb RJ. A percutaneous implant using a porous metal surface coating for adhesion to bone and a velour covering for soft tissue attachment: results of trials in pigs. J Biomed Mater Res. 1977;11:883–891.CrossRefPubMedGoogle Scholar
  15. 15.
    Francis KC, Marchetti PG, Caruso M. Inter-scapulo-thoracic resection (Tikhoff-Linberg Operation) [in Italian]. Arch Putti Chir Organi Mov. 1964;19:331–340.PubMedGoogle Scholar
  16. 16.
    Freels DB, Kilpatrick S, Gordon ES, Ward WG. Animal model for evaluation of soft tissue ingrowth into various types of porous coating. Clin Orthop Relat Res. 2002;397:315–322.CrossRefPubMedGoogle Scholar
  17. 17.
    Gosheger G, Hillmann A, Lindner N, Rodl R, Hoffmann C, Burger H, Winkelmann W. Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Relat Res. 2001;393:264–271.CrossRefPubMedGoogle Scholar
  18. 18.
    Greisler HP, Tattersall CW, Henderson SC, Cabusao EA, Garfield JD, Kim DU. Polypropylene small-diameter vascular grafts. J Biomed Mater Res. 1992;26:1383–1394.CrossRefPubMedGoogle Scholar
  19. 19.
    Heitmann C, Erdmann D, Levin LS. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am. 2002;84:2216–2223.PubMedGoogle Scholar
  20. 20.
    Higuera CA, Inoue N, Lim JS, Zhang R, Dimaano N, Frassica FJ, Chao EY. Tendon reattachment to a metallic implant using an allogenic bone plate augmented with rhOP-1 vs. autogenous cancellous bone and marrow in a canine model. J Orthop Res. 2005;23:1091–1099.CrossRefPubMedGoogle Scholar
  21. 21.
    Huffman GR, Tibone JE, McGarry MH, Phipps BM, Lee YS, Lee TQ. Path of glenohumeral articulation throughout the rotational range of motion in a thrower’s shoulder model. Am J Sports Med. 2006;34:1662–1669.CrossRefPubMedGoogle Scholar
  22. 22.
    Kassab M, Dumaine V, Babinet A, Ouaknine M, Tomeno B, Anract P. [Twenty nine shoulder reconstructions after resection of the proximal humerus for neoplasm with mean 7-year follow-up]. Rev Chir Orthop Reparatrice Appar Mot. 2005;91:15–23.PubMedGoogle Scholar
  23. 23.
    Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998;26:764–772.PubMedGoogle Scholar
  24. 24.
    Kiss J, Sztrinkai G, Antal I, Szendroi M. Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors. J Shoulder Elbow Surg. 2007;16:273–279.CrossRefPubMedGoogle Scholar
  25. 25.
    Kitagawa Y, Thai DM, Choong PF. Reconstructions of the shoulder following tumour resection. J Orthop Surg (Hong Kong). 2007;15:201–206.Google Scholar
  26. 26.
    Kumar VP, Satku SK, Mitra AK, Pho RW. Function following limb salvage for primary tumors of the shoulder girdle. 10 patients followed 4 (1–11) years. Acta Orthop Scand. 1994;65:55–61.PubMedGoogle Scholar
  27. 27.
    LaBerge M, Bobyn JD, Rivard CH, Drouin G, Duval P. Study of soft tissue ingrowth into canine porous coated femoral implants designed for osteosarcomas management. J Biomed Mater Res. 1990;24:959–971.CrossRefPubMedGoogle Scholar
  28. 28.
    Lukin AV, Kiss EE, Grishkin VA, Chernova VI. Individual endoprosthesis in a malignant tumor of the humerus [in Russian]. Vestn Khir Im I I Grek. 1987;139:65–66.PubMedGoogle Scholar
  29. 29.
    Malawer M. Surgical technique and results of limb sparing surgery for high grade bone sarcomas of the knee and shoulder. Orthopedics. 1985;8:597–607.PubMedGoogle Scholar
  30. 30.
    Malawer MM. Tumors of the shoulder girdle. Technique of resection and description of a surgical classification. Orthop Clin North Am. 1991;22:7–35.PubMedGoogle Scholar
  31. 31.
    Malawer MM, Sugarbaker PH, Lampert M, Baker AR, Gerber NL. The Tikhoff-Linberg procedure: report of ten patients and presentation of a modified technique for tumors of the proximal humerus. Surgery. 1985;97:518–528.PubMedGoogle Scholar
  32. 32.
    Marcove RC, Lewis MM, Huvos AG. En bloc upper humeral interscapulo-thoracic resection. The Tikhoff-Linberg procedure. Clin Orthop Relat Res. 1977;124:219–228.PubMedGoogle Scholar
  33. 33.
    Mazurkiewicz T, Warda E, Kopacz J, Mazurkiewicz M. Results of the megaprosthesis replacement reconstruction proximal femoral resection bone tumors. Ortop Traumatol Rehabil. 2005;7:595–599.PubMedGoogle Scholar
  34. 34.
    Moran M, Stalley PD. Reconstruction of the proximal humerus with a composite of extracorporeally irradiated bone and endoprosthesis following excision of high grade primary bone sarcomas. Arch Orthop Trauma Surg. 2009;129:1339–1345.CrossRefPubMedGoogle Scholar
  35. 35.
    Mourikis A, Mankin HJ, Hornicek FJ, Raskin KA. Treatment of proximal humeral chondrosarcoma with resection and allograft. J Shoulder Elbow Surg. 2007;16:519–524.CrossRefPubMedGoogle Scholar
  36. 36.
    Neer CS, 2nd. Prosthetic Replacement of the Humeral Head: Indications and Operative Technique. Surg Clin North Am. 1963;43:1581–1597.PubMedGoogle Scholar
  37. 37.
    O’Connor MI, Sim FH, Chao EY. Limb salvage for neoplasms of the shoulder girdle. Intermediate reconstructive and functional results. J Bone Joint Surg Am. 1996;78:1872–1888.Google Scholar
  38. 38.
    Ochiai Y, Imoto Y, Sakamoto M, Kajiwara T, Sese A, Watanabe M, Ohno T, Joo K. Mid-term follow-up of the status of Gore-Tex graft after extracardiac conduit Fontan procedure. Eur J Cardiothorac Surg. 2009;36:63–67; discussion 67–68.CrossRefPubMedGoogle Scholar
  39. 39.
    Petrovic P, Lotina S, Djordjevic M, Avramov S, Pfau J, Velimirovic D, Fabri M, Stojanov P, Savic D. Results of 132 PTFE (Gore-Tex) bifurcated graft implantations. J Cardiovasc Surg (Torino). 1989;30:897–901.Google Scholar
  40. 40.
    Picci P, Mercuri M, Ferrari S, Alberghini M, Briccoli A, Ferrari C, Pignotti E, Bacci G. Survival in high-grade osteosarcoma: improvement over 21 years at a single institution. Ann Oncol. 2009 Nov 4. [Epub ahead of print].Google Scholar
  41. 41.
    Probyn LJ, Wunder JS, Bell RS, Griffin AM, Davis AM. A comparison of outcome of osteoarticular allograft reconstruction and shoulder arthrodesis following resection of primary tumours of the proximal humerus. Sarcoma. 1998;2:163–170.CrossRefPubMedGoogle Scholar
  42. 42.
    Quill G, Gitelis S, Morton T, Piasecki P. Complications associated with limb salvage for extremity sarcomas and their management. Clin Orthop Relat Res. 1990;260:242–250.PubMedGoogle Scholar
  43. 43.
    Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops HS, van Horn JR. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol. 2000;73:198–205.CrossRefPubMedGoogle Scholar
  44. 44.
    Ross AC, Wilson JN, Scales JT. Endoprosthetic replacement of the proximal humerus. J Bone Joint Surg Br. 1987;69:656–661.PubMedGoogle Scholar
  45. 45.
    Runne WC, van Sambeek KJ, Stierum JL, van Tongerloo RB. Femoral endoprosthesis fixation with a soft, flexible low modulus stem coating. Four to six year clinical results. Orthopedics. 1989;12:529–535.PubMedGoogle Scholar
  46. 46.
    Sim IW, Tse LF, Ek ET, Powell GJ, Choong PF. Salvaging the limb salvage: management of complications following endoprosthetic reconstruction for tumours around the knee. Eur J Surg Oncol. 2007;33:796–802.PubMedGoogle Scholar
  47. 47.
    Thai DM, Kitagawa Y, Choong PF. Outcome of surgical management of bony metastases to the humerus and shoulder girdle: a retrospective analysis of 93 patients. Int Semin Surg Oncol. 2006;3:5.CrossRefPubMedGoogle Scholar
  48. 48.
    Toyoda Y, Shinohara N, Harabayashi T, Abe T, Akino T, Sazawa A, Nonomura K. Survival and prognostic classification of patients with metastatic renal cell carcinoma of bone. Eur Urol. 2007;52:163–168.CrossRefPubMedGoogle Scholar
  49. 49.
    Verhagen HJ, Blankensteijn JD, de Groot PG, Heijnen-Snyder GJ, Pronk A, Vroom TM, Muller HJ, Nicolay K, van Vroonhoven TJ, Sixma JJ, Eikelboom BC. In vivo experiments with mesothelial cell seeded ePTFE vascular grafts. Eur J Vasc Endovasc Surg. 1998;15:489–496.CrossRefPubMedGoogle Scholar
  50. 50.
    Wittig JC, Bickels J, Kellar-Graney KL, Kim FH, Malawer MM. Osteosarcoma of the proximal humerus: long-term results with limb-sparing surgery. Clin Orthop Relat Res. 2002;397:156–176.CrossRefPubMedGoogle Scholar
  51. 51.
    Wodajo FM, Bickels J, Wittig J, Malawer M. Complex reconstruction in the management of extremity sarcomas. Curr Opin Oncol. 2003;15:304–312.CrossRefPubMedGoogle Scholar
  52. 52.
    Yang Q, Li J, Yang Z, Li X, Li Z. Limb sparing surgery for bone tumours of the shoulder girdle: the oncological and functional results. Int Orthop. 2009 Aug 23. [Epub ahead of print].Google Scholar
  53. 53.
    Yang X, Tare RS, Partridge KA, Roach HI, Clarke NM, Howdle SM, Shakesheff KM, Oreffo RO. Induction of human osteoprogenitor chemotaxis, proliferation, differentiation, and bone formation by osteoblast stimulating factor-1/pleiotrophin: osteoconductive biomimetic scaffolds for tissue engineering. J Bone Miner Res. 2003;18:47–57.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • German A. Marulanda
    • 1
  • Eric Henderson
    • 1
  • David Cheong
    • 2
  • G. Douglas Letson
    • 2
  1. 1.Department of Orthopaedics and Sports MedicineUniversity of South FloridaTampaUSA
  2. 2.Sarcoma ProgramH. Lee Moffitt Cancer Center & Research InstituteTampaUSA

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