Shoulder and Elbow Cases to Consider.

Last updated Friday, August 29, 2008

Figure 1

Figure 2

Limb salvage hemiarthroplasty for proximal humerus parosteal osteosarcoma

Clinical presentation

This 45 year old female presented with a one-year history of gradually increasing left shoulder pain and gradual loss of range of motion (see figure 1). The patient recalled an injury about one year prior to presentation when some boxes she was carrying were forced into her shoulder by a closing door.

On examination no soft tissue mass was present around her shoulder region.There was tenderness to palpation over her anterior deltoid. There was loss of motion of the affected shoulder particularly involving external rotation and forward elevation. Her neurovascular examination was unremarkable.

Her general health and overall physical examination was normal expect for a past history of benign thyroid nodules.

Our concerns include :

• Establishing an accurate diagnosis of the bony / soft tissue lesion.
• What further investigations were necessary?
• Possible management strategies depending on the diagnosis.

Management

Our differential diagnosis from history and radiographic appearance included myositis ossificans, high grade surface osteosarcoma, and parosteal osteosarcoma. Further studies used to help differentiate and stage the lesion included a CT scan of her shoulder and chest, MRI of her shoulder, technetium bone scan and appropriate blood workup.

Following these studies an open biopsy was performed through the anterior edge of the deltoid which could be later sacrificed if a formal resection was required. Biopsy confirmed the diagnosis of "parosteal osteosarcoma".

The options of management were then discussed at length with the patient and included:

1. Limb salvage via a proximal humeral allograft
2. Shoulder disarticulation
3. Tikhof-Lindberg
4. Allograft arthrodesis
5. Mega-prosthesis

A mutual decision was made to perform a limb salvage procedure via a proximal humeral allograft and a cemented long stem Neer prosthesis as seen in the current radiograph (see figure 2). This was performed through an extended anterior deltopectoral approach. Adequate margins were achieved by resecting the proximal 1/3 of the humerus including part of the cuff and part of deltoid, pectoralis major, latissimus dorsi, and teres major. Neurovascular structures were able to be preserved.

The remaing cuff and capsule were reattached to the allograft. The deltoid insertion to the humerus was preserved. Microscopic pathology revealed adequate margins.

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