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En Bloc Shoulder Resection with Total Shoulder Prosthetic Replacement: Indications and Imaging Findings

¹ Department of Radiological Sciences, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Center for the Health Sciences, 10833 Le Conte Ave., Los Angeles, CA 90095.
² Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048.
³ Department of Orthopaedics, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —44-year-old woman with chondrosarcoma of right proximal humerus. Anteroposterior radiograph shows destructive lesion of right proximal humerus with wide zone of transition containing chondroid matrix.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —44-year-old woman with chondrosarcoma of right proximal humerus. Axial inversion recovery MR image shows lobular extension of mass into surrounding soft tissues and glenohumeral joint. Note encasement of long head of biceps tendon (arrow) and articular extension, indicating extraarticular resection by means of Tikhoff-Linberg procedure.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —29-year-old man with chondrosarcoma of right scapula. Axial IV contrast-enhanced CT scan reveals that scapular tumor (black arrow) does not involve axillary neurovascular bundle (white arrow), making Tikhoff-Linberg procedure a safe limb-sparing option.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —33-year-old man with right scapular chondrosarcoma. Axial T1-weighted MR image shows scapular chondrosarcoma with central necrosis (arrow) that has not invaded axillary neurovascular bundle.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —33-year-old man with right scapular chondrosarcoma. Axial CT scan shows posterior chest wall invasion (arrow), relative contraindication for Tikhoff-Linberg procedure.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —33-year-old man with right scapular chondrosarcoma. Anteroposterior conventional radiograph shows limb-sparing surgery, resecting involved part of chest wall along with proximal humerus, distal clavicle, and entire scapula and replacing it with total shoulder prosthesis (Scapular Implant, version 1.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). This patient had not experienced recurrence at 12-month follow-up.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —29-year-old woman with Ewing sarcoma of right scapula. Intraoperative photograph shows size difference between resected scapula and implant (Scapular Implant, version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]) that will replace it. Also note anteversion of glenoid cavity in both resected specimen (arrow) and implant.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —29-year-old woman with Ewing sarcoma of right scapula. Intraoperative photograph shows implant (Scapular Implant, version 2.0, Nonmodular Humeral Implant) sewn to posterior chest musculature.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —29-year-old woman with Ewing sarcoma of right scapula. Anteroposterior radiograph shows implant (Scapular Implant, version 2.0, Nonmodular Humeral Implant) in place postsurgically.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —63-year-old man after Tikhoff-Linberg procedure and total shoulder prosthetic reconstruction for metastatic renal cell carcinoma of scapula. Photograph shows modular version of humeral endoprostheses (Scapular Implant, version 1.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]), consisting of proximal humeral segment (1), intercalary segment (2), and intramedullary component (3).

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —63-year-old man after Tikhoff-Linberg procedure and total shoulder prosthetic reconstruction for metastatic renal cell carcinoma of scapula. Anteroposterior radiograph shows modular humeral implant in place along with scapular implant (Scapular Implant, version 1.0, Modular Humeral Implant).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —19-year-old man after Tikhoff-Linberg procedure and total shoulder prosthetic reconstruction for Ewing sarcoma of left scapula. Anteroposterior internal rotation radiograph shows implant (Scapular Implant, version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]) in good anatomic position with no dislocation or periprosthetic fracture present.

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —19-year-old man after Tikhoff-Linberg procedure and total shoulder prosthetic reconstruction for Ewing sarcoma of left scapula. Transscapular oblique radiograph shows scapular implant body sitting flush against posterior chest wall.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —63-year-old man with metastatic renal cell carcinoma of scapula. Lateral chest radiograph shows dislocation between intercalary (2) and intramedullary (3) components of modular humeral implant (1) (Scapular Implant, version 1.0, Modular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —63-year-old man with metastatic renal cell carcinoma of scapula. Photograph shows manner in which surgeon reinforced modular humeral model.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —63-year-old man with metastatic renal cell carcinoma of scapula. Lateral chest radiograph shows reinforced implant in place.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —33-year-old man with right scapular chondrosarcoma after resection and implant placement (Scapular Implant, version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). Anteroposterior radiograph shows dislocation of humeral head from scapular glenoid.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —56-year-old man with left scapular chondrosarcoma after resection and implant placement. (Scapular Implant Version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). Anteroposterior chest radiograph shows scapular implant in good position immediately after surgery. Also note that postsurgical shoulder lies slightly more inferior in relation to unaffected side, normal postoperative positioning due to small size of scapular implant.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —56-year-old man with left scapular chondrosarcoma after resection and implant placement. (Scapular Implant Version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). Anteroposterior chest radiograph 1 year after surgery shows increased axillary soft-tissue density, with loss of muscle planes and scapular implant displaced superiorly and laterally secondary to recurrent tumor. Note that postsurgical shoulder now lies more superior in relation to unaffected limb due to upward pressure from tumor recurrence.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —56-year-old man with left scapular chondrosarcoma after resection and implant placement. (Scapular Implant Version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). Coronal STIR image again shows recurrent tumor (black arrows) displacing scapular prosthesis (white arrow) superolaterally.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D —56-year-old man with left scapular chondrosarcoma after resection and implant placement. (Scapular Implant Version 2.0, Nonmodular Humeral Implant; Stryker Orthopaedics [formerly Howmedica Osteonics]). Axial STIR image highlights large, lobulated recurrent tumor (black arrows) laterally displacing scapular implant (white arrow).

View larger version (77K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —52-year-old man with right shoulder melanoma recurrence after primary resection and prosthetic placement. Follow-up axial CT scan shows artifact caused by implant (curved arrow) and no significant axillary lymph node enlargement (arrow).

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —52-year-old man with right shoulder melanoma recurrence after primary resection and prosthetic placement. Axial CT scan obtained 3 months after A shows enlarged axillary lymph nodes (arrows), which could represent reactive hyperplasia or recurrent melanoma below level of scapular implant (curved arrow).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —52-year-old man with right shoulder melanoma recurrence after primary resection and prosthetic placement. Axial MR image shows enlarged and irregular axillary lymph node (arrow). Dark area above lymph node indicated implant (curved arrow).

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