DOI:10.2214/AJR.07.3286
AJR 2008; 191:482-489
© American Roentgen Ray Society
En Bloc Shoulder Resection with Total Shoulder Prosthetic Replacement: Indications and Imaging Findings
Rinat Masamed1,
Thomas J. Learch2 and
Lawrence R. Menendez3
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.
Received October 13, 2007;
accepted after revision February 7, 2008.
All prostheses manufactured by Stryker Orthopaedics (formerly Howmedica
Osteonics).
Address correspondence to R. Masamed.
Abstract
OBJECTIVE. Our purpose was to highlight the importance of radiologic
studies in assessing the appropriateness of total scapular resection and total
shoulder prosthetic reconstruction and to examine the role of imaging in
evaluating for postoperative complications.
CONCLUSION. Evolving surgical and reconstructive techniques for
treatment of shoulder girdle tumors require radiologists to familiarize
themselves with novel imaging findings associated with these procedures.
Readers will better understand the indications for limbsparing surgery with
total shoulder prosthetic reconstruction, normal postoperative radiologic
findings, and common complications.
Keywords: en bloc shoulder resection • prosthesis • scapula • shoulder girdle • Tikhoff-Linberg resection
Introduction
Sarcomas compose less than 1% of all adult and 15% of pediatric
malignancies [1], the shoulder
girdle being a relatively common site for these malignant tumors.
Chondrosarcomas are the most common primary malignancy of the scapula,
although 12% occur in the proximal humerus, which is also the third most
common site for osteosarcomas. Ewing sarcomas occur in the proximal humerus 7%
of the time, and in the scapula 4–5% of the time
[2]. Thirteen percent of
soft-tissue sarcomas occur in the upper extremities
[1]. The shoulder girdle is
also a common area for metastases.
Dramatic change has occurred in the treatment of shoulder girdle neoplasia.
Forequarter amputation (removal of the upper extremity including the scapula
and clavicle) was once the treatment of choice. Today, most shoulder girdle
tumors are treated with limbsparing procedures such as the Tikhoff-Linberg
procedure. The operation consists of removal of the scapula, humeral head,
outer third of the clavicle, and surrounding soft tissue. Modern techniques
involve total shoulder prosthetic reconstruction to achieve maximal function
of the salvaged upper extremity. Depending on the extent of involvement of the
osseous and soft-tissue structures surrounding the shoulder, other surgical
options may include intraarticular proximal humeral resection, partial
scapulectomy, intraarticular total scapulectomy, or extraarticular humeral and
glenoid resection [1]. The
focus of this pictorial essay is the Tikhoff-Linberg procedure (extraarticular
proximal humeral, distal clavicular, and total scapular resection) with total
shoulder prosthetic reconstruction. Published reports documenting imaging
findings both pre- and postoperatively are limited. In this pictorial essay,
we give an overview of these important radiologic findings.
Materials and Methods
A retrospective chart and film review was performed of 13 patients who
underwent the Tikhoff-Linberg procedure with total shoulder prosthetic
reconstruction at the authors' institution over a 6-year period from 1999 to
2005. The types of tumors treated included five chondrosarcomas (four scapular
and one proximal humeral), two Ewing sarcomas, one pleomorphic leiomyosarcoma,
three metastatic renal cell carcinomas, one metastatic uterine leiomyosarcoma,
and one metastatic melanoma. All patients underwent preoperative
anteroposterior scapula, transscapular oblique, and humeral anteroposterior
internal–external rotation conventional radiography. CT or MRI or both
of the affected shoulder were performed in addition to any staging imaging
performed to assess the extent of disease. Postoperative conventional
radiography with similar technique was performed within 1 week after surgery,
as well as at 1- to 6-month intervals depending on the patient's particular
situation. Dedicated advanced imaging of the postsurgical site was ordered a
few weeks postoperatively to serve as a baseline study. In addition, CT, MRI,
and nuclear medicine studies were performed on an as-needed basis for detailed
evaluation of complications and disease recurrence.
Protocols
The most frequently requested advanced postoperative imaging techniques
include CT and MRI. CT of the chest is obtained to evaluate for metastatic
disease. Routine chest protocols are used. The prosthesis is imaged on these
examinations. The affected arm is usually at the side because of difficulty in
positioning it overhead.
Dedicated advanced imaging of the postsurgical site is ordered a few weeks
postoperatively to serve as a baseline study for comparison for all future
studies. Both MRI and CT examinations have inherent limitations because of
metallic artifact. Both studies may be ordered and can be additive and
complementary. CT is particularly valuable at assessing alignment of the
scapular–humeral component articulation and periprosthetic fractures of
the humeral stem. MRI excels at assessment of surrounding soft-tissue
abnormalities such as tumor recurrence, lymphadenopathy, and postoperative
fluid collections. These problems may also be identified on CT.
For CT, the opposite arm is positioned above the head. The affected arm is
placed at the side with the palm next to the thigh in a comfortable position.
The patient is placed in the gantry so that the area of interest is as close
to the center of the gantry as possible. The field of view is chosen to cover
the lateral chest, axilla, shoulder, and proximal humerus; 1-mm-thick
transverse slices with 50% overlap are obtained; mA is increased to 400; and
kV is increased to 140.
MRI protocols are designed to reduce and minimize metal artifact. This
includes T1 and inversion sequences using fast spin-echo, high echo-train
lengths (9–19), and the highest bandwidth possible (300 kHz and above).
Phase and frequency encoding are planned to deflect artifact away from area of
interest. If IV gadolinium is used, T1-weighted sequences are used. Fat
saturation is not attempted because of the large amount of metal.
Review of these imaging studies helped identify important preoperative
imaging techniques and findings that would assess the appropriateness of this
procedure for a particular patient. In addition, common complications were
recognized based on postoperative image review.
Results and Discussion
The following is a pictorial representation of the information gleaned from
the chart and film review of this group of patients as well as a review of the
literature regarding this limb-salvage procedure.
Indications, Contraindications, and Preoperative Imaging Studies
Imaging plays an important role in deciding whether the Tikhoff-Linberg
procedure is appropriate for a given patient. In his 1928 paper, Boris
Edmunovich Linberg [3], a
Russian surgeon, proposed three uses for this limb-sparing operation. The
first was for the treatment of malignant tumors of the proximal humerus,
scapula, or clavicle that have likely invaded all parts of the shoulder and
its joints (Figs. 1A,
1B, and
2). The second was removal of
tumors that do not involve the axillary neurovascular bundle (Figs.
2 and
3). And the third was
operations that had potential results equivalent to or better than amputation,
with preservation of good elbow and hand function
[3]. As previously shown,
preoperative imaging including conventional radiographs, and particularly CT
or MRI, is needed to assess the extent of tumor involvement because the
Tikhoff-Linberg procedure is absolutely contraindicated when the tumor
involves the axillary neurovascular bundle due to a high risk of recurrence.
Relative contraindications include tissue contamination at biopsy, pathologic
fracture, and chest wall invasion, although a patient in our series with chest
wall involvement underwent a successful operation without recurrence at
12-month follow-up [1] (Figs.
4A and
4B). In addition, preoperative
CT or MRI can help estimate whether there will be enough soft tissue remaining
for the reconstruction.
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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.
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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.
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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.
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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.
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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.
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Reconstruction and Implant Types
Multiple reconstructive techniques have been attempted in efforts to
stabilize the upper extremity after the Tikhoff-Linberg procedure. Early
attempts at preventing a flail upper extremity included various versions of a
humeral intramedullary rod that was fixed proximally to either the second rib
or the remaining clavicle. Although there was success in preserving distal arm
function, a variety of problems were noted, including the potential for
proximal migration, skin perforation, and mechanical failure, with little
restoration of shoulder function
[4–7].
Modern designs have evolved to include humeral and scapular components that
fit together to restore normal force vectors, improving function at the
shoulder [2,
7,
8]. The rotator cuff muscles,
which arise from or insert on the scapula or proximal humerus, are removed en
bloc along with the scapula, distal clavicle, and proximal humerus.
Extraarticular resection of the glenohumeral joint is, therefore, performed.
The portions of the deltoid, biceps, triceps, coracobrachialis, pectoralis,
latissimus dorsi, teres major, serratus anterior, trapezius, and rhomboids
that insert on the resected bones are taken down for later use in stabilizing
the prostheses. If portions of these muscles are involved with tumor, they are
resected as well.
The scapular component of the prosthesis, although anatomically smaller
than the human scapula, is created to mimic the normal 40–45° of
anteversion of the glenoid cavity with respect to the coronal plane of the
body to restore the normal range of motion (Figs.
5A and
5B). This represents the second
version of the scapular implant. The scapular implant used in the first
several patients in this series had a glenoid cavity that faced laterally,
without any anteversion. The proximal humeral implant first had a modular
design, with three standardized components that could be mixed and matched to
fit any patient (Figs. 6A and
6B). Complications with this
version (discussed later) led to the practice of custom-designing a humeral
component for each patient.
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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.
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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.
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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).
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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).
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The scapular prosthesis is sutured to the musculature of the chest wall
and, usually, the remaining serratus anterior through multiple fenestrations
along its borders. Depending on the extent of the remaining muscles, they are
sutured to each other and to the implant in a manner that will help restore
their normal function and to completely cover the implant. Ideally, the biceps
and coracobrachialis may be sutured together and reattached to the remaining
clavicle, and the pectoralis major is closed over the new glenohumeral joint.
Posteriorly, the levator scapulae, trapezius, rhomboids, and deltoid may be
sutured to each other and to the prosthesis
[1]. At times, latissimus dorsi
flaps may be used to help completely cover the implant.
The total shoulder prosthesis could be categorized as a
"constrained" device in that the head of the humeral implant locks
into the glenoid cavity of the scapular component. The locking mechanism
serves to restore the normal force vectors of the shoulder previously enforced
by the rotator cuff muscles, which served to counteract the upward force
exerted on the humeral head by the deltoid muscle. Abduction is therefore
achieved without upward migration of the humeral head, seen in nonconstrained
models [1].
Postoperative Imaging Studies
Baseline imaging—Baseline postoperative conventional
radiography studies are usually obtained within 1 week of surgery. These
studies consist of chest radiography and anteroposterior scapula,
transscapular oblique, and anteroposterior internal–external rotation
radiography of the humerus. Baseline studies serve as a benchmark for
comparison for all future imaging studies.
Normal findings include the humeral implant in anatomic position with the
scapular implant sitting flush against the posterior chest wall. Scapular and
humeral components should show no signs of dislocation, and there should be no
periprosthetic humeral fracture (Figs.
7A and
7B). MDCT should be included
in the diagnostic workup of complex periprosthetic fractures. The chest
radiograph is also scrutinized for possible pneumothorax.
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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.
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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.
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Follow-up imaging—Follow-up conventional radiography studies
are obtained with protocol and positioning similar to baseline studies.
Hardware alignment and positioning should remain stable and unchanged from the
baseline studies. A variety of common complications may be encountered and
diagnosed with conventional radiography. In addition, follow-up CT examination
of the chest is performed to evaluate for lung metastases. Although these
studies are not optimal for evaluation of the shoulder, abnormalities and
postoperative complications may still be encountered.
Perioperative complications in our series included: three (23%)
dislocations (two scapular, one modular humeral), two (15%) local recurrences,
one (8%) distant (nonpulmonary) metastasis, and two (15%) lung metastases.
Other complications included three (23%) wound seromas and two (15%) incidents
of poor wound healing. Three patients have since died of recurrent or
metastatic disease.
As shown, dislocation (23%) and disease recurrence (38% overall including
local, distant nonpulmonary metastases, and pulmonary metastases) were the
most common complications. Dislocations occurred between the components of the
modular humeral implant (Figs.
8A,
8B, and
8C) as well as between the
humeral head and the scapular glenoid
(Fig. 9). Asavamongkolkul et
al. [9] reported upward humeral
head migration at a rate of 7%. Two (15%) patients in our series required
revision surgeries secondary to dislocations.
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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]).
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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.
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Disease recurrence was seen locally and at distant sites. Rates of local
recurrence after limb-sparing surgery are reported to range between 5% and 20%
[10,
11]. The local recurrence rate
in our series was 15%. Evidence of increased soft-tissue density and rotation
or winging of the prosthetic scapula helps with the diagnosis on conventional
radiography (Figs. 10A and
10B). Advanced imaging, such
as CT and MRI, can delineate recurrent tumor more clearly (Figs.
10C and
10D) and might detect more
subtle signs of recurrence such as lymph node enlargement (Figs.
11A,
11B, and
11C).
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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.
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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.
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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.
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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).
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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).
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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).
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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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Because total shoulder prosthetic reconstruction is a novel procedure,
complication rates have been extrapolated from rates reported for
reconstructions using modular spacers or proximal humeral endoprostheses
cemented into the remaining humerus. Although proximal humeral endoprostheses
are reported in recent studies to show the highest rates of prosthetic
survival and the lowest rates of revision and complications
[10], some problems may be
evident radiologically. The complications (and rates) reported in the
literature in the past 10 years include periprosthetic fracture
(0–0.7%), deep infection (0–3.4%), and loosening of the humeral
prosthesis (0–10.3%) [7,
9–13].
Most of these complications were not encountered in our series of patients,
and illustrations are therefore not included. However, infection and loosening
of the humeral stem will share similar findings on conventional radiography,
with progressive, abnormally widened interfaces evident between bone and the
prosthetic stem. Advanced imaging, nuclear medicine studies, or imaging-guided
aspiration of fluid pockets can be used to aid in the differential
diagnosis.
Conclusion
Treatment for malignant tumors of the shoulder girdle has evolved
radically, with forequarter amputation being much less common today. In
addition, when limb-preservation surgery is safe, modern reconstructive
efforts try to restore some normal shoulder motion using total shoulder
prostheses. Tumors of the scapula or proximal humerus involving the
glenohumeral joint but sparing the axillary neurovascular bundle can be
considered for Tikhoff-Linberg procedure with total shoulder prosthetic
reconstruction. Imaging studies are helpful in identifying patients
appropriate for the procedure and recognizing complications
postoperatively.
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Abstract
Introduction
