Elbow Reconstruction Edit 01

8/14/2019 Elbow Reconstruction Edit 01

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Laboratory

- CBC : normal

- ESR : 29mm/h- SAP : 161 u/l (40 150)

- LDH : 303 u/m (230460)

Left elbow AP and lateral X-ray (January 2006) :

- Blastic and lytic lesions in the left distal humerus

- Periosteal reaction and soft tissue swelling

After neoadjuvant chemotherapy

tumor became more sclerotic & solid

Chest X-Ray : no evidence of metastatic feature

Bone scintigraphy : increased uptake only at the left elbow Neither showed no evidence of metastatic disease


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CT scan :- Lytic-sclerotic lesion with irregular margin

- Thickening of cortex and periosteal- New bone formation and good medullary cavity

Cytology examination :

Spindle cells, pleomorphic with osteoid positifPhoto 11

Clinico Pathological Conference (CPC)

- Diagnosed as conventional osteosarcoma neoadjuvant chemotherapy

- Planned for limb salvage surgery using an extracorporeal irradiation of distal humerus

First Stage :

- Resection of the half distal humerus that contain tumor mass Pathology

Anatomy Department

- Osteotomy of olecranon

- Conservation of n.radial, n.ulnar & muscle groups, except the part of the triceps& brachialis attached to the tumor mass

- The resected humerus was sent to BATAN for irradiation with dose 30,000 rads


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Second Stage :

- Reconstruction of the half distal humerus with plate and screw

- Olecranon fixation with TBW- Sutured common flexor & extensor origins to the original sites

- Histological examination of the surgical specimen:

So much residual viable tumor cells and the tumor classified as unresponder to the induction

chemotherapeutic agents (HUVOS 1)

-After surgery patient was planned to received adjuvant chemotherapy consisting of another

agents

SECOND CASE

Local Status :

Mass :

- 32 cm in circumferential length (23 cm in the health tissue)- Firm, tenderness, fixed with ill-defined margin- No venectation

Laboratory

- CBC : normal

- ESR 30 mm/h


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- SAP 192 u/l (40150)

- LDH : 165 u/m (230460)

X-ray of left elbow AP and lateral views (May 2006) : heavily mineralized mass attached by broad base to the posterior

aspect of left distal humerus and soft tissue swelling

- Chest X-Ray : no evidence of metastatic feature

- Bone scintigraphy : inceased uptake only at the left elbow

No evidence of metastatic disease

Review slide from first operation :

Spindle cells, minimal cytologic atypia and rare mitoticfigure, osteoid positif

Clinico Pathological Conference (CPC)

- Diagnosed as reccurrent parosteal osteosarcoma

- Planned to limb salvage procedure using extra corporealirradiation autograft

- Death : Nov 2007


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First Stage :

- Resection of the half distal humerus and excision ofthe tumor mass sent to Pathology Anatomy Dep.

- Resected humerus BATAN for irradiation 30,000rads

Second Stage :

- Reconstruction of the half distal humerus and elbow by fixed them into the

proximal shaft with plate and screw

- Olecranon was fixed with the tension band wire

- Common flexor and extensor origins were sutered again to the original sites

- Radiohumeral joint was fixed with the K wire for temporary


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Post-operative X rays :Humeral shaft fixed with plate and screw and olecranon fixed with TBW

Discussion- Primary malignant bone tumors rare lesions

- Before 1970s routine management was consisted of transbone amputations or disarticulation

dismal survival rate 10-20%

Dahlins bone tumors general aspects and data on 11,087 cases.1996. pp.143-95.

J Am Acad Orthop Surg 2003;11:25-37. hal. 24

Development of :- Effective chemotherapeutic agents

- CT and MRI

- Allow precise visualization of the anatomic location of

tumor and surrounding structures

- Better patient selection for spesific treatment of limb

salvage procedure

JAm Acad Orthop Surg 2003;11:25-37.

Consideration of Limb Salvage Procedure :

1. An upper extremity tumor needs resection of the

articular portion of the distal humerus or proximal ulna

2. Disfunction of the elbow, wrist, and hand due to

abundant of neurovascular structures in this location

3. Psychological problem associated with tradition and

aesthetic

J Bone Joint Surg [Br] 1996;78-B:652-57 hal 26


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Conclusion

- The management of malignant bone tumors still presents many challenge

- Advances in imaging, chemotherapy and reconstructive surgery can offered

limb sparing surgery

- Functional outcome and patient satisfaction appear to be at least as good,

and probably better after reconstruction than after ablation

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Elbow Reconstruction Edit 01