What is Distal Humerus Resection and Reconstruction?
Benign or malignant tumors can develop in or spread to the lower (distal) part of the humerus (upper arm bone), causing progressive bone tissue destruction associated with pain and disability. Distal humerus resection and reconstruction is a surgical procedure to remove diseased distal humerus bone tissue and tumors involving the distal humerus, followed by reconstruction with an artificial prosthesis and tissue graft to restore elbow/arm function. Such conditions were initially treated with amputation of the limb, but with modern medicine improving survival rates and advances in imaging, surgical technique, and implant design, limb salvage surgery now promises better functional and cosmetic outcomes.
The elbow is a region between the upper arm and forearm. The elbow joint is made up of 3 bones. The distal (lower) end of the humerus bone in the upper arm joins with the radius and ulna bones in the forearm to form the elbow joint. The bones of the elbow are supported by ligaments and tendons, muscles, nerves, and blood vessels. The elbow joint is very important for the movement of your arms and for coordination of daily activities.
Indications for Distal Humerus Resection and Reconstruction
Your doctor will recommend distal humerus resection and reconstruction after considering a number of factors including the extent of the tumor, its location, its radiographic features, the underlying diagnosis, your level of pain and expected survival.
Surgery is recommended if the tumor in the distal humerus is large, causing extensive bone destruction, does not respond to radiation or chemotherapy, has failed previous surgery, or is the only metastatic lesion that is present.
Some of the indications for distal humerus resection and reconstruction include:
- High-grade and low-grade bone sarcomas
- Soft-tissue sarcomas that invade or surround distal humerus
- Metastatic carcinomas with severe bony destruction
- Complications associated with conservative treatment for pathological fractures (nonunion or progression following radiation)
- Malignant tumors of the distal humerus
Preparation for Distal Humerus Resection and Reconstruction
In general, pre-procedure preparation for distal humerus resection and reconstruction will involve the following steps:
- A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo diagnostic tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure. Chemotherapy is usually performed before surgery to shrink the tumor and control its margins.
- Diagnostic studies also help determine the extent of bone and soft tissue resection necessary, whether a fracture is present, the proximity of the tumor to vital nerves and vessels, and the dimensions of the prosthesis required.
- In some instances, a biopsy of a lesion may be required to make a precise diagnosis. Cancer staging is performed for instances of malignant tumors. If the tumor is discovered to be a metastatic lesion, suitable tests are carried out to locate the primary tumor.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- Arrange for someone to drive you home after surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Procedure for Distal Humerus Resection and Reconstruction
This is a major procedure that is carried out under general anesthesia. In general, the surgical technique may involve the following:
- You will lie on the operating table and a long incision in an S-shaped pattern is made along the distal humerus and elbow joint area. Usually, an anterior surgical incision is made for resection and prosthetic replacement of the distal humerus and elbow joint.
- The underlying muscles are separated to expose the treatment area and inspected for tumors and extent of soft tissue and bone damage.
- The elbow joint is accessed anteriorly, and the capsule is released circumferentially from the ulna-olecranon and radial head. The humero-ulnar and radiohumeral joints are then disarticulated.
- Humeral osteotomy is performed with an oscillating saw at the location determined with preoperative imaging. Care is taken to avoid injury to the soft tissues.
- Reconstruction of the distal humerus and elbow joint is performed with a modular segmental distal humerus tumor prosthesis. The distal humeral prosthesis comprises of a semi-constrained hinge component that is connected to an ulnar component to recreate the elbow joint. Range of motion of the elbow is then tested.
- Soft-tissue reconstruction is then carried out to cover the prosthesis with muscle tissue. The muscles are positioned and sutured accordingly. A tendon tissue graft from the patient’s own body (autograft) may be used for minor tissue defects. A graft tissue from a donor (allograft) may be used to cover large tissue defects.
- Joint stability is then checked, surgical drains are placed, and the wound is closed.
Postoperative Care and Instructions
In general, postoperative care instructions and recovery after distal humerus resection and reconstruction will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
- You may need to stay in the hospital for 3 to 4 days before discharge to home.
- You may notice pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- Your arm may be secured with assistive devices such as a sling or a cast for the first few weeks to facilitate healing with instructions on restricted activities.
- Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
- Refrain from smoking as it can hinder the healing process.
- Refrain from strenuous activities for the first few months and lifting heavy weights for at least 6 months. Gradual increase in activities over a period of time is recommended.
- An individualized physical therapy protocol will be designed to help strengthen elbow muscles and optimize elbow function.
- You will be able to resume your normal activities in a month or two after surgery; however, return to sports may take at least 6 months or longer.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Distal humerus resection and reconstruction is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Skin necrosis
- Wound infection
- Damage to nerves and vessels
- Temporary nerve palsies
- Periprosthetic infection
- Local tumor recurrence
- Aseptic loosening of the prosthesis
- Thromboembolism or blood clots
- Anesthetic/allergic reactions