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Intralesional curettage, cement augmentation and fixation with Synthes Philos plate for pathological humeral fracture

    Overview

    Learn the Intralesional curettage, cement augmentation and fixation with Synthes Philos plate for pathological humeral fracture surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Intralesional curettage, cement augmentation and fixation with Synthes Philos plate for pathological humeral fracture surgical procedure.
    The humerus is the second most appendicular common site of osseous metastatic disease after the femur. Metastatic bone disease causes pain, swelling, fracture and subsequent dysfunction. The management of such patients needs to be pragmatic, balancing multiple conflicting patient and technical factors including but not limited to the age, fitness and willingness of a patient to have surgery, estimated prognosis, extent of osseous or visceral metastatic disease, severity of symptoms and dysfunction, impending or pathological fracture, curative or palliative intent.
    There are multiple surgical options although optimal use of non-operative interventions should not be overlooked by orthopaedic oncologists.
    The present case is a fairly typical presentation of a patient with multiple osseous sites of metastatic prostate carcinoma with a pathological humeral fracture and an impending femoral fracture, who, after discussion with his oncology team, underwent stabilisation of his humerus first to enable the use of crutches after femoral reconstruction. The use of cement augmented plate stabilisation was selected in favour of resection and endoprosthetic replacement as surgery was palliative (i.e. a non-curative intervention to alleviate pain & increase function) and because the bone destruction was minimal. You can read about the technique for proximal humeral endoprosthetic replacement here: https://www.orthoracle.com/library/proximal-humeral-replacement-mutars-reverse-geometry-shoulder-implantcast/
    Jonathan Stevenson FRCS (Tr&Orth)

    Indications

    INDICATIONS
    Indications for surgery include pain, fracture or impending fracture, dysfunction and reduced quality of life.
    Surgery ranges from internal fixation, with or without cement augmentation, to en-bloc excision and endoprosthetic replacement. Internal fixation may include plate stabilisation or intramedullary nail. An inappropriate choice of surgery risks mechanical failure, because the patient outlives the construct, and may hasten death because of the sequelae of surgical intervention. The decision to operate, as well as the choice of surgical procedure, depends on the estimated survival of the patient which is a calculation best made by a multidisciplinary orthopaedic oncology team.
    The Synthes Philos plate is favoured in this case as it contoured to the anatomy of the proximal humerus, is available up to 286mm in length for diaphyseal tumours and has combination holes for locking screws for use in osteoporotic bone.
    SYMPTOMS & EXAMINATION
    This patient presented with a pathological fracture sustained pushing himself up out of bed, with a background of pain requiring opiates for six weeks. Such low-energy fractures are not typically associated with neuro-vascular dysfunction but these should be assessed and documented distal to the fracture site. Usually pain, swelling and some bruising and swelling around the elbow is all that is evident with a pathological humeral fracture.
    IMAGING
    Measured radiographs of the whole humerus and MRI of the whole humerus including joints above and below are required for local surgical planning. The degree of bone loss must be assessed pre-operatively: if it is too extensive then an endoprosthesis may be required.
    Systemic staging of the patient is dependent upon histological diagnosis. In a case of metastatic bone disease CT chest-abdomen-pelvis to exclude visceral metastasis and whole-body bone scintigraphy to identify other skeletal metastases would be mandatory, although the bone scintigraphy may be performed afterwards to avoid any significant delay when a patient has already fractured.
    ALTERNATIVE OPERATIVE TREATMENT
    Surgical options range from plate stabilisation with cement augmentation to en-bloc resection and endoprosthetic reconstruction, which is determined by a) whether a curative resection is possible and b) the extent of osseous destruction in the humerus.
    NON-OPERATIVE MANAGEMENT
    In a patient without a fracture non-operative management in metastatic prostate carcinoma includes chemotherapy, immunotherapy, hormone therapy and radiotherapy. Consequently a discussion with the treating oncologist is advisable to ensure that all possible modalities of non-operative management have been considered before surgery.
    Once a patient has suffered a fracture, the priority becomes pain relief and restoration of function in the non-curative setting.
    CONTRAINDICATIONS
    Contraindications include other co-morbidities precluding anaesthesia and therefore surgical intervention. Relative contraindications to endoprosthetic replacement would be estimated survival less than six months.

    Setup

    Patient is positioned supine under a general anaesthetic with a supplementary interscalene block plus a head-ring and an arm table positioned level with the right shoulder.
    A U-Drape is secured beneath the axial and round to the anterior triangle of the neck.
    Imaging intensification is used to check that visualisation of the proximal humerus is possible before the draping.
    Chlorhexidine skin preparation and routine draping.
    After draping an Ioban incisional drape is applied to the skin.
    Diathermy and suction are made available.

    Operation – 1

    AP pre-operative radiograph of the whole right humerus shows an undisplaced pathological fracture of the right proximal diaphysis of the humerus with a radiolucent tumour with cortical loss medially. The right 5th rib has a sclerotic metastasis evident. The patient is known to have metastatic prostate cancer, not all prostate metastases are sclerotic as this radiograph demonstrates.

    Pre-operative sagittal T1 MRI sequence.
    Evidence of pathological fracture with area of low signal change at the level of the fracture, indicating the metastatic prostate carcinoma infiltrating the humeral diaphysis with loss of the cortex anteriorly and posteriorly and angulation of the humeral shaft. The medullary bone proximally does not contain tumour therefore the humeral head can be retained to optimise function. The extent of the tumour infiltration means a Philos plate approximately 200mm long will be required. This may need to be ordered in advance, so planning the reconstruction at this stage is mandatory.

    Post-operative AP humeral radiograph showing the curetted pathological fracture cavity with cement filling it proximally and distally and a long Philos plate with bicortical screws proximally and distally and locking screws into the humeral head.

    AP radiograph of the proximal femur showing an impending pathological fracture due to metastatic prostate carcinoma. This patient was scheduled to have surgery a week later to address this impending fracture.
    There is a balance to be struck between the urgency to avoid another pathological fracture versus the physiological insult of further early and major surgery.

    Post-operative AP radiograph with the proximal femur showing a proximal femoral endoprosthesis with hemiarthroplasty head and surgical clips.
    Addressing the fractured humerus first was imperative to permit the use of crutches to rehabilitate post-femoral surgery.
    You can read about the technique for proximal femoral endoprostheses here: https://www.orthoracle.com/library/endoprosthetic-proximal-femoral-replacement-trochanteric-reattachment-pathological-femoral-fracture/

    Mark skin incisionClinical photograph shows the skin incision for a deltopectoral approach. The landmarks are from the coracoid process along the deltopectoral interval and along the anterior aspect of the upper arm down to the biceps tendon. The U-Drape is shown with the arm positioned on the arm table.

    Skin preparation and drapingAfter skin cleansing and draping the Ioban incisional drapes are applied to the upper limb.

    Incise the skin along the delto-pectoral intervalThe skin incision is made along the marked line for the incision, from the coracoid process along the delto-pectoral interval proximally. Dissection continues through the subcutaneous fat down to the muscle layer. The skin incision can be extended down to the lateral edge of the biceps tendon as required.

    Identify the cephalic veinDeeper dissection is continued distally along the humeral shaft to identify the cephalic vein.

    Dissect the cephalic vein distal to proximallyThe (C) cephalic vein sits deep in the fat layer and marks the site for further blunt dissection to identify the delto-pectoral muscular interval, which is the plane leading to the humeral head.

    Develop the delto-pectoral intervalBlunt dissection is performed using an index finger to identify the interval between the anterior portion of the deltoid muscle and the pectoralis major muscle which inserts transversely onto the proximal humerus.
    The cephalic vein can be taken medially or laterally depending on the tributaries flowing into it from the muscle.

    Incise the clavipectoral fascia proximallyThe clavipectoral fascia is incised using diathermy to develop the plane proximally.
    This thin layer of clavipectoral fascia is pierced by the cephalic vein, which helps to identify this fascial layer. It lies deep to the clavicular portion of the pectorals major and arises from the clavicle, sheath of the axillary vessels, first rib and coracoid process.

    Develop the dissection distallyAfter the fascia has been released proximally the (PH) proximal humerus can be seen in the centre of the wound. Distally continue to deepen the dissection through the subcutaneous tissue keeping the (C) cephalic vein intact (laterally) aiming to expose the fascial layer beneath. Tributaries drawing into the cephalic vein should be anticipated and ligated.

    Expose the humeral fascial layerDistally the deep fascia (F) overlying the biceps muscle can be seen deep to the subcutaneous layer which is retracted.

    Incise the deep fascia overlying the biceps.The fascia overlying the biceps is incised using scissors or diathermy to enter the anterior compartment of the arm. Biceps is retracted medially to expose the humeral shaft. This step was unusual in this case because the tumour and fracture had led to the issues being more inflammatory. The McIndoe’s dissecting scissors have been placed under this area of inflammatory tissue in the clinical photograph prior to incision with diathermy to reveal the humeral fracture site.

    Partially release the deltoid insertion off the humerusThe (D) deltoid insertion laterally on the humeral shaft is partially released using diathermy to increase the exposure of the humeral shaft as shown. This facilitates application of the plate and later soft-tissue coverage the plate at closure. The axillary nerve that innervates the deltoid lies 4-6cm distal to the lateral edge of the acromion depending upon the size of the patient between the deep surface of the deltoid muscle and the humerus and is not in danger with this step which occurs distal to the axillary nerve.

    Pectoralis major insertion demonstrated for orientationJust medial to the insertion of the deltoid tendon the traversing fibres of the (P) pectoral major muscle (P) can be seen inserting onto the humeral shaft. The McIndoe scissors have been placed underneath the pectoralis muscle for identification. This can be released off the humeral shaft for later reattachment if exposure is required to address the tumour.

    Distal fragment identifiedBlunt dissection using a digit is used to identify the humeral shaft distally. The retractor arm are carefully placed onto biceps medially and the deep fascia laterally without damaging the cephalic vein to maintain exposure of the distal humeral shaft fragment. The plate will be applied lateral to biceps and medial to deltoid.

    Sub-periosteal dissection proximallyA pennybacker periosteal dissector is used to release the periosteum off the humeral shaft proximally to permit application of the plate and to help delineate the pathological fracture.

    Sub-perisoteal dissection distallyThe sub-periosteal dissection is continued distally to identify the humeral shaft distal to the pathological fracture site.

    Pathological fracture exposedThe pathological fracture has been exposed between the (P) proximal and (D) distal humeral shafts. The tissues at the level of the pathological fracture are involved with tumour and clearly abnormal. Also seen are (De) deltoid, (Br) brachialis split in the midline and (Bi) biceps muscles.
    With the humerus exposed it is now time to address the Synthes Philos plate.

    The Synthes Philos plate set has various options and is worth familiarising yourself with:
    1. Philos plate – These are usually packed separately and different lengths are available. The most commonly use plate is the 3 hole Philos plate. Note that there are also diaphyseal Philos plate variations that come in different lengths. These are reserved for proximal shaft fractures.
    2. Smooth locking guides for use with the aiming device
    3. 2.5mm drill bit for small fragment cortical screws and 2.8mm calibrated drill for locking screws
    4. Drill sleeve for 2.5mm drill
    5. Measure
    6. Threaded locking guides for locking screws
    7. Screw caddy for cortical and locking screws
    8. Screw driver with torque limiter attachment

    The aiming device with nose is useful for applying the proximal locking screws in an efficient manner.

    This is applied to the Philos plate using a small fragment hexagonal screw driver.

    This is applied to the Philos plate using a small fragment hexagonal screw driver.
    The wire should be sited just distal to the tip of the greater tuberosity.
    Note that when checking with fluoroscopy, it is important to align the x-ray beam perpendicular to the proximal humerus to avoid misinterpretation of the plate position due to an oblique image.
    With experience, this step may be skipped as the height can be determined visually.

    Operation – 2

    The plate is aligned to the shaft and the 2.5mm drill bit is used in the centre of the elongated combi-hole to allow for adjustment of height if needed.

    The measure is used after drilling to determine the length of the cortical screw.
    Note that if the plate is note applied flush to the bone, some allowance has to be made for when the screw is applied so that the tip is not too proud when secured.
    Conversely, it should be long enough to ensure bicortical hold.

    The triple sleeve system is designed for use with the aiming device.
    The most inner centring sleeve is used to pass a 1.6mm Kirschner wire for temporary positioning (not used in this procedure).
    The middle centring sleeve is for use with the 2.8mm drill bit.
    The outer sleeve is used for guiding the 5mm locking screw once the hole has been drilled and ensures that the screws follows the drilled track.

    The remaining 2 distal shaft screws are applied using the threaded locking guide.
    Ideally, there should be 6 cortices of hold distally. If this is compromised, a longer plate should be considered.
    Care is taken to ensure that the threaded locking guide is applied concentrically and is not cross-threaded within the plate to allow engagement of the locking screws in the plate.

    The bone is drilled using the 2.8mm calibrated drill guide.
    The length can be measured off the threaded guide. If there is doubt as to the length of the screw, it is best to check using the measure before applying the locking screw.

    Position the plate optimally on the proximal fragment and temporarily secure with two K-wiresThe Philos plate is positioned on the humeral shaft, two K-wires are inserted in the proximal fragment. No contouring is usually required with this plate.
    The most proximal K-wire is positioned to be level with the greater tuberosity to avoid the plate causing impingement.

    Check the position of the plate using fluoroscopyIntraoperative radiograph showing position of the most proximal K-wire level with top of the humeral head and the greater tuberosity, confirming correct placement of the plate to avoid impingement post-operatively.

    Drill and measure for proximal humeral locking screwsThe drill sleeves are screwed into the Philos plate proximally and used to drill and measure for locking screws into the humeral head. The 2.8mm drill bit has laser marks to enable measurement off the drill sleeve.

    Reduce and hold the distal fragment using the plate holding forcepsDistally the humeral plate is held using a bone-holding forceps as shown to hold the plate in the optimum position in the centre of the humeral shaft distally.

    Tumour excisionThe non-toothed forceps are used to highlight in this clinical photograph the tumour at the level of the fracture site which needs to be excised.

    Intralesional curettage proximallyCurettes are used to remove the metastatic prostate cancer from the pathological fracture as shown.

    Intralesional curettage distallyThe curettes are used in the distal fragments to remove further tumour distally, with the plate elevated off the distal fragment to facilitate access.

    Check that the narrow cement nozzle will fit inside the canalTop tip: Check that the narrow cement nozzle will fit inside the canal. A narrow cement nozzle is inserted into the distal fragment to confirm it will enter the medullary canal.

    Insert cement proximallyPalacos high viscosity cement is introduced into the proximal fragment. The cement curing time is approximately ten minutes which allows sufficient time for the subsequent steps which may include inserting pre-drilled screws through the cement.

    Insert cement distallyThe process is completed for the distal fragment with palacos cement inserted into the distal fragment.

    Insert pre-drilled bicortical screw in compression mode distallyWhilst the cement in curing, the pre-drilled bicortical screws are inserted into the distal fragment in compression mode distally, to compress the distal fragment towards the proximal fragment. This is facilitated by eccentric positioning of the drill holes.

    Augment curetted cavity with further cementThe further cement is introduced into the curetted fracture cavity to augment the cement fixation. The cement is digitally compressed into the fracture cavity.

    Plate stabilisation completeThe clinical photograph shows that place stabilisation has been completed and in the centre of the photograph, just medial to the plate the cement augmentation is visualised.

    The deltoid is sutured to the pectoralis tendonThe elevated deltoid incision is sutured to the pectoralis major tendon to facilitate soft-tissue coverage of the plate. Care is taken not to inadvertently suture the brachial vessels or musculocutaneous nerve located medially.

    The deep part of the wound is closedAfter thorough lavage, the deep part deep portion of the wound is closed with interrupted vicryl 2.0 sutures.

    Superficial wound closureThe superficial portion of the wound is closed with interrupted 3.0 vicryl sutures to the deep dermis as shown.

    Skin closureSkin closure is completed with clips to the epidermis. An aquacel dressing, wool and crepe bandaging are applied and a sling for comfort.

    Post Operative

    HDU care.
    VTE prophylaxis early mobilisation, flowtrons until mobile and TED stockings thigh length for six weeks, LMWH is not indicated in upper limb surgery but is indicated for endoprosthetic replacement around the hip for 28 days.
    Removal of clips at two weeks.
    24 hours of post-operative intravenous antibiotics (flucloxacillin).
    Check x-rays AP lateral.
    Post-operative radiotherapy after wound check at six weeks (single fraction of 8Gy of external beam radiotherapy each site).

    Recommended Reading

    Metastatic prostate carcinoma is the most common form of metastatic bone disease in males presenting to orthopaedic oncologists. There are many published methods for predicting survival in this group or patients. A UK study found biomarkers independently associated with poor survival were: low Hb, low Alb, relatively low PSA (< 30 mmol/l), and a raised ALP (https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.100B12.BJJ-2018-0697.R1).
    Subspecialty training and patient and tumour characteristics influence the decision for operative management and the decision for a specific implant in metastatic fractures of the humerus (https://www.sciencedirect.com/science/article/pii/S1877056817303560). Orthopaedic oncologists are less likely to recommend medullary nail stabilisation of pathological humeral fractures and more likely to recommend cement augmented plate stabilisation or endoprosthetic reconstruction as these latter two options are believed to optimise pain relief and function and to reduce the incidence of mechanical failure and revision surgery (https://www.researchgate.net/profile/Teun_Teunis/publication/268336365_Outcome_of_operative_treatment_of_metastatic_fractures_of_the_humerus_a_systematic_review_of_twenty_three_clinical_studies/links/54c4dd170cf256ed5a95f3f7.pdf). Pathological fractures cannot be relied upon to heal after stabilisation and non-union is the most common indication for revision (https://pure.uva.nl/ws/files/29442597/Chapter_7.pdf).
    Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union and is associated with excellent clinical outcomes (https://pdfs.semanticscholar.org/93ae/bf1ec1d9962425532eda8651a60ffe9d360f.pdf). En-bloc excision and endoprosthetic reconstruction should be preserved for solitary metastases or where the humeral head is destroyed necessitating replacement.
    Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union and is associated with excellent clinical outcomes (https://pdfs.semanticscholar.org/93ae/bf1ec1d9962425532eda8651a60ffe9d360f.pdf). En-bloc excision and endoprosthetic reconstruction should be preserved for solitary metastases or where the humeral head is destroyed necessitating replacement.

    Reference

    • orthoracle.com

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