Function and return to sports after proximal humeral replacement in patients with primary bone sarcoma

Between October 2007 and April 2020, a total of 606 patients underwent resection of a primary bone sarcoma of the long bones and subsequent reconstruction with a single-design modular universal tumour and revision system (MUTARS, Implantcast, Buxtehude, Germany) in our department in a tertiary university hospital. For 112 (18%) of these patients, the location of the tumour was the proximal humerus. Exclusion criteria for the present study were death (n = 65), patients living overseas (n = 8), and subsequent amputation (n  = 1), leaving 38 patients. Six patients could not be contacted for the study, leaving a final cohort of 32 patients (Fig. 1, Table 1).

Fig. 1figure 1

STROBE study flow diagram

Table 1 Demographics and oncological and surgical detailsSurgical technique

All patients underwent a planned wide tumour resection with histopathological confirmation of surgical margins. In order to achieve these wide surgical margins, the axillary nerve had to be resected or could be preserved. In patients with tumour infiltration of the glenohumeral joint, an extraarticular tumour resection was performed. For soft-tissue reconstruction, an attachment tube (Trevira, Implantcast, Buxtehude, Germany) was used [13, 14]. As of 2006, silver-coated implants were available and used in all patients [15]. As of 2010, implants for reverse shoulder reconstruction were available and used in patients in whom the axillary nerve and a sufficient portion of the deltoid could be preserved [11,12,13].

Data collection

Clinical data regarding the oncological and surgical treatment as well as subsequent complications were obtained from the patients’ electronic medical records. Functional outcome and pre- and post-operatively performed levels of sports were evaluated using standardized scoring systems.

Assessment of functional outcome and classification of complications

The functional outcome was determined using the Musculoskeletal Tumor Society Score (MSTS), the Toronto Extremity Salvage Score (TESS) and the Subjective Shoulder Value (SSV). MSTS and TESS are commonly used in tumour orthopaedics to assess the functional outcome following limb-sparing surgery, and there are specifically designed versions of each for upper and lower extremities, respectively [16, 17]. The upper extremity version of the MSTS includes six questions on dexterity, pain, emotional acceptance, function, hand positioning and the ability to lift objects with the affected arm [17]. Each question is scored on a scale from 0 (very limited) to 5 (no restriction), with a maximum score of 30 points [17]. The upper extremity version of the TESS includes 29 questions, each scored on a scale from 1 (impossible to do) to 5 (not at all difficult), on everyday upper extremity tasks such as cutting vegetables or doing household chores [16]. The maximum score is 145 points, which is converted to a percentage to allow easier comparability [16]. Furthermore, we obtained the SSV, where a patient rates the function of the operated shoulder (as a percentage) compared to the contralateral shoulder [18].

The performed level of sports activities was assessed using the Tegner Activity Score (TS) and the modified Weighted Activity Score (WAS). For the TS, the patient states his highest level of performed sports on a scale from 1 (cannot move) to 10 (participates in competitive contact sports—national elite level) [19, 20]. The WAS is an individual performance score covering the frequency, duration and type of performed sports (low, medium or high impact) [21]. The score is obtained by multiplying the frequency (per week), duration (in hours) and weighted points based on the respective impact of the performed sports activity—e.g. a sports activity with a low load (e.g. swimming) equals a factor of 1 and a sports activity with a high load (e.g. soccer) equals a factor of 3 (Table 2) [21,22,23]. If more than one activity was performed, the respective scores for each individual activity were added to the final WAS [21, 22]. WASs from 0 to 10 indicate low-activity patients and WASs higher than 10 indicate high-activity patients.

Table 2 Impact of performed sports activities according to Healy et al. [21]

Endoprosthetic complications were classified according to Henderson et al. as soft tissue failure (type 1), aseptic loosening (type 2), structural failure (type 3), infection (type 4) and tumour progression (type 5) [24].

Statistical analysis

Statistical analyses were performed using SPSS 25.0 (IBM Corp., Armonk, NY, USA). The duration of follow-up was calculated from the date of surgery to the date of the event or the last documented contact with the patient as of December 2021. The data distribution was determined with the Kolmogorov–Smirnov test. Non-parametric analyses were performed with the Mann–Whitney U test, and parametric analyses were performed with Student’s t test. All p values were two-sided and a p value of less than 0.05 was considered statistically significant.

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