Résections-reconstructions pour tumeurs osseuses malignes du membre supérieur

Malignant bone and soft-tissue tumours are less common in the upper limb than in the lower limb (ratio 1:2). They mainly affect the shoulder, particularly the proximal humerus. Limb-sparing surgery may be considered in about 80% of patients with malignant shoulder tumours. In contrast, in patients with more distal malignancies (at the elbow level, or below) that involve extraosseous tissue, amputation is frequently required. A biopsy must be performed prior to treatment of the tumour, together with investigations aimed at assessing the tumour extension in the bone and soft tissues, the relationships between the tumour and the joints, vessels and nerves, the regional spread, and potential metastatic disease. After scapulectomy, the proximal humerus is suspended to the clavicle or ribs. Massive scapular prostheses or allografts are rarely used. When the proximal humerus can be resected without removing the deltoid muscle, reconstruction can be achieved using a composite inversed Delta prosthesis, a massive allograft, or a composite humeral prosthesis. When deltoid excision is required, scapulohumeral arthrodesis with allogeneic and autologous grafting is performed. After resection of the humeral diaphysis, reconstruction relies on allogeneic and autologous graft implantation with internal fixation. For elbow reconstruction, arthrodesis, massive prosthesis, or massive allograft is generally used. For reconstruction of the distal radius, we usually perform arthrodesis of the distal radius to the first row of carpal bones. Alternatives include implantation of a vascularized fibular graft and massive allografting for arthrodesis or arthroplasty. After resection of the distal ulna, reconstruction is not necessary. Primary bone malignancies of the hand are more rare; they usually involve metacarpal bones. Conservative resection is rarely feasible, and most patients require complete or partial hand amputation to obtain tumour-free margins.