Indications for Limb-Sparing Surgery and Reconstruction

The following are the original and modern indications for Tikhoff-Linberg limb-sparing procedure. Also, note the indications for post-operative total scapular and shoulder joint reconstruction.

Limb-Sparing Surgery

Original Indications10

In his 1928 paper, Linberg proposed that this limb-sparing surgery (MSTS S123, Malawer Type IV) should fulfill the following requirements:

  • Used in the treatment of tumors of the proximal humerus, scapula, or clavicle that have likely invaded all parts of the shoulder and its joints.
  • No axillary neurovascular involvement.
  • Potential results should be equivalent to or better than amputation with preservation of good elbow and hand function.
Modern Indications1
  • High grade malignancies of the scapula or proximal humerus, especially with extension into the rotator cuff or glenohumeral joint.
  • May be used for some low grade sarcomas of the scapula.
  • May be used for some periscapular soft tissue tumors.
  • No involvement of the axillary neurovascular bundle.

Note: Humeral bone tumors or perihumeral soft-tissue tumors may require more extensive humeral resection if they have invaded more distally (MSTS S1234 or S12345, Malawer Type VI). See MRI below for example.

STIR MRI, coronal: This patient's tumorhas extended distally into the humerus, requiring more humeral resection

Absolute Contraindications1
  • Inability or unwillingness of patient to tolerate limb-sparing resection.
  • Extension of tumor into the axillary neurovascular bundle.

T1 MRI, coronal: Note the axillary neurovascular bundle (black arrow) encased by tumor. This patient had prior resection and subsequently developed an axillary recurrence (outlined in pink). Note metallic artifact from implant in place (white arrow).

Relative Contraindications

  • Inappropriate biopsy site with extensive tissue contamination.
  • Pathological fracture.
  • Extension of tumor into lymph nodes or chest wall.

CT, axial: This 34-year old male, with a history of multiple hereditary exostoses, had extensive chest wall involvement, as seen on the CT at left, with chondrosarcoma invading the posterior chest wall (arrow).

Conventional radiographs, AP: The above patient underwent a modified Tikhoff-Linberg procedure with multiple rib resection due to chest wall involvement. Baseline post operative study with implant in place below left. Also note multiple osteochondromas on the remaining humerus (arrows) below right.


Total Scapular and Shoulder Joint Reconstruction

  • Tumor involves the glenoid, coracoid, or lateral aspect of the scapula.
  • Sufficient periscapular soft-tissue will remain to cover the endoprosthesis.24

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