Application of reverse shoulder prosthesis combined with ligament advanced reinforcement system in resection and reconstruction for proximal humerus malignant tumors

Application of reverse shoulder prosthesis combined with ligament advanced reinforcement system in resection and reconstruction for proximal humerus malignant tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of reverse shoulder prosthesis combined with ligament advanced reinforcement system in resection and reconstruction for proximal humerus malignant tumors Guolong Bin, Bin Liu, Fuzhi Pang, Junnan Wang, Zhenchao Yuan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7743805/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Evaluation of the application value of reverse shoulder prosthesis combined with ligament advanced reinforcement system (LARS) in reconstruction following resection of proximal humerus malignant tumors. Methods We retrospectively analyzed ten patients with proximal humerus malignant tumors who underwent reconstruction using reverse shoulder prosthesis combined with LARS at our institution from March 2021 to May 2023. The cohort included six males and four females, with a mean age of 38.6 ± 18.7 years. Preoperative core needle biopsy confirmed pathological diagnoses in all patients: osteosarcoma (n = 5), chondrosarcoma (n = 2), solitary metastatic squamous cell carcinoma (n = 1), Ewing sarcoma (n = 1), and synovial sarcoma (n = 1). Surgical procedures involved en bloc resection of the proximal humeral tumor segment followed by reverse shoulder arthroplasty. Postoperative radiographic assessment included X-ray and CT. Shoulder range of motion (ROM) was measured quantitatively. Functional outcomes were evaluated using the Musculoskeletal Tumor Society (MSTS-93) Score and Constant-Murley Shoulder Score. Results All ten patients underwent uneventful procedures. The mean osteotomy length was 15.3 ± 5.1 cm. All patients were followed up for a mean duration of 28.1 ± 14.1 months. At final follow-up, the mean shoulder ROM measurements were: abduction 105.3° ± 13.1°, forward flexion 120.5° ± 16.2°, external rotation 75.3° ± 6.8°, and internal rotation 48.2° ± 3.5°. Functional outcomes averaged 24.5 ± 2.6 points on the MSTS-93 score and 74.6 ± 3.4 points on the Constant-Murley Score. Postoperative complications included shoulder instability in one patient. Conclusions Reinforcement of the deltoid insertion and rotator cuff reconstruction using LARS following resection of proximal humerus malignant tumors contributes to improved postoperative forward flexion, abduction, and rotational function while reducing prosthetic dislocation rates. However, long-term functional outcomes and implant stability require further follow-up observation. Bone tumor Reverse shoulder arthroplasty Prosthesis LARS shoulder Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The proximal humerus serves as a predilection site for both benign and malignant primary bone tumors and is also a common location for metastatic disease[ 1 ][ 2 ]. Surgical management of proximal humerus malignant tumors typically necessitates tumor segment resection, where the requirement for wide resection margins to ensure oncological safety often mandates extensive removal of shoulder tissues, thereby posing significant challenges for reconstruction strategy selection. Conventional reconstruction techniques include hemiarthroplasty, composite allograft-prosthesis reconstruction, and osteoarticular autograft or allograft transplantation. Resection of stabilizing structures such as the rotator cuff and joint capsule contributes to postoperative complications including superior prosthesis migration or dislocation, graft fracture, and nonunion, while also resulting in suboptimal shoulder function with mean abduction and forward flexion typically measuring less than 60°, which significantly impairs patients' occupational and daily living activities[ 3 ][ 4 ]. Reverse shoulder arthroplasty (RSA) was initially developed for massive rotator cuff tears. Its unique design—featuring a glenosphere fixed to the glenoid and a concave cup on the proximal humerus—medializes the center of rotation, recruiting more deltoid fibers to compensate for rotator cuff deficiency and thereby improving function[ 5 ]. Since biomechanical properties of rotator cuff-deficient shoulders resemble those after tumor resection, RSA principles apply to reconstructing osseous defects following proximal humerus malignant tumor resection[ 6 ]. An increasing number of surgeons now utilize RSA for reconstructing proximal humeral malignancies while preserving the axillary nerve and deltoid, achieving favorable functional outcomes[ 1 , 5 , 7 ]. The procedure leverages deltoid contraction to substitute for deficient rotator cuff function. Consequently, current consensus favors RSA without routine rotator cuff reconstruction. Houdek et al.[ 8 ] propose that functional rotator cuff preservation is unnecessary in RSA reconstruction, while Fares et al.[ 9 ] emphasize that RSA relies more on deltoid integrity than rotator cuff dependence. However, some reports cite suboptimal rotation and prosthetic dislocations when soft tissue reconstruction is omitted[ 6 , 10 ]. Pan et al.[ 5 ] observed significantly restricted rotation and strength decline in seven patients at mean eight-month follow-up, with one dislocation occurring within a month postoperatively in a patient with detached deltoid insertion. Multiple studies indicate absent rotator cuff limits rotational recovery after RSA, with mean rotation typically measuring less than 35° and high dislocation rates[ 10 , 11 , 12 ]. To enhance functional outcomes and reduce dislocation risk, this retrospective study analyzes ten patients undergoing RSA combined with LARS reconstruction at our institution. Study objectives are: (1) To evaluate early-to-midterm outcomes of RSA combined with LARS for proximal humerus malignant tumors; (2) To analyze postoperative complications and preventive strategies for this reconstruction technique. Patients and methods Between March 2021 and May 2023, ten patients meeting the following criteria were enrolled: Inclusion Criteria: (1) Primary or metastatic malignant tumor involving the proximal humerus; (2) Reconstruction using RSA combined with LARS ; (3) Intraoperative preservation of deltoid muscle and/or axillary nerve viability; (4) Complete radiographic documentation and follow-up data. Exclusion Criteria: (1) Tumor invasion of deltoid or axillary nerve precluding their preservation; (2) Systemic metastasis deemed unresectable; (3) Poor systemic conditions contraindicating surgery; (4) Prior amputation or distal humerus involvement. The cohort comprised six males and four females with a mean age of 38.6 ± 18.7 years. All patients presented with unilateral involvement. Preoperative core needle biopsy confirmed pathological diagnoses in all cases: osteosarcoma (n = 5), chondrosarcoma (n = 2), solitary metastatic squamous cell carcinoma (n = 1), Ewing sarcoma (n = 1), and synovial sarcoma (n = 1). All patients reported shoulder pain and limited ROM. This study was approved by the Ethics Committee of the Guangxi Medical University Cancer Hospital (KY2025667), and all patients signed the informed consent form. Design of the reverse shoulder prosthesis The reverse shoulder prosthesis consists of modular components including the glenoid baseplate, glenosphere, polyethylene liner, liner tray, humeral osteotomy segment, and humeral stem. The glenoid assembly comprises the glenoid baseplate and glenosphere. The baseplate is secured to the scapular glenoid with up to four screws, while the glenosphere converges into the baseplate. The humeral assembly includes the polyethylene liner, liner tray, and humeral stem (Fig. 1 ). Surgical procedures Following general anesthesia, the patient was positioned supine. Standard preoperative disinfection and draping were performed. An S-shaped incision was made over the proximal humerus, incorporating the prior biopsy tract. After incising skin, subcutaneous tissue, and deep fascia, osteotomy was performed three-five cm distal to the tumor margin as preoperatively planned, ensuring the osteotomy site remained below the deltoid insertion. Tumor-involved soft tissues were resected en bloc, and the tumor was dissected from surrounding normal tissue along safe margins, with care taken to preserve the axillary nerve if uninvolved. The glenohumeral joint capsule was then opened. Glenoid articular cartilage was burred, and the baseplate was positioned and secured with screws after angle adjustment, followed by glenosphere attachment. The humeral canal was reamed, and a cementless humeral stem prosthesis was inserted. The deltoid was retracted distally while suturing its insertion and residual rotator cuff in abduction. For cases with excessive osteotomy length, supplemental distal plate fixation was applied. Joint reduction was performed after confirming prosthesis stability and absence of prosthesis-glenoid impingement. The resected deltoid insertion and residual rotator cuff were tensioned and securely sutured to the LARS circumferentially wrapped around the prosthesis. Finally, layered closure was performed, the surgical field was copiously irrigated, and a drain was placed (Fig. 2 ). Postoperative management and follow‑up The drainage tube was removed when output was < 50 ml/day. Active ROM exercises for the hand, wrist, and elbow joints commenced on postoperative day one. An abduction brace maintained the shoulder at 60° abduction until four weeks postoperatively. Active shoulder exercises were initiated after brace removal. Each follow-up assessment included: Evaluation of patient survival status, Assessment of tumor status and Prosthesis survival, Measurement of ROM and Functional scoring using standardized metrics. Assessment methodology Postoperative follow-up included regular X-ray and CT examinations to assess for local tumor recurrence, distant metastasis, baseplate loosening, proper glenosphere-glenoid alignment, and humeral prosthesis loosening or fracture; shoulder function was evaluated using the MSTS-93 and Constant-Murley score, with documentation of abduction, forward flexion, internal rotation, and external rotation angles at final follow-up. Results General results All ten patients in this cohort underwent successful surgical procedures, with a mean operation duration of 182.2 ± 50.3 minutes. The average intraoperative blood loss was recorded at 453.5 ± 223.6 ml, and no significant intraoperative complications were observed. The average length of osteotomy was 15.3 ± 5.1 cm. Each patient participated in a follow-up assessment, which occurred at an average interval of 28.1 ± 14.1 months. At the final follow-up, none of the patients reported experiencing shoulder pain. Oncological results At final follow-up, pulmonary metastases were detected in two patients. One patient demonstrated slow tumor progression despite long-term anlotinib therapy with suboptimal response. Another patient received CyberKnife radiosurgery at an external institution, with subsequent imaging showing reduced metastatic lesion size. Both patients remain alive with disease. No local recurrence or distant metastasis occurred in the remaining patients. There were no patient deaths. Radiological results At final follow-up, radiographic evaluation of all patients demonstrated neither scapular notching nor periprosthetic radiolucent lines. Both the glenoid baseplate and humeral stem remained well-fixed with stable alignment (Fig. 3 ). Functional outcomes At the final follow-up, the 10 patients exhibited a mean shoulder abduction of 105.3° ± 13.1°, forward flexion of 120.5° ± 16.2°, external rotation of 75.3° ± 6.8°, and internal rotation of 48.2° ± 3.5°, with mean functional scores of 24.5 ± 2.6 points on the MSTS-93 score and 74.6 ± 3.4 points on the Constant-Murley score (Table.1). Complications One patient developed multidirectional shoulder instability during activity, manifesting as mild pain and transient momentary instability during abduction or external rotation maneuvers; symptoms resolved spontaneously with preserved ROM and strength. No further intervention was undertaken due to absence of significant functional impairment. Discussion Large shoulder defects following proximal humeral malignant tumor resection predispose to postoperative functional impairment and prosthetic instability. Conventional hemiarthroplasty reconstruction is contraindicated in rotator cuff-deficient patients, as it leads to suboptimal functional outcomes with risks of superior prosthesis migration and dislocation; allograft reconstruction carries additional concerns of postoperative fracture and nonunion, along with poor early functional recovery[ 3 , 13 ]. In contrast, reverse shoulder prosthesis—characterized by its deltoid-driven mechanism independent of rotator cuff integrity—enables immediate improvement in forward flexion and abduction. Consequently, this technique has been increasingly adopted by surgeons for reconstruction after proximal humeral tumor resection[ 1 , 5 , 7 ]. The reverse shoulder prosthesis compensates for rotator cuff deficiency by utilizing deltoid contraction to restore biomechanical function, preserving substantial forward flexion and abduction capabilities. Schwartz et al.[ 14 ] demonstrated through biomechanical testing that deltoid preservation enhances flexion and abduction moment arms. In Lädermann et al.[ 15 ]'s series of 49 patients with partial deltoid preservation, mean abduction improved from 50° to 121° at 38 months postoperatively. For patients with preserved deltoid integrity, reconstruction of its insertion is critical. Historically, deltoid insertion resection was considered an absolute contraindication for RSA. With advancements in synthetic material-assisted insertion reconstruction techniques, this is no longer an absolute contraindication. Multiple investigators have reconstructed the deltoid insertion using synthetic mesh, achieving mean postoperative abduction and forward flexion exceeding 100°[ 16 , 17 ]. Yang et al.[ 18 ] compared 27 patients in the mesh group versus 14 in the non-mesh group, demonstrating nearly 50% greater abduction improvement in the mesh cohort at final follow-up. Synthetic mesh reconstruction enhances soft tissue attachment and restores biomechanical force transmission capacity between the deltoid insertion and prosthesis. The LARS—exhibiting superior mechanical strength and biocompatibility among synthetic meshes—facilitates early peri-prosthetic tissue encapsulation and long-term inductive healing, thereby improving functional outcomes. Its porous architecture provides additional suture fixation points during deltoid reconstruction, enabling stress distribution to mitigate retear risk. In Stavropoulos et al.[ 19 ]'s cohort, 18 patients undergoing shoulder tumor reconstruction with prosthesis-LARS composite exhibited satisfactory prosthesis stability and improved MSTS-93 score and Toronto Extremity Salvage Score (TESS) metrics. Similarly, Tong et al.[ 20 ] reported 22 cases reconstructed using LARS augmentation, demonstrating satisfactory shoulder function recovery in 20 patients at 48.2-month follow-up with no prosthesis failure; mean MSTS-93 reached 25.8 points and American Shoulder and Elbow Surgeons (ASES) score 85.7 points. In our cohort of ten patients, intraoperative deltoid insertion reattachment to LARS achieved mean postoperative abduction of 105.3°±13.1° and forward flexion of 120.5°±16.2°, indicating favorable functional outcomes. Following RSA, patients utilizing the deltoid as the primary motor source typically demonstrate improved forward flexion and abduction; however, rotational recovery remains dependent on residual rotator cuff musculature. Studies confirm that persistent rotator cuff defects after isolated reverse arthroplasty often result in suboptimal rotational restoration, whereas rotator cuff repair enhances postoperative rotation and stability[ 1 , 12 , 21 ]. The transverse force couple formed by the subscapularis, teres minor, and infraspinatus is critical for rotational stability. Subscapularis repair augments anterior stability, while combined teres major insertion reconstruction further improves internal rotation[ 22 , 23 , 24 ]. Teres minor repair synergizes with the infraspinatus to partially restore external rotation; its postoperative co-activation with the middle deltoid also optimizes complex shoulder kinematics[ 25 , 26 ]. Growing recognition of soft tissue reconstruction importance has prompted diverse surgical approaches. In Boileau et al.[ 27 ]'s series of 17 patients receiving RSA with combined latissimus dorsi and teres major transfer, mean external rotation improved from − 21° to 13°. Callamand et al.[ 28 ] documented tendon transfer-augmented RSA in five cases, showing increased external rotation from 7° to 38° postoperatively. Tang et al.[ 29 ] reported 73.0°±6.8° external rotation at 45-month follow-up in 15 patients undergoing prosthesis-LARS reconstruction versus 56.0°±5.2° in 14 prosthesis-only controls (≈ 30% improvement). Suture fixation of rotator cuff tendons to LARS promotes scar tissue ingrowth for robust healing, ultimately forming a biologic rotator cuff analog that enhances long-term rotational stability[ 30 ]. The LARS enhances the connection between residual rotator cuff and prosthesis by increasing tendon-prosthesis interface contact area, thereby distributing stress to improve prosthetic stability and postoperative rotation. In our cohort of ten patients undergoing rotator cuff reconstruction with LARS augmentation, mean external rotation reached 75.3°±6.8° and internal rotation 48.2°±3.5°, demonstrating favorable rotational restoration (Fig. 4 ). While reverse shoulder prostheses significantly improve postoperative function, their semi-constrained design predisposes to complications such as dislocation—reported in 18% to 22% of cases according to literature[ 6 , 7 , 11 , 17 ]. Trovarelli et al.[ 6 ] attribute dislocations to excessive osteotomy compromising deltoid reattachment and reducing muscular tension. Extensive soft tissue defects following tumor resection also contribute to dislocation through inadequate prosthesis encapsulation. In Bonnevialle et al.[ 12 ]'s cohort with 33% dislocation rate, intraoperative deltoid and insertion resection was identified as the primary etiology. When extensive resection of periarticular muscles and insertions necessitates soft tissue reconstruction to address dynamic stabilizing structure deficiencies, LARS serves as an optimal solution. Its porous architecture provides enhanced implantation sites for deltoid insertion and rotator cuff repair, augmenting passive constraints to maintain joint stability. In Tang et al.[ 29 ]'s cohort, none of the 14 patients receiving prosthesis-LARS composite reconstruction of rotator cuff and deltoid insertion experienced prosthesis dislocation during 45-month follow-up, whereas 5 of 15 non-LARS reconstruction controls developed superior prosthesis migration—including 2 anterior dislocations. Ji et al.[ 31 ] documented 85% prosthesis stability rate in 7 cases with intraoperative rotator cuff and deltoid reconstruction using LARS augmentation. Several investigators propose LARS for soft tissue reconstruction to restrict prosthesis excursion, maintaining shoulder stability in most patients[ 19 , 20 ]. In our cohort, all ten patients underwent LARS-augmented soft tissue reconstruction with no prosthesis dislocations. One patient developed multidirectional instability during shoulder motion, manifesting as mild pain and transient momentary instability during abduction or external rotation maneuvers—potentially attributable to premature postoperative rehabilitation before adequate periprosthetic encapsulation by scar tissue had formed. Limitation This study has several limitations. First, as a small-sample retrospective analysis with limited patient numbers and heterogeneous tumor types, it lacks standardized evaluation criteria—requiring expanded cohorts and refined assessment protocols. Second, the follow-up duration remains insufficient, with most patients not exceeding five years; extended surveillance is warranted to determine long-term outcomes. Third, modular reverse shoulder prostheses still fail to achieve optimal anatomical conformity with osseous defect geometries, necessitating future exploration of 3D-printed and biologic reverse shoulder arthroplasty solutions. Conclusions Reinforcement of the deltoid insertion and rotator cuff reconstruction using LARS following resection of proximal humerus malignant tumors contributes to improved postoperative forward flexion, abduction, and rotational function while reducing prosthetic dislocation rates. However, long-term functional outcomes and implant stability require further follow-up observation. Declarations Authors ’ contributions GB collected the patient data and was a major contributor in writing the manuscript. FP, JW participated in the following-up of the patients and assisted to complete the manuscript. BL, ZY and JT together made the treatment plan of the patients. ZY and JT reviewed the manuscript to complete this work. The authors read and approved the final manuscript. Funding This study was funded by the general project of Guangxi Natural Science Foundation (2024GXNSFAA010425) Availability of data and materials Data and materials supporting the findings are available upon reasonable request. Ethics approval and consent to participate The study received approval from the Ethics Committee of Guangxi Medical University Cancer Hospital (Approval No: KY2025667), and written informed consent was obtained from all participants. Competing interests There are no financial or non-financial conflicts of interest to disclose Author details Department of Bone and Soft Tissue Surgery, Guangxi Medical University Cancer Hospital No. 50 Liangyu Avenue, Liangqing Town, Liangqing District, Nanning City, Guangxi Zhuang Autonomous Region, China References Grosel TW, Plummer DR, Everhart JS, Kirven JC, Ziegler CL, Mayerson JL, et al. 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Synthetic mesh improves shoulder function after intraarticular resection and prosthetic replacement of proximal humerus. Clin Orthop Relat Res. 2015;473:1464–71. Ferguson PC. CORR Insights(®): synthetic mesh improves shoulder function after intraarticular resection and prosthetic replacement of proximal humerus. Clin Orthop Relat Res. 2015;473:1735–6. Ji T, Tang X, Guo W. Enhancing soft-tissue reattachment in proximal humeral endoprosthetic reconstruction. J Orthop Surg (Hong Kong). 2014;22:100–3. Table 1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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01:32:45","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":161314,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/57b8de83b97c94ba939d3ec1.png"},{"id":93978326,"identity":"e9fd1faf-e84a-4ff0-87b5-6bbf2fb1fcbc","added_by":"auto","created_at":"2025-10-21 01:40:45","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78444,"visible":true,"origin":"","legend":"","description":"","filename":"c753fb3630044dc39b92815b1a4de0a51structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/4d95b068646032f5c220693b.xml"},{"id":93977902,"identity":"6716614c-1a69-495d-bfb2-970e14e2e05d","added_by":"auto","created_at":"2025-10-21 01:32:45","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84517,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/c28ad3d30160745c8a82f818.html"},{"id":93977911,"identity":"e5c95c91-70d7-4a9e-8f61-6deb48511320","added_by":"auto","created_at":"2025-10-21 01:32:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2080291,"visible":true,"origin":"","legend":"\u003cp\u003eThe assembled reverse shoulder prosthesis and the LARS\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/a89d9509b8d3c4f4152e8c53.png"},{"id":93977894,"identity":"fd425d70-af98-4d00-a1e0-ca25038f246a","added_by":"auto","created_at":"2025-10-21 01:32:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2241436,"visible":true,"origin":"","legend":"\u003cp\u003eThe LARS was secured onto the prosthesis intraoperatively\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/46f6fba99d9b89d4e20d0980.png"},{"id":93977893,"identity":"dfcb8c28-5fe8-4767-a4f9-ac899357a29b","added_by":"auto","created_at":"2025-10-21 01:32:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":133352,"visible":true,"origin":"","legend":"\u003cp\u003eA 17-year-old male patient underwent proximal humeral osteosarcoma resection and was reconstructed with the assistance of a reverse shoulder prosthesis combined with LARS and distal double plate fixation\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/0e730dab500bcfea39a3ec15.png"},{"id":93977897,"identity":"6de391ae-27d7-41bb-8424-336351f4db92","added_by":"auto","created_at":"2025-10-21 01:32:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":280135,"visible":true,"origin":"","legend":"\u003cp\u003eThe 17-year-old patient demonstrated well-preserved shoulder function in abduction, forward flexion, and rotation at the 48-month postoperative follow-up\u003c/p\u003e","description":"","filename":"Fig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/3ca984f4adf38a1ce8e169a6.png"},{"id":98776859,"identity":"62268047-1fc0-4e47-81e6-4b7db26b492a","added_by":"auto","created_at":"2025-12-22 12:23:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5299373,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7743805/v1/9ecaa5a5-e417-48dc-a8ad-3b6cb474e961.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of reverse shoulder prosthesis combined with ligament advanced reinforcement system in resection and reconstruction for proximal humerus malignant tumors","fulltext":[{"header":"Background","content":"\u003cp\u003eThe proximal humerus serves as a predilection site for both benign and malignant primary bone tumors and is also a common location for metastatic disease[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Surgical management of proximal humerus malignant tumors typically necessitates tumor segment resection, where the requirement for wide resection margins to ensure oncological safety often mandates extensive removal of shoulder tissues, thereby posing significant challenges for reconstruction strategy selection. Conventional reconstruction techniques include hemiarthroplasty, composite allograft-prosthesis reconstruction, and osteoarticular autograft or allograft transplantation. Resection of stabilizing structures such as the rotator cuff and joint capsule contributes to postoperative complications including superior prosthesis migration or dislocation, graft fracture, and nonunion, while also resulting in suboptimal shoulder function with mean abduction and forward flexion typically measuring less than 60\u0026deg;, which significantly impairs patients' occupational and daily living activities[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReverse shoulder arthroplasty (RSA) was initially developed for massive rotator cuff tears. Its unique design\u0026mdash;featuring a glenosphere fixed to the glenoid and a concave cup on the proximal humerus\u0026mdash;medializes the center of rotation, recruiting more deltoid fibers to compensate for rotator cuff deficiency and thereby improving function[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since biomechanical properties of rotator cuff-deficient shoulders resemble those after tumor resection, RSA principles apply to reconstructing osseous defects following proximal humerus malignant tumor resection[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. An increasing number of surgeons now utilize RSA for reconstructing proximal humeral malignancies while preserving the axillary nerve and deltoid, achieving favorable functional outcomes[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The procedure leverages deltoid contraction to substitute for deficient rotator cuff function. Consequently, current consensus favors RSA without routine rotator cuff reconstruction. Houdek et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] propose that functional rotator cuff preservation is unnecessary in RSA reconstruction, while Fares et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] emphasize that RSA relies more on deltoid integrity than rotator cuff dependence. However, some reports cite suboptimal rotation and prosthetic dislocations when soft tissue reconstruction is omitted[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Pan et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] observed significantly restricted rotation and strength decline in seven patients at mean eight-month follow-up, with one dislocation occurring within a month postoperatively in a patient with detached deltoid insertion. Multiple studies indicate absent rotator cuff limits rotational recovery after RSA, with mean rotation typically measuring less than 35\u0026deg; and high dislocation rates[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo enhance functional outcomes and reduce dislocation risk, this retrospective study analyzes ten patients undergoing RSA combined with LARS reconstruction at our institution. Study objectives are:\u003c/p\u003e\u003cp\u003e(1) To evaluate early-to-midterm outcomes of RSA combined with LARS for proximal humerus malignant tumors; (2) To analyze postoperative complications and preventive strategies for this reconstruction technique.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eBetween March 2021 and May 2023, ten patients meeting the following criteria were enrolled: Inclusion Criteria: (1) Primary or metastatic malignant tumor involving the proximal humerus; (2) Reconstruction using RSA combined with LARS ; (3) Intraoperative preservation of deltoid muscle and/or axillary nerve viability; (4) Complete radiographic documentation and follow-up data. Exclusion Criteria: (1) Tumor invasion of deltoid or axillary nerve precluding their preservation; (2) Systemic metastasis deemed unresectable; (3) Poor systemic conditions contraindicating surgery; (4) Prior amputation or distal humerus involvement. The cohort comprised six males and four females with a mean age of 38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7 years. All patients presented with unilateral involvement. Preoperative core needle biopsy confirmed pathological diagnoses in all cases: osteosarcoma (n\u0026thinsp;=\u0026thinsp;5), chondrosarcoma (n\u0026thinsp;=\u0026thinsp;2), solitary metastatic squamous cell carcinoma (n\u0026thinsp;=\u0026thinsp;1), Ewing sarcoma (n\u0026thinsp;=\u0026thinsp;1), and synovial sarcoma (n\u0026thinsp;=\u0026thinsp;1). All patients reported shoulder pain and limited ROM.\u003c/p\u003e\u003cp\u003eThis study was approved by the Ethics Committee of the Guangxi Medical University Cancer Hospital (KY2025667), and all patients signed the informed consent form.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign of the reverse shoulder prosthesis\u003c/h2\u003e\u003cp\u003eThe reverse shoulder prosthesis consists of modular components including the glenoid baseplate, glenosphere, polyethylene liner, liner tray, humeral osteotomy segment, and humeral stem. The glenoid assembly comprises the glenoid baseplate and glenosphere. The baseplate is secured to the scapular glenoid with up to four screws, while the glenosphere converges into the baseplate. The humeral assembly includes the polyethylene liner, liner tray, and humeral stem (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical procedures\u003c/h3\u003e\n\u003cp\u003eFollowing general anesthesia, the patient was positioned supine. Standard preoperative disinfection and draping were performed. An S-shaped incision was made over the proximal humerus, incorporating the prior biopsy tract. After incising skin, subcutaneous tissue, and deep fascia, osteotomy was performed three-five cm distal to the tumor margin as preoperatively planned, ensuring the osteotomy site remained below the deltoid insertion. Tumor-involved soft tissues were resected en bloc, and the tumor was dissected from surrounding normal tissue along safe margins, with care taken to preserve the axillary nerve if uninvolved. The glenohumeral joint capsule was then opened. Glenoid articular cartilage was burred, and the baseplate was positioned and secured with screws after angle adjustment, followed by glenosphere attachment. The humeral canal was reamed, and a cementless humeral stem prosthesis was inserted. The deltoid was retracted distally while suturing its insertion and residual rotator cuff in abduction. For cases with excessive osteotomy length, supplemental distal plate fixation was applied. Joint reduction was performed after confirming prosthesis stability and absence of prosthesis-glenoid impingement. The resected deltoid insertion and residual rotator cuff were tensioned and securely sutured to the LARS circumferentially wrapped around the prosthesis. Finally, layered closure was performed, the surgical field was copiously irrigated, and a drain was placed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003ePostoperative management and follow‑up\u003c/h3\u003e\n\u003cp\u003eThe drainage tube was removed when output was \u0026lt;\u0026thinsp;50 ml/day. Active ROM exercises for the hand, wrist, and elbow joints commenced on postoperative day one. An abduction brace maintained the shoulder at 60\u0026deg; abduction until four weeks postoperatively. Active shoulder exercises were initiated after brace removal. Each follow-up assessment included: Evaluation of patient survival status, Assessment of tumor status and Prosthesis survival, Measurement of ROM and Functional scoring using standardized metrics.\u003c/p\u003e\n\u003ch3\u003eAssessment methodology\u003c/h3\u003e\n\u003cp\u003ePostoperative follow-up included regular X-ray and CT examinations to assess for local tumor recurrence, distant metastasis, baseplate loosening, proper glenosphere-glenoid alignment, and humeral prosthesis loosening or fracture; shoulder function was evaluated using the MSTS-93 and Constant-Murley score, with documentation of abduction, forward flexion, internal rotation, and external rotation angles at final follow-up.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eGeneral results\u003c/h2\u003e\u003cp\u003eAll ten patients in this cohort underwent successful surgical procedures, with a mean operation duration of 182.2\u0026thinsp;\u0026plusmn;\u0026thinsp;50.3 minutes. The average intraoperative blood loss was recorded at 453.5\u0026thinsp;\u0026plusmn;\u0026thinsp;223.6 ml, and no significant intraoperative complications were observed. The average length of osteotomy was 15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 cm. Each patient participated in a follow-up assessment, which occurred at an average interval of 28.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1 months. At the final follow-up, none of the patients reported experiencing shoulder pain.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOncological results\u003c/h3\u003e\n\u003cp\u003eAt final follow-up, pulmonary metastases were detected in two patients. One patient demonstrated slow tumor progression despite long-term anlotinib therapy with suboptimal response. Another patient received CyberKnife radiosurgery at an external institution, with subsequent imaging showing reduced metastatic lesion size. Both patients remain alive with disease. No local recurrence or distant metastasis occurred in the remaining patients. There were no patient deaths.\u003c/p\u003e\n\u003ch3\u003eRadiological results\u003c/h3\u003e\n\u003cp\u003eAt final follow-up, radiographic evaluation of all patients demonstrated neither scapular notching nor periprosthetic radiolucent lines. Both the glenoid baseplate and humeral stem remained well-fixed with stable alignment (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eFunctional outcomes\u003c/h2\u003e\u003cp\u003eAt the final follow-up, the 10 patients exhibited a mean shoulder abduction of 105.3\u0026deg; \u0026plusmn; 13.1\u0026deg;, forward flexion of 120.5\u0026deg; \u0026plusmn; 16.2\u0026deg;, external rotation of 75.3\u0026deg; \u0026plusmn; 6.8\u0026deg;, and internal rotation of 48.2\u0026deg; \u0026plusmn; 3.5\u0026deg;, with mean functional scores of 24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 points on the MSTS-93 score and 74.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 points on the Constant-Murley score (Table.1).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eComplications\u003c/h2\u003e\u003cp\u003eOne patient developed multidirectional shoulder instability during activity, manifesting as mild pain and transient momentary instability during abduction or external rotation maneuvers; symptoms resolved spontaneously with preserved ROM and strength. No further intervention was undertaken due to absence of significant functional impairment.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLarge shoulder defects following proximal humeral malignant tumor resection predispose to postoperative functional impairment and prosthetic instability. Conventional hemiarthroplasty reconstruction is contraindicated in rotator cuff-deficient patients, as it leads to suboptimal functional outcomes with risks of superior prosthesis migration and dislocation; allograft reconstruction carries additional concerns of postoperative fracture and nonunion, along with poor early functional recovery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast, reverse shoulder prosthesis\u0026mdash;characterized by its deltoid-driven mechanism independent of rotator cuff integrity\u0026mdash;enables immediate improvement in forward flexion and abduction. Consequently, this technique has been increasingly adopted by surgeons for reconstruction after proximal humeral tumor resection[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe reverse shoulder prosthesis compensates for rotator cuff deficiency by utilizing deltoid contraction to restore biomechanical function, preserving substantial forward flexion and abduction capabilities. Schwartz et al.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] demonstrated through biomechanical testing that deltoid preservation enhances flexion and abduction moment arms. In L\u0026auml;dermann et al.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]'s series of 49 patients with partial deltoid preservation, mean abduction improved from 50\u0026deg; to 121\u0026deg; at 38 months postoperatively. For patients with preserved deltoid integrity, reconstruction of its insertion is critical. Historically, deltoid insertion resection was considered an absolute contraindication for RSA. With advancements in synthetic material-assisted insertion reconstruction techniques, this is no longer an absolute contraindication. Multiple investigators have reconstructed the deltoid insertion using synthetic mesh, achieving mean postoperative abduction and forward flexion exceeding 100\u0026deg;[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Yang et al.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] compared 27 patients in the mesh group versus 14 in the non-mesh group, demonstrating nearly 50% greater abduction improvement in the mesh cohort at final follow-up. Synthetic mesh reconstruction enhances soft tissue attachment and restores biomechanical force transmission capacity between the deltoid insertion and prosthesis. The LARS\u0026mdash;exhibiting superior mechanical strength and biocompatibility among synthetic meshes\u0026mdash;facilitates early peri-prosthetic tissue encapsulation and long-term inductive healing, thereby improving functional outcomes. Its porous architecture provides additional suture fixation points during deltoid reconstruction, enabling stress distribution to mitigate retear risk. In Stavropoulos et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]'s cohort, 18 patients undergoing shoulder tumor reconstruction with prosthesis-LARS composite exhibited satisfactory prosthesis stability and improved MSTS-93 score and Toronto Extremity Salvage Score (TESS) metrics. Similarly, Tong et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported 22 cases reconstructed using LARS augmentation, demonstrating satisfactory shoulder function recovery in 20 patients at 48.2-month follow-up with no prosthesis failure; mean MSTS-93 reached 25.8 points and American Shoulder and Elbow Surgeons (ASES) score 85.7 points. In our cohort of ten patients, intraoperative deltoid insertion reattachment to LARS achieved mean postoperative abduction of 105.3\u0026deg;\u0026plusmn;13.1\u0026deg; and forward flexion of 120.5\u0026deg;\u0026plusmn;16.2\u0026deg;, indicating favorable functional outcomes.\u003c/p\u003e\u003cp\u003eFollowing RSA, patients utilizing the deltoid as the primary motor source typically demonstrate improved forward flexion and abduction; however, rotational recovery remains dependent on residual rotator cuff musculature. Studies confirm that persistent rotator cuff defects after isolated reverse arthroplasty often result in suboptimal rotational restoration, whereas rotator cuff repair enhances postoperative rotation and stability[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The transverse force couple formed by the subscapularis, teres minor, and infraspinatus is critical for rotational stability. Subscapularis repair augments anterior stability, while combined teres major insertion reconstruction further improves internal rotation[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Teres minor repair synergizes with the infraspinatus to partially restore external rotation; its postoperative co-activation with the middle deltoid also optimizes complex shoulder kinematics[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Growing recognition of soft tissue reconstruction importance has prompted diverse surgical approaches. In Boileau et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]'s series of 17 patients receiving RSA with combined latissimus dorsi and teres major transfer, mean external rotation improved from \u0026minus;\u0026thinsp;21\u0026deg; to 13\u0026deg;. Callamand et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] documented tendon transfer-augmented RSA in five cases, showing increased external rotation from 7\u0026deg; to 38\u0026deg; postoperatively. Tang et al.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] reported 73.0\u0026deg;\u0026plusmn;6.8\u0026deg; external rotation at 45-month follow-up in 15 patients undergoing prosthesis-LARS reconstruction versus 56.0\u0026deg;\u0026plusmn;5.2\u0026deg; in 14 prosthesis-only controls (\u0026asymp;\u0026thinsp;30% improvement). Suture fixation of rotator cuff tendons to LARS promotes scar tissue ingrowth for robust healing, ultimately forming a biologic rotator cuff analog that enhances long-term rotational stability[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The LARS enhances the connection between residual rotator cuff and prosthesis by increasing tendon-prosthesis interface contact area, thereby distributing stress to improve prosthetic stability and postoperative rotation. In our cohort of ten patients undergoing rotator cuff reconstruction with LARS augmentation, mean external rotation reached 75.3\u0026deg;\u0026plusmn;6.8\u0026deg; and internal rotation 48.2\u0026deg;\u0026plusmn;3.5\u0026deg;, demonstrating favorable rotational restoration (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWhile reverse shoulder prostheses significantly improve postoperative function, their semi-constrained design predisposes to complications such as dislocation\u0026mdash;reported in 18% to 22% of cases according to literature[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Trovarelli et al.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] attribute dislocations to excessive osteotomy compromising deltoid reattachment and reducing muscular tension. Extensive soft tissue defects following tumor resection also contribute to dislocation through inadequate prosthesis encapsulation. In Bonnevialle et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]'s cohort with 33% dislocation rate, intraoperative deltoid and insertion resection was identified as the primary etiology. When extensive resection of periarticular muscles and insertions necessitates soft tissue reconstruction to address dynamic stabilizing structure deficiencies, LARS serves as an optimal solution. Its porous architecture provides enhanced implantation sites for deltoid insertion and rotator cuff repair, augmenting passive constraints to maintain joint stability. In Tang et al.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]'s cohort, none of the 14 patients receiving prosthesis-LARS composite reconstruction of rotator cuff and deltoid insertion experienced prosthesis dislocation during 45-month follow-up, whereas 5 of 15 non-LARS reconstruction controls developed superior prosthesis migration\u0026mdash;including 2 anterior dislocations. Ji et al.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] documented 85% prosthesis stability rate in 7 cases with intraoperative rotator cuff and deltoid reconstruction using LARS augmentation. Several investigators propose LARS for soft tissue reconstruction to restrict prosthesis excursion, maintaining shoulder stability in most patients[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our cohort, all ten patients underwent LARS-augmented soft tissue reconstruction with no prosthesis dislocations. One patient developed multidirectional instability during shoulder motion, manifesting as mild pain and transient momentary instability during abduction or external rotation maneuvers\u0026mdash;potentially attributable to premature postoperative rehabilitation before adequate periprosthetic encapsulation by scar tissue had formed.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, as a small-sample retrospective analysis with limited patient numbers and heterogeneous tumor types, it lacks standardized evaluation criteria\u0026mdash;requiring expanded cohorts and refined assessment protocols. Second, the follow-up duration remains insufficient, with most patients not exceeding five years; extended surveillance is warranted to determine long-term outcomes. Third, modular reverse shoulder prostheses still fail to achieve optimal anatomical conformity with osseous defect geometries, necessitating future exploration of 3D-printed and biologic reverse shoulder arthroplasty solutions.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eReinforcement of the deltoid insertion and rotator cuff reconstruction using LARS following resection of proximal humerus malignant tumors contributes to improved postoperative forward flexion, abduction, and rotational function while reducing prosthetic dislocation rates. However, long-term functional outcomes and implant stability require further follow-up observation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGB collected the patient data and was a major contributor in writing the manuscript. FP, JW participated in the following-up of the patients and assisted to complete the manuscript. BL, ZY and JT together made the treatment plan of the patients. ZY and JT reviewed the manuscript to complete this work. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the general project of Guangxi Natural Science Foundation (2024GXNSFAA010425)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData and materials supporting the findings are available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Ethics Committee of Guangxi Medical University Cancer Hospital (Approval No: KY2025667), and written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no financial or non-financial conflicts of interest to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Bone and Soft Tissue Surgery, Guangxi Medical University Cancer Hospital\u003c/p\u003e\n\u003cp\u003eNo. 50 Liangyu Avenue, Liangqing Town, Liangqing District, Nanning City, Guangxi Zhuang Autonomous Region, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGrosel TW, Plummer DR, Everhart JS, Kirven JC, Ziegler CL, Mayerson JL, et al. Reverse total shoulder arthroplasty provides stability and better function than hemiarthroplasty following resection of proximal humerus tumors. J Shoulder Elbow Surg. 2019;28:2147\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eFerlauto HR, Wickman JR, Lazarides AL, Hendren S, Visgauss JD, Brigman BE, et al. Reverse total shoulder arthroplasty for oncologic reconstruction of the proximal humerus: a systematic review. J Shoulder Elbow Surg. 2021;30:e647\u0026ndash;58.\u003c/li\u003e\n\u003cli\u003eWang Z, Guo Z, Li J, Li X, Sang H. Functional outcomes and complications of construction with three methods after intra-articular tumor resection of the proximal aspect of humerus. Chin J Orthop. 2008;28:106-111.\u003c/li\u003e\n\u003cli\u003eKumar D, Grimer RJ, Abudu A, Carter SR, Tillman RM. Endoprosthetic replacement of the proximal humerus. Long-term results. J Bone Joint Surg Br. 2003;85:717\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003ePan W, Lin N, Ye Z, Yan X, Huang X, Liu M, et al. Early functional result of modular reverse shoulder tumor prosthesis in the treatment of proximal humerus tumor. Chin J Orthop. 2020;40:971-978.\u003c/li\u003e\n\u003cli\u003eTrovarelli G, Cappellari A, Angelini A, Pala E, Ruggieri P. What Is the Survival and Function of Modular Reverse Total Shoulder Prostheses in Patients Undergoing Tumor Resections in Whom an Innervated Deltoid Muscle Can Be Preserved? Clin Orthop Relat Res. 2019;477:2495\u0026ndash;507.\u003c/li\u003e\n\u003cli\u003eStreitbuerger A, Henrichs M, Gosheger G, Ahrens H, Nottrott M, Guder W, et al. Improvement of the shoulder function after large segment resection of the proximal humerus with the use of an inverse tumour prosthesis. Int Orthop. 2015;39:355\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eHoudek MT, Sullivan MH, Broida SE, Barlow JD, Morrey ME, Moran SL, et al. Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis. JBJS Rev. 2024;12:e23.00217.\u003c/li\u003e\n\u003cli\u003eFares MY, Boufadel P, Berg J, Daher M, Haikal E, Abboud JA. Perioperative deltoid pathologies in the setting of reverse shoulder arthroplasty: a narrative review. Ann Jt. 2025;10:4.\u003c/li\u003e\n\u003cli\u003eAyvaz M, Cetik RM, Bakircioglu S, Tokgozoglu AM. Proximal Humerus Tumors: Higher-than-Expected Risk of Revision With Constrained Reverse Shoulder Arthroplasty. Clin Orthop Relat Res. 2020;478:2585\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eGuven MF, Aslan L, Botanlioglu H, Kaynak G, Kesmezacar H, Babacan M. Functional outcome of reverse shoulder tumor prosthesis in the treatment of proximal humerus tumors. J Shoulder Elbow Surg. 2016;25:e1-6.\u003c/li\u003e\n\u003cli\u003eBonnevialle N, Mansat P, Lebon J, Laffosse J-M, Bonnevialle P. Reverse shoulder arthroplasty for malignant tumors of proximal humerus. J Shoulder Elbow Surg. 2015;24:36\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eWang J, Dickinson IC. Functional outcome following shoulder tumor resection and reconstruction. Zhonghua Wai Ke Za Zhi. 2006;44:809\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eSchwartz DG, Kang SH, Lynch TS, Edwards S, Nuber G, Zhang L-Q, et al. The anterior deltoid\u0026rsquo;s importance in reverse shoulder arthroplasty: a cadaveric biomechanical study. J Shoulder Elbow Surg. 2013;22:357\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eL\u0026auml;dermann A, Walch G, Denard PJ, Collin P, Sirveaux F, Favard L, et al. Reverse shoulder arthroplasty in patients with pre-operative impairment of the deltoid muscle. Bone Joint J. 2013;95-B:1106\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eGuo Y, Feng D, Wang L, Ding Y, Liu Y, He J. Three-dimensional printing technology in reverse shoulder arthroplasty after resection of proximal humeral tumors. Chin J Orthop. 2023;43:559-566. \u003c/li\u003e\n\u003cli\u003eWang S, Luo Y, Wang Y, Zhang Y, Gong T, Tu C, et al. Early functional and therapeutic effect of reversed tumour shoulder prosthesis reconstruction after proximal humerus tumour resection. Front Surg. 2022;9:987161.\u003c/li\u003e\n\u003cli\u003eYang Y, Li Y, Liu W, Niu X. Mesh patch and anchors can improve clinical results of prosthetic replacement after resection of primary proximal humerus malignant tumor. Sci Rep. 2021;11:734.\u003c/li\u003e\n\u003cli\u003eStavropoulos NA, Sawan H, Dandachli F, Turcotte RE. Use of Ligament Advanced Reinforcement System tube in stabilization of proximal humeral endoprostheses. World J Orthop. 2016;7:265\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eTong X, He H, Zhang C, Liu Y, Zeng H, Qiu X, et al. Use of LARS for soft tissue function reconstruction during tumor-type hemi-shoulder replacement achieves a good prognosis: a retrospective cohort study. World J Surg Oncol. 2023;21:123.\u003c/li\u003e\n\u003cli\u003eGrosel TW, Plummer DR, Mayerson JL, Scharschmidt TJ, Barlow JD. Oncologic reconstruction of the proximal humerus with a reverse total shoulder arthroplasty megaprosthesis. J Surg Oncol. 2018;118:867\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eYi J, Chen W, Mi J. Biomechanical research progress of the Grammont prosthesis and its derivative reverse shoulder prostheses. Chin J Orthop. 2024;44:1239-1245.\u003c/li\u003e\n\u003cli\u003eDolan MT, Patetta MJ, Pradhan S, Peresada D, Rybalko D, Bobko A, et al. Evaluation of rotator cuff abduction moment arms for superior capsular reconstruction and reverse total shoulder arthroplasty. Int Orthop. 2021;45:1767\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eLee TQ. Editorial Commentary: Precise Repair of Partial Subscapularis Tendon Tears Is Essential. Arthroscopy. 2019;35:1314\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003ePietroski A, Zhou Y, Kasto J, Obinero C, Zhu K, Mazeh M, et al. Surface Electromyography Reveals Middle Deltoid as the Functionally Dominant Shoulder Muscle After Reverse Total Shoulder Arthroplasty. Cureus. 2025;17:e80229.\u003c/li\u003e\n\u003cli\u003eHaase L, Ina J, Harlow E, Chen R, Gillespie R, Calcei J. The Influence of Component Design and Positioning on Soft-Tissue Tensioning and Complications in Reverse Total Shoulder Arthroplasty: A Review. JBJS Rev. 2024;12:e23.00238.\u003c/li\u003e\n\u003cli\u003eBoileau P, Rumian AP, Zumstein MA. Reversed shoulder arthroplasty with modified L\u0026rsquo;Episcopo for combined loss of active elevation and external rotation. J Shoulder Elbow Surg. 2010;19:20\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eCallamand G, Barret H, Saint-Genez F, Bonnevialle P, Mansat P, Bonnevialle N. Reconstruction by allograft-prosthetic composite reverse shoulder arthroplasty after proximal humerus tumor resection: Clinical and radiographic assessment at a minimum 2years\u0026rsquo; follow-up. Orthop Traumatol Surg Res. 2022;108:102957.\u003c/li\u003e\n\u003cli\u003eTang X, Guo W, Yang R, Tang S, Ji T. Synthetic mesh improves shoulder function after intraarticular resection and prosthetic replacement of proximal humerus. Clin Orthop Relat Res. 2015;473:1464\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eFerguson PC. CORR Insights(\u0026reg;): synthetic mesh improves shoulder function after intraarticular resection and prosthetic replacement of proximal humerus. Clin Orthop Relat Res. 2015;473:1735\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eJi T, Tang X, Guo W. Enhancing soft-tissue reattachment in proximal humeral endoprosthetic reconstruction. J Orthop Surg (Hong Kong). 2014;22:100\u0026ndash;3.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003e\u003cimg 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Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bone tumor, Reverse shoulder arthroplasty, Prosthesis, LARS, shoulder","lastPublishedDoi":"10.21203/rs.3.rs-7743805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7743805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEvaluation of the application value of reverse shoulder prosthesis combined with ligament advanced reinforcement system (LARS) in reconstruction following resection of proximal humerus malignant tumors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed ten patients with proximal humerus malignant tumors who underwent reconstruction using reverse shoulder prosthesis combined with LARS at our institution from March 2021 to May 2023. The cohort included six males and four females, with a mean age of 38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7 years. Preoperative core needle biopsy confirmed pathological diagnoses in all patients: osteosarcoma (n\u0026thinsp;=\u0026thinsp;5), chondrosarcoma (n\u0026thinsp;=\u0026thinsp;2), solitary metastatic squamous cell carcinoma (n\u0026thinsp;=\u0026thinsp;1), Ewing sarcoma (n\u0026thinsp;=\u0026thinsp;1), and synovial sarcoma (n\u0026thinsp;=\u0026thinsp;1). Surgical procedures involved en bloc resection of the proximal humeral tumor segment followed by reverse shoulder arthroplasty. Postoperative radiographic assessment included X-ray and CT. Shoulder range of motion (ROM) was measured quantitatively. Functional outcomes were evaluated using the Musculoskeletal Tumor Society (MSTS-93) Score and Constant-Murley Shoulder Score.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll ten patients underwent uneventful procedures. The mean osteotomy length was 15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 cm. All patients were followed up for a mean duration of 28.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1 months. At final follow-up, the mean shoulder ROM measurements were: abduction 105.3\u0026deg; \u0026plusmn; 13.1\u0026deg;, forward flexion 120.5\u0026deg; \u0026plusmn; 16.2\u0026deg;, external rotation 75.3\u0026deg; \u0026plusmn; 6.8\u0026deg;, and internal rotation 48.2\u0026deg; \u0026plusmn; 3.5\u0026deg;. Functional outcomes averaged 24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 points on the MSTS-93 score and 74.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 points on the Constant-Murley Score. Postoperative complications included shoulder instability in one patient.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eReinforcement of the deltoid insertion and rotator cuff reconstruction using LARS following resection of proximal humerus malignant tumors contributes to improved postoperative forward flexion, abduction, and rotational function while reducing prosthetic dislocation rates. However, long-term functional outcomes and implant stability require further follow-up observation.\u003c/p\u003e","manuscriptTitle":"Application of reverse shoulder prosthesis combined with ligament advanced reinforcement system in resection and reconstruction for proximal humerus malignant tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-21 01:32:39","doi":"10.21203/rs.3.rs-7743805/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82471793-ee4f-4843-b444-920f4ee1e08c","owner":[],"postedDate":"October 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-21T15:09:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-21 01:32:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7743805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7743805","identity":"rs-7743805","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}