Letters about Published Papers

Re: Endoprosthetic replacement versus cement spacer in reconstruction of proximal humerus after tumor resection: cost and benefits. J Oncol Phram Pract, published online June 2017 (25/2). DOI: 10.1177/2309499017713937

To the Editor,

We read the recently published article by Rafalla and Abdullah ¹ with great interest. This study included 20 patients of malignant tumor of proximal humerus, in which endoprosthesis replacement was done in 8 cases and an on-table fabricated cement spacer was used in 12 cases. They concluded that relatively expensive endoprosthesis could be replaced by a much cheaper cement spacer if their function is comparable.

However, authors did not describe the method of preparing the cement spacer in detail in line with the authors in the literature. ² We have been using the cement spacer in different forms. ^{3 –5} We want to share our method of preparing cement spacer in tumor surgeries using syringe in syringe technique which is easier and cost-effective.

An 8-year-old male child with Ewing’s sarcoma of proximal humerus right side (Figure 1(a)) was admitted in our department. After three cycles of neoadjuvant chemotherapy, we resected the tumor mass. Reconstruction was done with a handmade cement spacer using two syringes of 10 ml and 20 ml, one Steinmann pin and bone cement.

Figure 1.

(a) Preoperative anteroposterior radiograph of Ewing’s sarcoma of proximal humerus in an 8-year-old boy. (b) Cement spacer by syringe in syringe technique. (c) After cement setting and heat production syringes removed. (d) Postoperative anteroposterior radiograph with cement spacer in place.

Proximal 13 cm of humerus (calculated on preoperative MRI) was resected. The resected segment had 30 mm diameter proximally and 14 mm diameter distally. We used readily available syringes of 10 ml and 20 ml, diameter of which matched with that of the resected segment. The hub and plunger of both syringes were removed. Ten-milliliter syringe was inserted into a 20-ml syringe from lower end to make the desired length same as the resected segment, that is 13 cm. But there was a mismatch in size, and assembly was loose. Ten-milliliter syringe was wrapped with a gauze piece to overcome this mismatch. Now, the cement was inserted from lower end of the 10-ml syringe. A 4-mm Steinmann pin was inserted into the assembly in the center from lower end of the 10-ml syringe, with 5 cm remaining outside distally (Figure 1(b)). After setting the bone cement and production of heat, syringes can be removed easily with multiple longitudinal cuts with a knife (Figure 1(c)). Our assembly is ready. The remaining 5 cm of Steinmann pin is inserted into the medullary canal of distal humerus to rest the lower end of the 10-ml syringe on the distal humeral shaft (Figure 1(d)).

This technique of two syringes can also be used in different scenarios, like masquelet technique for management of large bone defects.

Bharat Dhanjani¹, Saket Prakash¹ and Lalit Maini^{2 1}Maulana Azad Medical College, New Delhi, India ²Lok Nayak Hospital, New Delhi, India Corresponding author: [e-mail]