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Case Report DOI: 10.13107/jocr.2026.v16.i09.8072 PDF
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Proximal Humerus Ewing Sarcoma: Technical Challenges and Strategies for Bone Defect Reconstruction

Learning Point of the Article:

Biological reconstruction using a non-vascularized fibular autograft is a reliable option for proximal humerus Ewing sarcoma when the deltoid muscle, rotator cuff, glenoid, and axillary nerve are preserved, offering durable outcomes without the complications of prosthetic implants.

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  1. 1 Department of Orthopedics and Traumatology, Sahloul University Hospital, Sousse, Tunisia
Address of Correspondence: Dr. Rami Ben Mhenni, Department of Orthopedics and Traumatology, Sahloul University Hospital, Sousse, Tunisia. E-mail: ramibenmhenni@gmail.com

Received: Accepted: Published:

Copyright: © 2026 Indian Orthopaedic Research Group

Abstract

Introduction:

The proximal humerus is the most common site for primary malignant tumors of the upper limb, with chondrosarcoma, Ewing sarcoma, and osteosarcoma being the most frequent malignancies. Conservative treatment presents significant challenges regarding oncological resection due to the complex neurovascular anatomy and subsequent bone defect reconstruction.

Case Report:

We report the case of a 29-year-old North African male managed for Ewing sarcoma of the proximal humerus. Locoregional staging showed tumor extension to the triceps, but no involvement of the deltoid, rotator cuff, or neurovascular bundle. Distant staging revealed pulmonary nodules. The patient underwent neoadjuvant chemotherapy with complete resolution of pulmonary nodules and soft-tissue extension. The patient underwent tumor resection with reconstruction using a non-vascularized fibular graft and fixation with an anatomical plate and intramedullary pin, achieving good functional outcomes (Musculoskeletal Tumor Society at 80%) and no recurrence at 30 months of follow-up.

Conclusion:

Conservative treatment of proximal humeral tumors faces several challenges: achieving oncological resection due to the complex musculotendinous and neurovascular anatomy of the shoulder, and the subsequent challenge of reconstructing the bone defect. Indications and functional outcomes depend heavily on the involvement of the deltoid, axillary nerve, glenoid, and rotator cuff. Biological reconstruction represents a valuable alternative to prosthetic replacement in appropriately selected cases.

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Introduction

The proximal humerus represents the fourth most common site for primary malignant bone tumors and is the most frequent location in the upper limb [1]. The most common malignant tumors at this site include chondrosarcoma, osteosarcoma, and Ewing sarcoma [2].

Limb-sparing surgery of the shoulder girdle is technically demanding and must strictly respect oncological principles. Functional outcomes depend largely on the preservation of the glenoid, rotator cuff, deltoid muscle, and axillary nerve [3]. We report a case of proximal humerus Ewing sarcoma managed with conservative resection and biological reconstruction, highlighting technical considerations and reconstructive strategies.

Case Report

We present the case of a 29-year-old, right-handed, manual worker, with no significant medical history, who presented with mechanical left shoulder pain. Active and passive range of motion of the glenohumeral joint was preserved. No local inflammatory signs or satellite lymphadenopathy were noted. Plain radiography of the left shoulder revealed an osteolytic lesion of the left proximal humerus (Fig. 1). Magnetic resonance imaging (MRI) demonstrated an aggressive soft-tissue mass arising from the proximal humerus measuring 4 × 2 cm with cortical breakthrough and focal soft-tissue invasion (triceps long head). There was no evidence of involvement of the deltoid, rotator cuff, glenoid, or lymph nodes (Fig. 2). A surgical biopsy confirmed the diagnosis of Ewing sarcoma. Staging evaluation revealed a pulmonary metastasis but no other distant localizations.

Figure 1: Anteroposterior radiograph of the left shoulder demonstrating an osteolytic lesion involving the proximal humerus.
Figure 1: Anteroposterior radiograph of the left shoulder demonstrating an osteolytic lesion involving the proximal humerus.
Figure 2: Pre-operative magnetic resonance imaging of the left shoulder showing an aggressive soft tissue mass arising from the proximal humerus, measuring 4 × 2 cm, with cortical breakthrough and focal soft-tissue invasion of the triceps long head. No involvement of the deltoid muscle, rotator cuff, glenoid, or neurovascular bundle is noted.
Figure 2: Pre-operative magnetic resonance imaging of the left shoulder showing an aggressive soft tissue mass arising from the proximal humerus, measuring 4 × 2 cm, with cortical breakthrough and focal soft-tissue invasion of the triceps long head. No involvement of the deltoid muscle, rotator cuff, glenoid, or neurovascular bundle is noted.

Three cycles of neoadjuvant chemotherapy were initiated. A follow-up thoraco-abdomino-pelvic computed tomography (CT) scan showed complete resolution of pulmonary nodules. A follow-up MRI demonstrated the complete regression of the soft-tissue extension (Fig. 3).

Figure 3: Post-neoadjuvant chemotherapy magnetic resonance imaging demonstrating complete regression of the soft tissue extension with no residual extraosseous tumor mass.
Figure 3: Post-neoadjuvant chemotherapy magnetic resonance imaging demonstrating complete regression of the soft tissue extension with no residual extraosseous tumor mass.

A standard deltopectoral approach was used (Fig. 4). The patient underwent diaphyso-metaphyseal tumor resection, preserving the proximal two-thirds of the humeral head, which was not involved by the tumor. The resected specimen was sent for histopathological examination (Fig. 5). Reconstruction was performed using a non-vascularized fibular autograft stabilized with an anatomical plate and an intramedullary pin. Post-operative radiographs confirmed satisfactory implant positioning (Fig. 6). Macroscopic surgical margins appeared clear. However, microscopic margins were determined to be R0 at the epiphysis but R1 at the diaphysis. The patient received three additional cycles of adjuvant chemotherapy.

Figure 4: Intraoperative photograph showing patient positioning and surgical skin markings.
Figure 4: Intraoperative photograph showing patient positioning and surgical skin markings.
Figure 5: Gross pathological specimen following diaphyso-metaphyseal tumor resection, demonstrating en-bloc removal of the proximal humeral segment.
Figure 5: Gross pathological specimen following diaphyso-metaphyseal tumor resection, demonstrating en-bloc removal of the proximal humeral segment.
Figure 6: Immediate post-operative anteroposterior radiograph of the left shoulder showing the non-vascularized fibular autograft stabilized with an anatomical locking plate and an intramedullary pin.
Figure 6: Immediate post-operative anteroposterior radiograph of the left shoulder showing the non-vascularized fibular autograft stabilized with an anatomical locking plate and an intramedullary pin.

At the last follow-up of 30 months, clinical and radiological results were good with no evidence of tumor recurrence (Figs. 7 and 8).

Figure 7: Anteroposterior radiograph of the left shoulder at 30-month follow-up demonstrating good graft integration with no evidence of local tumor recurrence or hardware failure.
Figure 7: Anteroposterior radiograph of the left shoulder at 30-month follow-up demonstrating good graft integration with no evidence of local tumor recurrence or hardware failure.
Figure 8: Clinical photographs at final follow-up (30 months).
Figure 8: Clinical photographs at final follow-up (30 months).

Discussion

Conservative treatment for malignant tumors of the proximal humerus is gaining importance, largely due to advancements in chemotherapy. Indications for amputation and shoulder disarticulation have decreased [4,5,6]. Resection of these tumors must be oncologically sound and preoperatively planned. Accurate radiological evaluation before surgery is mandatory [7].

Limb-sparing surgery for proximal humerus tumors is often technically challenging as it involves a complex joint with intimate muscular, tendinous, and neurovascular relationships, rendering oncologic resection difficult. The essential risk of conservative treatment remains locoregional recurrence: a 10% recurrence rate at 5 years in O’Connor’s meta-analysis [8] and 34.5% in the Cochin series.

The method of reconstruction following proximal humerus tumor resection depends on several factors.

  • If the glenoid, rotator cuff, deltoid, and axillary nerve are intact, a tumor prosthesis is indicated in the case of humeral head involvement [3].

  • If the humeral head is intact, reconstruction can be performed using an intramedullary nail or an anatomical plate combined with a bone graft.

  • If the deltoid, glenoid, or axillary nerve is involved, glenohumeral arthrodesis is the treatment of choice [3]. Arthrodesis provides a stable, pain-free construct, allowing mobility through the scapulothoracic articulation, but it often yields less satisfactory functional outcomes [8,9].

In our case, we opted for reconstruction using a non-vascularized fibular autograft fixed with an anatomical plate and an intramedullary pin, given the preserved humeral head, glenoid, deltoid, rotator cuff, and axillary nerve.

Literature review indicates that allografts carry disadvantages including bone resorption and fatigue fractures [10]. Indeed, allografts possess osteoconductive but not osteoinductive properties. O’Connor recommends combining an allograft with a vascularized fibular autograft, which provides primary stability via the allograft and secondary strength through the hypertrophy of the vascularized fibula [8].

Conclusion

Conservative treatment of proximal humeral tumors faces several challenges: achieving oncological resection due to the complex musculotendinous and neurovascular relationships and the complexity of the shoulder joint, and the subsequent challenge of reconstructing the bone stock. Indications and functional outcomes depend heavily on the involvement of the deltoid, axillary nerve, glenoid, and rotator cuff.

Clinical Message

Preservation of the deltoid muscle, rotator cuff, glenoid, and axillary nerve allows effective biological reconstruction after proximal humerus tumor resection, providing durable function and oncological safety.

Conflict of Interest:

Source of Support:

Nil

Consent:

The authors confirm that informed consent was obtained from the patient for publication of this article

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© 2026 Journal of Orthopaedic Case Reports - Published by Indian Orthopaedic Research Group

About the Authors

 

How to cite this article: Mhenni R, Chtai S, Khlifa M, Siala A, Maitigue M, Bouattour K. Proximal Humerus Ewing Sarcoma: Technical Challenges and Strategies for Bone Defect Reconstruction. Journal of Orthopaedic Case Reports 2026 September, 16 (09): 303-307.

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