For Rose Truong, nagging pain in her right shoulder had become a fact of life. Through the years she’d heard it may have been caused by anything from a rotator cuff injury to frozen shoulder to stress to simply aging (though at the time she was still in her 30s). She’d even been told it was because her purse was too heavy. Physical therapy and steroid injections should have helped, yet her shoulder pain got consistently worse.
“What they were saying was kind of making sense, but it was lasting just a little bit longer each time,” she says. Her pain progressed to a point where it was waking her up multiple times a night and the over-the-counter pain medicine and patches were no longer cutting it. By the time a doctor ordered an ultrasound, Truong had been dealing with intermittent shoulder pain for nearly four years. That doctor told her he suspected a torn rotator cuff.
“I was just like, thank God,” she says. “Now it’s not in my head. For the first time someone’s given me something to work with.”
Around the same time, she learned that her entire department at work would be phased out in February 2020. She thought she was going to be laid off, so she had her newlywed husband add her to his insurance plan, though she ultimately ended up in a different position at the same company. Navigating a new health care system at the start of the pandemic wasn’t ideal, but Truong was desperate. She was in so much pain, she had no choice but to seek medical care.
“It was to the point where in order to brush my teeth, I had to prop my shoulder on the counter and bring my head down to my arm because it just hurt too much to raise it,” she says. “I was trying to learn to do things with my left arm. I just wanted someone to tell me what’s wrong with me, because at that point it was unbearable.”
Fortunately, with Scripps as her new health care system, she was in good hands.
Truong’s new primary care physician referred her to a Scripps orthopedic specialist for an ultrasound and an X-ray. The results left him stunned.
“He was like, ‘I’ve been practicing for 35-plus years, and I think I know what this is, but I’ve never seen it. I want you to go get a second opinion,’” she recalls. She was referred to Anna Kulidjian, MD, an orthopedic surgeon at Scripps Clinic Torrey Pines, and a specialist in orthopedic oncology with Scripps MD Anderson Cancer Center.
Dr. Kulidjian confirmed that Truong in fact was not suffering from a rotator cuff injury — she had chondrosarcoma of the glenoid, a very rare form of cancer that’s even more uncommon in younger patients.
As the saying goes: When you hear hoofbeats, look for horses, not zebras. “It’s really one of the rarest cancers,” says Dr. Kulidjian, “so it’s not uncommon to think, especially in a young person, that she has some shoulder problem, or that it’s just usual wear and tear.”
“I’d always been in fairly good health...to go from that to being told I had cancer and would need major surgery, it was pretty scary.”Rose Troung
Advanced imaging showed a golf-ball-size tumor next to her shoulder joint, which is considerably large for such a small space.
Fortunately, it hadn’t metastasized, but the tumor was impacting the intersection of the arm and scapula as well as the muscles that move the shoulder. Chondrosarcoma is unlike most cancers in that it does not respond to radiation or chemotherapy, so surgery was the only possible treatment. However, removing the afflicted glenoid (the shoulder bone socket that connects with the upper arm) typically renders the shoulder incapable of active motion — meaning Truong would never again be able to use her dominant hand to drive, fasten a seatbelt, brush her hair or her teeth, or even feed herself.
“I’d always been in fairly good health,” she says. “I would sometimes get migraines and occasional bronchitis or flu, but I’d never broken a bone or been hospitalized. To go from that to being told I had cancer and would need major surgery, it was pretty scary.”
At this point, she had to face facts and let her friends and family know about her diagnosis. To ease her mind, she consulted a cousin who’s a general practitioner in the Bay Area. He assured her she was in the best possible hands with Dr. Kulidjian and Scripps.
Multidisciplinary care is one of the hallmarks of Scripps, and this case was no different. Dr. Kulidjian enlisted the help of Heinz Hoenecke, Jr., MD, an orthopedic surgeon at Scripps Clinic. Dr. Hoenecke takes special interest in shoulder reconstruction and replacement and also conducts research on shoulder joint repair.
This dynamic doctor duo had to put their heads together and come up with a way to remove Rose Truong’s cancerous glenoid and reconstruct her shoulder in a way that would preserve as much movement as possible and spare her from complications down the line.
There are many ways to reconstruct a shoulder using metal, but Dr. Kulidjian and Dr. Hoenecke also would’ve had to replace the scapula, which would’ve increased Truong’s risk for long-term complications. They agreed that a live bone and cartilage transplant from the tissue bank would be the best option, since it could be reshaped to fit her small frame.
“Our hands were kind of tied,” Dr. Kulidjian says. “We had no way of doing anything traditional. This is where it was really helpful to marry research and innovation.”
Dr. Hoenecke remembered research he’d conducted on doing surgery planning via computer simulation, and he recruited the help of Darryl D’Lima, MD, PhD, director of orthopedic research at the Shiley Center for Orthopaedic Research and Education and an expert in biomechanics.
For weeks, Dr. D’Lima, Dr. Hoenecke and Dr. Kulidjian spent their off-hours creating virtual simulations and 3D models of Truong’s bones and tumor, in which they could visualize her surgery, practice removing the tumor without damaging the surrounding muscles, nerves and blood vessels, and account for any potential issues.
“There’s nothing like having something in your hands rather than just imagining what you’ve got,” says Dr. Hoenecke. “It improves the chances that you’re going to have a successful outcome on the first try. We’re very fortunate and unique in that we’ve had the last 20 years of research with Dr. D’Lima. We’re able to go over there and actually cook up solutions for patients.”
One of the challenges with operating in such a small area is that surgical screws are not an option—they would fracture the delicate bone. The surgeons eventually came to the conclusion that they could use a button and cable system to perform a partial joint transplant with the live graft from the tissue bank. They could leave a portion of the glenoid bone intact, so when they placed live cartilage and a shaved-down donor bone it could match closely enough that her body would accept it and heal the area over time.
It took a lot of work and creativity, but the 3D-printed replicas allowed Dr. Hoenecke and Dr. Kulidjian to come up with a plan to reach the tumor from the front and back simultaneously.
“We’ve been able to move the boundary of functional reconstruction because of collaboration with our colleagues who provide us with 3D printing,” says Dr. Kulidjian. “Resections at this stage are truly dependent on their ability to plan out surgery very carefully. When you’re dealing with a small bone with a very large tumor, without 3D printing it’s extremely hard to understand the dynamics of where to enter and exit without cutting off blood supply to the extremity.”
Once the doctors were confident in their technique and had procured the bone from a donor’s tibia, Truong’s surgery was scheduled for October 2020. They had to be precise, removing all the cancer but protecting the surrounding tissue —especially the brachial plexus nerve bundle, which transmits signals from the spine to the shoulder. An error of just a millimeter could either leave Truong with cancerous cells or remove too much bone, making reconstruction impossible.
Their planning and practice paid off. They removed the tumor, the margins were clear, and enough bone remained to complete the reconstruction. A few hours and more than 40 staples later, Rose was cancer free. “It was a very complex surgery, but it went smoothly,” says Dr. Kulidjian. “Every step, instrument, position, incision and team member —including the patient — decides if the next step is even possible. That is the key when it comes to musculoskeletal tumors, because the ability to functionally reconstruct the extremity really depends on careful planning. Every step counts.”
Although Truong’s tumor was gone, she wasn’t out of the woods yet — for the donated bone to take and heal correctly, her arm had to be kept perfectly still for several weeks.
“We created a surgical fracture, and really, bone loves immobilization,” says Dr. Kulidjian. “It’s not so good for the joint — that’s why people get stiff — but the bone has to be stable before you can start working the shoulder. If you start moving the shoulder, then the bone will be the weaker link at the fracture site. Usually, patients develop enough bone that you can move it safely in six to eight weeks. This was a coordinated effort, and the patient had to be part of that.”
Truong wore a brace that held her newly reconstructed shoulder at a specific angle. After she went home from the hospital, her range of motion was limited, since one wrong move — even a forceful sneeze — could significantly disrupt the healing process.
“The brace they’d given me came with its own pillow, but that wasn’t enough,” she says. “They actually strapped some foam on underneath, then they said, ‘Now you can't move and we’re going to have you prop your arm under this for the next six to seven weeks.”
Her husband, Primo Paderanga, took leave from work to be her caregiver, managing her medication; helping her with basic tasks like eating, washing her hair and using the bathroom; taking her for drives along the coast and accompanying her to her follow-up appointments. Truong recalls that the first time he saw her without the brace was while she was getting the staples removed: “I see his face turn green,” she says. “He’d taken a couple of pictures and he made a joke, ‘My little Frankenstein monster,’ and I was like, ‘Thank you very much.’ The nurses were giggling.”
What’s so special about this place is this willingness of people to come together, to bring their expertise... to make the process better.Dr. Anna Kulidjian, Orthopedic Surgeon, Scripps Clinic
Though the process is slow going, Truong is getting stronger every day. She appreciated that both Dr. Hoenecke and Dr. Kulidjian checked in on her during such a critical time in her recovery. They shared in a moment of excitement when she demonstrated that she could still grip her hand and use her fingers. “They let me know how concerned they were, and it made me optimistic,” she says, “like this might actually be okay.”
She got a less cumbersome brace a few weeks later and eventually started physical therapy to remobilize the soft tissue around her shoulder joint. She planned to resume working from home at the one-year mark.
Dr. Kulidjian says it usually takes 18 months to two years before the patient sees their full range of motion coming back, but continuous improvements can be expected for at least a year. Truong has entered the better part of recovery now, where her shoulder has started to move more freely.
Her type of chondrosarcoma typically does not return after resection, but her doctors will continue monitoring her for 10 years. Without collaboration and the multi-disciplinary team approach Scripps is known for, this type of oncologic and functional outcome wouldn’t be possible.
“What’s so special about this place is this willingness of people to come together, to bring their expertise in on their own hours at night, to try to figure out how to make the process better,” says Dr. Kulidjian. “You have the best in shoulder surgery, 3D printing, reconstructions, computer technology and science, and the best in tumor surgery — and then you have an outcome that would not have been possible otherwise.”
“Being collaborative and challenging each other in terms of pushing the envelope to achieve better functional results is where the future lies. And I’m very, very glad that we’re able to help.”