Allograft-Prosthetic Composite Reconstruction for Massive Proximal Humeral Bone Loss in Reverse Shoulder Arthroplasty

Sanchez-Sotelo, Joaquín; Wagner, Eric R.; Sim, Franklin H.; Houdek, Matthew T.

doi:10.2106/jbjs.16.01495

Cited by 61 publications

(52 citation statements)

References 18 publications

(14 reference statements)

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“…Delayed union was defined as visible fracture line without bridging callus at one year followup. Radiological union was defined when the junction was no longer visible and a bridged callus was visible on three of four cortices [17].…”

Section: Outcome Measuresmentioning

confidence: 99%

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

Halvachizadeh¹,

Berk²,

Rauer³

et al. 2020

PLoS ONE

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Introduction Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making. Methods This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm 3 bone-loss or an eggshell situation, where the patient refused arthroplasty. Results This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus-0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups.

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Section: Outcome Measuresmentioning

confidence: 99%

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

Halvachizadeh¹,

Berk²,

Rauer³

et al. 2020

PLoS ONE

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“…2,3 Numerous methods are available for the reconstruction of long bone defects following en bloc resection of the proximal humerus tumours, including vascularized fibular autograft, 4 osteoarticular allograft, 5,6 endoprosthetic reconstruction, 7,8 and allograft-prosthetic composite arthroplasty. [9][10][11] Nevertheless, these techniques are usually associated with bone absorption, nonunion, shoulder joint dislocation and poor shoulder function. More recently, more surgeons choose RSA for the shoulder joint reconstruction after resection of the proximal humerus tumours; the reason for this is that it can improve the shoulder function after reconstruction and decrease the complication rate.…”

Section: Introductionmentioning

confidence: 99%

<p>The Personalized Shoulder Reconstruction Assisted by 3D Printing Technology After Resection of the Proximal Humerus Tumours</p>

Liu

Zeng

et al. 2019

CMAR

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These authors contributed equally to this work Background: The reverse shoulder arthroplasty (RSA) may be a promising alternative for proximal humerus tumours because of good postoperative shoulder function. However, the conventional reverse shoulder prosthesis can not meet individual needs and RSA has been associated with a relatively high complication rate. Therefore, implant design and surgical reconstruction technique warrant further study. Methods: Between September 2015 and May 2018, 7 patients were treated via RSA after enbloc resection of the proximal humerus tumours. A 3D-printed guiding baseplate was used to assist the implant of the 3D-printed glenoid prosthesis; a personalized humerus prosthesis was used to reconstruct the proximal humerus. The functional outcomes were assessed by range of motion (ROM) of the shoulder joint, Musculoskeletal Tumour Society (MSTS) functional score, and Toronto Extremity Salvage Score (TESS). We also analyzed tumour recurrence, metastases, and complications associated with the reconstruction procedure. Results: All patients were observed for 14 to 36 months, with an average of 23.6 months. At the final follow-up, the mean MSTS score was 85.7% (range, 73.3-93.3%), and the mean TESS score was 90.0% (range, 84.1-95.9%). No instability, infection, scapular notching, loosening or fracture were observed in this series. One patient with GCT suffered from pulmonary metastasis, while one with osteosarcoma died because of pulmonary metastasis. Conclusion: The 3D-printed guiding baseplate facilitated the accurate implantation of the glenoid prosthesis. The RSA based on a 3D-printed glenoid prosthesis and a personalized custom-made humerus prosthesis significantly improved the shoulder function and decreased the complication rate. Further studies of a larger scale with longer follow-up are required to validate this technology.

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“…11,32,33,48 Although reconstruction of the proximal humeral bone stock, together with restoration of a functional glenohumeral joint, is desirable, such a complex surgical procedure is rare and remains a challenge for the shoulder surgeon. 12,13,17,19,34,46 Historically, different reconstructive techniques such as arthrodesis, 15 massive osteoarticular allografts, 24,25,42 and massive anatomic tumor prostheses 1,3,21,30 have been proposed. Because of the good results observed in patients with cuff tear arthritis or massive cuff tears, reverse shoulder arthroplasty (RSA) was introduced as a reconstructive option in patients with proximal humeral resection or bone loss.…”

mentioning

confidence: 99%

“…Because of the good results observed in patients with cuff tear arthritis or massive cuff tears, reverse shoulder arthroplasty (RSA) was introduced as a reconstructive option in patients with proximal humeral resection or bone loss. 9 Basically, modern reconstructive options for PHBL or resection include the use of a mega-tumor reverse prosthesis 11,27,29,33,48,50,54 and RSA without 7,27,29,33,48,50,54 or with allograft augmentation, 13,17,18,34,36,46 so-called reverse shoulder-allograft prosthesis composite (RS-APC).…”

mentioning

confidence: 99%

“…Although RS-APC is an attractive surgical option to reconstruct shoulders with severe PHBL, previous reports have reported high rates of humeral loosening (up to 30%), 50,54 allograft fragmentation and/or resorption (21%), 13,39 and allograft nonunion (ranging from 3.8% to 100%). 1,13,31,36,46 In an effort to solve the challenge of nonunion of the allograft-host bone junction and the problems of implant and/or graft stability, the senior author (P.B.) developed a specific technique for RS-APC.…”

mentioning

confidence: 99%

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Reverse shoulder–allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss

Boileau

Raynier

Chelli

et al. 2020

Journal of Shoulder and Elbow Surgery

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Background: The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer. Methods: An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a ''mirror step-cut osteotomy,'' without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years). Results: Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20 vs. 0 , P < .001) and forward elevation (140 vs. 90 , P ¼ .045). Conclusions: (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.

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Allograft-Prosthetic Composite Reconstruction for Massive Proximal Humeral Bone Loss in Reverse Shoulder Arthroplasty

Abstract: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cited by 61 publications

References 18 publications

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

<p>The Personalized Shoulder Reconstruction Assisted by 3D Printing Technology After Resection of the Proximal Humerus Tumours</p>

Reverse shoulder–allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss

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