Humeral Bone Loss in Revision Shoulder Arthroplasty

Abstract

Revision shoulder arthroplasty is becoming more prevalent as the rate of primary shoulder arthroplasty in the US continues to increase. The management of proximal humeral bone loss in the revision setting presents a difficult problem without a clear solution. Different preoperative diagnoses often lead to distinctly different patterns of bone loss. Successful management of these cases requires a clear understanding of the normal anatomy of the proximal humerus, as well as structural limitations imposed by significant bone loss and the effect this loss has on component fixation. Our preferred technique differs depending on the pattern of bone loss encountered. The use of allograft-prosthetic composites, the cement-within-cement technique, and combinations of these strategies comprise the mainstay of our treatment algorithm. This article focuses on indications, surgical techniques, and some of the published outcomes using these strategies in the management of proximal humeral bone loss.

Evaluation and treatment of postoperative periprosthetic humeral fragility fractures

“…Cox et al and Sanchez-Sotelo et al described a technique of allograft prosthesis composite (APC) recommended for fractures with proximal humeral bone loss greater than 5 cm. [48][49][50][51] The technique described is using a humeral stem that bypasses the fracture site with proximal humeral allograft around the stem fixed with cable wiring or compression plating. Notable advantages for APC are to improve humeral component support and fixation, provide attachment sites for surrounding soft-tissue structures, and provide structural humeral length.…”

Management of Humeral and Glenoid Bone Defects in Reverse Shoulder Arthroplasty

“…Longer-term outcomes were studied by Cox et al 14 who followed 73 patients who underwent RTSA with APC from 2 years postoperatively up to 10 years postoperatively. Patient-reported outcomes and range of motion markedly improved, but complications were notable, with 14 patients undergoing revision for prosthetic fracture (6), glenosphere dissociation (2), humeral loosening (2), and infection (2). The survival rate dropped off markedly with prolonged follow-up with a reoperationfree survival rate of 88% at 5 years, 78% at 10 years, and 67% after 10 years.…”

“…Beyond approximately 150 micrometers of motion, bone ingrowth is unlikely and the implant will eventually fail through gross loosening. 1,2 RTSA is commonly used in the revision setting because its design accommodates for soft-tissue deficiencies of the rotator cuff and stabilizing capsule. However, the semiconstrained nature of this implant transmits increased forces to the bone-implant interface.…”

Periprosthetic Humeral Fractures in Shoulder Arthroplasty

“…Sanchez-Sotelo et al also reported good results with this technique 27 . McLendon et al recommended that proximal humeral bone loss of .5 cm should warrant use of allograft-prosthesis composite 47 . When possible, tendons can be sutured to the allograft.…”