Original Research

Treating Humeral Bone Loss in Shoulder Arthroplasty: Modular Humeral Components or Allografts

Publish date: February 15, 2018

References

1. Chacon A, Virani N, Shannon R, Levy JC, Pupello D, Frankle M. Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite. J Bone Joint Surg Am. 2009;91(1):119-127. doi:10.2106/JBJS.H.00094.

2. Hattrup SJ, Waldrop R, Sanchez-Sotelo J. Reverse total shoulder arthroplasty for posttraumatic sequelae. J Orthop Trauma. 2016;30(2):e41-e47. doi:10.1097/BOT.0000000000000416.

3. Sewell MD, Kang SN, Al-Hadithy N, et al. Management of peri-prosthetic fracture of the humerus with severe bone loss and loosening of the humeral component after total shoulder replacement. J Bone Joint Surg Br. 2012;94(10):1382-1389. doi:10.1302/0301-620X.94B10.29248.

4. Trompeter AJ, Gupta RR. The management of complex periprosthetic humeral fractures: a case series of strut allograft augmentation, and a review of the literature. Strategies Trauma Limb Reconstr. 2013;8(1):43-51. doi:10.1007/s11751-013-0155-x.

5. Khatib O, Onyekwelu I, Yu S, Zuckerman JD. Shoulder arthroplasty in New York State, 1991 to 2010: changing patterns of utilization. J Shoulder Elbow Surg. 2015;24(10):e286-e291. doi:10.1016/j.jse.2015.05.038.

6. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.

7. Cil A, Veillette CJ, Sanchez-Sotelo J, Sperling JW, Schleck CD, Cofield RH. Survivorship of the humeral component in shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(1):143-150. doi:10.1016/j.jse.2009.04.011.

8. Wright TW. Revision of humeral components in shoulder arthroplasty. Bull Hosp Jt Dis. 2013;71(2 suppl):S77-S81.

9. Duquin TR, Sperling JW. Revision shoulder arthroplasty—how to manage the humerus. Oper Tech Orthop. 2011;21(1):44-51. doi:10.1053/j.oto.2010.09.008.

10. Cil A, Veillette CJ, Sanchez-Sotelo J, Sperling JW, Schleck C, Cofield RH. Revision of the humeral component for aseptic loosening in arthroplasty of the shoulder. J Bone Joint Surg Br. 2009;91(1):75-81. doi:10.1302/0301-620X.91B1.21094.

11. Cofield RH. Revision of hemiarthroplasty to total shoulder arthroplasty. In: Zuckerman JD, ed. Advanced Reconstruction: Shoulder. 1st edition. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007;613-622.

12. Budge MD, Moravek JE, Zimel MN, Nolan EM, Wiater JM. Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary? J Shoulder Elbow Surg. 2013;22(6):739-744. doi:10.1016/j.jse.2012.08.008.

13. Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997;79(5):857-865.

14. Throckmorton TW. Reconstructive procedures of the shoulder and elbow. In: Azar FM, Beaty JH, Canale ST, eds. Campbell’s Operative Orthopaedics. 13th edition. Philadelphia, PA: Elsevier; 2017;570-622.

15. Williams GR Jr, Wong KL, Pepe MD, et al. The effect of articular malposition after total shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement. J Shoulder Elbow Surg. 2001;10(5):399-409. doi:10.1067/mse.2001.116871.

16. De Wilde L, Walch G. Humeral prosthetic failure of reversed total shoulder arthroplasty: a report of three cases. J Shoulder Elbow Surg. 2006;15(2):260-264. doi:10.1016/j.jse.2005.07.014.

17. Owens CJ, Sperling JW, Cofield RH. Utility and complications of long-stem humeral components in revision shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(7):e7-e12. doi:10.1016/j.jse.2012.10.034.

18. Stephens SP, Paisley KC, Giveans MR, Wirth MA. The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):1519-1526. doi:10.1016/j.jse.2015.02.020.

19. Werner BS, Abdelkawi AF, Boehm D, et al. Long-term analysis of revision reverse shoulder arthroplasty using cemented long stems. J Shoulder Elbow Surg. 2017;26(2):273-278. doi:10.1016/j.jse.2016.05.015.

20. Cuff D, Levy JC, Gutiérrez S, Frankle MA. Torsional stability of modular and non-modular reverse shoulder humeral components in a proximal humeral bone loss model. J Shoulder Elbow Surg. 2011;20(4):646-651. doi:10.1016/j.jse.2010.10.026.

21. Kassab M, Dumaine V, Babinet A, Ouaknine M, Tomeno B, Anract P. Twenty nine shoulder reconstructions after resection of the proximal humerus for neoplasm with mean 7-year follow-up. Rev Chir Orthop Reparatrice Appar Mot. 2005;91(1):15-23.

22. Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg. 2007;98(2):292-300. doi:10.2106/JBJS.E.01310.

23. Gagey O, Pourjamasb B, Court C. Revision arthroplasty of the shoulder for painful glenoid loosening: a series of 14 cases with acromial prostheses reviewed at four year follow up. Rev Chir Reparatrice Appar Mot. 2001;87(3):221-228.

24. Abdeen A, Hoang BH, Althanasina EA, Morris CD, Boland PJ, Healey JH. Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am. 2009;91(10):2406-2415. doi:10.2106/JBJS.H.00815.

25. Getty PJ, Peabody TD. Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am. 1999;81(8):1138-1146.

26. Chen CF, Chen WM, Cheng YC, Chiang CC, Huang CK, Chen TH. Extracorporeally irradiated autograft-prosthetic composite arthroplasty using AML® extensively porous-coated stem for proximal femur reconstruction: a clinical analysis of 14 patients. J Surg Oncol. 2009;100(5):418-422. doi:10.1002/jso.21351.

27. Kelly JD 2nd, Purchase RJ, Kam G, Norris TR. Alloprosthetic composite reconstruction using the reverse shoulder arthroplasty. Tech Shoulder Elbow Surg. 2009;10(1):5-10.

28. Cannon CP, Paraliticci GU, Lin PP, Lewis VO, Yasko AW. Functional outcome following endoprosthetic reconstruction of the proximal humerus. J Shoulder Elbow Surg. 2009;18(5):705-710. doi:10.1016/j.jse.2008.10.011.

29. Chao EY, Fuchs B, Rowland CM, Ilstrup DM, Pritchard DJ, Sim FH. Long-term results of segmental prosthesis fixation by extracortical bone-bridging and ingrowth. J Bone Joint Surg Am. 2004;86-A(5):948-955.

30. Goulding KA, Schwartz A, Hattrup SJ, et al. Use of compressive osseointegration endoprostheses for massive bone loss from tumor and failed arthroplasty: a viable option in the upper extremity. Clin Orthop Relat Res. 2017;475(6):1702-1711. doi:10.1007/s11999-017-5258-0.

31. Guven MF, Aslan L, Botanlioglu H, Kaynak G, Kesmezacar H, Babacan M. Functional outcome of reverse shoulder tumor prosthesis in the treatment of proximal humeral tumors. J Shoulder Elbow Surg. 2016;25(1):e1-e6. doi:10.1016/j.jse.2015.06.012.

32. Wang ML, Ballard BL, Kulidjian AA, Abrams RA. Upper extremity reconstruction with a humeral tumor endoprosthesis: a novel salvage procedure after multiple revisions of total shoulder and elbow replacement. J Shoulder Elbow Surg. 2011;20(1):e1-e8. doi:10.1016/j.jse.2010.07.018.

Budge and colleagues¹² prospectively enrolled 15 patients with substantial proximal humeral bone loss (38.4 mm) who had conversion to RTSA without allografting after a failed TSA. All patients showed improvements in terms of the American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value, Constant score, and Visual Analog Scale (VAS) pain score, as well as an improved active range of motion (ROM) and good radiographic outcomes at 2-year follow-up. Although the complication rate was high (7 of 15), most of the complications were minor, with only 2 requiring operative intervention. The only component fracture occurred in a patient with a modular prosthesis that was unsupported by bone proximally. Budge and colleagues¹² suggested that concerns about prosthetic fracture can be alleviated using a nonmodular monoblock design. No prosthesis-related complications occurred in their series, leading them to recommend monoblock humeral stems in patients with severe proximal humeral bone loss.

Stephens and colleagues¹⁸ reported revision to RTSA in 32 patients with hemiarthroplasties, half of whom had proximal humeral bone loss (average 36.3 mm). Of these 16 patients, 10 were treated with monoblock stems and 6 with modular components, with cement fixation of all implants. At an average 4-year follow-up, patients with proximal bone loss had improved motion and outcomes, and decreased pain compared to their preoperative condition; however, they had lower functional and pain ratings, as well as less ROM compared to those of patients with intact proximal bone stock. Complications occurred in 5 (31%) of those with bone loss and in 1 (0.6%) of those without bone loss. Three of the 16 patients with bone loss had humeral stem loosening, with 2 of the 3 having subsidence. Only 1 patient required return to the operating room for the treatment of a periprosthetic fracture sustained in a fall. Of the 16 patients with bone loss, 14 patients demonstrated scapular notching, which was severe in 5 of them. Because patients with altered humeral length and/or standard length stems had worse outcomes, the authors recommended longer stems to improve fixation and advocated the use of a long-stemmed monoblock prosthesis over an allograft-prosthesis composite (APC).¹⁸

However, Werner and colleagues¹⁹ reported high rates of loosening and distal migration with the use of long-stemmed humeral implants in 50 patients with revision RTSA. They noted periprosthetic lucency on radiographs in 48% of patients, with more than half of them requiring revision. In 6 patients with subsidence of the humeral shaft, revision was done using custom, modular implants, with the anatomic curve being further stabilized using distal screw and cable fixation to provide rotational stability.

Using a biomechanical model, Cuff and colleagues²⁰ compared 3 RTSA humeral designs, 2 modular designs, and 1 monoblock design in 12 intact models and in 12 models simulating 5 cm of proximal humeral bone loss. They observed that proximal humeral bone loss led to increased humeral component micromotion and rotational instability. The bone loss group had 5 failures compared to 2 in the control group. All failures occurred in those with modular components, whereas those with monoblock implants had no failures.

ALLOGRAFT-PROSTHESIS COMPOSITE

Composite treatment with a humeral stem and a metaphyseal allograft was described by Kassab and colleagues²¹ in 2005 and Levy and colleagues²² in 2007 (Figures 1A-1C) in patients with tumor resections²¹ or failed hemiarthroplasties.²² Allograft was used when there was insufficient metaphyseal bone to support the implant, and a graft was fashioned and fixed with cerclage wire before the component was cemented in place. In the 29 patients reported by Levy and colleagues,²² subjective and objective measurements trended toward better results in those with an APC than in those with RTSA alone, but this difference did not reach statistical significance. Several authors have identified a lack of proximal humeral bone support as 1 of the 4 possible causes of failure, and suggested that the allograft provides structural support, serves as an attachment for subscapularis repair, and maximizes deltoid function by increasing lateral offset and setting the moment arm of the deltoid.^21-23

$A 71-year-old woman presented with a long-standing atrophic nonunion of a proximal humeral shaft fracture$

Continue to: In a prospective study of RTSA...

References

2. Hattrup SJ, Waldrop R, Sanchez-Sotelo J. Reverse total shoulder arthroplasty for posttraumatic sequelae. J Orthop Trauma. 2016;30(2):e41-e47. doi:10.1097/BOT.0000000000000416.

6. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.

8. Wright TW. Revision of humeral components in shoulder arthroplasty. Bull Hosp Jt Dis. 2013;71(2 suppl):S77-S81.

9. Duquin TR, Sperling JW. Revision shoulder arthroplasty—how to manage the humerus. Oper Tech Orthop. 2011;21(1):44-51. doi:10.1053/j.oto.2010.09.008.

13. Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997;79(5):857-865.

16. De Wilde L, Walch G. Humeral prosthetic failure of reversed total shoulder arthroplasty: a report of three cases. J Shoulder Elbow Surg. 2006;15(2):260-264. doi:10.1016/j.jse.2005.07.014.

27. Kelly JD 2nd, Purchase RJ, Kam G, Norris TR. Alloprosthetic composite reconstruction using the reverse shoulder arthroplasty. Tech Shoulder Elbow Surg. 2009;10(1):5-10.

Treating Humeral Bone Loss in Shoulder Arthroplasty: Modular Humeral Components or Allografts

References

ALLOGRAFT-PROSTHESIS COMPOSITE

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