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Humeral Bone Loss in Revision Shoulder Arthroplasty

February 15, 2018 | Surgery
Paul B. McLendon, MD ; Jacob L. Cox, MD ; Mark A. Frankle, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Frankle reports that he receives royalties and consulting fees from DJO Surgical and is a paid consultant for Cayenne Medical. The other authors report no actual or potential conflict of interest in relation to this article.

Dr. McLendon is a Shoulder and Elbow Fellow, Florida Orthopaedic Institute, Tampa, Florida. Dr. Cox is an Orthopedic Resident, Morsani College of Medicine, University of South Florida, Tampa, Florida. Dr. Frankle is Chief, Shoulder and Elbow Department, Florida Orthopaedic Institute, Tampa, Florida.

Address correspondence to: Mark A. Frankle, MD, Shoulder and Elbow Department, Florida Orthopaedic Institute, 13020 N Telecom Pkwy, Tampa, FL 33637 (tel, 813-978-9700; fax, 813-558-6135; email, mfrankle@floridaortho.com).

Paul B. McLendon, MD Jacob L. Cox, MD Mark A. Frankle, MD . Humeral Bone Loss in Revision Shoulder Arthroplasty. Am J Orthop. February 15, 2018

TAKE-HOME POINTS

  • Different preoperative diagnoses lead to distinct patterns of bone loss in revision shoulder arthroplasty.
  • A variety of techniques should be utilized to address the specific pathologies encountered.
  • Advanced proximal humeral bone loss results in limited substrate available for humeral component fixation.
  • Monoblock humeral stems can be used without allografts in cases with mild humeral bone loss.
  • The revision of loose humeral stems dictates the use of large diaphyseal allografts in the majority of cases.

In more advanced cases of bone loss, our data shows that use of APCs can result in equally satisfactory results. In a series of 25 patients with an average bone loss of 54 mm, patients were able to achieve statistically significant improvements in pain, ROM, and function with high rates of allograft incorporation.9 Overall, a low rate of complications was noted, including 1 infection. This finding is consistent with an additional study looking specifically at factors associated with infection in revision SA, which found that the use of allografts was not associated with increased risk of infection.41

As stated previously, the size of allograft needed for the APC construct is related to the distinct pathology encountered. In our experience, we have noted that well-fixed stems can be treated with short metaphyseal APCs in 85% of cases. On the other hand, loose stems require long allografts measuring >10 cm in 90% of cases. As such, these cases typically require mobilization of the deltoid insertion as described above, and therefore it is important that the surgeon is prepared for this aspect of the procedure preoperatively.

Finally, the cement-within-cement technique, originally popularized for use in revision total hip arthroplasty, has demonstrated reliable results when utilized in revision SA.42 To date, there are no recommendations regarding the minimal length of existing cement mantle that is needed to perform this technique. In situations in which the length of the cement mantle is questionable, our preference is to combine the cement-within-cement technique with an APC when possible.

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