Friday, August 23, 2013

Reverse total shoulder in a person with osteoporosis - impaction grafting hybrid

Patients with rotator cuff tear arthropathy needing a reverse total shoulder often have osteoporosis and often have a tendency to fall because of balance problems and poor vision and lower extremity dysfunction.
This is a bad combination in that conventional approaches to reverse total shoulder arthroplasty involve cementing a metal stem in a manner that stiffens the bone down to the end of the cement and then provides a sudden transition to the thin bone below (see the way the white cement on this x-ray ends suddenly).

A fall on such an arm risks fracture at the tip of the cemented prosthesis because of this stress riser and because the reverse total shoulder does not have the 'give' of a normal shoulder. 

For these reasons, we've been exploring a hybrid method for fixing the humeral stem in which a smaller stem is selected, the canal around the stem is filled by impaction grafting and cement is used only at the upper end of the prosthesis as shown for the osteoporotic shoulder below.

Note the absence of cement in the canal except for the upper end and the canal filled with impaction grafted bone.

Here's another similar case from this week in a lady with paralysis of the opposite arm.

Note again the small stem and impacted bone graft.

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