Monday, June 11, 2018

Is there an advantage to mini humeral stems and lesser tuberosity osteotomy in shoulder arthroplasty?

Shoulder arthroplasty using mini‑stem humeral components and a lesser tuberosity osteotomy

These authors conducted a retrospective review of 75 patients who underwent anatomic shoulder arthroplasty utilizing a short stemmed humeral component inserted using a lesser tuberosity osteotomy with mean follow-up of 27.8 months (24–50 months).

Sixty-seven (89.3%) shoulders had uneventful LTO healing. There were five (6.67%) LTO failures, one (1.33%) fibrous union, and two (2.67%) osteotomies that had displaced > 4 mm at 6 weeks; four of the five failures required open repair, including one converted to reverse TSA. The other failure, the fibrous union, and the two displaced osteotomies were without clinical deficits and elected for non-operative management. One patient required intraoperative conversion to a long stem due to concern that metaphyseal bone integrity was compromised, in part, by the LTO. Four (5.33%) stems subsided, with one of them also being frankly loose and requiring revision, while the other three were asymptomatic, not requiring treatment.

Comment: This article points to the risks of poor healing after lesser tuberosity osteotomy and the risks of humeral component loosening and subsidence when lesser tuberosity osteotomy and a short stemmed humeral component are combined.

As illustrated in the figure below from this article,  the amount of bone removed with a standard stem (left) is not greater than that removed for a short stemmed implant (right).  It is also the case that a tightly fit short stem can give rise to proximal stress shielding as suggested in the x-ray below right (arrow).

Our practice is to use an impaction grafted standard humeral stem inserted without a lesser tuberosity osteotomy as shown in this post (see link).

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