Monday, January 13, 2020

Stemless humeral components - what is their value?

Stemless Humeral Implants in Total Shoulder Arthroplasty

These authors point out that, while stemless humeral implants carry an increased cost, "The relatively low number of outcome reports, the mixed study methodologies, and the short-term follow-up time lengths do not permit definitive comparative conclusions between stemmed and stemless components. To date, no author has suggested that stemless or canal-sparing unconstrained shoulder arthroplasty outcomes are superior to those of stemmed implants from clinical and radiologic perspectives". If value = benefit/cost, stemless implants would have to have superior outcomes to attain the same value as standard stemmed implants.

The 2019 Orthopaedic Network News, provides a cost comparison (ASP = average selling price).

The rationale behind stemless implants, according to these authors, include "bone preserving", "less stress shielding distally", "no diaphysial stress riser", and "less lateralization".

We observe that an impaction grafted standard stem is also bone preserving, without distal stress shielding, without a diaphysial stress riser, and with the desired amount of lateralization.
The authors list the disadvantages of stemless humeral components as "dependence on proximal bone stock, increased cost, subscapularis fixation limitation, FDA approvals and proximal bone response". None of which apply to the standard impaction grafted stem.

This report also details the complications seen with stemless components (rates ranging from 4.9% to 37%), including intraoperative cracks,  humeral component loosening, periprosthetic fractures, rotator cuff tears, greater tuberosity osteolysis, nerve injuries, subscapularis failure, corolla displacements, and glenoid component failure.

We continue to use an impaction grafted standard humeral component, finding that it is safe, efficient, cost effective, and adaptable to almost all situations.

A standard stem also enables us to use an anteriorly eccentric humeral head if necessary to manage excessive posterior translation if this is encountered at surgery.

Finally, we note that every new prosthesis requires a new learning curve for each surgeon

To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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