Wednesday, April 30, 2014

Removing the humeral component in shoulder arthroplasty revision

Humeral windows and longitudinal splits for component removal in revision shoulder arthroplasty

These authors reviewed records of 427 patients undergoing revision shoulder arthroplasty, identifying those requiring a window or longitudinal split.

26 patients had a window created to help remove the stem. Six intraoperative fractures were documented: 5 in greater tuberosity and 1 in humeral shaft. At radiographic follow-up, 23 of 26 windows healed; 2 patients had limited follow-up, and 1 did not have follow-up at their institution.

19 patients had a longitudinal osteotomy. One had intraoperative fracture in greater tuberosity. At radiographic follow-up, 17 of 19 longitudinal splits healed; 1 had limited radiographic follow-up, and 1 did not have follow-up at their institution.

Three patients had both window and longitudinal osteotomy. At radiographic follow-up, all shoulders healed, and there were no intraoperative or postoperative fractures or malunions.

Comment: Humeral component revision is often necessary in the management of failed arthroplasty. Humeral component removal is made more difficult when the component is cemented, if an ingrowth surface or trabecular metal component is used, or if a tight fit exists between the distal tip of the component and the endosteal cortex. For this reason we use impaction grafting to fix the humeral component. Should revision be necessary, the humeral component can be removed by driving it vertically out of the humerus without having to compromise the integrity of the shaft by windowing or split.

Should it prove difficult to remove a cemented, ingrowth, trabecular metal, or impacted stem, we use a longitudinal split followed by a bodice repair as shown here.  The bodice repair avoids the risks associated with circlage (e.g. radial nerve injury, circumferential weakening of the shaft).

We avoid making a window whenever possible to obviate the need for soft tissue detachment as well as the need for a long stem to bypass the weakened shaft.


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