Stemmed versus stemmed total shoulder arthroplasty: A comparison of operative times: Stemmed vs stemless TSA operative time
These authors reviewed their master sample of 154 consecutive patients who underwent stemmed and stemless humeral implants. Only primary TSA without augmented glenoid components were included, given the increased operative time for cases with augmented implants. This brought their final sample to 80. Of the included patients, 40 patients (50.0%) underwent stemless TSA and 40 patients (50.0%) underwent stemmed TSA. A stemmed implant was used if a patient exhibited contraindications to stemless TSA, including severe osteoporosis or evidence of poor cancellous bone in the operating room based upon thumb test (pressing into the bone with the thumb to assess rigidity and bone density).
The stemmed cohort included 15 males and 25 females and the stemless cohort had 18 males and 22 females.
Patients in the stemless group were younger with a mean age of 61 compared to 68 in the stem group (P<0.01).
Operative time for the stemmed humeral implants was 100 minutes vs 87 minutes for the stemless implants (p=0.04).
This study did not compare the clinical outcomes or adverse outcomes for the two types of implants.
Comment: The authors point out that a stemless component depends on metaphyseal bone quality for fixation. Apparently, half of their patients were deemed inappropriate for the stemless implant based on "contraindications to stemless TSA, including severe osteoporosis or evidence of poor cancellous bone"; therefore it would seem necessary to have both stemmed and stemless implants available so that the decision between implants could be made based on the intraoperative "thumb test".
They also point out that stemless implants may be associated with increased cost, so that the savings resulting from a shorter operative time may be offset by the expense of the implant.
Our practice is to maximize our skill using a single versatile method for total shoulder arthroplasty with a standard stemmed implant inserted with impaction autografting; this is an approach that works for osteoporotic bone as well as for more normal bone.
Our method is shown in this link.
