Reverse shoulder arthroplasty–allograft for revision of failed arthroplasty associated with proximal humeral bone deficiency

Clinical outcomes following reverse shoulder arthroplasty–allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up

These authors report the results of 73 patients were treated with a reverse shoulder allograft composite for failed prior arthroplasty. A typical preoperative defect is shown below

Press-fit stems were removed using a combination of burrs and osteotomes to separate the bone-implant interface, followed by impaction devices and mallets to remove the stem.  For cemented stems, if the previous cement mantle was stable and there was no concern for infection, the cement was left intact and a cement-within-cement technique was performed.

If the degree of bone loss compromised the stability of the revision prosthetic stem, a fresh-frozen allograft was shaped using an oscillating saw and a step-cut technique.

 

The prepared allograft was then cabled to the host bone using multiple 1.7-mm cables, and the definitive humeral component was cemented into the final construct. 

Patients were significantly improved and were usually satisfied, but the self-assessed function remained limited: the Simple Shoulder Test score improved from 1.3 to 3.5.  Range of flexion improved from 49° to 75°.  Revision was required in 14 patients (19%) for periprosthetic fracture (n = 6), instability (n = 2), glenosphere dissociation (n = 2), humeral loosening (n = 2), and infection (n = 2) at a mean of 38 months postoperatively. 

The reoperation-free survival rate of all reconstructions was 88% (30 of 34) at 5 years, 78% (21 of 27) at 10 years, and 67% (8 of 12) beyond 10 years. 

Ten patients had radiographic evidence of humeral loosening at final follow-up.

Comment: Failed reverse total shoulders often have associated loss of proximal bone with poor remaining bone quality - factors that complicate surgical revision.

The authors of this paper have extensive experience with these revisions. As they point out, infection, host bone quality that is insufficient for circlage, and massive amounts of bone loss present additional challenges. Finding an appropriately sized proximal humeral allograft of the desired side can also be a major problem. Hand crafting the humerus using struts and a long stem prosthesis may be necessary.

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Revision of failed shoulder arthroplasty with reverse total shoulder - allograft needed?

Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary?

It is well known that one of the highest complication rates in reverse total shoulder is when this procedure is used for failed prior arthroplasty. These patients often have complex problems, including instability, glenoid bone deficiency, humeral bone deficiency, subscapularis deficiency and possibly low grade infection. This study reports the results of RTSA without proximal humeral allograft in 15 patients with proximal humeral bone loss after failed shoulder arthroplasty. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years. Overall function was improved. Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture in 1 modular humeral stem.

The authors do point out that when a modular humeral stem is used in patients with bone deficiency, the addition of proximal humeral allograft may increase the stability of the construct and prevent fracture at the modular stem–cup junction.

The key things to consider is that (1) reverse total shoulders apply a greater rotational moment to the humeral fixation than a standard total shoulder and (2) that there is less resistance to this rotational moment when the tuberosities are deficient (as is often the case in revision of a prior arthroplasty). Humeral component fixation in the shaft becomes very important. Conceivably, a secure allograft might further increase the resistance to torque. 

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Biologic resurfacing with meniscal allograft

Biologic resurfacing of the glenoid with meniscal allograft: long-term results with minimum 2-year follow-up

The idea of resurfacing the arthritic glenoid with a cadaver meniscus along with a humeral hemiarthroplasty was thought to be a reasonable option for managing arthritis without using a plastic glenoid prosthesis. 

These authors report on 19 shoulders treated with meniscal allograft glenoid resurfacing and shoulder hemiarthroplasty at a minimum of two years after surgery.  Six of the patients required revision surgery. In the shoulders having revision surgery the grafts had been reabsorbed. 

While seemingly initially attractive, this procedure depends on the allograft healing to the underlying glenoid bone and on its maintaining its integrity under the severe loading conditions of the glenohumeral joint. 

We continue to offer the ream and run procedure to individuals with glenohumeral arthrits who wish to avoid the risk of glenoid component failure. 

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How Much Are Upper or Lower Extremity Disabilities Associated with General Health Status in the Elderly? CORR

How Much Are Upper or Lower Extremity Disabilities Associated with General Health Status in the Elderly? CORR

This paper uses a population of 272 individuals without a history of surgery for musculoskeletal disease or trauma to test the hypothesis that the DASH score (Disabilities of the Arm Shoulder and Hand - a self-reported measure of upper extremity comfort and function) is correlated with the SF 36 (a self-reported measure of overall well-being. Not surprisingly, the results of the two are correlated, the DASH is particularly associated with the physical component summary scale of the SF 36.

In that there was no documentation of the presence of upper extremity disability in these individuals, one might expect that the observed effect would have been even stronger in those with known rotator cuff tears, arthritis, carpal tunnel syndrome and the like. We have previously reported on the correlation of comorbidity with function of the shoulder and health status of patients who have glenohumeral degenerative joint disease and on the relationship of the SF 36 and shoulder function in degenerative disease and rheumatoid arthritis.

What was particularly interesting was the effect of gender and age on the DASH. Recalling that a score of 0 is no disability and 100 is total disability, males averaged a score of 15.67 ± 13.34 while women average 27.07 ± 20.00 (p<0.001). Individuals aged 65 to 75 averaged 19.60 ± 17.20 while those over 75 averaged  24.68 ± 18.80 (p<0.029).  This indicates that, in contrast to the usual practice, DASH scores need to be normalized by age and gender and that combining ages and genders in reporting results may lead to erroneous conclusions.

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Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. JSES

Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. This article provides a useful approach for managing severe glenoid bone loss in the performance of a reverse total shoulder. They have taken the innovative step of using a ring of femoral neck allograft to help support the base plate and to contain autograft cancellous bone within. This method enables the surgeon to customize the graft to accommodate asymmetric glenoid defects.  In the five cases they reported, the grafts united.

In the application of this method, it seems important to (1) assure a solid contact between the graft and the residual glenoid bone and (2) to robustly compress the graft into the bone using secure screw placement in the patient's scapula.

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shoulderarthritis@uw.edu

Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

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