Reverse Shoulder Arthroplasty With Proximal Humeral Replacement for the Management of Massive Proximal Humeral Bone Loss

Abstract

Background: Substantial proximal humeral bone loss may compromise reverse shoulder arthroplasty secondary to limited implant support, insufficient soft tissue tension due to shortening, lack of attachment sites for the posterosuperior cuff when present, and lack of lateral offset of the deltoid. In these circumstances, use of a proximal humeral replacement may be considered. Patients/Methods: Between 2012 and 2014, 34 consecutive reverse shoulder arthroplasties were performed using a proximal humeral replacement system. The indications were failed shoulder arthroplasty (15), oncology reconstruction (9), humeral malunion/nonunion (7), prior resection arthroplasty (2), and intraoperative fracture (1). All patients were included in the survival analysis. Twenty-two patients with minimum 2-year follow-up were included in analysis of clinical results. Results: Among the cohort of 34 patients, there were 8 additional reoperations: humeral loosening (3), periprosthetic fracture (2), irrigation and debridement (2), and glenoid loosening (1). Humeral component loosening occurred exclusively in patients undergoing revision shoulder arthroplasty. The 4 patients had an average 3.75 prior procedures before the proximal humeral replacement. Two of the revisions were from cemented to uncemented stems. Among the 23 patients with minimum 2-year follow-up, there was significant improvement in pain scores (4.1 vs 0.6), forward elevation (31 vs 109) degrees, and 81% were satisfied. Conclusion: Use of a proximal humeral replacement when performing a reverse shoulder arthroplasty in the complex setting of substantial proximal humerus bone loss provides good clinical results and a particularly low dislocation rate. However, the rate of loosening of the humeral component in the revision setting suggests that proximal humeral replacement components should be cemented when revising a previously cemented stem. IRB: 16-006966.

The Use of Tumor Prostheses for Primary or Revision Reverse Total Shoulder Arthroplasty With Proximal Humeral Bone Loss

“…Guven et al 3 also demonstrated slightly better results with a mean Constant-Murley score of 53.7%. The lower postoperative PROs reported in the current investigation may be partially explained by lower preoperative status, specifically demonstrated by higher preoperative VAS scores in our patients compared to those reported by Shukla et al 4 (7.0 vs. 4.1 respectively), decreasing the ability of patients to achieve satisfactory results. However, further investigations are warranted to better understand differences in PRO based on surgical techniques, implants and indications.…”

“…Despite overall improvements in PROs following surgery for patients in the current study, postoperative outcomes were generally poor, with less than half of maximum points achieved for average measures of ASES (47.5/100), SANE (40.3%), and SST (30.8%). In contrast, Shukla et al 4 reported an 81% satisfaction rate in patients postoperatively, and Wafa et al 23 reported an average Musculoskeletal Tumor Society functional score of 83% at latest follow-up. Guven et al 3 also demonstrated slightly better results with a mean Constant-Murley score of 53.7%.…”

“…Prosthesis dislocation and implant migration have been associated with inadequate deltoid tensioning and lack of rotator cuff attachment, as these structures are necessary to provide additional stabilization. 4 , 7 , 18 In a study by Guven et al 3 examining clinical outcomes of RSA with a tumor prosthesis following tumor resection, 2 patients experienced postoperative instability. Both patients underwent open reduction and prosthesis augmentation with remnant rotator cuff fibrous tissue, joint capsule and the deltoid muscle with no recurrent instability reported at latest follow-up.…”

“…In the setting of revision surgery, decisions surrounding humeral stem fixation also play a role in implant stability. 4 Specifically, Shukla et al 4 reported that in 50% of cases ( n = 2 of 4) complicated by humeral stem loosening, an uncemented prosthesis was placed following the removal of a cemented stem. Based on their findings, the authors recommended cementing the humeral stem in any revision case where cement was previously used in the humeral canal.…”

“…1 Initially indicated primarily for management of rotator cuff tear arthropathy, 2 RSA is increasingly used for the treatment of acute, complex proximal humerus fractures with rotator cuff deficiency, proximal humeral malunions or nonunions, inflammatory arthritis, revision shoulder arthroplasty, or tumors of the proximal humerus. [2][3][4][5][6] In the settings of revision arthroplasty with substantial proximal humeral bone loss, proximal humerus fractures with severe comminution, or extensive tumor burden, soft tissue stabilizers and their bony attachments are frequently disrupted. Additionally, surgeons are faced with the challenge of achieving appropriate implant fixation due to limitations in the host bone.…”