Abstract
Background: Humeral hemiarthroplasty is an established treatment for
patients with selected fractures of the proximal part of the humerus. However,
a subset of patients have development of glenoid arthritis and rotator cuff
deficiency due to tuberosity failure. To date, there has been no reliable
salvage procedure for this problem.
Methods: Over a period of five years, twenty-nine patients
(twenty-five women and four men) with a mean age of sixty-nine years (range,
forty-two to eighty years) were managed with removal of a hemiarthroplasty
prosthesis and revision with a Reverse Shoulder Prosthesis alone or in
combination with a proximal humeral allograft. Patients were followed
clinically and radiographically for an average of thirty-five months. All
patients were evaluated with use of the American Shoulder and Elbow Surgeons
score; the Simple Shoulder Test; range-of-motion measurements, including
abduction, forward flexion, and external rotation; and a rating scale for
overall satisfaction with the outcome of the surgery. Patients were assessed
preoperatively and at all follow-up points beginning at three months
postoperatively.
Results: The average total American Shoulder and Elbow Surgeons
score improved from 22.3 preoperatively to 52.1 at the time of the last
follow-up (p < 0.001). The average American Shoulder and Elbow Surgeons
pain score improved from 12.2 to 34.4 (p < 0.001), and the average American
Shoulder and Elbow Surgeons function score improved from 10.1 to 17.7 (p =
0.058). The average Simple Shoulder Test score improved from 0.9 to 2.6 (p =
0.004). Forward flexion improved from 38.1° to 72.7° (p < 0.001),
and abduction improved from 34.1° to 70.4° (p < 0.001). The overall
complication rate was 28% (eight of twenty-nine). At the time of the latest
follow-up, sixteen patients rated the outcome as good or excellent, seven
rated it as satisfactory, and six were dissatisfied. Four of the six patients
who were dissatisfied had been managed with a Reverse Shoulder Prosthesis
alone.
Conclusions: The Reverse Shoulder Prosthesis offers a salvage-type
solution to the problem of failed hemiarthroplasty due to glenoid arthritis
and rotator cuff deficiency following tuberosity failure. The early results
reported here are promising. In cases of severe proximal humeral bone
deficiency, augmentation of the Reverse Shoulder Prosthesis with a proximal
humeral allograft may improve patient satisfaction.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Humeral head replacement is a well-established treatment option for
four-part and selected three-part fractures of the proximal part of the
humerus, as was first reported by
Neer1-3.
Excellent or satisfactory results have been reported in as many as 91% of
these
patients1,2,4-9.
The results of later studies involving hemiarthroplasty, however, have been
mixed, with many patients reporting pain relief, with varying functional
results10-18.
A challenge exists with regard to how to successfully manage patients who have
had a failure. The causes of failure of hemiarthroplasties performed for the
treatment of proximal humeral fractures are thought to be multifactorial and
include both patient and surgeon-based
factors18-20.
More commonly reported complications include stiffness, tuberosity malunion or
nonunion19-24,
rotator cuff tear, instability, glenoid arthritis, infection, and component
malpositioning4,6-8,21,22,25.
Failures that result in glenoid arthritis and rotator cuff deficiency due
to tuberosity malunion, nonunion, or resorption can be devastating. Additional
challenges such as humeral stem loosening and infection may be present as
well. This subset of patients presents with a complex interaction of shoulder
abnormalities, including loss of glenohumeral alignment, glenoid wear,
proximal humeral bone loss, rotator cuff tendon and muscle loss, soft-tissue
contractures, and instability (Figs. 1-A
and 1-B). Such abnormalities usually manifest in a clinical
picture of severe pain and loss of function of the shoulder. Until now, there
has been no reliable salvage procedure for this problem.
The Reverse Shoulder Prosthesis offers a possible solution to this problem.
This prosthesis, by adding a more conformed articulation, compensates for
muscular imbalance in which the glenohumeral articulation is unable to provide
the inherent stability that is necessary for shoulder function (Figs.
2-A and 2-B). In addition, it
provides an opportunity to reconstruct humeral offset with bone-graft
augmentation (Figs. 3-A and
3-B). Although this prosthesis initially was designed to address
rotator cuff deficiency in the setting of glenohumeral arthritis, we have
utilized the Reverse Shoulder Prosthesis in the revision setting to treat
failed hemiarthroplasty for proximal humeral fractures associated with glenoid
arthritis and rotator cuff deficiency. To our knowledge, this is the first
such report in the literature on this topic.
Between 1999 and October 2005, fifty-seven patients who had pain and
loss of function after undergoing a primary hemiarthroplasty procedure for the
treatment of a proximal humeral fracture were found to have glenoid arthritis
and rotator cuff deficiency. All patients had some degree of glenoid arthritis
(seen on preoperative radiographs and/or intraoperatively) and an irreparable
rotator cuff (suspected clinically and confirmed intraoperatively) due to
fracture malunion, nonunion, or tuberosity resorption. All patients were
managed with a single-stage revision to a Reverse Shoulder Prosthesis (Encore
Medical, Austin, Texas). Twenty-nine of these patients were followed for a
minimum of two years and were included in the study.
All procedures were performed by the senior author (M.F.). Initially, all
patients were managed with a Reverse Shoulder Prosthesis alone. However, two
of the initial six patients had development of three humeral-sided mechanical
failures. All of these patients had severe proximal humeral bone loss.
Mechanical failure of the humeral socket was thought to be related to lack of
cortical bone support needed for rotational and structural stability due to
proximal humeral bone loss. This bone loss, not present after the initial
hemiarthroplasty, was likely due to tuberosity nonunion or resorption. Thus,
as surgeon comfort with the use of the Reverse Shoulder Prosthesis improved,
patients with extensive proximal humeral bone loss were managed with a
proximal humeral allograft-Reverse Shoulder Prosthesis complex. Eight
shoulders were reconstructed with use of a proximal humeral allograft-Reverse
Shoulder Prosthesis complex, and twenty-one were reconstructed with use of a
Reverse Shoulder Prosthesis alone. The study group included twenty-five women
and four men with a mean age of sixty-nine years (range, forty-two to eighty
years).
In order to be included in the present study, a patient had to have had a
previous hemiarthroplasty for the treatment of a proximal humeral fracture
followed by the development of severe pain and loss of function of the
shoulder. All patients had had a failure of all attempts at nonoperative
measures, including medical management, physical therapy, and cortisone
injections. Patients with previous infections were not excluded. There were
six such patients, three of whom had been previously managed with a staged
procedure in which an antibiotic spacer had been placed. In all patients, the
extent of glenoid arthritis and rotator cuff deficiency was assessed
preoperatively by means of clinical and radiographic examination and was
confirmed intraoperatively. Patients were excluded if reconstruction could be
achieved by other means (i.e., repairable tuberosities or isolated glenoid
arthritis).
Operative Technique
The patient was positioned in the upright beach-chair position with the
head firmly secured and the arm draped free. The involved arm was positioned
sufficiently off the side of the table to allow for unobstructed movement of
the shoulder in adduction and hyperextension. All patients were given general
anesthesia in addition to a scalene block. An extended deltopectoral approach
was used, and as much as two-thirds of the pectoralis major tendon was
released. The subdeltoid, subacromial, and subcoracoid spaces were released.
Tuberosity position and integrity were assessed. If either tuberosity was not
united, it was removed to freely release the rotator cuff. Additionally, if
the greater tuberosity was malunited in an inferior-posterior position, the
rotator cuff was released. If the subscapularis tendon was intact, it was
released just medial to the long head of the biceps, allowing atraumatic
dislocation of the humeral hemiarthroplasty implant with gentle external
rotation and extension of the arm. The subscapularis was tagged for future
repair to either the host or the allograft proximal part of the humerus.
Specimens were obtained for intraoperative frozen-section analysis and culture
at this time. The humeral hemiarthroplasty prosthesis was then removed, with
the previous cement mantle being left intact. In cases in which the results of
intraoperative frozen-section analysis revealed more than five
polymor-phonuclear neutrophils per high-power field, the entire cement mantle
was removed26.
Heterotopic ossification and osteophytes were resected, a neck cut was made in
30° of retroversion, and a trial broach was placed into the cement mantle
until it was just distal to the neck cut. This was followed by reaming of the
proximal humeral metaphysis. Next, the glenoid was exposed with use of a
360° periglenoid capsular release. A centering hole was drilled and tapped
with a 15° inferior tilt. The glenoid was prepared with a cannulated
convex reamer. A fixed-angle glenoid baseplate was then screwed into place,
ensuring at least 60 in-lb (6.8 N-m) of torque. Additional 3.5-mm peripheral
fixation screws were then attached to the glenoid baseplate. One of a variety
of glenosphere sizes was chosen (32 mm, 36 mm, 40 mm), depending on the degree
of soft-tissue contracture, stability, and resulting motion, and this
glenosphere was fit onto the baseplate by means of a Morse taper (initially,
only the 32-mm glenosphere was available).
After reduction with the humeral broach and a trial polyethylene component,
the appropriate size of humeral implant that would allow a 2-mm
circumferential cement interface around the component was selected and a trial
reduction was performed. In cases in which there was proximal humeral bone
loss such that the prosthesis would remain unsupported by metaphyseal bone, a
proximal humeral allograft was prepared (as described below) and was secured
with cerclage wire fixation. The stem was then cemented into the previous
cement mantle. The reduction was checked for stability, especially in
abduction, extension, and internal rotation, and achievement of full passive
elevation was confirmed. The subscapularis was repaired through drill-holes
into the native proximal part of the humerus or was sutured to the allograft
subscapularis tendon, followed by a routine closure with use of number-2
braided polyester sutures.
Proximal Humeral Allograft Preparation
A fresh-frozen proximal humeral allograft (University of Miami Tissue Bank,
University of Miami Miller School of Medicine, Miami, Florida) was prepared to
match the proximal part of the patient's humerus. The humeral head was
resected at the anatomic neck. All of the cancellous allograft bone was
removed from the intramedullary canal. An oscillating saw was then used to
create a step-cut of the metaphyseal bone such that 5 cm of bone remained
laterally and 1 to 2 cm of bone remained medially, resulting in a lateral
plate. All soft tissue was removed, with the exception of the subscapularis
tendon. The allograft tendon attachment would later be used for repair of the
subscapularis.
Antibiotic Prophylaxis
At the time of surgery, specimens were obtained from all patients for
intraoperative frozen-section analysis and cultures for aerobic, anaerobic,
and fungal organisms as well as acid-fast bacilli. Patients who were known to
have had a preoperative infection, those who had positive results on culture,
and those for whom frozen-section analysis revealed more than five
polymorphonuclear neutrophils per high-power field were managed with a minimum
of six weeks of intravenous antibiotics as directed by an infectious disease
specialist. Additionally, all but one of the patients who underwent an
allograft reconstruction were managed with prophylactic intravenous
antibiotics for a minimum of two weeks as dictated by an infectious disease
specialist on the basis of the results of the final intraoperative cultures
and pathology studies.
Postoperative Rehabilitation
A shoulder immobilizer was worn for six weeks, and passive range-of-motion
exercises were performed. These passive-motion exercises (consisting of
pendulum exercises only) were started on the day after surgery under the
supervision of a physical therapist. After the first six weeks, the arm was
placed in a sling and gentle active and active-assisted activities were begun.
Resistive exercises were delayed until twelve weeks.
Preoperative and Postoperative Assessment
Clinical Assessment
Patients were assessed preoperatively and at all follow-up points beginning
at three months postoperatively. Patients completed forms that included the
American Shoulder and Elbow Surgeons (ASES) assessment for pain and
function27, the
Simple Shoulder Test
(SST)28,29,
and a rating scale for overall satisfaction with the outcome of surgery
(dissatisfied, satisfied, good, or excellent). An orthopaedic surgeon (J.L.)
who was not involved in the treatment of the patients measured the range of
shoulder motion preoperatively and postoperatively with use of a goniometer
while digital clinical videos were played back on a computer. Preoperative and
postoperative flexion, abduction, and external rotation data were available
for all patients.
Radiographic Assessment
All patients were evaluated with anteroposterior, Y lateral, internal and
external rotation
Grashey30, and
axillary plain radiographs.
Preoperative radiographic markers: Preoperative radiographs were
assessed for glenoid bone loss, glenoid arthritis, the condition of the
tuberosities, evidence of instability, evidence of humeral loosening, and the
presence of proximal humeral bone loss. Glenoid bone loss on radiographs was
assessed on the basis of the intraoperative classification system of Antuna et
al.31. First, the
presence or absence of glenoid bone loss was noted. If present, the extent of
bone loss was judged on the basis of whether it was central or peripheral.
Finally, the location of peripheral glenoid bone loss was specified as
anterior, posterior, superior, inferior, or a combination of the above (for
example, anterosuperior). Glenoid arthritis was simply judged on the basis of
its presence or absence. As noted above, all patients in the present study had
some degree of glenoid arthritis that was noted either on preoperative
radiographs or intraoperatively. Careful attention was given to the condition
of the tuberosities on radiographs, with the presence or absence of malunion,
nonunion, and/or resorption being noted. Evidence of instability was judged on
the basis of the presence and direction of the translation of the center of
the prosthetic head relative to the center of the glenoid (anterior,
posterior, superior, inferior, or a
combination)31.
Humeral loosening was judged radiographically as being present or absent by
looking for humeral radiolucencies. If present, loosening was judged as being
either partial or global. Finally, preoperative and immediate postoperative
radiographs were compared to determine the presence or absence of proximal
humeral bone loss.
Postoperative radiographic markers: The last available
postoperative radiographs were analyzed for the presence or absence of
baseplate loosening (radiolucency around the baseplate screws), inferior
glenoid notching, and instability (dislocation of the glenosphere from the
polyethylene component). Radiographs were also evaluated for any evidence of
hardware failure, and the type of failure was noted. Finally, the presence or
absence of a healed allograft was also noted.
Statistical Analyses
Pain and function scores and range-of-motion values were compared
preoperatively and postoperatively by an independent statistician with use of
a difference-of-means test (Stat-View; SAS Institute, Cary, North Carolina).
The subsets of patients with proximal humeral bone loss who were managed with
and without allograft reconstruction were compared on the basis of an
independent t test for equality of means. The level of significance was set at
p <0.05.
The clinical results, including the ASES and SST scores as well as
the range-of-motion measurements, are summarized in
Table I. Range of motion
improved significantly as compared with the preoperative values. Forward
flexion improved by an average of 34.6°, from 38.1° to 72.7° (p
< 0.001), and abduction improved by an average of 36.3°, from 34.1°
to 70.4° (p < 0.001). This result is similar to the average 50°
improvement in forward flexion for patients managed with a primary Reverse
Shoulder Prosthesis for rotator cuff
deficiency32.
At the time of the latest follow-up, sixteen (55%) of the twenty-nine
patients rated the result as good or excellent, seven (24%) rated it as
satisfactory, and six (21%) stated that they were dissatisfied. Patients with
substantial proximal humeral bone loss were divided into two groups: those who
had been managed with an allograft-Reverse Shoulder Prosthesis combination and
those who had been managed with a Reverse Shoulder Prosthesis alone. Four of
the six dissatisfied patients had been managed with a Reverse Shoulder
Prosthesis alone. In addition, six of the eight patients who had been managed
with an allograft-prosthesis combination rated the result as good or
excellent, compared with ten (48%) of the twenty-one patients who had been
managed with the Reverse Shoulder Prosthesis alone. While no significant
difference was found between the two methods of treating proximal humeral bone
loss on the basis of the numbers available, all functional scores (with the
exception of forward elevation) showed trends of improvement, with higher
scores in patients who had been managed with a proximal humeral
allograft-Reverse Shoulder Prosthesis construct.
Of the six dissatisfied patients, two had failure because of a lack of
proximal humeral bone support, one had development of a postoperative
infection, one had an intraoperative complication (cement extravasation) with
a temporary radial nerve palsy, and one had been poorly selected for the
procedure. The final dissatisfied patient was only available for a phone
interview, six years after the procedure. As no radiographic or clinical
examinations were possible, the cause of dissatisfaction in that case could
not be determined.
Preoperative radiographs revealed proximal humeral bone loss in 83%
(twenty-four) of the twenty-nine patients, glenoid bone loss in 72%
(twenty-one), glenohumeral instability in 72% (twenty-one), glenoid arthritis
in 76% (twenty-two), and humeral loosening in 24% (seven). Radiographic
evaluation of the tuberosities demonstrated malunion in 24% (seven) of the
twenty-nine patients, nonunion in 17% (five), and evidence of resorption in
76% (twenty-two) (see Appendix).
Evaluation of the last follow-up radiographs demonstrated radiolucency
around the baseplate in three (10%) of the twenty-nine patients, no instances
of glenoid notching, and four instances in which there was evidence of
hardware failure (including two instances of failure of the polyethylene
socket, one dislocation, and one instance of breakage of a cerclage wire that
had been used for tuberosity fixation). Evaluation of the eight allografts
that had been placed during the initial Reverse Shoulder Prosthesis procedure
demonstrated that four were integrated, one had been removed during
débridement for the treatment of infection, and two had been nearly
completely resorbed. The remaining allograft did not completely integrate. One
additional patient had had placement of an allograft during revision surgery
after the initial Reverse Shoulder Prosthesis had failed. On the basis of the
last available radiograph, that allograft also did not completely
integrate.
Three patients with a known preoperative infection underwent a staged
procedure. Two of these patients had findings on frozen-section analysis that
demonstrated acute inflammation (more than ten polymorphonuclear neutrophils
per high-power field). Only one of these patients had positive growth
(methicillin-resistant Staphylococcus aureus) on culture. Two
patients without a previously known infection had positive findings on
frozen-section analysis. One patient with a single focus of five
polymorphonuclear neutrophils per high-power field had growth of Candida
albicans on culture. The other patient was found to have more than ten
polymorphonuclear neutrophils per high-power field, but the cultures were
negative. Finally, one patient without a presumed infection had a negative
result on frozen-section analysis and had growth of coagulase-negative
Staphylococcus on culture. All patients with previous infections, positive
results on frozen-section analysis, and positive cultures were managed with
intravenous antibiotics as directed by an infectious disease specialist.
Complications
Complications occurred in three of the eight patients who had been managed
with an allograft-Reverse Shoulder Prosthesis combination. One patient fell
and sustained a periprosthetic humeral fracture distal to the humeral stem
along with a fractured polyethylene socket at twenty months and later
sustained a dislocation at twenty-five months. The implant in this patient was
revised to a larger glenosphere (36 mm, -4), and the patient had an overall
satisfactory outcome. The second patient had development of a postoperative
infection that was treated twice with débridement and polyethylene
exchange. The allograft was removed at the time of the initial
débridement. This patient was dissatisfied with the overall outcome.
The third patient had a postoperative dislocation, which was reduced and did
not recur. Eighteen months after the placement of the Reverse Shoulder
Prosthesis, she had excellent function and was pain-free. She rated the result
as excellent at that time. This patient then sustained a massive stroke, with
loss of function in the involved extremity. At the time of the two-year
follow-up, radiographs revealed the Reverse Shoulder Prosthesis to be
dislocated. However, she did not have a substantial amount of pain in the
involved shoulder. The prosthesis was thus left dislocated because of the
patient's high risk for additional surgery and lack of symptoms. At the time
of the latest follow-up, this patient rated the overall outcome as excellent
as she was satisfied with a painless shoulder in an extremity with poor
function due to weakness from the stroke.
Complications occurred in five of the twenty-one patients who had been
managed with a Reverse Shoulder Prosthesis alone. One patient had failure of
the baseplate with broken screws and underwent a revision of the glenosphere,
with placement of a femoral head allograft to support the polyethylene socket,
at twenty-three months. This patient sustained an acute polyethylene
dissociation and fracture at twenty-seven months, and the implant was revised
to a Reverse Shoulder Prosthesis alone. At forty-four months, this patient had
a second polyethylene fracture and the implant was revised to one with a long
humeral stem combined with a proximal humeral allograft. At forty-eight
months, this patient had a dislocation that was treated with revision with a
larger glenosphere (40 mm) with a structural supporting allograft. This
shoulder subsequently dislocated again and continued to be unstable. The
patient was dissatisfied with the overall outcome. A second patient had
dislocation of the prosthesis at eight months and was managed with open
reduction. At twenty-eight months, the polyethylene socket fractured and was
revised to a Reverse Shoulder Prosthesis without allograft. At the time of the
latest follow-up, the patient rated the overall outcome as good. A third
patient had development of humeral stem loosening at twenty-two months, and
the implant was revised to a long-stem prosthesis. This patient was
dissatisfied with the overall outcome. A fourth patient underwent revision
with reaming of the cement mantle at the site of the previous
hemiarthroplasty. Penetration of the cortex with extravasation of the cement
resulted. The patient had development of a postoperative radial nerve palsy,
which subsequently resolved. This patient was also dissatisfied with the
overall outcome. The fifth patient had two dislocations and was successfully
managed with closed reduction. This patient was later diagnosed with dystonia.
The patient rated the overall outcome as excellent.
The causes of unsatisfactory outcomes after humeral hemiarthroplasty
for the treatment of proximal humeral fracture are
multifactorial24,33.
When isolated complications arise, various treatments are currently available.
Patients with an isolated malunion or nonunion of the tuberosities may undergo
revision to reattach the tuberosities. Patients who have development of
isolated glenoid arthritis may undergo revision to a standard total shoulder
arthroplasty33,34.
Patients who have development of humeral loosening may have a revision humeral
hemiarthroplasty. Patients with a rotator cuff tear may undergo an attempt at
rotator cuff repair or tendon transfer. Patients with fragments of bone that
are causing impingement may undergo arthroscopic subacromial decompression.
Patients with a periprosthetic fracture may be managed on the basis of the
location of the fracture and often require
revision35.
Finally, patients with infection may undergo
one-stage36 or
two-stage revision of the
prosthesis37.
Unfortunately, multiple complications usually exist. Bigliani et al. noted
multiple causes of failure in 83% (twenty-four) of twenty-nine shoulders in
patients who had been managed with hemiarthroplasty for the treatment of
fracture38. When
several of these complications present together, the treatment becomes much
more challenging and, to date, we are not aware of any study that has
documented the successful treatment of pain and loss of function in this
population of patients.
In the present report, we described the single-stage revision to a Reverse
Shoulder Prosthesis. Our overall outcomes are promising, with sixteen patients
rating the outcome as good or excellent, seven rating it as satisfactory, and
six rating it as unsatisfactory at a minimum of two years. Four of the six
unsatisfactory results were found in patients who had been managed with a
Reverse Shoulder Prosthesis without a proximal humeral allograft.
We found the treatment of substantial proximal humeral bone loss to be a
challenge. Unlike patients who have glenohumeral arthritis in association with
rotator cuff deficiency, those who have undergone a hemiarthroplasty for the
treatment of a fracture often have inadequate proximal humeral bone stock for
reconstructive purposes. In addition to the initial traumatic injury and
iatrogenic loss during the hemiarthroplasty procedure, subsequent bone loss in
this region may be progressive over time.
We found that patients with a malunited greater tuberosity in the
posterior-inferior position required release of the posterior rotator cuff.
Early attempts to preserve the malunited tuberosity resulted in a difficult
reduction of the Reverse Shoulder Prosthesis and instability of the trial
reduction. Furthermore, the malunited position of the tuberosity may prevent
humeral lengthening that is required for proper soft-tissue balancing during
the reconstruction. We now recommend releasing the posterior rotator cuff from
the proximal part of the humerus. Once it has been released from the malunited
fragment, stability and soft-tissue balancing can be achieved.
Failures can be divided into four groups: those due to lack of proximal
humeral bone support, those due to intraoperative complications, those due to
infection, and those due to patient selection. The initial failures in
patients with substantial proximal humeral bone loss were thought to be due to
inadequate proximal humeral bone support. Both De Wilde and
Plasschaert39 and
Boileau et al.40
recognized the risk of humeral-sided failures in patients with a lack of
proximal humeral bone support. In the present series, five patients with
extensive proximal humeral bone loss had humeral-sided failures: one due to
polyethylene dissociation, two due to polyethylene failure, one due to humeral
loosening, and one due to both polyethylene failure and humeral loosening.
Introduction of a proximal humeral allograft to augment the Reverse Shoulder
Prosthesis was based on the early humeral-sided failures seen in these
patients.
Augmentation of the Reverse Shoulder Prosthesis with a proximal humeral
allograft provides three distinct advantages. First, the cortical support of
the proximal humeral allograft provides additional rotational and structural
stability, which diminishes the stress on the humeral component. The only
humeral component failure among patients managed with a proximal humeral
allograft-Reverse Shoulder Prosthesis combination occurred after a traumatic
event. Second, the allograft provides a subscapularis tendon that is utilized
for subscapularis repair. This adds additional stability and internal rotation
strength to the reconstruction. Finally, reestablishing the proximal part of
the humerus may improve the function of the deltoid muscle. The addition of a
proximal humeral allograft increases the lateral offset from the center of
rotation and improves the moment arm of the deltoid. Additionally, augmenting
the allograft reconstruction reestablishes the contour of the proximal part of
the humerus, allowing the deltoid to increase the total resultant force
through a pulley
mechanism41.
One intraoperative complication occurred. Alarming intraoperative
complications related to cement extravasation have been described during
revision surgery to convert a failed hemiarthroplasty to a reverse shoulder
design42. This
complication was seen in one patient in the present series, who had
development of a temporary radial nerve palsy. In this patient, the cement
mantle required reaming to seat a longer prosthesis. The result in this
patient was unsatisfactory. In the remainder of the reconstructions, in which
the Reverse Shoulder Prosthesis stem had been consistently cemented into the
previous cement mantle, this complication was not seen. The small size of the
Reverse Shoulder Prosthesis allows the revision stem to be cemented directly
into the mantle without the need to remove cement. In cases in which a long
humeral stem is required, intraoperative fluoroscopic guidance can help to
minimize the risk of distal cortical penetration, which may allow cement
extravasation.
One failure due to infection was seen. In this series of failed prostheses,
concurrent infection as an associated pathologic process leading to mechanical
failure must be suspected initially. All patients in the present series
underwent intraoperative frozen-section analysis, histological studies, and
cultures for anaerobic, aerobic, and fungal organisms as well as acid-fast
bacillus. This resulted in the identification of two previously undiagnosed
infections. All patients with a positive result on frozensection analysis, a
positive culture, or a known preoperative infection were managed with at least
six weeks of intravenous antibiotics as directed by an infectious disease
specialist, and none had development of a postoperative infection. We believe
that this protocol was associated with an acceptable infection rate of 3% (one
of twenty-nine patients).
Improper patient selection led to one failure. An analysis of the patient's
preoperative evaluation did not identify a clear explanation for the patient's
preoperative level of pain and functional loss. This emphasizes the importance
of defining clear indications for this procedure. The minimal indications are
rotator cuff deficiency (due to rotator cuff failure, tuberosity malunion,
tuberosity nonunion, or tuberosity resorption) with glenoid arthritis
associated with severe pain and loss of function. Additional findings that may
support these indications include infection, humeral stem loosening, and
periprosthetic fractures. When the minimal indications are not present, this
procedure no longer becomes a reliable solution for patients with a failed
outcome following a hemiarthroplasty for the treatment of a proximal humeral
fracture.
In conclusion, to our knowledge, this is the first report on the surgical
treatment of failed hemiarthroplasty for proximal humeral fracture in the
setting of glenoid arthritis and rotator cuff deficiency. The challenging
combination of pathological findings in these patients leaves few options for
even the most experienced shoulder surgeon. The reverse ball-and-socket design
offers a solution that directly addresses both of the pathological elements:
irreparable rotator cuff deficiency and glenoid arthritis. The early results
reported in the present study are promising. We believe that, in patients with
extensive proximal humeral bone loss, revision surgery with the Reverse
Shoulder Prosthesis requires augmentation with a proximal humeral allograft to
avoid humeral component failure, to provide for reattachment of the
subscapularis, and to maximize the deltoid pulley mechanism. We also believe
that this procedure should be performed by surgeons who have experience in
reconstructive shoulder surgery.
A table showing detailed information on all twenty-nine patients is
available with the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
Neer CS 2nd. Displaced proximal humeral fractures. I.
Classification and evaluation. J Bone Joint Surg Am.1970;52:
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