Humeral Stem Research Articles

The treatment of proximal humerus nonunions in older patients with the reverse shoulder arthroplasty

Introduction The experience of the treatment of proximal humeral nonunions with the reverse total shoulder arthroplasty is limited. We report our results. Patients Eighteen patients with proximal humeral atrophic nonunion were treated with the reverse total shoulder prosthesis. There were 12 women and 6 men, with a mean age of 78.8 years (range, 75–84 years). The mean follow-up after the reverse arthorplasty was 28 months (range, 24–32 months). Extensive proximal humeral bone loss that was found in six cases was treated adding a proximal humeral allograft. A long humeral stem was always used. Results The mean constant score increased from 26% preoperatively to 55% postoperatively ( p < 0.0001). The average anterior elevation increased from 35° to 90° ( p < 0.0001), abduction from 35° to 85° ( p < 0.0001), external rotation from 15° to 30° ( p < 0.0001) and internal rotation from 25° to 55° ( p < 0.0001). The average subjective shoulder score increased from 10% preoperatively to 50% postoperatively ( p < 0.0001). All but 4 patients would undergo the same procedure again if faced with the same problem. Eight patients were very satisfied, 6 satisfied and 4 unhappy with the operation. We had one case of transitory axillary nerve palsy and two cases of infection. Two prosthetic dislocations occurred. They were successfully treated by revision with a larger polyethylene glenosphere of 44 mm. Conclusions The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high.

Titanium Metallosis in a Cobalt-chrome-polyethylene Bipolar Shoulder Replacement

We report a patient who developed titanium metallosis after uncemented bipolar shoulder replacement, where the bipolar bearing was cobalt-chrome-molybdenum alloy on ultra-high molecular weight polyethylene. At revision surgery, extensive metallosis in the tissues was noted. Examination of the retrieved prosthesis revealed no evidence of wear of the bipolar articulation, although areas on the humeral stem were found where the porous titanium coating had debonded and separated from the stem. Analysis of the tissues revealed the metallic particles within the soft tissues to be almost exclusively titanium, which most likely originated from the debonded porous titanium coat.

Shoulder function and pain level after revision of failed reverse shoulder replacement to hemiarthroplasty

Background:The reverse total shoulder replacement has become a popular treatment option for cuff tear arthropathy and other shoulder conditions requiring arthroplasty in the setting of a deficient rotator cuff. Despite a revision rate of as much as 10%, to date, there are few reports of reverse replacement conversion to hemiarthroplasty, and none specifically examining shoulder function.Materials and Methods:Six patients with a reverse replacement that was dislocated, infected or loose were revised an average of 9.2 months after the reverse replacement. Two of the three patients that were dislocated also had a known deep infection. Patients with known infection were treated with explant of the reverse prosthesis and conversion to a preformed antibiotic spacer hemiarthroplasty. In three cases with gross loosening of the glenosphere without infection, treatment was performed with removal of glenosphere only, bone grafting of glenoid with allograft and conversion of humeral stem to hemiarthroplasty. Patients were evaluated with outcome scores and physical examination an average of 26.5 months after removal of the reverse prosthesis.Results:The average range of motion postoperatively was forward elevation 42.5 degrees and external rotation 1.7 degrees. The VAS pain score was 2.42 (range 0–6); simple shoulder test was 3.17 (range 1–5); and ASES score was 52.1 ± 8.5. There were no reoperations to date, and five patients had anterosuperior escape.Conclusions:Safe removal of a reverse replacement and conversion to hemicement spacer or hemiarthroplasty can provide pain relief in those patients with a dislocated or infected reverse replacement. However, the shoulder will likely have very poor function and anterosuperior escape postoperatively. Further studies are needed to determine the optimal treatment for the failed reverse shoulder replacement.Level of Evidence:Therapeutic Level IV.

A quantitative three-dimensional templating method for shoulder arthroplasty: biomechanical validation in cadavers

Press-fit humeral components for total shoulder arthroplasty have notable potential complications that may be minimized by preoperative templating and improvements in stem design. The purpose of this study was to develop a 3-dimensional templating technique for the humeral stem and to validate this templating in cadaveric specimens. A cylindrical stem and a stem with a rectangular cross-section were selected for templating and force measurements. Templating was carried out for 15 clinical patients and 16 cadaveric shoulders, including calculation of the cortical-implant volume ratio (CIVR). Insertion forces for stem broaching and impaction were measured for 15 patients and 8 paired cadaveric shoulders. Hoop strain and periprosthetic fractures were monitored in cadaveric shoulders with strain gauges. A significant difference in the CIVR was noted between rectangular and cylindrical stems. No difference was observed in impact forces for ideally sized rectangular or cylindrical stems. A difference in insertion forces was found between oversized cylindrical and oversized rectangular implant stems and also between ideal and oversized cylindrical implant stems. The difference in maximal hoop strain between ideally sized rectangular and cylindrical stems was also statistically significant. CIVR is useful to predict an ideal humeral stem size. Cylindrical stems have a different design rationale for fixation than rectangular stems. Surgeon awareness of the fixation rationale for a particular stem design is important because different stem types have different effects on the insertion force. More anatomic humeral stem designs may help to minimize the risk of complications and optimize stem fixation.

Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the posttraumatic shoulder

This study was conducted to test the hypothesis that patients would have improved pain and range of motion after conversion total shoulder arthroscopy but that overall outcome would be substantially affected by the need for removal of the humeral component and associated alterations of bony anatomy or soft tissue deficiencies. Thirty-four patients (34 shoulders) with HHR after a proximal humeral fracture underwent revision total shoulder arthroplasty for painful glenoid arthrosis, with mean follow-up of 9.4 years (range, 2.3-20.4 years). After initial review, repeat analysis was performed based on the complexity of osseous (humeral stem revision) and soft tissue management, including rotator cuff tear, greater tuberosity resorption, malunion or nonunion, or instability. Overall, patients had reduction in pain (P = .0001), and improved active abduction (P = .05) and external rotation (P = .0005). Less improvement in active abduction was documented in patients who required soft tissue management (P = .03). Results of the modified Neer rating documented 3 excellent, 9 satisfactory, and 22 unsatisfactory results (motion deficiencies in 14). Kaplan-Meier survival analysis free of repeat revision was 100% at 1 year, 96.8% at 5 years (95% confidence interval, 90%-100%), and 92.2% at 10 years (95% confidence interval, 82% to 100%). Conversion total shoulder arthroplasty is effective for addressing painful glenoid arthrosis after primary HHR for a proximal humeral fracture, with or without the need to change the humeral component. However, active motion may not improve in patients with rotator cuff tearing, a greater tuberosity nonunion, malunion, or resorption.

The Battle for Supremacy: Cemented Versus Uncemented Humeral Stems

The Battle for Supremacy: Cemented Versus Uncemented Humeral Stems

Fractures of the Shoulder Girdle: Editorial Comment

This symposium is a collection of manuscripts dealing with current concepts in the evaluation and management of fractures of the shoulder girdle. Given the relatively high incidence of fractures about the shoulder, particularly those of the proximal humerus, operative techniques and implant technology continue to evolve. The use of locked plating has improved the treatment of proximal humerus fractures in elderly patients with osteoporosis. In patients with osteoporosis or comminuted fractures, however, fixation failure may still occur as the fracture settles during healing, potentially leading to screw penetration within the glenohumeral joint. Strategies to mitigate this complication may include the use of fibular strut allograft within the medullary canal and the use of suture augment within the rotator cuff combined with locked plating while avoiding long locked screws close to the subchondral surface. In general, nonoperative treatment for Neer one-part proximal humerus fractures restores function with minimal or no pain. The use of locked plating for more severe fracture patterns may be associated with worse function compared with its use in less displaced fractures. Further, age may predict function after treatment of displaced proximal humerus fractures less than the initial fracture pattern. Patients can more accurately be advised of their potential function after operative treatment. The incidence of deep venous thrombosis after shoulder surgery appears to be higher than previously thought. The use of aspirin and mechanoprophylaxis after surgery for proximal humerus fractures may provide sufficient treatment to reduce its incidence. Certain proximal humerus fractures are not amenable to plate and screw fixation and are more reliably treated with shoulder arthroplasty. The use of hemiarthroplasty for displaced proximal humerus fractures in the elderly has been associated with variable function but reliable pain relief. It has become clear the healing of the greater tuberosity to the humeral stem represents the most important factor in long-term function. Therefore, the use of a fracture-specific stem over a conventional humeral implant may improve tuberosity healing and, ultimately, patient function. The reverse shoulder prosthesis has been used successfully in the setting of rotator cuff-deficient arthritis. While requiring confirmation, its use for treating fractures appears to be less reliant on greater tuberosity healing for achieving pain relief and overhead elevation. Surgery for select displaced midshaft clavicle fractures has increased given the higher reported incidence of nonunion and symptomatic malunion. As such, implants for clavicle fracture fixation have evolved to lower-profile, precontoured locked plates. The use of precontoured plates may reduce the need for hardware removal, resulting in higher patient satisfaction and clinical results comparable to those of noncontoured conventional plates. Distal clavicle fractures represent a difficult subset of clavicle fractures. The use of precontoured distal clavicle plates with supplemental use of sutures around the coracoid or coracoclavicular screw fixation may more reliably restore function with minimal pain. In the case of operatively treated midshaft clavicle fractures, a plateau in clinical improvement appears to be reached at 1 year after surgery. This may provide a prognostic timeline of recovery for patients who undergo this surgery. Concern over prominent hardware used to treat clavicle fractures has led to further interest in the use of intramedullary devices. The use of the Rockwood pin for displaced midshaft clavicle fractures has been associated with a substantial complication profile, especially wound breakdown, pin prominence, and fracture nonunion. Cautious use of this implant should perhaps be advised. Titanium elastic intramedullary nailing, combined with careful intraoperative fluoroscopy to assess lateral penetration and a more conservative postoperative rehabilitation protocol, may represent an alternative to conventional plate and screw fixation. In general, strict indications for surgery of scapula fractures have remained elusive. The majority of the extraarticular fractures can be treated without surgery without complications while restoring function. The appropriate radiographic evaluation has traditionally included trauma views, which are variable in quality and positioning. The use of CT imaging with three-dimensional reconstruction may allow for more accurate and reproducible measurements of fracture angulation and displacement. Furthermore, surgery for substantially displaced or angulated scapular fractures appears to yield comparable rates of healing and restoration of function to patients managed nonoperatively for less displaced fractures. If surgery is indicated, selective incisions may provide sufficient access to the major fracture lines while minimizing soft tissue dissection. The authors of these articles are to be congratulated for their contributions to our understanding of the diagnosis, operative management, and potential complications of fractures of the shoulder girdle. It is my sincere hope that this symposium will stimulate discussion and raise further questions so as to continue to advance the treatment of shoulder fractures. I hope you enjoy this symposium. Fig. 1 Dr. Konrad I. Gruson is shown.

The effect of implant malalignment on joint loading in total elbow arthroplasty: an in vitro study

Aseptic loosening is one of the leading causes of failure in total elbow arthroplasty. Incorrect implant positioning and alignment in other joints such as the knee have been found to lead to excessive loading and wear. Although similar alignment difficulties exist in the elbow, the effect of implant malalignment on wear-inducing loads is not yet known. This in vitro study determined the effect of anterior malpositioning and varus-valgus and internal-external malrotations on humeral stem loading in total elbow arthroplasty. Computer-navigated linked elbow arthroplasty was conducted in 8 cadaveric elbows. A modular, instrumented humeral component was used to measure loading during simulated elbow motion while the position of the ulna relative to the humerus was recorded. Loading increased for all malaligned implant positions tested (P < .05). During simulation of implant malpositioning, combinations of internal-external and varus-valgus malrotations that tended to preserve the line of action of the elbow flexors had lower loads than combinations that did not. This in vitro study showed that loading does increase after humeral component malalignment; however, further studies are required to determine the long-term effects on polyethylene wear and component loosening.

Letter to the Editor: Bony Increased-offset Reversed Shoulder Arthroplasty: Minimizing Scapular Impingement While Maximizing Glenoid Fixation

To the editor We congratulate Boileau et al. on their article, “Bony Increased-offset Reversed Shoulder Arthoplasty” [1], and their innovative idea of using an autograft to avoid the reduced motion and notching associated with humeral medialization. Their results are encouraging. However, we have some comments regarding parts of the Methods and Discussion sections. In the Methods section, they state that a 36-mm-diameter glenosphere usually was used for women, whereas the 42 mm was preferred for men. The disc of cancellous bone graft thickness was adjusted according to the size of the sphere. They stated that the reason why the thickness of the bone graft was adjusted according to the size of the sphere was because a 42-mm sphere already is more lateralized than the 36-mm sphere. It is unclear what they mean when they say it is already more lateralized. If they mean the center of rotation, then this is not correct. The center of rotation does not change by enlarging the diameter of the glenosphere. Unlike with a normal shoulder of an anatomic prosthesis, with a reverse prosthesis the humerus is not spinning around the center of rotation but is hinging around the center of rotation. Therefore by changing the diameter of the glenosphere, one does not change the center of rotation, but lateralize the hinging humerus [3]. If they mean that the humeral stem is lateralized more in the 42-mm glenosphere this is correct and it means that the humerus is lateralized in the same extent in both options (10-mm graft with 36-mm glenosphere [radius 18 mm] = 28 mm = 7-mm graft with 42-mm glenophere [radius 21 mm]). In the Discussion section, Boileau et al. stated inferior scapular notching occurred in 19%. This is lower than that reported with a standard medialized RSA [4]. Boileau et al. did not describe if there was a difference between the prevalence of scapular notching between the group with a 36-mm glenosphere and the group with a 42-mm glenosphere. This would be interesting to know because using a larger hemisphere on the same position of the baseplate means that there is more prosthetic overhang. Using a computer model we found that prosthetic overhang should reduce inferior impingement and presumably notching [2]. We believe that using a cancellous bone graft of 29 mm in diameter (identical to the radius of the baseplate) with either a 36-mm or a 42-mm glenopsphere is likely to decrease the risk of inferior impingement similarly (36-mm glenosphere [18 mm radius] and 29-mm diameter bone graft [14.5 mm radius] = 4.5-mm prosthetic overhang, 42-mm glenosphere [21 mm radius] and 29-mm diameter bone graft [14.5 mm radius] = 7.5-mm prosthetic overhang). We believe that prosthetic overhang caused by a larger sphere and a smaller bone graft can contribute to the lower rate of scapular notching reported by Boileau et al.

Humeral component revision arthroplasty: outcomes of a split osteotomy technique

The purpose of our study was to report results on 13 patients who underwent shoulder revision surgery of a well-fixed cemented humeral component assisted by a longitudinal split osteotomy. Limited data have been published on humeral stem revision using an osteotomy to facilitate removal of a well-fixed humeral component. Between July 1996 and July 2004, 13 humeral component revisions of well-fixed cemented stems were performed for pain and functional limitation. The patients' preoperative and postoperative function and outcome were evaluated by physical examination, visual analog scale (VAS) for pain, Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Short Form-12 (SF-12), and radiographic assessment. At a mean follow-up of 30 months, from preoperatively to postoperatively, the VAS pain score improved from 7.8 to 2.3 (P = .012), the ASES score improved from 19.6 to 58.9 (P < .011), the SST score improved from 1.4 to 4.6 (P < .011), and significant changes were demonstrated on the mental component of the SF-12, with improvement from 49.8 to 59.4 (P < .025). Analysis of range of motion from preoperatively to postoperatively revealed that the mean external rotation improved from 24.4° to 40° (P < .042), and mean forward elevation improved from 60.6° to 89.4°, although this change was not significant (P = .067). There were no iatrogenic fractures. Radiographic follow-up demonstrated no evidence of humeral loosening or nonunion. A longitudinal humeral split osteotomy is a safe and effective technique for revision of a well-fixed humeral stem.

Impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty

Our purpose was to evaluate the outcome of the Delta reverse shoulder prosthesis (DePuy France, Saint Priest, France) in a consecutive series of 68 shoulders and perform a comparison of patients with and without previous shoulder arthroscopy for cuff tear reconstruction. We assessed 68 shoulders in 66 patients (36 women and 30 men) with a mean age of 66 years (range, 53-84 years), first preoperatively and then at a minimum of 2 years' follow-up, using the Constant score for pain; Constant Shoulder Score; Oxford Shoulder Score; University of California, Los Angeles shoulder rating scale; and Disabilities of the Arm, Shoulder and Hand score. Any complications were assessed according to Goslings and Gouma. We report statistically significant improvements of all obtained scores at a mean follow-up of 42 months (range, 24-96 months) in both groups. Significant outcome differences between 29 patients with previous shoulder arthroscopy for cuff tear reconstruction and 39 patients without previous shoulder arthroscopy were not observed. In total, 8 complications occurred: 1 nerve lesion, 3 cases of loosening of the humeral stem, and 4 cases of luxation of the glenoid component. We conclude that reverse total shoulder arthroplasty with the Delta prosthesis is significantly beneficial in terms of less shoulder pain, greater stability, and gain in range of motion without this beneficial effect being significantly weakened by previous insufficient shoulder arthroscopy for cuff tear reconstruction. We believe that previous arthroscopic cuff tear reconstruction should therefore be included in the treatment algorithm.

The vertical humeral osteotomy for stem removal in revision shoulder arthroplasty: results and technique

Revision shoulder arthroplasty represents a complex and difficult problem for the treating surgeon, with multiple potential complications. In the setting of a well-fixed humeral component, removal can lead to fractures and compromise the outcome of the revision. The current study describes and evaluates the results of a novel vertical humeral osteotomy (VHO) for stem extraction. We hypothesized that the VHO will enable successful stem extraction without perioperative or postoperative fractures. Twenty-seven patients were retrospectively identified who had a VHO for revision shoulder arthroplasty, with 23 patients available for final follow-up. Records and radiographs were reviewed for postoperative complications. Final follow-up was completed with the inclusion of shoulder scores. There were no perioperative or postoperative fractures on clinical examination and radiographic review at an average follow-up of 41 months. Average American Shoulder and Elbow Surgeons (ASES) score was 64.7 (contralateral ASES, 76.9), average Simple Shoulder Test was 6.3, and the visual analog score pain average was 1.3. There were no instability events. The glenoid is the more common site for failure in both hemiarthroplasty and total shoulder arthroplasty. This can lead to a difficult revision procedure if the ingrown or cemented humeral stem requires removal. In the current study, we found the VHO was an effective tool for the removal of the humeral prosthesis with no perioperative or postoperative fractures.

Cemented Humeral Stem Fixation: Standard of Care

Cemented humeral stem fixation in shoulder joint arthroplasty has been, and continues to be, the gold standard to ensure satisfactory implant orientation and stability. The most commonly performed type of shoulder arthroplasty is hemiarthroplasty in the face of comminuted fracture. Appropriate stem height and version relative to the glenoid is paramount in obtaining a satisfactory result. This has been proven to be reliably reproducible through cement fixation of the stem with careful reattachment of the tuberosities. Total shoulder arthroplasty in rheumatoid patients with questionable bone stock likewise has relied upon cementation of the humeral component to ensure secure fixation, prevent loosening, and avoid subsidence. In younger patients, it is tempting to want to avoid cement in the proximal humerus; nonetheless, most studies have demonstrated loosening of the humeral component not to be problematic once cement has been used. In addition, newer modular components allow head removal (without stem removal), providing ready access to the glenoid should glenoid revision be needed. In addition, the ability to add antibiotics within the cement mantle in high-risk patients affords an advantage in treating and/or avoiding infection. Survivorship studies have not demonstrated an advantage of cementless versus cement fixation of the humeral component in shoulder arthroplasty.

Prosthetic replacement of elbow for intercondylar fractures (recent or ununited) of humerus in the elderly.

Forty-one patients with an intercondylar fracture of the humerus (21 recent and 20 ununited) were treated by total elbow arthroplasty using Baksi's recent version of the sloppy hinge from January 2003 to April 2009. Twelve were AO classification type C2 and nine were type C3 recent closed fractures of seven days' mean duration according to Muller classification. Patient's mean age was 64 years. There were 20 nonunions (nine untreated nonunions of a mean of 11 months duration and 11 following failed internal fixation of a mean of 14 months duration); mean patient age was 58 years. The follow up period was 12-88 (mean 55.5) months. Mean arc of postoperative elbow flexion was 25-130° obtained in 39 (95.1%) patients. Mean arc of 65° pronation and 60° supination was obtained in 33(80.5%) patients. According to the Mayo elbow performance score, in the fresh-fracture group, excellent results were seen in 19 (90.5%), good in one (4.8%), and failure in one (4.8%), whereas in the nonunion group, excellent results were obtained in 17 (85%), good in two (10%), and failure in one (5%). Failure in the two patients was due to deep infection requiring prosthesis removal. Other complications were transient ulnar neurapraxia in three, disassembly of the prosthesis in one, patchy heterotopic ossification in two and localised radiolucency around the flanges of the humeral stem in one.

Placement of the Stemless Humeral Component in the Total Evolutive Shoulder System (TESS)

Humeral implant design in shoulder arthroplasty has evolved over the years. The third generation shoulder prostheses have an anatomic humeral stem that replicates the 3-dimensional parameters of the proximal humerus. The overall complication rate has decreased as a result of these changes in implant design. In contrast, the rate of periprosthetic humeral fractures has increased. To avoid stem-related complications while retaining the advantages of the third generation of shoulder implants, the stemless total evolutive shoulder system has been developed. The indications, the surgical technique, and the complications of this humeral implant in shoulder arthroplasty will be described.

Beneficial and harmful effects of shoulder arthroplasty in patients with rheumatoid arthritis: results from a Cochrane review

To assess beneficial and harmful effects of arthroplasty in the shoulder joint in patients with RA. A systematic review within the framework of the Cochrane Collaboration identified randomized controlled trials (RCTs), controlled clinical trials and case series (included for assessment of complications) published between 1995 and 2008. Articles considered potentially relevant were retrieved in full text and assessed independently by two authors. Risk of bias and level of evidence were assessed according to the established criteria. One RCT (26 shoulders) compared cemented and uncemented humeral stem fixation during arthroplasty, reporting no significant differences between groups at 2-year follow-up (low-quality evidence). Nineteen case series (1155 shoulders) reported component loosening requiring revision at 5%, infections at 2% and minor complications at 7% (very low-quality evidence). The retrospective case series had several limitations related to methodological quality and standards of reporting. At present, there is very little research evidence supporting decisions about shoulder joint arthroplasty in patients with RA.

Hemiarthroplasty for osteoarthritis in shoulder with dysplastic morphology

Hemiarthroplasty for shoulder osteoarthritis with a glenoid dysplasia gives satisfactory results at medium-range follow-up. From 1998 to 2006, 9 patients (10 shoulders) with glenoid dysplasia and osteoarthritis were treated with shoulder hemiarthroplasty. The mean age at surgery was 54 years (range, 44-73 years). At a minimum of 24 months after surgery, all patients were retrospectively reviewed with a clinical and radiographic evaluation. The average duration of follow-up was 71 months (range, 28-126 months). One shoulder underwent revision surgery for anterior dislocation within 6 months after the initial procedure. The pain level improved significantly, with no or slight pain for 9 of the 10 shoulders. Postoperatively active external rotation and anterior elevation increased significantly, with a mean of 34.5° and 124°, respectively. The average American Shoulder and Elbow Surgeons score was 81.5 points at the last follow-up, and results were considered as excellent or satisfactory in 7 shoulders according to the modified Neer rating scale. Erosion of the glenoid was considered as slight on radiographs, and radiolucencies were seen around humeral stem in one case. The opportunity of glenoid component implantation in case of anatomic shoulder replacement with dysplastic morphology has to be carefully evaluate because of bone stock insufficiency, glenoid orientation, and the age of patients. Despite a limited number of patients in this study, hemiarthroplasty gave satisfactory clinical results in most cases. It seems to be a reliable option to treat osteoarthritis in case of dysplastic morphology of shoulder.

Cemented Glenohumeral Fixation: Standard of Care—Affirms

Cemented humeral stem fixation in shoulder joint arthroplasty has been, and continues to be the “gold standard” to ensure satisfactory implant orientation and stability. The most commonly performed type of shoulder arthroplasty is hemi-arthroplasty in the face of comminuted fracture. Appropriate stem height and version relative to the glenoid is paramount in obtaining a satisfactory result. This has been proven to be reliably reproducible through cement fixation of the stem with careful reattachment of the tuberosities. Total shoulder arthroplasty in rheumatoid patients with questionable bone stock likewise has relied upon “cementation” of the humeral component to ensure secure fixation, prevent loosening and avoid subsidence. In younger patients it is tempting to want to avoid cement in the proximal humerus, nonetheless most studies have demonstrated loosening of the humeral component not to be problematic once cement has been used. In addition, newer modular componentry allows head removal (without stem removal) providing ready access to the glenoid should glenoid revision be needed. The ability to add antibiotics within the cement mantle in high-risk patients additionally affords an advantage in treating and/or avoiding infection. Survivorship studies have not demonstrated any advantage of cementless versus cement fixation of the humeral component in shoulder arthroplasty. Temporizing techniques such as cup arthroplasty and hybrid techniques such as placing tantalum weave surfaces proximally for enhanced tuberosity fixation may have a role, but do not replace the long-standing efficacy of cement fixation of the humeral component in the vast majority of patients requiring shoulder arthroplasty.

Radiographic Stability of Ingrowth Humeral Stems in Total Shoulder Arthroplasty

Cemented and uncemented stem types are available for TSA. An early uncemented stem designed for bone ingrowth had radiographic loosening of approximately 10% at intermediate followup (mean 4.6 years). Subsequent stem modifications included circumferential metaphyseal porous coating to enhance ingrowth and reduce loosening rates. We asked whether the radiographic loosening rates would be lower after this design modification and whether the pain score and ROM would be improved. We reviewed the medical records and radiographs of 76 patients undergoing primary TSA with circumferential metaphyseal porous-coated stems for osteoarthritis between 1995 and 2005. All patients had a complete standardized series of radiographs preoperatively, postoperatively, and at final followup. Humeral stems were evaluated for any radiolucent lines by zone, progression of lucencies, and shift in component position. The minimum radiographic followup was 25 months (average, 52 months; range, 25-90 months). There were no radiolucencies seen on the initial postoperative radiographs. Five stems had 1-mm radiolucent lines in one to four of eight zones at final followup. One had a glenoid component judged at risk. None of the humeral components were judged at risk or loose or to have shifted. The pain scores and ROM improved postoperatively. Proximally coated humeral stems for TSA showed few radiolucencies and no loosening at short- to midterm followup, reflecting an improvement over previous series. We now use these stems for primary TSAs and reserve cemented stems only when uncemented fixation is not possible owing to bony deficiency. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Endoprothetischer Glenoidersatz mit Rekonstruktionsschale (EPOCA RECO®)

Alleviation of pain, restoration of function and active range of motion in the shoulder in case of cuff tear arthropathy. Cuff tear arthropathy with an insufficient coracoacromial arch and salvage operation of failed hemiprosthesis or reverse shoulder prosthesis. Active or chronic infections. Lesions of the plexus. Insufficiency of deltoid muscle or subscapularis muscle. Neurologic diseases. Young active patients. Deltopectoral approach. Resection of the humeral head and removal of the failed implant, respectively. Periarticular arthrolysis with preservation of neurovascular structures. Exposure of the glenoid and three-point fixation of the reconstruction socket (EPOCA RECO) at the glenoid, the acromion and the coracoid process. Cemented fixation of the polyethylene inlay. Cemented or cementless implantation of the humeral stem in 25 degrees retroversion related to the long axis of the forearm. Reconstruction of the subscapularis muscle. Bedding of the arm in a Gilchrist brace. Passive and active- assisted exercises including continuous passive motion. From 2002 to 2007, a total of 35 reconstruction sockets (EPOCA RECO) were implanted in 34 patients (six men, 28 women - one bilateral implantation was performed at an interval of 8 months in a female patient). Five EPOCA RECO implants had to be removed due to major complications. Three patients died, another three patients refused the follow-up examination. The remaining 23 patients (three men, 20 women, average age at the time of surgery 76 years [64-88 years]) were examined 2 years (4-60 months) postoperatively. The preoperative gender-related Constant Score was 21 and improved significantly (p < 0.001) to 58 postoperatively. The pain was significantly reduced. Range of motion for active elevation, internal and external rotation was improved (preoperatively/ postoperatively): elevation 37.2 degrees/65 degrees; internal rotation 14.8%/50%; external rotation 11.3%/47.5%. All patients would undergo the operation again. Overall, there were five major and two minor complications (complication rate 20%).