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Kang HW, Child C, Italia K, Karel M, Gilliland L, Ingoe H, Maharaj J, Whitehouse S, Cutbush K, Gupta A. Allograft Prosthetic Composite (APC) for Proximal Humeral Bone Deficiency in Revision Reverse Shoulder Arthroplasty: A Technical Note and Systematic Review. J Clin Med 2024; 13:6290. [PMID: 39458239 PMCID: PMC11508849 DOI: 10.3390/jcm13206290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 09/24/2024] [Accepted: 10/17/2024] [Indexed: 10/28/2024] Open
Abstract
Background: Proximal humeral bone deficiency in revision shoulder arthroplasty is an emerging and challenging problem as the use of reverse shoulder arthroplasty (RSA) increases. This paper presents a technical note discussing our detailed preoperative planning steps, surgical techniques, and their rationale in carrying out the use of an allograft prosthetic composite (APC) to address proximal humeral bone deficiency in revision RSA. The outcomes of this technique are also presented. This paper also presents a systematic review to further discuss the existing literature on RSA with APCs. Methods: The preoperative surgical planning and the surgical technique employed to execute proximal humeral reconstruction using APC during revision arthroplasty are discussed in the technical note. The preliminary clinical and radiological results of five patients who underwent revision shoulder arthroplasty with proximal humeral reconstruction using APCs are presented. The PRISMA guidelines were followed to perform the systematic review. A systematic search using PubMed, Embase, and Cochrane databases was conducted. All studies involving RSA and APCs were pooled, and the data were extracted and analyzed. Results: A total of 14 studies were eligible for inclusion in the systematic review, with a total of 255 patients and a mean follow-up of 57 months. All studies in the systematic review and the patients included in the author's case series showed improvements in the level of pain, range of motion, function, and satisfaction. Graft incorporation in the systematic review was 84%. Conclusions: Based on the available literature and the results of our case series, the use of an APC construct is a viable option for proximal humeral bone deficiency in revision shoulder arthroplasty.
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Affiliation(s)
- Hean Wu Kang
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- St Andrew’s War Memorial Hospital, Brisbane, QLD 4000, Australia
| | - Christopher Child
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- St Andrew’s War Memorial Hospital, Brisbane, QLD 4000, Australia
| | - Kristine Italia
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4101, Australia
| | - Mirek Karel
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- St Andrew’s War Memorial Hospital, Brisbane, QLD 4000, Australia
| | - Luke Gilliland
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Akunah, Brisbane, QLD 4101, Australia
| | - Helen Ingoe
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- St Andrew’s War Memorial Hospital, Brisbane, QLD 4000, Australia
| | - Jashint Maharaj
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
| | - Sarah Whitehouse
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
| | - Kenneth Cutbush
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- St Andrew’s War Memorial Hospital, Brisbane, QLD 4000, Australia
- School of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Ashish Gupta
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia; (H.W.K.); (C.C.); (K.I.); (M.K.); (L.G.); (H.I.); (J.M.); (S.W.); (K.C.)
- Australian Shoulder Research Institute, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- Akunah, Brisbane, QLD 4101, Australia
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Hao KA, Gutowski CT, Bindi VE, Srinivasan RC, Wright JO, King JJ, Wright TW, Fedorka CJ, Schoch BS, Hones KM. Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications. Indian J Orthop 2024; 58:1339-1348. [PMID: 39324078 PMCID: PMC11420417 DOI: 10.1007/s43465-024-01248-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/29/2024] [Indexed: 09/27/2024]
Abstract
Background This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Methods Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Results Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Discussion Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level of Evidence Level IV; Systematic Review. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-024-01248-7.
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Affiliation(s)
- Kevin A Hao
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL USA
| | | | | | | | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL USA
| | - Catherine J Fedorka
- Cooper Bone and Joint Institute, Cooper Medical School of Rowan University, Camden, NJ USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL USA
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Baldari A, Saccone L, Caldaria A, de Sanctis EG, De Angelis D'Ossat GM, La Verde L, Palumbo A, Franceschi F. Revision shoulder arthroplasty and proximal humeral bone loss: a comprehensive review and proposal of a new algorithm of management. J Orthop Traumatol 2024; 25:40. [PMID: 39225941 PMCID: PMC11372038 DOI: 10.1186/s10195-024-00784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024] Open
Abstract
With the rising prevalence of shoulder arthroplasty, the incidence of revision shoulder arthroplasty is also increasing. The complexity of these revision procedures poses significant challenges, with bone loss being a critical factor impacting treatment outcomes. Addressing substantial humeral bone defects is crucial for ensuring implant stability and functionality. A comprehensive literature review was conducted using PubMed, Medline, and Google Scholar to identify existing classification systems for proximal humeral bone loss in the context of revision shoulder arthroplasty. The study assessed the advantages and limitations of these classifications, using this information to propose a new diagnostic and therapeutic algorithm. Several classification systems for proximal humeral bone loss were identified. McLendon et al. classify proximal humeral bone loss based on a 5-cm bone loss threshold and suggest an allograft prosthesis composite for losses exceeding this limit. Boileau's system stratifies bone loss into four types based on the extent of loss, with specific recommendations for each category. The PHAROS classification provides a detailed anatomical assessment but lacks quantitative precision. The proposed PHBL-SCORe system offers a novel algorithm incorporating preoperative radiographic measurements to determine the percentage of bone loss and guide treatment options. Proximal humeral bone loss presents significant challenges in revision shoulder arthroplasty, necessitating precise preoperative planning and classification to guide surgical intervention. Existing classification systems provide valuable frameworks but often rely on average population values, neglecting individual anatomical variations. The proposed PHBL-SCORe system offers a patient-specific approach, improving the accuracy of bone loss assessment and optimizing treatment strategies. Implementing this classification in clinical practice could enhance surgical outcomes and reduce complications associated with rRSA (revision Reverse Shoulder arthroplasty). Further studies are required to validate this algorithm and explore its long-term efficacy in diverse patient populations.
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Affiliation(s)
- Angelo Baldari
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
- Faculty of Medicine and Surgery, Link Campus University, 00165, Rome, Italy
| | - Luca Saccone
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Campus Bio-Medico of Rome, 00128, Rome, Italy
| | - Antonio Caldaria
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy.
| | - Edoardo Giovannetti de Sanctis
- Institut Universitaire Locomoteur et du Sport (IULS), Hôpital Pasteur 2, CHU de Nice, 30, avenue Voie Romaine, 06000, Nice, France
| | | | - Luca La Verde
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Alessio Palumbo
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy
- Faculty of Medicine and Surgery, Link Campus University, 00165, Rome, Italy
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Rampam S, Segu H, Gonzalez MR, Lozano-Calderon SA. Complications and functional outcomes after reconstruction of the proximal humerus with allograft-prosthetic composite: a systematic review of the literature. J Shoulder Elbow Surg 2024; 33:1873-1883. [PMID: 38604399 DOI: 10.1016/j.jse.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/04/2024] [Accepted: 02/17/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Allograft prosthetic composite (APC) reconstruction is performed after resection of proximal humerus tumors or failure of arthroplasty implants. There is limited literature on the postoperative outcomes of this technique. We sought to assess implant survival, failure rates, and postoperative functional outcomes after APC reconstruction of the proximal humerus. METHODS A systematic review of the PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: 448,663). The Strengthening of the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Implant failure was determined using the Henderson classification for biological reconstruction. Functional outcome was primarily assessed using the Musculoskeletal Tumor Society score at last follow-up. RESULTS Twenty-five studies with a total of 488 patients were included. Mean follow-up in reporting studies ranged from 2.5 to 10 years. Five-year revision-free survival for implants ranged from 41% to 92%. Overall implant failure rate ranged from 9% to 54%, and reoperation rate ranged from 0% to 55%. Graft host nonunion (type 2) was the most common mode of failure, with rates ranging from 0% to 75%. The mean Musculoskeletal Tumor Society scores at last follow-up ranged from 57% to 90% across studies. A trend towards better functional outcomes was seen in patients having an APC with a reverse total shoulder arthroplasty (rTSA) compared with those with hemiarthroplasty. CONCLUSIONS APCs show promise in proximal shoulder reconstruction, with heterogeneous functional outcomes that are noninferior to other reconstruction techniques. Graft host nonunion is a common mode of failure and remains a concern in this type of prosthesis. Future studies should compare rTSA-APCs and rTSA endoprostheses while controlling for potential confounders.
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Affiliation(s)
- Sanjeev Rampam
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hitha Segu
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Cox RM, Mandava N, Lazarus MD, Williams GR, Namdari S. Management of proximal humerus bone loss with allograft prosthetic composite technique in shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:1306-1312. [PMID: 37981001 DOI: 10.1016/j.jse.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/11/2023] [Accepted: 09/25/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Proximal humerus bone loss in shoulder arthroplasty is a difficult problem with limited treatment options. It most commonly occurs in the setting of a previously failed shoulder arthroplasty; however, it is occasionally encountered in cases of primary shoulder arthroplasty. Reconstruction of the proximal humerus is essential for soft tissue tension for implant stability and maximizing function. The purpose of this study was to analyze the clinical and functional outcomes of the allograft prosthetic composite (APC) technique for the management of proximal humeral bone loss in shoulder arthroplasty. METHODS A retrospective review was performed of all patients who underwent primary or revision shoulder arthroplasty using an APC technique with a reverse shoulder arthroplasty prosthesis for the management of proximal humerus bone loss. Data collected included demographic variables, previous shoulder surgeries, indication for APC, type of allograft utilized, fixation technique, and reoperation and revision rates. Patients were contacted by phone and/or email survey to obtain the latest patient-reported functional outcome scores. RESULTS We identified 14 patients who underwent shoulder arthroplasty using the APC technique with a reverse shoulder arthroplasty prosthesis. One (7.1%) was performed as a primary arthroplasty, and 13 (92.9%) were performed as revision arthroplasties. The indications for APC were instability (21.4%), periprosthetic fracture (21.4%), periprosthetic joint infection (14.3%), humeral component loosening (14.3%), rotator cuff failure (14.3%), fracture sequelae (7.1%), and failed hemiarthroplasty (7.1%). In terms of allograft type, 10 (71.4%) were performed with proximal femur allograft and 4 (28.6%) with proximal humerus allograft. There were 6 patients (42.9%) who sustained postoperative complications, 5 patients (35.7%) had instability, and 1 (7.1%) patient had postoperative wound drainage. All patients with a complication required a revision arthroplasty. CONCLUSION The APC technique used to address proximal humerus bone loss in shoulder arthroplasty has a high complication rate with fair patient-reported functional outcome scores. Most of the postoperative complications and reoperations are related to implant instability.
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Affiliation(s)
- Ryan M Cox
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nikhil Mandava
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark D Lazarus
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerald R Williams
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Eckers F, Hochreiter B, Forsyth S, Ek ET. Proximal humerus reconstruction in reverse total shoulder arthroplasty with proximal humeral bone loss using a lower trapezius tendon transfer with Achilles tendon-bone allograft: surgical technique and report of 2 cases. JSES Int 2024; 8:508-514. [PMID: 38707582 PMCID: PMC11064716 DOI: 10.1016/j.jseint.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Affiliation(s)
- Franziska Eckers
- Melbourne Orthopaedic Group, Melbourne, Australia
- Department of Orthopedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, Melbourne, Australia
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Sarah Forsyth
- Melbourne Orthopaedic Group, Melbourne, Australia
- Melbourne Shoulder Group, Melbourne, Australia
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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Rodrigues-Lopes R, Silva F, Torres J. Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:722-737. [PMID: 37839627 DOI: 10.1016/j.jse.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty. METHODS Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model. RESULTS After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03). CONCLUSIONS This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.
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Affiliation(s)
| | - Fábia Silva
- Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
| | - João Torres
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
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Gregori P, Perricone G, Franceschetti E, Giurazza G, Papalia GF, Zà P, Papalia R. Allograft Prosthesis Composite (APC) for Proximal Humeral Bone Loss: Outcomes and Perspectives. J Pers Med 2023; 13:1301. [PMID: 37763069 PMCID: PMC10532464 DOI: 10.3390/jpm13091301] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: Allograft prosthetic composite (APC) represents one of the techniques used for reconstruction in large proximal humeral bone deficits. The present systematic review aimed at summarizing the state of the art of the technique and analyzing its outcomes. (2) Methods: The PRISMA guidelines were followed to perform this systematic review. A systematic electronic search was performed using PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. All the studies analyzing the rates of allograft prosthesis composite were pooled, and the data were extracted and analyzed. (3) Results: A total of 10 studies were eligible for inclusion in this systematic review for a total of 239 patients. The rate of patient satisfaction with surgery was reported in 7 studies with a mean of 86.4% ± 13.64. The mean constant score was 45.7 ± 3.51, the mean ASES score was 63.58 ± 8.37, and the mean SST was 4.6 ± 1.04. The mean revision rate observed was 10.32% ± 3.63 and the mean implant survival was 83.66% ± 14.98. (4) Conclusions: Based on the currently available data, allograft prosthesis composite represents a valuable option for the reconstruction of proximal humeral deficits. All studies analyzed showed the favorable impact of this surgical technique on clinical outcomes and patient satisfaction.
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Affiliation(s)
- Pietro Gregori
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Giovanni Perricone
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Edoardo Franceschetti
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Giancarlo Giurazza
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Giuseppe Francesco Papalia
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Pierangelo Zà
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Rocco Papalia
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy; (P.G.); (G.P.); (G.G.); (G.F.P.); (P.Z.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
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Hones KM, Gutowski CT, Srinivasan RC, Wright JO, King JJ, Wright TW, Fedorka CJ, Marigi EM, Schoch BS, Hao KA. Allograft-Prosthetic Composite Reconstruction for Proximal Humerus Bone Loss: A Systematic Review and Meta-Analysis of Outcomes and Complications. JBJS Rev 2023; 11:01874474-202308000-00009. [PMID: 37616466 DOI: 10.2106/jbjs.rvw.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND In smaller studies, allograft-prosthetic composite (APC) has been used for proximal humerus bone loss with some success, although with notable complication risk. This systematic review and meta-analysis sought to describe outcomes and complications after proximal humerus APC and how major APC complications are defined in the literature. METHODS A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for articles on APC for proximal humeral bone loss secondary to tumor, fracture, or failed arthroplasty. Primary outcomes included postoperative range of motion, outcome scores (Musculoskeletal Tumor Society [MSTS], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, visual analog scale [VAS], and subjective shoulder value [SSV]), and complication incidence. We also described individual study definitions of APC malunion/nonunion, methods of postoperative evaluation, malunion/nonunion rates, allograft fracture/fragmentation rates, and mean union time, when available. Secondarily, we compared hemiarthroplasty and reverse total shoulder arthroplasty. RESULTS Sixteen articles including 375 shoulders were evaluated (average age: 49 years, follow-up: 54 months). Fifty-seven percent of procedures were performed for tumors, 1% for proximal humerus trauma sequelae, and 42% for revision arthroplasty. Average postoperative forward elevation was 82° (69-94°), abduction 60° (30-90°), and external rotation 23° (17-28°). Average MSTS score was 82% (77%-87%), SST score 5.3 (4.5-6.1), ASES score 64 (54-74), Constant score 44 (38-50), VAS score 2.2 (1.7-2.7), and SSV 51 (45-58). There was a 51% complication rate with an 18% nonallograft surgical complication rate, 26% APC nonunion/malunion/resorption rate, and 10% APC fracture/fragmentation rate. Fifteen percent of nonunited APCs underwent secondary bone grafting; 3% required a new allograft; and overall revision rate was 12%. APC nonunion/malunion was defined in 2 of 16, malunion/nonunion rates in 14 of 16, fracture/fragmentation rates in 6 of 16, and mean union time (7 months) in 4 of 16 studies. CONCLUSION APC reconstruction of the proximal humerus remains a treatment option, albeit with substantial complication rates. In addition, there is a need for APC literature to report institutional definitions of nonunion/malunion, postoperative evaluation, and time to union for a more standardized evaluation. LEVEL OF EVIDENCE Level IV; systematic review. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Keegan M Hones
- College of Medicine, University of Florida, Gainesville, Florida
| | | | | | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Catherine J Fedorka
- Cooper Bone and Joint Institute, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Erick M Marigi
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, Florida
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10
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Gohlke F, Berner A, Abdelkawi A. [Humeral bone defects in revision shoulder arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:98-108. [PMID: 36651969 DOI: 10.1007/s00132-022-04335-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Revision shoulder arthroplasty is mainly performed with reverse TSA and should consider proper adjustment of the length and the amount of bone loss in humeral reconstruction. Whilst epi-/metaphyseal bone loss can mostly be compensated easily by stemmed standard implants, advanced bone loss exceeding 2° requires the support of longer revision stems. EXTENSIVE HUMERAL BONE LOSS Cementless fixation in the intact diaphyseal humerus is recommended in bone loss exceeding 2°, preferably with modular revision systems, because cemented reverse revision stems have higher loosening rates in the mid to long-term follow-up. In cases of advanced bone loss 3°-4° (more than 6-7 cm), structural humeral allografts should be considered to prevent instability and early loosening. Unfortunately, the access to fresh frozen allografts is very limited due to regulation of the German government in contrast to the situation in the US or Switzerland. Reverse tumor arthroplasty is an option with a higher complication rate and inferior function even when polyester mesh is used for ingrowth of soft tissues. DISTINCT DIAPHYSEAL DEFECTS In bone loss 4°-5° the minimal anchorage length is mostly critical due to the curvature of the medullary canal. The fixation of a revision stem is only possible when at least 2-3 widths of the diaphyseal diameter are available. Custom-made implants with flanges or distal locking screws, or bipolar tumor arthroplasty may be required. Additionally, strut allografts can be useful to achieve stable fixation. Two-stage biological reconstruction in impaction-bone-graft or the Masquelet technique are rarely used as a salvage procedure.
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Affiliation(s)
- Frank Gohlke
- Klinik für Orthopädie, Unfallchirurgie, Schulter- und Ellenbogenchirurgie und Endoprothetik, Rhön-Klinikum, Campus Bad Neustadt/Saale, Salzburger Leite 1, 97616, Bad Neustadt/Saale, Deutschland.
| | - Arne Berner
- Klinik für Orthopädie, Unfallchirurgie, Schulter- und Ellenbogenchirurgie und Endoprothetik, Rhön-Klinikum, Campus Bad Neustadt/Saale, Salzburger Leite 1, 97616, Bad Neustadt/Saale, Deutschland
| | - Ayman Abdelkawi
- Klinik für Orthopädie, Unfallchirurgie, Schulter- und Ellenbogenchirurgie und Endoprothetik, Rhön-Klinikum, Campus Bad Neustadt/Saale, Salzburger Leite 1, 97616, Bad Neustadt/Saale, Deutschland
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11
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Wang S, Luo Y, Wang Y, Zhang Y, Gong T, Tu C, Zhou Y. Early functional and therapeutic effect of reversed tumour shoulder prosthesis reconstruction after proximal humerus tumour resection. Front Surg 2022; 9:987161. [PMID: 36211281 PMCID: PMC9537544 DOI: 10.3389/fsurg.2022.987161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionReconstruction of proximal humeral tumours after resection is still controversial. And there are few articles describing oncology patients' postoperative function after reversed tumour shoulder prosthesis reconstruction. We investigated the functional results of patients who underwent reversed tumour shoulder prosthesis, including those who did not preserve the deltoid ending point.Patients and methodsWe retrospectively evaluated 16 patients with proximal humerus tumours who had undergone reversed tumour shoulder prosthesis. All patients underwent type Malawer I proximal humeral resection surgery and standard reverse tumour shoulder arthroplasty with a modular reverse shoulder prosthesis. We sutured the severed end of the deltoid to the brachialis muscle using the artificial patch for patients who had their deltoid ending point resected. Patients are rehabilitated and followed up according to our instructions.ResultAll patients were followed up for a mean of 27.4 months (13–59), and their mean age was 45.9 years (15–74). The mean length of the humeral resection was 11.6 cm (5–15). The mean shoulder mobility was 122° (82°–180°) in forward flexion; 39° (31°–45°) in posterior extension; 102° (65°–172°) in abduction; 43° (30°–60°) in external rotation; 83° (61°–90°) in internal rotation, and a mean MSTS score of 77.9% (63.3%–93.3%). The mean DASH score was 20.8 (2.5–35.8). The mean VAS score was 0.9. For patients who had their deltoid ending point resected, the mean length of the humeral resection was 14.0 cm; the mean shoulder mobility was 109° in forward flexion; 37.8° in posterior extension; 102.0° in abduction; 38.3° in external rotation; 86.3° in internal rotation, and the mean MSTS score was 78.8%; the mean DASH score was 21.6; the mean VAS score was 1.0.ConclusionPatients who underwent reverse tumour shoulder arthroplasty can achieve good early postoperative function, survival rate and low complication rate. In addition, patients who had their deltoid ending point removed also obtained good function after particular reconstruction.
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Affiliation(s)
| | | | | | | | | | | | - Yong Zhou
- Correspondence: Chongqi Tu Yong Zhou
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12
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Li X, Galvin JW, Zalneraitis BH, Gasbarro G, Parada SA, Eichinger JK, Boileau P, Warner JJP, Elhassan BT. Muscle Tendon Transfers Around the Shoulder: Diagnosis, Treatment, Surgical Techniques, and Outcomes. J Bone Joint Surg Am 2022; 104:833-850. [PMID: 35213452 DOI: 10.2106/jbjs.21.00398] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency. ➤ The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle. ➤ When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications. ➤ For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes. ➤ Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes. ➤ The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty. ➤ The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training.
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Affiliation(s)
- Xinning Li
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Gregory Gasbarro
- Orthopaedic Specialty Hospital, Mercy Medical Center, Baltimore, Maryland
| | | | | | - Pascal Boileau
- Institute for Sports and Reconstructive Bone and Joint Surgery, Nice, France
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13
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Walker MF, Kamineni S. Allograft reconstruction of olecranon after traumatic bone loss: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:250-253. [PMID: 37587965 PMCID: PMC10426560 DOI: 10.1016/j.xrrt.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite 2.2 million bone allografts conducted annually, their complication rate remains high, with recipients incurring infection, fracture, instability, and failure to incorporate. Nonunion rates in massive bone allografts-a bone segment ≥5 cm in length that also contains the total circumference of replaced bone-have been documented as high as 50%. However, if early complication can be avoided, a 75% success rate at 20 years postoperatively has been reported. Nonmassive allografts may yield decreased nonunion rates, as massive bone allografts must overcome a greater metaphyseal to diaphyseal incorporation rate and osteoconduction may not ensue beyond the bone periphery. The patient in this case is a 23-year-old male demonstrating absent bone in the right olecranon process of the ulna without attachment of the triceps brachii after a motorbike accident. The patient underwent olecranon allograft reconstruction with triceps brachii tendon reattachment. Four and a half years after allograft reconstruction of the right olecranon, the patient presents with minimal symptoms. However, he reports occasional aching at the site of injury. His current active arc of sagittal motion was 20°-130°, and pronation-supination was 70°-80°. His triceps strength was 4/5 Medical Research Council grade. Radiographic evaluation revealed a well-incorporated graft with a recontoured olecranon tip. Overall, this report demonstrates that operations involving a nonmassive allograft about the olecranon process may display minimal side effects in comparison to massive allografts, specifically regarding nonunion. Furthermore, this operation allows for improved range of motion after bone loss, allowing the patient to partake in activities of daily living.
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Affiliation(s)
| | - Srinath Kamineni
- Department of Orthopedic Surgery, Elbow Shoulder Research Center, University of Kentucky College of Medicine, Lexington, KY, USA
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Houdek MT, Wagner ER, Rose PS, Barlow JD, Elhassan BT, Sanchez-Sotelo J. Allograft prosthetic composite reconstruction using a reverse total shoulder arthroplasty for failed oncologic proximal humerus reconstruction. J Surg Oncol 2021; 125:775-781. [PMID: 34913481 DOI: 10.1002/jso.26772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Endoprosthetic or allograft reconstruction are the preferred reconstruction techniques for proximal humeral bone tumors. Failure of these reconstructions may occur, but historically revision is performed rarely due to the lack of reliable options. Reverse shoulder arthroplasty with an allograft prosthetic composite (rAPC) may provide a revision option. The purpose of the current study was to evaluate our institutional outcome of these procedures. METHODS Eleven (6 male, 5 female) patients (mean age 51 ± 17 years) underwent revision of a failed oncologic reconstruction of the proximal humerus utilizing a rAPC. The most common indication for revision was subluxation (n = 6) and the most common previous implant was an endoprosthesis (n = 5). RESULTS Revision resulted in improvements in shoulder elevation (39° vs. 62°, p = 0.02), external rotation (13° vs. 25°, p = 0.04), American Shoulder and Elbow Surgeons score (39 vs. 58, p = 0.004) and Musculoskeletal Tumor Society Scores (51% vs 69%, p = 0.002). There were 2 re-revision procedures performed. One for an allograft fracture and one for allograft resorption and loosening. CONCLUSIONS Revision with a rAPC can effectively restore patient function. Due to the complexity of the cases, we advocate for these procedures to be performed by subspecialty upper extremity surgeons trained in complex revision shoulder arthroplasty.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric R Wagner
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bassem T Elhassan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Arenas-Miquelez A, Arbeloa-Gutierrez L, Familiari F, de Pablos J. Salvage Procedures of the Shoulder: Glenohumeral Arthrodesis and Resection Arthroplasty. Indian J Orthop 2020; 55:27-37. [PMID: 34122752 PMCID: PMC8149774 DOI: 10.1007/s43465-020-00279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND With the advances of modern medicine and technology there has been an increase of indications of shoulder reconstruction techniques and shoulder arthroplasty. Consequently, the number of complications and failures have increased in parallel. Not negligible number of cases are driven to an end-stage situation where salvage procedures, such as glenohumeral arthrodesis (GHA) and shoulder resection arthroplasty (SRA), are the only remaining solution. METHODS The current literature on glenohumeral arthrodesis and shoulder resection arthroplasty was reviewed to determine the indications, surgical technique, complications and outcomes. The electronic search was conducted using the MEDLINE and EMBASE databases and the strategies used were "glenohumeral arthrodesis", "glenohumeral fusion", "shoulder arthrodesis" and "shoulder resection arthroplasty". RESULTS Indications for glenohumeral arthrodesis (GHA) include brachial plexus injury, tumor resections, chronic infection, failed prosthetic arthroplasty, persistent refractory instability or pseudoparalysis of the shoulder with combined irreparable rotator cuff and deltoid injuries. GHA provides good stability, pain resolution, although function is markedly compromised and relying mostly on scapulothoracic joint. The gold standard surgical technique continues to be open shoulder arthrodesis and still has a high complication rate. Shoulder resection arthroplasty (SRA) indications have evolved through the years, being nowadays a salvage procedure for recalcitrant infection of shoulder arthroplasty the main indication. Shoulder function after SRA is often severely compromised, but has a high infection rate resolution. SRA is not technically demanding and complications are rare, being the persistence of infection the most common one. DISCUSSION Despite GHA and SRA having negative connotations, in selected patients, these procedures can diminish pain, resolve persistent infections and provide an acceptable shoulder function. Hence, they should be retained as part of the treatment algorithm for complex shoulder pathology.
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Affiliation(s)
- Antonio Arenas-Miquelez
- grid.1004.50000 0001 2158 5405Shoulder and Elbow, Orthopaedics, Macquarie University Hospital, Suite 303, 2 Technology Place, Sydney, NSW 2109 Australia
| | | | - Filippo Familiari
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy
| | - Julio de Pablos
- Advanced Reconstructive Osseous Surgery, San Juan de Dios Hospital, Pamplona, Spain
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