Humeral bone grafting in stemless shoulder arthroplasty
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Humerale autologe Graftaugmentation im Rahmen der schaftfreien Schulterendoprothetik
Step 1: Exposure of the glenohumeral joint
Step 2: Humeral head osteotomy
The humeral osteophytes are removed completely to identify the anatomic neck of the humerus. Once the centromedullary humeral resection guide has been placed in a standard method, the humeral head is resected with an oscillating saw at the appropriate level (Fig. 2b). The cut surface is then palpated digitally to examine bone quality within the proximal humeral metaphysis (“thumb test” ).
Step 3: Examination of the humeral bony defect
As shown in Fig. 2c, a large solitary bone cyst is detected within the lateral aspect of the metaphyseal cut surface. After the cyst has been thoroughly debrided, curettage of the fibrous membrane is performed using a sharp spoon to explore the exact location, extent, and configuration of the bony defect (Fig. 2d). The diameter and depth of the resultant humeral lesion are measured with a ruler (Fig. 2e, f).
Step 4: Autograft preparation and impaction
A spongious autograft is harvested from the resected humeral head depending on the individual extent of the bony defect. It is important to gently remove the cortical bone with a saw or a burr (Fig. 2g, h). The shaped cancellous autograft is then impacted flush with the humeral cut surface (Fig. 2i–k). A saw is used to manually create a flat surface ensuring a circumferential contact area (Fig. 2l).
Step 5: Preparation of the central screw hole
The drill template is matched with the cortical rim and then placed on the resected plane to prepare the central hole for the cage screw using a hand coring reamer. It is important to manually ream the bone due to the underlying autograft (Fig. 2m). The length of the screw is measured using the standard devices and technique. A resection protector is used while preparing the glenoid.
The glenoid is prepared using a standard technique. Once the glenoid component has been implanted, the selected trunion is placed on the humeral cut and fixed with the appropriate cage screw (Fig. 2n). While tightening the screw, the graft is pressed into the metaphysis via the trunion. The humeral head prosthesis is impacted and the procedure is finalized by repositioning the humeral head and reattachment of the subscapularis tendon using both transosseous and tendon-to-tendon sutures (Fig. 2o).
Postoperatively, the shoulder is immobilized in a sling for 6 weeks, and passive range-of-motion exercises for abduction, flexion, and internal rotation are begun 2 weeks after surgery. After 6 weeks, conventional radiographic imaging is performed to assess component position and to check for signs of prosthetic loosening (Fig. 1e, f).
The main concern regarding the metaphyseal fixation of the humeral stemless components is poor bone quality due to osteoporosis, osteopenia, or metabolic bone diseases. The second major problem is the presence of a bone defect in the proximal humerus such as a subchondral cyst formation, which may be found in many articular diseases . In those cases, a stemmed prosthesis is currently a viable option to utilize diaphyseal fixation and enable primary implant stability, even though several stem-related complications have been reported, including intraoperative humeral fractures and postoperative stress-shielding, stem loosening, or osteolysis .
Among the various stemless humeral prostheses available to treat primary and secondary osteoarthritis, the Eclipse prosthesis is the only stemless system providing metaphyseal fixation by a fully threaded cylindrical central cage screw. Compared to the prostheses which are implanted using an impaction technique, the screw-in application is thought to be more bone preserving and leads to excellent compression of the autograft into the metaphysis.
Our technique represents a reliable option when treating patients with osteoarthritis in combination with a significant metaphyseal humeral bone defect using a stemless humeral prosthesis, together with a readily available humeral autograft.
Compliance with ethical guidelines
Conflict of interest
F. Plachel declares that he has no competing interests. M. Scheibel is an advisor at Arthrex.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975 (in its most recently amended version). Informed consent was obtained from all individual participants included in the study.
Humeral bone grafting in stemless shoulder arthroplasty
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