Advertisement

Management of Large Humeral Defects: Bone Grafts and Augmented Components

  • William R. Aibinder
  • Joaquin Sanchez-SoteloEmail author
Chapter

Abstract

Management of large proximal humeral bone defects at the time of revision shoulder arthroplasty can be challenging. Surgeons need to restore humeral length, provide adequate support for the revision implant, optimize deltoid tension, and provide soft tissue attachment sites to reconstruct a stable and functional shoulder. Although proximal humeral bone loss may also be encountered in complex primary cases (such as after resection of malignancies and after trauma), the focus of this chapter is on revision surgery. Options for the management of substantial proximal humerus bone loss include osteoarticular allografts, allograft-prosthetic composites (APCs), and proximal humeral prostheses with large metal replacement humeral bodies. Osteoarticular allografts are seldom used in the setting of revision surgery. The use of modular segmental metal proximal humeral prostheses is a viable option for relatively shorter defects and in situations when the potential for graft-to-host union is hindered, such as with that of radiation or chemotherapy. APCs are particularly appealing for longer defects, especially when soft tissue reattachment is considered important. Nonetheless, patients undergoing revision arthroplasty in the setting of proximal humeral bone loss are at an increased risk for poor range of motion, worse functional outcomes, dislocation, mechanical failure, and other complications when compared to cohorts of patients with preserved native proximal bone and soft tissue attachments; patients should be counseled accordingly.

Keywords

Proximal humeral bone loss Reverse shoulder arthroplasty Allograft-prosthetic composite Modular segmental metal proximal humerus prosthesis 

References

  1. 1.
    Abdeen A, Hoang BH, Athanasian EA, Morris CD, Boland PJ, Healey JH. Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am. 2009;91(10):2406–15.  https://doi.org/10.2106/JBJS.H.00815.CrossRefPubMedGoogle Scholar
  2. 2.
    Budge MD, Moravek JE, Zimel MN, Nolan EM, Wiater JM. Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary? J Shoulder Elbow Surg. 2013;22(6):739–44.  https://doi.org/10.1016/j.jse.2012.08.008.CrossRefPubMedGoogle Scholar
  3. 3.
    Chacon A, Virani N, Shannon R, Levy JC, Pupello D, Frankle M. Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite. J Bone Joint Surg Am. 2009;91(1):119–27.  https://doi.org/10.2106/JBJS.H.00094.CrossRefPubMedGoogle Scholar
  4. 4.
    Raiss P, Edwards TB, da Silva MR, Bruckner T, Loew M, Walch G. Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type-3 fracture sequelae). J Bone Joint Surg Am. 2014;96(24):2070–6.  https://doi.org/10.2106/JBJS.N.00405.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cheng EY, Gebhardt MC. Allograft reconstructions of the shoulder after bone tumor resections. Orthop Clin North Am. 1991;22(1):37–48.PubMedGoogle Scholar
  6. 6.
    Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am. 2007;89(2):292–300.  https://doi.org/10.2106/JBJS.E.01310.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ross AC, Wilson JN, Scales JT. Endoprosthetic replacement of the proximal humerus. J Bone Joint Surg Br. 1987;69(4):656–61.CrossRefGoogle Scholar
  8. 8.
    Getty PJ, Peabody TD. Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am. 1999;81(8):1138–46.CrossRefGoogle Scholar
  9. 9.
    Potter BK, Adams SC, Pitcher JD Jr, Malinin TI, Temple HT. Proximal humerus reconstructions for tumors. Clin Orthop Relat Res. 2009;467(4):1035–41.  https://doi.org/10.1007/s11999-008-0531-x.CrossRefPubMedGoogle Scholar
  10. 10.
    Rodl RW, Gosheger G, Gebert C, Lindner N, Ozaki T, Winkelmann W. Reconstruction of the proximal humerus after wide resection of tumours. J Bone Joint Surg Br. 2002;84(7):1004–8.CrossRefGoogle Scholar
  11. 11.
    Gebhardt MC, Roth YF, Mankin HJ. Osteoarticular allografts for reconstruction in the proximal part of the humerus after excision of a musculoskeletal tumor. J Bone Joint Surg Am. 1990;72(3):334–45.CrossRefGoogle Scholar
  12. 12.
    Black AW, Szabo RM, Titelman RM. Treatment of malignant tumors of the proximal humerus with allograft-prosthesis composite reconstruction. J Shoulder Elbow Surg. 2007;16(5):525–33.  https://doi.org/10.1016/j.jse.2006.12.006.CrossRefPubMedGoogle Scholar
  13. 13.
    Hartigan DE, Veillette CJ, Sanchez-Sotelo J, Sperling JW, Shives TC, Cofield RH. Reconstruction of the proximal humerus for bone neoplasm using an anatomic prosthesis-bone graft composite. Acta Orthop Belg. 2012;78(4):450–7.PubMedGoogle Scholar
  14. 14.
    Sanchez-Sotelo J, Wagner ER, Sim FH, Houdek MT. Allograft-prosthetic composite reconstruction for massive proximal humeral bone loss in reverse shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(24):2069–76.  https://doi.org/10.2106/JBJS.16.01495.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Bos G, Sim F, Pritchard D, Shives T, Rock M, Askew L, et al. Prosthetic replacement of the proximal humerus. Clin Orthop Relat Res. 1987;(224):178–91.Google Scholar
  16. 16.
    Cannon CP, Paraliticci GU, Lin PP, Lewis VO, Yasko AW. Functional outcome following endoprosthetic reconstruction of the proximal humerus. J Shoulder Elbow Surg. 2009;18(5):705–10.  https://doi.org/10.1016/j.jse.2008.10.011.CrossRefPubMedGoogle Scholar
  17. 17.
    Kumar D, Grimer RJ, Abudu A, Carter SR, Tillman RM. Endoprosthetic replacement of the proximal humerus. Long-term results. J Bone Joint Surg Br. 2003;85(5):717–22.CrossRefGoogle Scholar
  18. 18.
    Raiss P, Kinkel S, Sauter U, Bruckner T, Lehner B. Replacement of the proximal humerus with MUTARS tumor endoprostheses. Eur J Surg Oncol. 2010;36(4):371–7.  https://doi.org/10.1016/j.ejso.2009.11.001.CrossRefPubMedGoogle Scholar
  19. 19.
    Streitbuerger A, Henrichs M, Gosheger G, Ahrens H, Nottrott M, Guder W, et al. Improvement of the shoulder function after large segment resection of the proximal humerus with the use of an inverse tumour prosthesis. Int Orthop. 2015;39(2):355–61.  https://doi.org/10.1007/s00264-014-2560-2.CrossRefPubMedGoogle Scholar
  20. 20.
    Vander Griend RA. The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am. 1994;76(5):657–63.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryMayo ClinicRochesterUSA
  2. 2.Mayo Clinic and Mayo College of MedicineRochesterUSA

Personalised recommendations