A 60 y/o F with a failed hemiarthroplasty performed at a University Center presented to our office 1
year after her surgery. Her hemi-arthroplasty was performed for proximal humerus fracture. Her problems at the time of presentation to our office were: a nonunion of tuberosities, loose humeral stem, no subscapularis
function, active forward elevation (FE) to 30 deg, intact deltoid function, anterosuperior
escape with FE of the shoulder
She had no signs of infection at the time of surgery with normal lab values (WBC, CRP, ESR) at the time of presentation. 12 cultures obtained during surgery demonstrated the presence of the p acnes bacterium.
Her problems from this surgery were:
1) Infected loose humeral stem (p acnes)
2) fracture of the humeral stem during revision surgery that required ORIF
3) Neuropraxia of the radial nerve that resolved 10 weeks after her surgery
She was seen 18 months after her operation, she had minimal pain and active forward elevation of the shoulder to 140 degrees. The Xrays are shown below
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| This preop xray shows that the stem was cemented, there is failure of the tuberosity healing |
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| Anterior dislocation of the prosthesis with motion of the shoulder. Non union of the lesser tuberosity |
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| CT scan shows failure to reproduce the retroversion of the humerus or free rotation of the stem |
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| The failed hemi arthroplasty was revised to a reverse shoulder replacement, the humeral shaft fracture was fixed with 4.5mm DCP plate and eventually healed. Notice the working length of the plate |
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| 18 months after surgery and antibiotic treatment for 12 months she has minimal pain. The glenoid component shows no signs of loosening Her postoperative active shoulder forward elevation is shown below.    Same authors have suggested the use of humeral allograft for the proximal humeral bone loss as seen in this case. There is no high level evidence studies to support the use of allograft. In the setting of a possible low grade p acnes infection the use of allograft would have complicated the infection further. In addition based on the following study the chances of complications after reverse arthroplasty for failed hemi-arthroplasty are high including humeral fracture as in this case.
J Shoulder Elbow Surg. 2013 Jun;22(6):739-44. doi: 10.1016/j.jse.2012.08.008. Epub 2012 Sep 28.
Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary?AbstractBACKGROUND:
Patients undergoing revision shoulder arthroplasty frequently have deficient proximal humeral bone stock. Proximal humeral allograft has been recommended to augment reverse total shoulder arthroplasty (RTSA) to improve stability and function. This study reports the results of RTSA without proximal humeral allograft in patients with proximal humeral bone loss secondary to failed shoulder arthroplasty.
MATERIALS AND METHODS:
From 2005 to 2008, 251 patients were enrolled in a prospective RTSA cohort study. Significant humeral bone loss was demonstrated in 15 of 56 undergoing revision for failed arthroplasty. Average age was 67 years. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years with American Shoulder and Elbow Surgeons (ASES), Subjective Shoulder Value (SSV), Constant Score (CS), and visual analog scale (VAS) pain scores, as well as self-reported satisfaction and radiographs.
RESULTS:
Patients demonstrated significant improvement in mean CS (23.0 to 44.2), ASES (38.2 to 68.3), ASES activities of daily living (7.0 to 15.9), SSV (19.2 to 75.8), and VAS pain (4.6 to 1.6) scores. Thirteen of 15 patients reported satisfaction (87%). Range of motion improved in forward flexion (38.3° to 103.2°) and external rotation (-0.5° to 11.9°). Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture of 1 modular humeral stem.
CONCLUSIONS:
Use of RTSA for failed shoulder arthroplasty and deficient humeral bone stock provides a significant clinical benefit without the need for allograft augmentation. Monoblock humeral component use may diminish risk for prosthetic fracture.
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