Impaction autografting of the medial calcar in anatomic shoulder arthroplasty

Impaction humeral autografting using bone from the resected humeral head can provide an alternative option to cemeting the humeral component in anatomic shoulder arthroplasty in cases of osteopenia. This method is routinely performed at the University of Washington for standard size smooth stems and indeed is a good method of fixation of the stem. In case the stem has to be removed in the future resection is easy and not problematic due to avoidance of the excessive adherence or ingrowth of the stem to the humerus. In contrast to the hip arthroplasty, the shoulder arthroplasty stems do not see the torsional forces seen within the femoral canal and for that reason impaction autografting in primary anatomic shoulder arthroplasty is a valuable and appropriate method of fixation of the stem. The use of this technique in cases of implantation of a short stem is even more critical when the proximal humerus endosteal bone is osteopenic. The case below illustrates the radiographic appearance of this method. In this case the "fine tuning of the position of the humeral stem" was performed with impaction grafting as well as the press fit.

The arrow points in the humeral head autograft placed in the endosteal canal with impaction in this case. Radiopaque appearance indicates the increased density of the bone at the medial calcar reinforcing the fixation. Theses x-rays were obtained immediately post-op. We prefer to fix the component by impaction grafting the inside of the humerus (using bone harvested from the humeral head that has been removed) until a tight press fit of the implant is achieved.

The method and picture taken from UW Shoulder and Elbow Service is seen below as well as the their recent publication indicates 93.4% survivorship of the stem at 5 years with minimum of 2 year follow up:

Impaction autografting: bone-preserving, secure fixation of a standard humeral component

Robert M. Lucas, MD

,

Jason E. Hsu, MD

,

Albert O. Gee, MD

,

Moni B. Neradilek, MS

,

Frederick A. Matsen III, MDCorrespondence information about the author MD Frederick A. MatsenEmail the author MD Frederick A. Matsen

• J Shoulder and Elbow Surgery 

November 2016Volume 25, Issue 11, Pages 1787–1794

Background

When fixed with bone ingrowth, a tight diaphyseal press fit, or cement, the humeral component of a shoulder arthroplasty may present problems of malposition, stress shielding, or periprosthetic fracture or difficulty with removal at revision arthroplasty. We have avoided the need for these fixation methods by using impaction cancellous autografting of the humeral stem, minimizing contact between the prosthetic stem and the humeral cortex. This study presents the radiographic survivorship of impaction-autografted humeral implants using component subsidence as the primary endpoint.

Methods

We reviewed 286 primary anatomic shoulder arthroplasties having an average follow-up of 4.9 ± 2.7 years. Initial postoperative radiographs and minimum 2-year follow-up radiographs were evaluated by 3 observers to assess subsidence.

Results

Two different implants (Humeral Replacement Prosthesis [HRP] and Global Advantage prosthesis) were used. Of 286 stems, 267 (93.4%) had not subsided. The Global Advantage prosthesis had a subsidence-free survival rate of 98.5% at 5 years. The stiffer-stemmed HRP used early during the study had a higher rate of subsidence compared with the currently used Global Advantage stem (hazard ratio, 5.6; P = .001). Radiolucent lines of 2 mm or greater were less common for the Global Advantage prosthesis than for the HRP in each of 7 zones (P < .001). Total shoulder arthroplasty was associated with a higher rate of subsidence compared with hemiarthroplasty (hazard ratio, 2.6; P = .12).

Conclusions

Impaction autografting provides a secure, durable, bone-preserving means of humeral component fixation in anatomic shoulder arthroplasty.

Margin Convergence - successful rotator cuff repair 2 years after traumatic injury

This case illustrates that margin convergence can provide enough length for repair of large chronic traumatic retracted rotator cuff tears. In this scenario two tendons were involved in the tear, the supraspinatus and infraspinatus, the tear was 2 years old. As seen on the MRI there was Grade 2 fatty infiltration of the infraspinatus. The torn rotator cuff was reattached with an anchor to the footprint of the rotator cuff using the sutures limbs that were placed through the cuff for the margin convergence.

Reverse total shoulder arthroplasty for irreparable rotator cuff tear for an elderly patient

The "moonlight" period of the shoulder hemiarthroplasty. Revision to total shoulder replacement

In the following case a revision of a stiff painful hemiarthroplasty to an anatomic total shoulder replacement is demonstrated. There was a "moonlight" period of several years of improvement in pain after the index hemiarthroplasty which was followed by progressive stiffness and pain. For that reason, a biopsy using the arthroscope was performed prior to the conversion to the anatomic total shoulder prosthesis which did not indicate any signs of infection after holding the cultures for 21 days. The biopsy is helpful in those situations, it is a fast and relatively benign procedure and it does answer the question of p. acnes infection. The patient had a pain free shoulder after the revision surgery. Post op and preop images as well as arthroscopic imaging and preop MRI arthrogram done at an outside institution are demonstrated.

Arthroscopic picture shows the loss of the cartilage on the glenoid side.

Iliac crest bone grafting of the glenoid to address anterior subluxation after shoulder hemi-arthoplasty

This case illustrates the difficulties encountered in shoulder arthroplasty for the patient who is below 50 years of age. There is a history of prior bankart repair for anterior shoulder instability without bone loss. The anchors were prominent and the patient referred to me for reconstruction. X-rays below indicate the slight anterior subluxation of the humeral head which was persisted even after the hemi-arthoplasty. A second operation was required to reconstruct the anterior glenoid using iliac crest bone graft and address the subluxation which was causing persistent pain. The patient was pain free after the correction of the subluxation. The subscapularis repair was intact during the entire process which made things easier.

Anterior subluxation.

ICBG of the anterior inferior glenoid

Chronic posterolateral rotatory elbow instability. Surgical technique

Symptomatic chronic instability of the elbow is a rare condition. Despite its rarity it is the most common chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, when the elbow is flexed. The radial head is usually posteriorly subluxated or dislocated and the patients complain that the elbow is unstable. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. 

During clinical examination there might be positive active and passive apprehension tests, and examination under anaesthesia may more accurately indicate the problem. Surgical treatment is required, and reconstruction of the lateral collateral ligament complex is performed using tendon autograft or allograft.

In this case a palmaris longus autograft was used. The patient complained of "unstable" elbow during strenuous activities. He had a positive elbow apprehension test in the office and stress elbow xrays indicated "opening" of the radiocapitellar joint on the involved side (L) when compared to the uninvolved one (R). Please see below





Zooming on the lateral collateral ligament complex is beneficial as most of the time the LCL complex is disrupted from it humeral origin. Here we see the avulsed bony fragment. The MRI below confirms the diagnosis



The images below indicate the 'docking technique" for fixation of the palmar longus tendon allograft that was used in this case. One of the technical difficulties of this surgery is the "scarring" of the remaining LCL complex on the capsule and annular ligament which requires cautious dissection in order to separate the ligament from the surrounding structures. Below the anatomy is outlined and a schematic drawing of the point of isometry on the capitellum.  The insertion site of the graft on the ulna is indicated as well. The supinator crest needs to be palpated or exposed to identify the insertion area of the graft on the ulna

The xray above indicates the insertion site of the graft on the ulna. The distance between the two drill holes on the ulna is 1-3 cm.

This patient at 8 weeks had full ROM and no pain, no apprehension or feelings of instability of the elbow. 

Failed glenoid component after anatomic shoulder arthroplasty with glenoid bone deficiency

This is an interesting case of a middle aged patient who was seen in the office because of shoulder pain for the past 5 years. The patient had 15 years ago an anatomic shoulder replacement. Radiographic evaluation demonstrated well fixed press fit stemmed anatomic shoulder arthroplasty - implant that is not available in the US market anymore - and fractured glenoid with posterior displacement of the all poly glenoid component. There was no clinical signs of infection and the patient was keeping the arm in a sling for the past several years for comfort. Due to the young age of the patient and the history of multiple falls a decision was made to revise the implant to a smaller size humeral head hemiarthroplasty and avoid implantation of a reverse shoulder arthroplasty.

During surgery the keeled glenoid component was found loose, with loose cement, there was metallosis and 50 % of the posterior glenoid bone was deficient with a step off of 5 mm.

The purpose of the revision was to provide a less painful prosthetic implant that will allow the patient to use the wheelchair which is necessary to this patient for transportation.