Cement versus noncement: Humerus

Humeral head replacement arthroplasty has been performed for more than 40 years. As the technique has been refined and advances made in joint arthroplasty of the lower extremity, the indications and success of shoulder arthroplasty have greatly improved. The humeral component in a shoulder arthroplasty can be implanted with either cement or press fit fixation. Both techniques are precise and demand attention to detail if an orthopaedic surgeon wishes to obtain the optimum result for the patient. Press fit fixation, with or without porous coating for biological fixation, can be considered for a patient with good bone stock if it is felt that a stable interface can be obtained.In patients with abnormal bone, such as those with rheumatoid arthritis who are on corticosteroids and those with osteoporosis, the use of cement can provide stable long-term fixation.A review of the literature shows a humeral component loosening rate of only 0.9%. Humeral component complications are much less frequent than those on the glenoid side.     

The reverse shoulder prosthesis for primary and secondary treatment of proximal humeral fractures: a case report

Humeral head fractures are very common among elderly people, often requiring shoulder arthroplasty. One requirement for good function after shoulder arthroplasty is an intact or at least reparable rotator cuff. In patients with multifractured and or osteoporotic tuberosities, refixation leads to the potential risk of redislocation and resorption of the tuberosities or coexisting irreparable rotator cuff tears lead to a high failure rate after implantation of traditional fracture prosthesis, whereas the reverse shoulder arthroplasty may provide better outcome. Here we report of a 79-year-old woman, who fractured both humeral heads at different times. Her right side was treated with a fracture prosthesis, which had to be converted after 2 years to a reverse shoulder prosthesis. Because of coexisting irreversible rotator cuff tear accompanying the second humeral head fracture on her left side, this patient was primarily treated with a reverse shoulder prosthesis. During the most recent follow up, 33 months after reverse shoulder arthroplasty on the left side and 39 months on the right side, the age- and gender-adapted constant score was 88 compared to 59 on the right side. The primary or secondary implantation of the reverse shoulder prosthesis in proximal humeral fractures has to be planned carefully, since long-term results are still lacking and treatment options after failed reverse shoulder arthroplasty are few. Generally, primary implantation of traditional fracture prosthesis is indicated in most cases of humeral head fractures; but in carefully selected cases primary reverse shoulder arthroplasty may be superior and lead to better outcome. Therefore, future research should be conducted to find criteria where the reverse shoulder arthroplasty is indicated as first line treatment of proximal humeral head fractures in elderly patients.     

Prosthetic replacement for proximal humeral fractures

The ideal management of complex proximal humeral fractures continues to be debatable. Evolution of proximal humeral fracture management, during the past decade, led to the implementation of many innovations in surgical treatment. Even though the pendulum of treatment seems to swing towards new trends such as locked plating, hemiarthroplasty remains a valid and reliable option that serves the patient's needs well. Hemiarthroplasty is indicated for complex proximal humeral fractures in elderly patients with poor bone stock and when internal fixation is difficult or unreliable. Hemiarthroplasty provides a better result when it is performed early post-injury. Stem height, retroversion and tuberosity positioning are technical aspects of utmost importance. Additionally reverse total shoulder arthroplasty is an alternative new modality that can be used as a primary solution in selected patients with proximal humeral fracture treatment. Failed hemiarthroplasty and fracture sequelae can be successfully managed with reverse total shoulder arthroplasty. Individual decision-making and tailored treatment that takes into consideration the personality of the fracture and the patient's characteristics should be used.     

Total shoulder arthroplasty — current problems and possible solutions

The concept and design of a cemented unconstrained total shoulder arthroplasty (TSA), introduced by Charles Neer II 25 years ago, has been successful in the management of degenerative and inflammatory conditions of the shoulder, controlling pain and, in many patients, significantly improving function. The clinical outcome is very much determined by the nature and severity of the pathology, as well as by the surgeon's experience and ability to correctly locate and fix the components. Total shoulder arthroplasty is a technically difficult procedure with perhaps a greater potential for technical errors and complications compared with other commonly performed arthroplasties. Current systems are modular on the humeral side, with varying head diameters and neck lengths, allowing more accurate coverage of the cut surface of the humeral neck and improved ability to establish the position of the joint line within the requirements of correct soft tissue tension and balance. Cemented all-polyethylene glenoid components remain the most favored, but the majority now have an increased radius of curvature compared with their corresponding humeral head, to allow translation during movement. Aseptic glenoid component loosening is the most frequently encountered long-term complication and is hastened by conforming prostheses, incorrect positioning, rotator cuff tears, and capsular contractures, but is protected by secure glenoid fixation. Cemented one-piece metal-backed glenoids have been disappointing, but non-cemented glenoids are being trialed with promising early results, although they have introduced their own particular problems of rapid polyethylene wear and component dissociation. Although cemented humeral components have a very low incidence of symptomatic loosening, most surgeons currently use press-fit designs supplemented with metaphyseal porous coating for osseous integration. Based on increased understanding of the morphology of the upper humerus, current designs are evolving with increased modularity, allowing the surgeon to choose the appropriate size, inclination, offset and version of the humeral component. These changes will, it is hoped, result in improved functional recovery and increased survivorship of the glenoid component. Received for publication on April 15, 1998; accepted on July 31, 1998     

Severe glenoid retroversion is best treated with asymmetric reaming in total shoulder arthroplasty–Opposes

Degenerative arthritis of the shoulder is a common orthopaedic condition, and the number of total shoulder arthroplasty procedures is increasing with the aging population. During total shoulder arthroplasty, reconstruction of the glenoid side of the joint can be particularly difficult in the face of posterior wear or excessive retroversion. Treatment options for posterior wear or excessive retroversion of the glenoid include asymmetric reaming of the high anterior side, bone grafting, or posterior augmentation of the glenoid component. A posterior augmented glenoid component allows the surgeon to maintain bone stock while correcting the posterior deficiency of the glenoid and avoiding the potential for medialization of the humeral component with anterior high side reaming. Bone grafting can be beneficial but relies on graft healing to successfully obtain stability.     

Principles of shoulder prosthesis implantation

Patients with an intact rotator cuff and a humeral head that is centered in the glenoid fossa will benefit from both: a hemiarthroplasty and a total shoulder arthroplasty. However, the functional outcome following total shoulder arthroplasty is superior to that of hemiarthroplasty. Superior migration or mal-positioning of the humeral head in the anterior or posterior direction are generally associated with a maximum active flexion of 90 degrees and a high rate of loosening of the glenoid component. Total shoulder arthroplasty leads to superior results in patients with osteoarthritis and mal-positioning of the humeral head in the posterior direction. However, if the head can not be centralized in the glenoid fossa a significant risk of glenoid loosening remains. A superior functional outcome of total shoulder arthroplasty in patients with rheumatoid arthritis can be observed. On the other hand inferior bone quality and a rotator cuff might lead to loosening of the glenoid component. Radiographic signs of glenoid loosening are frequently observed. However, these hardly require operative revisions. If a glenoid component can not be inserted, a bipolar or inverse prosthesis might be considered an alternative.     

The superolateral approach for shoulder prosthesis

We describe a superolateral approach to the shoulder for implantation of total shoulder prostheses or humeral prostheses. The advantages of this approach include preservation of the supraspinatus tendon and an excellent exposure of the posterior part of the glenoid cavity. We illustrate this approach with three clinical examples: total shoulder arthroplasty with reconstruction of the posterior part of the glenoid using a screwed autograft for central degeneration with posterior wear of the glenoid, intermediate arthroplasty for excentric degeneration with irreparable rotator cuff tears, and simple humeral arthroplasty with bone suture of the tuberosities for cephalotuberosity fracture.     

The effect of humeral component anteversion on shoulder stability with glenoid component retroversion

BACKGROUND: Posterior glenoid bone loss is often seen in association with glenohumeral osteoarthritis. This posterior asymmetric wear can lead to retroversion of the glenoid component and posterior instability after total shoulder arthroplasty. Options for the treatment of this asymmetric wear include eccentric reaming of the so-called high side, bone-grafting, and/or anteverting the humeral component. Although anteverting the humeral component has been advocated by many, it has not been substantiated on the basis of biomechanical data. The purpose of the present study was to determine whether anteverting the humeral component increases the stability of a total shoulder replacement with a retroverted glenoid component. METHODS: A total shoulder arthroplasty was performed in eight human cadaveric shoulders. The glenoid component was placed in 15 degrees of retroversion. Two humeral versions were tested for each specimen: anatomic version and 15 degrees of anteversion relative to anatomic version. The specimens were mounted supine in a custom fixture on a servohydraulic testing system. The humerus was translated posteriorly by one-half of the width of the glenoid. Three positions of humeral rotation were tested for each position of humeral version. Both the energy and the peak load were analyzed as measures of joint stability. RESULTS: There was no significant difference in either energy or peak load between the tests performed with the humeral component in 15 degrees of anteversion and those performed with the component in anatomic version in any of the three rotational positions (p > 0.05). CONCLUSIONS: Although anteverting the humeral component during total shoulder arthroplasty to compensate for glenoid retroversion has been advocated, these data suggest that compensatory anteversion of the humeral component does not increase the stability of a shoulder replacement with a retroverted glenoid component.     

Humeral windows in revision shoulder arthroplasty

Currently, there are no published results of patients in whom a window in the humeral cortex had been created to facilitate revision of a failed shoulder arthroplasty. Therefore, we reviewed the results of patients who underwent creation of a humeral window in the course of a revision shoulder arthroplasty to determine the complications and rate of healing. Twenty patients underwent humeral osteotomy to remove a well-fixed humeral component during the course of revision shoulder arthroplasty at our institution between January 1, 1987, and December 31, 2002. There were 17 cemented humeral components and 3 fully textured, press-fitted components. Of the shoulders, 16 had an anterior window, 3 had a medial window, and 1 had combined anterior and medial windows. There were 4 intraoperative fractures: 3 in the humeral shaft and 1 in the greater tuberosity. At the most recent radiographic follow-up at a mean of 3.3 years (range, 3-176 months), 17 of 20 windows had healed. Among 3 patients with limited radiographic follow-up (1, 3, and 4 months), 2 were healing and 1 did not demonstrate radiographic signs of healing. There were no cases of window malunion. No humeral components have developed clinical loosening. The data from this study suggest that humeral windows may facilitate controlled removal of well-fixed humeral components with a high rate of union. Further evolution of this technique may result in a lower fracture rate.     

Ipsilateral total shoulder arthroplasty and total elbow replacement arthroplasty: a caveat

Shoulder and elbow replacement arthroplasty both achieve a high degree of success in patients with inflammatory arthritis. When both arthroplastics are performed on the same side, a stress riser can occur in the humeral diaphysis between the tips of the 2 humeral components. When the shoulder arthroplasty is performed first, a short-stemmed humeral component is advised. If a long-stemmed humeral component at either joint is already in place, the cement column for the subsequent arthroplasty should extend to and include the cement column of the extant component.     

Revision total elbow replacement

The range of general and specific adverse event in total elbow arthroplasty is similar in principle and practice to all other revision prosthetic arthroplasty but with three particular challenges: loss of humeral and ulnar bone stock; insufficiency of the extensor ‘mechanism’; and the management of the ulnar nerve. Total elbow replacement is presently performed for the management of complex non-reconstructable distal humeral fractures in osteoporotic bone, for post-traumatic arthropathy, and for medically managed inflammatory arthritides in which metaphyseal bone architecture is often preserved while the articular surface is degenerate. In all these conditions the patient often presents for revision total elbow arthroplasty with relevant co-morbidities and relevant musculoskeletal dysfunction (for example: ipsilateral shoulder, wrist, thumb or hand dysfunction).Infection is a universal concern for revision arthroplasty but where the soft tissue ‘envelope’ is compromised and already limited, as in the proximal forearm, it is difficult to eradicate, particularly in immunocompromised patients.Bone loss compromises subsequent implantation of a revision prosthesis, while failure to restore the working lengths of the humerus and ulna reduces the strength of the flexor and extensor compartment muscles for elbow motion.Failure to restore the continuity of the triceps aponeurosis - antebrachial fascia and triceps medial head-olecranon components of the extensor ‘mechanism’ also compromises extensor power. Prior triceps-dividing surgical approaches will determine the elasticity, and therefore pliability, of the extensor ‘mechanism’: this will have a role in determining how much gain in length of the humeral side can be safely achieved.The ulnar nerve, and its management during elbow arthroplasty, is a source of frequent concern, particularly for revision of an elbow arthroplasty undertaken for distal non-reconstructable humeral articular fractures or post-traumatic arthropathy, in which the position of the ulnar nerve is never anatomic. For these reasons revision total elbow replacement (RTER) is challenging: it requires experience with surgical exposures of the elbow including the major nerve trunks, familiarity with the restoration of bone stock, a range of prostheses and techniques for prosthetic implantation, the ability to achieve adequate soft tissue cover and primary closure, and a logical approach to individualised rehabilitation.     

Glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty—Opposes

When considering shoulder arthroplasty in a younger patient the surgeon can choose between stemmed, stemless or resurfacing implants for humeral reconstruction. Resurfacing arthroplasty can reproduce humeral anatomy independent of the humeral shaft, minimize bone resection and offer potential easier revision surgery. The resurfacing implant has been in use for over 30 years and has favorable long-term outcome.     

The cemented humerus and non-cemented glenoid: The optimal hybrid solution for total shoulder arthroplasty

Hybrid fixation of total joint arthroplasty has been recognized as an accepted form of surgical approach in multiple joints. Principles of implant fixation should focus on durability and on providing secure long-term function. To date, there is no conclusive evidence that pressed-fit humeral stem fixation has an advantage over well-secured cemented humeral fixation. Although revision may require cement removal, a well-fixed bone—ingrowth implant may require slatting and osteotomy of the humerus. On the contrary, need for revision in arthroplasty due to inadequate implant fixation has almost universally revolved around the failure of cement fixation and loosening of the glenoid component. A case will be made based on 30 years of experience of a surgeon performing total shoulder arthroplasty using secure modern cement-fixation techniques of humeral components. More recently, over the past 10 years an extremely high rate of durable secure glenoid implant fixation has been achieved using press-fit tantalum porous anchorage of polyethylene glenoid components. This has resulted in no cases of loosening of glenoid fixation and only one case of glenoid component fracture with greater than 95% survivorship over a 10-year period. A combination of well-cemented humeral stem and trabecular metal anchorage of the glenoid has provided durable and long-lasting function in primary total shoulder arthroplasty.     

肱骨近端Neer 3部分或4部分骨折治疗的加速康复研究

目的研究加速康复理念在严重肱骨近端骨折治疗中应用的意义。 方法成都大学附属医院2017年1月至2020年1月应用加速康复方法治疗37例Neer分型属于3部分或4部分骨折的肱骨近端骨折患者,其中采用骨折切开复位内固定术29例（内固定组）、人工肱骨头置换手术8例（关节置换组）。从手术时间、术中出血量、手术操作难度、术后患者骨愈合情况以及术后肩关节功能情况进行对比分析,评估手术治疗疗效并总结手术治疗体会及加速康复经验。 结果内固定组和关节置换组患者在平均手术时间、平均出血量、平均住院时间和引流管放置时间上差异无统计学意义。加速康复理念始终贯穿于术前病情评估、术中细节处理、术后功能锻炼等整个治疗过程中。术后随访,内固定组有27例术后3个月时达到骨愈合,1例因术后2个月时外伤再发骨折行翻修手术,1例发生骨折延迟愈合,予患肢悬吊,术后5个月时达到骨愈合。关节置换组8例患者均在术后3 ~ 4个月达到术后骨性愈合,术后无肩峰骨折及肩胛骨骨折病例。两组患者术后视觉模拟评分无显著差异,内固定组患肢肩关节功能评分在术后3个月、6个月及1年时明显优于关节置换组（P<0.05）。 结论严重的肱骨近端骨折应根据不同的骨折类型选择手术方案。加速康复治疗理念自始至终贯穿于肱骨近端骨折的诊治过程中,对术后疗效影响显著。     

半或全肩关节置换治疗肱骨近端严重病损

[目的]探讨采用半或全肩关节置换术治疗肱骨近端严重病损的手术适应证、手术要点以及假体的选择。[方法]选择12例患者,全肩关节置换4例,半肩关节置换8例;肱骨四分骨折6例,肱骨头坏死2例,肱骨头合并关节盂坏死1例,类风湿关节炎合并肩关节强直2例,骨巨细胞瘤1例。采用美国肩肘关节医师协会肩关节评估表对肩关节进行术后功能评估。平均随访14个月。[结果]9例无痛,3例轻微疼痛,12例均无松动,肩关节平均外展100°,10例患者对治疗效果表示满意。[结论]半或全关节置换是一种治疗肱骨近端严重病损的有效方法,成功的关键在于科学的手术治疗方案、适宜的假体和有效的康复计划。     

Shoulder arthroplasty for proximal humeral nonunions

Between 1980 and 1997, 27 patients underwent shoulder arthroplasty because of pain or functional impairment due to a proximal humeral nonunion. Twenty-five of the 27 shoulders with a mean 6-year follow-up period (range, 2-15 years) were included in the study. There were 19 women and 6 men, with a mean age of 65 years. The most frequent original fracture types were 2-part surgical neck (64%) and 3-part greater tuberosity fractures (28%). Twenty-one shoulders underwent hemiarthroplasty, and 4 underwent total shoulder arthroplasty. Shoulder arthroplasty resulted in significant pain relief, with mean pain scores decreasing from 4.6 to 1.8 points (P <.05). Mean active elevation improved from 41 degrees preoperatively to 88 degrees postoperatively (P <.05), and mean external rotation from 22 degrees to 38 degrees (P =.045). In 11 shoulders the greater tuberosity resorbed or was nonunited. Two of the 25 shoulders required another operation after the arthroplasty: one for periprosthetic humeral fracture and one for instability. Twenty shoulders were much better or better, and 5 were the same or worse. On the basis of a modified Neer result rating system, there was 1 excellent result, 11 satisfactory results, and 13 unsatisfactory results. Patients who have significant functional impairment from a nonunion of the humeral surgical neck with failed internal fixation, severe osteoporosis, cavitation of the humeral head, or secondary osteoarthritis may benefit from shoulder arthroplasty. Although function is not completely restored, pain relief and high levels of subjective satisfaction can be achieved.     

Radiographic analysis of polyethylene glenoid components using modern cementing techniques

The purpose of this study was to examine the initial radiographic appearance and changes occurring over time in patients who have undergone total shoulder arthroplasty by modern methods of bone preparation and current cement techniques. Sixty-five patients underwent seventy total shoulder arthroplasties by use of a cemented all-polyethylene, keeled glenoid component. The surface radius was equal to the radius of a one-piece humeral component. The mean clinical follow-up was 4.18 years (range, 2-8.6 years); radiographic follow-up averaged 3.9 years (range, 2-8.6 years). Three observers evaluated radiographs 1 to 2 months postoperatively and at final follow-up. The glenoid component was considered at risk for clinical problems if there was a complete lucent line surrounding the component and some part of the line was 1.5 mm or greater in width or two of three or all three observers identified a shift in component position. Similarly, a humeral component was judged to be at risk if three or more zones had lucent lines 2 mm or greater in width or a shift in component position had occurred. On the early radiographs, 10 glenoid components had incomplete lucencies behind the keel. On the most recent radiographs, 59 glenoid components had incomplete lucent lines and 3 had complete lucent lines. Eight components were judged to have shifted in position. When data for lucent lines and shifting were combined, 10 (14%) of the glenoid components were at risk. At follow-up, no cemented humeral components were at risk whereas 3 (6%) of the 54 tissue ingrowth components were at risk for clinical loosening. Given the number of shoulders in this study, there were no associations between radiographic changes and clinical results. Improvements have occurred in glenoid component fixation. However, additional advances are possible and may occur from improved surgical technique, decreased particle-related osteolysis, enhanced joint kinematics, or novel fixation methods.     

Placement of the stemless humeral component in the Total Evolutive Shoulder System (TESS)

Humeral implant design in shoulder arthroplasty has evolved over the years. The third generation shoulder prostheses have an anatomic humeral stem that replicates the 3-dimensional parameters of the proximal humerus. The overall complication rate has decreased as a result of these changes in implant design. In contrast, the rate of periprosthetic humeral fractures has increased. To avoid stem-related complications while retaining the advantages of the third generation of shoulder implants, the stemless total evolutive shoulder system has been developed. The indications, the surgical technique, and the complications of this humeral implant in shoulder arthroplasty will be described.     

Subscapularis function after total shoulder replacement: results with lesser tuberosity osteotomy

Until recently, little consideration was placed on the integrity of the subscapularis tendon after total shoulder arthroplasty. We have noted that several of our patients exhibited loss of internal rotation strength and subscapularis function after total shoulder arthroplasty utilizing an anatomic soft tissue repair of the subscapularis, both with and without bone tunnels. On the basis of those results, we began removing the subscapularis with a small piece of bone by a lesser tuberosity osteotomy in an attempt to achieve improved subscapularis function through bony healing at the repair site. A retrospective review of 28 patients (30 shoulders) was done of patients who had total shoulder arthroplasty performed between 2001 and 2003. The lesser tuberosity and attached subscapularis were repaired through bone tunnels in all cases. The mean follow-up was 1.1 years. Terminal internal rotation was evaluated by the belly-press examination. Subscapularis function was assessed by the patient's ability to tuck in a shirt behind the back, and 25 of 30 patients (83.3%) reported no difficulty. Belly-press examination results were normal in 18 of 30 patients (60%). Removal of the subscapularis through a lesser tuberosity osteotomy results in reliable restoration of internal rotation strength after total shoulder arthroplasty, as measured by the ability to perform a stomach press and to tuck in a shirt. In comparing these results with our earlier cohort of patients with similar demographics and postoperative rehabilitation that had soft tissue repair, improved results were seen in the group that underwent lesser tuberosity osteotomy.     

Resurfacing arthroplasty for contained cuff tear arthropathy

Cuff tear arthropathy has been among the most difficult management problems faced by the shoulder surgeon. Ability to restore motion and alleviate pain has been challenging and has led Neer to coin the term “limited goals” when discussing outcomes of surgery in this group of patients. Over the past 15 years evidence of improved outcomes has been demonstrated with use of the reverse total shoulder prosthetic implant. However, with longer follow-up, a high rate of complication has also been demonstrated with these implants. Furthermore, their utilization significantly affects the local anatomy and takes away a significant amount of native bone stock. In addition, these implants cost in many cases, three to four times the price of a more conventional prosthesis. Not all patients with cuff tear arthropathy have the same degree of pathology. Many patients retain a “captured” humeral head underneath the coracoacromial arch without demonstrating anterior/superior escape and can be managed with a more conventional prosthesis. Indiscriminate use of the reverse prosthesis on all patients with cuff tear arthropathy presents a relatively reckless and irresponsible use of resources while limiting the ability to perform revision in the face of implant failure. Use of a CTA humeral head implant or cup resurfacing in a valgus position provides a seamless covering over the humeral head, which allows smooth seating within a “socket” formed by the coracoacromial arch. Such patients function quite well with excellent pain relief. Should revision ultimately be needed at a later date, a reverse arthroplasty can easily be performed without damage to the existing architecture. Reverse arthroplasty should be reserved for the physiologically older patient with limited demands and anterior/superior escape of the humeral head. Valgus resurfacing should be the procedure of choice in younger, more active patients whose humeral head remains captured within the coracoacromial arch.