Revision Shoulder Arthroplasty
Shoulder arthroplasty has experienced an exponential increase in available implants, indications, and techniques in contemporary orthopedics. Good to excellent results have been reported with both hemiarthroplasties and total shoulder replacements for the treatment of proximal humerus fractures, end-stage degenerative arthritis, and rotator cuff arthropathy. However, as the frequency of primary shoulder arthroplasty increases, the number of failures and required revisions will also grow.
Revision shoulder arthroplasty represents a complex and difficult problem for the treating surgeon. The extent to which component removal is necessary depends on the mode of failure. Failures can manifest due to glenoid erosion, glenoid component loosening, instability, infection, component malposition, and rarely, humeral component loosening. In the context of revision surgery with a well fixed humeral component that requires removal, the procedure can be extremely challenging, with significant complications. Extensive bone ingrowth and a large, intact cement mantle contribute to the difficulty with extraction of the humeral stem. However, the thin cortical bone of the humerus makes it difficult to create a safe window or L-shaped osteotomy. Resultant fracture or loss of tuberosity integrity can lead to severe postoperative dysfunction. Thus, without a safe and reliable technique for stem removal, the proximal humerus may be unnecessarily fractured or denuded of bone stock.
Sperling et al has previously described an anterior or medial cortical windowing technique to facilitate humeral stem removal. However, they reported a 20% rate of intraoperative fracture associated with this procedure and noted that, with refinement, further techniques could be developed that significantly lowered this rate. Subsequently, we have developed a vertical humeral osteotomy (VHO) technique to remove both cemented and uncemented humeral components, as described previously. The technique was designed to allow component removal without significant damage to the proximal humerus and to avoid distal windows, thus allowing reimplantation without the need for a long stem implant. The purposes of the current study were to describe the VHO technique, report the perioperative complications, and evaluate the longer-term follow-up results. We hypothesized that the VHO would enable successful stem extraction without perioperative or postoperative fractures.