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Vertical Humeral Osteotomy for Stem Revision in Total

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Vertical Humeral Osteotomy for Stem Revision in Total Vertical Humeral Osteotomy for Revision of Well-Fixed Humeral Components: echniques Case Report and Operative Technique T & Geoffrey S. Van Thiel, MD, MBA, Dana Piasecki, MD, and Gregory Nicholson, MD Abstract ingrowth or a large, intact cement mantle can make The increase in the number of shoulder arthroplasties humeral stem extraction precarious. The humerus has also created a paradoxical increase in the num- differs from the femur in that the cortical bone is ber of revision procedures. These revision surgeries much thinner, creation of a safe window or L-shaped can be complicated by well-fixed humeral compo- osteotomy is more difficult, and loss of tuberosities can echnologies nents that require removal. lead to severe dysfunction. Without a safe and reliable T In this article, we report a representative revision arthroplasty that involved a novel technique, verti- technique for stem removal, the proximal humerus may cal humeral osteotomy, which allowed for safe and be unnecessarily fractured or denuded of bone stock. effective humeral stem extraction with no need for distal windows, no proximal bone loss, and no need for a long-stemmed prosthesis. “The technique described rthopedic houlder arthroplasty has undergone rapid in this case report will O advances in recent years, with more options available to the practicing orthopedist. From significantly lower the Shemiarthroplasty to either conventional or iatrogenic fracture rate.” reverse total shoulder replacement, consistently good to excellent results have been reported for the treatment of proximal humerus fracture, end-stage degenerative This was demonstrated by Wall and colleagues29 with a arthritis, and rotator cuff arthropathy.1-17 However, as 24.1% iatrogenic fracture rate in revision procedures. indications expand and more shoulder arthroplasties are Sperling and Cofield30 described an anterior or medial performed, an increase in the number of failed recon- cortical windowing technique for facilitating humeral structions and required revisions is expected.18,19 stem removal. However, they reported a 20% rate of The extent to which a component must be removed intraoperative fracture associated with this procedure during revision shoulder arthroplasty depends on the and noted that, with refinement, further techniques mode of failure. Failures can result from glenoid ero- sion, glenoid component loosening, instability, infec- tion, component malpositioning, and, seldom, humeral component loosening.18-28 Given that the humeral com- ponent represents an uncommon mechanism for failure, revision can become particularly challenging when a well-fixed prosthesis must be removed. Extensive bone Dr. Van Thiel is Resident, and Dr. Piasecki is Sports Medicine Fellow, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Dr. Nicholson is with Division of Shoulder and Elbow, Midwest Orthopaedics at Rush, and is Associate Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Address correspondence to: Gregory Nicholson, MD, Midwest Orthopaedics at Rush, Rush University Medical Center, 1725 W Harrison St, Suite 1063, Chicago, IL 60612 (tel, 312-432-2300; fax, 825-642-0123; e-mail, [email protected]). Figure 1. Preoperative radiograph shows well-fixed, Am J Orthop. 2009;38(2):XX-XX. Copyright, Quadrant HealthCom cemented bipolar humeral prosthesis with medial and Inc. 2009. All rights reserved. superior erosion. 14 The American Journal of Orthopedics® G. S. Van Thiel et al could be developed to lower the fracture rate significantly. Carroll and colleagues19 as well as Petersen and Hawkins31 alluded to an osteotomy proce- dure for extraction of a humeral stem, but nei- ther group described the technique in the literature. In this article, we report a representative revision arthroplasty that involved a novel technique, vertical Figure 3. Vertical osteotomy before fixation (right shoulder). humeral osteotomy, which allowed for safe TECHNIQUE and effective humeral The procedure was performed with the patient under stem extraction with scalene regional and general anesthesia and in the beach- no need for distal win- chair position. The previous extended deltopectoral inci- dows, no proximal sion was used in developing the deltopectoral interval. Figure 2. Osteotomy site. © Copyright and courtesy of bone loss, and no need The humeral component was found herniating into this Primal Pictures Ltd. for a long-stemmed muscular plane during the exposure. Dense scar tissue prosthesis. was released from the undersurface of the deltoid and proximal humerus. The subscapularis and the supe- CASE REPORT rior rotator cuff were completely absent. Enhancing the At our clinic, a healthy woman in her early 80s presented humeral exposure involved releasing abundant scar tis- with complaints of right shoulder pain and an inability to sue and remnant glenohumeral capsule from the anterior, actively elevate the right arm. Four years earlier, she had inferior, and posterior glenoid rim. The axillary nerve was undergone a bipolar hemiarthroplasty for rotator cuff tear palpated and protected during this step. After this release, arthropathy. She recalled that, though initially she had the proximal humerus was easily delivered into the open enjoyed modest pain relief after that surgery, she later surgical wound with flexion and external rotation of the had persistent difficulty elevating the arm. Between then arm. The humeral component was well-fixed. and now, she had noted progressive worsening of the Our technique for removing a well-fixed humeral pain and steady deterioration in function. component, either cemented or uncemented, is to per- The patient had a well-healed deltopectoral incision form a vertical humeral osteotomy. This allows the and a neurovascularly intact upper limb. Active motion surgeon to “debond” the humeral stem from the cement was limited to 45° of elevation secondary to pain. Passive mantle without having to go distal to the stem tip. A motion to 90° was possible but with significant discom- small osteotome is first used around the top of the pros- fort. External rotation strength was well preserved, but thesis to interrupt the interface between the implant and the patient maintained only 3/5 forward elevation power the tuberosity bone. Cautery is then used to expose the with a subcutaneously palpable humeral prosthesis in the humerus vertically beginning just lateral to the biceps anterosuperior aspect of the shoulder during active flex- groove and extending distally between the anterior ion. The deltoid was both intact at its acromial insertion deltoid and lateral pectoralis insertions. This extends and highly functional. A complete infectious workup was approximately 10 cm distally on the humerus (Figures negative. Radiographs showed a well-fixed cemented 2, 3). A MicroAire oscillating saw (Model series 1000; hemiarthroplasty with the bipolar shell tipped in varus MicroAire Surgical Instruments, Charlottesville, VA) is beneath the acromion with chronic erosion apparent. used to create a linear unicortical osteotomy along this Superior and medial glenoid erosion to the base of the vertical line, perforating both the cortex and the underly- coracoid process had also occurred (Figure 1). ing cement mantle down to the implant. This type of saw Having already failed an extensive trial of conservative has a small blade that is easily controllable and makes a management, including physical therapy and steroid injec- thin cut into the bone. The osteotomy is extended distally tions, the patient elected to undergo revision of the bipolar to just below the deltoid insertion but not below the tip of hemiarthroplasty to a reverse shoulder arthroplasty. the implant. Next, a series of osteotomes is used to gen- We have obtained the patient’s informed, written con- tly “flex” open the humeral shaft at the osteotomy, with sent to publish her case report. care taken to avoid fracturing the opposite cortex. The February 2009 15 Vertical Humeral Osteotomy for Revision of Well-Fixed Humeral Components range of motion were deemed adequate. A size-10 stem was opened on the back table. In this specific case, the stem was longer than the position of the distal cement and plug. Instead of removing the well-osteointegrated distal cement, the surgeon shortened the stem. The tip of the prosthesis was removed with a diamond-tipped burr. Once the canal was irrigated and dried, cement was inserted in a standard semipressurized fashion using a large injection syringe and finger packing. The prepared humeral implant was then hand-inserted into the center of the cement mantle. Excess cement was removed from the osteotomy site with a freer. Anatomical retroversion was maintained, cerclage cables were fully tightened, and the cement was allowed to harden. A very small amount of excess cement extrud- ing from the osteotomy site was removed with a curette. Figure 4. Vertical osteotomy stabilized with cerclage wires. Final trialing was then performed, and the corresponding humeral cup was seated on the humeral stem. The final osteotomes are placed vertically within the osteotomy construct was tested once more. Excellent stability and (perpendicular to the shaft) and gently twisted to open deltoid tension were noted, with no abutment to 35° of the humeral envelope. Gently repeating this “open book- external rotation and 50° of internal rotation. Throughout ing” of the unicortical osteotomy several times creates a
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