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CASE REPORT

Stemless revision of a failed hemiarthroplasty: casereport and surgical technique

Matthias Vanhees, MDa, Kjell C.J. Jaspars, MDa, Roger van Riet, MD, PhDa,b,Olivier Verborgt, MD, PhDa,c, Geert Declercq, MDa,*

aDepartment of Orthopedic Surgery, AZ Monica, Antwerp, BelgiumbDepartment of Orthopedic Surgery, University Hospital Brussels, Brussels, BelgiumcDepartment of Orthopedic Surgery, University Hospital of Antwerp, Antwerp, Belgium

Revision shoulder arthroplasty can be challenging andtechnically demanding. This is regardless of whether theindex surgery was a hemiarthroplasty or total shoulderarthroplasty. However, with an increasing number ofprimary shoulder arthroplasties, the incidence of revisionsurgery has significantly increased in the last decades.20 Inmost cases, the revisions take place as a result of malpo-sitioning of the humeral component or are due to causes notrelated to the humeral side, such as cuff failure or glenoid-related problems. Revision of the humeral component dueto aseptic loosening is rare.4,11,16,19 Revision of a well-fixedstemmed prosthesis can be technically difficult and inva-sive, compromising the final result and future surgicaloptions.

We report a case of a patient suffering from progressivepain and loss of function after a hemiarthroplasty foravascular necrosis of the humeral head. At the time ofthe index surgery, an uncemented humeral component waspositioned in a proud position, and this resulted insecondary rotator cuff dysfunction. A revision of the well-fixed humeral component to a total shoulder arthroplastywith a cementless stemless component was performed withgood medium-term outcome. The use of a stemless humeralcomponent in a revision setting has not been reported so farin the literature.

uests: Geert Declercq, MD, Shoulder Surgery, Department

urgery, AZ Monica Hospital, Stevenslei 20, 2100 Deurne,

ss: ortho-spm@azmonica.be (G. Declercq).

ee front matter � 2013 Journal of Shoulder and Elbow Surgery

/10.1016/j.jse.2013.05.014

Case description

A 62-year old right-handed man presented at our outpatient clinicwith a painful left shoulder. Four years earlier, an avascularnecrosis of the humeral head developed after osteosynthesis fora complex 4-part proximal humeral fracture.12 This was treatedwith a cementless stemmed humeral head replacement. Post-operatively, the patient was never asymptomatic or fully func-tional. He continued to have symptoms of pain with movementand occasionally in rest and at night. Clinical examinationdemonstrated a decreased range of motion: abduction, 40�;forward flexion, 90�; external rotation, 10�; and internal rotationto the level of the sacrum. Neurovascular examination findingswere normal, and the surgical scar had healed well. The DASHscore7 was 20.8, the Oxford score6 was 19, the Constant score5

was 36, and the UCLA shoulder rating scale1 was 13 (Table I).Standard radiographs showed a proud position of the humeral

component with a narrowed acromiohumeral distance. There wereno signs of humeral component loosening (Fig. 1).

In June 2009, revision surgery took place through the previousdeltopectoral approach. The biceps tendon was located and usedas a marker for the rotator cuff interval. The interval was exposedand a tenotomy of the subscapularis tendon was performed, about1 cm medial to the bicipital groove. The proximal humerus, withthe hemiprosthesis, was exposed, and the malpositioning of thehumeral component was confirmed (Fig. 2). The component wasimplanted more than 10 mm above the anatomical neck, but therotator cuff was found to be intact. Next, the shoulder was dis-located by external rotation, adduction, and extension of thehumerus. The humeral component was extracted without the needof a vertical split or window (Fig. 3). After removal of thecomponent, a more distal osteotomy was done at the level of theanatomical neck with an oscillating saw, and a punch was placedonto the humerus. Next, the glenoid was exposed, showing

Board of Trustees.

Table I Summary of preoperative and postoperative shoulderoutcome scores

DASH Oxford Constant UCLA

Preoperative 20.8 19 36 13Postoperative 3.3 46 88 34

Figure 1 Preoperative radiograph of the hemiprosthesis.

Figure 2 This perioperative view confirms the overstuffedposition of the humeral head.

Stemless revision in shoulder arthroplasty e15

degenerative changes to the glenoid cartilage. Subsequently, theglenoid was reamed, drilled, and sized, after which a polyethyleneglenoid component was cemented in place. As there was stillsufficient metaphyseal bone stock, it was decided to proceed to theimplantation of a stemless humeral implant (TESS, Biomet,Warsaw, IN, USA; this implant is not approved by the Food andDrug Administration for use in the United States).

An implant-specific humeral template was used for sizing, anda pin was drilled through the center of the humeral template.Autologous bone graft from the resected anatomical neck wasplaced into the humeral defect, the appropriately sized humeralcorolla puncher was impacted into the bone over the guide pin,and the pin was removed. Finally, the corolla was impactedinto the bone for three quarters of its height (Fig. 4), and thenew head was impacted onto the corolla. The cementless,anatomical humeral head replacement was stable, and the tendonof the subscapularis muscle could be reattached anatomically.Physiotherapy was initiated immediately after surgery; pendulum

exercises and intermediate passive mobilizationdwithin the limitsof paindwere allowed during the first 2 weeks. Subsequently,progressive passive and active mobilization was initiated.

At final follow-up, 3 years after revision surgery, the range ofmotion had improved significantly: abduction, 120�; forwardflexion, 150�; external rotation, 30�; and internal rotation to thelevel of L1. He was asymptomatic (visual analogue scale score,0 of 10) and reported to be nearly fully functional for dailyactivities and even for some sports activities. The DASH scoreimproved from 20.8 to 3.3, the Oxford score increased from 19 to46, the Constant score increased from 36 to 88, and the UCLAshoulder rating scale increased from 13 to 34 (see Table I).

Standard radiographs 3 years postoperatively showed a correctposition of the humeral stemless component with no signs ofloosening compared with the immediate postoperative radiographs(Figs. 5 and 6). The glenohumeral joint line remained wellpreserved without glenoid lucent lines.

Discussion

The case of a male patient was described who suffereda 4-part proximal humeral fracture, initially treated with anosteosynthesis. He developed an avascular necrosis, forwhich he was treated with a hemiarthroplasty with the hu-meral component in a proud position. The patient continuedto suffer from pain and a decreased shoulder function. Fiveyears after the index surgery, the hemiarthroplasty wasreplaced by a total shoulder arthroplasty with a cementless

Figure 3 The hemiprosthesis was removed without additionalloss of metaphyseal bone stock.

Figure 4 The final corolla was impacted into the humerus forthree quarters of its height.

Figure 5 Radiograph of the left shoulder immediately aftersurgery.

e16 M. Vanhees et al.

stemless component. Soon after the revision surgery, the painhad decreased and the shoulder function had increasedremarkably. At final follow-up, 3 years after revision surgery,the humeral and glenoid components remained well fixedwithout signs of radiolucencies, tilt, or migration of the

component. The shoulder outcome scores at that stage hadsignificantly improved.

The most common problems related to stemmedhumeral arthroplasties are periprosthetic fractures, asepticloosening, and the challenge of removal of the stemmedcomponent during revision surgery. The risk of a peri-prosthetic fracture is low, with a rate of 1.5%. This risk isincreased in female patients, during revision surgery, andwith press-fit humeral components.2,10,14 Aseptic loos-ening of the humeral component is rare, as stated earlier.Malpositioning of the humeral component, cuff disease,and glenoid-related problems are the most common causesfor revision surgery.4,11,16,19 During revision surgery,extensive stem ingrowth or a thick cement mantle can bechallenging. In these cases, humeral osteotomies orwindows may be required to remove the humeral compo-nent, but this carries a significant risk of accompanyingcomplications.15,17,18

A stemless shoulder prosthesis allows anatomical re-construction of the proximal humeral head, whereas nothaving to ream distally will preserve diaphyseal humeralbone stock.8 A second and equally important advantage ofa stemless implant is that it is potentially easily revisable toa stemmed implant (e.g., in case of secondary cuff failureor glenoid-related complications) if revision to a reversed

Figure 6 Radiograph of the left shoulder at 3 years of follow-up.

Stemless revision in shoulder arthroplasty e17

prosthesis were to become necessary. Mid-term follow-upstudies show results comparable to those of total shoulderarthroplasty.3,8,9,13 Sufficient metaphyseal bone stock is ofcourse essential for good fixation of the stemless compo-nent. This is rarely a problem in primary surgery, but it canbe a limiting factor in revision surgery. In this case, thebone quality was good and the stem of the primary hemi-arthroplasty was placed proud, leaving sufficient meta-physeal bone stock after removal of the stem. After theosteotomy at the level of the anatomical neck was per-formed, the stemless humeral head punch was impacted. Atthis point, 2 important criteria need to be verified beforerevision to a stemless prosthesis can be considered. Themost important is the rotational and anteroposteriorstability of the humeral head punch or trial implant. If thereis any doubt about the stability, revision to a stemmedprosthesis should be performed. Another important crite-rion is metaphyseal bone quality and bone stock. If this isfound to be insufficient, stemless revision is not an option.As the ultimate decision can be made only perioperatively,we recommend that each case be scheduled as a revision toa stemmed prosthesis to ensure that the necessary materialis present.

Additional bone grafts can be used, but this shouldnot influence the ultimate decision. In this case, we did notuse bone grafts because of sufficient bone stock andstability.

If a cemented stem was used or if an uncemented stemwas placed correctly at the anatomical neck, it would havebeen more challenging or even impossible to achieve goodfixation of the stemless component during revision. In thatcase, a standard stemmed humeral component with orwithout cement can be used.

Conclusion

Stemless shoulder arthroplasty is now commonly used inprimary surgery, but its use in revision surgery had notbeen reported so far. Although stem-to-stem revisionsurgery remains the standard, the reported case demon-strates that revision of a humeral component witha stemless design is technically possible with goodfunctional and radiological outcome and can beconsidered in the younger patient with preserved meta-physeal humeral bone stock in a low number of cases.

Acknowledgment

We wish to thank Kristien Vuylsteke (MoRe Founda-tion) for her assistance in preparing this manuscript.This study was supported by the MoRe Foundation.

Disclaimer

Dr. Geert Declercq received royalties and consultantpayments from Biomet Company (Warsaw, IN, USA),which is related to the subject of this work. All the otherauthors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of this article.

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