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Journal of Shoulder and Elbow Surgery

A retrospective review of revision proximal humeral allograft-prosthetic composite procedures: an analysis of proximal humeral bone stock restoration

Published:February 12, 2020DOI:https://doi.org/10.1016/j.jse.2019.10.029

      Background

      Allograft-prosthetic composite (APC) reconstruction of the proximal humerus is a technique for reconstruction of large bone deficits, provides improvement in pain and function, and is thought to restore bone if revision surgery is needed. The purpose of this study was to evaluate the ability of proximal humeral APCs to restore usable bone at the time of revision surgery.

      Methods

      Two institutional electronic medical records were reviewed to evaluate proximal humeral APC procedures performed between 1970 and 2018. We identified 115 cases, of which 14 underwent revision for aseptic causes. The indications for revision included nonunion (n = 7), glenohumeral instability (n = 5), and allograft fracture (n = 2). Three categories were used to classify the amount of usable allograft retained at revision surgery: type A, complete allograft retention; type B, partial retention; and type C, no retention.

      Results

      A total of 14 patients (6 male and 8 female patients) underwent revision of the APC reconstruction at a mean of 22.8 months. At revision, allograft retention was classified as type A in 6 shoulders, type B in 3, and type C in 5. Type A cases were associated with nonunion with a well-fixed stem, type B cases were associated with instability and were converted from a hemiarthroplasty to a reverse total shoulder arthroplasty, and type C cases were associated with an allograft fracture or nonunion with a loose humeral component.

      Conclusion

      A substantial number of revisions of proximal humeral APC reconstructions maintain a portion of the allograft bone (64.3%). This study supports the ongoing use of the APC reconstruction technique for large bone deficits.

      Level of evidence

      Keywords

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      References

        • Abdeen A.
        • Hoang B.H.
        • Athanasian E.A.
        • Morris C.D.
        • Boland P.J.
        • Healey J.H.
        Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship.
        J Bone Joint Surg Am. 2009; 91: 2406-2415https://doi.org/10.2106/JBJS.H.00815
        • Aibinder W.R.
        • Sanchez-Sotelo J.
        Management of large humeral defects: bone grafts and augmented components.
        in: Tashjian R. Complex and revision shoulder arthroplasty. Springer, Cham2019: 237-250
        • Aponte-Tinao L.A.
        • Ayerza M.A.
        • Muscolo D.L.
        • Farfalli G.L.
        Allograft reconstruction for the treatment of musculoskeletal tumors of the upper extremity.
        Sarcoma. 2013; 2013: 925413https://doi.org/10.1155/2013/925413
        • Benedetti M.G.
        • Bonatti E.
        • Malfitano C.
        • Donati D.
        Comparison of allograft-prosthetic composite reconstruction and modular prosthetic replacement in proximal femur bone tumors: functional assessment by gait analysis in 20 patients.
        Acta Orthop. 2013; 84: 218-223https://doi.org/10.3109/17453674.2013.773119
        • Black A.W.
        • Szabo R.M.
        • Titelman R.M.
        Treatment of malignant tumors of the proximal humerus with allograft-prosthesis composite reconstruction.
        J Shoulder Elbow Surg. 2007; 16: 525-533https://doi.org/10.1016/j.jse.2006.12.006
        • Blackley H.R.
        • Davis A.M.
        • Hutchison C.R.
        • Gross A.E.
        Proximal femoral allografts for reconstruction of bone stock in revision arthroplasty of the hip. A nine to fifteen-year follow-up.
        J Bone Joint Surg Am. 2001; 83: 346-354
        • Chacon A.
        • Virani N.
        • Shannon R.
        • Levy J.C.
        • Pupello D.
        • Frankle M.
        Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite.
        J Bone Joint Surg Am. 2009; 91: 119-127https://doi.org/10.2106/JBJS.H.00094
        • Cox J.L.
        • McLendon P.B.
        • Christmas K.N.
        • Simon P.
        • Mighell M.A.
        • Frankle M.A.
        Clinical outcomes following reverse shoulder arthroplasty-allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up.
        J Shoulder Elbow Surg. 2019; 28: 900-907https://doi.org/10.1016/j.jse.2018.10.023
        • Cuff D.
        • Levy J.C.
        • Gutierrez S.
        • Frankle M.A.
        Torsional stability of modular and non-modular reverse shoulder humeral components in a proximal humeral bone loss model.
        J Shoulder Elbow Surg. 2011; 20: 646-651https://doi.org/10.1016/j.jse.2010.10.026
        • El Beaino M.
        • Liu J.
        • Lewis V.O.
        • Lin P.P.
        Do early results of proximal humeral allograft-prosthetic composite reconstructions persist at 5-year followup?.
        Clin Orthop Relat Res. 2019; 477: 758-765https://doi.org/10.1097/CORR.0000000000000354
        • Enneking W.F.
        • Campanacci D.A.
        Retrieved human allografts: a clinicopathological study.
        J Bone Joint Surg Am. 2001; 83: 971-986
        • Enneking W.F.
        • Mindell E.R.
        Observations on massive retrieved human allografts.
        J Bone Joint Surg Am. 1991; 73: 1123-1142
        • Hamadouche M.
        • Blanchat C.
        • Meunier A.
        • Kerboull L.
        • Kerboull M.
        Histological findings in a proximal femoral structural allograft ten years following revision total hip arthroplasty: a case report.
        J Bone Joint Surg Am. 2002; 84: 269-273https://doi.org/10.2106/00004623-200202000-00015
        • Hartigan D.E.
        • Veillette C.J.
        • Sanchez-Sotelo J.
        • Sperling J.W.
        • Shives T.C.
        • Cofield R.H.
        Reconstruction of the proximal humerus for bone neoplasm using an anatomic prosthesis-bone graft composite.
        Acta Orthop Belg. 2012; 78: 450-457
        • King J.J.
        • Nystrom L.M.
        • Reimer N.B.
        • Gibbs Jr., C.P.
        • Scarborough M.T.
        • Wright T.W.
        Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections.
        J Shoulder Elbow Surg. 2016; 25: 45-54https://doi.org/10.1016/j.jse.2015.06.021
        • Mayle Jr., R.E.
        • Paprosky W.G.
        Massive bone loss: allograft-prosthetic composites and beyond.
        J Bone Joint Surg Br. 2012; 94: 61-64https://doi.org/10.1302/0301-620X.94B11.30791
        • McLendon P.B.
        • Cox J.L.
        • Frankle M.A.
        Large diaphyseal-incorporating allograft prosthetic composites: when, how, and why: treatment of advanced proximal humeral bone loss.
        Orthopade. 2017; 46: 1022-1027https://doi.org/10.1007/s00132-017-3498-z
        • Ogilvie C.M.
        • Wunder J.S.
        • Ferguson P.C.
        • Griffin A.M.
        • Bell R.S.
        Functional outcome of endoprosthetic proximal femoral replacement.
        Clin Orthop Relat Res. 2004; : 44-48https://doi.org/10.1097/01.blo.0000136840.67864.78
        • Patterson F.R.
        • Hwang J.S.
        • Beebe K.S.
        • Uglialoro A.D.
        • Flynn J.
        • Benevenia J.
        An innovative approach to concave-convex allograft junctions: a biomechanical study.
        Am J Orthop (Belle Mead NJ). 2012; 41: 214-219
        • Potter B.K.
        • Adams S.C.
        • Pitcher Jr., J.D.
        • Malinin T.I.
        • Temple H.T.
        Proximal humerus reconstructions for tumors.
        Clin Orthop Relat Res. 2009; 467: 1035-1041https://doi.org/10.1007/s11999-008-0531-x
        • Ruggieri P.
        • Mavrogenis A.F.
        • Guerra G.
        • Mercuri M.
        Preliminary results after reconstruction of bony defects of the proximal humerus with an allograft-resurfacing composite.
        J Bone Joint Surg Br. 2011; 93: 1098-1103https://doi.org/10.1302/0301-620X.93B8.26011
        • Sanchez-Sotelo J.
        • Wagner E.R.
        • Sim F.H.
        • Houdek M.T.
        Allograft-prosthetic composite reconstruction for massive proximal humeral bone loss in reverse shoulder arthroplasty.
        J Bone Joint Surg Am. 2017; 99: 2069-2076https://doi.org/10.2106/JBJS.16.01495
        • Shukla D.R.
        • Lee J.
        • Mangold D.
        • Cofield R.H.
        • Sanchez-Sotelo J.
        • Sperling J.W.
        Reverse shoulder arthroplasty with proximal humeral replacement for the management of massive proximal humeral bone loss.
        J Shoulder Elbow Arthroplasty. 2018; 2: 1-6https://doi.org/10.1177/2471549218779845
        • van de Sande M.A.
        • Dijkstra P.D.
        • Taminiau A.H.
        Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction.
        Int Orthop. 2011; 35: 1375-1380https://doi.org/10.1007/s00264-010-1152-z
        • Wheeler D.L.
        • Haynie J.L.
        • Berrey H.
        • Scarborough M.
        • Enneking W.
        Biomechanical evaluation of retrieved massive allografts: preliminary results.
        Biomed Sci Instrum. 2001; 37: 251-256
        • Wilke B.
        • Cooper A.
        • Gibbs C.P.
        • Spiguel A.
        Reverse-reamed intercalary allograft: a surgical technique.
        J Am Acad Orthop Surg. 2018; 26: 501-505https://doi.org/10.5435/JAAOS-D-17-00052
        • Wilke B.K.
        • Houdek M.T.
        • Rose P.S.
        • Sim F.H.
        Proximal femoral allograft-prosthetic composites: do they really restore bone? A retrospective review of revision allograft-prosthetic composites.
        J Arthroplasty. 2019; 34: 346-351https://doi.org/10.1016/j.arth.2018.10.020