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Review
. 2024 Oct 21;13(20):6290.
doi: 10.3390/jcm13206290.

Allograft Prosthetic Composite (APC) for Proximal Humeral Bone Deficiency in Revision Reverse Shoulder Arthroplasty: A Technical Note and Systematic Review

Hean Wu Kang  1   2   3   4 , Christopher Child  1   2   3   4 , Kristine Italia  1   2   5 , Mirek Karel  1   2   3   4 , Luke Gilliland  1   5 , Helen Ingoe  1   2   3   4 , Jashint Maharaj  1   2 , Sarah Whitehouse  1 , Kenneth Cutbush  1   2   4   6 , Ashish Gupta  1   2   3   5
Affiliations
Review

Allograft Prosthetic Composite (APC) for Proximal Humeral Bone Deficiency in Revision Reverse Shoulder Arthroplasty: A Technical Note and Systematic Review

Hean Wu Kang et al. J Clin Med. .

Abstract

Background: Proximal humeral bone deficiency in revision shoulder arthroplasty is an emerging and challenging problem as the use of reverse shoulder arthroplasty (RSA) increases. This paper presents a technical note discussing our detailed preoperative planning steps, surgical techniques, and their rationale in carrying out the use of an allograft prosthetic composite (APC) to address proximal humeral bone deficiency in revision RSA. The outcomes of this technique are also presented. This paper also presents a systematic review to further discuss the existing literature on RSA with APCs. Methods: The preoperative surgical planning and the surgical technique employed to execute proximal humeral reconstruction using APC during revision arthroplasty are discussed in the technical note. The preliminary clinical and radiological results of five patients who underwent revision shoulder arthroplasty with proximal humeral reconstruction using APCs are presented. The PRISMA guidelines were followed to perform the systematic review. A systematic search using PubMed, Embase, and Cochrane databases was conducted. All studies involving RSA and APCs were pooled, and the data were extracted and analyzed. Results: A total of 14 studies were eligible for inclusion in the systematic review, with a total of 255 patients and a mean follow-up of 57 months. All studies in the systematic review and the patients included in the author's case series showed improvements in the level of pain, range of motion, function, and satisfaction. Graft incorporation in the systematic review was 84%. Conclusions: Based on the available literature and the results of our case series, the use of an APC construct is a viable option for proximal humeral bone deficiency in revision shoulder arthroplasty.

Keywords: allograft prosthetic composite; preoperative planning; proximal humeral bone deficiency; revision shoulder arthroplasty.

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Conflict of interest statement

K.I. and L.G. are employees of Akunah (Akunah, Brisbane, Australia). A.G. is the founder and CEO of Akunah (Akunah, Brisbane, Australia). H.I., W.K., M.K., J.M., and S.W. declare no conflicts of interest related to this paper. A.G. and K.C. are the Co-Directors of QUASR, which receives grant funding from Stryker, Zimmer Biomet, Australian Research Council, and QUT, none of which have any conflicts with this paper. In addition, the Australian Shoulder Research Fellowship receives an educational grant from both Arthrex Device Technology and Stryker, none of which are in conflict with this publication.

Figures

Figure 1
Figure 1
(a) Preoperative X-ray of right humerus with periprosthetic fracture; (b) 3D modeling with the implants in situ; (c) metal subtraction of the right humerus; (d) mirroring of the contralateral humerus (orange); (e) extent of defect determined after overlaying the contralateral humerus (orange).
Figure 2
Figure 2
Image from ReflectTM from Akunah (Brisbane, Australia) showing the pathologic humerus overlayed on the mirrored contralateral humerus (orange) with the implant in situ subtracted to allow for an accurate assessment of the bony deficiency.
Figure 3
Figure 3
Preoperative X-rays showing proximal stress shielding and bony resorption above the level of the pectoralis major insertion.
Figure 4
Figure 4
(a) Long window humerotomy being carried out from the bicipital groove to the site of pectoralis major tendon insertion (Pec), with cerclage suture placement including Pec, latissimus dorsi (LD), and teres major (TM) tendons. (b) Preservation of Pec, LD, and TM tendon attachments en bloc during disimpaction of well-fixed stem. (D, deltoid; SS, supraspinatus; IS, infraspinatus).
Figure 5
Figure 5
Preoperative plan with the native humerus overlayed on the pre-morbid humerus (orange). (a) The length of the bony deficiency is determined by using the predicted pre-morbid humerus as a reference; (b) the diaphyseal diameter at the level of the planned osteotomy site is measured preoperatively to ensure the allograft–humerus construct can accommodate the distal portion of the humeral revision stem; (c) the position of the chosen implant is planned after determining the appropriate proximal humerus reconstruction and humeral height.
Figure 6
Figure 6
Preparation of the APC at the back table. (a) A step-cut osteotomy is performed on the allograft after determining the appropriate length needed for reconstruction. Multiple all-suture anchors to be used for the tendon reattachments are inserted into the proximal humeral allograft prior to cementing and inserting the definitive humeral prosthesis. (b) The chosen humeral stem is cemented into the proximal humeral allograft to form the APC construct. (c) Cementing of the APC construct onto the native humerus.
Figure 7
Figure 7
(a) Cementing of APC construct onto native humerus. (b) Reattachment of tendons: posterosuperior cuff and subscapularis, latissimus dorsi (LD), pectoralis major (Pec), and teres major (TM).
Figure 8
Figure 8
(a) Preoperative anteroposterior (AP) X-ray showing bone loss on the proximal humerus; (b) immediate postoperative AP X-ray showing reconstruction of the proximal humeral defect using an APC; (c) coronal CT scan showing union of the APC with the native humeral shaft.
Figure 9
Figure 9
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram depicting article identification, subsequent exclusions, and analysis for techniques and complications. APC = allograft prosthetic composite; RSA = reverse shoulder arthroplasty.
See this image and copyright information in PMC

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