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

Figures

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  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).

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  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.

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  Figure 3. Preoperative X-rays showing proximal stress shielding and bony resorption above the level of the pectoralis major insertion.

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  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).

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  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.

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  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.

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  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).

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  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.

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  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.