n

Review Article

upper
extremity
S P OT L I G H T O N

Instructions
1. Review the stated learning objectives at the beginning
of the CME article and determine if these objectives match
your individual learning needs.
2. Read the article carefully. Do not neglect the tables
and other illustrative materials, as they have been selected to
enhance your knowledge and understanding.
3. The following quiz questions have been designed to
provide a useful link between the CME article in the issue
and your everyday practice. Read each question, choose
the correct answer, and record your answer on the CME
Registration Form at the end of the quiz.
4. Type or print your full name and address and your date
of birth in the space provided on the CME Registration Form.
5. Indicate the total time spent on the activity (reading
article and completing quiz). Forms and quizzes cannot be
processed if this section is incomplete. All participants are
required by the accreditation agency to attest to the time spent
completing the activity.
6. Complete the Evaluation portion of the CME Registration
Form. Forms and quizzes cannot be processed if the Evaluation
portion is incomplete. The Evaluation portion of the CME
Registration Form will be separated from the quiz upon receipt at
Orthopedics. Your evaluation of this activity will in no way affect
the scoring of your quiz.
7. Send the completed form, with your $15 payment (check
or money order in USdollars drawn on a USbank, or credit
card information) to: Orthopedics CME Quiz, PO Box 36,
Thorofare, NJ 08086, OR take the quiz online. Visit www.
Healio.com/EducationLab/Orthopedics for details.
8. Your answers will be graded, and you will be advised
whether you have passed or failed. Unanswered questions will
be considered incorrect. A score of at least 80% is required to
pass. If a passing score is achieved, Vindico Medical Education
will issue an AMA PRA Category 1 certificate within 4-6 weeks.

cme
ARTICLE

Bone Grafting in Shoulder

Arthroplasty
Jonathan C. Riboh, MD; Grant E. Garrigues, MD

educational objectives
As a result of reading this article, physicians should be able to:
1. Describe options for managing posterior glenoid bone loss in primary anatomic total shoulder arthroplasty.
2. Describe the indications for and results of bone grafting for glenoid loss in
revision anatomic total shoulder arthroplasty.

9. Be sure to mail the CME Registration Form on or before

the deadline listed. After that date, the quiz will close. CME
Registration Forms received after the date listed will not be
processed.

3. Describe options for managing superior glenoid bone loss and discuss
the role of bony lateralization in primary reverse total shoulder arthroplasty.

CME ACCREDITATION
This activity has been planned and implemented
in accordance with the Essential Areas and policies of the
Accreditation Council for Continuing Medical Education through
the joint sponsorship of Vindico Medical Education and
Orthopedics. Vindico Medical Education is accredited by the
ACCME to provide continuing medical education for physicians.
Vindico Medical Education designates this Journal-based
CME activity for a maximum of 1 AMA PRA Category 1 Credit.
Physicians should claim only the credit commensurate with
the extent of their participation in the activity.
This CME activity is primarily targeted to orthopedic
surgeons, hand surgeons, head and neck surgeons, trauma
surgeons, physical medicine specialists, and rheumatologists.
There is no specific background requirement for participants
taking this activity.

4. Describe the design features of fracture stems and options for bone grafting
augmentation in the treatment of proximal humerus fractures.

FULLDISCLOSUREPOLICY
In accordance with the Accreditation Council for Continuing
Medical Educations Standards for Commercial Support, all
CME providers are required to disclose to the activity audience
the relevant financial relationships of the planners, teachers,
and authors involved in the development of CME content. An
individual has a relevant financial relationship if he or she has
a financial relationship in any amount occurring in the last
12 months with a commercial interest whose products or
services are discussed in the CME activity content over which
the individual has control.
Drs Riboh and Garrigues have no relevant financial
relationships to disclose. Dr Aboulafia, CME Editor, has no
relevant financial relationships to disclose. Dr DAmbrosia,
Editor-in-Chief, has no relevant financial relationships to
disclose. The staff of Orthopedics have no relevant financial
relationships to disclose.
UNLABELED AND INVESTIGATIONAL USAGE
The audience is advised that this continuing medical
education activity may contain references to unlabeled uses
of FDA-approved products or to products not approved by the
FDA for use in the United States. The faculty members have
been made aware of their obligation to disclose such usage.

966

Abstract
Shoulder arthroplasty is one of the fastestgrowing fields in orthopedic surgery. Deficiency of the glenoid or humeral bone
stock is a major challenge that can result
from degenerative arthritis, component
loosening or extraction, fracture, or malignancy. Approximately 15% of primary
reconstructions will require bone graft-

ing, and the rate is higher for revisions.

The authors present a systematic review
of the current literature focused on the indications for and results of bone grafting
techniques. This provides the practicing
surgeon with a set of strategies to address
bone loss in the primary and revision settings, whether using an anatomic or reverse design.

Drs Riboh and Garrigues are from the Department of Orthopaedic Surgery, Division of Sports
Medicine and Shoulder Surgery, Duke University, Durham, North Carolina.
The material presented in any Vindico Medical Education continuing education activity does not
necessarily reflect the views and opinions of Orthopedics or Vindico Medical Education. Neither
Orthopedics nor Vindico Medical Education nor the authors endorse or recommend any techniques,
commercial products, or manufacturers. The authors may discuss the use of materials and/or products
that have not yet been approved by the US Food and Drug Administration. All readers and continuing
education participants should verify all information before treating patients or using any product.
Correspondence should be addressed to: Grant E. Garrigues, MD, Department of Orthopaedic
Surgery, Division of Sports Medicine and Shoulder Surgery, Duke University, DUMC Box 3639,
Durham, NC 27710 (grant.garrigues@gmail.com).
doi: 10.3928/01477447-20121023-11

ORTHOPEDICS | Healio.com/Orthopedics

Bone Grafting in Shoulder Arthroplasty | Riboh & Garrigues

cme
ARTICLE

houlder arthritis is a common cause

of pain and function loss among
older adults. The number of total
shoulder arthroplasties (TSAs) performed
yearly is increasing.1 Twenty-seven thousand TSAs were performed in 2008, and
that number is increasing by 3000 to 4000
per year.1 In primary glenohumeral arthritis, 10% to 15% of patients have enough
posterior glenoid erosion to make prosthesis implantation impossible without bone
grafting.2,3 Glenoid deficiency can also occur from the asymmetric superior forces of
the humeral head in cuff tear arthropathy.
In revision TSA, glenoid component loosening or removal frequently compromises
available bone. Humeral defects are rarely
degenerative. Rather, they result from the
removal of well-fixed components at the
time of revision, periprosthetic fractures, or
the excision of proximal humeral malignancies. Shoulder surgeons should have a detailed understanding of the indications for
and techniques of bone grafting.

Classification of Bone Loss

Primary posterior glenoid wear from
glenohumeral arthritis was first described
by Neer and Morrison (known as Neers
classification).2 Walch et al3 would later
define a classification system that encompasses the various glenoid erosion patterns.
In a type A glenoid, the humeral head is
centered. This group is subdivided based on
the amount of erosion into type A1 (minor
erosion) and type A2 (marked erosion). In a
type B glenoid, the humeral head is subluxated posteriorly. A type B1 glenoid shows
asymmetric narrowing of the posterior joint
space, whereas a type B2 glenoid has more
extensive posterior wear resulting in a biconcave glenoid. Finally, a type C glenoid
has retroversion in excess of 25. In addition, Hill and Norris4 proposed a standardized radiographic assessment based on an
axillary radiograph or computed tomography scan. Posterior glenoid defects are described based on the version of the defect
relative to the normal glenoid version; the
extent of the defect relative to the entire

NOVEMBER 2012 | Volume 35 Number 11

glenoid surface, expressed as a percentage;

and the maximum depth of the defect at the
glenoid margin.
In contrast to primary glenohumeral osteoarthritis, cuff tear arthropathy results in
superior glenoid wear from the high-riding
humeral head. These frontal plane changes
were described by Favard et al,5 who proposed 4 stages: E0 through E3, with E0 representing a normal glenoid, E1 symmetric
wear in the frontal plane, E2 asymmetric
superior wear with biconcavity of the glenoid, and E3 severe superior wear.5
Glenoid defects resulting from component removal at the time of revision are more
complex. Antuna et al6 described a system
based on intraoperative assessment of the
glenoid. Defects were described as central,
peripheral, or combined. Within each group,
the defect was described as mild, moderate,
or severe. They found this classification useful in guiding surgical decision making.6
Although multiple classifications exist
for glenoid bone loss, no currently accepted
classification system exists for bony defects
of the proximal humerus. For research purposes, the zones of osteolysis of the hip proposed by Gruen et al7 have been used to describe osteolysis around humeral implants,
but this classification is not used widely for
clinical decision making.

Primary Anatomic Total Shoulder

Arthroplasty
Glenoid
In primary TSA, posterior glenoid wear
is the most common bone deficiency encountered. Some lesions can be overcome
by asymmetric reaming, but in larger defects, overaggressive asymmetric reaming
can lead to a smaller glenoid face, violation
of the supporting subchondral bone, medialization of the joint line, and more frequent
peg penetration.8 In a cadaveric study, the
upper limit of glenoid retroversion that
could be safely corrected with eccentric
reaming was 15.9 An alternative is to leave
the glenoid retroversion unchanged, but data
suggest that glenoid component retroversion
greater than 10 results in increased stress at

the cement mantle, increased motion at the

bonecement interface, higher shear stresses, and a higher likelihood of failure.10,11
Therefore, overcoming large areas of posterior wear and excessive glenoid retroversion
requires structural augmentation.
Augmented glenoid components with a
thicker posterior than anterior polyethylene
have been used for this purpose. Mid-term
outcome data of 1 design suggested that it
did not significantly improve outcomes.12
Bone grafting of posterior glenoid lesions
has a longer track record. It was first described by Neer and Morrison in 1988,2
who used a custom-fashioned corticocancellous fragment of the patients humeral
head to fill the posterior glenoid defect.
When small, the bone graft was impacted
into the remaining glenoid vault. Larger
grafts were fixed with 2 cancellous screws
using a lag technique.2
Three studies described the outcomes
of this technique (Table 1).2,4,13 A total of
64 patients were followed for a minimum
of 2 years. Radiographic union of the bone
graft was achieved in 57 cases. Half (n532)
of the patients had an excellent Neer outcome score, 17 (27%) had a satisfactory
score, and 15 (23%) had an unsatisfactory
score. Complications occurred in 9 (14%)
patients, with instability being the most
common finding.
Bone graft can be used for more than its
structural properties. Wirth et al14 reported
a technique in which morselized bone graft
from the humeral head is inserted between
flutes on the central peg. This technique is
hypothesized to facilitate bony ingrowth.
They provided radiographic outcomes for
44 patients at a mean of 3 years. Twenty
shoulders had perfect seating and radiolucency grades, 30 had increased radiodensity
between the flutes of the central peg, and 3
demonstrated osteolysis. No cases of clinical glenoid loosening were observed at a
mean 4-year follow-up.14
Humerus
Bone grafting of the proximal humerus
in primary TSA has been reported. In 2003,

967

n Review Article

cme
ARTICLE

Table 1

Summary of the Literature on Structural Bone Grafting

of Posterior Glenoid Defects in Primary Total Shoulder Arthroplasty
Study

Level of
Evidence

Population
Characteristics

Radiographic
Union, n/N

Pain VAS

Neer Functional
Rating

Complications

Neer &
Morrison2

IV

19 patients, minimum
2-y follow-up

19/19

N/A

16 excellent,
1 satisfactory,
2 limited

2 broken screws

Hill & Norris4

IV

21 patients over 9 y,
17 with minimum 2-y
follow-up

14/17

N/A

3 excellent,
6 satisfactory,
8 unsatisfactory

1 massive rotator cuff tear,

2 persistent instability,
1 improper glenoid position,
1 loss of graft fixation

Steinmann &
Cofield13

IV

31 patients over 16 y,
28 with minimum 2-y
follow-up

24/28

16 no pain,
6 slight pain,
5 moderate pain,
1 severe pain

13 excellent,
10 satisfactory,
5 unsatisfactory

1 anterior dislocation,
1 posterior subluxation

Abbreviation: N/A, not applicable; VAS, visual analog scale.

Hacker et al15 described a technique in

which cancellous bone from the humeral
head is impacted into the humeral metaphysis and shaft, after which the humeral prosthesis is press fit using a standard technique.
Although no clinical data were presented to
suggest that impaction grafting improved
patient outcomes, the radiographic appearance was improved. Using computed
tomography, the authors demonstrated that
the void between the prosthesis and the
bone of the proximal humerus could be significantly decreased.15

Revision Anatomic Total Shoulder

Arthroplasty
Glenoid Bone Loss
Bone loss is encountered frequently in
the revision setting due to glenoid loosening, bone loss during prostheses extraction,
and osteolysis. Defects of the glenoid can
present with a preserved or an absent vault.
This distinction guides surgical decision
making because the absence of a vault dictates the use of structural bone graft as opposed to cancellous graft.16
Glenoid component removal with bone
grafting is the most commonly described
treatment for a loose, painful glenoid with
significant bone loss. Four studies described

968

the results of this treatment (Table 2).16-19 As

a whole, the data suggest that modest pain
reduction16,19 and patient satisfaction16-18
can be achieved. However, graft subsidence
is the norm, with progressive medialization
of the humeral head. In the only study that
compared cancellous allograft with structural femoral head allograft, subsidence was
higher with use of structural graft; however,
the groups are so small that it is difficult to
generalize this result.16
For patients who have undergone glenoid removal and bone grafting but have
persistent pain, the option of glenoid reimplantation remains. The procedure is
uncommon, reported in only 18 patients
across 4 studies.6,20-22 Antuna et al20 reported a case series of 3 patients with 2- to
8-year follow-up. Based on Neers classification, 1 had an excellent result, 1 had a satisfactory result, and 1 had an unsatisfactory
result. Cheung et al21 reported 7 patients
with a minimum 2-year follow-up. Pain visual analog scale score decreased from 4.6
to 2.4, and range of motion was unchanged.
According to Neers classification, 1 patient
had an excellent result, 1 had a satisfactory
result, and 3 had an unsatisfactory result.21
Only 2 studies directly compared outcomes between patients with glenoid bone

grafting without resurfacing and those

undergoing glenoid revision after bone
grafting. Elhassan et al22 retrospectively
compared 3 patients with glenoid bone
grafting and revision TSA with 5 patients
undergoing only glenoid bone grafting. No
significant differences were found in Constant scores or range of motion.22 Antuna
et al20 reported a larger study comprising
a retrospective comparison of 18 shoulders
with glenoid component removal and bone
grafting and 5 shoulders that subsequently
underwent glenoid component revision.
The revision group had significantly better external rotation at a minimum 2-year
follow-up. When the glenoid was not replaced, a mean of 7.5 mm of graft subsidence occurred.20
Humeral Bone Loss
It is less common to lose enough bone
in the proximal humerus to warrant bone
grafting but still have enough intact soft tissue structures to allow for successful anatomic TSA. A single case report described
the use of a cortical strut allograft in addition to impaction cancellous allografting
for the treatment of proximal humeral deficiency in a multiply revised shoulder.23 At
29 months, the patient had no pain and was

ORTHOPEDICS | Healio.com/Orthopedics

Bone Grafting in Shoulder Arthroplasty | Riboh & Garrigues

cme
ARTICLE

Table 2

Summary of the Literature on Bone Grafting of Glenoid Defects During Revision Total Shoulder Arthroplasty
Level of
Evidence

Population
Characteristics

Scalise &
Iannotti16

IV

11 patients,
minimum 2-y
follow-up

Young et al17

IV

6 patients,
minimum 1-y
follow-up

Tricortical
iliac crest

3 without erosion,
2 with partial
erosion, and 1
with complete
collapse

N/A

Constant score,
36.8-59.8;
subjective,
5 satisfied, 1
unsatisfied

1 conversion to
RSA

Neyton et al18

IV

9 patients,
minimum 2-y
follow-up

Bicortical iliac crest

Mean, 4.1 mm

N/A

Neer, 5
satisfactory, 4
unsatisfactory;
Constant,
46.3-49.9

1 graft erosion, 1
reoperation for
massive rotator
cuff tear

Phipatanakul
& Norris19

IV

24 patients,
minimum 2-y
follow-up

Cancellous
allograft chips

10 without, 6
between 3 and 6
mm, 1 between
7 and 9 mm, 3
.10 mm

N/A

4 glenoid
reimplantations
for persistent
pain

Study

Grafting
Technique
6 cancellous
allograft chips
and 5 femoral
head structural
allografts

Graft Subsidence
3 ,5 mm, 6
between 5 and
10 mm, 2 .10
mm

Pain VAS
Penn
Shoulder
Score: 1017

18/24 with
satisfactory
pain relief

Functional
Scores
Penn Shoulder
Score: 23-57

Complications
1 conversion
to RSA, 1
explantation
for septic
arthritis

Abbreviation: N/A, not applicable; RSA, reverse shoulder arthroplasty; VAS, visual analog scale.

able to perform all activities of daily living

and play golf. However, the patient was unable to perform any overhead activities.23
A more common application of bone
grafting in the humerus is to assist in the
healing of a proximal humeral window. A
window may be required to remove a wellfixed humeral component at the time of revision. Sperling and Cofield24 reported 20
patients who were followed for a minimum
of 3 months. The humeral window was
filled with cancellous allograft, after which
a cemented humeral prosthesis was used
and secured with cerclage cables. Clinical
and radiographic union was achieved in all
patients.24

Primary Reverse Total Shoulder

Arthroplasty
Glenoid bone deficiency can be an issue
in reverse TSA. Frequently, the defect in
cuff tear arthropathy is superior instead of
posterior, as in osteoarthritis. Minor glenoid
deficiency can be overcome by a modified
reaming technique in which a cannulated

NOVEMBER 2012 | Volume 35 Number 11

reamer is directed down the centerline of

the scapular spine. This allowed for correction of 34 of 56 glenoid deficiencies in
a recent case series.25 If eccentric reaming
does not allow for 80% bony coverage of
the glenoid base plate, augmentation with
humeral head bulk autograft provides satisfactory results.25 The defect is created by
humeral head wear, and a section of the
head generally fits well.
For massive uncontained glenoid lesions
in the presence of a massive rotator cuff tear,
a femoral neck allograft centrally packed
with a humeral head autograft can be used
to augment the glenoid bone stock for the
glenosphere. Results of this technique have
been reported in 5 patients with a minimum
1-year follow-up.26 Computed tomography
scans at 6 months showed complete graft
incorporation in all cases, but no pain or
functional outcomes were reported.26
Boileau et al27 proposed the routine use
of bone grafting to improve the outcomes of
reverse TSA. The technique is called bony
increased-offset reverse shoulder arthro-

plasty, or Bio-RSA. A cylinder of cancellous bone from the humeral head is cut with
a guide to exactly match the size of the glenoid base plate. A central hole is then drilled
in the disk of bone to allow it to slide over
the central peg of the glenoid (Figure 1). By
providing bony lateralization, this is hypothesized to reduce scapular notching, improve
shoulder contour, and allow for a greater
arc of motion. Once the graft incorporates,
these benefits are achieved without increasing torque at the baseplatebone interface,
as may occur with prosthetic lateralization.
Boileau et al27 reported their results with
Bio-RSA in 42 patients with a minimum
2-year follow-up. Computed tomography
and radiographic evaluations showed complete graft incorporation in 98% of patients.
In addition, 86% of patients could internally rotate sufficiently to reach their back over
their sacrum. Scapular notching occurred in
only 19% of patients, as compared with the
50% to 90% reported in the literature. No
graft resorption or glenoid loosening were
observed during the short-term follow-up.27

969

n Review Article

cme
ARTICLE

1A

1E

1C

1B

1F

1D

1G

Figure 1: Use of the bony increased-offset reverse shoulder arthroplasty (Bio-RSA) technique and a bone graftaugmented fracture stem for treatment of a proximal
humeral fracture in the setting of advanced glenohumeral osteoarthritis. Anteroposterior radiograph of the left shoulder of an 80-year-old patient showing advanced
glenohumeral osteoarthritis (A). Anteroposterior radiograph of the left shoulder of the same patient showing a 2-part proximal humeral fracture after a fall from
standing (B). Postoperative anteroposterior radiograph of the left shoulder showing the result of reconstruction with a reverse shoulder prosthesis (C). A conical
piece of cancellous bone from the humeral head is harvested (D) and placed around the central peg of the glenosphere (E). A punch is then used to obtain a wedge
of cancellous bone from the remaining humeral head (F), which is perfectly sized for insertion into the metaphyseal window of the humeral prosthesis (G).

Revision Reverse Total Shoulder

Arthroplasty
Glenoid Bone Loss
When faced with glenoid deficiency in
revision reverse TSA, the humeral head
is absent, and an alternate source of bone
graft is needed. Satisfactory results have
been obtained with the use of autologous
iliac crest structural graft.5,28 Kelly et al28
first described the technique for using an
iliac crestglenoid baseplate composite.
The baseplate is implanted directly onto
the pelvis, and the iliac crest is then cut
and fashioned to match the glenoid defect
(Figure 2). They reported the results of
this technique in 12 patients as part of a
larger series of 30 revision reverse TSAs.
Constant and American Shoulder and Elbow Surgeons scores improved significantly, and 80% of patients were satisfied
or very satisfied, according to the authors
criteria.28

970

Neyton et al29 reported 9 reverse TSAs

using iliac crest autograft, 6 of which were
revisions or conversions from conventional
implants. At 2-year follow-up, 5 patients
were pain free (visual analog scale score,
0/10), 1 patient had significant pain (visual
analog scale score, 8/10), and 3 patients had
moderate pain (visual analog scale score,
2-5/10). All patients could elevate their arm
at least 90. According to the authors criteria, 4 patients were very satisfied, 3 were
satisfied, and 2 were disappointed. No evidence was found of component loosening
or graft failure.29
Humeral Bone Loss
Significant humeral bone loss in the
setting of revision reverse TSA requires a
more complex approach. The cylindrical
nature of the humeral shaft does not provide torsional stability for the stem without
the proximal humerus to cup the proximal

part of the implant. In addition, it is felt

that the lack of proximal humerus bone can
lead to poor deltoid tension and concomitant implant instability and weakness.30
Chacon et al31 described the use of a prosthesisallograft composite for this application in 25 patients (Figure 3). They custom
shaped a proximal humeral allograft to
match each patients bone defect. The allograft was then secured to the patients
proximal humerus with cerclage cables,
and the humeral component was cemented
into the construct. They reported excellent
results in 19 patients, satisfactory results in
5 patients, and an unsatisfactory result in 1
patient, according to Neers criteria. American Shoulder and Elbow Surgeons scores
improved from 31.7 to 69.4. Metaphyseal
incorporation of the allograft was achieved
in 84% of patients, and diaphyseal incorporation was achieved in 76%. Complications
occurred in 4 patients: 2 dislocations, 1 as-

ORTHOPEDICS | Healio.com/Orthopedics

Bone Grafting in Shoulder Arthroplasty | Riboh & Garrigues

cme
ARTICLE

2E
2A

2B

2F

2C

2G

2D

2H

2I

Figure 2: Use of autologous tricortical iliac crest graft for staged conversion of an infected, loose total shoulder arthroplasty to a reverse prosthesis. A 78-year-old
man presented with a painful right shoulder 1 year after right total shoulder arthroplasty at an outside hospital. On examination, he had subscapularis insufficiency
and pseudoparalysis. Inflammatory laboratories were elevated. An anteroposterior radiograph revealed radiolucent lines around the glenoid pegs and a large osteolytic
lesion of the proximal humerus (A). Intraoperative tissue samples showed evidence of acute inflammation, and antibiotic-coated cement was fashioned into a ball and
placed in the glenohumeral joint after removal of all component and debridement (B). A postoperative computed tomography scan showed a cavitary central defect of
the glenoid (C). After completion of 6 weeks of intravenous antibiotic therapy for methicillin-sensitive Staphylococcus aureus and Proprionobacterium acnes, a second
procedure was performed, with placement of a reverse shoulder prosthesis and bone graft augmentation of the glenoid defect (D). The central glenoid defect was filled
with cement to provide a template (E, F). An autologous iliac crest graft was harvested and shaped to match the cement template (G). The baseplategraft composite
was fixed with standard screw technique (H). Five months postoperatively, the patient demonstrated excellent active range of motion of the right shoulder (I).
Figure 3: Use of a proximal femoral allograft for
reconstruction of a tuberosity nonunion after
hemiarthroplasty for trauma. A 67-year-old woman sustained a 4-part fracture of the left proximal
humerus that was treated with hemiarthroplasty
after fracture displacement occurred with conservative management (A). She had persistent pain
and pseudoparalysis. An anteroposterior radiograph at 14 months revealed a nonunion of the
greater tuberosity (B). She was treated with conversion to a reverse prosthesis. In the setting of
marked proximal humeral bone loss, the humeral
component was secured into a proximal femoral
allograft using standard cement technique and
cerclage wires (C).

ymptomatic allograft fracture treated conservatively, and 1 nondisplaced acromial

fracture.31 Proximal femoral allograft is an-

NOVEMBER 2012 | Volume 35 Number 11

3A

other option with benefits of greater cortical

thickness and a large greater trochanter that
tensions the deltoid.28

3B

3C

Arthroplasty for Fracture

When performing hemiarthroplasty for
comminuted proximal humeral fractures,

971

n Review Article

cme
ARTICLE

4A

4B

Figure 4: Use of a proximal humerus allograftprosthesis composite for reconstruction after wide resection of a proximal humeral osteosarcoma. A 22-year-old man presented with left shoulder pain. Workup
revealed a proximal humeral osteosarcoma, seen best on magnetic resonance imaging (A). After resection
of his proximal humerus, reconstruction with a proximal humerus allograftprosthesis composite was
performed. Repair of the rotator cuff, pectoralis major, and latissimus dorsi were performed. A longstemmed reverse prosthesis was used and augmented with plate fixation (B).

the most critical challenge is achieving

union of the tuberosities. Boileau et al32
compared the results of Aequalis (Tornier,
Inc, Bloomington, Minnesota) standard,
open, and fracture stems in 384 patients, of
whom 300 received the standard stem, 53
received the open stem, and 31 received the
fracture stem. The open prosthesis provides
a window for placing bone graft but has a
sagittal fin that prevents anatomic positioning of the tuberosities, and the rough neck
surface can lead to rupture of the tuberosity
sutures. These design limitations were addressed with the fracture stem, which allows for bone grafting within the implant
window and laterally, where the greater
tuberosity is attached. Functional and pain
scores were not significantly different at
6-month follow-up. However, migration of
the greater tuberosity decreased from 26%
with the standard prosthesis to 13% with
the open prosthesis and 10% with the fracture stem. Nonunion of the greater tuberosity decreased from 49% with the standard
prosthesis to 36% with the open prosthesis
and 25% with the fracture prosthesis.32
Krause et al33 studied the effect of bone
grafting on tuberosity displacement after hemiarthroplasty for the treatment of
3- or 4-part proximal humeral fractures.
They retrospectively compared 31 patients

972

treated with standard hemiarthroplasty

and suture fixation of the tuberosity with
27 patients treated with hemiarthroplasty
and bone grafting with cable fixation. Tuberosity dislocation was more frequent in
the group without bone grafting. Failed
tuberosity fixation was associated with decreased activity levels, range of motion, and
strength.33
Levy and Badman34 described a technique used in 7 patients in which the humeral head remnant was shaped into a
horseshoe and grafted near the greater
tuberosity when performing reverse TSA
for 3- or 4-part fractures. At 1 year, they
achieved tuberosity union in 86% of patients. According to Neers criteria, excellent results were achieved in 4 patients, satisfactory results in 2, and an unsatisfactory
result in 1. Mean forward flexion was 117,
and mean external rotation was 19.34
The indications for bone grafting in the
treatment of periprosthetic humeral fractures are unclear. The largest series of such
fractures was reported by Kumar et al.35
They reported a retrospective series of 16
patients collected over a 25-year period. For
a type A fracture (at the prosthesis tip with
proximal extension) or a type B fracture
(at the prosthesis tip with distal extension)
with a stable stem, they recommended the

use of autologous iliac crest bone graft to

augment plate fixation. In the setting of a
loose stem, they recommended revision
TSA with a cemented long-stem prosthesis and cancellous allograft augmentation.
They also reported the successful use of a
free vascularized fibular graft for nonunion
of a periprosthetic type B fracture. All 16
fractures healed at a mean of 278 days.35
For type C fractures (occurring distal
to the prosthesis tip), internal fixation and
strut allograft augmentation has been described. Martinez et al36 reported a series
of 6 patients treated in this fashion. At a
mean 14-month follow-up, all 6 fractures
had united, and mean Constant score was
64. Patient satisfaction and range of motion
were restored to prefracture status in all but
1 patient. On follow-up radiographs, 3 patients had evidence of grafthost union, and
3 had graft resorption.36

Arthroplasty in the Setting of

Malignancy
A unique reconstructive challenge is
encountered after resection of a humeral
malignancy. Reconstructive options are
limited because of the complex loss of
bone, articular surface, and stabilizing soft
tissues. An allograftprosthesis composite can be used in such situations (Figure
4).37,38 The allograft can include the humeral head, the humeral shaft, the anterior
shoulder capsule, the rotator cuff tendons,
and the insertional segments of the deltoid,
pectoralis major, and latissimus dorsi. The
graft is cut at the anatomic neck, and a standard proximal humeral implant is placed
within the medullary canal. The construct
is then cemented into the humerus, and all
of the soft tissues are repaired to their native
counterparts.37,38

Conclusion
Various bone grafting techniques are
available to surgeons faced with complex
reconstructive challenges in the shoulder.
The principal indications are inadequate
glenoid or humeral bone stock and augmentation of component fixation in the setting

ORTHOPEDICS | Healio.com/Orthopedics

Bone Grafting in Shoulder Arthroplasty | Riboh & Garrigues

cme
ARTICLE

of osteoporotic bone or trauma. Although

only low-level evidence is available in support of these techniques, the reported outcomes are encouraging. Larger prospective
studies will help refine the indications and
techniques for bone grafting in TSA.

13. Steinmann SP, Cofield RH. Bone grafting for

glenoid deficiency in total shoulder replacement. J Shoulder Elbow Surg. 2000; 9(5):361367.

references

14. Wirth MA, Loredo R, Garcia G, Rockwood

CA Jr, Southworth C, Iannotti JP. Total shoulder arthroplasty with an all-polyethylene
pegged bone-ingrowth glenoid component:
a clinical and radiographic outcome study. J
Bone Joint Surg Am. 2012; 94(3):260-267.

1. Kim SH, Wise BL, Zhang Y, Szabo RM.

Increasing incidence of shoulder arthroplasty
in the United States. J Bone Joint Surg Am.
2011; 93(24):2249-2254.

15. Hacker SA, Boorman RS, Lippitt SB, Matsen

FA III. Impaction grafting improves the fit of
uncemented humeral arthroplasty. J Shoulder
Elbow Surg. 2003; 12(5):431-435.

2. Neer CS II, Morrison DS. Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint
Surg Am. 1988; 70(8):1154-1162.

16. Scalise JJ, Iannotti JP. Bone grafting severe

glenoid defects in revision shoulder arthroplasty. Clin Orthop Relat Res. 2008; 466(1):139145.

3. Walch G, Badet R, Boulahia A, Khoury A.

Morphologic study of the glenoid in primary
glenohumeral osteoarthritis. J Arthroplasty.
1999; 14(6):756-760.
4. Hill JM, Norris TR. Long-term results of total
shoulder arthroplasty following bone-grafting
of the glenoid. J Bone Joint Surg Am. 2001;
83(6):877-883.
5. Huguet D, Favard L, Lautman S, Sirveaux F,
Kerjean Y, Oudet D. Epidemiology, imaging
and classification of glenohumeral osteoarthritis with massive and non-reparable rotator cuff
tear. In: Walch G, Boileau P, Mole D, eds. 2000
Shoulder Prostheses: Two to Ten Year Followup. Montpellier, France: Sauramps Medical;
2001:233-240.

17. Young AA NL, Molony DC, Boileau P, Walch

G. Glenoid tricortical iliac crest structural bone
graft enhanced with resorbable cement for the
treatment of aseptic glenoid loosening. Tech
Should Elbow Surg. 2011; 12(1):12-17.
18. Neyton L, Walch G, Nove-Josserand L,

Edwards TB. Glenoid corticocancellous bone
grafting after glenoid component removal in
the treatment of glenoid loosening. J Shoulder
Elbow Surg. 2006; 15(2):173-179.
19. Phipatanakul WP, Norris TR. Treatment of glenoid loosening and bone loss due to osteolysis
with glenoid bone grafting. J Shoulder Elbow
Surg. 2006; 15(1):84-87.

6. Antuna SA, Sperling JW, Cofield RH,
Rowland CM. Glenoid revision surgery after
total shoulder arthroplasty. J Shoulder Elbow
Surg. 2001; 10(3):217-224.

20. Antuna S, Sperling JW, Cofield RH.

Reimplantation of a glenoid component after
component removal and allograft bone grafting: a report of 3 cases. J Shoulder Elbow Surg.
2002; 11(6):637-641.

7. Gruen TA, McNeice GM, Amstutz HC.

Modes of failure of cemented stem-type
femoral components: a radiographic analysis
of loosening. Clin Orthop Relat Res. 1979;
(141):17-27.

21. Cheung EV, Sperling JW, Cofield RH.

Reimplantation of a glenoid component following component removal and allogenic
bone-grafting. J Bone Joint Surg Am. 2007;
89(8):1777-1783.

8. Gillespie R, Lyons R, Lazarus M. Eccentric

reaming in total shoulder arthroplasty: a cadaveric study. Orthopedics. 2009; 32(1):21.

22. Elhassan B, Ozbaydar M, Higgins LD, Warner

JJ. Glenoid reconstruction in revision shoulder arthroplasty. Clin Orthop Relat Res. 2008;
466(3):599-607.

9. Clavert P, Millett PJ, Warner JJ. Glenoid resurfacing: what are the limits to asymmetric reaming for posterior erosion? J Shoulder Elbow
Surg. 2007; 16(6):843-848.
10. Hopkins AR, Hansen UN, Amis AA, Emery R.
The effects of glenoid component alignment
variations on cement mantle stresses in total
shoulder arthroplasty. J Shoulder Elbow Surg.
2004; 13(6):668-675.
11. Farron A, Terrier A, Buchler P. Risks of loosening of a prosthetic glenoid implanted in
retroversion. J Shoulder Elbow Surg. 2006;
15(4):521-526.
12. Rice RS, Sperling JW, Miletti J, Schleck C,
Cofield RH. Augmented glenoid component
for bone deficiency in shoulder arthroplasty.
Clin Orthop Relat Res. 2008; 466(3):579-583.

NOVEMBER 2012 | Volume 35 Number 11

23. Nystuen CM, Leopold SS, Warme WJ,

Simmons GE. Cancellous impaction and cortical strut allografting for revision shoulder
arthroplasty: a case report. J Shoulder Elbow
Surg. 2006; 15(2):244-248.
24. Sperling JW, Cofield RH. Humeral windows
in revision shoulder arthroplasty. J Shoulder
Elbow Surg. 2005; 14(3):258-263.
25. Klein SM, Dunning P, Mulieri P, Pupello D,
Downes K, Frankle MA. Effects of acquired
glenoid bone defects on surgical technique
and clinical outcomes in reverse shoulder
arthroplasty. J Bone Joint Surg Am. 2010;
92(5):1144-1154.
26. Bateman E, Donald SM. Reconstruction of

massive uncontained glenoid defects using a
combined autograftallograft construct with

reverse shoulder arthroplasty: preliminary results. J Shoulder Elbow Surg. 2012; 21(7):925934.
27. Boileau P, Moineau G, Roussanne Y, OShea
K. Bony increased-offset reverse shoulder
arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin
Orthop Relat Res. 2011; 469(9):2558-2567.
28. Kelly JD II, Zhao JX, Hobgood ER, Norris
TR. Clinical results of revision shoulder arthroplasty using the reverse prosthesis [published
online ahead of print February 22, 2012]. J
Shoulder Elbow Surg.
29. Neyton L, Boileau P, Nove-Josserand L,

Edwards TB, Walch G. Glenoid bone grafting
with a reverse design prosthesis. J Shoulder
Elbow Surg. 2007; 16(3 suppl):S71-S78.
30. Cuff D, Levy JC, Gutierrez S, Frankle MA.
Torsional stability of modular and non-modular reverse shoulder humeral components in a
proximal humeral bone loss model. J Shoulder
Elbow Surg. 2011; 20(4):646-651.
31. Chacon A, Virani N, Shannon R, Levy JC,
Pupello D, Frankle M. Revision arthroplasty
with use of a reverse shoulder prosthesis-allograft composite. J Bone Joint Surg Am. 2009;
91(1):119-127.
32. Boileau P, Coste JS, Ahrens PM, Staccini P.
Prosthetic shoulder replacement for fracture:
results of the multicentre study. In: Walch
G, Boileau P, Mole D, eds. 2000 Shoulder
Prostheses: Two to Ten Year Follow-up.
Montpellier, France: Sauramps Medical; 2001.
33. Krause FG, Huebschle L, Hertel R.

Reattachment of the tuberosities with cable
wires and bone graft in hemiarthroplasties done
for proximal humeral fractures with cable wire
and bone graft: 58 patients with a 22-month
minimum follow-up. J Orthop Trauma. 2007;
21(10):682-686.
34. Levy JC, Badman B. Reverse shoulder prosthesis for acute four-part fracture: tuberosity fixation using a horseshoe graft. J Orthop
Trauma. 2011; 25(5):318-324.
35. Kumar S, Sperling JW, Haidukewych GH,

Cofield RH. Periprosthetic humeral fractures
after shoulder arthroplasty. J Bone Joint Surg
Am. 2004; 86(4):680-689.
36. Martinez AA, Calvo A, Cuenca J, Herrera A.
Internal fixation and strut allograft augmentation for periprosthetic humeral fractures. J
Orthop Surg (Hong Kong). 2011; 19(2):191193.
37. Abdeen A, Healey JH. Allograftprosthesis

composite reconstruction of the proximal part
of the humerus: surgical technique. J Bone
Joint Surg Am. 2010; 92(suppl 1 pt 2):188-196.
38. Abdeen A, Hoang BH, Athanasian EA, Morris
CD, Boland PJ, Healey JH. Allograftprosthesis composite reconstruction of the proximal
part of the humerus: functional outcome and
survivorship. J Bone Joint Surg Am. 2009;
91(10):2406-2415.

973