Revision of a Stemless Anatomic Implant into a Stemless Reverse Implant

Introduction. Stemless anatomic implants are the growing standard for solving osteoarthritis of the shoulder. If there are secondary rotator cuff insufficiency and the need to revise the implant into a reverse total shoulder, there is usually the option to revise it into a stemmed implant with losing the benefits of stemless implants. There are only a few stemless reverse implants available on the market. Usually, they are recommended as primary implants, but not for revision surgery. Case Report. A 61-year-old male with an indwelling anatomic stemless TESS (Total Evolutive Shoulder System, Zimmer Biomet, Warsaw, USA) implant presented in our clinic with growing pain and loss of range of motion. The TESS was implanted in 2007 as a hemishoulder arthroplasty. The X-ray was showing a stable implanted corolla with clearly growing protrusion of the glenoid. Because of the clinical presentation and the ultrasound investigation that showed only remnants of the supraspinatus and infraspinatus left, we decided that it is necessary to revise the stable implant in a reverse total shoulder arthroplasty. As the TESS was not designed to be convertible, it was clear that it has to be explanted. Due to the young age of the patient, we proposed an “off-label” change to a stemless reverse implant, e.g., the LIMA SMR stemless reverse prosthesis. A revision was possible without much bone loss, so the stemless reverse implant could be used. The clinical and radiological 2-year follow-up showed a good result. Conclusion. Stemless implants are well known for anatomic implants, rarely for reverse implants, and seldom used for revision into reverse stemless. This case report shows that it is possible to revise a stemless anatomic implant with a stemless reverse, as long as the rules for implantation are applicable.

An Unusual Case of Humeral Shaft Non-Union

Background: Humeral shaft fractures account for 1% to 3% of all fractures and approximately 20% of all fracture involving the humerus. The prevalence of non-union for diaphyseal humeral fractures has been reported as 1% to 10% after non-surgical and 10% to 15% after surgical management. Various devices used in treatment of humeral diaphyseal non-union are limited contact dynamic compression plates, locking compression plate (LCP), wave plates, humerus interlocking nail (IMN), Ilizarov external fixators and bone graft struts. Case Description: A 68-year-old man reported a humeral shaft fracture on the left side, due to a simple fall. It was reduced and fixed by IMN. He underwent clinical and radiological follow up. Three months after the intervention, due to persistent pain and impaired function of the left shoulder, the nail was removed and a cemented endoprosthesis was implanted. 3 years later, unsatisfied with the results, he came to our attention and was diagnosed an atrophic non-union in the site of the previous humeral shaft fracture. Moreover, the exams showed a rotator cuff insufficiency. It was decided to perform a single-stage intervention to achieve two goals: cure the humeral shaft non-union and restore the function of the left shoulder. The cemented endoprosthesis was removed, followed by an extensive curettage of the non-union site. A reverse prosthesis was implanted, with an extra-long stem used to stabilize the non-union site, as it was an IMN. An allograft was harvested from a cadaver femur and fixed with two metal cerclages. The patient underwent clinical and radiological follow-up. Complete healing was achieved 8 months later. Conclusion: Humeral shaft nonunion still represent a pathology that pose a serious problem to the surgeon. A correct management should include an accurate pre-operative planning, to achieve the best result possible for the patient.

Evaluation of results of three and four-part fracture dislocations of proximal humerus in young adults using philos (proximal humerus internal locking system)

Background: The fractures of proximal humerus constitute about 5% of fractures in adults third in number to fracture colles and hip usually in elderly patients due to a low energy trauma. In young patients the fractures are mostly due to high energy trauma and as such are associate with other soft tissue injuries. A sub group of young patients have a three or four fracture dislocation of shoulder joint. The aim of this study was to find the results of fixation by PHILOS in these young patients.Methods: This study was done in a teritiary referral centre over a period of about 1 year. All patients were operated within three weeks. Open fractures, patients with age more than 50 years were excluded from the study. All patients underwent open reduction and fixation using commercially available PHILOS. A minimum of 6 months follows up was essential for inclusion into the study. Final functional results were evaluated by Constant Murley scoring.Results: 14 patients were included in the study. The average age of patients was 38.42years. All fractures united. We had 71.4% excellent or good results. The complications noted were shoulder stiffness in 3, inadequate post op reduction, rotator cuff insufficiency, head necrosis, secondary osteo arthritis 1 each.Conclusions: Despite the relatively high rate of complications encountered in the management of these complicated high-energy fractures, the PHILOS plating system could be considered an adequate management of these patients.