Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Louis U. Bigliani, MD*,
Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
Posted January 2007
This is a well-written and well-documented article
describing the technique and indications for the use of proximal humeral
compaction bone-grafting in shoulder arthroplasty. There is very little in the
literature concerning compaction bone-grafting as an alternative to cement
fixation, and this paper provides us with a clinical and radiographic follow-up
of such a series. Several points are worthy of discussion.
First, the problem of radiolucent lines about an uncemented
humeral component was reviewed in this article, but the review addressed older
humeral stem designs. These systems did not have precise reamers or multiple
stem sizes. In contrast, contemporary humeral systems can achieve a proper press-fit
of a humeral stem with use of reamers that sequentially ream in 1-mm increments
to adapt to the irregular contour of the internal anatomy of the proximal
humeral canal, as described by Robertson et al.1. Also, contemporary
systems offer stems that are slightly smaller than the permanent stems and that
also increase in 1-mm increments. If the bone quality is good, then cement or
bone-grafting is not required. If the bone quality is poor, then cement is
probably the best alternative as grafting may not achieve stability.
Second, from the data contained in this article, it is hard
to make the conclusion that humeral compaction bone-grafting improves the overall
results of shoulder arthroplasty. This study included a diverse and varied
subset of patients with several different diagnoses, and some of the patients
were undergoing revision procedures. Results in patients with osteoarthritis
vary substantially from results in patients with rheumatoid arthritis and cuff
tear arthroplasty. It would be helpful to know why the patients underwent the
various procedures. Given the heterogeneous cohort, there needs to be more
discussion concerning the indications for bone-grafting, especially since bone
quality can vary depending on the patient's diagnosis.
Lastly, in reference to technique, it is unclear how to
achieve a uniform distribution of bone graft throughout the proximal and distal
portions of the shaft. Also, I have some concern about what the measurements
reflected because there is no way to determine if the bone graft ever got to
the areas being evaluated.
Overall, the article is a worthwhile and helpful description
of an alternative technique of cement fixation and press-fit techniques that
can be used during implantation of a humeral component.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
Reference
1. Robertson DD, Yuan J, Bigliani LU, Flatow EL, Yamaguchi K. Three-dimensional analysis of the proximal part of the humerus: relevance to arthroplasty. J Bone Joint Surg Am. 2000;82:1594-602.
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