Reverse shoulder arthroplasty in the setting of massive proximal humeral bone loss: a systematic review

Massive proximal humeral bone loss (PHBL) poses a technical challenge during reverse shoulder arthroplasty (RSA). Surgical treatment strategies include allograft-prosthetic composite (APC) reconstructions, endoprostheses, and other reverse shoulder arthroplasty constructs; however, there is a paucity of literature summarizing the outcomes and complications unique to this complex patient population. This study aimed to systematically review the literature to evaluate (1) patient-reported outcome measures, (2) functional outcomes, and (3) complications according to surgical treatment strategy for patients with massive PHBL who undergo primary or revision shoulder arthroplasty.

A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes and complications of reverse shoulder arthroplasty in patients with significant PHBL. Methodological quality was assessed for included studies. Patient-reported outcome measures, radiographic outcomes, and postoperative functional outcomes were collected.

Eleven studies evaluating clinical outcomes and complications of reverse shoulder arthroplasty in the setting of PHBL comprising 277 patients were included for review. The mean age was 66 years (range, 60-79 years). American Shoulder and Elbow Surgeons score, Visual Analog Scale, and range of motion were the most common outcomes collected, and patients exhibited significant improvements in mean scores postoperatively. Of the types of prostheses reported, there were 155 reverse shoulder arthroplasty (RSA) with allograft-prosthetic composite (APC) reconstructions, 48 proximal humeral replacement (PHR) endoprostheses, 41 RSA, 15 custom RSA, and 2 RSA with fibular strut allografts. The overall pooled complication rate was 30.1% (82/272) with revision/reoperation as the most common complication at 21% (57/272). The overall complication rate for RSA-APC reconstructions was 51% (79/155). The overall complication rate for PHR endoprostheses was 64.6% (31/48). Revision/reoperation rates were the most complication for both RSA-APC and PHR endoprostheses with rates of 20% and 31.3%, respectively.

Treatment by APC reconstruction is the most common surgical technique described in the setting of massive PHBL. While shoulder arthroplasty can yield acceptable results for patients with substantial PHBL, such patients are at increased risk for complications and revision surgery.