Management of proximal humeral bone loss: a narrative review

The optimal management of proximal humeral bone loss (PHBL) in shoulder arthroplasty is a debated topic. PHBL is a challenging problem for surgeons due to its effect on implant fixation and stability. Supplemental fixation options in the form of allograft-prosthetic composites (APCs) or reverse shoulder arthroplasty (RSA) endoprostheses are options to consider, each with its own benefits and complication profiles. This narrative review aims to evaluate current strategies for managing PHBL.

A comprehensive literature search was performed using databases including PubMed, Cochrane Library, and Google Scholar using appropriate search terms. Studies published between 2013 and 2024 were included. All included studies were peer-reviewed and addressed PHBL in the setting of shoulder arthroplasty or proximal humerus resection.

A total of nineteen studies were included, comprising 7 retrospective case series, 4 prospective case series or cohort studies, 2 systematic reviews, 1 retrospective registry study, 3 descriptive papers of proposed classification systems, and 2 technique papers. Described classification systems categorize PHBL by integrity of the epiphysis, greater tuberosity, calcar, metaphysis, diaphysis, and cortices. Depending on the degree of bone loss, revision RSA without allograft, revision RSA with APC augmentation, and endoprosthesis are described as management options. In patients with greater than 5 cm of PHBL, use of APC or endoprosthesis has proven effective but with high complication profiles and revision rates. No paper directly compares endoprosthesis and APC outcomes.

PHBL is a rare but important problem in the setting of tumor resection and revision shoulder arthroplasty. While small cohort studies have reported successful outcomes with both APC and endoprosthesis, systematic reviews have failed to demonstrate a clear benefit of one option over the other. Complication and reoperation rates can be high with both surgical options. With a focus on standardized classification and evaluation of patients with PHBL, we can hope to refine the surgical techniques and indications for optimal patient outcomes.