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Available online at www.sciencedirect.com

www.elsevier.com/locate/semvascsurg

A review of humeral stem removal during revision

shoulder arthroplasty
Ryan P. Donegan, MD, MS, and Leesa M. Galatz, MDn
Shoulder and Elbow Service, Washington University Orthopedics, Barnes-Jewish Hospital, St. Louis, MO

AR T IC LE INFO

AB STR A C T
Despite the overwhelming clinical success of shoulder arthroplasty, several situations may

Keywords:

arise that necessitate revision arthroplasty. This often requires removal of the humeral

revision shoulder arthroplasty

component. Extraction of a humeral prosthesis is a technically demanding procedure,

humeral stem removal

which requires an understanding of the indications for humeral component explantation,

humeral component failure

careful preoperative planning, knowledge of the humeral component to be removed, a

grasp of several different methods of stem removal, and the tools required. Cement
extraction often poses substantial technical challenges and requires further specialized
instruments. Surgeons should be prepared to manage specic complications that may arise
such as canal perforation and humerus fracture.
& 2013 Elsevier Inc. All rights reserved.

1.

Introduction

Total shoulder arthroplasty has been accepted as a successful

treatment alternative for the management of glenohumeral
arthropathy [1]. Furthermore, shoulder hemiarthroplasty also
represents a viable treatment for a variety of traumatic and
degenerative shoulder conditions including proximal humerus
fracture, glenohumeral arthrosis in a young, active patient,
proximal humeral avascular necrosis, and rotator cuff-tear
arthropathy. Long-term studies have shown that revision rates
after total shoulder replacement are quite low with 84%
survivorship at 15 years [2]. In addition, hemiarthroplasty
has been shown to have excellent implant survival with 88%
survivorship at 10 years across a variety of indications [3]. The
rates of shoulder arthroplasty including hemiarthroplasty,
standard total shoulder arthroplasty, and reverse total
shoulder arthroplasty have continued to grow exponentially
over the last decade and as a result, the burden of revision
shoulder arthroplasty has increased concomitantly [4].
Due to the increasing demands of revision shoulder arthroplasty, it is critical that surgeons who perform these cases
have a clear understanding of the pertinent techniques and

issues specic to implant extraction, most notably humeral

stem removal. Failure to adequately prepare for these complex procedures and execute a well thought out surgical plan
may result in limitations when it comes to potential reconstructive options. The purpose of this article is to summarize
the indications, preoperative planning, and techniques for
humeral component removal and cement extraction.

2.

Indications for humeral stem removal

Revision shoulder arthroplasty and humeral stem removal is

most often indicated in the following clinical circumstances:
implant loosening, infection, periprosthetic fracture, mechanical failure due to rotator cuff insufciency, and glenoid erosion
associated with pain after hemiarthroplasty.
Implant loosening after shoulder arthroplasty is variably
reported in the literature depending on several factors including
the component reported (glenoid or humeral), the type of
arthroplasty performed (hemiarthroplasty, standard total
shoulder arthroplasty, and reverse total shoulder arthroplasty),
and the method of xation used. Long-term follow-up of

n
Address reprint requests to Leesa M. Galatz, MD, Washington University Orthopedics, Barnes-Jewish Hospital, Suite 11300 W Pavilion,
Campus Box 8233, St. Louis, MO 63110.
E-mail address: galatzl@wudosis.wustl.edu (L.M. Galatz).

1045-4527/$ - see front matter & 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.sart.2013.04.007

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cemented all-polyethylene glenoid components demonstrated

that approximately 95% of patients were free of glenoid revision
at 15-year follow-up [5]. However, glenoid component loosening
still represents one of the major causes for implant failure and
a reason for humeral component extraction to allow for appropriate reconstruction. Humeral component loosening requiring revision arthroplasty represents an uncommon clinical
scenario. A recent paper demonstrated that approximately 2%
(9/419) of cemented total shoulder arthroplasties resulted in a
loose humeral component; however, only 1 patient required
revision of the humeral component [6]. Reverse total shoulder
arthroplasty has not been reported to be associated with
humeral component loosening; however, accurate rates have
not been reported previously in the literature [7].
Infection after shoulder arthroplasty has been previously
reported in the literature by Singh et al. In their long-term
series, there was an exceedingly low rate of deep periprosthetic
infection after total shoulder replacement (o1%) [8]. Several
studies have asserted that implant retention and debridement
for subacute, or chronic deep periprosthetic infections, are
associated with a lower rate of infection eradication, and therefore, most surgeons have favored either one- or two-stage
revision arthroplasty with explantation of components, cement
extraction, and reimplantation [9].
Periprosthetic humeral fracture is a relatively uncommon
clinical circumstance and can be managed either surgically or
non-surgically depending on the location and displacement
of the fracture and most importantly the stability of the
humeral component. A recent study of over 3000 primary and
revision total shoulder arthroplasties and humeral head
replacement demonstrated a 0.6% rate of postoperative periprosthetic humeral fracture [10]. If the fracture compromised
implant xation, most surgeons today would recommend
component extraction with revision to long-stemmed prosthesis bypassing the fracture site [11].
Rotator cuff insufciency after total shoulder arthroplasty
has been shown to lead to superior migration of the prosthetic humeral head and the development of eccentric forces
on the glenoid component [12]. These forces have been
shown to lead to early glenoid loosening and the need for
prosthetic revision. Despite strict indications including a
well-functioning and intact rotator cuff at the time of primary
shoulder arthroplasty, the development of secondary rotator
cuff insufciency has become a well-recognized problem
after total shoulder arthroplasty with approximately 17% of
patients demonstrating superior migration of the prosthetic
humeral head at an average of approximately 9-year followup [13]. Glenoid loosening secondary to this phenomenon
may necessitate extraction of the glenoid and humeral
components and revision arthroplasty.
The development of symptomatic glenoid wear after hemiarthroplasty is a common clinical scenario, which often necessitates revision. A recent paper by Levine et al. evaluated
results of hemiarthroplasty for primary glenohumeral arthritis.
It demonstrated an overall revision rate of 26% (8/31 shoulders)
and an overall Neer satisfaction rating of 25% at an average of
17-year follow-up. In this setting, depending on the pathoanatomical circumstances (extent of glenoid wear, condition of the
rotator cuff, etc), extraction of the humeral component may be
necessary to complete a revision procedure [14].

3.

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Surgical planning

Successful removal of a humeral component requires the

development of a preoperative surgical plan, which relies on
careful analysis of the preoperative radiographs.
Review of preoperative radiographs should include a careful assessment of the previously placed humeral component.
Evaluation of this component should include an understanding of the implant geometry and mode of xation. As the
incidence of shoulder arthroplasty continues to increase in
younger patients [4], interest in short-stem humeral components that, in theory, may preserve more diaphyseal bone has
lead to implants that ll the metaphysis in order to gain
xation (Fig. 1). This should be noted on preoperative lms as
the remaining metaphyseal bone may be quite thin. In
addition, the proximal implant geometry may include a wide
collar, which makes it difcult to access the boneimplant
interface at the proximal aspect of the humeral stem.
Evaluation of the overall mode of xation (cemented versus
uncemented) also is a critical variable to assess preoperatively. If
an uncemented implant has been placed, an assessment of the
length of the ingrowth surface is critical to help determine how
far distal one must work in order to disrupt the xation interface. Cemented components should be evaluated for the length
of cement mantle and for any lucency that may suggest
loosening of the component. Fully cemented and uncemented
humeral components with a long ingrowth surface may require
a lower threshold to consider osteotomy/cortical window to gain
access to the more distal aspects of the humeral stem (Fig. 2).
Review of preoperative radiographs should also include an
assessment of the existing bone stock. Cortical defects and
areas of severe cortical thinning should be identied and
carefully observed during humeral extraction as propagation
of fractures may occur and require consideration during
reconstruction (Fig. 3).
Extraction of the humeral component in the setting of
infection represents a clinical circumstance that necessitates

Figure 1 A short-stemmed, metaphyseal-lling,

uncemented humeral component. Explantation of this type
of stem may result in little remaining metaphyseal bone.

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Figure 2 Fully cemented humeral component with robust

distal cement mantle. Utilization of an osteotomy or cortical
window may be necessary given the extensive distal
cement xation.

removal of all potentially infected material including previously placed cement. This may require a more extensive
surgical dissection or a lower threshold to consider osteotomy/cortical window in order to gain access to cement, which
may have been placed distally in the humeral canal (Fig. 3).

4.

Methods of humeral component extraction

The most common technique utilized for extraction of a wellxed humeral component is the dis-impaction technique.
This technique is often initially attempted during all humeral

Figure 3 Fully cemented humeral component with thinned

proximal lateral cortex and cement located deep within the
humeral canal. Tensile forces imparted on the humerus
during implant extraction may result in humeral fracture in
areas of cortical thinning.

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component revisions prior to consideration of other methods

such as humeral osteotomy or creating a cortical window.
This method is predicated on disruption of the interface
between the native humeral bone or cement mantle and
the prosthesis itself. In order to create this interface several
instruments can be used. A series of straight and curved 1/4
and 1/2 osteotomes may help develop this interval. In
addition, the utilization of exible osteotomes may be
inserted along the boneimplant interface to disrupt implant
xation and allow for easier extraction of the component. The
use of exible osteotomes may reduce the risk of cortical
perforation associated with placement of more rigid instruments between the prosthesis and humeral bone. Focus should
be placed on attempting to disrupt implant xation circumferentially around the prosthesis, and as such, surgical exposure should allow for complete access to the proximal humerus.
Furthermore, special attention should be placed on removing
residual bone and soft tissue from around the collar of the
humeral prosthesis to create a wide entry point for placement
of osteotomes. This can be achieved by the use of a simple
narrow rongeur or the use of a high-speed burr. After attempted
circumferential disruption of the xation interface surrounding
the humeral prosthesis, a round or square bone tamp can be
placed on the undersurface of the humeral component collar
and the prosthesis can be malleted out in a retrograde fashion
(Fig. 4A and B). Due to the high tensile forces placed on the bone
during removal, there is a high risk of fracture and careful
inspection for cortical perforations should take place during this
portion of stem extraction.
Another method commonly used to extract a well-xed
humeral stem is the use of a vertically directed humeral
osteotomy (VHO). This technique and its associated clinical
results have been well described by Van Thiel et al. [15]. This
method includes the use of a standard deltopectoral
approach to the shoulder and the use of either a subscapularis tenotomy or a lesser tuberosity osteotomy to provide
access to the glenohumeral joint surface. Soft tissue and
hypertrophic bone is then cleared free from the undersurface
of the implant collar and the prosthetic humeral head is

Figure 4 (A and B) Dis-impaction of the stem with the use of

long bone tamp placed underneath the implant collar. (Color
version of gure is available online.)

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Figure 5 Location of a vertically directed humeral

osteotomy (VHO) (slotted line). (Color version of gure is
available online.)

removed. A 1/4 osteotome is then placed around the proximal aspect of the humeral stem in a circumferential fashion
to disrupt the associated proximal sites of xation. Electrocautery is used to mark a vertically directed linear osteotomy
extending, on average, approximately 10 cm from the proximal aspect of the humerus (this depends on the length of the
humeral stem) (Fig. 5). The osteotomy is located in the dense
cortical bone of the lateral margin of the biceps groove
between the anterior margin of the deltoid and the lateral
most margin of the pectoralis insertion. A small oscillating
sagittal saw is then used to create the osteotomy and should
extend through the cortical bone and the underlying cement
mantle down to the underlying implant. Small osteotomes
are then placed in the osteotomy site in a vertical direction
and gently twisted to open the osteotomy site like a book
until a gap is created around the underlying implant. Signicant hoop stresses are created during this portion of the
procedure and care should be taken to ensure that fracture of
the contralateral cortex does not occur. A small laminar
spread may be used to hold the osteotomy site open while
attention is turned toward further disruption of the cement
mantle. A bone tamp is then placed underneath the previously cleared collar and the implant is malleted out from the
humerus. Van Thiel et al. [15] retrospectively reviewed 23
patients who underwent a VHO for extraction of a well-xed
humeral stem in the setting of revision arthroplasty with a
mean follow-up of 41 months. Patients were undergoing
revision arthroplasty for a variety of indications, which
included infection, glenoid component loosening, glenoidbased pain associated with hemiarthroplasty, and recurrent
shoulder instability after total shoulder arthroplasty. In this
series, there were 14 cemented and 9 uncemented humeral
components. There were no perioperative or postoperative
fractures noted on serial postoperative radiographs, and at
nal follow-up, the average ASES score was 64.7, simple
shoulder test was 6.3, and VAS pain scale was 1.3.
Another method of removal of a well-xed humeral stem is
the utilization of a cortical window as described by Sperling

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and Coeld [16]. In their series of revision arthroplasties using

an anterior cortical window, a deltopectoral approach was
used in the majority of cases and the subscapularis tendon
was managed via a tenotomy or lesser tuberosity osteotomy.
Wide, circumferential exposure of the proximal humerus was
obtained prior to completion of the osteotomy. The level and
size of the cortical window was determined based on the
needs of the individual case as determined by the distribution
of the cement or the location of the ingrowth surface,
location of bone deciency, and the anticipated length of
the revision stem desired.
The cortical window is created using a combination of an
oscillating micro-sagittal saw and a series of straight and
curved 1/4 and 1/2 osteotomes. The anterior window most
commonly starts just distal to the metaphyseal are of the
proximal humerus with its medial extent being located
within the dense cortical bone of the biceps groove. The
width of the window is on an average approximately 1.52 cm
and extends lateral to the lateral extent of the biceps groove
(Fig. 6). The length of window is determined by how much
distal access to the humeral diaphysis is required. Once the
cortical window is created, the cement mantle or distal
xation surface should be readily accessible. Once this interface is disrupted, a bone tamp can be used to mallet the
implant from the humerus. The cortical window is then
replaced and an attempt is made to reduce this piece
anatomically to the native humerus. The bony fragment is
then xed using either heavy (#5), non-absorbable suture
through drill holes or using circumferential cerclage cables/
wires.
Sperling and Coeld retrospectively reviewed 20 patients
who underwent an anterior cortical window in the course of
revision shoulder arthroplasty [16]. In their series, 17 patients
had fully cemented humeral stems and 3 patients had fully
textured press-t humeral components. There were 4 intraoperative fractures noted, with 3 fractures occurring in the
humeral shaft and 1 greater tuberosity fracture. All fractures
occurred during implant extraction. Average follow-up was
3.3 years (range 3176 months) and demonstrated that 17 of

Figure 6 Location of an anterior cortical window

(slotted line). (Color version of gure is available online.)

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20 patients had radiographic union of their cortical window.

The 3 patients that did not have radiographic union had
limited radiographic follow-up (1, 3, and 4 months). None of
the patients who underwent replantation of a humeral
component developed clinical loosening, and only 2 patients
developed radiographic evidence of implant loosening. The
authors concluded that utilization of an anterior cortical
window represents a viable technique for humeral implant
extraction when more distal xation is present. However,
they recommended exercising caution during implant extraction as creation of the cortical window creates a stress riser,
which predisposes to humeral fracture.
Deep prosthetic joint infection often necessitates explantation of the humeral component and complete removal of
associated cement when present. Utilization of ultrasonic
cement extraction devices has been extensively reported in
the total hip arthroplasty literature with excellent success
[17]. These devices create dynamic stress waves centered at
the tip of the device, which when placed in polymethylmethacrylate (PMMA) generates heat that preferentially melts
the cement mantle [18]. The authors have found that the use
of this device is particularly helpful when addressing the
distal cement plug. Alternative use of sharp tipped reamers,
drills, and gouges may lead to inadvertent and potentially
unrecognized cortical perforation. Furthermore, the use of
humeral osteotomies or cortical windows in order to extract
cement may add to the time and morbidity associated with
the revision surgery. The use of ultrasonic cement extraction
devices allows the distal cement plug to be melted and
removed in a stepwise fashion. Once the more distal aspects
of the canal are accessed, cement hooks and assorted chisels
from a revision total hip arthroplasty set (Moreland, Depuy,
Warsaw, IN) can be used to remove any remaining cement
from the medullary canal of the humerus.
Extreme caution should be exercised when using ultrasonic
cement extraction devices as these instruments can generate
extreme heat. As such, they should be turned on in a pulsed
fashion (23 s/use) to limit the duration of heat generated.
Furthermore, a constant ow of room temperature saline
from a bulb syringe should be used to help dissipate the heat
and cool the surrounding tissues while this cement extraction device is used.
A recent paper by Goldberg et al. demonstrated the dangers
associated with the use of the ultrasonic cement-extraction
device in the upper extremity [18]. In their review, a case was
presented of a patient who underwent explantation of a
cemented total elbow arthroplasty for infection. An ultrasound
device was used for cement removal. Postoperatively the patient
developed complete radial nerve palsy, in addition to a latent (2
weeks) postoperative humeral shaft fracture, at the site of the
humeral cement plug without any signicant trauma. The
patient was taken back to the operating room for xation of
her fracture, and at the time of surgery, widespread muscle
necrosis was noted in addition to a 6-cm attenuated and
thinned segment of radial nerve which corresponded to its
course along the spiral groove along the posterior humeral
shaft. No cortical perforations were noted. It is important to
note that no irrigation was used during the use of the ultrasound device and that a tourniquet remained inated during
cement extraction.

5.

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Conclusion

Due to the rising incidence of shoulder arthroplasty for the

treatment of both degenerative and post-traumatic conditions of the glenohumeral joint, the burden of revision
surgery will also continue to rise. A subset of these revision
procedures requires extraction of the humeral component.
This portion of the revision procedure is technically demanding and requires careful evaluation of preoperative radiographs, familiarity with the current humeral component, and
a variety of techniques that may aid in successful removal of
the humeral prosthesis. The use of exible osteotomes to
disrupt the prosthesis from the underlying bone or cement
mantle with dis-impaction of the component using a bone
tamp is the most common method used to remove a humeral
component as it attempts to preserve as much humeral bone
stock as possible and obviates the surgical morbidity of
humeral osteotomies. The use of a vertically directed humeral osteotomy or anterior cortical window is most appropriate when the xation interface extends distally and one must
gain access to this portion of the humeral component to
safely remove the prosthesis. The use of ultrasonic cementextraction devices may aide in removing the cement plug and
accessing the more distal aspects of the humeral canal.
However, this tool generates extreme heat and care must be
taken to prevent signicant bone and soft tissue damage.

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