J Shoulder Elbow Surg (2016) 25, 45-54

www.elsevier.com/locate/ymse

Allograft-prosthetic composite reverse total

shoulder arthroplasty for reconstruction of
proximal humerus tumor resections
Joseph J. King, MDa, Lukas M. Nystrom, MDb, Nickolas B. Reimer, MDc,
C. Parker Gibbs Jr, MDa, Mark T. Scarborough, MDa, Thomas W. Wright, MDa,*
a

Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA

Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
c
Emory Orthopaedics and Spine Center, Atlanta, GA, USA
b

Background: Proximal humerus reconstructions after resection of tumors are challenging. Early success of
the reverse shoulder arthroplasty for reconstructions has recently been reported. The reverse allograftprosthetic composite offers the advantage of improved glenohumeral stability compared with hemiarthroplasty for proximal humeral reconstructions as it uses the deltoid for stability.
Methods: This article describes the technique for treating proximal humeral tumors, including preoperative planning, biopsy principles, resection pearls, soft tissue tensioning, and specifics about reconstruction
using the reverse allograft-prosthetic composite. Two cases are presented along with the functional outcomes with use of this technique. Biomechanical considerations during reconstruction are reviewed,
including techniques to improve the deltoid compression force.
Results: Reported instability rates are less with reverse shoulder arthroplasty reconstruction as opposed to
hemiarthroplasty or total shoulder arthroplasty reconstructions of tumor resections. Reported functional
outcomes are promising for the reverse allograft-prosthetic composite reconstructions, although complications are reported.
Conclusion: Reverse allograft-prosthetic composites are a promising option for proximal humeral reconstructions, although nonunion of the allografthost bone junction continues to be a challenge for this
technique.
Level of evidence: Level IV, Case Report with Narrative Review, Treatment Study.
2016 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Reverse total shoulder arthroplasty; allograft-prosthetic composite; proximal humerus reconstruction; glenohumeral joint; tumor resections

The Western Institutional Review Board approved this study: No. 1112376.
*Reprint requests: Thomas W. Wright, MD, University of Florida,
Orthopaedic and Sports Medicine Institute, 3450 Hull Road, Gainesville,
FL 32622, USA.
E-mail address: wrightw@ortho.ufl.edu (T.W. Wright).

Limb-sparing resections of malignant tumors of the

proximal humerus pose reconstructive challenges. This is
largely due to the fact that the glenohumeral joint is
inherently unstable and requires an intricate static and dynamic stabilization system through the periarticular soft
tissues for function, much of which requires resection to

1058-2746/$ - see front matter 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2015.06.021

46
obtain a wide margin with bone resections. Many different
treatments have been suggested to manage these reconstructive challenges, including allograft arthrodesis,36
fibular autograft arthrodesis,6,43 clavicula pro humeri reconstructions,40 osteoarticular allografts,14,19,28 endoprostheses,5,6 and allograft-prosthetic composite (APC)
reconstructions.1,2,7
APC reconstructions offer the benefit of soft tissue
repair for enhanced stability combined with the durability
of a prosthetic articular surface. Classically, these have
been performed in an anatomic fashion with either a
standard stemmed hemiarthroplasty1 or a resurfacing
hemiarthroplasty. More recently, some investigators have
suggested the use of a reverse total shoulder prosthesis
combined with allograft10 as a reconstructive option.
The use of reverse total shoulder arthroplasty has classically been reserved for the elderly, low-demand patient.
We have used reverse shoulder arthroplasty in reconstructions of tumor resections in young patients, given
reports of excellent functional results. The experience at
our institution is that in carefully selected cases, the reverse
total shoulder APC reconstruction offers optimal function
and stability. The limited data regarding this technique
demonstrate encouraging results. The purpose of this paper
is to describe the surgical technique for reverse APC reconstructions in detail and to examine the biomechanical
considerations of this reconstructive option.

Biopsy
The process of staging a potential malignant tumor of the
proximal humerus should begin with physical examination
and appropriate imaging studies of the patient and is
completed with a biopsy of the lesion. The location of the
biopsy track must be carefully considered, as it must be
excised with the tumor at the time of resection, especially
for tumors with no effective adjuvant treatments. For tumors of the proximal humerus, we perform the biopsy
through the anterior third of the deltoid musculature, just
lateral to the deltopectoral interval. This allows preservation of the maximal amount of deltoid after resection of the
tumor and the biopsy track. The biopsy is done through a
small incision, adhering to general biopsy principles. It is
preferable that the surgeon performing the definitive
resection perform the biopsy.32,33

Preoperative planning
As part of the staging process, high-quality magnetic
resonance imaging is obtained. This should include the
entire humerus to fully evaluate the extent of the tumor
with respect to the resection length. Proximally, the T1
axial reconstructions should be scrutinized for margins with
respect to the axillary artery and vein, brachial plexus, and

J.J. King et al.

axillary nerve. Close inspection should be made of the
glenohumeral joint to ensure that tumor has not extended
into this space, necessitating extra-articular resection and
precluding the use of this technique.
Calculations should be made of the planned resection
length as well as of outer cortical and endosteal diameters
at the level of the planned resection. This information must
be communicated with the allograft provider. In addition,
we recommend that all tendon attachments be left on the
allograft as they are used to enhance glenohumeral stability.
An appropriate implant must then be selected to span the
allograft-host junction by a minimum of 2 cortical diameters. We prefer to span with as much length as possible
as afforded by the residual humerus and available prosthetic
lengths. In addition to arthroplasty implants, we recommend that the surgeon have available small and large
fragment plate and screw sets to apply a unicortical locking
plate for added rotational stability of the construct. Shortlength locking screws (10 mm or less) should be available
to achieve unicortical fixation, avoiding the intramedullary
stem and cement mantle.

Resection of the tumor

An ellipse is formed around the biopsy track along with the
skin incision (Fig. 1, A). The skin incision should extend
from the acromioclavicular joint toward the deltoid tubercle
and then in line with the anterolateral approach to the humerus. Specific anatomic aspects of the tumor dictate
certain portions of the dissection in each case. The deltoid
is split in line with the biopsy track so as to leave all
contaminated deltoid with the resected tumor. A carefully
planned biopsy should allow maximal preservation of the
deltoid. The dissection then is carried into the subdeltoid
bursa. The biopsy track is dissected down where it enters
the humerus (Fig. 1, B), and care is taken to avoid avulsion
to the biopsy track from the proximal humerus.
The axillary nerve is identified by palpation along the
inferior aspect of the subscapularis. The subscapularis and
pectoralis are tenotomized from the proximal humerus,
leaving a safe margin. The anterior capsulotomy is performed with the subscapularis takedown. The remaining
rotator cuff muscles as well as superior and posterior
capsule are identified and transected, leaving a safe margin
but preserving the maximum length possible. The long head
of the biceps is tenotomized at the rotator interval. The
latissimus dorsi and teres major should then be identified
and transected with a safe margin. The axillary nerve is
protected and the inferior capsule released from the humerus. This should completely deliver the proximal humerus from the glenoid.
The dissection is then carried distal as far as the tumor
requires on the basis of preoperative planning. If possible,
the deltoid insertion should be preserved. If the deltoid
insertion cannot be spared because of tumor involvement, it

Allograft-prosthetic composite reverse total shoulder arthroplasty

47

Figure 1 (A) Photograph of the patient positioned in the beach chair position with the hydraulic arm positioner. The skin incision with
the ellipse of the biopsy track is demonstrated. (B) Intraoperative photograph of the dissection of the mass while the biopsy track is
maintained.

Figure 2 Photograph demonstrating the en bloc resection of the

chondrosarcoma.

is best to preserve as much of the tendinous insertion as

possible for later repair. The radial nerve should be identified and carefully protected posteriorly where it passes
between the medial and lateral heads of the triceps, which
will need to be released of the humerus. Once the desired
level of resection has been encountered, the humerus is
carefully subperiosteally dissected, while the radial nerve
has been visually protected. A saw is then used to osteotomize the humeral shaft with Bennett retractors placed
circumferentially to protect surrounding structures. The
tumor and biopsy track can be passed off the table en bloc
(Fig. 2). In performing the osteotomy, great care is taken to
ensure a perpendicular cut. Intraoperative consultation with
a pathologist must then be sought to ensure wide margins.

Figure 3 Intraoperative photograph demonstrating the inferior

aspect of the baseplate guide aligning with the inferior glenoid to
assist with pilot hole placement in preparation for glenoid reaming.

Glenoid preparation
The entire glenoid surface is exposed by excising the labrum,
which is often normal in the situation of tumor resections.
Releasing the entire capsule from the glenoid is not necessary
because of the excellent exposure afforded by the proximal
humeral resection. By use of the glenoid baseplate guide
aligned with the inferior aspect of the glenoid (Fig. 3), a pilot
hole is marked. In reverse shoulder arthroplasty designs with
a lateralized center of rotation, placement of the glenosphere
on the inferior edge is not required (Fig. 4). Minimal reaming
of the glenoid cartilage is then performed to avoid reaming of
the strong subchondral bone. Ream slightly more inferiorly
than superiorly, taking care not to ream the subchondral

48

J.J. King et al.

Figure 5 Center cage hole drilled in the glenoid with preferential

inferior placement, which is specific to the implant in Case 2.

Figure 4 Postoperative anteroposterior radiograph at 18 months

demonstrating a nonunion at the host boneallograft boneallograft
junction, with more superior glenoid placement that is specific to
the implant in Case 1.

bone, so that the baseplate is tilted inferiorly. A center cage

hole is then drilled, which is specific to the implant used in
this case (Fig. 5). The baseplate is then press-fit into position,
followed by placement of at least 4 glenoid screws (prosthesis dependent). A combination of compression and locking screws is preferred to increase implant stability. Some
implants have compression screws with subsequently placed
locking caps to enhance baseplate fixation to the glenoid
(prosthesis dependent). The glenosphere is then engaged on
the baseplate. Consider using a lateralized glenosphere if
there is deltoid loss or concern for deltoid dysfunction.
Lateralization of the glenosphere will also lateralize the
humeral component, creating a more compressive force from
the deltoid. This is an important consideration, especially if a
portion of the lateral deltoid required resection.

Humeral preparation
The allograft humeral head cut is made in the standard
fashion on the back table. The resection length of the native
proximal humerus is measured or estimated. Cut the
proximal humeral allograft distally approximately 1 cm
longer than the measured resection length. Care is taken to
make a perpendicular osteotomy. Resection of the purposely long allograft is favored over adding length to the
proximal humeral component if length is needed. Sequentially ream and then broach the allograft while holding it
with a vise grip or Lane clamp. Knowing the available
component lengths and sizes is essential. Ream and broach

to allow a minimum 1-mm cement mantle in the allograft.

We then over-ream the allograft compared with the host
bone to allow a better fit at the host boneallograft junction.
After allograft preparation is performed, ream the native
distal humeral canal. We prefer to cement the stem into the
host bone; alternatively, cementless fixation can be used,
and in this case reaming should be performed appropriate to
that technique. Place the humeral trial prosthesis in the
allograft with the smallest humeral liner. Place the trial
APC in the native humerus. Assess soft tissue tension and
ability of reduction. If this construct appears to have
excessively lengthened the humerus, additional allograft
should be resected from the distal margin and the construct
should be reassessed. If the construct is too loose, humeral
height can be added by adjusting the height of the proximal
humeral liner. Full assessment of stability may be difficult
because of minimal rotational control with the trial, but the
proximal to distal tension can be assessed.
Before construction of the APC implant, the humeral
allograft is affixed to the native distal humerus using a
unicortical plate in compression mode followed by locking
mode. If there is a concern for malalignment of the
perpendicular bone cuts before placement of the plate, either
the allograft or the native bone is recut. This allows
compression and appropriate alignment of the host
boneallograft junction. The screws in the allograft bone are
then removed and replaced later during final reconstruction.

Reconstruction of the proximal humerus

Once the stability and soft tissue tension appear to be
appropriate, reconstruction of the proximal humerus is
performed. If there is a concern about stability, you can
assemble the APC using the implantable stem and trial
humeral adapter/liner.

Allograft-prosthetic composite reverse total shoulder arthroplasty

49

Figure 6 Construction of the reverse APC on the back table.

The prosthesis is cemented into the allograft, and care has been
taken to ensure that cement is free of the osteotomy site.

Thoroughly irrigate the entire wound, the distal humerus,

and the APC. Place a cement restrictor so there will be
another 1 cm of cement distal to the stem in the native bone.
Construct the final prosthesis or final stem and trial humeral
liner. Cement the final stem into the allograft and then cement
the APC in the distal humerus using standard cement pressurization techniques while the cement is still soft (Fig. 6).
About 1 cm before the component is fully seated, remove all
excess cement as well as some cement distally within the
canal to prevent further cement from invading the junction.
Compress the APC into the native humerus with the appropriate proximal humeral retroversion. Replace the screws in
the allograft section of the unicortical plate while the cement
is hardening (Fig. 7). Test stability with a standard shuck test
as well as impingement in external rotation and extension.
Modular proximal humeral components can still be changed
at this point if necessary to increase tension as needed. In this
technique, the unicortical plate neutralizes the rotational
forces and enhances compression at the host boneallograft
junction. We routinely use vancomycin in the cement for
massive allograft cases.
This described technique is a change of our previously
used technique. We changed our technique because the first
2 cases (presented in this manuscript) had a nonunion in the
host boneallograft junction. Previously, we cemented the
allograft to the stem (no over-reaming) and allowed this to
harden, followed by cementation of the APC construct to
the native humerus. In our previous technique, the unicortical plate was also placed after the cement hardened,
which prevented any compression at the host
boneallograft junction. We currently use the cementation
and plating techniques described in this manuscript.

Soft tissue reconstruction

If any of the native rotator cuff tendons are intact and
compliant, we repair the native tendons to the allograft tendons using interrupted nonabsorbable suture in a horizontal
mattress fashion (Fig. 8, A and B). Repair of any of the
external rotators as well as of the subscapularis will help with
functional rotation and stability. Whereas the posterior

Figure 7 Reconstructed proximal humerus with unicortical

locking plate added for rotational control.

rotator cuff tendons are difficult to visualize after reduction of

a standard reverse shoulder arthroplasty, given the large
dissections required in APC reconstructions, the posterior
rotator cuff is easily accessible for reconstruction (Fig. 8, B).
Latissimus dorsi transfer is an option to help improve
shoulder external rotation if the posterior rotator cuff tendons
were sacrificed with the resection. The deltoid will allow
abduction and forward elevation. If the deltoid insertion has
been fully resected, it is then anchored into the allograft at the
appropriate length using suture anchors. We do not repair the
pectoralis major tendon because of the risk of an adduction
contracture. The superficial muscle layer should then be
repaired with interrupted absorbable sutures to decrease the
potential space to reduce the chance of hematoma formation.

Rehabilitation protocol
Postoperative rehabilitation consists of a sling for at least 6
weeks. We allow sling removal for hygiene and elbow
range of motion. Passive range of motion is delayed until 6
weeks. Active range of motion is delayed until 12 weeks. If
the deltoid is taken down, an abduction pillow is used for 8
weeks. The patient is advised to do no lifting over 2 pounds
until 3 months at the earliest or until healing at the allograftnative bone junction is seen.

Cases
Case 1 is a 22-year-old woman who underwent a massive
allograft-prosthetic reconstruction with a reverse shoulder
arthroplasty for osteosarcoma on her nondominant arm.
Resection length of the proximal humerus was 11 cm with

50

J.J. King et al.

Figure 8 (A) Intraoperative photograph demonstrating the reduced APC and soft tissue repair of the native supraspinatus and infraspinatus tendons to the allograft tendon stumps. (B) Close-up view demonstrating the soft tissue repair of the native cuff tendons to the
allograft tendon stumps.

negative margins. Subscapularis and infraspinatus tendons

were repaired, and the latissimus was transferred to allow
external rotation. The anterior third of the deltoid was
resected with the biopsy track. A nonunion developed
postoperatively (Fig. 4). She underwent a revision open
reduction and internal fixation of the host boneallograft
junction with allograft strut and Dall-Miles cables at
18 months postoperatively. At 7-year follow-up, she had no
glenoid or humeral loosening on radiographs (Fig. 9).
Case 2 is a 40-year-old man who underwent a massive
allograft-prosthetic reconstruction with a reverse shoulder
arthroplasty for chondrosarcoma on his nondominant arm.
Resection length of the proximal humerus was 14.5 cm with
negative margins. Intra-articular resection was performed
with the native rotator cuff tendons and axillary nerve intact.
A significant amount of anterior deltoid was removed along
with the biopsy track. He developed a nonunion at the host
boneallograft junction 6 months postoperatively (Fig. 10,
A) and underwent revision open reduction and internal fixation with a 6-hole unicortical plate, strut allograft, and
viscoelastic cables. Autograft cancellous iliac crest bone
graft was also used at the nonunion site. At 18-month
follow-up after the initial reconstruction, the patient was
doing well despite an apparent fracture of the allograft
without known trauma (Fig. 10, B).
Functional outcomes were similar between these 2
consecutive patients. The average Simple Shoulder Test
score was 8.5. The average American Shoulder and Elbow
Surgeons score was 81.7. The average normalized Constant
score was 62.7. The average University of CaliforniaLos
Angeles score was 27.5. The average 12-Item Short Form
Health Survey score was 37. Case 1 had good active
shoulder range of motion: 108 forward elevation, 100
abduction, 5 external rotation, and internal rotation to T11.
Case 2 had similar active shoulder range of motion: 120
forward elevation, 90 abduction, 0 external rotation, and
internal rotation to T11. Both patients rated their pain 0 on
a daily basis. Neither patient had problems with sleeping.
One patient reported ability to work as normal and one

Figure 9 Postoperative anteroposterior radiograph at 7 years

after the initial reconstruction demonstrating healing at the host
boneallograft junction and incorporation of the strut allograft
after revision open reduction and internal fixation.

reported it as slightly difficult. Neither patient had any

issues with personal hygiene. Despite both patients undergoing revision open reduction and internal fixation of
the host boneallograft junction, the patients had good
postoperative function.

Discussion
Stability
The reverse shoulder arthroplasty lends improved stability
in tumor resection cases compared with the standard total

Allograft-prosthetic composite reverse total shoulder arthroplasty

51

Figure 10 (A) Postoperative anteroposterior radiograph at 6 months demonstrating a nonunion at the host boneallograft junction. (B)
Postoperative anteroposterior radiograph at 18 months after the initial reconstruction demonstrating a stable construct with fracture of the
strut allograft after revision open reduction and internal fixation.

shoulder replacement. Stability in an anatomic shoulder

APC reconstruction relies solely on native rotator cuff
tendon to allograft tendon healing for stability. In the case
of the reverse prosthesis, native soft tissue tension from the
conjoined tendon and the deltoid will provide stability. We
prefer to repair the rotator cuff tendons in a reverse APC
reconstruction if possible to try to obtain healing, which
can provide further stability and enhanced rotational function. Repair of the shoulder capsule to improve stability, as
described in APC reconstructions using total shoulder
arthroplasty or hemiarthroplasty,1,35 is not believed to be
necessary in reverse APC reconstructions.
Instability of anatomic shoulder reconstructions for
proximal humeral resections has been reported as a significant clinical problem, although to varying degrees.
Wang et al42 reported a 40% instability rate after reconstruction of proximal humerus tumors using APCs, endoprostheses, and osteoarticular allografts. High rates of
instability ranging from 28% to 76% have also been reported
in
conventional
endoprosthetic
reconstructions,11,35,38 although there are several series
describing a much lower rate.4,31,41 One study of 36 APC
reconstructions with total shoulder arthroplasty or hemiarthroplasty reported 1 dislocation and 5 with superior
humeral head migration (17% instability rate) despite
meticulous soft tissue reconstruction.2 van de Sande et al41
reported an 80% rate of proximal migration of the humeral
head in patients treated with anatomic proximal humerus
APC reconstructions.

In reviewing the available literature for instability in

reverse reconstructions, early instability of reverse APC
reconstruction has been reported in 1 series, but no
instability was present at final follow-up at an average of
7.7 years with conservative treatment.15 A second study
reported a dislocation rate of 10% in 10 patients with
reverse shoulder arthroplasty after tumor resections.27
Another series evaluating reverse APC reconstructions
for revision shoulder arthroplasty performed for proximal
humeral bone loss reported an 8% instability rate; however, no patients in this series were treated for reconstruction of a tumor resection.12 A recent series of 10
patients with reverse proximal humeral reconstructions (2
APCs, 3 proximally coated with cement, and 5 uncoated)
reported a 30% dislocation rate, which is the highest rate
in the reverse shoulder arthroplasty for tumor reconstruction literature.10 One series of 18 reverse proximal
humeral endoprosthetic reconstructions reported a 22%
instability rate.39 None of these studies reported on lateralized glenosphere or lateralized humeral component
implants.
With regard to reverse total shoulder reconstruction,
lateralization of the center of rotation or lateralizing the
humeral shaft compared with the proximal humeral
component increases the compression of the humeral
component on the glenosphere, which increases prosthesis
stability.24,26 These improvements in design help prevent
impingement and theoretically reduce the possibility of
dislocation.

52
Humeral lengthening also increases the construct stability.9,29 This can be accomplished by any combination of
placing the baseplate inferior on the glenoid, increasing the
humeral height on the prosthesis, or incorporating a longer
allograft segment than was resected. Additional stability
can be achieved with increasing constraint of the polyethylene liner. Whereas increasing humeral liner constraint
lends improved stability at lower arcs of motion,24 earlier
impingement is seen that can lead to dislocation at smaller
maximal arc of motion compared with a less constrained
liner.26
Subscapularis repair is also important in the anterior
stability of the reverse prosthesis,16 especially if there is
deficiency of the anterior deltoid that has been shown to
increase forces on the subscapularis.22 Repair or reconstruction of the subscapularis should improve anterior stability in a reverse APC reconstruction.

Function
Historically, anatomic endoprosthetic or APC reconstructions of the proximal humerus have had limited
functional success. The best reports of active abduction and
forward elevation have been limited to 90 .15 Mean active
abduction with an intact deltoid was 72 in another study of
anatomic APC reconstructions.2
De Wilde et al report improved functional outcomes of 9
patients who underwent reverse APC reconstruction for
bone tumors with average active abduction of 157 .15 One
study of 10 reverse shoulder arthroplasty reconstructions
after tumor resections reported average abduction to 78 ,
forward elevation to 98 , and external rotation to 32 .27 In a
study of reverse APCs for failed arthroplasty, postoperative
flexion improved to 82 from 33 .12 Another study of 10
reverse shoulder arthroplasty reconstructions after tumor
resection with 2 being APCs and the rest using a proximal
cement mantle or no proximal fixation reported mean active
elevation to 122 , external rotation to 2 , internal rotation
to L4, and normalized Constant score of 61%.10 Function
after reverse endoprosthetic reconstruction is promising
with abduction to 80 , elevation to 84 , and external rotation to 35 in 13 patients with a functional deltoid.39 Some
authors also advocate transfer of an intact teres major or
latissimus dorsi to the reverse shoulder arthroplasty after
proximal humeral resection if the infraspinatus and teres
minor are resected with the tumor.38
Impingement-free range of motion is also an important
consideration in regard to ultimate function as well as
stability. Inferior baseplate placement and inferior baseplate tilt will help prevent an adduction deficit due to
inferior impingement.23,34 Larger diameter glenospheres
have been shown to increase the impingement-free arc of
motion in the Grammont-style implants.13,37 In addition,
lateralization of the component has been shown to increase
the impingement-free arc of motion.23,25 These techniques,

J.J. King et al.

which avoid scapular notching, are also important as this
can lead to glenoid lucent lines30 and ultimately glenoid
baseplate loosening.
Remaining rotator cuff function will lead to improved
function in reverse shoulder arthroplasty. Even with a fully
functioning deltoid, external rotation is weak in a reverse
shoulder arthroplasty without functioning external rotators.
Restoring function of the teres minor or infraspinatus will
provide improved active external rotation function as has
been shown in primary reverse shoulder arthroplasty.9
Alternatively, a latissimus dorsi transfer to the greater tuberosity may help improve active external rotation if the
rotator cuff tendons cannot be repaired.8,18,20 Subscapularis
repair or reconstruction may lead to improved active internal rotation strength. A cadaver model of reverse
shoulder arthroplasty demonstrated significant moment
arms for external rotation in the infraspinatus and teres
minor and for internal rotation in the subscapularis,3
although the external rotation moment arm diminished
beyond 30 of abduction. Another biomechanical study
established that center of rotation lateralization maintained
rotational function of the subscapularis and teres minor in a
primary reverse shoulder model.21 The importance of these
biomechanical considerations as applied to the reverse APC
reconstruction in massive resections for malignant tumors
is unclear and is likely a factor of the quality of soft tissue
repair.

Nonunion
Nonunion continues to be a problem with the reverse APC
reconstruction of the proximal humerus. Nonunion has
been reported as the most common complication in
allograft-prosthetic reconstructions in 1 study.17 To try to
prevent nonunion, several options or a combination of options may be employed: the use of a longer unicortical plate
to help with rotational control, the addition of autograft
bone graft to help the biology, the use of step cut instead of
a perpendicular cut, and the addition of a strut allograft
with cables or cable plate to decrease the stress at the host
boneallograft junction. At our institution, we have elected
to change our reconstruction technique to use the unicortical plate as a compression and locking plate by placing
it before cementation using compression mode, taking it off
of the allograft, and replacing it while the cement is hardening in both the allograft and host bone as described in
this technique paper to decrease the chance of nonunion.

Pearls and pitfalls

1. Do not compromise the tumor resection for functional
or reconstructive considerations.
2. Consider using a lateralized glenosphere in cases with
partial deltoid resection or possible axillary nerve
dysfunction. A lateralized glenosphere will also

Allograft-prosthetic composite reverse total shoulder arthroplasty

3.

4.
5.

6.

7.

lateralize the humerus and improve deltoid tension. It

will also increase the deltoid compressive forces at the
glenohumeral joint.
Repair any rotator cuff tendons that can be repaired.
Subscapularis is important for anterior stability as well
as for internal rotation. Infraspinatus and teres minor
are important for external rotation.
Deltoid tendon repair to the allograft is key when using
a reverse APC.
Place the glenoid component inferiorly on the glenoid
with slight inferior tilt and allow inferior overhang to
prevent notching, adduction impingement, and possible
glenoid component failure.
Make sure to avoid any cement in the allografthost
bone interface. Because nonunion is a common
complication with APC reconstructions, one may
consider the addition of autograft bone graft to the
allografthost bone junction to help prevent nonunion.
Using a unicortical locking plate is important for
rotational control. We recommend placing the unicortical plate before full implantation in compression
mode followed by locking mode to maximize
compression at the host boneallograft junction. Allograft screws in the plate are removed and then replaced
using the final reconstruction before the cement
hardens.

Disclaimer
The authors, their immediate families, and any research
foundation with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.

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