Proximal years; consequently, the frequency of revision

Proximal Humeral reconstruction in patients with
massive bone loss is a challenging procedure due to difficulties in
reconstruction of large skeletal defects, replacing the low quality bone(1), maintaining post-operative component  fixation and prosthetic stability(2). Disruption of rotator cuff attachment and stripping
of surrounding soft tissue coupled with alteration of the deltoid tension due
to changes in humeral length make reconstructive surgery technically demanding
in order to restore shoulder functions(3). Custom-made endoprosthetic replacement was first
introduced in 1943 for proximal femoral reconstruction after wide excision of
giant cell tumour in USA (4). The use of these implants was limited until late
seventies when it became the gold standard technique after excision of
osteosarcoma due to advances of chemotherapy protocols and development in new diagnostic
imaging techniques(5, 6). This allows orthopaedic oncologists to precisely
assess tumours extension within the bone and surrounding soft tissues(6). The wide use of endoprosthesis for reconstruction
after bone sarcomas excision helped the development of the modular systems that
enable surgeons to choose the optimum implant size for each patient(5). Modular Endoprosthetic replacement (MEPR) was implanted
to  provide a satisfactory solution in
limb salvage procedure after a wide excision of bone sarcomas, metastatic
lesions and aggressive benign bone tumours e.g., giant cell tumours with the
surrounding soft tissues when amputation was the only acceptable option(7). O’Connor et al. emphasised that limb salvage is
still emotionally preferred by the vast majority of patients despite the fact
there is an obvious reduction of limb functions compared to movements before
surgery(8). MEPR has recently become an option for
reconstruction after failed revision arthroplasties(9). The rates of
shoulder arthroplasty has risen dramatically throughout the last few decades
reaching approximately 2500 in the UK annually(10). Cofield R.
reported that 88% of the performed arthroplasties have survival rate of 10
years; consequently, the frequency of revision surgeries is expected to
increase (11, 12).  Bone loss
after failed arthroplasty can result from bone
resection in prosthetic infection, aseptic loosening, after removal of a
well-fixed prosthesis and peri-prosthetic fractures(13). Few studies in the literature are available about
the results of MEPR in revision arthroplasty as many orthopaedic surgeons
prefer to use other common techniques for reconstruction such as allograft and
leave MEPR as a last option(1). Indications for MEPR have been also expanded to
include patients with post resection osteomyelitis and  highly comminuted poorly vascularized
fractures particularly for elderly osteoporotic populations when non-union is
highly unexpected (1). Wirganowicz et al. classified modes of failure after
MEPR into mechanical and non-mechanical factors. Mechanical failure which trace
the abnormal relationship between prosthesis and surrounding bone and soft
tissue such as, aseptic loosening, periprosthetic fatigue fracture and failure
of  bony supporting structure. Despite
the fact that non-mechanical (biological) factors such as infection requires
implant removal or revision, it does not violate normal relationship between
prosthesis and surrounding tissues (14, 15). The majority of literature focuses on oncology limb
salvage survival and only a few reports the functional outcomes after proximal
humeral reconstruction.

The aim of this study is to review the underlying pathology
for massive proximal humeral bone loss, analyse the degree of pain relief
postoperative and report
clinical and functional outcomes and to review complications associated with
these types of prostheses.

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