Cement That Shoulder? John W. Sperling and William H Seitz, Jr. Debate

In the Crossfire this week is a very sticky topic—cementing that shoulder replacement. Says John W. Sperling “If we look over all the literature one can see that cement fixation is frankly not necessary.” Not so fast says William H. Seitz, Jr., “Cement has become the gold standard and there are new designs and new techniques and we also have new techniques for cementing as well.” It’s a lively and informative debate, for sure.

This week’s Orthopaedic Crossfire® debate was part of the 16th Annual CCJR – Spring meeting, which took place in Las Vegas this past May. This week’s topic is “The Non-Cemented Humerus: The Optimal Hybrid Solution.” For the proposition is John W. Sperling, M.D. from the Mayo Clinic in Minnesota. William H. Seitz, Jr., M.D. of the Cleveland Clinic in Ohio is in opposition. Moderating is Thomas P. Sculco, M.D. from the Hospital for Special Surgery.

Dr. Sperling: We know, of course, that there’s a very low rate of humeral component loosening and there are significant challenges associated with trying to remove a failed humeral component that has been cemented in place. If we look over all the literature one can see that cement fixation is frankly not necessary. Literature shows us that there is a very low rate of loosening of ingrowth or press fit humeral components. At our institution, we looked at a large number of patients that underwent total shoulder arthroplasty and then subsequently how many patients required revision on the humeral side. Out of over 1, 500 shoulder replacements the rate of isolated humeral loosening was essentially 1%. So incredibly rare. At our institution if we see a loose humeral component, we consider it infected until proven otherwise. It’s that uncommon. What that study also showed is the need for revision was very uncommon and it was either related to infection or if the humeral component did need to be removed, it was to gain access to the glenoid itself.

In my practice, I think removing cemented components is one of the real challenges for me. You really risk significant destruction to the humerus. I think the analogy is trying to remove cement from the humerus is like trying to remove concrete from an ice cream cone due to the very thin nature of the humeral cortices.

In my practice, I would say 99% to essentially 100% of patients get an uncemented component. Even in the fracture setting now I’ve gone to using an uncemented component. I like to have ingrowth proximally, but polished distally, so if I have to remove the component, it’s very reasonable in that regard. At the end of the day I think the rate of humeral component loosening is very rare. I think what we want to do is think about the next step. What are we going to do if and when this component fails to be able to make future revision surgery easier.

Dr. Seitz: Cementation, in my mind, is preferable in terms of setting the head height properly. Especially in fracture work. Trabecular metal may have a theoretical medical advantage for having tuberosity healing but it also has some very rigid ingrowth. There is variety of types of surface treatments such as HA to provide additional ongrowth, which can be effective. But in the 64 years since shoulder replacements have been done, we went from using press fit and when they were loose to using cement, and cement has become the gold standard for many years. A well-fixed implant which is press fit can be just as difficult to remove as one that’s cemented with all of the same techniques. So where are we? There have been a number of cadaver studies…Harris and Jobe showed that full cementation with proximal cement is better than press fit. Peppers and Jobe demonstrated the same thing in terms of axial micro-motion in laboratory studies. And it worked…distal canal fill with cement is much stronger in these biomechanical studies. Torchia and Cofield from the Mayo Clinic demonstrated that implant/bone radiolucent lines were present in 70% of uncemented humeral stems and 40% demonstrated a shift in position.

So if you fill well distally and you have a good cement mantle, even in the rheumatoid and fracture patients, you’re able to get very good stability.

I do believe that uncemented stems are appropriate in younger patients. I think they’re a good idea. With some of the partially treated surfaces they can be easier to remove, but if there’s any doubt in my mind in patients with questionable bone stock, I will cement them.

On the other side of the joint, I will do press fit implants using a tantalum porous implant because it significantly shortens the operative time, there is much less prep, and it provides for an easier revision if you have to do a revision. We’ve looked at 76 cases of patients with more than two-years of follow-up and we’ve seen no lucent lines. There was one first generation keel fracture, and when we went in the tantalum still in the bone looked and functioned like bone, and was easy to revise.

So in my mind the cemented stem and a trabecular metal glenoid is the ideal hybrid for the patient with adequate bone stock on the glenoid side, but frequently somewhat less adequate bone stock on the humeral side.

Moderator Sculco: Okay, there you have it good arguments on both sides. John, you get in on a shoulder and you cut through the humeral neck and the bone is just so soft. You put the trial in and it’s just mush. You going to proceed with a non-cementedstem?

Dr. Sperling: No problem. I think we’ve learned from our hip and knee colleagues in that regard, so for me I would use the proximal humerus as bone graft, if necessary. As long as I get a tight fit proximally that’s all I care about in that regard. A number of us have shifted over completely to uncemented stems in that regard. Even in those circumstances, being able to bone graft that and having appropriate sizes, you can work your way up or down in terms of stem size.

Moderator Sculco: Isn’t it sometimes you just end up with such a huge metal mass in some of these in order to get any kind of press fit? The cortices are thin, the bone is very osteoporotic. The implant looks just huge in comparison to the patient. What’s your thought on that?

Dr. Sperling: We’re very fortunate in the shoulder. For a while, frankly, we were pretty far behind the hip and knee surgeons in regards to the technology we had available. But I think now most systems out there have a real wide breadth of different stems widths available where you can go ahead and get a press fit proximally. That’s what I’ve gone to under those circumstances. In my practice, the worst revisions are trying to remove those cemented components. So we like to think about what am I going to do next if there’s a problem.

Moderator Sculco: Would you ever cement a humeral component? When have you cemented a component in the last year? And why?

Dr. Sperling: I haven’t cemented a humeral component in an osteoarthritic patient in probably the last eight years. I would think in a fracture patient if there was an issue where I had to maintain rotational control and height control and there was an issue, but a straight-forward total shoulder arthroplasty, a 24-year-old male or a 96-year-old woman, uncemented component.

Moderator Sculco: Problems like subsidence are less of a problem because you’ve got the humeral head sort of blocking subsidence. What about rotational control? It seems like these things could spin. Is that a problem at all?

Dr. Sperling: It hasn’t been a problem thankfully; again I think the stresses on the shoulder are less than on the hip or knee, so it’s more forgiving in that regard. I think what we’ve seen across a variety of different authors and different systems, thankfully the rate of loosening is very low.

Moderator Sculco: What about removing a non-cemented stem? Sometimes proximally may have no bone left it’s well ingrown.

Dr. Sperling: That’s exactly right. It depends on the component. If there is ingrowth proximal and polishing distally, the stem can be relatively straightforward to remove. But you’re exactly right. If it’s textured all the way down, sometimes it will be press fit at the very bottom, it can make it very difficult to remove.

Moderator Sculco: Okay, Bill, let’s go to you now. John has presented a very powerful argument here for non-cemented stems. Do you ever use a stem without cement?

Dr. Seitz: Yes I do. I use it in patients who are young and active and have very good cortices where I’m not concerned about their ability to heal and bond to the bone. I think that we’ve moved away from a process of doing good technique in cementing for the sake of saying it’s easier to just bang in a press fit stem and therefore you don’t have to deal with cement and so forth. A poorly cemented implant is just as bad as a poorly press fit implant. And the revisions reflect that.

Moderator Sculco: In the hip, of course, we’ve started to do hybrid fixation and we’ve evolved more to non-cemented femoral fixation. Do you find that you are non-cementing more humerus? Are you moving more in that direction? Are you still pretty much a cemented humeral component guy?

Dr. Seitz: My patient population tends to be older and the bone stock is not so good. I don’t get a tremendous number of very young, 50-60 year olds that require replacements. Most of them are more frail. They have poorer bone stock. I want to do one operation, so in that older age population with less robust bone, I will use cement most of the time.

Moderator Sculco: Do you use the same technique that John talked about—cement-within-cement if you have to revise one of these…

Dr. Seitz: Yes, yes. Obviously in the non-infected situation.

Moderator Sculco: And you use a cement plug in these cases or not?

Dr. Seitz: I do use a cement plug in the primaries. Not in the cement-within-cement.

Moderator Sculco: So there we have it. I think it’s been a great discussion. You can take back to your practices either cementing or non-cementing. I think there is an argument for both of them. Congratulate the speakers for a great discussion.

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