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Unconstrained Shoulder Arthroplasty for Treatment of Proximal Humeral NonunionsSurgical Technique
Thomas R. Duquin, MD1; John W. Sperling, MD1; Robert H. Cofield, MD1
1 Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for R.H. Cofield: cofield.robert@mayo.edu
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Based on an original article: J Bone Joint Surg Am. 2012 Sep 5;94(17):1610-7.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2013 Apr 10;3(2):e7 1-10. doi: 10.2106/JBJS.ST.M.00001
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Anatomic unconstrained arthroplasty for the treatment of proximal humeral nonunion is challenging and may require management of rotator cuff tearing or scarring, glenohumeral instability, shoulder capsule fibrosis, poor bone quality and bone defects, and glenohumeral arthritis and may require internal fixation and bone-grafting for stimulation of healing.

Step 1: Preoperative Planning

Obtain anteroposterior, axillary, and lateral scapular Y views of the shoulder to assess the fracture for the size and position of the humeral head, humeral shaft, and greater and lesser tuberosities as well as for fracture nonunion.

Step 2: Positioning and Surgical Approach

In cases with substantial contracture or difficult exposure, use an anteromedial approach.

Step 3: Fracture Mobilization, Contracture Release, and Articular Assessment

For three and four-part fractures, secure the tuberosity fragments with strong sutures and then mobilize them from the articular fragment and the humeral shaft.

Step 4: Humeral Preparation and Trial Reduction

The tuberosity bone fragment should be reduced to the prosthesis with positioning 6 to 10 mm below the top of the humeral head component.

Step 5: Humeral Component Insertion

Fixation of the humeral stem usually requires cement, but avoid cement in the area of the tuberosity nonunion to help prevent necrosis of the bone resulting in further nonunion.

Step 6: Tuberosity Fixation and Bone-Grafting

To achieve tuberosity healing in anatomic alignment, reduce the tuberosities anatomically followed by bone-grafting and rigid fixation.

Step 7: Closure and Postoperative Rehabilitation

Patients use a shoulder immobilizer for six weeks, begin formal physical therapy at two to four weeks, and initiate a shoulder strengthening program at about ten to twelve weeks.


The management of proximal humeral nonunion is challenging and historically results have shown reasonable pain relief with limitations in function.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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