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47 (); 106-114
doi:
10.1016/j.jor.2023.11.029

Cement-within-cement technique in revision reverse shoulder arthroplasty: A systematic review of biomechanical data, and clinical outcomes

,
a Department of Orthopedic Surgery, Clinica Universidad de Los Andes, Santiago, Chile
b Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
c Independent Researcher, Rochester, MN, USA

∗Corresponding author: Ausberto Velasquez Garcia. velasquezgarcia.ausberto@mayo.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The purpose of this research was to systematically review and summarize the existent literature on the use of the cement-within-cement technique for revision reverse shoulder arthroplasty (RSA).

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed/Medline, Scopus, and EMBASE databases were searched for relevant studies. We included clinical studies in which patients underwent RSA revision using the cement-within-cement method for the humeral component, and studies that evaluated the biomechanical performance or described the surgical technique. The methodological risk of bias was assessed using the methodological index for non-randomized studies scale.

The search yielded 516 records, of which two clinical and one biomechanical study met the inclusion criteria, involving 133 patients and 20 synthetic humeri. The intraoperative complication rate was 18%, all of which involved humeral fractures. The postoperative complication rate was 18% among 35 patients. The combined re-revision rate was 9%, with a reported humeral component survival rate of 100% at 2 years and 96% at 5 years. Periprosthetic fractures (1.5%) and humeral stem loosening (1.5%) led to re-revision surgeries in all cases. All studies reported improved patient-reported outcomes and range of motion. The biomechanical study demonstrated increased rotational stability in models that used larger humeral stems.

The cement-within-cement method is a viable option for revision RSA, showing positive outcomes in terms of stability, range of motion, and clinical functional scores. The complication rate is similar to that of other revision strategies; however, the prevalence of intraoperative humeral fractures may be higher. Nevertheless, future studies with larger sample sizes and longer follow-up periods are needed to refine patient selection, determine the efficacy of long-term use, and identify factors that may influence outcomes after the cement-within-cement revision technique. Further research on an optimized stem fixation strategy is needed to improve outcomes and reduce avoidable complications.

Level IV, Systematic reviews.

Keywords

Cement-within-cement
Revision reverse shoulder arthroplasty
Humeral stem revision
Shoulder arthroplasty
Cement mantle retention
Intraoperative humeral fracture

1- Introduction

The number of primary shoulder arthroplasty procedures has increased considerably in recent years.1–3 These procedures are expected to increase by more than 300% between 2011 and 2030, even in young patient populations with a high risk of revision.3 The annual revision rate has increased annually, which will probably continue.1,3,4 Revision shoulder arthroplasty is technically challenging, expensive, and shows less predictable outcomes than primary surgeries.5–8 In recent decades, reverse shoulder arthroplasty (RSA) has gained popularity as an essential option for revision, and multiple studies have reported satisfactory outcomes.9–12

Several conditions such as proximal humeral bone loss, stem loosening, periprosthetic fracture, implant malposition, and medialization often require revision of the humeral component after prosthesis failure.13–16 Retaining the humeral component in convertible systems offers various benefits, but well-implanted and properly fixed stems are not always suitable for retention.13,17 In such cases, surgeons face the challenge of preserving the bone stock while providing a solid basis for humeral component revision, which is particularly demanding when removing a well-fixed cemented humeral component.18–20 This can result in substantial intraoperative bone loss, increased surgical time and fracture risk, and postoperative complications that may compromise the long-term results and implant survival.7,15,21–23

The cement-within-cement technique requires re-cementing a thinner and shorter stem on the preserved previous cement mantle, as described in 1978 for total hip revision arthroplasty.24 Cumulative clinical evidence has shown low perioperative complication rates and dislocations, leading to positive patient-reported outcomes (PRO) and a long-term track record of revision-free survival following hip surgery.25–27Furthermore, after initial conflicting results, newer biomechanical evidence shows that fatigue and aging of the pre-revision cement may not significantly influence the mechanical performance of the bonding strength at the cement-cement interface, supporting the use of this technique in hip revision surgery.28

When the cement mantle is intact and the risk of infection is low, the cement-within-cement technique may be used during revision RSA. This technique reduces the need for cement removal, potentially decreasing the associated risk of humeral bone stock compromise and radial nerve injury.29–31 However, the optimal patient characteristics and technical conditions for performing this approach have not been well established, and no systematic literature review has been conducted. Therefore, the purpose of this study was to systematically review and synthesize the literature on the use of the cement-within-cement technique for revision RSA, specifically with regard to optimal patient indications and surgical technique, clinical effectiveness, and biomechanical evidence supporting this approach.

2

2 Materials and methods

2.1

2.1 Eligibility criteria

Eligible articles written in English were included in this study, regardless of the level of evidence. The following criteria were used for inclusion: (1) clinical studies in patients who underwent revision RSA using the cement-within-cement technique for the humeral component, (2) studies that determined the biomechanical characteristics of the cement-within-cement technique using human samples or synthetic models, and (3) studies that described the cement-within-cement surgical technique. The minimal number of cases per study was not limited. Exclusion criteria involved studies irrelevant to the research and studies investigating revision procedures with cement-within-cement techniques but in joints other than the shoulder. Reviews, letters, book chapters, conference abstracts, unpublished manuscripts, editorials, and articles written in languages other than English were excluded.

2.2

2.2 Search strategy and selection process

This systematic review followed The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).32,33 We comprehensively searched 3 electronic databases: PubMed/Medline, Scopus, and EMBASE. Our search strategy included the following medical subject headings (MeSH) and free text terms: (1) "cement-within-cement" OR "cement-in-cement" OR "cemented revision" OR "cement augmentation" OR "mantle retention" OR "cement mantle" OR "cemented fixation" AND (2) " reverse shoulder arthroplasty" OR "total shoulder arthroplasty" OR "shoulder replacement" OR "shoulder joint replacement" (Supplementary file 1).

Articles from the database's inception to January 31, 2023, were included in this study. Two independent reviewers (AVG, KM) evaluated each article and considered it for inclusion. The screening process involved manual selection by analyzing titles and abstracts before the full-text analysis stage. Duplicate articles were eliminated and eligibility disagreements were resolved by consensus. Furthermore, we reviewed the citations of the included articles, reviews, book chapters, systematic reviews, and meta-analyses to identify other potentially relevant articles as additional search methods.

2.3

2.3 Data collection

Two reviewers (AVG and KM) extracted the data using a customized Microsoft Excel spreadsheet. Data extracted from the reviewers were compared to guarantee coherence throughout the process. When the studies stratified the population according to the diagnosis of radiographic humeral loosening, the results were analyzed separately, if feasible. Differences between the two spreadsheets were resolved through discussion.

2.4

2.4 Data items

The selected articles were classified into 3 relevant categories for data extraction: clinical, biomechanical, and surgical technique. The collected study information included but was not limited to authors, publication date, journal name, study design, level of evidence, number of patients and shoulders, age and sex, mean follow-up time, and surgical details. In clinical studies, the primary outcomes were implant survival rate, intraoperative and postoperative complications, overall perioperative complications, 30-day mortality rate, reoperations, re-revisions, and surgical time. Re-revision surgery was defined as the surgical removal of any bone-fixed prosthetic component, while reoperations involved any other type of surgical intervention.

Secondary outcomes included the number of patients with humeral stem radiolucency based on the postoperative anteroposterior radiographic findings reported in the studies. We also extracted radiographic data based on the reported thickness of periprosthetic lucency. There were 5 grades described; Grade 1: radiolucency less than 1 mm wide and incomplete; Grade 2: radiolucency 1 mm wide and complete; Grade 3: radiolucency 1.5 mm wide and incomplete; Grade 4: radiolucency 1.5 mm wide and complete; and Grade 5: radiolucency 2 mm wide and complete.29 Grade 4 or higher or evidence of subsidence was classified as "at-risk" components.29 When available, the location of periprosthetic humeral lucency was recorded according to the modified Gruen zone criteria for cemented humeral stems.34,35 We collected the results of radiographic assessments, including the filling ratio (defined as the area occupied by the humeral stem/combined areas of the stem and cement), cement layer area, and stem areas. The PROs, range of motion (ROM), and patient satisfaction were recorded. For biomechanical studies, the data items included biomechanical setup, model features, and loading forces. The primary outcome was rotational stability of the humeral stem under specific rotational load-to-failure conditions.

2.5

2.5 Risk of bias assessment

Two researchers (AVG, KM) evaluated the potential for bias in each study using the Methodological Index for Non-Randomized Studies (MINORS).36 MINORS assesses and rates studies by considering their research design and level of bias, with a top score of 24 for comparative research and 16 for non-comparative research. Elevated scores signify greater methodological rigor and decreased potential for bias. In cases where the reviewers had differing opinions, consensus was reached through discussion. We assessed the studies' evidence levels by applying the criteria set forth by Wright et al.37

2.6

2.6 Synthesis methods and effect measures

We used the κ statistic, as interpreted by Landis and Koch,38 to evaluate the level of agreement between raters in their selection of articles at each stage.39 Additionally, we used weighted means and standard deviations (SD) to synthesize demographic data and measure the effects of the outcomes of interest.

3

3 Results

3.1

3.1 Study selection

First, 516 entries were obtained from electronic databases. These entries were then transferred to Mendeley Desktop (version 1.19.8) to eliminate duplicate records and articles that were not written in English. In our analysis, 3 studies met the inclusion criteria: 2 clinical studies29,40 and 1 biomechanical study.41Fig. 1 shows the PRISMA search flow diagram. The agreement between the reviewers was almost perfect in the title and abstract stage (κ = 0.88, 95% CI 0.79–0.92) and perfect (κ = 1) during the stage of reviewing the full-text.

Prisma flow diagram of the literature search.
Fig. 1 Prisma flow diagram of the literature search.
3.2

3.2 Study characteristics

The biomechanical study included in this review was an in vitro experiment with 20 synthetic humerus models. The two clinical studies were retrospective case series involving 133 patients.29,40 The average age of the patients undergoing surgery was 67.2 years, and 43% were female.29,40 The average follow-up was 4.2 years. Fifty patients, constituting 39% of the sample, underwent radiographic rather than clinical follow-up. These research studies were released in the period spanning from 2017 to 2020 (Table 1).

Table 1 Characteristics of the studies included in the systematic review.
Authors Year Study period LOE Study Design Sample size No. Lost to clinical FU No. Age, years Mean ± SD (range) Female No. (%) FU, years Mean ± SD (range) MINORS
Biomechanical studies
Allen Gorman et al. 2020 – – Basic science 20 – – – – 19
Clinical studies
Wagner et al. 2017 2005–2012 IV Case series 38 9 70 (55–89) 24 (63) 3.7 (2–7) 10
Gorman et al. 2020 2004–2016 IV Case series 8a90 41 59 (43–77)a67 (28–90) 4 (50)a55 (61) 4.5 (2–13) 11
a Subgroup of patients with humeral stem loosening.
3.3

3.3 Risk of potential bias

The average MINORS score was 13.3 for the 3 included studies, ranging from 10 to 19. (Table 1).

3.4

3.4 Surgical details

Data regarding the reasons for revising the cement-within-cement technique, as well as the specific indications for such revisions, were not presented in any of the studies. Retrospective data gathering was conducted on individuals who had undergone a revision procedure in which the original cemented humeral component of their initial arthroplasty was replaced with a cemented reverse prosthesis. Furthermore, no details were available regarding the exclusion criteria for the patients analyzed in those studies.29,40 None of the retrieved studies were technical notes relevant to this research. The deltopectoral approach was used, and most humeral components were extracted using a simple extraction technique.29,40 Three of 133 revisions (2%) required anterolateral humeral windows to achieve implant removal, as reported in a single study.29 The type of primary implant removed was not reported in any of the studies.

Multiple culture tissue samples were used to rule out infection, but the proportion of positive cultures was not available.29,40 The primary cement mantle was roughened before cementation and implantation of the RSA revision components in all patients.29,40 A single study reported the use of several implants for the revision technique.29 A total of 38 implants were used in the revision technique, including 5 models from 4 different brands.29 A short and narrow humeral stem was consistently used for revisions in both included clinical studies.29,40

One study reported the use of allograft-prosthetic composites in 33 of 98 (34%) cement-within-cement revision cases for patients with extensive bone loss along the medial cortex. However, no further details were provided for this subgroup of patients.40 Another study used corticocancellous autografts to enhance stem fixation of the stem.29 The research articles examined in this study did not report details regarding the specific cementation method employed or its generation. The mean surgical time was 153 min (range, 84–280 min), based on 38 revisions.29

In a single biomechanical study, 20 Sawbones humeri (utilizing 4th Generation osteoporotic composite humeri with a solid foam cancellous core of 10 PCF, identified by model# 3404-4 and provided by Pacific Research Laboratories in Vashon, WA) were surgically implanted with a 12 mm stem during the initial procedure.41 These stems were then revised using the cement-within-cement method with 6 mm or 10 mm stems (AltiVate, DJO Surgical, Dallas, TX).41 Two types of bone defects, 2.5 or 5 cm in length, were simulated on the Sawbones for both stem sizes to create four groups of 5 humeral models.41 A servo-electric axial/torsional test frame was used to establish the baseline torsional stability, and the models were repeatedly loaded until catastrophic failure ocurred.41

3.5

3.5 Complications and reoperations

Intraoperative complications were found in 18% of patients (7), all of which were humeral fractures, and the postoperative complication rate was 18% according to a single study29 (Table 2). Another article showed 12% of complications requiring re-revision surgery, but no other complications unrelated to revisions were documented,40 preventing us from calculating the pooled postoperative complication rates among studies. In this review, glenoid loosening was the most prevalent postoperative complication in 4 cases (3%).29,40

Table 2 Cement-within-cement technique complications and implant survival.
Authors Intraoperative Postoperative Perioperative ReoperationsRate,No. (%)b Implant survival Re-RevisionRate,No. (%)
ComplicationsNo. (%) ComplicationsNo. (%) ComplicationsNo. (%) RSA Humeral component
Wagner et al., 2017,No. = 35 Intraoperative humeral fracture, 7 (19%) Glenoid loosening, 1 (3%)*Periprosthetic instability, 1 (3%)aPeriprosthetic humerus fracture, 1 (3%)aHematoma, 1 (3%)HO, 1 (3%)Anterior dislocation, 1 (3%) 13 (37%) Debridement, 1 (3%)HO Excision and neurolysis, 1 (3%)Polyethylene upsize, 1 (3%) 2 years = 95%5 years = 91% 2 years = 100%5 years = 96% 3 (8%)
Gorman et al., 2020,No. = 98 NR Glenosphere dissociation, 3 (3%)aInfection, 3 (3%)aPeriprosthetic instability, 2 (2%)aHumeral loosening, 2 (2%)aPeriprosthetic humerus fracture, 1 (1%)aBroken baseplate, 1 (1%)* NR NR Time to revision:3 years (range, 0.75–9.8) NR In cases with humeral stem loosening:5 of 7 (71%)In cases without humeral stem loosening7 of 90 (8%)Overall, 12 (12%)
a Complications requiring re-revision.
b Reoperations, excluding re-revisions.

The most common complications associated with the humeral component were periprosthetic fractures (1.5%) and humeral stem loosening (1.5%), leading to re-revision surgeries in all cases29,40 (Table 2). The rate of reoperations was reported in a single study,29 with 3 out of 35 cases (9%) requiring reoperation, which involved debridement, excision of heterotopic ossification and neurolysis, or polyethylene upsizing.29 The 30-day mortality rate was not reported in any of these articles.29,40

3.6

3.6 Implant survival and re-revisions

A single study conducted a formal time-to-revision analysis, reporting an overall revision-free survival rate of 95 and 91% at 2 and 5 years, respectively, for 35 patients followed.29 Specifically, the survival rates of the humeral component at 2 and 5 years were 100 and 96%, respectively.29 The remaining clinical study found that the mean time for revision was 3 years (range, 0.75–9.8 years).40 The pooled re-revision rate was 9% (8%–12%),29,40 but there was no information regarding the specific re-revision procedures performed. A summary of the causes of re-revision after the cement-within-cement technique is presented in Table 2.

3.7

3.7 Clinical outcomes

Two clinical studies investigating the cement-within-cement technique in revision RSA reported clinical and radiographic results and documented two PROs: American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST).29,40 All studies reported improved PRO and ROM compared with baseline or satisfactory postoperative values.29,40 The examination of the clinical results encompassed a cohort of 92 individuals, with a pooled satisfaction rate of 77%.29,40 There were no calculations of the Minimally Clinical Important Difference (MCID), Substantial Clinical Benefit (SBC), or Patient Acceptable Symptom State (PASS). The clinical outcomes are summarized in Table 3.

Table 3 Cement-within-cement technique clinical outcomes.
Outcomes Mean value ± SD No. of patients References
Patient-reported outcomes
Preoperative ASES 35 ± 17 57 16
Postoperative ASES 59 84 [16, 47]
Δ ASES 22 ± 22 57 16
Preoperative SST 2 ± 2 57 16
Postoperative SST 5 84 [16, 47]
Δ SST 3 ± 4 57 16
Pain a [%]
Preoperative (Moderate or Severe) 86% 35 47
Postoperative (Moderate or Severe) 14% 35 47
Range of motion [°]
Preoperative FF 57 ± 33 57 16
Postoperative FF 104 ± 48 57 16
Δ FF 47 ± 54 57 16
Preoperative ABD 52 92 [16, 47]
Postoperative ABD 101 92 [16, 47]
Δ ABD 46 ± 42 57 16
Preoperative ER 17 ± 20 57 16
Postoperative ER 29 ± 29 57 16
Δ ER 12 ± 38 57 16
Satisfaction [%] 77 92 [16, 47]
a Pain levels were classified as none, mild, moderate while performing daily activities, moderate while resting, or severe.
3.8

3.8 Periprosthetic radiolucency

All three studies in this systematic review reported radiolucency around the humeral stem.29,40,41 Biomechanical testing of Sawbones models showed that over 60% of the samples had periprosthetic radiolucency in all four assessed subgroups.41 Moreover, bone models only displayed Grade 1 and 2 radiolucency thickness, with Gruen zones ranging from 1 to 6 across the groups (Table 4).41 Among clinical studies, the combined radiolucency of the humeral stem reported at the last follow-up was 8% (range, 8%–16%), including 127 revisions.29,40 The radiolucency ranged from Grade 1 to 4, with only 1 stem (0.8%) classified as “at-risk,” which did not require re-revision surgery.29 In a single clinical study reporting the Gruen zones, radiolucency was observed in zones 2, 5, and 641.

Table 4 Preoperative and postoperative radiographic and biomechanical evaluation of the cement-within-cement technique in revision reverse shoulder arthroplasty.
Authors Filling ratio Cement mantle area [mm2] Humeral stem area [mm2] Post-op periprosthetic radiolucency of humeral stemNo. (%) [Gruen zones] Torsional stabilityLoad to failureNma
Biomechanical studies
Allen Gorman et al., 2020f Pre-op = 0.48Post-op = 0.28Δ = - 0.20 Pre-op = 6272Post-op = 9168Δ = 2896 Pre-op = 5741Post-op = 3487Δ = −2253 3 stems (60%)Grade 1: 1 (20%) [Zone 1]Grade 2: 2 (40%) [Zones 3,4,5] 15
Allen Gorman et al., 2020g Pre-op = 0.48Post-op = 0.28Δ = - 0.20 Pre-op = 5165Post-op = 8135Δ = 2969 Pre-op = 4719Post-op = 3093Δ = −1626 5 stems (100%)Grade 1: 4 (80%) [Zones 2,5,6]Grade 2: 1 (20%) [Zone 3] 12.5
Allen Gorman et al., 2020d Pre-op = 0.47Post-op = 0.39Δ = - 0.09 Pre-op = 6390Post-op = 7954Δ = 1564 Pre-op = 5762Post-op = 5068Δ = −694 4 stems (80%)Grade 1: 2 (40%) [Zones 2,5]Grade 2: 2 (40%) [Zone 2,5,6] Not failure and 17.5
Allen Gorman et al., 2020e Pre-op = 0.49Post-op = 0.40Δ = - 0.09 Pre-op = 5124Post-op = 6743Δ = 1619 Pre-op = 4845Post-op = 4489Δ = −356 4 stems (80%)Grade 1: 4 (80%) [Zones 3,4,5]Grade 2: 2 (40%) [Zone 4,5] Not failure at 17.5
Clinical studies
Wagner et al., 2017No. = 35 NR NR NR 6 stems (17%)Grade 1–2: 3 (9%) [Zones NR]Grade 3: 2 (6%) [Zones NR]Grade 4: 1 (3%) [Zone NR] NA
Gorman et al., 2020bNo. = 8 Pre-op = 0.59Post-op = 0.41Δ = - 0.18P = .017 Pre-op = 8521Post-op = 9332Δ = 811P = .484 Pre-op = 12,353Post-op = 6102Δ = −6251P = .025 Included in the overall series NA
Gorman et al., 2020cNo. = 90 Pre-op = 0.65Post-op = 0.41Δ = - 0.24P < .0001 Pre-op = 8748Post-op = 13,129Δ = 4380P < .0001 Pre-op = 15,519Post-op = 8175Delta = −7343P < .0001 Included in the overall series NA
Gorman et al., 2020No. = 98 Pre-op = 0.64Post-op = 0.41Δ = −0.23P < .0001 Pre-op = 8730Post-op = 12,819Δ = 4089P = .001 Pre-op = 15,260Post-op = 8006Δ = 7254P < .0001 8 stems (8%)Grade 1: 2 (40%) [Zones 2,5]Grade 2: 2 (40%) [Zone 2,5,6] NA
a All bone models were subjected to a torsional loading of between ± 2.5 Nm at a rate of 2 Nm/sec. The loading was increased in increments of 2.5 Nm for internal-external rotation every 1000 cycles, while remaining under 392 N of axial compressive load, until catastrophic failure occurred. The failure was defined as excessive (5°/sec) stem rotation, indicating loosening of the implant-cement or bone-cement interface. No., Sample size; NA, Not applicable; NR, Not reported; Preoperative; Post-op, Postoperative; SD, Standard deviation.
b Subgroup of patients with humeral stem loosening.
c Subgroup of patients without humeral stem loosening.
d 6-mm revision stem, 2.5 cm of humeral bone deficiency.
e 6-mm revision stem, 5 cm of humeral bone deficiency.
f 10-mm revision stem, 2.5 cm of humeral bone deficiency.
g 10-mm revision stem, 5 cm of humeral bone deficiency.
3.9

3.9 Filling ratio

All biomechanical and clinical studies performed a radiographic evaluation before and after the cement-within-cement revision.29,40,41 The biomechanical study, conducted with 6- and 10-mm revision stems, showed a decrease in the filling ratio of 0.20 and 0.09, respectively41 (Table 4). Among the 98 patients reviewed, a clinical study reported a mean filling ratio of 0.64 before surgery and a significant decrease of 0.23 after surgery (P < .0001).40 Additionally, one study analyzed the mean filling ratio for patients with and without postoperative humeral stem loosening40 (see Table 4).

3.10

3.10 Cement mantle area

In the biomechanical study, the cement mantle showed an increase in the area of 2896 and 2969 mm2 for 6-mm stems and 1564 and 1619 mm2 for 10-mm stems, respectively41 (Table 4). Furthermore, a clinical study reported a significant increase (4380 mm2, P = .001) in the cement mantle area in 98 patients.40

3.11

3.11 Humeral stem area

The mean humeral stem area after cement-within-cement revision decreased proportionally with the implantation of smaller and thinner stems and the size of the bony defect, as demonstrated in a single biomechanical study.41 A clinical study also reported measurements of the humeral stem area,40 as presented in Table 4.

3.12

3.12 Biomechanical results

A biomechanical analysis was conducted to examine the association between the size of the humeral stem, area of the cement mantle, and rotational stability of the humeral component for revision RSA.41 The study results demonstrated that larger stems had a more significant effect (P < .001) on implant rotational stability than the cement mantle area, since the 10 mm stem remained stable after the maximum load tested (17.5 Nm), regardless of bone loss.41 In contrast, models revised with a 6 mm stem failed at 12.5 and 15 Nm41 (Table 4).

4- Discussion

This systematic review revealed a paucity of evidence supporting or discouraging the use of the cement-within-cement technique in revision RSA. Despite an exhaustive search, we identified only 3 articles that presented biomechanical data or clinical outcomes using this technique. Although these limited data suggest that the cement-within-cement technique may offer initial stability and favorable short-term clinical outcomes in revision RSA, its indications, fixation strategies, long-term outcomes, potential complications, and implant survival remain inadequately established.

When shoulder arthroplasty fails, the most common reasons are prosthetic instability, glenoid loosening, or infection, while the humeral component might remain well-fixed.42,43 Revision arthroplasty of the shoulder, specifically focusing on establishing a stable humeral stem position, poses notable difficulties. These challenges encompass the extraction of the existing implant and cement mantle, preservation of the humeral bone, and achieving secure fixation of the replacement stem.8,18,19,22,31,44

Convertible stem systems could allow the retention of the humeral component and could offer substantial benefits in terms of complication rates, operating time, blood loss, and fewer reinterventions.6,14,17 However, humeral stem retention is not always possible due to excessive soft tissue tension created during conversions or ROM impairments, which require unforeseen revisions of the humeral component.13 Theleen et al. found that 28% of patients with primary convertible humeral stems underwent unforeseen stem revision.13 Moreover, anticipated revisions of the humeral component, such as loosening, periprosthetic fractures, joint stability concerns, humeral shortening or medialization, misalignment, loss of humeral bone, and potential for infections, may be equally likely, regardless of the utilization of a convertible humeral stem during the initial procedure, as they shared the same modes of failure.17

Removal of well-fixed implants and the cement mantle may require extensive surgical exposure for split longitudinal osteotomy, humeral windows, or a combination of both techniques.18–20 In addition, these procedures can potentially compromise the bone stock of the proximal humerus and increase the risk of intraoperative fractures by up to 20%.19 However, Sahota et al. reported reasonable clinical outcomes without bone nonunion or loosening in 26 well-fixed humeral stem revisions, including 18 primarily cemented ones.20 This review found that only 2% of revisions required humeral windows for component extraction.

In cases where humeral osteotomies are not performed, the total removal of the cement mantle may result in humeral bone loss.29 This is especially true in cases of osteoporosis or bone deficiency.45 In addition, humeral bone loss is also associated with a risk of intraoperative fracture, postoperative joint instability, or humeral loosening.7,15,21 In addition, cement removal may result in complications, such as fracture development, nerve damage, and increased blood loss.22,46 Furthermore, prolonged surgery time and higher blood loss may increase the likelihood of infection, medical complications, and reoperation.22,23 In this review, the mean surgical time for 38 cement-within-cement revisions (153 min) was found to be lower than that reported by Dilisio et al. for patients revised with retention of the humeral stem (179 min) or extraction (237 min).47

The cement-within-cement approach is a well-established method in revision procedures after hip replacement that has demonstrated high implant survival, positive functional results, and comparable or superior complication and dislocation rates compared to other techniques.25,27 In this review, although limited to a single study, 18% of the patients experienced intraoperative complications, all fractures, and 18% had postoperative complications. Based on a combined national registry dataset, Ingoe et al. showed that humeral fracture was the most prevalent complication of revision shoulder arthroplasty, with a lower rate of 3.5% (50 cases).48 According to a previous systematic review and meta-analysis that included 5379 revision shoulder arthroplasties, Ravi et al. found lower intraoperative and higher postoperative complication rates than those of the cement-within-cement technique, accounting for 8% and 22%, respectively. Additionally, they found a higher pooled re-revision rate of 13% among 3843 surgeries than the 9% estimated in this review.

Shoulder arthroplasty is often revised owing to component loosening, which primarily affects the glenoid.11 Complications associated with the humeral component account for up to 21% of revision procedures.21 After revision surgery of RSA, humeral loosening has been identified as a concerning complication.49 In a systematic review by Gray et al., the pooled rate of aseptic loosening of the humeral stem after RSA was 2%, which increased to 4% in revision cases. They also reported a 16% periprosthetic radiolucency around cemented humeral stems after primary RSA.50 This study found that 8% (range 8–16%) of the humeral stem at a mean follow-up of 4.2 years, with 2% aseptic loosening identified among 133 revision cases using the cement-within-cement approach.

The implant survival rate following revision of the RSA is not well-defined. Nevertheless, Goldenberg et al. conducted a systematic review that included 286 shoulders and reported a 99% implant survival rate at 2 years and 91–98% at 5 years after primary RSA. These findings are similar to those found in this study for the cement-within-cement technique, including implant survival rates of 95 and 91% for the RSA and 100 and 96% for the humeral component at 2 and 5 years, respectively.29

The MCID, SCB, or PASS have not been extensively investigated after revision RSA. While a distribution-based approach may be used to determine the MCID in systematic reviews, its accuracy may be compromised by the limited studies available.51 This review found that the cement-within-cement technique exceeded previously reported MCID for ASES and SST (13.6 ± 2.3 and 1.5 ± 0.3, respectively) after total shoulder arthroplasty.52 Similarly, the SBC for ASES and SST scores (31.5 ± 2.0 and 3.4 ± 0.3, respectively) previously reported after total shoulder arthroplasty were also achieved after the cement-within-cement technique.53 However, we cannot definitively conclude that this procedure leads to clinically meaningful improvements because none of the included studies had population-specific MCID, PASS, or SCB calculations.

There are two common approaches to achieving stable stem fixation during cement-within-cement revision RSA.41 The first strategy involves the utilization of the widest feasible stem diameter that can fit within the pre-existing cement layer, with the aim of reducing the quantity of fresh cement required. The second fixation strategy involves using the smallest possible stem, allowing more cement to be added.41 The findings of this systematic review indicated that the selection of fixation strategy was based on the specific needs of the patients and expertise of the surgeon and generally favored maximizing cement mantle volume over stem size.29,40

As a result, the clinical and radiographic data were based only on the second fixation strategy. Furthermore, the lesser increase in the area of the cement mantle from preoperative to postoperative in patients who exhibit radiographic evidence of stem loosening compared to those without radiolucency substantiates the effectiveness of this approach.40 However, it is worth noting that relying solely on two-dimensional radiographic area measurements to assess volume (fill ratio) can potentially introduce inaccuracies in the findings of radiographic analyses. This approach does not account for subtle deviations in implant rotation and angulation, which may affect the precision of the obtained results.

In the biomechanical study included in this review, the hypothesis that increasing the cement area and decreasing the stem area in revision cases would improve rotational stability was challenged.41 Their results showed that all the samples in the 6-mm stem diameter group failed under a 12.5 to 15 Nm rotational force. In comparison, no failures were observed in the group with a 10 mm stem diameter.41 These findings suggest that the assumption of better rotational stability with a larger cement area and smaller stem area may not be valid and that other factors should be considered when selecting the appropriate fixation strategy.

4.1

4.1 Limitations

This systematic review yielded limited results on the number of available studies and analyses, potentially introducing bias into our findings. However, it provides insight into the current state of research while highlighting the limitations of existing studies, mainly regarding indications and patient selection, optimal surgical techniques, ideal conditions of the primary cement mantle and its preparation, cementation techniques, and stem fixation strategies. Although the included studies used clinically applicable radiographic protocols for postoperative assessment, we were unable to perform further subgroup comparisons to draw more specific conclusions from the available data. However, the limited scope of our study, which was based on only two clinical case series from institutions with extensive experience in revision RSA and one biomechanical study with synthetic models, means that the generalizability of our findings is potentially restricted. Additionally, the relatively small sample size and high loss to follow-up prevented us from reaching definitive conclusions.

Our findings revealed that cement-within-cement in revision RSA is associated with high complication and reoperation rates, underscoring the importance of clear communication with patients considering this approach. However, the available data on this technique suggest that it is comparable to other strategies for shoulder arthroplasty revision and offers some theoretical advantages in terms of decreased surgical time and associated complications.

Although biomechanical findings in synthetic models may compel surgeons to reconsider previous clinical recommendations on the fixation strategy, experimental models of cadaveric samples under a more accurate simulation of the in vivo forces may reveal different insights into the modes of failure and optimize stem size selection. More data from comparative research gathered prospectively from multiple centers is required to pinpoint which patient subgroup would benefit the most from this technique and to determine the optimal surgical strategy for enhancing stem fixation, minimizing complications, and improving outcomes.

5- Conclusions

This systematic review provides evidence that the cement-within-cement technique is a feasible option for revision RSA because it leads to favorable outcomes in terms of stability, ROM, and functional scores. Although the complication profile and implant survival are similar to those of other revision strategies, the prevalence of intraoperative humeral fractures appears higher. However, further investigation with larger sample sizes and longer follow-up is required to refine patient selection, establish the efficacy for long-term use, and identify factors that may influence outcomes after the cement-within-cement revision technique. Further research on an optimized humeral stem fixation strategy is needed to improve outcomes and reduce avoidable complications.

Author's contribution

Ausberto Velasquez Garcia, M.D.: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Visualization; Writing – original draft; Writing – review &; Editing.

Katina Marinakis R.N.: Conceptualization; Formal analysis; Investigation; Methodology; Validation; Writing – review & editing.

Funding/sponsorship

This research did not receive any financial support from funding agencies in the public, private, or non-profit sectors.

Informed consent

N/A.

Institutional ethical committee approval

N/A (no individual patient data/details required as this is a systematic review and meta-analysis).

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