Cement in Shoulder Arthroplasty

Cement in Shoulder Arthroplasty

Midhat Patel MD1 and Niloofar Dehghan MD FRCSC1,2

1Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA

2The CORE Institute, Phoenix, AZ, USA

Clinical scenario

  • A 55‐year‐old right‐hand‐dominant man, semiretired accountant with progressively increasing left shoulder pain and decreasing range of motion.
  • He complains of pain with use of the affected extremity, difficulty golfing and playing with his grandchildren, and sleeping on his left side due to shoulder pain.
  • On physical exam, active and passive range of motion is forward elevation to 100°, abduction to 60°, and external rotation to neutral, with notable grinding and catching during range of motion. He has good strength of his rotator cuff. He is neurovascularly intact.
  • Radiographs of shoulder show end‐stage osteoarthritis, with no proximal migration of the humeral head.

Top three questions

  1. In patients with advanced shoulder osteoarthritis, does cemented fixation of the humeral component result in improved functional outcomes compared to uncemented fixation?
  2. In patients undergoing anatomic total shoulder arthroplasty (TSA), is there a difference in implant survival with a cemented versus uncemented technique?
  3. In patients undergoing anatomic TSA with a cemented glenoid and/or humeral component, is there a difference in infection rates with the use of antibiotic‐impregnated cement compared to plain cement?

Question 1: In patients with advanced shoulder osteoarthritis, does cemented fixation of the humeral component result in improved functional outcomes compared to uncemented fixation?


Both cemented and uncemented humeral stems can be utilized in TSA. Cemented fixation may provide better stability in osteoporotic bone; however, bone ingrowth into the proximal porous coating of an uncemented humeral stem may provide improved survivorship and functional outcome.1 An uncemented implant has a shorted operative time, and potentially simpler revision surgery compared to a cemented stem (in case of revision surgery for infection or loosening).2,3 These theoretical benefits have not been empirically validated and it is important to consider risks/benefits of TSA with a cemented humeral component as compared to an uncemented stem.

Clinical comment

Current opinion suggests that most surgeons prefer to use an uncemented humeral component in North America, and implant manufacturers have therefore developed and marketed uncemented implants over recent years.4 However, there is limited evidence comparing functional outcomes of cemented versus uncemented humeral components in TSA.

Available literature and quality of the evidence

  • Level I: 1 prospective randomized study.
  • Level III: 2 retrospective cohort studies.


In a prospective randomized study, Litchfield et al. compared cemented (n = 80 patients) with uncemented (n = 81) humeral components (Bigliani/Flatow Total Shoulder Solution, Zimmer, Warsaw, IN, USA) for TSA. They showed a significant difference in Western Ontario Osteoarthritis of the Shoulder (WOOS) score at postoperative intervals of 12, 18, and 24 months (p = 0.009, 0.001, 0.028, respectively) in favor of the cemented humeral component. The authors reported no difference in motion or strength improvement between the two groups, compared to preoperative values. Operative time was significantly less for the uncemented group: 1.7 hours versus 2.3 hours (p = 0.03). The authors concluded that a cemented humeral component provides better quality of life than an uncemented humeral component. It is important to note that in this study there was a significantly higher number of men in the cemented group compared to the uncemented group, and the differences between the two groups may be due to improvement in male participants. Additionally, the prosthesis used in this study was not specifically designed for bony ingrowth, which could significantly alter outcomes for the uncemented group.5 Therefore, it may be difficult to extrapolate the results of this study to other implants.

Though there are no other studies directly comparing outcomes in anatomic TSA between cemented and uncemented humeral components, there are two retrospective cohort studies comparing outcomes with cemented and uncemented humeral stems in reverse total shoulder arthroplasty (rTSA). In a review of 100 operations (51 with cemented and 32 with uncemented humeral stems) performed using the Exactech Equinoxe® System, King et al. showed significant improvement in the 12‐item Simple Shoulder Test, 12‐item Short Form, Shoulder Pain and Disability Index 130 (SPADI‐130), American Society of Shoulder and Elbow Surgeons (ASES) score, and normalized Constant scores for both groups, with no significant differences between the two at two‐year follow‐up. Additionally, there was no significant difference in complication rate between the two groups.1

In a second retrospective cohort study comparing outcomes between cemented and uncemented humeral components in rTSA, Wiater et al. compared 64 cases of cementless rTSA with 37 cases of cemented rTSA. Outcome measures included Constant–Murley scores, American Shoulder and Elbow Surgeons scores, Visual Analog Scale (VAS) pain scores, range of motion, patient satisfaction, and radiographic evidence of complication. Findings included significant improvements in all functional scores, forward flexion, and internal rotation with no significant difference between these values in cemented versus uncemented rTSA. Similarly, there were no differences in radiographic evaluation or complication rate between the two cohorts.6

Resolution of clinical scenario

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Cement in Shoulder Arthroplasty

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