An alternative technique of shoulder reconstruction has been proposed using reconstructive RSA designs without the use of allograft in the setting of proximal humeral bone loss (see Fig. 21.2). Exclusion of allograft bone augmentation avoids the additional cost of the graft, added operative time and complexity, and complications of infection, graft resorption, or nonunion. Budge et al. [14] recently published results of fifteen patients treated with this technique. Patients had average follow-up of 34.5 months and average preoperative bone loss of 38.4 mm (range, 26–72). Thirteen patients (87 %) reported satisfaction with their procedure. Only one patient experienced instability and later sustained a fracture of the humeral stem proximally at the modular metaphyseal connection two and a half years postoperatively. This reconstruction technique was preferred for several reasons. First, there is the avoidance of allograft cost and related complications of infection and nonunion. Second, the potential to reattach a chronically detached and deficient subscapularis to an allograft is most often unfeasible. Finally, the ability to establish rotational and length stability with only the use of long-stem components negates the need for structural allograft.

Several options exist for reconstruction, and choice of technique may depend largely on the amount of proximal bone deficiency. Boileau et al. [4] recently reported an analysis of thirty-seven patients after RSA revision, only ten of which had proximal humeral bone loss. Five patients were treated with a long monoblock RSA stem, three were treated with proximal humeral allograft stem supplementation, and two elderly patients were reconstructed with a built-up cement mantle around the stem. The authors stress their finding that humeral shortening and medialization increase the risk of instability, and failing to recognize this issue leads to insufficient deltoid tensioning and recurrent instability.