CASE REPORT Stemless revision of a failed hemiarthroplasty: case report and surgical technique Matthias Vanhees, MD a , Kjell C.J. Jaspars, MD a , Roger van Riet, MD, PhD a,b , Olivier Verborgt, MD, PhD a,c , Geert Declercq, MD a, * a Department of Orthopedic Surgery, AZ Monica, Antwerp, Belgium b Department of Orthopedic Surgery, University Hospital Brussels, Brussels, Belgium c Department of Orthopedic Surgery, University Hospital of Antwerp, Antwerp, Belgium Revision shoulder arthroplasty can be challenging and technically demanding. This is regardless of whether the index surgery was a hemiarthroplasty or total shoulder arthroplasty. However, with an increasing number of primary shoulder arthroplasties, the incidence of revision surgery has significantly increased in the last decades. 20 In most cases, the revisions take place as a result of malpo- sitioning of the humeral component or are due to causes not related to the humeral side, such as cuff failure or glenoid- related problems. Revision of the humeral component due to aseptic loosening is rare. 4,11,16,19 Revision of a well-fixed stemmed prosthesis can be technically difficult and inva- sive, compromising the final result and future surgical options. We report a case of a patient suffering from progressive pain and loss of function after a hemiarthroplasty for avascular necrosis of the humeral head. At the time of the index surgery, an uncemented humeral component was positioned in a proud position, and this resulted in secondary rotator cuff dysfunction. A revision of the well- fixed humeral component to a total shoulder arthroplasty with a cementless stemless component was performed with good medium-term outcome. The use of a stemless humeral component in a revision setting has not been reported so far in the literature. Case description A 62-year old right-handed man presented at our outpatient clinic with a painful left shoulder. Four years earlier, an avascular necrosis of the humeral head developed after osteosynthesis for a complex 4-part proximal humeral fracture. 12 This was treated with a cementless stemmed humeral head replacement. Post- operatively, the patient was never asymptomatic or fully func- tional. He continued to have symptoms of pain with movement and occasionally in rest and at night. Clinical examination demonstrated a decreased range of motion: abduction, 40  ; forward flexion, 90  ; external rotation, 10  ; and internal rotation to the level of the sacrum. Neurovascular examination findings were normal, and the surgical scar had healed well. The DASH score 7 was 20.8, the Oxford score 6 was 19, the Constant score 5 was 36, and the UCLA shoulder rating scale 1 was 13 (Table I). Standard radiographs showed a proud position of the humeral component with a narrowed acromiohumeral distance. There were no signs of humeral component loosening (Fig. 1). In June 2009, revision surgery took place through the previous deltopectoral approach. The biceps tendon was located and used as a marker for the rotator cuff interval. The interval was exposed and a tenotomy of the subscapularis tendon was performed, about 1 cm medial to the bicipital groove. The proximal humerus, with the hemiprosthesis, was exposed, and the malpositioning of the humeral component was confirmed (Fig. 2). The component was implanted more than 10 mm above the anatomical neck, but the rotator cuff was found to be intact. Next, the shoulder was dis- located by external rotation, adduction, and extension of the humerus. The humeral component was extracted without the need of a vertical split or window (Fig. 3). After removal of the component, a more distal osteotomy was done at the level of the anatomical neck with an oscillating saw, and a punch was placed onto the humerus. Next, the glenoid was exposed, showing *Reprint requests: Geert Declercq, MD, Shoulder Surgery, Department of Orthopedic Surgery, AZ Monica Hospital, Stevenslei 20, 2100 Deurne, Belgium. E-mail address: ortho-spm@azmonica.be (G. Declercq). J Shoulder Elbow Surg (2013) 22, e14-e18 www.elsevier.com/locate/ymse 1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.05.014