Compressive osseointegration endoprosthesis for massive bone loss in the upper extremity: surgical technique Steven J. Hattrup, MD a, *, Krista A. Goulding, MD b , Christopher P. Beauchamp, MD a a Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA b Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC, Canada ARTICLE INFO Keywords: Compressive osseointegration Upper extremity Bone loss Revision arthroplasty Limb salvage Upper extremity tumor Level of evidence: Level 5, Surgical Technique Background: Reconstruction of large segments of bone loss can be very difficult. The use of a pre- stressed ingrowth implant can offer an attractive surgical option in these challenging cases. Methods: This report describes the surgical technique in depth, combining the experience of the authors. Nuances of the technique are emphasized. Results: Although published reports are uncommon, long-term restoration of extremity function is pos- sible with this technology. Conclusions: The use of compressive osseointegration endoprostheses is not yet widespread in the upper extremity, but this technology adds to the host of surgical options for managing massive bone loss and difficult revision surgery. © 2018 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). The need to reconstruct the humerus after segmental bone loss is, fortunately, relatively uncommon. It can present, however, from such conditions as resection for an extremity neoplasm, traumatic injury to the extremity, and as a sequelae of aseptic or septic loos- ening of prosthetic implants. Options for management include use of an allograft prosthetic composite, osteoarticular graft, and modular or custom devices. 3,4,18,21,22,24 A short remaining segment of native bone presents additional challenges in satisfactory implant fixa- tion in the near and far time frames. In such circumstances, a prestressed ingrowth implant (Compress; Zimmer Biomet, Warsaw, IN, USA) has been successfully used to reconstruct massive seg- ments of bone loss in the lower extremity and more recently has been described in the upper extremity. 10,13,14 This report describes the nuances of the use of such a device in the upper extremity. Materials and methods Indications The indication for the use of this technology is the existence of limited remaining bone stock. As noted, this could be from trau- matic bone loss, resection of tumor, or after prior arthroplasty. If the remaining bone from these conditions jeopardizes the secure placement of a new implant, then a compressive osseointegration implant offers an attractive option for reconstruction (Figs. 1 and 2). The technology is contraindicated if the remaining bone is too short in length (generally <5 cm of remaining bone) or of such poor quality that it cannot withstand the application of the compres- sive load (residual cortex thinner than 2.5 mm). These devices are also inappropriate in the presence of infection or an uncoopera- tive patient. Set up The procedure is typically performed with a combination of general anesthesia and a preoperatively administered interscalene block to aid in postoperative analgesia. The patient is placed in the beach chair position, with the head and trunk elevated approxi- mately 45°. The patient’s head is secured in the neutral position to minimize traction on the brachial plexus during the procedure. Pre- serving the ability to extend the shoulder intraoperatively is critical because this is necessary to instrument the humeral canal. Shoul- der extension can be maintained by translating the patient’s trunk laterally to the side of the operative table or by using a table break- away attachment, as is our preference (Skytron Beach Chair, Grand Rapids, MI, USA). Exposure Surgical exposure of the humerus revolves around 2 standard approaches. A crucial concept in exposure is the need to circumferentially control the remaining portion of the humeral shaft for safe insertion of the locking pins. This length depends on the spindle chosen. Our experience is with the short spindle The Mayo Clinic Institutional Review Board exempted this study from review. * Corresponding author: Steven J. Hattrup, MD, Department of Orthopedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA. E-mail address: hattrup.steven@mayo.edu (S.J. Hattrup). https://doi.org/10.1016/j.jses.2017.12.006 2468-6026/© 2018 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). JSES Open Access 2 (2018) 34–39 Contents lists available at ScienceDirect JSES Open Access journal homepage: www.elsevier.com/locate/jses