51
|
Abstract
The prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6-2.4%. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6% and 0.9% and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.
Collapse
|
52
|
Abstract
Periprosthetic humerus fractures are relatively uncommon occurrence that can be difficult to manage nonoperatively. Locking plate technology has enhanced the surgical management of these fractures. However, adequate fixation around the stem remains of some concern. We describe an osteosynthesis technique using a locking plate utilizing eccentrically placed screw holes to place "skive screws" in the proximal end of the plate to achieve fixation around the stem of the implant. A clinical series of 5 consecutive patients treated with this technique is presented with an average follow-up of 29 months (range, 12-48). Two additional patients had less than 1-year follow-up. All patients demonstrated fracture healing. Functional outcomes were limited with only 1 patient achieving forward elevation above 90 degree, and the average American Shoulder and Elbow Surgeons Function score was 28. Pain relief was nearly uniform with an average visual analog scale pain score of 0.5.
Collapse
|
53
|
Churchill RS, Chuinard C, Wiater JM, Friedman R, Freehill M, Jacobson S, Spencer E, Holloway GB, Wittstein J, Lassiter T, Smith M, Blaine T, Nicholson GP. Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study. J Bone Joint Surg Am 2016; 98:552-60. [PMID: 27053583 DOI: 10.2106/jbjs.15.00181] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S. METHODS One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively. RESULTS One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components. CONCLUSIONS The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | | | | | - Richard Friedman
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | | | - Jocelyn Wittstein
- Clinical Research Division, Bassett Healthcare Network Research Institute, Cooperstown, New York
| | - Tally Lassiter
- Clinical Research Division, Bassett Healthcare Network Research Institute, Cooperstown, New York
| | | | - Theodore Blaine
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Gregory P Nicholson
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
54
|
Kirchhoff C, Kirchhoff S, Biberthaler P. [Classification of periprosthetic shoulder fractures]. Unfallchirurg 2016; 119:264-72. [PMID: 26992712 DOI: 10.1007/s00113-016-0159-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The key targets in the treatment of periprosthetic humeral fractures (PHF) are the preservation of bone, successful bony consolidation and provision of a stable anchoring of the prosthesis with the major goal of restoring the shoulder-arm function. A substantial problem of periprosthetic shoulder fractures is the fact that treatment is determined not only by the fracture itself but also by the implanted prosthesis and its function. Consequently, the exact preoperative shoulder function and, in the case of an implanted anatomical prosthesis, the status and function of the rotator cuff need to be assessed in order to clarify the possibility of a secondarily occurring malfunction. Of equal importance in this context is the type of implanted prosthesis. The existing classification systems of Wright and Cofield, Campbell et al., Groh et al. and Worland et al. have several drawbacks from a shoulder surgeon's point of view, such as a missing reference to the great variability of the available prostheses and the lack of an evaluation of rotator cuff function. The presented 6‑stage classification for the evaluation of periprosthetic fractures of the shoulder can be considered just as simple or complex to understand as the classification of the working group for osteosynthesis problems (AO, Arbeitsgemeinschaft für Osteosynthesefragen), depending on the viewpoint. From our point of view the classification presented here encompasses the essential points of the existing classification systems and also covers the otherwise missing points, which should be considered in the assessment of such periprosthetic fractures. The classification presented here should provide helpful assistance in the daily routine to find the most convenient form of therapy.
Collapse
Affiliation(s)
- C Kirchhoff
- Sektion Schulter- und Ellenbogentraumatologie, Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675, München, Deutschland.
| | - S Kirchhoff
- Institut für Klinische Radiologie, Ludwig-Maximilians Universität München, Campus Innenstadt, München, Deutschland.,Radiologie Starnberger See, Klinikum Starnberg, Starnberg, Deutschland
| | - P Biberthaler
- Sektion Schulter- und Ellenbogentraumatologie, Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675, München, Deutschland
| |
Collapse
|
55
|
Abstract
Stemless shoulder arthroplasty was originally introduced in 2004 by a single manufacturer. Now, over a decade later, numerous designs are available outside the USA, but as yet, only one implant has been cleared by the Food and Drug Administration (FDA) and is available for use within the USA. Often referred to as "canal sparing," these implants are designed for metaphyseal fixation to minimize humeral bone removal, avoid intraoperative and postoperative humeral fracture complications, and to decrease morbidity associated with revision operations. Recently, the second generation of stemless arthroplasty, a convertible implant allowing use in either anatomic or reverse arthroplasty configuration, was released for use outside the USA. This paper will review the available designs, reported results, and raise potential concerns for this emerging technology.
Collapse
Affiliation(s)
- R Sean Churchill
- Aurora Medical Center-Grafton, 975 Port Washington Rd #110, Grafton, WI, 53024, USA.
| | - George S Athwal
- University of Western Ontario, St Joseph's Health Care, London, Ontario, Canada
| |
Collapse
|
56
|
What Are Risk Factors for Intraoperative Humerus Fractures During Revision Reverse Shoulder Arthroplasty and Do They Influence Outcomes? Clin Orthop Relat Res 2015; 473:3228-34. [PMID: 26162412 PMCID: PMC4562920 DOI: 10.1007/s11999-015-4448-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 06/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND With the increase in shoulder arthroplasty rates, the number of perioperative complications, such as periprosthetic fractures, continues to be a rise; however, the risk factors and incidence of intraoperative complications, such as fractures, during revision reverse shoulder arthroplasty are not well established. QUESTIONS/PURPOSES We evaluated patients receiving a reverse shoulder arthroplasty to determine (1) the frequency and characteristics of intraoperative humerus fractures, (2) the risk factors for fracture, (3) the complications associated with treatment of fractures, and (4) clinical and functional outcomes after treatment. METHODS Using one institution's total joint registry, we performed a retrospective analysis of medical records of 224 patients (230 shoulders) who underwent revision surgery to reverse shoulder arthroplasty, from 2005 to 2012, for failed total shoulder arthroplasty. Reverse shoulder arthroplasty was used when there was a deficient rotator cuff, prior instability, or deficient glenoid bone stock. Intraoperative periprosthetic humerus fractures occurred in 36 shoulders (16%) (36 patients). The clinical outcome analysis included 29 patients with a minimum 2-year clinical followup (mean followup, 3.1 years; range, 2.0-6.3 years). The control group consisted of 188 patients (194 shoulders), and it was used for risk-factor calculation; whereas only 150 patients (154 shoulders) in the control group had a minimum 2-year followup, and thus only 150 patients (154 shoulders) made up the comparators (controls) for outcome-analysis comparisons. Risk factors were assessed using univariate analysis with odds ratios (OR), whereas implant survival and complications were assessed using the Kaplan-Meier method. RESULTS Three displaced and 33 nondisplaced fractures occurred during revision reverse total shoulder arthroplasties. Most of the fractures (81%) occurred during component removal of cemented (n = 11) and cementless (n = 25) components. Intraoperative fractures only were treated with stabilization of the prosthetic stem in 28 patients, while adjunctive internal fixation was used in eight patients. Risk of intraoperative periprosthetic fractures was increased by factors including female sex (n =18 women; OR, 2.41; range, 1.11-5.68; p = 0.03); history of instability (n = 27; OR, 2.65; range, 1.18-5.93; p = 0.02); and prior hemiarthroplasty (n = 22; OR, 2.34; range, 1.13-4.84; p = 0.03). There were two postoperative fractures in patients who had an intraoperative fracture and both were treated nonoperatively. Overall, three (8%) revision procedures were performed in patients with intraoperative fractures, with 2- and 5-year survivorship estimates of 94% and 85%, respectively, compared with 89% and 84%, respectively for patients without an intraoperative fracture (p = 0.45). At latest followup, patients experienced good postoperative pain relief, improved shoulder abduction, and good American Shoulder and Elbow Surgeon and Simple Shoulder Test scores. CONCLUSIONS Intraoperative humeral fractures occur in approximately 16% of shoulders undergoing revision surgery. Fractures during revision reverse TSA are not uncommon secondary to the risks of component removal in revision surgery and poor remaining bone stock. The risk seems to be greatest for female patients, patients with instability, and patients who have undergone previous hemiarthroplasties. Intraoperative humeral fractures should be approached in a systematic way to achieve anatomic reduction and stable fixation. When properly stabilized, these fractures appear not to substantially influence overall final outcome. This study provides a foundation for future investigation of methods to reduce the risk for intraoperative humeral fractures attributable to reverse revision TSA. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
57
|
Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management. INTERNATIONAL ORTHOPAEDICS 2015; 39:1965-9. [PMID: 26318881 DOI: 10.1007/s00264-015-2972-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to record the incidence and management of periprosthetic humeral fractures (PHF) using reverse total shoulder arthroplasty (RTSA) in our institution. METHODS We performed a retrospective study of 203 RTSA implanted in 200 patients between 2003 and 2014. The mean follow-up was 78.82 months (range, 12-141). Mean age of the study cohort was 75.87 years (range, 44-88). There were only 25 male patients (12.5 %). We assessed the presence of periprosthetic humeral fractures studying the medical files and X-rays of all patients. RESULTS We identified seven periprosthetic humeral fractures in 203 RTSA (3.4 %): three intra-operative (1.47 %) and four post-operative (1.97 %). The average age at the time of the fracture was 75.14 years (59-83). All patients were women (100 %). Three patients with post-operative fractures type B were treated by osteosynthesis, and one patient with post-operative fracture type A was treated conservatively. All intra-operative fractures needed cerclage wire and in one case long cemented stem. All our periprosthetic fractures healed. CONCLUSIONS Surgical treatment with osteosynthesis in type B post-operative fractures with a stable stem is recommended. Conservative treatment is sufficient in non-displaced type A post-operative fracture. Special attention should be paid to bone quality patients using non-cemented stems in primary surgery but especially in revision shoulder surgery.
Collapse
|
58
|
Piccioli A, Rossi B, Sacchetti FM, Spinelli MS, Di Martino A. Fractures in bone tumour prosthesis. INTERNATIONAL ORTHOPAEDICS 2015; 39:1981-7. [PMID: 26306584 DOI: 10.1007/s00264-015-2956-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of the present narrative review is to report the different aspects related to the fractures around tumour prosthetic implants in terms of technical and medical issues. METHODS A non systematic literature review on the topic was performed. RESULTS Given the increased rate of limb salvage procedures and megaprostheses implanted for bone tumours, the increased number of osteoporotic periprosthetic fractures, and the burden of revision arthroplasty, the number of surgeries using endoprosthetic implants is likely to increase in the near future. Surgeons will face more frequently the complications related to tumour endoprosthetic implant. Endoprosthetic reconstruction has a higher risk of intra-operative and post-operative complications compared to conventional prosthetic replacement. CONCLUSIONS Very rare reports and recommendations are available in literature regarding the treatment of periprosthetic fractures after megaprosthesis, and there is currently no consensus about which should be the standard management for periprosthetic fractures in this population of patients.
Collapse
Affiliation(s)
- Andrea Piccioli
- Centro Oncologico di Palazzo Baleani, Azienda Policlinico Umberto I, Roma, Italy.
| | - Barbara Rossi
- Presidio Ospedaliero Gubbio Gualdo Tadino, ASL Umbria 1, Roma, Italy
| | | | - Maria Silvia Spinelli
- Department of Orthopaedic and Traumatology, Catholic University Hospital, Rome, Italy
| | - Alberto Di Martino
- Department of Orthopaedics and Trauma Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| |
Collapse
|
59
|
Abstract
Complications after revision shoulder arthroplasty are similar to those in the primary setting which include instability, fracture, bone loss, infection, nerve injury, and loosening. Unlike in the primary setting, however, the rate of complications for revisions is significantly greater and the management is more complex because of overlapping complications and limited treatment options. Furthermore, there is a paucity of evidence-based literature to direct the management options in these patients. The purposes of this review are to broadly outline the major complications that are seen in revision shoulder arthroplasty and to provide general principles on how to recognize and approach these complex cases.
Collapse
Affiliation(s)
- Hithem Rahmi
- />Philadelphia College of Osteopathic Medicine, Philadelphia, PA USA
| | - Andrew Jawa
- />New England Baptist Hospital, Boston, MA USA
| |
Collapse
|
60
|
Stainless steel wire versus FiberWire suture cerclage fixation to stabilize the humerus in total shoulder arthroplasty. J Shoulder Elbow Surg 2014; 23:1568-74. [PMID: 24810079 DOI: 10.1016/j.jse.2014.02.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/30/2014] [Accepted: 02/10/2014] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS No. 5 FiberWire (Arthrex, Naples, FL, USA) cerclage (FWC) and 1.25-mm stainless steel wire cerclage (SSWC) are biomechanically similar in resistance to prosthetic subsidence in shoulder arthroplasty. METHODS In this laboratory bench study, 3 different surgical knot configurations (4-throw knot, cow hitch, and simple hitch) using a No. 5 FWC were evaluated and compared with a 1.25-mm SSWC. First, distraction tests were performed using bovine femoral cortical half shells mounted on a testing jig. Cerclage tightening, load to a 3-mm gap opening, and load to total failure were measured. Second, uncemented humeral prosthetic stems were inserted into an experimentally split humeral medullary canal, secured by the cerclage. After 100 N of preloading, the prosthesis was advanced into the humerus at a speed of 0.2 mm/s, and resistance during subsidence up to a penetration depth of 10 mm, as well as gap opening, was measured. RESULTS Tightening force showed higher values for SSWC (618 N) than FWC (131-137 N) (P < .001). Load to total failure was comparable among the 3 different FWC knots (2,642-2,804 N), which were significantly stronger than SSWC (1,775 N, P < .001). At 3 mm of distraction, SSWC (1,820 N), cow hitch (1,803 N), and single-throw hitch (1,709 N) performed significantly better than a 4-throw knot (1,289 N) (P < .01). Subsidence testing showed no difference in force restraint or gap opening between the best FWC and SSWC. CONCLUSIONS FWCs appear, in vitro, equally suitable to steel wires to stabilize nondisplaced periprosthetic humeral fractures. To actively reduce a displaced fracture, steel wires may still be the first choice.
Collapse
|
61
|
Angelini A, Battiato C. Past and present of the use of cerclage wires in orthopedics. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:623-35. [PMID: 25186972 DOI: 10.1007/s00590-014-1520-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
Abstract
Cerclage wiring is a simple technique that has been practiced widely since the advent of surgical treatment of fractures. Many studies have reported the use of various cerclage technologies with a wide range of results and clinical applications. The increasing numbers of periprosthetic fractures have led to a revival of interest for this simple technique. When cerclages function as implants, they may be used alone or together with a protecting device such as external or internal splints (such as plates, nails, stems of prosthesis or a combination of thereof). This article presents a review of the available literature relating cerclage-wiring techniques and updates the recommendations for clinical use.
Collapse
Affiliation(s)
- Andrea Angelini
- Department of Orthopedics, Rizzoli Orthopedic Institute, University of Bologna, Via Pupilli, 1, 40136, Bologna, Italy,
| | | |
Collapse
|
62
|
Adler D, Siekmann H. [Conservative therapy with a brace for periprosthetic humeral fractures. Clinical and radiological results after 19 months]. DER ORTHOPADE 2014; 43:575-81. [PMID: 24824920 DOI: 10.1007/s00132-014-2312-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Due to the increasing number of implanted shoulder prostheses following trauma or omarthritis in the recent past, an increase in the occurrence of periprosthetic humeral fractures is to be expected in the future. PROBLEM For type B fractures according to Worland the current literature clearly recommends operative treatment with fixed angle plate osteosynthesis or a long-stemmed cement-free revision endoprosthesis. This article presents a case study on the clinical and radiological results of a conservatively treated periprosthetic humeral fracture (Wright type B or type B2 according to Worland) and a discussion of the current literature. MATERIAL AND METHODS A 70-year-old woman was diagnosed with a periprosthetic humeral fracture with an enclosed fracture endoprosthesis (Wright type B). The operative treatment with fixed angle plate osteosynthesis and the alternative conservative therapy with a brace construct were discussed with the patient. The patient decided on the conservative therapy with regular radiological course control. RESULTS The conservative therapy of periprosthetic type B2 humeral fractures according to Worland using retention in an upper arm brace can lead to excellent radiological and functional results.
Collapse
Affiliation(s)
- D Adler
- Universitätsklinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Universität Halle, Halle, Deutschland,
| | | |
Collapse
|
63
|
Spross C, Ebneter L, Benninger E, Erschbamer M, Erhardt J, Jost B. Short- or long-stem prosthesis for intramedullary bypass of proximal humeral fractures with severe metaphyseal bone loss: evaluation of primary stability in a biomechanical model. J Shoulder Elbow Surg 2013; 22:1682-8. [PMID: 23619248 DOI: 10.1016/j.jse.2013.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 02/09/2013] [Accepted: 02/18/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral fractures with substantial metaphyseal comminution are challenging to treat. In the elderly with osteoporotic bone, arthroplasty sometimes remains the only valuable option; however, the minimally required length of stem fixation is not known. The aim of this study was to investigate the primary stability of cemented short- and long-stem prostheses with different intramedullary fracture bypass lengths. MATERIALS AND METHODS Osteoporotic composite bone models of the humerus (Synbone, Malans, Switzerland) with 3 different fracture levels (group A, 6 cm distal to surgical neck; group B, 7 cm distal to surgical neck; and group C, 8 cm distal to surgical neck) were prepared with a cemented standard short (S)- or long (L)-stem prosthesis and were tested for torque to failure. As a reference, we used models with intact bone (group R-O) and a short-stem prosthesis implanted at the surgical neck (group R-P). The radiographic bypass index (BI) was calculated before testing (fracture level to stem tip [in millimeters]/outer cortical diameter at fracture level [in millimeters]). RESULTS The resulting BIs of each group were as follows: 1.7 in group A-S, 3.4 in group A-L, 1.4 in group B-S, 3.2 in group B-L, 1.0 in group C-S, and 2.9 in group C-L. Compared with group R-O, the torques to failure of groups B-S and C-S were significantly lower, whereas only group C-S was significantly weaker than group R-P (P < .01). Comparing short- and long-stem bypasses of different fracture heights, we found that only group C-L showed a significantly higher resistance to torque (P < .01). CONCLUSIONS A short-stem bypass with a BI of 1.7 was sufficient for primary stability tested by torque to failure in this biomechanical setting. For smaller BIs, a long-stem prosthesis should be considered. LEVEL OF EVIDENCE Basic science study, biomechanics.
Collapse
Affiliation(s)
- Christian Spross
- Department of Orthopaedics and Traumatology, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | | | | | | | | |
Collapse
|
64
|
[Periprosthetic humeral fracture: complex circumstances need critical selection of therapy]. DER ORTHOPADE 2013; 42:654-7. [PMID: 23881166 DOI: 10.1007/s00132-013-2151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although periprosthetic humeral fractures were previously rare injuries, they will increase because of the rising life expectancy of patients and increasing implantation of shoulder prostheses. This article describes a case of an 86-year-old female patient with very thin humeral cortex and a prosthesis filling the medullary cavity. The morphology of fractures and the surrounding circumstances determine choice of therapy.
Collapse
|
65
|
Affiliation(s)
- John W Sperling
- Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA.
| | | | | | | |
Collapse
|
66
|
Eid A, Elhewala TA. A peculiar periprosthetic humeral fracture managed in a simple but effective way. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2013; 6:135-6. [PMID: 23495285 PMCID: PMC3590706 DOI: 10.4103/0973-6042.106228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Abdelsalam Eid
- Department of Orthopaedic Surgery, Faculty of Medicine, Zagazig University, Egypt
| | | |
Collapse
|
67
|
Trompeter AJ, Gupta RR. The management of complex periprosthetic humeral fractures: a case series of strut allograft augmentation, and a review of the literature. Strategies Trauma Limb Reconstr 2013; 8:43-51. [PMID: 23457000 PMCID: PMC3623919 DOI: 10.1007/s11751-013-0155-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 02/19/2013] [Indexed: 11/15/2022] Open
Abstract
There is little published discussion on the management of postoperative periprosthetic humeral fractures where rotator cuff function is poor, the bone stock is dwindling or both. This is a phenomenon increasingly seen in the older, more osteoporotic population and presents an interesting challenge especially in when faced with these patients with poor bone quality. We present the treatment of three fractures with the use of long-stem reverse geometry arthroplasty and other surgical techniques more commonly reserved for periprosthetic fractures of the proximal femur such as cortical strut allograft augmentation. We believe revision to reverse geometry long-stem implant with cortical strut allograft augmentation to be safe and appropriate in the management of these complex injuries, although technically challenging, and has excellent initial and medium-term results.
Collapse
Affiliation(s)
- Alex J Trompeter
- Rowley Bristow Department of Trauma and Orthopaedics, St. Peter's Hospital, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK,
| | | |
Collapse
|
68
|
Braman JP, Harrison AK. Surgical outcomes of internal fixation and revision arthroplasty for periprosthetic humeral fractures: commentary on an article by Jaron R. Andersen, MD, et al.: "Surgically treated humeral shaft fractures following shoulder arthroplasty". J Bone Joint Surg Am 2013; 95:e6. [PMID: 23283382 DOI: 10.2106/jbjs.l.01321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
69
|
Andersen JR, Williams CD, Cain R, Mighell M, Frankle M. Surgically treated humeral shaft fractures following shoulder arthroplasty. J Bone Joint Surg Am 2013; 95:9-18. [PMID: 23283369 DOI: 10.2106/jbjs.k.00863] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We reviewed a consecutive series of patients with a humeral fracture around either an anatomic or a reverse shoulder prosthesis treated with either open reduction and internal fixation (ORIF) or revision shoulder arthroplasty. The purposes of the study were to (1) describe the treatment of these fractures by either method, (2) report the outcomes, and (3) assess the validity of a current classification system. METHODS Indications for surgery were a displaced unstable fracture, a fracture around a loose humeral stem, or a patient who was unable to tolerate conservative treatment. Outcomes were reported for two groups (patients treated with revision arthroplasty and those treated only with ORIF) and included American Shoulder and Elbow Surgeons (ASES) scores, radiographic evidence of fracture union, and complications. RESULTS The mean ASES score for the entire cohort was 50.3 (95% confidence interval: 41.2 to 59.5). Thirty-five of the thirty-six fractures healed, in a mean of 7.2 months (range, 3.25 to 13.5 months). Complications occurred in fourteen (39%) of the thirty-six patients. Our ability to classify these fractures with a previously defined system had a low interobserver reliability (mean kappa, 0.37; range, 0.24 to 0.50) and a high intraobserver reliability (mean kappa, 0.69; range, 0.52 to 0.89). CONCLUSIONS Periprosthetic fracture around a humeral stem implant is a difficult clinical problem involving complex decision-making. Fracture union occurred in 97% of our patients. Complications were frequent, and a reoperation was required in 19% of the patients. More than half of the patients in our study had a loose humeral component that required revision.
Collapse
Affiliation(s)
- Jaron R Andersen
- Foundation for Orthopaedic Research and Education, Tampa, FL 33637, USA
| | | | | | | | | |
Collapse
|
70
|
Mineo GV, Accetta R, Franceschini M, Pedrotti Dell'Acqua G, Calori GM, Meersseman A. Management of shoulder periprosthetic fractures: our institutional experience and review of the literature. Injury 2013; 44 Suppl 1:S82-5. [PMID: 23351878 DOI: 10.1016/s0020-1383(13)70018-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fractures of the humerus in patients with total shoulder replacement are rare and difficult to treat. The treatment of periprosthetic humeral fractures depends on the location of the fracture in relation to the humeral stem and the stability of the stem/bone interface. We wished to determine the treatment outcomes in a series of patients managed in our institution with periprosthetic humeral fractures. We also carried out a review of the literature. Over a 5 year period, out of 10 patients, 7 were available at the final follow up with a mean age of 72 years (range 68-75). A fall from standing height was the most common mechanism of injury. All patients were found to have stable prosthesis in situ and were treated with angular stable plates and cerclage wiring. The mean time from the total shoulder replacement to injury (fracture) was 11.2 months (range 8-21). All fractures united without complications at a mean time of 5.1 months (range 4-6). The literature review revealed a limited number of publications reporting on the management of approximately 40 patients. The outcome noted in these patients is also presented.
Collapse
Affiliation(s)
- G V Mineo
- University Department of Orthopaedic, Orthopaedic Institute Gaetano Pini, University of Milan, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
71
|
Singh JA, Sperling J, Schleck C, Harmsen W, Cofield R. Periprosthetic fractures associated with primary total shoulder arthroplasty and primary humeral head replacement: a thirty-three-year study. J Bone Joint Surg Am 2012; 94:1777-85. [PMID: 23032588 PMCID: PMC3448303 DOI: 10.2106/jbjs.j.01945] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to assess the frequency of, and risk factors for, periprosthetic fractures during and after shoulder arthroplasty. METHODS All adults treated with a primary total shoulder arthroplasty or humeral head replacement at the Mayo Clinic Medical Center from 1976 to 2008 were identified. Periprosthetic fractures were validated by medical record review. Univariate and multivariable-adjusted logistic regression analyses were used to assess the association of demographic factors (age, sex, and body mass index [BMI]), underlying diagnosis, implant fixation (cemented or uncemented), American Society of Anesthesiologists (ASA) class, and comorbidity as assessed with the Deyo-Charlson index. RESULTS The cohort consisted of 2207 patients treated with a total of 2588 primary total shoulder arthroplasties and 1349 patients treated with 1431 humeral head replacements. Seventy-two medical-record-confirmed periprosthetic fractures occurred in association with the total shoulder arthroplasties. These consisted of forty-seven intraoperative fractures (forty humeral fractures, five glenoid fractures, and two fractures for which the site was unclear) and twenty-five postoperative fractures (twenty humeral fractures, three glenoid fractures, and two fractures for which the site was unclear). There were thirty-three fractures associated with the humeral head replacements. Fifteen were intraoperative (eight humeral fractures and seven glenoid fractures), and eighteen were postoperative (sixteen humeral fractures and two glenoid fractures). In the multivariable regression analysis of the total shoulder arthroplasties, female sex (odds ratio [OR], 4.19; 95% confidence interval [CI], 1.82 to 9.62; p < 0.001; a 2.4% rate for women versus 0.6% for men) and the underlying diagnosis (p = 0.04; posttraumatic arthritis: OR, 2.55; 95% CI, 0.92 to 7.12) were associated with a significantly higher risk of intraoperative humeral fracture in general, and female sex was associated with the risk of intraoperative humeral shaft fracture (OR, infinity; p < 0.001). In combined analyses of all patients (treated with either total shoulder arthroplasty or humeral head replacement), a higher Deyo-Charlson index was significantly associated with an increased risk of postoperative periprosthetic humeral shaft fracture (OR, 1.27; 95% CI, 1.11 to 1.45); p < 0.001), after adjusting for the type of surgery (total shoulder arthroplasty or humeral head replacement). CONCLUSIONS The overall risk of periprosthetic fractures after total shoulder arthroplasty or humeral head replacement was low. Women had a significantly higher risk of intraoperative humeral shaft fracture. The underlying diagnosis (especially posttraumatic arthritis) was significantly associated with the risk of intraoperative humeral fracture, and comorbidity was significantly associated with the risk of postoperative humeral shaft fracture. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Jasvinder A. Singh
- University of Alabama, Faculty Office Tower 805B, 510 20th Street South, Birmingham, AL 35294. Email address:
| | - John Sperling
- Department of Orthopedic Surgery (J.S. and R.C.) and Health Sciences Research (C.S. and W.H.), Mayo Clinic School of Medicine, Rochester, MN 55905
| | - Cathy Schleck
- Department of Orthopedic Surgery (J.S. and R.C.) and Health Sciences Research (C.S. and W.H.), Mayo Clinic School of Medicine, Rochester, MN 55905
| | - William Harmsen
- Department of Orthopedic Surgery (J.S. and R.C.) and Health Sciences Research (C.S. and W.H.), Mayo Clinic School of Medicine, Rochester, MN 55905
| | - Robert Cofield
- Department of Orthopedic Surgery (J.S. and R.C.) and Health Sciences Research (C.S. and W.H.), Mayo Clinic School of Medicine, Rochester, MN 55905
| |
Collapse
|
72
|
Seybold D, Citak M, Königshausen M, Gessmann J, Schildhauer TA. Combining of small fragment screws and large fragment plates for open reduction and internal fixation of periprosthetic humeral fractures. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2012; 5:105-7. [PMID: 22223961 PMCID: PMC3249927 DOI: 10.4103/0973-6042.91004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Operative treatment of periprosthetic humeral fractures in elderly patients with osteoporotic bone requires a stable fixations technique. The combination of 3.5 cortical screws with washers in a 4.5 Arbeitsgemeinschaft für Osteosynthesefragen, Limited-contact dynamic compression plate or Locking plate, allows a stable periprosthetic fixation with the small 3.5 screws and 4.5 screws above and below the prosthesis, respectively. This combination is a cost-effective technique to treat periprosthetic humeral fractures.
Collapse
Affiliation(s)
- Dominik Seybold
- Department of General and Trauma Surgery, Berufsgenossenschaftliches-Universitätsklinikum Bergmannsheil, Ruhr-University Bochum, Germany
| | | | | | | | | |
Collapse
|
73
|
Hoenecke HR, Tibor LM, Elias DW, Flores-Hernandez C, Steinvurzel JN, D'Lima DD. A quantitative three-dimensional templating method for shoulder arthroplasty: biomechanical validation in cadavers. J Shoulder Elbow Surg 2012; 21:1377-83. [PMID: 22137376 DOI: 10.1016/j.jse.2011.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 10/04/2011] [Accepted: 10/10/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Press-fit humeral components for total shoulder arthroplasty have notable potential complications that may be minimized by preoperative templating and improvements in stem design. The purpose of this study was to develop a 3-dimensional templating technique for the humeral stem and to validate this templating in cadaveric specimens. MATERIALS AND METHODS A cylindrical stem and a stem with a rectangular cross-section were selected for templating and force measurements. Templating was carried out for 15 clinical patients and 16 cadaveric shoulders, including calculation of the cortical-implant volume ratio (CIVR). Insertion forces for stem broaching and impaction were measured for 15 patients and 8 paired cadaveric shoulders. Hoop strain and periprosthetic fractures were monitored in cadaveric shoulders with strain gauges. RESULTS A significant difference in the CIVR was noted between rectangular and cylindrical stems. No difference was observed in impact forces for ideally sized rectangular or cylindrical stems. A difference in insertion forces was found between oversized cylindrical and oversized rectangular implant stems and also between ideal and oversized cylindrical implant stems. The difference in maximal hoop strain between ideally sized rectangular and cylindrical stems was also statistically significant. CONCLUSIONS CIVR is useful to predict an ideal humeral stem size. Cylindrical stems have a different design rationale for fixation than rectangular stems. Surgeon awareness of the fixation rationale for a particular stem design is important because different stem types have different effects on the insertion force. More anatomic humeral stem designs may help to minimize the risk of complications and optimize stem fixation.
Collapse
Affiliation(s)
- Heinz R Hoenecke
- Department of Orthopaedic Surgery and Sports Medicine, Scripps Clinic, La Jolla, CA 92037, USA.
| | | | | | | | | | | |
Collapse
|
74
|
Sewell MD, Kang SN, Al-Hadithy N, Higgs DS, Bayley I, Falworth M, Lambert SM. Management of peri-prosthetic fracture of the humerus with severe bone loss and loosening of the humeral component after total shoulder replacement. ACTA ACUST UNITED AC 2012; 94:1382-9. [DOI: 10.1302/0301-620x.94b10.29248] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.
Collapse
Affiliation(s)
- M. D. Sewell
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - S. N. Kang
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - N. Al-Hadithy
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - D. S. Higgs
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - I. Bayley
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - M. Falworth
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - S. M. Lambert
- The Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| |
Collapse
|
75
|
Wolf H, Pajenda G, Sarahrudi K. Analysis of factors predicting success and failure of treatment after type B periprosthetic humeral fractures: a case series study. Eur J Trauma Emerg Surg 2011; 38:177-83. [PMID: 26815835 DOI: 10.1007/s00068-011-0145-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 07/20/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to investigate which factors predict the failure and success of treatment of periprosthetic type B humeral fractures that have occurred traumatically. METHODS The institutional admission database and the trauma registry were retrospectively reviewed. A total of 8 patients suffering from periprosthetic humeral fractures were included. The time span was 10 years (2000-2010). RESULTS The average age at the time of the fracture was 77 years. Surgery was performed at an average of 5.6 days after injury. In three patients with a well-fixed and one with an unstable humeral component, open reduction and internal fixation with the use of a plate and screws was performed. Two patients with a Delta prosthesis had an unstable humeral component. A proximal humeral resection and an implantation of an HMRS prosthesis was performed in one patient. The other patient received a Delta revision stem prosthesis, cable and plate fixation. Two patients were treated conservatively. CONCLUSIONS Early surgical treatment with angular stable implants in fractures with a stable stem and replacement with a revision long-stem component in fractures with a loose prosthesis is recommended. Special attention should be paid to bone quality and anatomical proximity to the radial nerve. Conservative treatment of type B fractures is not sufficient to achieve union, especially in short oblique or transverse fractures.
Collapse
Affiliation(s)
- H Wolf
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - G Pajenda
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - K Sarahrudi
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| |
Collapse
|
76
|
Martinez AA, Calvo A, Cuenca J, Herrera A. Internal fixation and strut allograft augmentation for periprosthetic humeral fractures. J Orthop Surg (Hong Kong) 2011; 19:191-3. [PMID: 21857043 DOI: 10.1177/230949901101900212] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To report 6 patients with periprosthetic humeral fractures treated with open reduction and internal fixation with plate and strut allograft augmentation. METHODS 6 women aged 69 to 79 (mean, 73) years underwent open reduction and internal fixation with plate and strut allograft augmentation for periprosthetic humeral fractures (type C) after a fall. They had undergone reverse shoulder arthroplasty for rotator cuff arthropathy. The mean interval between the initial arthroplasty and the fracture was 17 (range, 11-21) months. RESULTS The mean follow-up period was 14 (range, 12-16) months. The mean time to union was 5.4 (range, 4-6) months. All fractures united without complications. The mean Constant score at the last follow-up was 64 (range, 56-80). The range of shoulder movement and patient satisfaction were restored to pre-fracture status in all patients, except for one who had more pain in the lateral area of the arm (probably because of soft-tissue irritation by the plate and wires). Three patients had evidence of graft-to-host union and 3 others had graft resorption. CONCLUSION Internal fixation with plate, cable wires and strut allogaft augmentation achieves satisfactory results for periprosthetic humeral fractures.
Collapse
Affiliation(s)
- Angel A Martinez
- Department of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Medicine School, University of Zaragoza, Zaragoza, Spain.
| | | | | | | |
Collapse
|
77
|
Abstract
Periprosthetic fractures around the shoulder and elbow are rare and are often difficult to treat. Treatment options depend on the stability of the prosthesis, the location of the fracture, and the bone quality. The basic principles of treatment are that loose or unstable prostheses are removed and revised to a longer prosthesis with the possible addition of cortical struts and/or plate and screws. If the prosthesis is stable, nonoperative measures may be tried initially. In cases of nonunion, surgical treatment is recommended. This article describes the current literature related to periprosthetic fractures around the shoulder and the elbow.
Collapse
|
78
|
Gonzalez JF, Alami GB, Baque F, Walch G, Boileau P. Complications of unconstrained shoulder prostheses. J Shoulder Elbow Surg 2011; 20:666-82. [PMID: 21419661 DOI: 10.1016/j.jse.2010.11.017] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 11/12/2010] [Accepted: 11/17/2010] [Indexed: 02/01/2023]
Affiliation(s)
- Jean-François Gonzalez
- Department of Orthopedic Surgery and Traumatology, Hôpital d'Instruction des Armées Legouest, Metz Armées, France
| | | | | | | | | |
Collapse
|
79
|
Abstract
Periprosthetic fractures are fractures that occur in association with an orthopaedic implant, most often used for joint arthroplasty or fracture fixation. They are associated with significant morbidity and increased mortality in some cases. The incidence of periprosthetic fractures appears to be increasing as a result of increasing patient longevity, more demanding activity levels that persist into advanced age for some patients, and as a result of the increasing rate of revision arthroplasty which accompanies increasing patient longevity. Implant, surgeon, and patient factors all contribute to the risk of periprosthetic fracture. In this review, we intend to discuss current trends in periprosthetic fractures and risk factors associated with their development in the joint arthroplasty and fracture patient.
Collapse
|
80
|
Mavrogenis AF, Angelini A, Guerra E, Rotini R. Humeral fracture between a total elbow and total shoulder arthroplasty. Orthopedics 2011; 34. [PMID: 21469626 DOI: 10.3928/01477447-20110228-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This article presents a case of a 71-year-old woman with a humeral fracture between a cementless reverse total shoulder arthroplasty and a cemented total elbow arthroplasty and discusses our treatment plan. Surgical treatment was performed after the patient was informed of possible complications and the benefits of surgery including: early, complete restoration of arm anatomy, greater functional improvement of the adjacent joints, and increased risk of nonunion with nonoperative treatment.The fracture was comminuted and extended proximally around the shoulder prosthesis. Through the posterior approach, the radial nerve was identified and protected. Both prostheses were found firmly fixed to bone. The fracture around the shoulder prosthesis was reduced first using a strut allograft and reduction clamps. Next, arm alignment restoration and distal humerus reduction were performed. The construct was neutralized with a 3.5-mm locking plate spanning the whole length of the humerus. The locking plate was positioned posterolaterally and the strut medially in a 90° to 90° configuration secured with wires and cables.A hinged elbow brace was applied for 6 weeks postoperatively. Active range of motion exercises of the wrist and hand and passive motion of the elbow and shoulder were started at 4 to 5 days postoperatively. At 2 weeks postoperatively, passive motion of the elbow and shoulder progressed to strengthening exercises. Thereafter, the patient underwent several weeks of physical therapy to restore motion, strength, and function of the upper extremity with instructions not to overload the arm and avoid heavy work and sports for as long as 1 year. At 10 months postoperatively, radiographs of the arm showed a stable construct; the patient had resumed full activities of daily living.
Collapse
|
81
|
Kieser DC, Taylor F, Ball CM, Ball CM, Bal CM. The allograft sleeve: a case report of the surgical management of an interprosthetic fracture between a shoulder and elbow joint replacement. J Shoulder Elbow Surg 2011; 20:e4-9. [PMID: 21315620 DOI: 10.1016/j.jse.2010.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 10/28/2010] [Accepted: 11/01/2010] [Indexed: 02/01/2023]
|
82
|
Ricchetti ET, Williams GR. Total Shoulder Arthroplasty—Indications, Technique, and Results. ACTA ACUST UNITED AC 2011. [DOI: 10.1053/j.oto.2010.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
83
|
Flury MP, Schmoelz W, Schreiber U, Goldhahn J. Biomechanical testing of rectangular humeral shaft prosthesis: higher torsional stability without increased fracture risk. Arch Orthop Trauma Surg 2011; 131:267-73. [PMID: 20857127 PMCID: PMC3034038 DOI: 10.1007/s00402-010-1170-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rectangular cementless femur shaft prostheses have a higher primary stability than round shafts. A novel rectangular humeral shaft design was tested with two questions: does the rectangular design cause a higher fracture risk during implantation than round designs, and does it increase the torsional stiffness? MATERIALS AND METHODS Two series with six paired human humeri (total 24) were tested on one side with the rectangular shaft and on the contralateral side with a round shaft. In the first series, the shaft implantation was carried out with a constant speed of 100 mm/min and the maximum force was measured when the fracture occurred. In the second series, the implants were preloaded with 50 N and then rotated at 2° per second with monitoring of the torsional torque. RESULTS The maximum force at fracture showed no significant difference for the two designs (p = 0.34). Higher age and low bone density reduced the force required for fracture. The rectangular shaft showed significant higher torsional moments (p < 0.05). CONCLUSIONS In biomechanical testing, the rectangular shaft had a significantly higher primary torsional stability than the round shaft without a higher risk of fracture during cementless implantation. Fracture risk and torsional stability are influenced by age and bone density.
Collapse
Affiliation(s)
- Matthias P. Flury
- Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland
| | - Werner Schmoelz
- Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria
| | | | - Joerg Goldhahn
- Research Upper Extremity, Schulthess Clinic, Zurich, Switzerland
| |
Collapse
|
84
|
Sommacal R, Bloch HR, Ghidelli A, Bettelli G, Dalla Pria P. Comminuted periprosthetic humeral fracture after reverse shoulder prosthesis. Musculoskelet Surg 2009; 93 Suppl 1:S83-7. [PMID: 19711175 DOI: 10.1007/s12306-009-0013-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Periprosthetic fractures represent a severe complication after joint replacement. A case of comminuted displaced humeral fracture around the stem of a SMR reverse shoulder prosthesis is reported. The patient was a 81-year-old lady who had had a total shoulder replacement 28 months previously. The surgical solution consisted of a partial revision of the modular implant with conservation not only of the glenoid component but also of the prosthetic humeral body, which was well fixed in the humeral metaphysis. The humeral stem was removed and a long uncemented revision stem was implanted providing fracture stabilisation and allowing early mobilisation.
Collapse
Affiliation(s)
- Renato Sommacal
- Reparto di Ortopedia, Regionalspital, 8780, Einsiedeln, Switzerland.
| | | | | | | | | |
Collapse
|
85
|
Lill H, Hepp P, Rose T, Korner J, Josten C. Mennen clamp-on plate fixation of periprosthetic fractures of the humerus after shoulder arthroplasty—a report on 3 patients. ACTA ACUST UNITED AC 2009; 75:772-4. [PMID: 15762271 DOI: 10.1080/00016470410004184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Helmut Lill
- Department of Trauma and Reconstructive Surgery, University of Leipzig, DE-04103 Leipzig, Germany.
| | | | | | | | | |
Collapse
|
86
|
Sarraf KM, Singh R, Corbett SA. Distal humeral plating of an intramedullary nail periprosthetic fracture using a miss-a-nail technique: a case report. CASES JOURNAL 2009; 2:6704. [PMID: 19829846 PMCID: PMC2740021 DOI: 10.1186/1757-1626-2-6704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Accepted: 04/08/2009] [Indexed: 11/20/2022]
Abstract
The treatment of distal humeral periprosthetic fractures is not widely described in the literature. We present a difficult clinical scenario of a 72-year-old man who sustained a displaced distal humeral periprosthetic fracture about a Polarus Plus intramedullary nail. In this case, stable fixation was achieved using bicondylar Acumed Mayo congruent Plates using a miss-a-nail technique. Four months following the post operative period, the patient regained satisfactory range of movement with full function and no further complications up to 18 months post fixation. Treatment of such complex periprosthetic fractures is technically achievable and with potentially good results.
Collapse
Affiliation(s)
- Khaled M Sarraf
- Department of Orthopaedic Surgery, Guy’s and St Thomas’s Hospital, London, UK.
| | | | | |
Collapse
|
87
|
Athwal GS, Sperling JW, Rispoli DM, Cofield RH. Periprosthetic humeral fractures during shoulder arthroplasty. J Bone Joint Surg Am 2009; 91:594-603. [PMID: 19255219 DOI: 10.2106/jbjs.h.00439] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Currently, there is little information available on the treatment and outcome of intraoperative periprosthetic humeral fractures that occur during shoulder arthroplasty. The purpose of this study was to report on the incidence, treatment, and outcome of, as well as the risk factors for, intraoperative periprosthetic humeral fractures. METHODS Between 1980 and 2002, forty-five intraoperative periprosthetic humeral fractures occurred during shoulder arthroplasty at our institution. Twenty-eight fractures occurred during primary total shoulder arthroplasty, three occurred during primary hemiarthroplasty, and fourteen occurred during revision arthroplasty. Nineteen fractures involved the greater tuberosity, sixteen involved the humeral shaft, six involved the metaphysis, three involved the greater tuberosity and the humeral shaft, and one involved both the greater and lesser tuberosities. All patients were followed for a minimum of two years. At the time of the latest follow-up, outcomes were assessed, radiographs were examined, and relative risks were calculated. RESULTS Over the twenty-two-year study period, the rate of intraoperative humeral fractures at our institution was 1.5%. All fractures healed at a mean of seventeen weeks. In the primary arthroplasty group (thirty-one patients), range of motion and pain scores improved significantly (p < 0.05) at the time of follow-up. In the revision arthroplasty group (fourteen patients), range of motion remained unchanged whereas pain scores improved significantly (p < 0.005). Transient nerve injuries occurred in six patients. Four fractures displaced postoperatively and were then treated nonoperatively; all four healed. Significant relative risks for intraoperative fracture were female sex, revision surgery, and press-fit implants (p < 0.05). CONCLUSIONS The data from the present study suggest that although intraoperative humeral fractures are associated with a high rate of healing, there was a substantial rate of associated complications, including transient nerve injuries and fracture displacement. Significant risk factors for intraoperative fractures include female sex, revision surgery, and press-fit humeral implants.
Collapse
|
88
|
Wutzler S, Laurer HL, Huhnstock S, Geiger EV, Buehren V, Marzi I. Periprosthetic humeral fractures after shoulder arthroplasty: operative management and functional outcome. Arch Orthop Trauma Surg 2009; 129:237-43. [PMID: 18807052 DOI: 10.1007/s00402-008-0746-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Currently, little information is available on functional outcome of periprosthetic humeral fractures after shoulder arthroplasty. This investigation aimed to evaluate functional and radiological outcome and patients' satisfaction following this type of injury treated by open reduction and internal fixation. METHODS Retrospective chart analysis of patients treated at two level-I trauma centers. Patients were examined clinically and radiologically. Additionally, functional outcome was assessed using the established DASH-questionnaire and standardized examination for calculation of the Constant score. RESULTS Five out of six patients showed complete fracture consolidation with satisfying functional results (mean follow up time 62 weeks). One patient showed major complications with poor outcome. DASH and Constant scores were comparable to those described after primary shoulder arthroplasty. CONCLUSIONS Periprosthetic humeral fractures after shoulder arthroplasty can be treated by angular stable plating with low complication rates and acceptable results.
Collapse
Affiliation(s)
- Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of J.W. Goethe-University, 60590 Frankfurt, Germany.
| | | | | | | | | | | |
Collapse
|
89
|
McConkey MO, Baslaim AM, Regan WD. Case reports: ipsilateral shoulder and elbow arthroplasty using custom interlocking prostheses. Clin Orthop Relat Res 2008; 466:2548-51. [PMID: 18654825 PMCID: PMC2584297 DOI: 10.1007/s11999-008-0376-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 06/23/2008] [Indexed: 01/31/2023]
Abstract
Ipsilateral shoulder and elbow arthritis is not an uncommon problem seen in patients of upper extremity surgeons. If arthroplasty is required in both joints, there is a significant risk of periprosthetic fracture resulting from the stress riser occurring between the implants. We report the placement of custom interlocking shoulder and elbow prostheses in a patient with rheumatoid arthritis. The elbow prosthesis with an uncemented humeral component was placed followed 18 months later by a custom-designed shoulder prosthesis. An internal strut between the two prostheses was created. Seven years postoperatively, the patient was asymptomatic with no radiographic signs of impending failure.
Collapse
Affiliation(s)
- Mark O McConkey
- Department of Orthopedics, University of British Columbia, 2nd floor, Unit 2C, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5.
| | | | | |
Collapse
|
90
|
Shoulder arthroplasty. Eur Radiol 2008; 18:2937-48. [PMID: 18618117 DOI: 10.1007/s00330-008-1093-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2008] [Revised: 05/17/2008] [Accepted: 06/07/2008] [Indexed: 10/21/2022]
Abstract
Shoulder prostheses are now commonly used. Clinical results and patient satisfaction are usually good. The most commonly used types are humeral hemiarthroplasty, unconstrained total shoulder arthroplasty, and semiconstrained inversed shoulder prosthesis. Complications of shoulder arthroplasty depend on the prosthesis type used. The most common complications are prosthetic loosening, glenohumeral instability, periprosthetic fracture, rotator cuff tears, nerve injury, infection, and deltoid muscle dysfunction. Standard radiographs are the basis of both pre- and postoperative imaging. Skeletal scintigraphy has a rather limited role because there is overlap between postoperative changes which may persist for up to 1 year and early loosening and infection. Sonography is most commonly used postoperatively in order to demonstrate complications (hematoma and abscess formation) but may also be useful for the demonstration of rotator cuff tears occurring during follow-up. CT is useful for the demonstration of bone details both pre- and postoperatively. MR imaging is mainly used preoperatively, for instance for demonstration of rotator cuff tears.
Collapse
|
91
|
Abstract
The incidence of periprosthetic humerus fracture associated with shoulder arthroplasty is approximately 0.6% to 3%. Fractures of the humerus occur most often intraoperatively and are more common during total shoulder arthroplasty than hemiarthroplasty because of difficulties in gaining access to the glenoid. Osteopenia, advanced age, female sex, and rheumatoid arthritis are medical comorbid factors that may contribute to humerus fractures and associated delayed healing and poorer function. When the humeral prosthetic component is loose or the fracture line overlaps the majority of the length of the prosthesis, revision with a long-stem implant should be considered. When the fracture overlaps the tip of the prosthesis and extends distally, open reduction and internal fixation is recommended. When the fracture is completely distal to the prosthesis and satisfactory alignment at the fracture site can be maintained with a fracture brace, then a trial of nonsurgical treatment is recommended. The primary goals of treatment are fracture union and pain relief. Loss of glenohumeral motion has limited the successful treatment of this challenging problem.
Collapse
|
92
|
Groh GI, Heckman MM, Wirth MA, Curtis RJ, Rockwood CA. Treatment of fractures adjacent to humeral prostheses. J Shoulder Elbow Surg 2008; 17:85-9. [PMID: 18069012 DOI: 10.1016/j.jse.2007.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 05/23/2007] [Indexed: 02/01/2023]
Abstract
Fifteen patients with fractures adjacent to a humeral prosthesis were treated between 1986 and 2002. There were 10 females and 5 males. The average age was 58 years. The fractures were classified as to location relative to the prosthesis. Type I fractures (N = 3) occurred proximal to the tip of the prosthesis. Type II fractures (N = 7) occurred in which the fracture line extended from the proximal portion of the humeral shaft to beyond the distal tip of the prosthesis. Type III (N = 5) fractures occurred entirely distal to the tip of the prosthesis. Two type I and 3 type II fractures were managed with a fracture orthosis. The remainder of the fractures were treated surgically with a combination of cerclage wires and long stem prosthesis. All fractures progressed to union at an average of 11 weeks. Average forward elevation for the group was 124 degrees . No patient required a shoulder spica or bone grafting to obtain union. Treatment resulted in fracture union, prosthesis stability, and a paucity of complications.
Collapse
Affiliation(s)
- Gordon I Groh
- Blue Ridge Bone and Joint Clinic, Asheville, NC, USA
| | | | | | | | | |
Collapse
|
93
|
Lee M, Chebli C, Mounce D, Bertelsen A, Richardson M, Matsen F. Intramedullary reaming for press-fit fixation of a humeral component removes cortical bone asymmetrically. J Shoulder Elbow Surg 2007; 17:150-5. [PMID: 18029200 DOI: 10.1016/j.jse.2007.03.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2007] [Revised: 03/19/2007] [Accepted: 03/25/2007] [Indexed: 02/01/2023]
Abstract
Periprosthetic humeral fractures are major complications of shoulder arthroplasty. Bone removal during surgical reaming is a risk factor for these fractures. Although it is recognized that the endosteal surface of the humerus is asymmetrical whereas the reamers are symmetrical, to our knowledge, the effect of cylindrical reaming on the pattern of cortical bone removal during reaming has not been previously studied. The medullary canals of 10 cadaveric humeri (mean age, 73 years) were reamed in a manner similar to that used during humeral arthroplasty. Cortical dimensions were obtained from computed tomography scans before and after reaming. In unreamed humeri, the anterior-posterior endocortical diameter was 20% smaller than the medial-lateral diameter. The average medial-lateral diameter (15.6 +/- 2.3 mm) was significantly greater than the anterior-posterior diameter (12.5 +/- 1.9 mm) at 13 cm distal to the tuberosity (P < .00005). Successive cylindrical reaming preferentially thinned the anterior and posterior cortices. This bone loss would not be apparent on anterior-posterior radiographs. Intramedullary reaming to obtain substantial cortical contact asymmetrically removes cortical bone in a manner that may increase the risk of periprosthetic fracture.
Collapse
Affiliation(s)
- Michael Lee
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | | | | | | | | | | |
Collapse
|
94
|
Choo AMT, Hawkins RH, Kwon BK, Oxland TR. The effect of shoulder arthroplasty on humeral strength: an in vitro biomechanical investigation. Clin Biomech (Bristol, Avon) 2005; 20:1064-71. [PMID: 16122858 DOI: 10.1016/j.clinbiomech.2005.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2004] [Revised: 06/21/2005] [Accepted: 06/24/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Periprosthetic humeral fractures are a serious complication of shoulder arthroplasty. While adequate reaming of the canal and insertion of an oversized implant optimizes fit, such maneuvers also weaken the bone and predispose it to fracture. METHODS The impact of the humeral arthroplasty was assessed in vitro on human cadaveric specimens. Strain gauges were attached to the distal diaphyses and the specimens were mounted in a torsion-loading fixture throughout the tests. An initial series examined the effect of reaming of the canal to its clinically appropriate diameter using uniaxial strain gauges. A second series utilized strain rosettes to evaluate the cumulative effects of reaming, broaching, and implant insertion. FINDINGS Reaming of the canal to its clinically appropriate diameter significantly increased (P=0.007) uniaxial strain measurements by a mean of 30% with five of eight specimens showing increases of over 49% on at least one of four diaphyseal locations. In the second series, the surface strain was significantly affected by arthroplasty (P<0.008). Post-hoc analysis showed that the maximum in-plane shear strain following implant insertion was significantly increased relative to strain levels following reaming and broaching (P<0.009). The direction of the principal strain axes did not significantly change (P>0.46). Unexpected decreases in some strain measurements were observed as the arthroplasty procedure progressed perhaps reflecting overt mechanical failure within the humeral shaft. INTERPRETATION The strain increase following reaming suggests a reduction in torsional strength by over 33% which is further reduced following broaching and implant insertion. For the practicing surgeon, post-operative strength can be adversely affected by both canal preparation and implant insertion.
Collapse
Affiliation(s)
- Anthony M T Choo
- Department of Orthopaedics, The University of British Columbia, 910 West 10th Avenue, Vancouver, BC, Canada V5Z 4E3
| | | | | | | |
Collapse
|
95
|
Kent ME, Sinopidis C, Brown DJ, Frostick SP. The locking compression plate in periprosthetic humeral fractures A review of two cases. Injury 2005; 36:1241-5. [PMID: 15985264 DOI: 10.1016/j.injury.2005.02.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2004] [Revised: 02/10/2005] [Accepted: 02/18/2005] [Indexed: 02/02/2023]
Affiliation(s)
- M E Kent
- Upper Limb Unit, Orthopaedics Department, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.
| | | | | | | |
Collapse
|
96
|
Kim DH, Clavert P, Warner JJP. Displaced periprosthetic humeral fracture treated with functional bracing: a report of two cases. J Shoulder Elbow Surg 2005; 14:221-3. [PMID: 15789019 DOI: 10.1016/j.jse.2004.05.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- David H Kim
- Harvard Shoulder Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | | |
Collapse
|
97
|
Abstract
BACKGROUND Currently, there is little information concerning periprosthetic humeral fractures after shoulder arthroplasty. Therefore, we reviewed our experience with these fractures to determine the results of treatment, the risk factors for periprosthetic fracture, and the rates of reoperation. METHODS Between 1976 and 2001, nineteen postoperative periprosthetic humeral fractures occurred among 3091 patients who had undergone shoulder arthroplasty at our institution. Sixteen patients had a complete series of radiographs and were included in this study. The average time from the arthroplasty to the fracture was forty-nine months. Seven patients had severe osteopenia. Twelve fractures occurred at the tip of the prosthesis; of these, six extended proximally (type-A fractures) and six did not (type-B fractures). Three fractures occurred distal to the implant and extended into the distal humeral metaphysis (type-C fractures). One fracture occurred in the proximal metadiaphyseal region because of osteolysis. RESULTS Six fractures healed after an average of 180 days of nonoperative treatment. Five fractures were treated operatively after an average of 123 days of unsuccessful nonoperative treatment. The remaining five fractures had immediate operative treatment. All sixteen fractures healed. One patient required multiple operations over a period of three years before union was achieved. With the exclusion of this patient and one other patient who received a custom prosthesis, the average time between the first operative procedure and union was 278 days. CONCLUSIONS Our data do not clearly indicate the need for operative treatment of type-A fractures unless the humeral component is loose. A trial of nonoperative treatment may be considered for well-aligned type-B fractures that are associated with a well-fixed humeral component; however, operative intervention should be considered for type-B fractures that have not progressed toward union by three months. If the component is well fixed, open reduction and internal fixation may be performed. If the component is loose, revision with a long-stem component is recommended. For type-C fractures, a trial of nonoperative treatment is recommended.
Collapse
Affiliation(s)
- Sanjay Kumar
- Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | | | | | | |
Collapse
|
98
|
Abstract
The incidence of periprosthetic fracture during or after shoulder arthroplasty is 1% to 3% of all shoulder arthroplasties. The frequency with which this injury occurs may be increasing, however. Contemporary implants have been designed specifically for uncemented use and often have larger proximal bodies. During insertion, attempts are made to achieve a tight, line-line fit. Consequently the risk for periprosthetic fracture may be higher than estimated.
Collapse
Affiliation(s)
- Gerald R Williams
- Shoulder and Elbow Service, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
| | | |
Collapse
|
99
|
Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg 2002; 11:130-5. [PMID: 11988723 DOI: 10.1067/mse.2002.121146] [Citation(s) in RCA: 301] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.
Collapse
Affiliation(s)
- Tom R Norris
- California Pacific Medical Center, San Francisco, California, USA
| | | |
Collapse
|
100
|
Cameron B, Iannotti JP. Periprosthetic fractures of the humerus and scapula: management and prevention. Orthop Clin North Am 1999; 30:305-18. [PMID: 10196432 DOI: 10.1016/s0030-5898(05)70085-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The management of humerus fractures is complicated by the presence of a prosthesis. Vigilance in addressing the mechanisms and predisposing factors for periprosthetic fracture may prevent their occurrence. In the event of a periprosthetic fracture, attention to prosthetic stability, fracture location and stability, and bone quality will help guide treatment decisions. Treatment should be commensurate with the goals of fracture stability, early rehabilitation, and maintaining a well-functioning prosthesis.
Collapse
Affiliation(s)
- B Cameron
- Fellow, Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine; and Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|