[Periprosthetic humeral fractures: Strategies and techniques for osteosynthesis]

[Periprosthetic fractures-Diagnostics, classification and treatment]

BACKGROUND

Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed.

OBJECTIVE

The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications.

MATERIAL AND METHOD

Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective.

CONCLUSION

With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed.

[Periprosthetic fractures of the shoulder girdle]

Periprosthetic fractures of the shoulder girdle will increasingly become part of routine clinical practice due to rising numbers of joint replacements and the demographic changes. Diagnostically, the status of the rotator cuff, bed of the implant (stable or loose), type of shoulder arthroplasty as well as exclusion of joint infections are crucial for therapeutic decision-making. Novel imaging tools, such as dual-energy computed tomography provide improved preoperative planning options. The unified classification system describes the fracture location, stability of the prosthesis and quality of the bone. While nonoperative treatment is reserved for patients with severe pre-existing conditions and nondisplaced fractures, the standard treatment of fractures with a stable bed include fixation with cerclage wiring and angular stable plates. Modern implant systems with variable angle screw holes, attachment plates and hinges enable secure fixation around the stem. In cases of a loose stem revision arthroplasty is necessary. There are currently only a limited number of clinical studies with only few patients that analyzed clinical and radiological results. Thus, increased research efforts are indispensable in order to compare treatment options and improve treatment quality.

[Conservative treatment of periprosthetic humeral fractures years after cemented fracture prostheses : A case series]

BACKGROUND

The exact incidence of postoperative periprosthetic humeral fractures (PPHF) months or years after fracture-related implantation of a hemiprosthesis is unknown. The currently available literature is predominantly concerned with operative treatment approaches. As a rule, these involved older patients and severe fracture conditions so that severe complications and unsatisfactory healing results were described. This article presents an alternative conservative treatment approach which is discussed based on the results of treatment.

PATIENTS AND METHODS

Between 2011 and 2016 a conservative treatment of 5 female patients with PPHF could be carried out. Of the patients 4 were clinically and radiologically controlled at a mean follow-up time of 23 months. The fifth patient died 2 months after the trauma and only partial information of the treatment was available.

RESULT

There were no intrahospital complications and just one posthospital complication. In the case of the patient who later died, repeated and unauthorized removal of the upper arm brace occurred in the nursing institution resulting in a lesion of the radial nerve. Of the four patients who completed treatment, three were very satisfied with the outcome of treatment. The mean DASH (Disabilities of Arm, Shoulder and Hand) and Oxford shoulder scores were on average 74 and 25 points, respectively. At the time of the follow-up examination all patients were free of pain, without the use of analgesics; however, there were still some limitations in the activities of daily life, which in three of the four patients was similar to the results following implantation of the fracture prosthesis.

CONCLUSION

The conservative treatment of PPHF can be a safe treatment option in multimorbid and chronically ill patients. A close outpatient control and good patient compliance are important. In incompliant and dementia patients, the risk of failure of conservative treatment is increased.

Validation of a new classification for periprosthetic shoulder fractures

INTRODUCTION

Successful treatment of periprosthetic shoulder fractures depends on the right strategy, starting with a well-structured classification of the fracture. Unfortunately, clinically relevant factors for treatment planning are missing in the pre-existing classifications. Therefore, the aim of the present study was to describe a new specific classification system for periprosthetic shoulder fractures including a structured treatment algorithm for this important fragility fracture issue.

METHODS

The classification was established, focussing on five relevant items, naming the prosthesis type, the fracture localisation, the rotator cuff status, the anatomical fracture region and the stability of the implant. After considering each single item, the individual treatment concept can be assessed in one last step. To evaluate the introduced classification, a retrospective analysis of pre- and post-operative data of patients, treated with periprosthetic shoulder fractures, was conducted by two board certified trauma surgery consultants.

RESULTS

The data of 19 patients (8 male, 11 female) with a mean age of 74 ± five years have been analysed in our study. The suggested treatment algorithm was proven to be reliable, detected by good clinical outcome in 15 of 16 (94%) cases, where the suggested treatment was maintained. Only one case resulted in poor outcome due to post-operative wound infection and had to be revised.

CONCLUSIONS

The newly developed six-step classification is easy to utilise and extends the pre-existing classification systems in terms of clinically-relevant information. This classification should serve as a simple tool for the surgeon to consider the optimal treatment for his patients.