Suture cerclage for stabilizing the humeral shaft during shoulder arthroplasty

Operative and nonoperative treatment of periprosthetic humerus fractures after shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

Periprosthetic humerus fracture is a relatively rare complication following shoulder arthroplasty. As shoulder arthroplasty volume increases, more periprosthetic fractures are anticipated. Some surgeons routinely operate on humerus shaft fractures adjacent to a humeral stem, while others recommend first-line nonoperative treatment. The purpose of this study was to identify and describe the prevalence of operative and nonoperative treatment options for periprosthetic humerus fractures, their associated outcomes, and complications. Our goal was to provide clinical insights for surgeons on the outcomes and complications associated with various treatment options.

METHODS

We performed a systematic review of studies reporting clinical or radiographic outcomes and complications after operative or nonoperative treatment of postoperative periprosthetic humerus fractures following shoulder arthroplasty. Subgroup analysis was conducted for differences in surgical outcomes between open reduction internal fixation (ORIF) and revision arthroplasty.

RESULTS

Twenty studies met the inclusion criteria (196 humeri). The mean clinical follow-up period was 2.6 years. Most fractures were Cofield B (42%), followed by C (27%), and A (12%); 19% were not classified. Forty-two percent of index implants were reverse total shoulders, 27% anatomic total shoulders, 16% hemiarthroplasties, and 1% resurfacing; implant design was not reported for 14%. The average time from index procedure to fracture was 2.9 years. One hundred sixty-seven (85%) fractures were treated operatively, 26 (13%) were treated nonoperatively, and 3 (2%) were missing information. Overall complication rate was 46%. Nonoperatively treated fractures had a higher complication rate (69% vs. 43%, P = .04) and increased risk of malunion (19% vs. 1%, P = < .001). Nonoperative management failed in 57% of Cofield B fractures. Time to union was shorter in the ORIF group than the revision arthroplasty group (24 weeks vs. 30 weeks, P < .001). Among operatively treated fractures, revision arthroplasty was associated with more complications (61% vs. 25%, P = .04) and higher nonunion rates (22% vs. 0%, P = .008) than ORIF.

CONCLUSIONS

Complications may be more frequent than previously understood. With a 70% healing rate, nonoperative management is a viable treatment option, but should be weighed against high risk of complications and need for future procedures, especially in Cofield B fractures. Treatment with ORIF is associated with a higher union rate and fewer complications than revision arthroplasty.

Fish Mouth Closure of Horizontal Cleavage Tear of the Meniscus using Self-locking Modified Racking Hitch Knot (HitPat knot). - A Technical Note

Introduction

Horizontal cleavage tears (HCT) of the meniscus are treated with fish-mouth closure with sutures using different methods. Using a no. 0 fiber wire and taking bites through both the flaps using a suture passing device and tying multiple knots is a cost-effective technique. A racking hitch knot is an option for all inside repairs of HCT. It needs multiple half hitches for locking the knot.

Surgical Technique

We used a modification of the racking hitch knot (HP knot), making it a self-locking knot, so it does not need half hitches. Loop of no. 0 fiber wire is passed across both the flaps of the meniscus and a modified racking hitch knot tied in one goes closing the fish mouth.

Conclusion

This modification (HP knot) saves operative time, it is cost-effective and has the distinct advantage of a reduction in the size of the final knot construct.

Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series

PURPOSE

Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA.

METHOD

Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures.

RESULTS

Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection.

CONCLUSION

Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.

Lesser Tuberosity Osteotomy for the Management of the Subscapularis During Total Shoulder Arthroplasty

Subscapularis integrity is critical after anatomic total shoulder arthroplasty, with failure leading to potential instability, loss of function, and revision surgery. The three well-described subscapularis mobilization techniques during total shoulder arthroplasty include tenotomy, peel, and lesser tuberosity osteotomy (LTO). While several comparative studies exist, the optimal approach remains controversial. LTO has been associated with the highest healing rates, but techniques and repair constructs are highly variable. The purpose of this article was to provide an overview of LTO with attention on radiographic assessment, repair options, and clinical outcomes.

Periprosthetic fractures after shoulder arthroplasty: a systematic review

Purpose

The goal of this study was to review available literature on periprosthetic shoulder fractures to evaluate epidemiology, risk factors and support clinical decision-making regarding diagnostics, preoperative planning, and treatment options.

Methods

Two authors cross-checked the PubMed and Web of Science medical databases. The inclusion criteria were as follows: original human studies published in English, with the timeframe not limited, and the following keywords were used: 'periprosthetic shoulder fracture,' 'total shoulder arthroplasty periprosthetic fractures,' 'total shoulder arthroplasty fracture,' and 'total shoulder replacement periprosthetic fracture.' Seventy articles were included in the review. All articles were retrieved using the aforementioned criteria.

Results

The fracture rate associated with total shoulder arthroplasty varied between 0 and 47.6%. Risk factors for periprosthetic fractures were female gender, body mass index < 25 kg/m2, smoking, rheumatoid arthritis, and Parkinson's disease. The most commonly used classification is the Wright and Coefield classification. Periprosthetic fractures can be treated both, conservatively and operatively.

Conclusion

Periprosthetic fracture frequency after shoulder arthroplasty ranges from 0 to 47.6%. The most common location of the fracture is the humerus and most commonly occurs intraoperatively. The most important factor influencing treatment is stem stability. Fractures with stem instability require revision arthroplasty with stem replacement. Fractures with a stable stem depending on the location, displacement and bone stock quality can be treated both conservatively and operatively. For internal fixation plates with cables and screws are most commonly used.

Intraoperative periprosthetic humeral fracture during reverse shoulder arthroplasty: a sequelae of prior biceps tenodesis

Intraoperative periprosthetic humeral fractures are a rare but debilitating complication of reverse shoulder arthroplasty and can occur during multiple stages of the procedure. Prior biceps tenodesis has been found to reduce cortical humeral strength and predispose the patient to humeral fracture. We present a case of a 68-year-old female with a previous history of biceps tenodesis due to an irreparable rotator cuff tear. Months later, and after symptoms persisted, a reverse shoulder arthroplasty was performed. During the surgery and while performing final reduction, a fracture line was observed involving the hole used for the previous tenodesis procedure. The fracture was repaired, and the patient reported favorable outcomes. We report several factors that might have contributed to sustenance of this intraoperative fracture including prior biceps tenodesis, use of a press fit humeral stem, and the sex of the patient.

Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement

BACKGROUND

The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up.

METHODS

A retrospective analysis was performed on acute PHFs "with a medial calcar fragment" (group A) and "without a calcar fragment" (group B) treated with a RTSA and cementless metaphyseal stem fixation.

RESULTS

At an average follow-up of 6.7 years (5-7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference.

CONCLUSION

RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.

Biomechanical Value of a Protective Proximal Humeral Cerclage in Reverse Total Shoulder Arthroplasty

Reverse shoulder arthroplasty (RSA) is a commonly performed salvage procedure for failed proximal humeral fracture fixation. The rate of intraoperative periprosthetic fractures is higher compared to primary RSA. The goal of this study was to investigate the biomechanical value of a protective cerclage during stem impaction in a revision surgery setting. Twenty-eight fresh-frozen human humeri were used to assess different configurations for steel wire and FiberTape cerclages. A custom-built biomechanical test setup simulated the mallet strikes during the stem impaction process with the Univers Revers prothesis stem. The mallet energy until the occurrence of a first crack was not different between groups. The total energy until progression of the fracture distally to the cerclage was significantly higher in the cerclage groups compared to the native humerus (9.5 J vs. 3.5 J, respectively; p = 0.0125). There was no difference between the steel wire and FiberTape groups (11.4 J vs. 8.6 J, respectively; p = 0.2695). All fractures were located at the concave side of the stem at the metaphyseal calcar region. This study demonstrates that a protective cerclage can successfully delay the occurrence of a fracture during stem impaction in reverse shoulder arthroplasty. A FiberTape cerclage is biomechanically equally efficient compared to a steel wire cerclage.

Biomechanical comparison of different cerclage types in addition to an angle stable plate osteosynthesis of distal tibial fractures

BACKGROUND

Different stand-alone cerclage configurations and their optimal twisting techniques have been investigated over the years. This study tests for the stabilizing effect of different supplemental cerclage materials in combination with locked plating of distal tibia fractures.

METHODS

Locking plate fixation of a distal tibial spiral fracture was tested as stand-alone and with supplemental cerclage materials (one cable, two cables, wire, fiber tape). Construct stiffness and fracture gap movements were investigated under quasi-static and dynamic loads and compared to the stand-alone locking plate.

RESULTS

With each of the tested cerclages, stiffness was significantly higher than for a solitary plate osteosynthesis. Most reduction in fracture gap movement was achieved by cable cerclages, followed by double-looped wire and double-looped fiber tape cerclages. Under dynamic loading an additional cable cerclage reduces excessive gap movement.

CONCLUSION

Compared to solitary plate osteosynthesis all supplemental cerclage materials were generally superior with reduced fracture gap movements whereas cable cerclages showing the greatest stabilizing effect.

Is suture cerclage fixation a valid treatment for intraoperative nondisplaced calcar fractures in reverse total shoulder arthroplasties?

Background

Implantation rates of reverse total shoulder arthroplasties continue to grow worldwide. Despite satisfying results, a distinct number of complications persist. Intraoperative fractures of the humeral shaft might occur in a certain number of cases. The literature is sparse regarding incidence and treatment options. This study analyzed the treatment using suture cerclage or stainless-steel-cable cerclage.

Methods

Our prospectively followed-up cohort of 860 patients who received primary reverse total shoulder arthroplasty in a tertiary referral hospital between September 2005 and August 2018 was screened for intraoperative medial humeral calcar fractures. The patients were retrospectively analyzed as per the treatment algorithm using (1) suture cerclage with FiberWire, (2) cable cerclage with stainless steel cable, or (3) no intervention. The outcome was radiologically and clinically (Subjective Shoulder Value and Constant score) evaluated.

Results

A total of 39 (4.5%) intraoperative calcar fractures of the humeral shaft were identified with 29 cases available for analysis at a mean follow-up time of 52 ± 27 months. Sixteen of them were treated with suture cerclage, 7 with metal cable cerclage, and 6 without intervention. All fractures were nondisplaced or could be reduced anatomically and healed without any stem subsidence or loosening within the first 4.5 months. The intervention groups reached similar values for the Subjective Shoulder Value (68%±27% vs. 79%±19%, suture vs. cable) and relative Constant score (65 % ± 25 % vs. 75 % ± 23).

Conclusion

Intraoperative medial calcar fractures can be sufficiently treated with metal or suture cerclage fixation. High-strength polyblend-polyethylene sutures seem to be a valid therapeutic option for selected medial calcar fractures of the humerus. In selected cases, however, benign neglect can result in excellent results as well.