Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature

Prior fragility fractures are associated with a higher risk of 8-year complications following total shoulder arthroplasty

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications.

PURPOSE

As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture.

METHODS

Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery.

RESULTS

The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001).

CONCLUSIONS

Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

LEVEL OF EVIDENCE

III.

Evaluation and treatment of postoperative periprosthetic humeral fragility fractures

Postoperative periprosthetic humeral shaft fractures represent a growing and difficult complication to treat given the aging patient population and associated bone loss. Determining the best treatment option is multifactorial, including patient characteristics, fracture pattern, remaining bone stock, and implant stability. Possible treatment options include nonoperative management with bracing or surgical intervention. Nonoperative treatment has been shown to have higher nonunion rates, thus should only be selected for a specific patient population with minimally displaced fractures or those that are unfit for surgery. Surgical management is recommended with prosthetic loosening, fracture nonunion, or failure of nonoperative treatment. Surgical options include open reduction and internal fixation, revision arthroplasty, or hybrid fixation. Careful evaluation, decision making, and planning is required in the treatment of these fractures.

[Revision surgery in reverse shoulder arthroplasty : Management of the most common complications]

BACKGROUND

In recent years, the number of reverse shoulder arthroplasty implantations has increased continuously and a higher number of revision surgeries due to complications can be expected in the future. Current data show a mean complication rate for RSA of around 4%. The most common complications are instability, infection, component loosening, and periprosthetic fracture.

TREATMENT OPTIONS

Revision surgery for RSA is challenging, and an individual treatment plan is necessary. For prosthetic instability, different operative or non-operative treatment options are available. Revision surgery for periprosthetic infection with replacement of the prosthesis is usually necessary for infection management. The treatment of periprosthetic fractures is based on techniques of general fracture treatment and depends on the fracture type. Knowledge of complications and risk factors may decrease complication rates in primary reverse shoulder arthroplasty in the future.

Is the Posterior Approach With Posterior locking compression plate and Anterior Allograft Useful and Safe in the Treatment of Periprosthetic Humeral Fractures Following Reverse Total Shoulder Arthroplasty?

Introduction

As the reverse total shoulder arthroplasty (RTSA) surgery has dramatically increased in the last few decades, many complications have followed through. The periprosthetic fracture, at the moment, is still a subject of debate in the orthopedic world. In this monocentric study, along with a literature review of periprosthetic humeral fractures, we would present our institutional experience with the treatment of periprosthetic humeral fractures with a posterior humeral approach, posterior cortex plate fixation, anterior strut allograft, screws, and cerclage wires.

Materials and Methods

Our study consisted in a prospective monocentric study based on 18 patients, with a mean age of 75.3 years (range 64–88), all following a reverse shoulder total arthroplasty (RTSA). Postoperative follow-ups were taken at 1, 6, and 12 months with objective measurement of shoulder motion and strength, while clinical outcome measures were assessed using the American Shoulder and Elbow Surgeons (ASES score) and visual analog scale (VAS) for pain. Together with that, we performed a literature review focused on the management of periprosthetic humeral fractures after shoulder arthroplasty.

Results

All fractures consolidated without complication at a mean 4.2 months (range 3–6). At final follow-up, the average active shoulder flexion was 88° (range 62–129°), active abduction 73° (range 52–91°) and active external rotation 22° (range 3–56°). The average ASES score was 73 (range 59–97), while average VAS score was 1.1 (range 0–3).

Discussion

Surgical treatment of periprosthetic humeral fractures following a shoulder arthroplasty remains a hard challenge for every surgeon, and their treatment must consider fracture’s location, displacement, and local bone quality.

Conclusions

The posterior approach with a posterior plate placement and anterior strut allograft, which is appliable only in case of a B or C type fracture according to Worland classification, could be a good treatment option for periprosthetic humeral fractures.

Mechanical complications and fractures after reverse shoulder arthroplasty related to different design types and their rates: part I

The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.Zumstein et al defined a 'complication' following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient's final outcome.High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture. Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039.

Intermediate to long term results of stemless metaphyseal reverse shoulder arthroplasty: A five to nine year follow-up

BACKGROUND

Shoulder arthroplasty incidence is increasing as is the volume of revision surgeries. Revision surgery is easier if humeral bone stock is preserved with minimal bone defects and osteolysis. This has led to an increased focus on the development of various short stemmed and stemless implants which provides stable fixation whilst preserving humeral bone stock.

PURPOSE

To review the medium to long term clinical and radiological outcomes, complications and survival rates of a stemless reverse shoulder prosthesis.

PATIENTS AND METHOD

Patients with a minimum follow-up of 60 months following a reverse stemless shoulder arthroplasty were deemed eligible. Clinical and radiological data on twenty-one patients operated between 2009 and 2014 were recorded prospectively. Survivorship and patient recorded symptoms with the end point of revision surgery were recorded.

RESULTS

Mean follow-up of 78 months (60-114 months). Mean range of active elevation was 136° (80-170°). Mean range of active abduction and active external rotation was 122° (70-170°) and 47° (10-75°) respectively. Mean Oxford score improved from 12 pre-operatively to 44 at final follow up (p < 0.0001). Mean Constant Murley Score improved from 18 to 72 (p < 0.0001). Mean ADLEIR score of 13 pre-operatively increased to 32 post-operatively (p < 0.0001). Notching was seen in 23.5% of cases and no radiolucent areas were observed around the glenoid component. There were two cases of post traumatic peri-prosthetic fractures that were managed conservatively and one case of deep-seated infection that required a washout. The survivorship at the most recent follow-up was 100%.

CONCLUSION

The advantages of bone preservation with the stemless metaphyseal prosthesis combined with encouraging medium to long term clinical and radiological results are very promising, particularly with the improved post-operative patient satisfaction scores. This is the first study that reports the results with a minimum of 5 year follow-up and has the longest mean follow-up period.

CLINICAL RELEVANCE

The reverse stemless shoulder prosthesis is an effective and reliable option for elective shoulder arthroplasty.

[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.