Short Stem Reverse Total Shoulder Arthroplasty Periprosthetic Type A Fracture

Periprosthetic proximal humerus fractures require an individualized treatment approach-results of a multicenter retrospective study

BACKGROUND

In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications.

METHODS

Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated.

RESULTS

A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77 years. PPHF occurred a mean of 50 months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4, stem replacement 1).

CONCLUSION

The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions.

LEVEL OF EVIDENCE

Level IV, epidemiologic study.

Periprosthetic Postoperative Humeral Fractures After Shoulder Arthroplasty

The increased utilization of shoulder arthroplasty, including revision procedures, combined with rises in life expectancy, is expected to translate into a substantial increase in periprosthetic humeral fractures. The evaluation and management of these fractures needs to be updated to consider fractures that complicate anatomic and reverse arthroplasties and contemporary short-stem and stemless implants. Although conservative treatment is successful in a large proportion of these fractures, several surgical reconstructive techniques are required for the management of all fracture types. Surgical options include internal fixation, graft augmentation, standard revision procedures, and occasionally complex reconstructions including modular segmental prosthesis and allograft prosthetic composites. Most studies on the outcomes of periprosthetic humeral fractures have analyzed small samples and have typically reported on anatomic total shoulders with a standard-length humeral implant. Additional research is required to optimize the management of periprosthetic postoperative humeral fractures in the era of reverse arthroplasty, short stems, and stemless arthroplasty.

Management of periprosthetic fractures of the humerus : a systematic review

AIMS

The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature.

METHODS

A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database.

RESULTS

Overall, 40 studies were included, involving a total of 210 patients. The fractures were reported using very heterogeneous classification systems, as were the functional outcome scores. A total of 60 patients had nonoperative treatment with a 50% rate of nonunion. Fixation was undertaken in 99 patients; successful union was obtained in 93 (93%). Revision of either the humeral stem or the whole arthroplasty was reported in 79 patients with a high rate of union (n = 66; 84%), and a mean rate of complications of 29% (0% to 41%).

CONCLUSION

This study highlighted a lack of uniformity in classifying these fractures and reporting the outcome of their treatment. The results may help to inform decision-making with patients, particularly about the rate of complications of nonoperative treatment. There is a need to improve the reporting of the pattern of these fractures using a uniform classification system, and the harmonization of the collection of data relating to the outcome of treatment. Based on this review, we propose a minimum dataset to be used in future studies. Cite this article: Bone Joint J 2022;104-B(4):416-423.

Nonoperative Treatment of Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty

Few studies report on periprosthetic humeral shaft fractures after reverse total shoulder arthroplasty (RTSA). The authors evaluated outcomes of 5 patients with this complication who were initially treated nonoperatively. Of 152 patients who underwent RTSA at the authors' institution from 2012 to 2017, 4 experienced periprosthetic humeral shaft fractures. One patient was referred to the authors for fracture treatment. All 5 patients were initially treated nonoperatively. The mean duration of follow-up was 11.5 months (range, 1.5-26 months). The authors analyzed time to fracture union, Single Assessment Numeric Evaluation (SANE) score, visual analog scale (VAS) score for pain, and active shoulder range of motion. Fracture union occurred in 4 patients treated nonoperatively at a mean of 4.4 months. Mean SANE score was 55 of 100 (range, 20-85). Mean VAS score was 3.4 of 10 (range, 0-8). Mean forward elevation was 83° (range, 45°-110°); mean abduction was 65° (range, 45°-80°); and mean external rotation with the arm at the side was 15° (range, 0°-30°). Many factors must be considered when customizing treatment for patients with periprosthetic fracture after RTSA. This case series indicates that nonoperative treatment of postoperative periprosthetic humeral shaft fractures can be successful. [Orthopedics. 2020;43(6):e553-e560.].

Periprosthetic Fractures in Reverse Total Shoulder Arthroplasty: Current Concepts and Advances in Management

PURPOSE OF REVIEW

Expanded indications for reverse total shoulder arthroplasty (RSA) have raised awareness of associated complications, including periprosthetic fractures. The purpose of this article was to provide a comprehensive update on how, when, and why RSA-related periprosthetic fractures occur, as well as to describe the current treatment strategies.

RECENT FINDINGS

Periprosthetic acromial and scapular spine fractures occur in up to 4.3% of cases and periprosthetic humeral fractures occur in approximately 3.5% of RSA procedures. Fractures of the coracoid process and clavicle have also been reported. Current literature has identified several risk factors for intraoperative or postoperative fracture, including underlying osteoporosis, revision arthroplasty, use of a superiorly placed screw during metaglene fixation, and disruption of the scapular ring by transection of the coracoacromial ligament. Periprosthetic fracture associated with RSA is a clinically significant event that warrants prolonged postoperative vigilance, timely diagnosis, and shared patient decision-making regarding treatment. Further research is needed to identify optimal treatment strategies and characterize long-term clinical outcomes following RSA-related periprosthetic fracture.