[Periprosthetic humeral fractures: Strategies and techniques of revision arthroplasty]

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.

Inadvertent, intraoperative, non- to minimally displaced periprosthetic humeral shaft fractures in RTSA do not affect the clinical and radiographic short-term outcome

INTRODUCTION

Little information is available on the clinical and radiographic outcome of intraoperative, non- to minimally displaced humeral fractures that occur during implantation of a stemmed, reverse shoulder prosthesis but are only recognized on routine postoperative radiographs. The goal of this study is to report the clinical and radiographic outcome for this rarely reported fracture type.

MATERIALS AND METHODS

39 conservatively treated non- to minimally displaced intraoperative periprosthetic humeral fractures after stemmed RTSA were detected from our radiographic database between 1.1.2006 and 31.1.2018. Exclusion criteria were lack of patient consent, preoperative humeral fracture, and revision arthroplasties. Clinical (absolute and relative Constant score, the Subjective Shoulder Value) and radiographic (conventional radiographs) assessment was performed preoperatively, at 6 weeks (only radiographically) and at latest follow-up with a minimum follow-up of 2 years.

RESULTS

35 patient's with a mean age of 72 years (range 32-88, SD ± 11 years) and a mean follow-up of 53 months (range 24-124, SD ± 31) were included in the study. At latest follow-up, all clinical outcome parameters except external rotation improved significantly. A complication rate of 17% (n:6) was recorded. At 6 weeks after the index surgery, none of the radiographs showed a fracture displacement or a sintering of the stem. At latest follow-up, all fractures were healed and no stem loosening was observed in any of the shoulders.

CONCLUSIONS

Non- to minimally displaced intraoperative periprosthetic humeral fractures in RTSA have an incidence of about 5% in this series of mainly uncemented press-fit stems. They generally heal without any further treatment and are not associated with stem loosening or compromise the clinical outcome after primary RTSA. Except slight restriction in the postoperative rehabilitation protocol, no further attention or action is needed.

[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.