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Scientific Articles   |    
Periprosthetic Humeral Fractures After Shoulder Arthroplasty
Sanjay Kumar, MD, PhD1; John W. Sperling, MD1; George H. Haidukewych, MD1; Robert H. Cofield, MD1
1 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for J.W. Sperling: sperling.john@mayo.edu
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):680-689
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Abstract

Background: Currently, there is little information concerning periprosthetic humeral fractures after shoulder arthroplasty. Therefore, we reviewed our experience with these fractures to determine the results of treatment, the risk factors for periprosthetic fracture, and the rates of reoperation.

Methods: Between 1976 and 2001, nineteen postoperative periprosthetic humeral fractures occurred among 3091 patients who had undergone shoulder arthroplasty at our institution. Sixteen patients had a complete series of radiographs and were included in this study. The average time from the arthroplasty to the fracture was forty-nine months. Seven patients had severe osteopenia. Twelve fractures occurred at the tip of the prosthesis; of these, six extended proximally (type-A fractures) and six did not (type-B fractures). Three fractures occurred distal to the implant and extended into the distal humeral metaphysis (type-C fractures). One fracture occurred in the proximal metadiaphyseal region because of osteolysis.

Results: Six fractures healed after an average of 180 days of nonoperative treatment. Five fractures were treated operatively after an average of 123 days of unsuccessful nonoperative treatment. The remaining five fractures had immediate operative treatment. All sixteen fractures healed. One patient required multiple operations over a period of three years before union was achieved. With the exclusion of this patient and one other patient who received a custom prosthesis, the average time between the first operative procedure and union was 278 days.

Conclusions: Our data do not clearly indicate the need for operative treatment of type-A fractures unless the humeral component is loose. A trial of nonoperative treatment may be considered for well-aligned type-B fractures that are associated with a well-fixed humeral component; however, operative intervention should be considered for type-B fractures that have not progressed toward union by three months. If the component is well fixed, open reduction and internal fixation may be performed. If the component is loose, revision with a long-stem component is recommended. For type-C fractures, a trial of nonoperative treatment is recommended.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Robert H. Cofield
    Posted on August 06, 2004
    Drs. Cofield and Sperling respond:
    Mayo Clinic

    To the Editor:

    We appreciate Mr. Norris’ very relevant comments. Periprosthetic fractures after shoulder arthroplasty, even with stemmed implants, are very uncommon, being 0.46 percent in our patient group. However, as other complications decrease, such as symptomatic glenoid loosening, periprosthetic fracture is becoming a more prevalent complication. Importantly, however, the article was written to illustrate some of the difficulties in obtaining healing of these fractures, although healing almost always eventually occurs.

    Our article did not address intraoperative fractures, and these are even less common. We believe intraoperative fractures can be avoided by careful preoperative planning including preoperative templating; adequate exposure of the shoulder with complete soft tissue releases in the bursa and of the shoulder capsule to avoid torsional forces on the humerus; correct alignment of the instrumentation during bone preparation, including the use of intraoperative x-rays where this may be in doubt, such as in old fractures with some degree of malunion; and use of implant systems that offer a suitable number of prosthetic sizes so that one can obtain an optimal humeral fit. It is also well recognized that if a cortical defect in the humerus exists for some reason, the stem should bypass the defect by four to five centimeters.

    Mr. Norris mentions that he prefers surface replacement humeral arthroplasty,and this is a very reasonable treatment option. We have traditionally preferred to use a stem and continue to prefer that approach as we feel we can obtain better soft tissue releases, better prepare and fix the glenoid component, and achieve both proximal and distal fixation of the humeral component. Of course, when arthroplasty is chosen to treat comminuted fractures of the proximal humerus, stems are necessary.

    We agree that use of a stem can create some of the problems which lead to later fracture. In addition to a large number of these patients having pre-existing osteopenia in this series, three of the arthroplasties had complete radiolucent lines around the stem, and three had a shift in component position, all indicative of component loosening. In two, there was substantial osteolysis, and in one, reaming at surgery was slightly more then typical. So even though uncommon, the use of a stemmed component can create a situation that might engender a fracture subsequent to an injury.

    Mr.Norris mentions the ease of revision surgery with surface components. We would recommend that for those fractures with slight displacement and a well fixed humeral component, nonoperative treatment is sufficient, at least initially. For fractures with a well fixed component and substantial displacement, we recommend open reduction and internal fixation. Revision surgery is usually reserved for patients with a loose humeral component.

    These fractures can be very slow to heal: nonoperative treatment requires about six months and operative treatment about nine to twelve months to observe bone union. Thus, these are difficult fractures, and it is a very good idea to do a variety of things to avoid them when at all possible. Mr. Norris suggests one of the options to do so.

    Mark C Norris
    Posted on June 22, 2004
    Could periprosthetic fractures following shoulder arthroplasty be avoided by choice of implant?
    Princess Royal Hospital, Lewes Road, West Sussex RH16 4EX. United Kingdom.

    To the Editor

    We read with interest the article “Periprosthetic Humeral Fractures After Shoulder Arthroplasty” (2004;86:680-9), by Kumar et al.

    The authors state that periprosthetic fractures following shoulder arthroplasty are relatively uncommon. However, they also state that the prevalence of this complication is 2.4%[1] and that peri-prosthetic fracture may account for 20%[2] of all complications associated with total shoulder arthroplasty. Most of these injuries involve the humeral shaft and occur at the time of the operation[3].

    We use the Cementless Surface Replacement Arthroplasty CSRA (Copeland prosthesis). This prosthesis has published results equivalent to stemmed humeral implants[4,5]. The CSRA does not involve reaming or insertion of a stem into the humeral shaft thereby reducing risk of periprosthetic fracture. Only one case of periprosthetic fracture is noted in Levy and Copeland’s series[4]. This was easily revised using a stemmed prosthesis.

    We therefore feel that the results of CRSA are equivalent to those of a stemmed prosthesis and are associated with a reduced risk of periprosthetic fracture. If such a fracture does occur, it is easier to revise due to the preservation of bone stock.

    References

    1. Worland RL, Kim DY, Arredondo J. Periprosthetic humeral fractures: management and classification. J Shoulder Elbow Surg. 1999;8:590-4.

    2. Wirth MA. Periprosthetic fractures in the upper extremity. In: Rockwood D, Green DP, Bucholz RW, Heckman JD, eds. Fractures in adults. Philadelphia: J.B. Lippincott, 1996;1:540-576.

    3. Wirth MA, Rockwood CA. Current concepts review: complications of total shoulder replacement arthroplasty. J Bone Joint Surg [Am] 1996;78- A:603-16.

    4. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. 5-to 10-year results with the Copland Mark-2 prosthesis. J Bone Joint Surg [Br] 2001;83-B:213-21.

    5. Levy O, Copeland SA. Cementless surface replacement arthroplasty (Copeland CRSA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg 1993;13:268-71.

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