Challenges and Outcomes in the Management of Periprosthetic Humeral Fractures: A Retrospective Study and Review of Current Approaches.

Abstract

Periprosthetic humeral fractures are a rare and increasing entity due to the rising number of shoulder arthroplasties. These fractures pose a significant challenge for surgeons, with incidence rates ranging from 1.2% to 19.4%. They can occur intraoperatively or as late complications, often influenced by trauma, prosthetic wear, or loosening. A retrospective study was conducted on all patients admitted with periprosthetic humeral fractures over a four-year period (2018-2022). Inclusion criteria were postoperative periprosthetic humeral fractures with a minimum follow-up of six months. Exclusion criteria included intraoperative fractures, fractures of the glenoid or coracoid process, and cases with follow-up of less than six months or incomplete data. The study included six patients with an average age of 83.1 years, predominantly female (four females andtwo males). All fractures occurred postoperatively: four on reverse shoulder prostheses, one on an anatomical prosthesis, and one on a hemiarthroplasty. The mechanism was low-energy trauma, with fractures occurring an average of 96 months post-initial surgery. Fractures were classified using the Campbell system: three in region 4, two in region 3, and one in region 2. Radiographs showed four cemented and two uncemented stems. Three patients underwent surgical treatment with either prosthetic replacement using a long stem and fracture cerclage or lockingcompression plate (LCP). The remaining three patients were treated conservatively with a Sarmiento brace due to advanced age, bone fragility, low functional demand, and comorbidities. Radial nerve palsy was a complication in two patients post-trauma, with one recovering fully and the other not recovering before death due to associated complications. All fractures consolidated within an average of seven months (range: 5-8 months).Functional recovery was satisfactory with a median Constant-Murley Shoulder Score of 69in surgically treated patients, with range of motion between 100 and 140 degrees. Only two conservatively treated patients achieved fracture consolidation, and functional recovery was inadequate. Managing periprosthetic humeral fractures remains challenging. Treatment goals include fracture healing, maintaining prosthetic stem stability, preserving glenohumeral motion, and restoring shoulder function. Despite various classification systems, the literature shows limited and variable data on incidence and treatment outcomes. Conservative treatment may be considered for stable implants and acceptable alignment, but surgical intervention is often necessary for displaced fractures or implant loosening. The management of periprosthetic humeral fractures requires a tailored, multidisciplinary approach to optimize outcomes and improve patient quality of life. With the increasing incidence of these fractures due to the growing use of shoulder arthroplasty, ongoing research and development of new techniques and therapeutic strategies are essential to address this clinical challenge effectively.