Conservative Treatment Achieving Bone Union in a Displaced Wright and Cofield Type B Periprosthetic Humeral Fracture After Reverse Shoulder Arthroplasty: A Case Report.

PHILOS plating of periprosthetic humeral shaft fracture after onlay-type reverse total shoulder arthroplasty: a case report

ObjectivesTo evaluate CT imaging findings in symptomatic patients with and without revision surgery (RS) after reverse shoulder arthroplasty (RSA).Materials and methodsIn this retrospective study, two radiologists assessed CT imaging findings in symptomatic patients with RSA over 5 years, including material fracture and loosening of the peg, baseplate, screws, and humeral stem, screw positioning, prosthesis dislocation, glenoid notching, fractures, and deltoid muscle quality. The primary outcome parameter was RS. Patients were assigned Group 1 (RS) or Group 2 (No RS).ResultsNinety-nine patients (mean age 70.4 ± 10.3 years, 61 females) met the inclusion criteria. Fifty-two patients (29 females) received RS after 34.0 ± 38.3 months. The only CT imaging finding significantly associated with RS was prosthesis dislocation (P = .007, odds ratio (OR) 10.95, 95% CI 1.34–89.24). All other evaluated CT imaging findings were not associated with RS. Yet, loosening of the peg (30% vs. 16%), baseplate (15% vs. 6%), and superior screw (18% vs. 7%) and periprosthetic humeral fractures (29% vs. 13%)—as common reasons for RS—were more frequent in patients with RS than in those without, however not reaching significance (P ≥ .11). The large majority of patients had glenoid notching (79% vs. 94%), irrespective of RS.ConclusionIn this cohort of symptomatic patients after RSA, prosthesis dislocation was the only CT imaging finding associated with RS. Besides, there was a trend with higher numbers of loosening of the peg, baseplate, and superior screw, as well as periprosthetic humeral fractures in patients with RS, though not reaching significance.

Where Are We Now? The frequency of shoulder arthroplasty in today's population has increased, in part due to the growing number of older patients with degenerative and traumatic disorders of the shoulder, as well as the extension of arthroplasty solutions to younger patients who feel they have exhausted reasonable nonsurgical alternatives. As a consequence, more revision shoulder arthroplasties should be anticipated. From its introduction for narrow indications into the United States more than a decade ago, reverse shoulder arthroplasty has emerged as the preferred treatment, in many instances, for failed shoulder arthroplasties that require prosthetic revision. However, the severity and frequency of complications with this approach are well described. It also is clear that patients undergoing reverse shoulder arthroplasty as part of a revision shoulder arthroplasty do not do as well as those undergoing reverse total shoulder arthroplasty for cuff-tear arthropathy, failed rotator cuff repairs, and posttraumatic sequelae. Part of this difference may derive from the need, in many instances, to remove the existing humeral prosthesis. The paper by Wagner et al. supports this idea; 16% (36 of 230) patients undergoing revision to a reverse total shoulder arthroplasty experienced an intraoperative humerus fracture, and most of these fractures occurred during removal of the humeral component. While the authors mention that the frequency of intraoperative fractures was higher during revision arthroplasty with a reverse versus anatomic component, the reader is left to speculate the reasons for the difference. Curiously, only in the presence of hemiarthroplasty, as opposed to total shoulder arthroplasty, was the risk of intraoperative fracture increased. Perhaps the majority of hemiarthroplasties were performed for fracture treatment, and resulted in variable patterns and degrees of tuberosity union, all of which may add complexity and risk to component explantation. Where Do We Need To Go? With nearly four decades of experience with shoulder arthroplasty at their institution, the authors are much better prepared than most surgeons to mitigate the occurrences and effects of intraoperative complications of shoulder arthroplasty, such as periprosthetic fractures of the humerus during revision reverse shoulder arthroplasty as reported in this paper. It would benefit the reader to know what technical measures the authors routinely undertook to minimize the risk of humeral fracture during revision reverse shoulder arthroplasty. Several questions regarding the risk factors associated with intraoperative humerus fractures during revision reverse shoulder arthroplasty remain, including (1) What alternate humeral implant removal techniques, some previously described but not used by the authors in this study, could prevent certain intraoperative periprosthetic humerus fractures? (2) What prophylactic options are available to reduce the chances of humeral fracture during the phases of implantation? (3) What characteristics did untreated greater tuberosity fractures (˜90%) have in common and how did they differ from the ones that underwent adjunctive fixation? (4) How did prior instability, a complication often attributable to multiple causes, emerge as a significant risk factor for intraoperative humerus fracture? (5) What are the influences of instability direction and reducibility? It seems intuitive that the explantation of a terminally incarcerated cemented or cementless humeral prosthesis should have a higher rate of humerus fracture than one that is loose or less securely fixed. (6) Depending upon the composition of the cohort of patients under study, is it possible that the fracture rate, outcomes, and even risk factors might be at variance with the present study? (7) What factors other than porosity of bone render the female sex at higher risk for intraoperative fractures of the humerus during revision reverse shoulder arthroplasty? (8) Is it possible to take advantage of the humeral prosthesis for fracture fixation, and if so, what are those opportunities? How Do We Get There? A number of aspects of management and effect on outcomes should be elucidated. The authors have generously shared their results and established their institutional benchmark for the incidence and outcome of a particular complication of revision reverse shoulder arthroplasty. At this point, the risk factors that have been exposed are, at best, only superficially understood. Demographics, diagnosis, tissue properties and the postsurgical pathological state are immutable. A clearer picture of risk will hopefully emerge with a better understanding of their interrelationships in this setting. While an accounting of details of the surgical technical method is vital to the understanding of iatrogenic humerus fracture, the influence of the intangible virtues of patience, anticipation, caution, and judgment cannot be overlooked. For example, an investigation of intraoperative periprosthetic greater tuberosity fractures might take into account not only their location, pattern, intrinsic stability, soft-tissue attachments, and opportunities to optimize fixation to the bone and the adjacent prosthesis but also how particular treatment decisions are synthesized. Superior prosthetic instability usually accompanies shoulder prosthetic failures resulting from irreparable rotator cuff tear and is probably the most common instability pattern encountered during prosthetic revision. It is important that future investigations seeking to corroborate the results of the present study more clearly define the direction and status of prosthetic instability and how it may come to bear on the incidence and influence of intraoperative periprosthetic fractures. Humeral bone preservation at the time of revision reverse shoulder arthroplasty is the key to successful implantation of the revision humeral prosthesis. While aseptic prosthetic humeral loosening is rare, many current humeral prostheses for cemented and cementless usage are equipped with design geometry and surface enhancements to facilitate long-term fixation. Additional information will be gained from investigations that take into account specific features of the humeral prosthesis and the collateral damage to the humerus anticipated coincident to its explantation. Likewise, future studies should evaluate the utility of the so-called platform humeral prosthesis, which can be implanted at the time of the index (anatomic) total shoulder arthroplasty, but which can be converted later to a reverse total shoulder arthroplasty should the need arise. Such an implant potentially obviates the necessity for entire humeral component removal perhaps with less risk to the structural integrity of the humerus in the revision setting.

Management of periprosthetic humeral fractures after shoulder arthroplasty: A case report on open reduction and internal fixation with strut allograft.

The purpose of this study was to record the incidence and management of periprosthetic humeral fractures (PHF) using reverse total shoulder arthroplasty (RTSA) in our institution. We performed a retrospective study of 203 RTSA implanted in 200 patients between 2003 and 2014. The mean follow-up was 78.82 months (range, 12-141). Mean age of the study cohort was 75.87 years (range, 44-88). There were only 25 male patients (12.5 %). We assessed the presence of periprosthetic humeral fractures studying the medical files and X-rays of all patients. We identified seven periprosthetic humeral fractures in 203 RTSA (3.4 %): three intra-operative (1.47 %) and four post-operative (1.97 %). The average age at the time of the fracture was 75.14 years (59-83). All patients were women (100 %). Three patients with post-operative fractures type B were treated by osteosynthesis, and one patient with post-operative fracture type A was treated conservatively. All intra-operative fractures needed cerclage wire and in one case long cemented stem. All our periprosthetic fractures healed. Surgical treatment with osteosynthesis in type B post-operative fractures with a stable stem is recommended. Conservative treatment is sufficient in non-displaced type A post-operative fracture. Special attention should be paid to bone quality patients using non-cemented stems in primary surgery but especially in revision shoulder surgery.

Primary stability of fixation methods for periprosthetic fractures of the humerus: a biomechanical investigation.

Occurring in 0.5-3% of cases, periprosthetic humerus fractures pose a challenge, necessitating effective management strategies. A comprehensive review was conducted using PubMed. Used terms included 'Periprosthetic humerus fractures; complications; periprosthetic fractures shoulder arthroplasty; periprosthetic humeral fracture treatment; nerve palsy humeral revision arthroplasty; infections after shoulder arthroplasty; postoperative complications AND open reduction AND humeral fractures; allograft AND long humeral stem'. Studies were excluded if they did not meet the actual topic, included more than primary shoulder arthroplasty and/or were in non-English or non-German language. Thirty-eight papers with evidence levels ranging from two to three were selected for this review. Various classification systems have been implemented; their validation though was based on studies with only a limited number of patients. Risk factors include osteopenia/osteoporosis, rheumatoid arthritis, age, age-related lifestyle and gender. Treatment options range from conservative approaches to plate osteosynthesis or revision to a longer stem. Nevertheless, there is a lack of biomechanic studies and randomized-controlled clinical studies; hence, the evidence is low. Complications in revision arthroplasty encompass infections, nonunions, and nerve palsies, highlighting the importance of individualized treatment planning. The management of periprosthetic humeral fractures requires careful consideration of risk factors and tailored treatment plans. Existing literature relies on small case series and expert opinions, highlighting the need for further research to establish optimal treatment strategies for these challenging fractures.

Bony increased-offset reverse shoulder arthroplasty vs. metal augments in reverse shoulder arthroplasty: a prospective, randomized clinical trial with 2-year follow-up.

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.].

Clinical results of bony increased-offset reverse shoulder arthroplasty (BIO-RSA) associated with an onlay 145° curved stem in patients with cuff tear arthropathy: a comparative study

IntroductionAs 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 MethodsOur 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.ResultsAll 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).DiscussionSurgical 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.ConclusionsThe 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.

There are few reports on the revision or reintervention of reverse total shoulder arthroplasty (RTSA) in South Korea. The purpose of this study was to evaluate the true incidence of complications and reintervention of RTSA and clinical and radiological outcomes based on our 14-year experience in RTSA in a Korean population. Between March 2008 and June 2022, 412 consecutive cases of RTSA were performed in 388 patients with an average age of 74.4 years at our institute. Excluding 23 patients lost to follow-up, 365 patients (373 shoulders including 8 bilateral cases) who underwent primary RTSA with more than 6 months of follow-up were enrolled in this study. We evaluated those who had complications or reintervention including revision RTSA for failed RTSA. Patient charts were reviewed, and clinical outcomes including clinical scores, complications, and reintervention and radiologic outcomes were evaluated at the last follow-up. Among the 373 shoulders that underwent primary RTSA, complications were found in 50 patients (13.94%, 10 men and 40 women with a mean age of 75.9 ± 6.7 years [range, 51-87 years]). The causes of complications were as follows: 13 acromion, coracoid, or scapular spine fractures, 10 loosening (glenoid: 5, humeral stem: 5), 5 infections, 4 periprosthetic fractures, 2 instability, 2 neurologic complications, and 14 miscellaneous complications. Twenty patients (5.63%, 4 men and 16 women with a mean age of 74.2 ± 8.2 years [range, 51-87 years]) underwent reintervention. The interval to the first reintervention was 27.8 ± 23.1 months (range, 0.1-78 months). The causes of reintervention (20 cases) were 8 loosening (glenoid: 4, humeral stem: 4), 5 infections, 5 fractures, and 2 instability. Among them, 15 component revisions (4.02%) were performed. At the last follow-up, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Simple Shoulder Test scores were improved from 25.4, 12.4, and 1.6 preoperatively to 40.4, 16.2, and 3.2, respectively. Forward flexion (48° to 87°), abduction (52° to 79°), external rotation (18° to 22°), and internal rotation (buttock to L2) were improved. After primary RTSA in a Korean population, the complication, reintervention, and revision rates were 13.94%, 5.63%, and 4.02%, respectively. Careful evaluation of the complications and adequate treatments should be performed.

Background/Objectives: Periprosthetic humeral fractures (PF) after reverse total shoulder arthroplasty (RSA) are expected to increase. This study investigated PF after RSA with short stems and reported outcomes. Methods: A total of 165 patients underwent short-stem RSAs between 2014 and 2023. Among them, patients who developed postoperative PFs were identified and classified by fracture location and stem loosening. Operative data, complications, and bone union time were analyzed. Clinical outcomes before injury and at final follow-up were evaluated. Results: PF occurred in 5/165 patients (3.0%). Based on our classification, four had type B1 fractures and one had a type B3 fracture. All underwent revision RSA (Re-RSA) with conversion to long-stem implants. Bone union was achieved in four patients, while one patient experienced infection without union. Among the four patients without complications, mean shoulder flexion declined from 138° pre-injury to 103°, abduction from 118° to 95°, external rotation from 37° to 31°, the American Shoulder and Elbow Surgeons (ASES) score from 82.0 to 68.7, Constant Score from 67 to 43, while the Visual Analog Scale (VAS) pain score increased from 1.7 to 2.6. Conclusions: All five cases of PF following short-stem RSA were stem-level (type B) fractures. All patients underwent Re-RSA using long-stem conversion. Four patients had bone union. Clinical outcomes at one year postoperatively had deteriorated mildly compared to pre-fracture. However, this change was not statistically significant. One patient had a postoperative infection, and bone union was not observed. This study indicates the need for caution regarding postoperative infections after RSA.

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.

Background and aim of the work: Post-operative periprosthetic shoulder fractures incidence is gradually raising due to aging of population and increasing of reverse total shoulder arthroplasty (RTSA). Management of this complication represents a challenge for the orthopedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of post-operative periprosthetic humeral fractures occurring on RTSA. Methods: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. Results: 31 studies including reviews, meta-analysis, case reports, clinical and biomechanical studies were selected. Conclusions: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation and revision arthroplasty are both valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate. (www.actabiomedica.it)