Periprosthetic fractures in total shoulder replacement

Abstract

Periprosthetic fracture is an uncommon complication of shoulder arthroplasty. Over an 18-year period, we identified 38 fractures occurring either during or subsequent to a shoulder arthroplasty. Among intraoperative fractures, the humeral shaft was involved in nine cases, the greater tuberosity in five, the proximal humeral metaphysis in two, the glenoid in four, and the coracoid process in two. Postoperative fractures involved the humeral shaft in 15 cases and the coracoid process in one. Thirty-three fractures occurred in women compared with five in men. Rheumatoid arthritis was the most common diagnosis. Our results suggest that intraoperative shaft fractures occurring at or below the stem tip can be successfully managed by using a long stem implant to bypass the fracture. Supplementary cerclage wires or cables are added if additional stabilization is needed. Eleven of the 15 postoperative shaft fractures were initially treated with a cast or brace. Nonoperative treatment led to union in 6 of the 11 (54.5%), but failed in 5. We recommend a trial of closed treatment if a satisfactory reduction can be obtained and maintained. If acceptable alignment cannot be achieved, or if delayed or nonunion develops, recommended surgical options include internal fixation with a plate if the prosthesis is well fixed, or revision with a long-stem prosthesis. Three of the four intraoperative glenoid fractures precluded glenoid resurfacing. Except for a nonunion in one case, greater tuberosity fractures did not impact the ultimate clinical outcome. Coracoid process fractures were also not clinically significant.