Management of peri-prosthetic fracture of the humerus with severe bone loss and loosening of the humeral component after total shoulder replacement

Abstract

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

Shoulder linked arthroplasty in patients with obstetric brachial plexus palsy can improve quality of life and function at short-term follow-up

“…This occurred early at a mean of 8 months, was nonprogressive, and was not associated with component subsidence. Although we have not observed this finding previously in complex SA with this device, 21,22 impaired limb movement in combination with the design may result in greater predisposition (the humeral stem is a conical distal loading device).…”

“…Four 3.5-mm or 4.5-mm cortical screws (DePuy Synthes, Solothurn, Switzerland) are used to achieve primary fixation into the lateral column of the scapula, base of coracoid, and body and spine of scapula. 21 Secondary fixation relies on bone or stable fibrous ongrowth to the hydroxyapatitecoated shell. A polyethylene liner is cemented into the glenoid shell to provide a constrained articulation with the humeral head.…”

Late Partial Dissociation of a Humeral Head Morse Taper Associated with Periprosthetic Proximal Humeral Fracture

“…The loose component may result in increased metallosis, which may lead to increasing pain and discomfort; however, we are aware of only one such instance following total shoulder arthroplasty in the literature, which occurred within two years postoperatively 11-13 . Our report indicates that glenoid loosening and humeral stem loosening are not the only two modes of late hardware failure in total shoulder arthroplasty 14,15 . Late dissociation of the humeral head from the stem after shoulder arthroplasty is possible and can be caused by a fracture.…”

Original Fixation Technique for Periprosthetic Humeral Fractures: Locking Plate for Lockable Stem

“…We believe that when there is a doubt about the stability of the implant, only intraoperative testing will allow us to decide. If the locking holes were accessible during the osteosyn- Kurma, et al [8] showed a mean time of 6 months for conservative treatment and Sewell, et al [9] reported bone union in 7 months after changing the stem. Campbell described achieving bone union in 2.3 months in patients who received intramedullary fixation (long stem that bridges the fracture and extends more than 3 cortical diameters beyond the fracture site), in 3.5 months in those who underwent conservative treatment and in 8.7 months in those who received a standard stem with a different internal fixation method.…”