Since the approval in 2004 of the use of reverse total shoulder arthroplasty (RTSA) in the United States,1 the number of total shoulder arthroplasties (TSAs) performed each year has increased, in part because of the increasing use of RTSA.2 Simultaneously, the number of complications is also increasing at a rate faster than that of any other type of arthroplasty.3 Complications of RTSA include aseptic loosening, glenohumeral instability, rotator cuff tear, infection, neural injury, deltoid dysfunction, and periprosthetic fracture.4–8 Periprosthetic fracture of the humerus after shoulder arthroplasty is uncommon, with a reported incidence of 1% to 2%.4,6,7,9,10 The incidence of postoperative periprosthetic humeral shaft fracture after RTSA is not widely reported, and the literature provides little direction regarding optimal treatments for and outcomes of this complication.
Treatment of periprosthetic humeral fractures after hemiarthroplasty or anatomic TSA is well documented, and current treatment options for periprosthetic humeral fractures were developed according to experience treating fractures after hemiarthroplasty and TSA.6,7,9–13 The stability and function of the reverse prosthesis depends on the compression between the humeral socket and glenosphere and is enhanced by the increased deltoid tension created by medializing the center of rotation and lengthening the humerus.14 Theoretically, a humeral fracture that occurs proximal to the deltoid insertion with displacement and shortening may cause instability of the components and/or worse outcomes if the proper length is not restored. Therefore, fracture tolerances that may be acceptable after anatomic TSA or hemiarthroplasty may not be acceptable after RTSA.
The authors report their experience with 5 patients with periprosthetic humeral fracture after RTSA, who were initially treated nonoperatively regardless of fracture pattern or humeral stem stability. This study received institutional review board approval.
Materials and Methods
Between 2012 and 2017, 152 RTSAs (147 primary and 5 revision procedures) were performed at the authors' institution by one of the authors (U.S.). Of these patients, 100 were women and 52 were men. Their mean age at the time of RTSA was 69 years (range, 46–91 years).
The authors included all patients with a periprosthetic humeral fracture who could complete outcome questionnaires. Five patients (4 women) with 5 periprosthetic humeral shaft fractures met the inclusion criteria (Table 1). Four fractures occurred after primary RTSA, and 1 occurred after revision RTSA. Four patients had undergone RTSA by the same surgeon, and 1 patient had undergone RTSA at another institution and was referred to the authors for fracture treatment. Of the 5 patients who underwent primary RTSA, the indications were acute proximal humerus fracture (n=2), fracture sequelae (n=1), rotator cuff arthropathy (n=1), and revision of a failed hemiarthroplasty for a proximal humeral fracture (n=1). The mean patient age at the time of fracture was 68 years (range, 54–76 years). The mean duration of follow-up was 11.5 months (range, 1.5–26 months).
Patient Characteristics, Fracture Characteristics, and Treatment Methods for 5 Patients With Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty
Fractures were classified by location relative to the distal tip of the humeral implant, according to the system of Wright and Cofield7: type A, fractures at the tip of the prosthesis with extension proximally; type B, fractures at the tip of the prosthesis with minimal or no extension proximally and variable extension distally; and type C, fractures distal to the tip of the prosthesis. Although the Wright and Co-field system is the most commonly cited classification system for periprosthetic fractures, it has poor interobserver reliability.15 All classifications in this study were performed by 1 author because the Wright and Cofield system has high intraobserver reliability.15 Fracture location was categorized according to the 4 regions of the humerus described by Campbell et al10: region 1, greater or lesser tuberosity; region 2, proximal humeral metaphysis; region 3, proximal diaphysis; and region 4, mid- and/or distal humeral shaft. Fracture pattern was categorized as transverse, oblique, spiral, or comminuted.
Fracture angulation and displacement were graded according to the system of Wright and Cofield7 as none; mild (angulation, 1º–15º; displacement, less than one-third of the humeral shaft diameter); moderate (angulation, 16º–30º; displacement, one-third to two-thirds of the humeral shaft diameter); or severe (angulation, 30º or greater; displacement, greater than two-thirds of the humeral shaft diameter).7
Osteopenia was graded radiographically according to the system of Campbell et al,10 which is based on the ratio of the sum of the widths of the mid-diaphyseal cortices to the diameter of the diaphysis as follows: severe osteopenia, less than 20%; mild osteopenia, 25% to 50%; and normal bone, greater than 50%.
Treatment and Outcomes
All patients were initially treated with a splint followed by a fracture brace or sling worn for 6 to 8 weeks. Patients were followed clinically and radiographically until, at minimum, fracture union. Clinical fracture union was defined as a painless fracture site on examination. Radiographic fracture union was defined as evidence of bridging bone on 2 views without evidence of instrumentation failure.16 In patient 4, fracture union was confirmed intraoperatively. If fracture union did not occur, patients were followed until surgery. Follow-up after fracture union was performed at regular intervals as is standard after TSA. The outcomes the authors analyzed were fracture incidence; time to fracture union; Single Assessment Numeric Evaluation (SANE) score; visual analog scale (VAS) score for pain; 1-year mortality rate; complications; strength in abduction, external rotation at the side, and internal rotation at the side (measured using manual muscle testing on a scale of 0 to 5); and active shoulder range of motion in forward elevation, abduction, external rotation at the side, external rotation at 90° of shoulder abduction, internal rotation, and internal rotation with the shoulder at 90° of shoulder abduction. Strength tests were performed after fracture union was achieved, which was typically 5 months after initiation of treatment.
Fracture Incidence and Classification
The incidence of periprosthetic humeral shaft fracture in this series was 2.6% (4 of 152 patients). One patient was referred to the authors for fracture treatment after undergoing RTSA at another institution and was not included in the incidence calculation. Patients 1 and 2 had type C fractures, patients 4 and 5 had type A fractures, and patient 3 had a type B fracture (Table 1).
Patients 1 to 4 experienced fracture union with nonoperative treatment at a mean of 4.4 months. The active ranges of shoulder motion for the 5 patients at their most recent follow-up visit are listed in Table 2. (Data reported for patient 4 were obtained 1.5 months after nonoperative treatment, before the patient experienced a second fracture.) 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°). Internal rotation around the back to the lumbar spine was achieved in 1 patient, to the sacrum in 2 patients, to the hip in 1 patient, and to the greater trochanter in 1 patient. Strength testing was performed after fracture union was achieved. Data were available for all patients except patient 4, who had a second fall before fracture union and underwent open reduction and internal fixation (ORIF). The strength scores (excluding the patient who had a second fracture) for abduction were 5 in 2 patients, 4+ in 1 patient, and 4 in 1 patient. The strength scores for external rotation at the side were 5 in 1 patient, 4+ in 1 patient, 4 in 1 patient, and 3 in 1 patient. Strength scores for internal rotation at the side were 5 in 3 patients and 4 in 1 patient. The mean VAS score for pain for the 5 patients was 3.4 of 10 (range, 0–8). The mean SANE score was 55 of 100 (range, 20–85). Two patients (patients 3 and 4) died during the follow-up period. Patient 3 died 23 months after his periprosthetic fracture because of complications associated with end-stage renal disease. Patient 4 had a history of chronic obstructive pulmonary disease and died from pneumonia 5 months after her initial periprosthetic facture. The 1-year mortality rate among patients who experienced a periprosthetic fracture after RTSA was 50% (2 of 4 patients), whereas the 1-year mortality rate among patients who did not experience a periprosthetic humeral shaft fracture after RTSA was 2.0% (3 of 148 patients).
Outcomes and Complications of 5 Patients With Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty
Complications were radial nerve palsy (patient 1), acromial stress fracture (patient 3), second periprosthetic fracture after a subsequent fall (patient 4), and hypertrophic nonunion treated with surgery (patient 5) (Table 2).
The radial nerve palsy occurred at the time of fracture. At 10 weeks after fracture, the patient showed no signs of recovery. Magnetic resonance imaging neurography showed entrapment of the nerve at the fracture site. Four months after fracture, the patient underwent nerve and muscle transfers.
At 6 weeks after treatment initiation, patient 4 experienced a second periprosthetic humeral shaft fracture in a different location after a fall. She chose to undergo ORIF of the second fracture. At the time of surgery, the prosthetic stem was stable and the initial fracture was healed. The new fracture was stabilized with a 3.5-mm locking compression plate (DePuy Synthes, Warsaw, Indiana), screws, and cerclage cable.
Patient 5 underwent surgery to treat nonunion. Initial radiographs showed a nondisplaced fracture around the prosthetic stem. The patient was treated with a Sarmiento brace but did not comply with brace wear. Displacement of the fracture was noted at 6-week follow-up, but the patient chose to continue non-operative treatment. She subsequently developed a hypertrophic nonunion and underwent ORIF 3 months after the fracture. The reverse joint was stable at the time of surgery, although the humeral stem was loose, but not grossly unstable. The authors treated the fracture with ORIF and retained the original stem to avoid additional surgical dissection and operative time.
As the indications for RTSA continue to expand, more surgeons will be faced with the challenge of treating periprosthetic humeral fractures. The authors have reported on 5 patients who were initially treated nonoperatively for periprosthetic humeral shaft fractures after RTSA (Figures 1–5). The incidence of periprosthetic humeral shaft fractures after RTSA is not widely reported. The authors report an incidence of 2.6%, which is similar to the 1.97% reported by García-Fernández et al.17 The current authors' finding is also similar to the 1% to 2% incidence reported after anatomic TSA and hemiarthroplasty.4,6,7,9,10
Patient 1, a 67-year-old woman who experienced a low-energy mechanical fall from standing height 7 months after undergoing cemented reverse total shoulder arthroplasty for a proximal humeral fracture malunion. Anteroposterior radiograph of the shoulder in a fracture brace showing a spiral fracture distal to the prosthetic stem with 18° of apex lateral angulation, 10° of apex posterior angulation, and more than two-thirds of cortical width translation (A). Anteroposterior radiograph at 1-year follow-up showing fracture union (B).
Patient 2, a 73-year-old woman who experienced a low-energy mechanical fall from standing height 34 months after undergoing cemented reverse total shoulder arthroplasty for an acute fracture. Anteroposterior radiograph showing a Wright and Cofield type C fracture in Campbell region 4. The patient was treated with a Sarmiento brace (A). Anteroposterior radiograph showing fracture union at 7 months (B).
Patient 3, a 76-year-old man who experienced a mechanical slip and fall from standing height 5 months after undergoing cemented reverse total shoulder arthroplasty for an acute fracture. Anteroposterior radiograph showing a Wright and Cofield type B fracture in Campbell region 4 (A). Anteroposterior radiograph at 6-month follow-up showing fracture union (B).
Patient 4, a 73-year-old woman who experienced a mechanical fall from standing height 4 months after undergoing uncemented reverse total shoulder arthroplasty and latissimus/teres major tendon transfer for rotator cuff arthropathy. Anteroposterior radiograph after the patient experienced a second fall 3.5 months after the original injury showing a transverse fracture just distal to the end of the humeral stem (A). Anteroposterior radiograph after open reduction and internal fixation (B).
Patient 5, a 54-year-old woman with a Wright and Cofield type A fracture in Campbell region C 7 months after revision to reverse total shoulder arthroplasty after failed hemiarthroplasty performed for an acute fracture. Anteroposterior radiograph showing a minimally displaced fracture around the prosthesis (A). Anteroposterior radiograph after open reduction and internal fixation (B).
Periprosthetic humeral shaft fractures are different from native humeral shaft fractures, in which nonunion rates have been reported as low as 1% after nonoperative treatment and 10% after operative treatment.18 The rate of nonunion is higher after nonoperative treatment of periprosthetic humeral shaft fractures.7,9,15,19–21 Fractures that involve the prosthetic stem tip (the most common location) are most likely to result in nonunion.4 This likely is attributable to the stress riser that exists at the metal-bone interface.22 In the current series, 4 of 5 fractures treated nonoperatively healed. Patient 5, who was noncompliant with fracture bracing, developed a hypertrophic nonunion. In patient 4, the initial periprosthetic fracture healed; however, 6 weeks after initiating treatment, she experienced another fall causing a periprosthetic fracture in another location and chose to undergo ORIF. Both of these patients had a history of alcoholism. The mean time to fracture union in the current study was 4.4 months. Other studies have reported on fracture union after nonoperative treatment of periprosthetic humeral shaft fractures.10,22,23 Atoun et al22 reported on 3 metaphyseal fractures that were treated nonoperatively, and all healed. García-Fernández et al17 reported on 1 Wright and Cofield type A fracture that healed at 4 months. These results differ from those of Andersen et al,15 who reported on 7 patients with a 100% failure rate of nonoperative treatment after a mean of 7 months of fracture bracing. In all reports of such fractures treated operatively, there have been no reports of non-union.
The most common cause of this type of injury is a low-energy fall.10,23 Other reported mechanisms include motor vehicle accidents,9,19 skiing,20 and manipulation under anesthesia.19 Four of the current 5 patients experienced low-energy falls from standing height. Patient 5 fractured her humerus while supporting her body weight on her elbow. Interestingly, 3 of 5 patients received their initial RTSA for an acute proximal humeral fracture or fracture sequelae after a low-energy fall. The risk of a periprosthetic fracture for patients who underwent RTSA for proximal humeral fractures was 4.3% (2 of 46) vs 1.9% (2 of 106) for all other indications. The higher incidence of periprosthetic fractures in the former could be related to balance issues that predisposed the patients to further injury.
Information regarding the treatment and outcomes of postoperative periprosthetic humeral shaft fractures after RTSA is limited to a few case reports and case series, most of which include fractures treated operatively.15,17,21,22,24–32
There are few data on the nonoperative treatment of this complication. Atoun et al22 reported on 3 cases that healed with “good function” after nonoperative treatment. García-Fernández et al17 reported no complications in a Wright and Cofield type A fracture treated nonoperatively. Andersen et al15 reported a 100% failure rate of nonoperative treatment after a mean of 7 months of fracture bracing.
Current treatment options are based on research of fractures occurring after anatomic TSA or hemiarthroplasty. Campbell et al10 recommend against functional bracing because of the risks of immobilization, such as stiffness and skin breakdown. However, they stated that “fractures that are distal to the prosthesis in patients with stable and well-functioning shoulders, cast or orthosis immobilization is a reasonable alternative, particularly if the patient is older or has severe osteopenia.”10 Kumar et al12 also recommended nonoperative treatment for fractures that occur distal to the prosthetic stem tip if an acceptable closed reduction can be obtained using an orthosis. In their series of 16 patients who had periprosthetic humeral shaft fracture around an anatomic TSA or hemiarthroplasty, they recommended a trial of nonoperative treatment for Wright and Cofield type B and type C fractures with a well-fixed humeral component. However, in their series, 4 of 5 type B fractures treated nonoperatively failed to heal and eventually required surgery. Therefore, they recommended that surgery be considered for a type B fracture that has not progressed toward union by 3 months. Regarding type A fractures, they recommended nonoperative treatment unless the humeral component is loose. They noted that because of the substantial overlap between the length of the fracture and that of the humeral stem, the humeral component has a high likelihood of being loose. If this is the case, they recommended revision with a cemented long-stem component. Type C fractures, located distal to the tip of the prosthesis, respond well to nonoperative treatment.6,10,19 A high rate of nonunion has been reported in most case reports and studies of the nonoperative treatment of type A and type B fractures.7,9,15,20,21 The current authors agree with the recommendation by Kumar et al12 that a 3-month trial of nonoperative treatment is useful for type A fractures with a well-fixed humeral component, well-aligned type B fractures, and type C fractures. In the current series, the authors note 2 cases in which the stem had signs of loosening or was confirmed to be loose at the time of surgery. The one treated nonoperatively went on to heal, and the patient declined further surgery to address the humeral stem (Figure 2). The other was treated only with ORIF, and the patient (patient 4) was satisfied, suggesting that this approach may be an alternative to revision to a cemented long stem.
This study was limited by its retrospective design and small number of patients. Few studies have reported on the operative and nonoperative treatment of these challenging fractures, and most have included only 1 to 10 patients.7,10,13,21,25,26 Therefore, a direct comparison of outcomes after nonoperative vs operative fixation is difficult. Many variables, such as patient age, initial diagnosis, surgical history, history of revision arthroplasty, and comorbidities, influence decisions about treatment. Conclusions based on limited data can be misleading. Therefore, the authors present their data without making specific treatment recommendations.
Many factors must be considered when customizing treatment for patients with periprosthetic fracture after RTSA, including the patient's age and functional level, degree of osteopenia, location and configuration of the fracture, and stability of the humeral stem. A trial of nonoperative treatment seems to be appropriate for most fracture patterns, particularly for type A fractures with a well-fixed humeral component, well-aligned type B fractures, and type C fractures, but studies with a larger patient population are needed to confirm this recommendation.
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Patient Characteristics, Fracture Characteristics, and Treatment Methods for 5 Patients With Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplastya
|Variable||Patient 1||Patient 2||Patient 3||Patient 4||Patient 5|
|Age at time of fracture, y||67||73||76||72||54|
|Extremity (dominance)||Right (dominant)||Left (nondominant)||Left (nondominant)||Right (dominant)||Left (nondominant)|
|Indication for RTSA||Fracture sequelae||Acute fracture||Acute fracture||Rotator cuff arthropathy||Revision after failed hemi-arthroplasty|
|Time from fracture to RTSA, mo||7||34||5||4||7|
|Initial treatment||Fracture brace||Fracture brace||Fracture brace||Sling||Fracture brace|
Outcomes and Complications of 5 Patients With Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty
|Outcome||Patient 1||Patient 2||Patient 3||Patient 4||Patient 5|
|Time to fracture union, mo||3||7||6||1.5||NA|
|Complication||Radial nerve palsy||None||Acromial stress fracture||Second fracturea||Hypertrophic nonunionb|
|Before fracture assessment|
| Active range of motion|
| External rotation||10º||NA||NA||30º||0º|
| Forward elevation||110º||NA||NA||130º||90º|
| Internal rotation around the back||NA||NA||NA||Sacrum||NA|
| External rotation||NA||NA||NA||NA||5|
| Internal rotation||NA||NA||NA||NA||5|
| SANE score||80||NA||30||70||80|
| VAS score for pain||0||NA||2||3||3|
| Active range of motion|
| External rotation||10º||5º||30º||30º||0º|
| Forward elevation||100º||45º||110º||70º||90º|
| Internal rotation around the back||Hip||Greater trochanter||Lumbar||Sacrum||Sacrum|
| External rotation||4||3||4+||NA||5|
| Internal rotation||5||4||5||NA||5|
| SANE score||85||30||85||20||60|
| VAS score for pain||0||7||0||8||2|