Periprosthetic Fractures Associated with Primary Total Shoulder Arthroplasty and Primary Humeral Head Replacement: A Thirty-three-Year Study - JBJS

Periprosthetic Fractures Associated with Primary Total Shoulder Arthroplasty and Primary Humeral Head Replacement: A Thirty-three-Year Study - JBJS describes the Mayo Clinic's experience with fractures during or after shoulder arthroplasty (total shoulder or humeral hemiarthroplasty). The majority of these fractures were of the humerus (shaft and tuberosities) in women with cemented humeral components. Risk was increased for patients with post-traumatic arthritis and poorer overall health (higher Deyo-Charlson scores, higher ASA class).  The cases below are not from this article, but are perhaps representative of the more serious periprosthetic humeral fractures.

This is an important article is that it points out that fragile bone and bone with post-traumatic deformity is at risk for fracture during and after arthroplasty surgery - extreme care is required during exposure and during prosthesis insertion to minimize the risk of this complication. 

We have sought to minimize the risk of intraoperative and postoperative humeral fractures by avoiding cement (which can create a stress riser at the end of the cement), by avoiding endosteal reaming (which can create a stress riser by notching the inside of the diaphysis), by avoiding a tight cortical fit of the prosthetic stem (which can create a stress riser at the tip of the prosthesis), and by avoiding forcing a too-large prosthesis into smallish bone.

Instead we use intramedullary reamers only to size the canal, stopping as soon as the reamer engages the endosteal surface ('love a first bite') and then using impaction grafting (also shown here and here) to build up the inside of the humeral shaft so that a snug fit is achieved without tight contact between the metal stem and the cortex. Here are five cases from our OR yesterday in which impaction grafting was used to fix the humeral component. 

So far, knock on wood, we've had neither humeral prosthesis loosening or periprosthetic fractures with this approach.

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