Fractures during shoulder arthroplasty surgery - how might they be avoided, what is the role of short stems?

 Intraoperative Fractures in Shoulder Arthroplasty: Risk Factors and Outcomes

These authors characterized the incidence of intra-operative fracture during shoulder arthroplasty and sought to identify risk factors for these fractures using an institutional database of shoulder arthroplasties (N = 1,773; 994 anatomic, 779 reverse).

They documented twenty-one (1.2%) intra-operative fractures (20 of the humerus one of the glenoid), the majority of which (91%) occurred in reverse shoulder arthroplasties compared to anatomic procedures (overall incidence:2.5% vs 0.2%). There were 7 intra-operative fractures of the greater tuberosity (33.3%), 8 metaphyseal fractures (38.1%), and 6 diaphyseal fractures (28.5%).

This study did not assess the effect of osteopenia on fracture risk.

Fractures occurred most commonly during either stem broaching (33%) or seating (33%), and were most likely to involve the metaphysis (53%) or greater tuberosity (33%). 5 fractures occurred during revision arthroplasty while 16 fractures occurred during primary procedures (overall incidence: 3.0 vs 1.0.

Risk factors included female gender, liver disease, and the use of short stems: 95% of the humeral fractures occurred with metaphyseal-fitting short stems while only 1 (5%) occurred with diaphyseal-fitting long stems. 

Comment: This study calls attention to the risk of fracture with short humeral stems in reverse total shoulder arthroplasty. Impaction grafting of a standard stem may provide a safer approach, especially if bone quality is an issue; see this link.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Obesity is a risk factor for dislocation, fracture, and revision after shoulder arthroplasty

Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis

These authors conducted a systematic review to investigate the impact of obesity ( (body mass index > 30 kg/m2) on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

They found that patients who were obese were at increased odds of a dislocation (OR, 2.49; 95% confidence interval [CI], 2.32-2.66), fracture (OR, 1.92; 95% CI, 1.77-2.08), and revision (OR, 1.49; 95% CI, 1.40-1.58) following TSA or RTSA. 

Comment: Shoulder arthroplasty is most often an elective procedure. Obesity appears to be a risk factor for surgical complications, but is also likely to be associated with risks of medical complications, such as obstructive sleep apnea, deep venous thrombosis, and pulmonary emboli. 

To see a YouTube of our technique for a total shoulder arthroplasty, click on this link.

To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse shoulder arthroplasty with two Wright Medical designs

Grammont humeral design versus onlay curved-stem reverse shoulder arthroplasty: comparison of clinical and radiographic outcomes with minimum 2-year follow-up

These authors assessed the outcomes of two Wright Medical reverse total shoulder designs: Grammont (below left) or an onlay curved short-stem humeral component (below right) in 68 patients with cuff tear arthropathy.

Both prostheses provided significant differences between preoperative and postoperative scores and both provided similar postoperative shoulder mobility. 

The lateralized curved stem was associated with higher delta scores for external rotation (P = .002) and lower rates of scapular notching (P = .0003), glenoid radiolucency (P = .016), and humeral bone remodeling (P = .004 and P = .030 for cortical thinning and spot weld, respectively).

Complications were reported for 8% (3 of the 36) Aequalis II Grammont prostheses: two dislocations and one "feeling of instability" all managed without surgical revision.

Complications were reported for 18% (7 of the 38) Ascend Flex curved stems: two fractures of the scapular spine (treated without surgery) and an acromial fracture treated with surgery. In this group there were three infections, and one case of instability. There were two shoulders in the Ascend Flex group that had prosthesis revision surgery: one because of instability and one because of infection.

Comment: It is not clear how patients were assigned to receive one prothesis or the other and it is not clear whether the same surgeons used both prostheses or whether some surgeons used the Grammont and other surgeons used the onlay short stem.

In any event, it is not clear from this study whether there is an advantage to the patient of one design or the other.

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Use the "Search" box to the right to find other topics of interest to you. 

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Economics and shoulder surgery - how much will the sea change?

Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures

These authors note that low socioeconomic status and Medicaid insurance as a primary payer have been associated with major disparities in resource utilization and risk-adjusted outcomes for patients undergoing totaljoint arthroplasty.

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database they identified patients who were treated for proximal humeral fractures (PHFs) from 2002 to 2012.

In an effort to minimize confounding variables, each Medicaid patient was matched to a privately insured patient on the basis of gender, race, year of procedure, and age (but notably not to fracture type or type of treatment):

Of the 678,831 patients treated with PHF, 4.9% (33,263) had Medicaid as the primary payer during the 10-year period. Medicaid patients were found to have a significantly higher risk (P < .05) of postoperative in-hospital complications, including postoperative infection (odds ratio [OR], 2.00 [1.37-2.93]), wound complications (OR, 1.69 [1.04-2.75]), and acute respiratory distress syndrome (OR, 1.34 [1.15-1.59]).

They concluded that Medicaid patients have a significantly higher risk for certain postoperative hospital complications and consume more resources after treatment for PHFs.

Comment: It is apparent that our health care system is on the cusp of change with the new administration. Under most any system, however, the observation that Medicaid insurance (which provides relatively low reimbursement) can be a risk factor for an increased rate of complications and for increased per-case expense will continue to create an ethical, social and economic challenge for the providers. This is especially the case if there are penalties for the increased readmission rates that are likely to be necessary to manage the increased rate of complications. Our hope is that broad-based discussion will lead to a well-informed approach so that our patients can get the care they need.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Failed prosthesis for fracture: the 'absent tuberosity sign'

One of the most difficult aspects of proximal humeral fracture surgery is getting the tuberosity reduced, fixed and healed. This problem is not made easier by placing a large humeral implant, which reduces the amount of bone left to reattach the displaced tuberosity.

Here's an example of this problem: a shoulder with pseudoparalysis after a post-traumatic deformity was treated with a total shoulder. Note on the AP view that the tuberosity is missing (there is no bone lateral to the arrow).

The axillary view shows the displaced, ununited greater tuberosity fragments (arrows) as well as some anterior translation of the humeral head on the glenoid.

Revision of this prosthesis to a reverse total will be complicated by (1) the bony ingrowth surface on the humeral prosthesis 

as well as (2) the bone loss that may occur when the glenoid component is removed.

Unless the tuberosity can be mobilized and fixed securely, a primary reverse total shoulder might have been a consideration at the index surgery, as shown in the x-ray below of a reverse total shoulder  (also with an 'absent tuberosity sign').

Note that, in contrast to our usual impaction grafting approach, this stem needed cement for control of prosthetic height and version.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Periprosthetic fracture of the humerus below an arthroplasty stem - fixation with plate and dodging screws

A lady sustained a fracture below the stem of the humeral prostheses. A repair was attempted at another hospital using a plate and circlage wires. 

However, this fixation did not have adequate purchase on the upper fracture fragment and it failed and became infected. The plate was removed.

After the infection resolved, the patient came to our colleague Jason Hsu who securely repaired the fracture using a long plate and dodging screws that pass anterior and posterior to the stem of the implant.

Comment: Fixation of periprosthetic fractures can be a major challenge.

One of the main issues is getting rotational control of the two fragments, recognizing the torque that can be applied to the distal fragment by the hand and forearm when the elbow is flexed. This is a particular issue when the glenohumeral joint is stiff.

Conversion to a long stemmed prosthesis requires removal of the extant implant, which can be very difficult. Circlage wires may not be effective in controlling rotation, especially if the bone around the fracture site is soft.

When possible we prefer to retain the prosthesis and fix the fracture with dodging screws as shown in this case and here.

Dr Hsu pointed out that the use of a broad plate allows for more flexibility in screw placement.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Short stem press fit humeral component with periprosthetic fracture

While some surgeons are interested in short stemmed humeral prostheses, these prostheses carry a risk of stress shielding (see here) if the distal end of the implant is wedged in the diaphysis, as seen below.

Another consequence of a wedged short stem is periprosthetic fracture as shown by a case that presented to us this week (x-rays below)

For these reasons we continue to prefer a standard length stem inserted without endosteal reaming or broaching and with impaction grafting (see below), so that the distal end of the prosthesis is not wedged in the diaphysis. This approach is intended to minimize the risk of stress shielding and periprosthetic fracture.

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Fracture fixation complicated by Propionibacterium

An otherwise health man in his 60s sustained this fracture.

It was treated by open reduction and internal fixation

Four months later he was having pain and stiffness. 

Seven months later his symptoms were worse.

He presented to a different physician who removed his hardware. After that his films looked like this.

He presented for shoulder arthroplasty. There was no clinical evidence of infection. All labs were normal. There was no cloudy joint fluid or synovitis. We sent multiple tissue samples for cultures and proceeded to perform a total shoulder. 

After surgery he was placed on the yellow protocol. A week later he was changed to the red protocol because four of his specimens grew out Propionibaterium. Three of the positive cultures were from the humeral bone and one from the synovium. Two of the cultures had two different colony types.


Comment: While he is doing very well at two months after his surgery, only time will tell if his infection was successfully managed by his surgery and antibiotics.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

CTA prosthesis in a skier - subsequent fracture.

Two years ago an active skier in his seventies presented with cuff tear arthropathy as shown in the x-ray below.

He had active elevation above 90 degrees and wanted to return to skiing so he chose a CTA arthroplasty instead of a reverse total shoulder to minimize the risk of serious fracture in the case of a fall.

This procedure was performed with impaction grafting to avoid the stress riser effects of a cemented prosthesis and that of a stem tightly fit in the diaphysis.

He returned to active skiing and subsequently returned to have the same procedure performed on his opposite side.

Again he returned to skiing with minimal complaints related to his shoulders.

He took a fall and sustained this fracture. Note that is is not a periprosthetic fracture - it took place below the tip of his prosthesis.

At 2.5 weeks his local doctors were concerned about lack of alignment as shown on this film and were considering operative treatment.

However, we pointed out that the above film was taken with the arm in external rotation, rather than in the sling position. We recommended keeping the arm in a sling and avoiding external rotation.

Five weeks after the fracture we were sent the films below showing good alignment and early healing.

We are anticipating that he'll be back on the slopes again next year.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Acromial fractures after reverse total shoulder arthroplasty

Classification of postoperative acromial fractures following reverse shoulder arthroplasty.

Acromial / scapular spine fractures are noted in approximately 5% of patients having reverse total shoulders. These authors investigated 18 patients having pain along the acromion or scapular spine after a reverse total shoulder.

Pausing there for a moment, this scenario strongly suggests a fatigue fracture of the acromion/scapular spine no matter what the imaging findings might be (compare to a runner who after increasing the workouts develops pain and transverse tenderness across the mid/distal tibia). 

Anyway, the authors set out to investigate the ability of observers to detect these fractures on radiographs and to  establish fracture union (again, isn't resolution of the pain a pretty good way to track progress to union?).

In this series, if radiographic findings were negative, computed tomography (CT) scans were performed. Sixteen of the 18 had radiographic confirmation of fracture.  The authors tried to classify the fractures on the basis of the imaging studies (again, wouldn't clinical exam localize the fracture in relation to the anatomy of the acromion and scapular spine?). 

In their classification,  type I included fractures through the mid part of the acromion, involving a portion of the anterior and middle deltoid origin; type II fractures involved at least the entire middle deltoid origin with a portion but not all of the posterior deltoid origin; type-III fractures involved the entire middle and posterior deltoid origin. Among the 16 with radiographic confirmation, there were 2 type Is, 8 type IIs, and 6 type IIIs.

The clinical outcomes were poor in 1 of 2 of the type Is, 1 of 8 of the type IIs and in both of the type IIIs.

These cases came from a series of  157 reverse shoulder arthroplasties (152 patients) performed by a single surgeon over a period of fifty-six months, from November 2006 through July 2011.  This is a rate of 10%, higher than those often reported. It would be really nice to know how the patients in this series with fractures differed from those who did not have recognized fractures with respect to factors such as age, gender, bone quality, lengthening of arm, component selection and more. From this information we might learn how to avoid these problems in the future.

Well, within 24 hours of putting up the post above, we get a call that one of our patients who had a reverse in November of 2012 and who had been doing exceptionally well, put her arm out to the side and felt a sudden soreness over the back of her shoulder blade. On exam she was able to pinpoint the tender spot - the mid scapular spine (zone II in the illustration below). Knowing the diagnosis at that point, we reviewed the plain images obtained by another provider.

The scapular spine crack can be seen between the ends of the two black lines in the image below.

We plan to reduce her arm use for 6 weeks in anticipation that this fracture will heal.

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.