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.

===
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.

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

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.

===

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.

Periprosthetic joint infections and chronic antibiotic suppression - what can we learn from the hip and knee folks?

Chronic Suppression of Periprosthetic Joint Infections with Oral Antibiotics Increases Infection-Free Survivorship.

While we know that periprosthetic hip and knee infections play by different rules than periprosthetic  infections of the shoulder, there is something to learn from this report.

These authors reviewed the records on all irrigation and debridement procedures with polyethylene exchange and two-stage revisions performed from 1996 to 2010 for hip or knee periprosthetic joint infection. They defined 'chronic suppression' as post debridement treatment with oral antibiotics for a minimum of 6 months after an initial course of IV antibiotics.  These patients were compared with a matched cohort (ratio of 1:3) who did not receive chronic oral antibiotics.   

For the antibiotic-suppression group the five-year infection-free prosthetic survival rate was 68.5% and 41.1% for the non-suppression group. Stratification by the type of surgery and the infecting organism showed a higher five-year survival rate for the patients in the suppression group who underwent irrigation and debridement with polyethylene exchange (64.7%) compared with those in the non-suppression group who underwent irrigation and debridement with polyethylene exchange and a higher five-year survival rate for the patients in the suppression group who had a Staphylococcus aureus infection (57.4%) compared with those in the non-suppression group who had a Staphylococcus aureus infection (40.1%).

Comment: The of mix bacteria treated in this study and the types of procedures are different from those we regularly encounter with periprosthetic infections of the shoulder; however, we do subscribe to the use of chronic oral antibiotics after the surgical and IV antibiotic treatment of shoulder infections - most commonly Propionibacterium or coagulase negative Staph. Our approach to shoulders suspected of having a periprosthetic infection is shown in this link. 

What is not discussed in this paper and should not be overlooked is the potential risks of long term antibiotics, especially of pseudomembranous enterocolitis from Clostridium Difficile. Patients on a protracted course of antibiotics should be carefully monitored for this and other adverse events.

A final comment is that the delayed, 'stealth' presentation (see this link) of Propionibacterium or coagulase negative Staph infections makes it very difficult to determine an "infection-free prosthetic survival rate" for shoulder infections.

===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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.

Propionibacterium periprosthetic infections of hip, knee and shoulder

Treatment of prosthetic joint infections due to Propionibacterium

These authors conducted a retrospective cohort study to evaluate treatment success at 1- and 2-year follow-up after treatment of 60 Propionibacterium-associated prosthetic joint infections (PJI) of the shoulder, hip, and knee at a median duration of 21 (0.1-49) months  39 patients received rifampicin combination therapy, with a success rate of 93% (95% CI: 83-97) after 1 year and 86% (CI: 71-93) after 2 years. The success rate was similar in patients who were treated with rifampicin and those who were not.

Most of the blood tests for inflammation were unremarkable. On average 6 specimens were sent for culture and on average 3 of these were positive for Propi. The specifics of the culturing protocol for Propi is not explained.

An open debridement and prosthesis retention was performed if an early postoperative or acute hematogenous PJI was diagnosed. Those patients with a late chronic infection were managed with a 2-stage exchange arthroplasty. Patients who, preoperatively, were not suspected of having an infection, e.g. with aseptic loosening, polyethylene wear, instability, or prosthesis dysfunction, were treated with a 1-stage exchange arthroplasty. In these patients, a PJI was therefore diagnosed from positive intraoperative cultures.

The combination of surgery and long-term antibiotic treatment postoperatively resulted in an overall success rate of 93% at 1-year follow-up and 86% at 2-year followup. At two year followup 7 of 36 patients had failed - four with evidence of ongoing infection with Propionibacterium and 3 with an infection by a different organism.

Comment: One of the first things to catch our eye was the number of Propionibacterium periprosthetic infections identified for the hip and knee. Up until recently, Propi infections were thought to be primarily in the shoulder. Most of the patients presented with the 'stealth' mode typical of Propi:  49 of the 60 patients with pain and 25 with stiffness.

The results of this series combining three different joints are quite similar to those we have previously note for the shoulder. Perhaps our hip and knee colleagues should consider the possibility of Propionibacterium periprosthetic infections in those patients with apparently 'aseptic' joint pain and stiffness.

In that this was not a prospective study, it is difficult make robust conclusions about the role of Rifampin in the management of these infections. There is no question that Rifampin can complicate the postoperative course by interfering with the action other medications the patient may need.



===

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.

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

Managing periprosthetic infections: Is there a place for spacers and the two-stage?

The Fate of Spacers in the Treatment of Periprosthetic Joint Infection.

These authors identified 504 cases of periprosthetic joint infection (326 knees and 178 hips) treated with resection arthroplasty and spacer insertion as part of a two-stage exchange arthroplasty. 

The mean follow-up duration after initial spacer implantation was 56.2 months. Reimplantation occurred in the joints of 83% of 504 cases. Of these 417 cases, 80% had a minimum one-year follow-up, and 82% of these had successful treatment. The mean duration from resection arthroplasty to reimplantation was 4.2 months (range, 0.7 to 131.7 months). 12% of the 504 joints required interim spacer exchange(s). Of the eighty-seven cases that did not undergo reimplantation, 7% required amputation, 6% underwent a Girdlestone procedure, 5% underwent arthrodesis, and 83% underwent spacer retention. Thirty-six patients died in the interstage period.

Thus of the 504 cases, one out of five did not complete the second stage of the planned two-stage treatment. Of those who did, one out of seven had a subsequent infection.

The authors concluded that the commonly held belief that two-stage exchange arthroplasty carries a high success rate for the eradication of periprosthetic joint infection may need to be reexamined. A considerable number of patients undergoing the first stage of a two-stage procedure did not undergo a subsequent reimplantation for a variety of reasons or required an additional spacer exchange in the interim. Reports on the success of two-stage exchange should account for the mortality of these patients and for patients who never undergo reimplantation.

Comment: This is an article about the use of antibiotic impregnated spacers which, for many, is the preferred method for the management of hip and knee periprosthetic infections. We include it on the shoulder blog because the analysis is compelling and it seems reasonable to believe that the results for the use of spacers in the shoulder would be similar.

The culture results of this study (shown below) are interesting. We can wonder if some of the culture negative joints might have had Propionibacterium that could have been overlooked because the challenging culture approaches for this organism were not in place.

We would like to call attention to related study: Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. These authors reviewed the literature on the treatment of patients with infected total hip arthroplasties and used these data to conduct a Markov cohort simulation decision analysis. They found that the 12 month and the 10 year models favored direct-exchange revision over the two-stage approach, regardless of whether surgeon or patient-derived utilities were used. 

We use a single stage primary exchange to a hemiarthroplasty for cases of suspected periprosthetic shoulder infections, recognizing that the diagnosis of an infection may not be made until week after the procedure. Our approach is described in greater detail here.

===

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.

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

Infection in shoulder arthroplasty - are we winning the battle?

Periprosthetic shoulder infection in the United States: incidence and economic burden

These authors used the Nationwide Inpatient Sample from 2002 to 2011 to study hemi, total and reverse total shoulder arthroplasty with specific reference to periprosthetic joint infection (PJI). They found that the rate of PJI remained essentially constant at 1% over this period. The risk of PJI was heightened by (1) weight loss/nutritional deficiency, (2) drug abuse, and (3) anemia from blood loss  or iron deficiency - each with an odds ratio of about 2. The risk was also increased in younger and male patients. Doing the math, the authors concluded that the increasing incidence of shoulder arthroplasty and a constant infection rate will result in greater overall shoulder PJI burden.

Comment: The concern with these numbers is that they are very likely to underestimate the actual rate of periprosthetic infections after shoulder arthroplasty. The authors used a methodology similar to that employed in identifying infection rates in the hip and knee arthroplasty population using the NIS database by identifying shoulder PJI from ICD-9 diagnosis code 996.66 (prosthetic infection) in conjunction with the shoulder prosthesis codes (81.80, 81.81, 81.88, 80.01). While this methodology captures cases diagnosed with PJI during the primary arthroplasty hospitalization as well as those that underwent arthrotomy and removal of arthroplasty hardware for diagnosis of infection, it is unlikely to capture periprosthetic infections with Propionibacterium (the most common organism cultured from failed arthroplasties) because these cases are frequently thought to represent 'aseptic' failure of the arthroplasty and because they often present late after the index joint replacement.  It seems likely that a substantial number of these cases would not be coded 996.66.  This problem does not exist (at least to the same extent) in hip and knee infections where Propionibacterium is relatively rarely identified.

The bottom line is that the problem of shoulder PJI is distinct from that in hip and arthroplasty where we appear to be winning the battle; in the shoulder, the battle is just beginning.

===
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.

What what are the antibiotic sensitivities of Propionibacterium acnes isolated from orthopaedic implant-associated infections?

Antibiotic susceptibility of Propionibacterium acnes isolated from orthopaedic implant-associated infections

These authors investigated the susceptibility of 55 clinical isolates of P. acnes, obtained from orthopaedic implant-associated infections of the knee joint (n = 5), hip joint (n = 17), and shoulder joint (n = 33), to eight antimicrobial agents: benzylpenicillin, clindamycin, metronidazole, fusidic acid, doxycycline, moxifloxacin, linezolid and rifampicin. Synergy testing was also conducted, in which rifampicin was combined with each of the remaining seven antibiotics.

Phylogenetic typing based on tly sequence analysis showed that 31 isolates were type IA, 13 isolates type IB, and 11 isolates type II.

All isolates (n = 55) were susceptible to most of the antibiotics tested, with the exception of 100% resistance to metronidazole, five (9.1%) isolates displaying decreased susceptibility to clindamycin, and one (1.8%) to moxifloxacin.

None of the antimicrobial agents investigated were synergistic with each other when combined and nine isolates were antagonistic for various antimicrobial combinations. The majority of the antimicrobial combinations had an indifferent effect on the isolates of P. acnes. However, the combination of rifampicin and benzylpenicillin showed an additive effect on nearly half of the isolates.

Comment: This article is very interesting from a number of standpoints:

(1) 22 of the 55 isolates came from hip and knee infections - Propionibacterium is not just a shoulder issue
(2) Clindamycin is not universally effective against Propionibacterium. This is important in that many surgeons use this antibiotic for prophylaxis.
(3) Rifampin appears to be a useful adjunct against Propionibacterium.

Here is another important presentation regarding antibiotics and Propionibacterium. It makes the important observation that a significant percentage of the bacteria isolated from acne patients are now resistant to the most common antibiotics used in acne treatment: Clindamycin, Erythromycin, Tetracycline, Doxycycline and Minocycline. We can only assume that the same is true for the Propionibacterium found in failed arthroplasty.

As our infectious disease experts point out, we seeing two worrisome trends: (1) there are fewer antibiotics available to us for the prevention and management of infections and (2) the bacteria are becoming increasingly resistant to the antibiotics that we do have.

===

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'

Periprosthetic shoulder infections with Propionibacterium - how many surgeries are needed?

Arthroscopic Tissue Culture for the Evaluation of Periprosthetic Shoulder Infection

The senior authors evaluated approximately 350 painful shoulder arthroplasties performed during the study time period. Of these, 19 patients had undergone culture of arthroscopic biopsy tissue during the evaluation of a possible chronic periprosthetic shoulder infection. None of the patients in the study population had concomitant elevation of the WBC, ESR, and CRP values. The mean age at the time of the index arthroplasty was 56.7 years, and the mean interval (and standard deviation) between the index arthroplasty and the arthroscopic biopsy was 3.0 ± 2.0 years (range, 0.7 to 7.7 years)

Of these 19, 10 had negative arthroscopic biopsy cultures and negative open biopsy cultures taken at the time of surgical revision.

For those shoulders with positive cultures, the mean time for the culture to turn positive was 10.1 ± 3.79 days (range, 5 to 18 days).

7 had positive arthroscopic biopsy cultures for Propionibacterium and positive cultures for this same organism at the time of surgical revision.

2 had positive arthroscopic biopsy cultures for Propionibacterium but no cultures were taken at the time of revision.

6 shoulder joint fluid aspirations were done on patients who were subsequently found to have positive biopsy cultures for Propionibacterium - only one of the aspirates was culture positive.

The authors performed complete removal of the prosthetic components and placement of a custom antibiotic spacer in eight of the nine patients with a positive arthroscopic tissue biopsy culture at a mean of 11.2 ± 8.9 weeks (range, 3.4 to 29.3 weeks). The ninth patient had a single stage revision without apparent recurrence of infection.

Comment: This is a retrospective study of a small percentage of the authors' patients having revision surgery. The authors state that "Arthroscopy was performed in patients for whom the diagnosis of periprosthetic infection could not be reasonably confirmed or refuted by the patient history, physical examination, imaging studies, and laboratory data." One would think that there would be more than 19 of the 350 painful arthroplasties that met these criteria. The case the authors show in figure one is a common scenario: A patient with two years of pain and stiffness after a left TSA. Laboratory results were normal, and there was no growth from a fluoroscopically guided glenohumeral aspiration. An anteroposterior radiograph showed notable radiolucency about the pegged glenoid component". As prior recent posts have pointed out, glenoid or humeral component loosening is strongly suggestive of the presence of Propionibacterium. Again, since glenoid component loosening is a primary cause of failure of total shoulder arthroplasty, one might expect more cases like that shown in figure 1 among the 350. 

It is of interest that the time between between the index arthroplasty and the diagnosis of positive cultures was long:  3.0 ± 2.0 years (range, 0.7 to 7.7 years). This is consistent with the results discussed in a prior post.

Perhaps a bigger question is the protocol to be used in evaluating shoulders for possible Propionibacterium and for treating shoulders with positive cultures. The protocol one might conclude from this paper is that, since as their data show, the presence of Propionibacterium is not at all excluded by the absence of clinical and laboratory evidence of infection, all revisions should be preceded by an arthroscopic biopsy under anesthesia. If the culture results are negative, then a single stage revision is performed. If the culture results are positive a two stage revision is performed. This means that revision of a failed shoulder arthroplasty would commonly require two or three surgical procedures. 

By contrast in our practice (as summarized here), we try to reduce the number of anesthetics to one by obtaining cultures at the time of the revision, performing a single stage prosthesis revision to an uncemented Vancomycin-impregnated impaction grafted hemiarthroplasty followed by systemic antibiotic treatment until the culture results are finalized (at which time the antibiotic program is modified by our infectious disease consultations). We have yet to find convincing data to support the routine use of cement spacers in the management of Propionibacterium-positive failed arthroplasties.

Finally, as shown in this paper, culture of needle aspirated joint fluid is helpful only if the culture is positive, but not it it's negative.

===

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'

Infections in shoulder arthroplasty - the role of biofilms

The term 'biofilm' refers to bacteria embedded in an extracellular slime layer consisting of polysaccharides, extracellular DNA, proteins and lipids. Biofilms can develop channels allowing for diffusion of nutrients to the embedded bacteria. Because of the limited ability of oxygen to enter, the biofilm provides a range of environments from aerobic on the surface to anaerobic at the depth. Spatial separation of metabolic environments allows for niches for different types of bacteria. Bacteria in biofilms behave differently from those in the free-floating (planktonic) form.

Biofilms can form on all orthopaedic implants, including metal, plastic, and cement. They can be found in fibrous membranes surrounding implants. Because they are viscoelastic liquids, they can resist detachment and can flow across surfaces.

Biofilms protect bacteria from host defenses (1) forming conglomerates too large for phagocytosis by inflammatory cells and  (2) blocking antibodies from diffusing in to reach the bacteria. They also protect the bacteria from antibiotics such that the levels a 1000 times greater concentration is required to kill bacteria in biofilms in comparison to planktonic bacteria.

Biofilms make bacteria difficult to recover. Even though a prosthesis has a bacteria-ladened biofilm, joint fluid aspiration may well be negative because the bacteria are not present in the fluid. Bacteria in biofilms are not easily recovered because conventional culturing methods may not dislodge the biofilm. Even if the biofilm is recovered, host factors such as endonucleases may prevent the bacteria from growing. Bacteria in biofilms may enter a dormant or slow growing phenotype that grows slowly or not at all in cultures.

Essentially all periprosthetic infections involve biofilms. These can progress very slowly and may be non-symptomatic for years. Biofilm infections may exert their pathological effects by triggering insidious tissue damage (such as bone resorption) rather than by creating the usual signs of inflammation. Thus it may be very difficult to differentiate prosthetic loosening from the chronic effects of a biofilm from 'aseptic' mechanical loosening. These infections do not resolve spontaneously and usually require surgical debridement and antibiotics.

Biofilms may serve as sources of more obvious planktonic infection if the biofilm is stimulated or if the host is weakened.

These observations regarding biofilms have informed our current approach to failed shoulder arthroplasty.

===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

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.

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.

===
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.

Humeral fractures after shoulder replacement

Surgically Treated Humeral Shaft Fractures Following Shoulder Arthroplasty

This is a report regarding 36 patients with humeral periprosthetic fractures treated surgically. 19 had loose humeral components and were treated with revision arthroplasty; the remainder were treated with internal fixation leaving the prosthesis in place. 17 had fractures around the humeral component of reverse total shoulders. 16 had severe osteopenia. After treatment 35 had healed in 3 to 14 months. The average ASES score was 50. Fourteen of the surgically managed fractures had complications including prosthesis failure, non union, radial nerve plasy, infection, and prosthesis loosening.

The authors emphasize the need for careful preoperative evaluation and presurgical planning in that a wide variety of surgical techniques were required.

It is of note that many of these fractures appear to have involved the tip of a cemented or press fit prosthesis where an abrupt transition in structural properties of the humerus takes place.

On the one hand we need to explore ways for humeral component fixation that avoid this critical stress riser and on the other hand we need to advise our patients about minimizing the risk of falling, especially when they have soft bone into which a stiff prosthesis has been inserted.

---

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.

See from which cities our patients come.

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