Nonoperative periprosthetic humeral fracture treatment may achieve union
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Published results showed nonoperative treatment of periprosthetic humeral shaft fractures after reverse total shoulder arthroplasty may achieve fracture union.
Of 152 patients who underwent reverse TSA, Uma Srikumaran, MD, MBA, MPH, and colleagues identified five patients who experienced postoperative periprosthetic humeral shaft fracture, including two type A fractures, one type B fracture and two type C fractures. Researchers treated the five patients with a splint followed by a fracture brace or sling worn for 6 to 8 weeks and analyzed time to fracture union, single assessment numeric evaluation (SANE) scores, VAS score for pain and active shoulder range of motion.
Results showed four patients achieved fracture union with nonoperative treatment at a mean of 4.4 months. The mean SANE score was 55 and the mean VAS score was 3.4. The mean forward elevation was 83°, mean abduction was 65° and mean external rotation with the arm at the side was 15°, according to results. Researchers found complications included radial nerve palsy, acromial stress fracture, second periprosthetic fracture after a subsequent fall and hypertrophic nonunion treated with surgery.
“Not all periprosthetic fractures around a reverse TSA need surgical treatment,” Srikumaran told Healio Orthopedics. “This small case series suggests many of these periprosthetic fractures around a reverse TSA may benefit from a trial of nonoperative treatment, particularly for type A fractures with a well-fixed humeral component, well-aligned type B fractures and type C fractures.”
Perspective
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The authors discuss a small series of patients with humeral fracture associated with reverse arthroplasty. The data is limited, aligns with prior publications and likely will not alter current treatment patterns. Despite the additional information, we still lack clarity about potential differences in the behavior of these fractures around reverse implants compared with anatomical shoulder implants.
Patients with these injuries are often older, low-demand patients with comorbidity and significant osteopenia. Initial trial of nonoperative care is indicated for many patients with this injury. If needed, operative intervention can be successfully performed on a delayed basis. Early fixation is indicated for patients with loose stems, infection (beware of C. acnes) and some type B fractures. In these situations, early surgery is easier and may have a more predictable outcome than delayed operative intervention.
Prevention of fracture may be a key intervention. Avoid over-reaming the canal. Do not try to fill the canal with the implant stem. Perform bone health consultation for patients with osteopenia.
Future studies should have greater power to identify if the current classification system is applicable to fractures around reverse implants, if short stems behave differently or if early surgical intervention is advantageous.
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