Management of the Failed Arthroplasty for Proximal Humerus Fracture

Djuro Petkovic, MD; David Kovacevic, MD; William N. Levine, MD; Charles M. Jobin, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(2):39-49. 

In This Article

Clinical Presentation

Common complaints of patients with a failed arthroplasty for fracture care include pain, loss of motion, weakness, and instability. The onset and timing of pain should be elucidated. Pain that never improved after the index procedure is concern for an indolent low-grade infection. Pain that developed after an interval period of months or years of minimal symptoms may suggest the development of glenohumeral arthritis or rotator cuff dysfunction, the latter of which can develop secondary to tuberosity malunion, nonunion, or resorption. Pain with mechanical symptoms of instability with elevation and extension may suggest anterior instability, whereas posterior instability is commonly found during forward elevation and adduction. Pain with pseudoparalysis suggests rotator cuff dysfunction. Pain with chronic stiffness both actively and passively may indicate capsular contracture, scar, oversized components, or low-grade chronic deep infection.[6]

Loss of passive motion is suggestive of infection, suboptimal component position, version, sizing, or dislocation. An oversized humeral head increases the lateral humeral offset and over tensions the rotator cuff causing pain and stiffness.[6] Infection should always be considered in any painful or stiff shoulder arthroplasty, regardless of overt signs like loosening of components, draining sinus, swelling, induration, and elevated inflammatory markers.

Periprosthetic instability can occur with component-related and soft-tissue–related complications. An undersized or excessively retroverted humeral head can lead to posterior instability, whereas excessive anteversion of the head or subscapularis insufficiency can lead to anterior instability. Commonly rotator cuff deficiency from tuberosity resorption or secondary tearing will lead to weakness, pseudoparalysis, and sometimes instability. Failure to regain active motion after hemiarthroplasty for fracture despite appropriate component and tuberosity union may indicate neurologic deficiency or rotator cuff failure. Nerve dysfunction is commonly secondary to the trauma or may be iatrogenic from surgery and is more common in the deltoid-splitting approach.[7]

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