Commentary & Perspective

Commentary & Perspective on
"Periprosthetic Humeral Fractures After Shoulder Arthroplasty"
by Sanjay Kumar, MD, PhD, et al.

Commentary & Perspective by
Louis U. Bigliani, MD*,
The Shoulder Service, Columbia University, New York, NY

This very well-written paper addresses an infrequent but devastating complication of shoulder arthroplasty. Prior to this study, these important data could only be gleaned from smaller series, but now we have information on nonoperative and operative management of this complication from the large experience of a single institution.

The authors clearly identify osteopenia as a potential risk factor for periprosthetic fracture, as it was present in all of the sixteen patients (mild in nine patients and severe in seven) in the series. This finding should alert the treating physician that patients with osteopenia may be at risk for fracture and may require preventive treatment. In this study, the fractures are classified by their location in relation to the prosthesis as well as by fracture type and the degree of angulation and displacement. These classifications may allow us to establish some guidelines for deciding whether conservative treatment or operative treatment is indicated.

It would be helpful, however, to know more about the clinical course of these fractures with respect to their classification. For example, it is stated that four of the five type-B fractures that were treated nonoperatively eventually needed operative intervention. An analysis of these fractures not only by location but also by type and by the amount of angulation and displacement might alert us to which types of fractures are more amenable to primary operative intervention.

An important lesson from this report is that although all the fractures healed, there were still a substantial number of unsatisfactory results. The most common reason for a poor result was poor motion in eight of nine patients. Thus, osseous union does not always mean that a satisfactory result was achieved.

I agree with the authors' rationale for the treatment of this complication. At our institution, we use similar criteria to decide between nonoperative and operative treatment. This paper will help the clinician manage a very difficult and challenging surgical problem and is a welcome contribution to the literature.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.