- Email: [email protected]
Humeral shaft fracture after a total elbow arthroplasty
Elbow
Vohme
5. 6. 7.
8. 9.
10.
Hanyu, Nakazono,
Surg 7, Number 5
j Shoulder
Jaber S, Lebergal M. Anterior dislocation of the elbow with fracture of the elecronon. Contemp Orthop 1992;24:714-6. Jackson ]A. Dislocation of the elbow joint with rupture of the brachial artery: a case report. Am J Surg 1940;47:479-86.
respective 172-3.
Lnscheid Rt, O’Drlscoll SW. Elbow dislocations, In: Morrey BF< editor. The elbow and its disorders. Philadelphia: WB Saunders; 1993. p. 441-52. Lnscheid Rt, Wheeler DK, Elbow dislocations. J Am Med Assoc 1965;194:1 171-6.
Neviiser
JS, “Wickstrom
Humerai Tadamasa
Hanyu,
jK.
Dislocation
of the elbow:
shaft fracture MD,
Kiyoshi
MD,
CA5E REPORT
From the School
Department of Medicine.
with rheumatoid the right elbow
of Orthopaedic
Surgery,
with
arthritis the
Niigata
had Kyocera
a
University
Reprint requests: Tadamasa Hanyu, MD, Department of Orthopaedic Surgery, Niigata Universib School of Medicine, l-757 Asahimachi-dori, Niigata 951-8510, Japan, J Shoulder Elbow Surg 1998;7:541-4. Copyright
8oard
@
1998
by journal
of .%ou/der
of Trustees.
1058-2746/98/$5.00
+ 0
32/4/88990
and
E/bow
Med
J 1977;70.
12.
OuryJH, Roe RD, tuning RC. A case of bilateral cations of the elbow. J Trauma 1972; 12: 170-3. Roberts PH. Dislocation of the elbow. J Surg 806-l 5.
14.
and Hajime
P
woman of
South
Srivastava KK, Kochbar VL Forward dislocation joint without fracture of the electronon. Austr 1974:44:71-4.
anterior
dislo-
Br 1969;56: of the elbow N Z J Surg
a ret-
eriprosthetic fractures occurring after total joint arthroplasty are troublesome complications. There are intraoperative fractures, postoperative fractures, and implant failures. Fractures of the femur occurring after hip or knee arthroplas have been well documented, but humeral fractures as a 7 ate complication after elbow arthroplasty have not been reported. The purpose of this case report is to describe a postoperative periprosthetic fracture adjacent to an unconstrained total elbow implant with a stem, which had been previously revised for implant fracture of the primary arthroplasty. We describe the techni ue and result of a clamp-on-plate (Mennen’s plate), in w1 ich no screws were used to fix the fracture. Because a significant number of elbows developed complications with the Kyocera type-l prosthesis,5 a new prosthesis with an intramedullary stem was designed by our group.7 The characteristics of the new prosthesis (NSK-type: Kyocera, Kyoto, Japan) include a stem attached to the distal one third of the humeral component in the sagittal plane so that the center of rotation can be moved anteriorly. This feature makes anterior angulation of the humeral component unnecessary. The thick stem can be inserted directly into the medullary canal and fixed tightly to the distal portion of the humerus. Bone cement is required occasionally including revision surgeries of the Kyocera type-l implant.
A 62-year-old primary arthroplasty
1 1.5 patients.
O’Driscoll SW. Classification and spectrum of elbow instab& ty: recurrent instability In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders: 1993. p 452-63.
after a total elbow
Nakazono,
of
541
11.
13.
Mehlhoff Tt, Noble PC, Bennett JB! Tulles HS. Simple dislocation of the elbow in the adult: results after closed ‘treatment. J Bone loint Sura Am 1988:7OA:244-9.
study
and lshikawa
Surgery
Ishikawa,
MD,
arthroplasty iwgafa,
~apclfl
type-l prosthesis without cement. Eight years after surgery she fell in the entrance hall of a department store, sustaining a surgical neck fracture of the right humerus. At that time she had no re orts of pain in the ipsilateral elbow with the uncemente K arthroplasty. However, 6 months after trauma she reported a gradual onset of pain in the right elbow. At that time she was 71 years old (Figure 1), and radiographs demonstrated a fracture of the humeral component. Revision surgery was performed with the NSK prosthesis. A bicortical bone block was harvested from the iliac crest and grafted in the bone defect on the ulnar side. After the humeral component was confirmed to be held by the stem and lateral condyle, the implant was fixed with cement (Figure 2). She fell again 1 year after her revision, sustaining a spiral fracture of the humeral shaft. A hanging cast followed by a functional brace (consisting of an anterior and posterior shell held together with Velcro straps) were used. The oor, and follow-up radiographs demonreduction was strated no visibe r callus formation after 2 months (Figure 3). The thick stem and minimal s ace within the medullary canal did not allow for plate an if screw fixation. Therefore open reduction and internal fixation (ORIF) was performed with the Mennen plate (Figure 4, A). The triceps muscle and tendon were divided in the mid-line, and the fracture site was exposed. The tip of the stem was covered with cement, and callus formation was not evident. Minimal periosteal stripping limited to the fracture site was done. The fracture was easily reduced and maintained with a bone-holding instrument. Then a Mennen’s tapered type plate was applied to the humeral shaft. Cancellous bone graft taken from the left anterior iliac crest was placed around the fracture and under the plate. After surgery the elbow was immobilized in 90’ of flexion in a long arm cast for 4 weeks. An elbow splint for protection against varus stress was applied for approximately 3 months. Clinical evaluation. Rating for the elbow developed by lnglis and Pelliccib Improved from 3 1 points before surgery to 81 points after surgery 1 year after the primary arthroplasty. At the time of the revision the score had decreased
542
Hanyu,
Nakazono,
and Ishikawa
j Shoulder
Elbow, c Surg
September/October
1998
Figure 1 Radiographs showing fracture of humeral component. A, Anteroposterior radiograph of right elbow, 8 years and 6 months after primary operation. Patient had satisfactory result, but elbow became sinful. Margins on radial side of humeral component appear irregular (arrow). 6, Humeral component retrieved ?rom elbow. Implant failure of humeral component occurred at posterior corner.
Figure 2 Radiographs showing appearance of elbow 3 months after revision surgery. With NSK stem was inserted directly into medullary canal and fixed tightly to distal portion of humerus. After block was grafted into ulnar box (arrow), both components were fixed with cement. A, Anteroposterior B, lateral radiograph. to 69 points because of pain but improved to 86 points with the revision surgery. At the last follow-up after ORIF, the score was 83 points. Results were satisfactory. No clinical evidence of a deep infection was seen. Range of motion. Active flexion improved 35O, from 9P before surgery to 125” after surgery, 1 year after the primary operation. However, active extension decreased 5’, from -30’ to -35”. Active supination improved an average of 50°, from 30’ before surgery to 80° after surgery, and active pronation improved an average of loo, from 70’ to 8P. At 6 months after ORIF, the arc of motion was from -30’ in extension to 140° in flexion. Active pronation was 80°, and active supination was 80”. The overall result was considered satisfactory, although a flexion contracture remained. She did not report any subiective sensation of instability. No episodes of dislocation or subluxation occurred after the arthroplasty. Radiographic follow-up. At 6 months after ORIF, anteroposterior and lateral radiographs showed that the plate
had not changed, healed. Neither the Ithadave developed progressive osition
mm in width
prosthesis, thick iliac crest bone radiograph.
and the fracture appeared to humeral nor ulnar component radiolucent line more than 1
(Figure 4, B, Cj.
DISCUSSION
Late complications of an unconstrained total elbow prosthesis include aseptic loosening, late infection, recurrent dislocation, nerve palsy, periprosthetic fracture, and implant failure. Recently, fractures of the humerus subsequent to shoulder arthroplasty have been reported.2,16 The incidence of humeral fractures in the study of Boyd et aI2 was 1.6% (7 of 436 shoulders), and in the study of Wright and Cofield,‘6 1.8% (9 of 499). However, no reports to an
of
postoperative
periprosthetic
fractures
ad’acent
unconstrained total elbow arthroplasty were / ound. Therefore the frequency of periprosthetic fractures ad’acent to unconstrained implants was reviewed from t h e intermediate and long-term follow-up studies of capitel-
Hanyu, Nakazono,
-I Shoulder Elbow Surg Volume 7, Number 5
Figure 3 Anteroposterior radiographs showing appearance Appearance of spiral fracture at time of injury. 6, Appearance lus formation was not evident.
Figure 4 Postoperative radiographs showing Mennen’s plate. nen’s tapered iype plate and cancellous bone graft (cast brace ;grn;rh of right elbow 6 months after open reduction and internal
locondylar total elbow arthroplas~.4,‘~,‘3~‘~ Its frequency varied from 0% to 5.9%, with an overall prevalence of approximately 2.2% (Table). The rate of postoperative humeral fractures was estimated to be 1.3%. On the other hand, Kudo et al9 reported, in 5 elbow arthroplasties without cement, a breakage of the humeral component at the junctional portion of its stem. However, in that series no periprosthetic fractures were seen.8 In our series there was a 2% incidence of periprosthetic fractures. It is important to remember that periprosthetic humeral fractures are usually a late complication and are infrequent. The fracture patterns can be oblique, spiral, or transverse, and man are centered on the tip of the prosthesis. The remain cr er occur in the humeral shaft proximal to the implant or condyle. We have classified the fractures
of periprosthetic 2 months after
and lshikawa
fracture of right humeral itjury. Reduction was poor,
shaft. A, and cal-
A, Immediate postoperative anteroposterior radiograph has been applied). B, Anteroposterior radiograph and
fixation.
Fracture
appears
united
radiographically
543
showing C, lateral
ancl is in good
Menradi-
align-
into 4 types, similar to Johannson et al’s10 classification of periprosthetic femoral fractures after total hip arthroplasty. Type 1 fractures involve the humerus distal to the tip of the prosthesis (including medial and lateral condyle]. A type 2 fracture is a long spiral fracture extending proximal and distal to the stem tip. A type 3 fracture is completely roximal to the stem tip. A type 4 fracture involves the u r na. The location and configuration of the fracture has an important effect on the management and outcome of treatment. Type 1 condyle fractures occurring after elbow arthroplasty can be treated with tension band wiring and bone graft, if there is adequate bone stock. Type 2 humeral fractures can be managed without surgery, if the implant is not found to be loose. As noted by Charnley,3 the presence or
544
Hanyu, Nakazono,
and Ishikawa
J Shoulder
Elbow
September/October
Table
Periprosthetic
fracture
after
elbow
arthroplasty
No. of operations
Study
et aI,4 1993 Ruth and Wilde,‘3 1992 Weiland et al,‘5 1989 Rosenberg and Turner,‘2
Ewald
Postoperative
total
periprosthetic
202
1984 fracture
Surg 1998
iA 28 rate 7 of 32 1: 2.2%.
Average follow-up
periprosfhetic fracture fracture
b-4
5.7 6.5 7.2 2.9 Postoperative
absence of bone cement did not affect the outcome. Transverse and short oblique fractures were associated with a reater incidence of delayed union or nonunion, whereas 1ractures with a long oblique or spiral pattern healed uneventful1 . Operative treatment is indicated when a satisfactory re K uction cannot be obtained, if the maintenance of the reduction is difficult, or in the presence of a radial nerve palsy. In a type 3 fracture or a transverse fracture of the humeral shaft, plate and screw fixation is recommended. With osteoporotic bone the use of cement augmentation for screw fixation is considered useful. If the size of the stem will not permit the placement of screws into the adiacent cortical bone, the application of cerclage wires or cables should be considered. Autogenous bone grafting is recommended when the fracture is cornminuted or when there is no evidence of bony union with nonoperative treatment. If the implant is found to be loose when the fracture site is exposed, a revision elbow arthroplasty with the insertion of a cemented long-stemmed humeral component is necessary. It may also be necessary to convert an unconstrained prosthesis to a semiconstrained type (hinge type). Our case was a type 2 long spiral fracture with comminution. Fortunately, loosening of the humeral component was not evident on clinical evaluation. Conservative treatment with a hanging arm cast followed by a humeral functional brace (as described by Sarmiento et alId) was selected. However, it was not possible to maintain satisfactory reduction. Because the size of the stem would not permit the placement of screws into the adiacent cortical bone, we used Mennen’s plate as an alternative option instead of cerclage wires or external fixation. l Mennen’s plate has been used in forearm fractures since 1978 with satisfactory results and for fractures of the metacarpals, humerus, and fibula.11 Its use has advantages. In our case the fracture was exposed through a posterior a preach with minimal periosteal stripping. The presence o r an offset gap between the main plate and the bone allowed for the preservation of the periosteal blood supply and an adequate amount of bone graft to be placed around the site of the fracture. Furthermore intramedullary circulation was not disturbed, because screw fixation was not used. Also, this plate provides more rigid internal fixation than cerclage wiring. We have adopted the use OF a new prosthesis (NSKty e) for an elbow arthroplasty. The humeral stem is thick, w IfI ich allows for better initial immobilization and fit of the rosthesis in the bone. The appropriately sized stem can E e placed with an accurate osteotomy and a reamer. HOWever, if a periprosthetic humeral fracture occurs, operative treatment can be difficult. The use of a Mennen’s plate is
fracture
2;
Ulnar 2, HumeraI shaft 1 Humeral shaft 1, Medial condyle
0 3.6 humeral
Postoperative
Pd
fracture
Ulnar
2
1
rate 4 of 32 1: 1.3%,
an easy and less time-consuming method. It does not require extensive periosteal strippin , and the instrumentation is simple. We believe the use o f a Mennen’s plate is a useful option in managing periprosthetic humeral fractures, REFERENCES 1.
2. 3. 4.
5
6. 7, 8
9
Biswas SP, Kurer MH Jr, Mackenney RP. External fixation for femoral shaft fracture after Stanmore total knee replacement. J Bone Joint Surg Br 1992;74B:3 13-5. Boyd ADJ, Thornhill TS, Lowry Barnes C. Fractures adiacent to humeral prostheses. J Bone Joint Surg Am 1992;74A: 1498.504. Charnley J. The healing of human fractures in contact with selfcuring acrylic cement. C/in Orthop 1966;47: 157-63. Ewald FCI Simmons ED, Sullivan JA, Thomas WH, Scoti RD, Pass R, et al. Capitellocondylar total elbow replacement in rheumatoid arthritis. J Bone Joint Surg Am 1993;75A: 498-507. Hanyu T, Tajima T, Murasawa A, Saito H, Takahashi C. Total replacement of rheumatoid elbow with hingeless ceramic prosthesis with or without stem. In: Hamalainen M, Harena FW, editors, Rheumatoid arthritis surgery of the elbow. Rheumatology. Basel: Karger; 1991. p. 88-97. lnglis AE, Pellicci PM. Total elbow replacement, J Bone Joint Surg Am 1980;62A: 1252-8. lnoue H, Yokoyama Y, Sumii H. Elbow arthroplasv with ceramic prostheses. Techniques Orthop 1991;6:27-32. Kudo H, lwano K. Total elbow arthroplasv with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis: a long-term follow-up study. J Bone Joint Surg Am 1990;72A:355-62. Kudo H> lwano KF Nishino J. Cementless or hybrid total elbow arthroplasty with titanium-alloy implants: a study of interim clinical results and specific complications. J Arthroplasiy 1994;9:269-78.
10.
johansson jE, McBroom R, Barrington TW, Hunter GA. Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 198 1;63A: 1435-42.
11.
Mennen U. A new method of internal fixation by a para-skeletal “clamp-on” plate. J Bone Joint Surg Br 1982;64B: 14.56.
12.
Rosenberg GM, Turner RH. Nonconstrained total elbow arthroplasty. Clin Orthop 1984; 187: 154-62. Ruth JT, Wilde AH. Capitellocondylar total elbow replacement: a Iona-term follow-up study. J Bone Joint Surg Am 1992;74A: 95-l 60.
13.
14.
1.5.
16.
Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Funcjional bracina of fractures of the shaft of the humerus. I Bone Joint Surg A; 1977;59A:596-601. Weiland AJ, Weiss AC, Wills RP, Russell Moore C. Capitellocondylar total elbow replacement: a long-term follow-up study. J Bone Joint Surg Am 1989;71 A:2 17-22. Wright plasty.
TW Cofield RH. Humeral fractures after shoulder J Bone Joint Surg Am 1995;77A: 1340-6.
arthro-
Vohme
5. 6. 7.
8. 9.
10.
Hanyu, Nakazono,
Surg 7, Number 5
j Shoulder
Jaber S, Lebergal M. Anterior dislocation of the elbow with fracture of the elecronon. Contemp Orthop 1992;24:714-6. Jackson ]A. Dislocation of the elbow joint with rupture of the brachial artery: a case report. Am J Surg 1940;47:479-86.
respective 172-3.
Lnscheid Rt, O’Drlscoll SW. Elbow dislocations, In: Morrey BF< editor. The elbow and its disorders. Philadelphia: WB Saunders; 1993. p. 441-52. Lnscheid Rt, Wheeler DK, Elbow dislocations. J Am Med Assoc 1965;194:1 171-6.
Neviiser
JS, “Wickstrom
Humerai Tadamasa
Hanyu,
jK.
Dislocation
of the elbow:
shaft fracture MD,
Kiyoshi
MD,
CA5E REPORT
From the School
Department of Medicine.
with rheumatoid the right elbow
of Orthopaedic
Surgery,
with
arthritis the
Niigata
had Kyocera
a
University
Reprint requests: Tadamasa Hanyu, MD, Department of Orthopaedic Surgery, Niigata Universib School of Medicine, l-757 Asahimachi-dori, Niigata 951-8510, Japan, J Shoulder Elbow Surg 1998;7:541-4. Copyright
8oard
@
1998
by journal
of .%ou/der
of Trustees.
1058-2746/98/$5.00
+ 0
32/4/88990
and
E/bow
Med
J 1977;70.
12.
OuryJH, Roe RD, tuning RC. A case of bilateral cations of the elbow. J Trauma 1972; 12: 170-3. Roberts PH. Dislocation of the elbow. J Surg 806-l 5.
14.
and Hajime
P
woman of
South
Srivastava KK, Kochbar VL Forward dislocation joint without fracture of the electronon. Austr 1974:44:71-4.
anterior
dislo-
Br 1969;56: of the elbow N Z J Surg
a ret-
eriprosthetic fractures occurring after total joint arthroplasty are troublesome complications. There are intraoperative fractures, postoperative fractures, and implant failures. Fractures of the femur occurring after hip or knee arthroplas have been well documented, but humeral fractures as a 7 ate complication after elbow arthroplasty have not been reported. The purpose of this case report is to describe a postoperative periprosthetic fracture adjacent to an unconstrained total elbow implant with a stem, which had been previously revised for implant fracture of the primary arthroplasty. We describe the techni ue and result of a clamp-on-plate (Mennen’s plate), in w1 ich no screws were used to fix the fracture. Because a significant number of elbows developed complications with the Kyocera type-l prosthesis,5 a new prosthesis with an intramedullary stem was designed by our group.7 The characteristics of the new prosthesis (NSK-type: Kyocera, Kyoto, Japan) include a stem attached to the distal one third of the humeral component in the sagittal plane so that the center of rotation can be moved anteriorly. This feature makes anterior angulation of the humeral component unnecessary. The thick stem can be inserted directly into the medullary canal and fixed tightly to the distal portion of the humerus. Bone cement is required occasionally including revision surgeries of the Kyocera type-l implant.
A 62-year-old primary arthroplasty
1 1.5 patients.
O’Driscoll SW. Classification and spectrum of elbow instab& ty: recurrent instability In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders: 1993. p 452-63.
after a total elbow
Nakazono,
of
541
11.
13.
Mehlhoff Tt, Noble PC, Bennett JB! Tulles HS. Simple dislocation of the elbow in the adult: results after closed ‘treatment. J Bone loint Sura Am 1988:7OA:244-9.
study
and lshikawa
Surgery
Ishikawa,
MD,
arthroplasty iwgafa,
~apclfl
type-l prosthesis without cement. Eight years after surgery she fell in the entrance hall of a department store, sustaining a surgical neck fracture of the right humerus. At that time she had no re orts of pain in the ipsilateral elbow with the uncemente K arthroplasty. However, 6 months after trauma she reported a gradual onset of pain in the right elbow. At that time she was 71 years old (Figure 1), and radiographs demonstrated a fracture of the humeral component. Revision surgery was performed with the NSK prosthesis. A bicortical bone block was harvested from the iliac crest and grafted in the bone defect on the ulnar side. After the humeral component was confirmed to be held by the stem and lateral condyle, the implant was fixed with cement (Figure 2). She fell again 1 year after her revision, sustaining a spiral fracture of the humeral shaft. A hanging cast followed by a functional brace (consisting of an anterior and posterior shell held together with Velcro straps) were used. The oor, and follow-up radiographs demonreduction was strated no visibe r callus formation after 2 months (Figure 3). The thick stem and minimal s ace within the medullary canal did not allow for plate an if screw fixation. Therefore open reduction and internal fixation (ORIF) was performed with the Mennen plate (Figure 4, A). The triceps muscle and tendon were divided in the mid-line, and the fracture site was exposed. The tip of the stem was covered with cement, and callus formation was not evident. Minimal periosteal stripping limited to the fracture site was done. The fracture was easily reduced and maintained with a bone-holding instrument. Then a Mennen’s tapered type plate was applied to the humeral shaft. Cancellous bone graft taken from the left anterior iliac crest was placed around the fracture and under the plate. After surgery the elbow was immobilized in 90’ of flexion in a long arm cast for 4 weeks. An elbow splint for protection against varus stress was applied for approximately 3 months. Clinical evaluation. Rating for the elbow developed by lnglis and Pelliccib Improved from 3 1 points before surgery to 81 points after surgery 1 year after the primary arthroplasty. At the time of the revision the score had decreased
542
Hanyu,
Nakazono,
and Ishikawa
j Shoulder
Elbow, c Surg
September/October
1998
Figure 1 Radiographs showing fracture of humeral component. A, Anteroposterior radiograph of right elbow, 8 years and 6 months after primary operation. Patient had satisfactory result, but elbow became sinful. Margins on radial side of humeral component appear irregular (arrow). 6, Humeral component retrieved ?rom elbow. Implant failure of humeral component occurred at posterior corner.
Figure 2 Radiographs showing appearance of elbow 3 months after revision surgery. With NSK stem was inserted directly into medullary canal and fixed tightly to distal portion of humerus. After block was grafted into ulnar box (arrow), both components were fixed with cement. A, Anteroposterior B, lateral radiograph. to 69 points because of pain but improved to 86 points with the revision surgery. At the last follow-up after ORIF, the score was 83 points. Results were satisfactory. No clinical evidence of a deep infection was seen. Range of motion. Active flexion improved 35O, from 9P before surgery to 125” after surgery, 1 year after the primary operation. However, active extension decreased 5’, from -30’ to -35”. Active supination improved an average of 50°, from 30’ before surgery to 80° after surgery, and active pronation improved an average of loo, from 70’ to 8P. At 6 months after ORIF, the arc of motion was from -30’ in extension to 140° in flexion. Active pronation was 80°, and active supination was 80”. The overall result was considered satisfactory, although a flexion contracture remained. She did not report any subiective sensation of instability. No episodes of dislocation or subluxation occurred after the arthroplasty. Radiographic follow-up. At 6 months after ORIF, anteroposterior and lateral radiographs showed that the plate
had not changed, healed. Neither the Ithadave developed progressive osition
mm in width
prosthesis, thick iliac crest bone radiograph.
and the fracture appeared to humeral nor ulnar component radiolucent line more than 1
(Figure 4, B, Cj.
DISCUSSION
Late complications of an unconstrained total elbow prosthesis include aseptic loosening, late infection, recurrent dislocation, nerve palsy, periprosthetic fracture, and implant failure. Recently, fractures of the humerus subsequent to shoulder arthroplasty have been reported.2,16 The incidence of humeral fractures in the study of Boyd et aI2 was 1.6% (7 of 436 shoulders), and in the study of Wright and Cofield,‘6 1.8% (9 of 499). However, no reports to an
of
postoperative
periprosthetic
fractures
ad’acent
unconstrained total elbow arthroplasty were / ound. Therefore the frequency of periprosthetic fractures ad’acent to unconstrained implants was reviewed from t h e intermediate and long-term follow-up studies of capitel-
Hanyu, Nakazono,
-I Shoulder Elbow Surg Volume 7, Number 5
Figure 3 Anteroposterior radiographs showing appearance Appearance of spiral fracture at time of injury. 6, Appearance lus formation was not evident.
Figure 4 Postoperative radiographs showing Mennen’s plate. nen’s tapered iype plate and cancellous bone graft (cast brace ;grn;rh of right elbow 6 months after open reduction and internal
locondylar total elbow arthroplas~.4,‘~,‘3~‘~ Its frequency varied from 0% to 5.9%, with an overall prevalence of approximately 2.2% (Table). The rate of postoperative humeral fractures was estimated to be 1.3%. On the other hand, Kudo et al9 reported, in 5 elbow arthroplasties without cement, a breakage of the humeral component at the junctional portion of its stem. However, in that series no periprosthetic fractures were seen.8 In our series there was a 2% incidence of periprosthetic fractures. It is important to remember that periprosthetic humeral fractures are usually a late complication and are infrequent. The fracture patterns can be oblique, spiral, or transverse, and man are centered on the tip of the prosthesis. The remain cr er occur in the humeral shaft proximal to the implant or condyle. We have classified the fractures
of periprosthetic 2 months after
and lshikawa
fracture of right humeral itjury. Reduction was poor,
shaft. A, and cal-
A, Immediate postoperative anteroposterior radiograph has been applied). B, Anteroposterior radiograph and
fixation.
Fracture
appears
united
radiographically
543
showing C, lateral
ancl is in good
Menradi-
align-
into 4 types, similar to Johannson et al’s10 classification of periprosthetic femoral fractures after total hip arthroplasty. Type 1 fractures involve the humerus distal to the tip of the prosthesis (including medial and lateral condyle]. A type 2 fracture is a long spiral fracture extending proximal and distal to the stem tip. A type 3 fracture is completely roximal to the stem tip. A type 4 fracture involves the u r na. The location and configuration of the fracture has an important effect on the management and outcome of treatment. Type 1 condyle fractures occurring after elbow arthroplasty can be treated with tension band wiring and bone graft, if there is adequate bone stock. Type 2 humeral fractures can be managed without surgery, if the implant is not found to be loose. As noted by Charnley,3 the presence or
544
Hanyu, Nakazono,
and Ishikawa
J Shoulder
Elbow
September/October
Table
Periprosthetic
fracture
after
elbow
arthroplasty
No. of operations
Study
et aI,4 1993 Ruth and Wilde,‘3 1992 Weiland et al,‘5 1989 Rosenberg and Turner,‘2
Ewald
Postoperative
total
periprosthetic
202
1984 fracture
Surg 1998
iA 28 rate 7 of 32 1: 2.2%.
Average follow-up
periprosfhetic fracture fracture
b-4
5.7 6.5 7.2 2.9 Postoperative
absence of bone cement did not affect the outcome. Transverse and short oblique fractures were associated with a reater incidence of delayed union or nonunion, whereas 1ractures with a long oblique or spiral pattern healed uneventful1 . Operative treatment is indicated when a satisfactory re K uction cannot be obtained, if the maintenance of the reduction is difficult, or in the presence of a radial nerve palsy. In a type 3 fracture or a transverse fracture of the humeral shaft, plate and screw fixation is recommended. With osteoporotic bone the use of cement augmentation for screw fixation is considered useful. If the size of the stem will not permit the placement of screws into the adiacent cortical bone, the application of cerclage wires or cables should be considered. Autogenous bone grafting is recommended when the fracture is cornminuted or when there is no evidence of bony union with nonoperative treatment. If the implant is found to be loose when the fracture site is exposed, a revision elbow arthroplasty with the insertion of a cemented long-stemmed humeral component is necessary. It may also be necessary to convert an unconstrained prosthesis to a semiconstrained type (hinge type). Our case was a type 2 long spiral fracture with comminution. Fortunately, loosening of the humeral component was not evident on clinical evaluation. Conservative treatment with a hanging arm cast followed by a humeral functional brace (as described by Sarmiento et alId) was selected. However, it was not possible to maintain satisfactory reduction. Because the size of the stem would not permit the placement of screws into the adiacent cortical bone, we used Mennen’s plate as an alternative option instead of cerclage wires or external fixation. l Mennen’s plate has been used in forearm fractures since 1978 with satisfactory results and for fractures of the metacarpals, humerus, and fibula.11 Its use has advantages. In our case the fracture was exposed through a posterior a preach with minimal periosteal stripping. The presence o r an offset gap between the main plate and the bone allowed for the preservation of the periosteal blood supply and an adequate amount of bone graft to be placed around the site of the fracture. Furthermore intramedullary circulation was not disturbed, because screw fixation was not used. Also, this plate provides more rigid internal fixation than cerclage wiring. We have adopted the use OF a new prosthesis (NSKty e) for an elbow arthroplasty. The humeral stem is thick, w IfI ich allows for better initial immobilization and fit of the rosthesis in the bone. The appropriately sized stem can E e placed with an accurate osteotomy and a reamer. HOWever, if a periprosthetic humeral fracture occurs, operative treatment can be difficult. The use of a Mennen’s plate is
fracture
2;
Ulnar 2, HumeraI shaft 1 Humeral shaft 1, Medial condyle
0 3.6 humeral
Postoperative
Pd
fracture
Ulnar
2
1
rate 4 of 32 1: 1.3%,
an easy and less time-consuming method. It does not require extensive periosteal strippin , and the instrumentation is simple. We believe the use o f a Mennen’s plate is a useful option in managing periprosthetic humeral fractures, REFERENCES 1.
2. 3. 4.
5
6. 7, 8
9
Biswas SP, Kurer MH Jr, Mackenney RP. External fixation for femoral shaft fracture after Stanmore total knee replacement. J Bone Joint Surg Br 1992;74B:3 13-5. Boyd ADJ, Thornhill TS, Lowry Barnes C. Fractures adiacent to humeral prostheses. J Bone Joint Surg Am 1992;74A: 1498.504. Charnley J. The healing of human fractures in contact with selfcuring acrylic cement. C/in Orthop 1966;47: 157-63. Ewald FCI Simmons ED, Sullivan JA, Thomas WH, Scoti RD, Pass R, et al. Capitellocondylar total elbow replacement in rheumatoid arthritis. J Bone Joint Surg Am 1993;75A: 498-507. Hanyu T, Tajima T, Murasawa A, Saito H, Takahashi C. Total replacement of rheumatoid elbow with hingeless ceramic prosthesis with or without stem. In: Hamalainen M, Harena FW, editors, Rheumatoid arthritis surgery of the elbow. Rheumatology. Basel: Karger; 1991. p. 88-97. lnglis AE, Pellicci PM. Total elbow replacement, J Bone Joint Surg Am 1980;62A: 1252-8. lnoue H, Yokoyama Y, Sumii H. Elbow arthroplasv with ceramic prostheses. Techniques Orthop 1991;6:27-32. Kudo H, lwano K. Total elbow arthroplasv with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis: a long-term follow-up study. J Bone Joint Surg Am 1990;72A:355-62. Kudo H> lwano KF Nishino J. Cementless or hybrid total elbow arthroplasty with titanium-alloy implants: a study of interim clinical results and specific complications. J Arthroplasiy 1994;9:269-78.
10.
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11.
Mennen U. A new method of internal fixation by a para-skeletal “clamp-on” plate. J Bone Joint Surg Br 1982;64B: 14.56.
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Rosenberg GM, Turner RH. Nonconstrained total elbow arthroplasty. Clin Orthop 1984; 187: 154-62. Ruth JT, Wilde AH. Capitellocondylar total elbow replacement: a Iona-term follow-up study. J Bone Joint Surg Am 1992;74A: 95-l 60.
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Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Funcjional bracina of fractures of the shaft of the humerus. I Bone Joint Surg A; 1977;59A:596-601. Weiland AJ, Weiss AC, Wills RP, Russell Moore C. Capitellocondylar total elbow replacement: a long-term follow-up study. J Bone Joint Surg Am 1989;71 A:2 17-22. Wright plasty.
TW Cofield RH. Humeral fractures after shoulder J Bone Joint Surg Am 1995;77A: 1340-6.
arthro-