Periprothetische Frakturen an der oberen Extremität

Zusammenfassung

Mit der zunehmenden Anzahl implantierter Endoprothesen an der oberen Extremität hat in naher Vergangenheit auch die Anzahl von Komplikationen, insbesondere der periprothetischen Frakturen, zugenommen. Deren Behandlung richtet sich nach dem implantierten Prothesentyp, der Lokalisation der Fraktur, der Frakturform, der aktuellen Stabilität der Prothese im Knochen und der Knochenqualität. Natürlich muss auch auf patientenspezifische Besonderheiten wie den Allgemeinzustand des Patienten und das Patientenalter Bedacht genommen werden. Wenige periprothetische Frakturformen können an der oberen Extremität konservativ behandelt werden. Meist ist ein operatives Vorgehen erforderlich, welches, je nach Situation, einen Wechsel auf eine Langschaftprothese, eine Stabilisierung der Fraktur mit Zerklagen und/oder eine winkelstabile Plattenosteosynthese oder bei schlechter Knochenqualität die Augmentation der Frakturzone mit überbrückenden kortikalen Knochenspänen (Strut Grafts) notwendig macht. Bei gelockerten Prothesen ist ein Prothesenwechsel unbedingt erforderlich. Bei ausgedehnten Knochendefekten kommt die Auffüllung des Markraums mit Spongiosa (Impaction Grafting) oder der Knochenaufbau mit Allografts in Verbindung mit Revisionsprothesen in Betracht. Durch ein individuelles Behandlungskonzept aufbauend auf bestimmten Grundregeln kann auch bei schwierigen, komplexen Situationen ein brauchbares funktionelles Ergebnis für den Patienten erreicht werden.

Abstract

According to an increasing number of joint replacements at the upper limb during the last decades, there is also a remarkable number of complications. Periprosthetic fractures are one of the main reasons for revision surgery. The current treatment of periprosthetic fractures at the humerus or forearm is strongly influenced by the type of prosthesis in place, the localization of the fracture, the fracture type, the stability of the implant-bone-interface and the local bone quality. Patient related factors like general health status, comorbidities as well as age have to be considered when establishing a specific treatment plan. In the upper limb only a few periprosthetic fractures may be treated conservatively, such as humeral shaft fractures or non displaced apophyseal fractures. In most of the cases an operative treatment seems to be appropriate. According to the specific situation a long stem prosthesis splinting the fracture zone with additional cerclage wires may lead to good stabilization and rapid fracture healing. In good bone quality a locking plate in a bridging technique may lead to good bone healing. These plates are preferably fixed with locking screws and cerclage wires or locking attachment plates. In poor bone quality, severe osteoporosis or osteolysis cortical strut allografts have been shown to successfully augment the bone at the fracture site. If there is severe ballooning of the shaft due to aseptic loosening, impaction grafting may improve bone quality and fixation of the prosthesis after revision. In severe defect situations a structural allograft-prosthesis-composite may be used to salvage these very difficult situations. By employing an individually adapted treatment protocol based on some guidelines and general recommendations a satisfying outcome may become realistic also in these very complicated complex cases with periprosthetic fractures.

• Literatur

• 1 Bohsali KI, Wirth AM, Rockwood jr. CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am 2006; 10: 2279-2292
• 2 Kim JM, Mudgal CS, Konopka JF et al. Complications of total elbow arthroplasty. J Am Acad Orthop Surg 2011; 19: 328-339
• 3 Steinmann SP, Cheung EV. Treatment of periprosthetic humerus fractures associated with shoulder arthroplasty. J Am Acad Orthop Surg 2008; 16: 199-207
• 4 OʼDriscoll SW, Morrey BF. Periprosthetic fractures about the elbow. Orthop Clin North Am 1999; 30: 319-325
• 5 Plausinis D, Greaves C, Regan WD et al. Ipsilateral shoulder and elbow replacements: On the risk of periprosthetic fracture. Clin Biomech 2005; 20: 1055-1063
• 6 Campbell JT, Moore RS, Iannotti JP et al. Periprosthetic humeral fractures: mechanism of fracture and treatment options. J Shoulder Elbow Surg 1998; 7: 406-413
• 7 Duncan CP, Haddad FS. Classification. In: Schütz M, Perka C, eds. Periprosthetic Fracture Management. Stuttgart, Thieme; 2013: 47-90
• 8 Talbot M, Zdero R, Schemitsch EH. Cyclic loading of periprosthetic fracture fixation constructs. J Trauma 2006; 64: 1308-1312
• 9 Shah S, Kim SY, Dubov A et al. The biomechanics of plate fixation of periprosthetic femoral fractures near the tip of total hip implant: cables, screws, or both?. Proc Inst Mech Eng H 2011; 225: 845-856
• 10 Lenz M, Perren SM, Gueorguiev B et al. Underneath the cerclage: an ex vivo study on the cerclage-bone interface mechanics. Arch Orthop Trauma Surg 2012; 132: 1467-1472
• 11 Dubov A, Kim SY, Shah S et al. The biomechanics of plate repair of periprosthetic femur fractures near the tip of total hip implant: the effect of cable-screw position. Proc Inst Mech Eng H 2011; 225: 857-865
• 12 McKee MD, Pugh DM, Richards RP et al. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 2003; 85: 802-807
• 13 Yeoh D, Tourret L. Total wrist arthroplasty: a systematic review oft he evidence from the last five years. J Hand Surg Eur 2014; [Epub ahead of print]
• 14 Kumar S, Sperling JW, Haidukewych GH et al. Periprosthetic humeral fracturea after shoulder arthroplasty. J Bone Joint Surg Am 2004; 86: 680-689
• 15 Foruria AM, Sanchez-Sotelo J, Oh LS et al. The surgical treatment of periprosthetic elbow fractures around the ulnar stem following semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 2011; 93: 1399-1407
• 16 Sanchez-Sotelo J, OʼDriscoll S, Morrey BF. Periprosthetic humeral fractures after elbow arthroplasty: treatment with implant revision and strut allograft augmentation. J Bone Joint Surg Am 2002; 84: 1642-1650
• 17 Kamineni S, Morrey BF. Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty. J Bone Joint Surg Am 2004; 86: 1223-1229
• 18 Morrey ME, Sanchez-Sotelo J, Abdel MP et al. Allograft-prosthetic composite reconstruction for massive bone loss including catastrophic failure in total elbow arthroplasty. J Bone Joint Surg Am 2013; 95: 1117-1124