Basic technique – cemented stem

Provisional reduction of the fracture may be provided by cerclage wire or sutures.

The appropriate plate for fixation may be applied and provisionally fixed proximally and distally, taking care not to obstruct the implantation of a planned humeral component. Provisional monocortical screws are recommended.

Pearl: Preoperative planning is needed to determine where the tip of the humeral implant, and therefore the cement mantle and cement restrictor, will reach, so that adequate plate length and screw distribution is achieved distal to the new implant.

Humeral shaft with implant removed. Plate with monocortical screws and cerclage wire

The canal is prepared using manual reamers of increasing size, until an appropriate diaphyseal fit is obtained.

Pitfall: Excessive torsion may disrupt the provisional fracture fixation. This can be avoided by incremental increase in the size of the reamers, and by taking care not to advance the reamer while applying torque.

$Humeral shaft periprosthetic fracture – the canal is prepared$

Pitfall: If fracture fixation has been performed, ensure that the reamer does not engage with the unicortical screws during canal preparation.

In the case of reamer engagement with the screws, the following options can be considered:

Replace the screw with a shorter screw, or a screw with a blunt tip.
Downsize the diameter of the humeral component.

$Humeral shaft periprosthetic fracture – ensure that the reamer does not engage with the unicortical screws during canal preparation$

A trial component is inserted.

The shoulder joint is reduced. Stability is assessed.

It may be difficult to assess joint stability if the trial is not stable in bone.

$Humeral shaft periprosthetic fracture – a trial component is inserted$

The shoulder is then dislocated, and the trial component is removed.

Pitfall: Care must be taken during dislocation not to disrupt the fracture fixation.

Pearl: A clamp supporting the fixation is helpful during dislocation.

$Humeral shaft periprosthetic fracture – the trial component is removed$

Implantation of humeral component

Standard canal preparation including irrigation and drying the canal should be followed. The standard surgical techniques for mixing and injecting cement should be followed. A cement restrictor is recommended.

$Humeral shaft periprosthetic fracture – cement is injected$

The definitive implant is inserted, and the cement is allowed to cure.

Pearl: Ensure the cemented component is at the same height as the trialed component to obtain shoulder joint stability.

$Humeral shaft periprosthetic fracture – the definitive implant is inserted$

The definitive implant is relocated. Definitive fracture fixation is completed, and appropriate soft-tissue repairs undertaken. The stability of the joint is assessed, and postoperative aftercare planned accordingly.

$Humeral shaft periprosthetic fracture – the definitive implant is relocated$