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Last updated Friday, August 29, 2008
Clinical presentation
This is the radiograph of a fifty year old woman with rheumatoid arthritis who presented to our unit with a complex shoulder history (see figure 1). Six years previously she underwent a right total shoulder replacement and did well until four years later, when she fractured her humerus below the stem of the prosthesis in an automobile accident. The fracture was treated with open reduction and internal fixation of the humerus using a plate and screws. Postoperatively, however, the arm became infected with staph aureus, requiring removal of the internal fixation and prosthesis and the insertion of antibiotic-impregnated cement beads around and within the humeral shaft. At the time of presentation to us, the patient's chief complaint was pain and inability to use her arm due to weakness and instability. She answered "no" to all 12 questions of the Simple Shoulder Test. There was no clinical evidence of infection, a sedimentation rate of 25, and the shaft fracture appeared healed. Her main question was whether a new joint could be re-inserted.
Our concerns include:
Management
After thorough discussion of the risks with the patient, she decided to have us explore the shoulder with the possibility of inserting a prosthesis if there was no evidence of sepsis. Without preoperative antibiotics, the shoulder was exposed through the previous deltopectoral incision. A large amount of residual scar tissue was identified yet there was no macro or microscopic evidence of underlying sepsis. After cultures were obtained, intravenous antibiotics were administered. The shaft appeared to be solidly healed. Although our initial plan was to insert a long stemmed component; removal of the beads from the intact shaft proved impossible. Rather than splitting the humerus to remove the remaining beads, we cut down the stem of a prosthesis to fit the available space in the medullary canal. A solid press fit was achieved without additional cement. This prosthesis provided a smooth and stable articulation with the remaining glenoid.
Forty-eight hours after surgery the patient was discharged with a comfortable shoulder which she could elevate to 140 degrees and externally rotate to forty degrees. She was pleased and already more functional than at the time of admission.
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