Pressurized Radio-Opaque Dye Integrity Test

Abstract not available. Introduction provided instead.

Intraoperative fracture and cortical perforation during total shoulder replacement is a rare but difficult complication, occurring at an incidence of 0.5%-3% according to data in the literature.^1,2,3 Reports of fracture and cortical perforations in the literature largely cite postoperative incidences,^4,5,6 which accounts for 20% of all complication after total shoulder arthroplasty (TSA).^1,2 There are limited accounts that exclusively analyze intraoperative fracture and cortical perforations in primary arthroplasty,^7-10 and even fewer assessing intraoperative fractures and cortical perforations in revision arthroplasty.^7,11 Review of published accounts of both postoperative and intraoperative fractures and cortical perforations concludes that many may have been avoided by better surgical technique,^1,3,12 and subsequently,
the associated complications could be avoided. A particularly difficult complication may arise when there is a cortical perforation not easily visualized on intraoperative fluoroscopic imaging. As the majority of revision arthroplasty involves humeral stem cementation, a perforation may allow the egress of cement in its liquid form. The potential harm caused by cement is significant as the exothermic reaction of the methylmethacrylate cement can cause thermal injury to surrounding tissue and, specifically, neurovascular tissue.^13,14

The radial nerve is most often injured in humeral shaft fractures and perforations, at an incidence of 1.8%-16%.¹⁵ The potential of thermal injury to the nerve by cement extrusion is high as the radial nerve wraps around the humeral shaft as it extends distally to the elbow. The median and ulnar nerves are also in close proximity to the humeral shaft and vulnerable to similar injury.

Here we present the Pressurized Radio-Opaque Dye Integrity Test (PROD-IT) surgical technique, which was developed to reduce complications from cement extrusion caused by unidentified intraoperative fractures or cortical perforations. By utilizing this technique, cement extrusion from the canal, which can cause suboptimal outcomes by damaging both local soft tissue and neurovascular structures, may be avoided.