Deltoid-splitting Approach Research Articles

Percutaneous Plating of the Proximal Humerus

Percutaneous plating was developed in an attempt to address the issues of humeral head necrosis associated with open reduction through an extensive approach and insufficient primary stability associated with previous attempts at limited exposure with minimal internal fixation. Our minimally invasive approach consists of 2 separate mini-incisions. The proximal incision is a direct anterolateral deltoid-splitting approach of <5 cm that exposes the humeral head and tuberosities. The distal incision of 1 to 2 cm exposes the humeral shaft and distal part of the plate. Before plate insertion underneath the deltoid, the axillary nerve must absolutely be identified and protected to prevent entrapment. The block guide attachment to the plate cannot be safely used as it stretches directly the nerve at the distal edge. With our approach, indirect reduction techniques are needed to achieve good reduction. Ideal fracture types include 2-part surgical neck fractures, isolated greater tuberosity fractures, and all valgus-type injuries. With increased experience, indications can be extended to many 3-part fractures and some 4 parts. Good outcomes can be expected if patients are well selected.

A New Surgical Technique for Extensive Exposure of the Proximal Humerus and Shoulder

Different techniques have been described for surgical exposure of the shoulder and proximal humerus. However, the neurovascular and muscular anatomy in the proximity of the humerus precludes the use of a "safe" extensive approach. We here present a new technique for extensive exposure of the proximal humerus and shoulder for wide resection of tumors. By reflecting the deltoid with its origin as an osteomyocutaneous flap downwards and backwards, the entire shoulder, including the rotator cuff and proximal humerus, are exposed with minimal damage to the blood supply and function of the deltoid muscle. This approach, which is a logical combination of anterior, transacromial and deltoid splitting approaches, was used in 17 patients, 11 achieving satisfactory functional results. Our new surgical approach reduces intraoperative damage to the blood supply of the deltoid and results in better function of the shoulder postoperatively because both the powerful intermediate muscle fibers of the deltoid and its acromial origin remain intact.

근위 상완골 골절의 수술적 치료에서 삼각근 분할 도달법과 삼각 대흉간 도달법의 임상적, 방사선학적 추시 결과 비교

Purpose: A comparison of the radiographic and the clinical outcomes between two different surgical approaches-Deltoid splitting and Delto-pectoral interval-on the proximal humerus fractures treated by locking compressive plate (LCP), is done. Materials and Methods: Medical records and pre- and postoperative radiographs were reviewed retrospectively for 75 adult patients who underwent surgical fixations with locking compressive plates from May 2005 to December 2011. Patients were divided into two groups according to the surgical methods. Differences in the neck-shaft angle between immediate postoperative period and final follow-up were compared between the two groups. Differences in constant score and Korean shoulder score (KSS) between affected arms and contralateral arms at final follow-up were also compared. Results: The differences in the neck-shaft angle between immediate postoperative period and at final follow-up was 12.04 degrees on average in Deltoid splitting approach and 10.20 degrees in Delto-pectoral interval approach, which was not statistically significant. Differences in constant score/KSS between the affected arm and the contralateral arm were 13.78/22.74 points in deltoid-splitting approach on average and 19.41/31.13 points in Delto-pectoral interval approach, showing that deltoid-splitting approach is significantly superior. Conclusion: Deltoid-splitting approach showed better functional outcomes in the fracture reduction and internal fixation using LCP for the treatment of unstable proximal humerus fractures.

Complex Proximal Humerus Fractures Treated With Locked Plating Utilizing an Extended Deltoid Split Approach With a Shoulder Strap Incision

The goal of the study is to analyze the outcome and complications after locked plating of proximal humerus fractures with the extended deltoid split approach though a shoulder strap incision. Prospective. Tertiary care referral center. Fifty-two adult patients with a displaced 3 or 4 part proximal humerus fracture or fracture dislocation. Open reduction and locked plate osteosynthesis through an extended deltoid split approach using a strap incision. Electrophysiological assessment of axillary nerve function at 6 weeks and at 3, 6, and 12 months postoperatively in those patients in whom an abnormality was detected postoperatively. Functional outcome measurement using normalized Constant scores at 6 and 12 months. Other measures include radiological assessment and complications. Traction injury to the anterior part of the axillary nerve was electrically evident but not clinically apparent in 4 patients. The normalized Constant score continued to show significant improvement 1 year post surgery, 67.3 ± 11.3 at 6 months and 80.2 ± 7.7 at 1 year (P = 0.001)). Union was obtained in all patients. Varus/valgus/tuberosity malreductions were seen in 8 patients. Loss of reduction was seen in 2 patients. Two patients had radiological evidence of avascular necrosis at 1-year follow-up. Locked plating of proximal humerus fractures through an extended deltoid split approach using a shoulder strap incision provides satisfactory outcomes. Axillary nerve injury is the only limitation of the approach and can be minimized with careful identification and protection of the nerve throughout the procedure. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shoulder hemiarthroplasty for proximal humeral fractures: comparisons between the deltopectoral and anterolateral deltoid-splitting approaches

Shoulder hemiarthroplasty is a widely accepted method for treating complex proximal humeral fractures, and the deltopectoral approach is the most popular route for this procedure. The purpose of the current study was to define and compare outcomes of shoulder hemiarthroplasty when using deltopectoral or anterolateral deltoid-splitting approaches. Two cohorts of patients were compared for clinical and radiographic outcomes at the same postoperative follow-up periods: a deltopectoral group (DP group) of 15 patients, from November 2004 to April 2007, and an anterolateral deltoid-splitting group (DS group) of 17 patients, from May 2007 to December 2009. Pain scores, goniometric measurements of the range of motion, and Constant scores were recorded for clinical assessment. Radiographic evaluations were recorded for stem osteolysis, tuberosity absorption, joint subluxation, and acromiohumeral distance. The 2 groups did not differ significantly in demographic data, preoperative fracture classification, surgical timing, early postoperative radiographic findings, and 2-year radiographic results. The DS group had less immediate postoperative pain (P=.025). At the 2-year follow-up assessment, the groups did not difference significantly in shoulder abduction and forward flexion. All prostheses survived until the 2-year assessment. When performing shoulder hemiarthroplasty for complex proximal humeral fractures, we found that the anterolateral deltoid-splitting approach provides an easier route for assessing posterior fracture fragments and managing rotator cuff tissue. The anterolateral deltoid-splitting approach was shown to be an acceptable alternative route for shoulder hemiarthroplasty than the standard deltopectoral approach.

Difference between radiological and functional outcome with deltoid-splitting approach versus deltopectoral approach for the management of proximal humeral fractures with philos plate

Background: Proximal humeral fractures are one of the common fractures of upper extremity. Good results by various studies have been reported for proximal humeral locking plate (PHILOS) fixation in proximal humeral fractures. We want to evaluate whether it is only the implant which has given good results or different surgical approach utilized for fixation of plate also affects result. Materials and Methods: A total of 57 patients with proximal humeral fractures were divided in two groups, in Group A, patient's classical deltopectoral approach utilized, while in Group B deltoid-splitting approach was used. All patients were managed by PHILOS plate fixation. Cases were followed up clinically as well as radiologically at 4-6 weeks after operation and thereafter at 10-12 weeks and then at 6 monthly for long-term complications. Functional outcomes of patient were accessed in terms Constant Scoring System, while radiological evaluation was done by taking x-rays to access quality of reduction and union of fracture. Results: All patients were followed for a minimum of 18 months. In Group B, reduction of tuberosities was better in 3 part and 4 part fractures. Mean Constant score in Group A at the end of 3 months was 56, while in Group B it was 62 and statistically significant (P = 0.02). At the end of 18 months, mean Constant score in Group A was 79, while in Group B it was 81 and statistically insignificant (P = 0.72). One patient in Group B showed axillary nerve paresis in postoperative period and recovered at the end of 3 months. Conclusion: We recommend that deltoid-splitting approach can be used in 3 part and 4 part complex proximal humeral fractures and in posterior fracture dislocation shoulder, which are difficult to approach with deltopectoral approach; however, care should be taken while inserting calcar screw in PHILOS plate fixation to avoid iatrogenic axillary nerve injury.

Proximal humeral fractures: The role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates

The aim of our study is to analyse the results of our surgical technique for the treatment of proximal humeral fractures and fracture dislocations using locking plates in conjunction with calcium sulphate bone-substitute augmentation and tuberosity repair using high-strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Optimal surgical management of proximal humeral fractures remains controversial. Locking plates have become a popular method of fixation. However, failure of fixation may occur if they are used as the sole method of fixation in comminuted fractures, especially in osteopenic bone. MethodsWe retrospectively analysed 22 proximal humeral fractures in 21 patients; 10 were male and 11 female with an average age of 64.6 years (range 37–77). Average follow-up was 24 months. Eleven of these fractures were exposed by the extended deltoid-splitting approach. Fractures were classified according to Neer and Hertel systems. Preoperative radiographs and computed tomography (CT) scans in three- and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were five two-part, six three-part, five four-part fractures and six fracture-dislocations (two anterior and four posterior). Results were assessed clinically with disabilities of the arm, shoulder and hand (DASH) scores, modified Constant and Murley scores and serial postoperative radiographs. ResultsThe mean DASH score was 16.18 and the modified Constant and Murley score was 64.04 at the last follow-up. Eighteen out of twenty-two cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. Four patients had a longer recovery period due to stiffness, associated wrist fracture and elbow dislocation. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients. ConclusionIn our experience, we have found the use of locking plates, calcium sulphate bone substitute and tuberosity repair with high-strength sutures to be a safe and reliable method of internal fixation for complex proximal humeral fractures and fracture-dislocations. Furthermore, we have also found the use of the extended deltoid-splitting approach to be safe and to provide excellent exposure facilitating accurate reduction for fixation of the fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations.

Plating of Proximal Humeral Fractures

The optimal treatment for proximal humeral fractures is controversial. Few data exist concerning the influence of the surgical approach on the outcome. The purpose of this study was to evaluate the clinical and radiological outcomes of proximal humeral fractures treated with locking plate fixation through a deltopectoral vs an anterolateral deltoid-splitting approach. Of 86 patients who met the inclusion criteria, 70 were available for follow-up examination. Thirty-three patients were treated through a deltopectoral approach and 37 through an anterolateral deltoid-splitting approach. In all cases, open reduction and internal fixation with a PHILOS locking plate (Synthes, Umkirch, Germany) was performed. Clinical follow-up included evaluation of pain, shoulder mobility, and strength. Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed. A clinical neurological examination of the axillary nerve was also performed. Consolidation, reduction, and appearance of head necrosis were evaluated radiographically. After a mean follow-up of 33 months, Constant scores, DASH scores, and American Shoulder and Elbow Surgeons scores showed no significant differences between the groups. Clinical neurologic examination of the axillary nerve revealed no obvious damage to the nerve in either group. Deltopectoral and anterolateral detoid-splitting approaches for plate fixation of proximal humeral fractures are safe and provide similar clinical outcomes. The results of this study suggest that the approach can be chosen according to surgeon preference.

Locked Plating for Proximal Humeral Fractures: Differences Between the Deltopectoral and Deltoid-Splitting Approaches

Locking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures. Between April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeon's preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed. There were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group. We found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.

The Plate–Joystick Technique to Reduce Proximal Humeral Fractures and Nonunions With a Varus Deformity Through the Extended Deltoid-Splitting Approach

Fractures and nonunions in which there is a varus deformity of the humeral head producing posterinferior subluxation of the articular surface are increasingly recognized as an important subgroup of proximal humeral fractures. Operative open reduction and internal fixation of these injuries is often recommended when the varus deformity is severe. We describe a simple technique to assist in the open reduction and locking plate stabilization of this challenging and complex fracture subtype using tools and implants that are readily available in most modern orthopaedic trauma operating rooms.

Restoration of Medial Hinge in Acute Complex Proximal Humeral Fractures using Intra-Medullary Strut Allograft

Background Proximal humerus fractures with medial column comminution/collapse often pose management dilemmas to the treating surgeon. Medial column mechanical support of these fractures plays a significant role in the ultimate stability of fixation until healing. Methods Twelve patients (four men and eight women) with unstable proximal humerus fractures were taken up for study. The fractures were stabilized with intramedullary strut allograft and locking plate (PHILOS) by a deltoid splitting approach. The outcome was assessed clinically by Oxford Shoulder Score and radiologically by measuring the head shaft angle at follow-up. Results The mean age of the patients was 65 years (range 54 years to 72 years) with the dominant arm affected in nine. All fractures progressed to union at an average of 4 months and 15 days (3 months to 11 months). At final follow-up (average 29.7 months), all patients had good functional outcome, with an average Oxford Shoulder Score of 19.2 (12 to 32). The average loss of head shaft angle was 6° (0° to 8°). Conclusion The technique has potential technical advantages in the management of proximal humeral fractures with medial column comminution/collapse. The rate of union has been encouraging and we recommend it as a method of treatment.

The extended deltoid-splitting approach to the proximal humerus

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.

Primary fracture arthroplasty of the proximal humerus using a new and freely adjustable modular prosthesis combined with compression osteosynthesis of the tuberosities

Prosthetic joint replacement in case of non-reconstructable proximal humerus fracture in order to obtain a pain-free shoulder and an acceptable range of motion. The non-reconstructable proximal humerus fracture in aged, frail patients (over 70 years of age or ASA 3). Patient inoperable or rehabilitation is inacceptable, pre-existing infection of the shoulder, coexisting bacteremia, or rotator cuff insufficiency. Using a deltopectoral or deltoid split approach, the head fragment is removed. After reaming of the humeral canal, a stem is cemented in place. The Affinis Fracture prosthesis consists of three parts: the stem (3 sizes), a metaphyseal part (2 sizes), and a ceramic head (3 sizes). The retroversion of the metaphyseal part is freely adjustable (360°) after cementing the stem. The length can be adjusted over 1 cm. After reconstruction of the height and retroversion, the tuberosities are reattached anatomically. Finally, a compression osteosynthesis of the tuberosities is realized, using a metal cable, compressing the tuberosities directly upon the metaphyseal part. As the stability of this construct is very high, early postoperative mobilization is allowed. In order to avoid adhesion, rehabilitation exercises are started the day after surgery. During the first few days, passive mobilization, within pain limits, is performed. As soon as possible, active assisted mobilization is started. No stretching is performed, especially in rotation, before the sixth postoperative week. The arm is supported in a sling, only for analgesic reasons. Using this technique, anatomical healed tuberosities were obtained in 84% of the 44 patients with a mean Constant score of 59 points.

The Trapezius-Splitting Approach: Modifications for Treating Disorders and Traumas Occurring in the Lateral Supraspinatus Fossa

Disorders or traumas requiring surgery other than suprascapular entrapment neuropathy that occur in the lateral supraspinatus fossa are decidedly uncommon. Because a wider operative field is necessary for treating these disorders, we have applied a trapezius-splitting approach with some modifications. The procedure comprises a saber cut incision along with trapezius-splitting of 5 cm to 6 cm proximally from the position coinciding with the posterior margin of the acromioclavicular joint. At the lateral aspect of this division, a Gelpi retractor is set on the clavicle and the scapular spine to widen the narrow interspace between them. The underlying adipose tissue and supraspinatus muscle are forced aside en bloc posteriorly. Four patients were surgically treated using this approach and were postoperatively followed up for 22.2 months ± 7.8 months. A sufficient operative field for the major maneuver was secured in all four patients. None developed postoperative paralysis or atrophy of the trapezius, supraspinatus, or infraspinatus muscles. The three patients treated for nonunion or delayed union of coracoid fracture exhibited successful union, and the patient treated for osteochondroma of the clavicle had no recurrence. The main advantages of this procedure are minimal trauma to the musculature, a clearly visible field of the most lateral fossa, and the ability to approach the anterior or posterior shoulder region through the extended skin incision and deltoid-splitting approach if required. Results indicate that the procedure would be advantageous in the surgical treatment of disorders and traumas occurring in the lateral supraspinatus fossa.

Minimal invasive long PHILOS®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus

Minimal invasive plate osteosynthesis (MIPO) not only meets the criteria of a “biological” osteosynthesis by minimising invasivity as well as iatrogenic soft tissue damage, but can also provide adequate stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the anterolateral deltopectoral approach for proximal plate insertion. Objective of the present study was to assess the feasibility and clinical outcome of MIPO for metadiaphyseal fractures of the proximal humerus through a lateral approach using angular stable long PHILOS®-plates.We retrospectively evaluated 29 patients (mean age 77 years, range 48–95 years) with displaced metadiaphyseal fractures of the proximal humerus treated with MIPO technique. For the first time, an angular stable long PHILOS®-plate through a lateral deltoid-split approach proximally and a brachialis/brachioradialis intermuscular approach with exposure of the radial nerve distally, were used.There were no infections and no iatrogenic injuries to the axillary and radial nerve. One patient showed subacromial impingement and one patient had to be reoperated for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Besides one patient who refused further follow-up, 28 patients could be followed up to a mean of 8 months (range 3–12 months) each with an entirely healed fracture. Furthermore, patient's quality of life was documented using the SF-36 questionnaire. Comparison with published United States normative data showed no significant deficits in the physical as well as in the mental domains 8 months after MIPO.Minimal invasive long PHILOS®-plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe procedure for the treatment of metadiaphyseal fractures of the proximal humerus with low morbidity and full restoration of quality of life in these elderly patients.

Surgery Was Superior to Physiotherapy for Small and Medium-Size Rotator Cuff Tears

Question: In patients with small or medium-size rotator cuff tears, how do surgery and physiotherapy compare? Design: Randomized (allocation concealed), blinded (outcome assessor) controlled trial with 12-month follow-up. Setting: A hospital in Baerum, Norway. Patients: 103 patients (mean age 60 y, 71 % men) with small (<1 cm) or medium-size (1 to 3 cm) tears of the rotator cuff. Inclusion criteria were lateral shoulder pain at rest or with exercise, a painful arc of shoulder motion, positive impingement signs, and a passive range of movement of ≥140° for abduction and flexion. Exclusion criteria included age of < 18 years, tears absolutely requiring surgery, concomitant local or systemic diseases affecting shoulder function, previous tendon surgery on the relevant shoulder, and medical comorbid conditions. Follow-up data were available for all patients. Intervention: Patients were allocated to surgery (n = 52) or physiotherapy (n = 51). Surgery involved mini-open oropen tendon repair. Following diagnostic arthroscopy and a deltoid-splitting approach, an anteroinferior acromioplasty was performed. The deltoid was repaired to the acromion through drill-holes. Patients in the physiotherapy group received outpatient treatment by 1 of 4 physiotherapists. 40-minute sessions were given on the average of twice weekly for 12 weeks, and thereafter at increasing intervals during the next 6 to 12 weeks. Exercises to center the humeral head in the glenoid fossa were done to achieve glenohumeral control, and then progressed to more challenging positions. Additional exercises were given, tailored to specific demands in work, sports, and leisure activities. Patients who did not improve after 15 sessions were reassessed and offered surgery if deemed necessary. Main outcome measures: The primary outcome measure was an assessment of shoulder function with use of the Constant score (range, 0 to 100; higher scores represent better function). Secondary outcomes included the self-report section of the American Shoulder and Elbow Surgeons (ASES) score (range, 0 to 100); the Short Form (SF)-36 (0 to 100 points; higher scores indicate better health condition); Constant subscores on pain-free active shoulder abduction, pain-free active shoulder flexion, and shoulder strength; and ASES subscore on shoulder pain. Main results: Analysis was by intention to treat. 9 patients (18%) in the physiotherapy group showed no improvement after a mean of 24 sessions and underwent secondary surgical treatment. Missing nonoperative follow-up data of these patients after secondary surgical treatment were handled by a last-observation-carried-forward principle, meaning that the last scoring result before secondary surgical treatment was used for analysis. Differences between the surgery and physiotherapy groups on the Constant and ASES scores showed greater improvement from baseline in the surgery group than in the physiotherapy group (Table). Among the subscores, the surgery group patients had larger increases in shoulder abduction and decreases in pain; groups did not differ with regard to shoulder flexion or shoulder strength (Table). The groups were not different with regard to SF-36 scores. Conclusion: In patients with small or medium-size rotator cuff tears, 1-year outcomes were better after surgery than after physiotherapy.

Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide

Objectives The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted in a locked position with the external guide. Methods Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve. Results The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide. Conclusions This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.

Tendon patch grafting using the long head of the biceps for irreparable massive rotator cuff tears

BackgroundSurgical treatment of massive rotator cuff tears is challenging for shoulder surgeons. The purpose of this study was to investigate both clinical outcomes and cuff integrity after tendon patch grafting using the long head of the biceps (LHB) tendon for irreparable massive rotator cuff tears. MethodsA short deltoid splitting approach was used to expose the torn cuff tendon stump. After tenodesis of the LHB tendon, its intraarticular portion was resected. If the size of the harvested tendon was smaller than that of the cuff defect, it was split into two layers. Then, the LHB tendon was sutured to the remnant cuff tendons and fi xed to the footprint using the transosseous suture technique. A total of 14 patients (12 men, 2 women; average age 64 years) underwent this procedure. The average postoperative follow-up period was 28 months (range 12–51 months). Active elevation angle of the shoulder as well as the Japanese Orthopaedic Association (JOA) score were assessed before surgery and at the time of follow-up. Postoperative cuff integrity was assessed using T2-weighted magnetic resonance imaging (MRI). ResultsAll cuff defects were successfully closed with this echnique. Average active elevation angle improved from 69° to 149°. Total JOA score also improved from 54.7 points to 83.1 points. Thirteen shoulders showed no re-tearing on T2-weighted MRI; a minor discontinuity of the repaired cuff tendon was observed in the other shoulder. ConclusionsThe LHB tendon is available in case tenodesis or tenotomy is needed. The resected tendon may be used as a graft for rotator cuff repair without any additional skin incision, which could reduce both the surgical invasion and the risk of infection. The LHB tendon patch grafting may be one of the useful options for surgical treatment of irreparable massive rotator cuff tears.

Second generation locked plating of proximal humerus fractures—A prospective multicentre observational study

Surgical treatment of most displaced proximal humerus fractures is challenging due to osteoporosis. Locking plates are intended to provide superior mechanical stability. In a prospective multicentre study 131 patients were treated with second generation locked plating (NCB-PH, Zimmer, Inc.). The open procedure (n = 78) was performed using a deltopectoral approach; the minimally invasive technique (n = 53) involved percutaneous reduction and an anterolateral deltoid split approach. Clinical and radiological follow-up was obtained. Improvement in function (ROM) was statistically significant. Fracture type (AO) had the most significant impact on the incidence of complications. The most frequent complications detected were intra-articular screw perforation (15%) and secondary displacement (8%). Complication rate and functional outcome of the NCB-PH are comparable to reports in the literature. Not all problems are likely to be solved by this new generation of implants, i.e. secondary dislocation still occurred in 8% of our patients.

Anatomical Study of Axillary Nerve for The Safety Deltoid Split Approach

Anatomical Study of Axillary Nerve for The Safety Deltoid Split Approach