Displacement Of Greater Tuberosity Research Articles

Classification and measurement of displacement of isolated greater tuberosity fractures: Intra and interobserver reliability

Background Literature demonstrates variability in the amount of displacement of isolated greater tuberosity (GT) fractures and measurement techniques that orthopaedic surgeons deem warrant surgical intervention. This study aims to assess the intra and interobserver reliability for classifying and measuring the displacement amount for isolated GT fractures. Methods Eight surgeons, consisting of four shoulder specialists and four trainee surgeons, reviewed 25 plain radiographs on two separate occasions, 3 months apart. They were required to morphologically classify the GT fracture, measure the displacement distance on anteroposterior and axillary views, calculate the GT displacement ratio, and state whether they would offer surgical treatment. Results There was a lack of good reliability for the classification of the depression and avulsion fracture types. There was good intraobserver but poor interobserver consistency in classifying the split-type fractures. The measurement of the displacement distance showed good intraobserver reliability, but not as good interobserver agreement. Also, the displacement ratio calculated revealed poor consistency. We found good agreement between and within the raters for the treatment decision. No significant difference was noted when comparing the senior surgeons to the junior surgeons. Conclusions This study has revealed ongoing inconsistency in the classification and measurement of isolated GT fractures.

Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted?

3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. 104 patients were included at mean follow-up of 55months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2mm (p = 0.001). We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.

CLINICAL OUTCOMES FOLLOWING GLENOHUMERAL DISLOCATION WITH GREATER TUBEROSITY FRACTURE

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury.We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded.The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement &gt;5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41.Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this.

Single knotless-anchor with two ethicon 2# for Ellman grade III bursal-side partial thickness rotator cuff tears: a cadaveric biomechanical study and short-term clinical evaluation

BackgroundSeveral surgical techniques are used to treat bursal-side partial thickness rotator cuff tears (PTRCTs). However, use of single knotless-anchor with two Ethicon 2# repair technique for PTRCTs has not been reported.Materials and methodsBursal-side PTRCTs (Ellman grade III, 75% thickness of tears) were created in the supraspinatus tendon in 16 fresh-frozen cadaveric shoulders. The specimens were randomly assigned to two equal groups: (1) Group A (Transtendon repair), a single knotless-anchor repair with two Ethicon 2#; (2) Group B, Conversion repair (Double-row, DR). Post-repair, each specimen was subjected to cyclic loading test from 5 to 100 N (50 cycles), followed by an ultimate failure test. The displacement of greater tuberosity (mm) and ultimate (N) were recorded. In the clinical study, 12 patients diagnosed with Ellman grade III Bursal-side PTRCTs (using a single knotless anchor with two Ethicon 2# repair techniques) were operated on and analyzed. Visual analog scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion (ROM) were assessed before surgery and at final minimum follow-up (>1year).ResultsThere was no significant between-group difference with respect to load-to-failure test (Group A, 359.25 ± 17.91 N; Group B, 374.38 ± 13.75 N, P > 0.05). There were no significant differences with respect to rotator cuff displacement of 10 mm (Group A, 190.50 ± 8.52 N; Group B, 197.25 ± 6.84 N, P > 0.05) and 15 mm (Group A, 282.25 ± 12.20 N; Group B, 291.13 ± 14.74 N, P > 0.05). However, there was significant between-group difference with respect to displacement of 3 and 5 mm (P < 0.05). In the clinical trial, all patients were followed up for an average of 20.4 months (12–29 months). At the last follow-up after surgery(minimum>1year), the VAS score was 0.50 ± 0.67 (0–2), the ASES score was 86.50 ± 3.96 (79–92), the CMS score was 85.08 ± 5.65 (74–93), the mean Forward flexion ROM was 154.00°± 12.48° (131°-169°), and the abduction ROM was 165.00°±13.26° (138°-173°). There was a statistically significant difference between the results of the preoperative and the last postoperative follow-up. The results of the last postoperative follow-up were statistically different from those of the preoperative follow-up (P < 0.05). Regarding complications, stiffness (2 cases) and shoulder impingement (1 case) occurred in 3 cases (25%).ConclusionA single knotless anchor with two Ethicon 2# may provide a biomechanically and clinically feasible option for the treatment of bursal-side Ellman grade III PTRCTs, particularly in resource-constrained settings.MeSH keywordsBursal-side Ellman Grade III; Single Knotless-anchor; Double-row repair; Biomechanical study; Short-term clinical evaluation.

Radiological analysis and outcomes of isolated greater tuberosity fracture-dislocations.

The purpose of this study was to investigate different radiological characteristics for isolated greater tuberosity (GT) fracture-dislocations and their effects on complication and reoperation rates. A two-centre, retrospective study was performed on patients with a minimum 1-year follow-up (median 4.5 years). Patients were split into two groups, Group A (<65 years old) and Group B (≥65 years old). Outcomes included initial injury characteristics (dislocation and fracture type, AC/BC ratio and distances), the reduction environment and postreduction outcomes including complications. A total of 55 patients were included in this study, with a reduction in the emergency department (ED) performed in 93% of patients. Complication rates (47% overall) were similar in both groups, with an overall nonunion rate of 27%. No nonunions occurred in fractures reduced in theatre compared with 29% occurring in reductions in ED (p<0.001); 11% of patients experienced surgical neck fractures, the majority of which were in Group B (p=0.003). A larger fracture fragment (i.e. higher AC/BC or AC distances) was correlated with a higher incidence of nonunion in Group B compared with Group A (p=0.003), and a higher risk of stiffness in both groups (p=0.049); 16% of patients demonstrated delayed displacement of their GT. This study highlights the high complication rates associated with these injuries. Age and specific radiological parameters should be taken into consideration when risk stratifying, as should reducing these fractures in a theatre setting. Interval radiographs are also advised to monitor GT displacement for at least 2-3 weeks.

Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study

BackgroundOpen reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation.MethodsWe retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors.ResultsThere were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was.ConclusionsNonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.

Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults

PurposeTo identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. MethodsPatients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. ResultsA total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3–5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0–3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1–4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2–4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. ConclusionsCalcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.

A new biomechanical classification system for split fractures of the humeral greater tuberosity: guidelines for surgical treatment

BackgroundSplit fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method.MethodsWe created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCT) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed.ResultsThe mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicate that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment.ConclusionsBiomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.

3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

Reliably recognizing the overall pattern and specific characteristics of proximal humerus fractures may aid in surgical decision-making. With conventional onscreen imaging modalities, there is considerable and undesired interobserver variability, even when observers receive training in the application of the classification systems used. It is unclear whether three-dimensional (3D) models, which now can be fabricated with desktop printers at relatively little cost, can decrease interobserver variability in fracture classification. Do 3D-printed handheld models of proximal humerus fractures improve agreement among residents and attending surgeons regarding (1) specific fracture characteristics and (2) patterns according to the Neer and Hertel classification systems? Plain radiographs, as well as two-dimensional (2D) and 3D CT images, were collected from 20 patients (aged 18 years or older) who sustained a three-part or four-part proximal humerus fracture treated at a Level I trauma center between 2015 and 2019. The included images were chosen to comprise images from patients whose fractures were considered as difficult-to-classify, displaced fractures. Consequently, the images were assessed for eight fracture characteristics and categorized according to the Neer and Hertel classifications by four orthopaedic residents and four attending orthopaedic surgeons during two separate sessions. In the first session, the assessment was performed with conventional onscreen imaging (radiographs and 2D and 3D CT images). In the second session, 3D-printed handheld models were used for assessment, while onscreen imaging was also available. Although proximal humerus classifications such as the Neer classification have, in the past, been shown to have low interobserver reliability, we theorized that by receiving direct tactile and visual feedback from 3D-printed handheld fracture models, clinicians would be able to recognize the complex 3D aspects of classification systems reliably. Interobserver agreement was determined with the multirater Fleiss kappa and scored according to the categorical rating by Landis and Koch. To determine whether there was a difference between the two sessions, we calculated the delta (difference in the) kappa value with 95% confidence intervals and a two-tailed p value. Post hoc power analysis revealed that with the current sample size, a delta kappa value of 0.40 could be detected with 80% power at alpha = 0.05. Using 3D-printed models in addition to conventional imaging did not improve interobserver agreement of the following fracture characteristics: more than 2 mm medial hinge displacement, more than 8 mm metaphyseal extension, surgical neck fracture, anatomic neck fracture, displacement of the humeral head, more than 10 mm lesser tuberosity displacement, and more than 10 mm greater tuberosity displacement. Agreement regarding the presence of a humeral head-splitting fracture was improved but only to a level that was insufficient for clinical or scientific use (fair to substantial, delta kappa = 0.33 [95% CI 0.02 to 0.64]). Assessing 3D-printed handheld models adjunct to onscreen conventional imaging did not improve the interobserver agreement for pattern recognition according to Neer (delta kappa = 0.02 [95% CI -0.11 to 0.07]) and Hertel (delta kappa = 0.01 [95% CI -0.11 to 0.08]). There were no differences between residents and attending surgeons in terms of whether 3D models helped them classify the fractures, but there were few differences to identify fracture characteristics. However, none of the identified differences improved to almost perfect agreement (kappa value above 0.80), so even those few differences are unlikely to be clinically useful. Using 3D-printed handheld fracture models in addition to conventional onscreen imaging of three-part and four-part proximal humerus fractures does not improve agreement among residents and attending surgeons on specific fracture characteristics and patterns. Therefore, we do not recommend that clinicians expend the time and costs needed to create these models if the goal is to classify or describe patients' fracture characteristics or pattern, since doing so is unlikely to improve clinicians' abilities to select treatment or estimate prognosis. Level III, diagnostic study.

Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands.

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries. Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed. Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates. Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases.

The purpose of this study is to analyze the radiological and functional outcome of complex proximal humerus fractures treated by open reduction and plate fixation, and how radiological parameters correlate with functional outcome. Retrospective study. Level-1 trauma center. One hundred twenty-seven patients were analyzed, with a mean follow-up of 5 (3-7) years. Radiological parameters studied were neck-shaft angle (NSA), greater tuberosity (GT) to articular surface (AS) distance, medial hinge reduction, and presence (or absence) of calcar screw. Functional outcome evaluated by DASH and Constant-Murley (C-M) score. The mean age is 53.8 years. All patients had a union in 14 (12-18) weeks. The mean NSA is 135° (112-155°). One hundred and thirteen patients with an NSA of >120° had a good functional outcome. Fourteen patients with NSA ≤120° had shoulder abduction <90°. The mean GT to AS distance is 7.2 mm (-2 to 16). The superior displacement of GT above AS is associated with abduction of <90° (16 patients). The mean medial gap is 3 mm (0-17). In 14 patients with a medial gap of >4 mm and without calcar screw, varus collapse is observed. All patients had a good outcome on DASH score and 122 patients had good to excellent outcome on C-M score. Five patients with poor outcome on C-M score had NSA <120° and displacement of GT above AS. Radiographic indicators for poor outcome are varus angulation with NSA <120°, superior displacement of GT above AS, the presence of medial gap >4 mm, and absence of calcar specific screw. This "terrible triad" of proximal humerus fracture should be avoided during operative fixation.

Quantitative 3-dimensional Computerized Tomography Modeling of Isolated Greater Tuberosity Fractures with and without Shoulder Dislocation.

The aim of this study was to assess differences in fracture morphology and displacement between isolated greater tuberosity (GT) fractures (i.e. fractures of the greater tuberosity without other fractures of the proximal humerus) with and without shoulder dislocation utilizing quantitative 3-dimensional CT imaging. Thirty-four CT-scans of isolated greater tuberosity fractures were measured with 3-dimensional modeling. Twenty patients (59%) had concomitant dislocation of the shoulder that was reduced prior to CT-scanning. We measured: degree and direction of GT displacement, size of the main fracture fragment, the number of fracture fragments, and overlap of the GT fracture fragment over the intact proximal humerus. We found: (1) more overlap -over the intact humerus- in patients without concomitant shoulder dislocation as compared to those with shoulder dislocation (P=0.03), (2) there was a trend towards greater magnitude of displacement between those without (mean 19mm) and those with (mean 11mm) a concomitant shoulder dislocation (P=0.07), and (3) fractures were comparable in direction of displacement (P=0.50) and size of the fracture fragment (P=0.53). We found substantial variation in degree and direction of displacement of GT fracture fragments. Variation in degree of overlap and displacement is partially explained by concomitant shoulder dislocation.

Single versus double row suture anchor fixation for greater tuberosity fractures \u2013 a biomechanical study

BackgroundFractures of the humeral greater tuberosity (GT) are a frequent injury progressively treated with arthroscopic suture anchor repair. Yet, no biomechanical study has been performed comparing fixation strength of arthroscopic single- (SR) vs. double row (DR) fixation.MethodsStandardized fractures of the greater tuberosity were created in 12 fresh frozen proximal humeri. After random assignation to the SR or DR group the fixed humeri were tested applying cyclic loading to the supraspinatus and infraspinatus tendon. Load to failure and fragment displacement were assessed by means of an electrodynamic material testing machine using an optical tracking system.ResultsLoad to failure values were higher in the DR group (649 N; ±176) than in the SR group (490 N; ±145) however without statistical significance (p = .12). In greater tuberosity displacement of 3–5 mm surgical treatment is recommended. The fixing constructs in this study did not reach displacement landmarks of 3 or 5 mm before construct failure as shown in previous studies. Thus the applied traction force (N) at 1 mm displacement was analyzed. In the SR group the load at 1 mm displacement was 277 N; ±46 compared to 260 N; ±62 in the DR group (p = .65).ConclusionThe results suggest that both techniques are viable options for refixation of greater tuberosity fractures.Level of Evidence: Laboratory study.

Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography: Validation of a Method on Plain Radiography to Guide Surgical Treatment: Erratum.

Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography: Validation of a Method on Plain Radiography to Guide Surgical Treatment: Erratum.

Biomechanical Contribution of Tension-Reducing Rotator Cuff Sutures in 3-Part Proximal Humerus Fractures.

Using a cadaveric 3-part fracture model and cyclic loading protocol, our study objectives were to quantify the stabilizing effect of tension-reducing rotator cuff sutures in terms of fracture displacement across the surgical neck and greater tuberosity compared with a control group in which no sutures were used. Six matched pairs of fresh frozen specimens underwent a standardized, 3-part, proximal humerus fracture and were split into 2 groups. The control group had the fracture fixed with a plate and screw construct only while the experimental group had additional suture fixation through the plate to each rotator cuff tendon. Active abduction through the rotator cuff was simulated for 100, 200, 300, and 400 cycles and to failure at 1000 N. A Mann-Whitney U test compared cyclic displacement of the greater tuberosity and surgical neck fracture gaps and load to failure between the 2 groups. There was no significant difference (P > 0.05) in fracture gap between fixation methods at the surgical neck at 100 (P = 0.13), 200 (P = 0.07), 300 (P = 0.49), and 400 (P = 0.07) cycles. There was no significant difference (P > 0.05) between fixation methods in the fracture gap at the greater tuberosity at 100 (P = 0.39), 200 (P = 1.00), 300 (P = 0.31), and 400 (P = 0.59) cycles. There was no significant difference (P > 0.5) at 1000 N at the surgical neck (P = 0.70) or the greater tuberosity (P = 0.39). Tension-relieving rotator cuff sutures do not add stability to the repair of 3-part proximal humerus fractures. Varus collapse and greater tuberosity displacement are common complications associated with 3-part fractures. No mechanical data exist to demonstrate benefit of adding suture to a plate and screw construct for limiting fracture displacement.

Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy.

This is a retrospective prognostic study on soft tissue injury following isolated greater tuberosity (GT) fractures of the proximal humerus with respect to the relationship between rotator cuff tears and GT displacement. Forty-three patients with isolated GT fractures were recruited and evaluated with a standardized interview and physical examination, quality of life and shoulder function questionnaires (Western Ontario Rotator Cuff Index, SF-12 Version 2, Constant, Quick-Disabilities of the Arm, Shoulder and Hand, Visual Analogue Scale), standard shoulder radiographs and an ultrasound. The main outcome measurements were: incidence of rotator cuff tears and atrophy, biceps pathology and sub-acromial impingement; superior displacement of the GT fragment; and questionnaire scores. Mean age was 57 years (31 years to 90 years) with a follow-up of 2.4 years (0.8 years to 6.8 years). In total, 16% had a full rotator cuff tear and 57% showed subacromial impingement on ultrasound. Full rotator cuff tears and supraspinatus fatty atrophy significantly correlated with decreased function and abduction strength. Significant atrophy (>50%) of the supraspinatus and infraspinatus, without a rotator cuff tear, was correlated with the worst function in the presence of a residual displacement of the greater tuberosity at the last-follow-up (7 mm). Residual displacement, full rotator cuff tear and muscle atrophy are associated with the worst outcomes. Soft tissue imaging could benefit patients with an unfavourable outcome after a GT fracture to treat soft tissue injury.

Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography

Residual displacement of greater tuberosity (GT) fractures has been shown to negatively affect shoulder function. However, accurate measurement of GT displacement remains a problem with errors up to 13 mm on plain radiography (XR). A new GT ratio for measuring fracture displacement on XR is described, validated, and correlated with computed tomography (CT) and surgical decision making. A retrospective review of shoulder radiographs was performed from 2007 to 2010 to identify all cases of isolated GT fractures with both XR and CT. The GT ratio was performed on all XR and correlated with superior GT displacement measured on CT. The GT ratio was then tested for accuracy of surgical decision using 5-mm superior displacement on CT as the cutoff. Finally, the inter- and intraobserver reliabilities of the GT ratio were calculated and compared with the Neer and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classifications. Forty cases of acute GT fractures with XR and CT were identified. The GT ratio correlated very well with superior displacement on CT (Pearson correlation = 0.852, P < 0.01) and accurately classified GT fractures as "surgical" (n = 9, 23%) or "nonsurgical" (n = 31, 77%). GT ratios ≤0.00 were nonsurgical, ≥0.50 were surgical, and 0.00-0.50 warranted further imaging (P < 0.01). The GT ratio performed as well as or better than the AO and Neer classifications for inter- and intraobserver reliabilities. The GT ratio described in this study correlates very well with CT for superior GT fracture displacement. It involves significantly less radiation and accurately classifies GT fractures as nonsurgical (ratio < 0.00), surgical (ratio > 0.50), or as benefiting from further imaging (0.00-0.50). It performs as well or better than the Neer or AO classification. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Late prosthetic shoulder hemiarthroplasty after failed management of complex proximal humeral fractures.

Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma. Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale. Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction. Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.

わずかな転位の大結節骨折後に起こった肩峰下インピンジメント症候群に対して鏡視下手術を行った１例

わずかな転位の大結節骨折後に起こった肩峰下インピンジメント症候群に対して鏡視下手術を行った１例

Proximal humeral fractures

Risk factors associated with poorer functional outcome after shoulder arthroplasty varied widely by study and by fracture type. The most common risk factors were increased age and greater tuberosity displacement or osteotomy. The overall functional and postoperative outcomes after shoulder arthroplasty were favorable across most studies. However, some studies were of poorer quality resulting in low methods scores and, therefore, the results of these studies should be viewed with caution.