Tubercle Osteotomy Research Articles

Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty

Introduction Lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate. Treatment for LTO nonunion is controversial and poorly described in the literature. The purpose of this study was to compare the surgical and nonsurgical treatment outcomes of LTO nonunion. Methods A retrospective case series of 9 consecutive patients with LTO nonunion after primary anatomic shoulder arthroplasty at 1 institution from 2010 to 2016 were studied. Outcomes measured were radiographic evaluation of LTO on axillary X-ray, clinical range of motion (ROM), subscapularis strength, and pain at the time of LTO nonunion diagnosis and after either conservative care or surgical repair of the LTO nonunion. Results LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. There were no significant differences in age, sex, or smoking status between groups. Treatment decision was a shared model of surgeon and patient. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group. Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128° forward elevation (FE) and 33° external rotation (ER) compared to 148° FE and 62° ER. Only 1 patient with LTO nonunion required conversion to reverse replacement. Conclusion LTO nonunion after shoulder arthroplasty is rare. Surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Subscapularis Management in Total Shoulder Arthroplasty: Current Evidence Comparing Peel, Osteotomy, and Tenotomy

The optimal approach to management of the subscapularis in total shoulder arthroplasty (TSA) is controversial. Options include the subscapularis tenotomy, lesser tuberosity osteotomy (LTO), and peel. This review provides a summary of subscapularis anatomy and function, outcomes associated with subscapularis management options in TSA, and postoperative subscapularis deficiency. Based on the available literature, LTO appears to result in improved function and subscapularis integrity relative to tenotomy, while peel and LTO have generally led to equivalent outcomes. The highest level of evidence to date is derived from a randomized controlled trial that demonstrated that outcomes following peel and LTO were not significantly different. There is currently a paucity of high-quality evidence as most studies have consisted of small retrospective series with varying outcome measures. Furthermore, the optimal approach to establishing the diagnosis of subscapularis deficiency following TSA is unclear.

Clincical efficacy of medial patellofemoral ligament reconstruction combined with tibial tuberosity osteotomy in treatment of recurrent patellar dislocation associated with patella alta

Objective To compare the efficacy of tibial tuberosity osteotomy (TTO) combined with medial patellofemoral ligament reconstruction (MPFLR) with simple TTO in treatment of recurrent patella dislocation associated with patella alta. Methods From July 2010 to December 2015, 50 patients with recurrent patella dislocation and patella alta were included in this study. There were 15 males and 35 females with an average age of 20.6 years. These patients received surgical treatment and their clinical data were collected and retrospectively analyzed by case-control study. According to surgical methods, patients were divided into TTO group (32 cases) and MPFLR+ TTO group (18 cases). The differences between preoperative status and postoperative status were evaluated by knee function scores including Tegner, international knee documentation committee (IKDC), Kujala scores, knee injury and osteoarthritis outcome score (KOOS). Patellar stability was checked at the last follow-up visit. Results The TTO group and MPFLR+ TTO group were followed up for (50.9±17.8)months and (22.3±10.1)months, respectively. Two patients occurred recurrent dislocation in TTO group, who showed positive in both extrapolation test and extrapolation apprehension test at 0°flexions of knee. All patients in MPFLR+ TTO group did not occur recurrent dislocation, who showed negative in both extrapolation test and extrapolation apprehension test at 0°flexions of knee. There was no significant difference between preoperative and postoperative results in TTO group in Tegner score (P>0.05), KOOS scores in pain and daily life activities subdomains (P>0.05), while differences in the rest of scores were statistically significant (P<0.05). Compared with TTO group, the differences of all scores were statistically significant (P<0.05) and KOOS scores in the pain and daily life activities subdomains were significantly improved postoperatively in MPFLR+ TTO group (P<0.05). Conclusions For patients with recurrent patellar dislocation associated with patella alta, both surgical methods are found to be effective. Postoperative improvements in pain and daily life activities are less obvious in TTO. While postoperative improvements in pain and daily life activities in MPFLR+ TTO are superior to those of TTO. Key words: Patellar dislocation; Surgical procedures, operative; Patella alta

Patellofemoral arthritis treated with resurfacing implant: Clinical outcome and complications at a minimum two-year follow-up

BackgroundThis study evaluated the clinical and radiographic outcomes of a series of patients treated with an anatomic inlay resurfacing implant, with a minimum two-year follow-up. MethodsFifteen patients underwent patellofemoral-resurfacing procedures using a HemiCAP Wave Patellofemoral Inlay Resurfacing implant from 2010 to 2013. Clinical outcomes included: Visual Analog Scale (VAS), Lysholm score, Knee Society Score (KSS), and evaluation of Kujala, and Hospital for Special Surgery Patellofemoral score (HSS-PF). The postoperative complications were analyzed. ResultsNineteen knees were evaluated; the average follow-up was 35.2months. Fourteen were women, with an average age of 54years. The pre-operative/postoperative clinical results presented a significant improvement: VAS 8/2.5, Lysholm 31.9/85.8, KSS 39.8/82.5, Kujala 32.1/79.3 and Hospital for Special Surgery Patellofemoral score (HSS-PF) 15.9/90.6. A total of 87% of patients were either satisfied or very satisfied with the overall outcome. There were no radiographic signs of loosening. Seven postoperative complications were recorded: two presented ongoing knee pain, one postoperative stiffness, one patellar bounce due to maltracking, two ilio-tibial band syndrome, and one tibial anterior tuberosity osteotomy nonunion. Two patients underwent a total knee arthroplasty conversion and were considered a failure. None of these complications were implant related. ConclusionsPatellofemoral inlay resurfacing for isolated patellofemoral arthritis was an effective and safe procedure with high levels of patient satisfaction. No mechanical implant failure was seen at a minimum two-year follow-up. This implant design appeared to be an alternative to the traditional patellofemoral prostheses. Concomitant osteochondral lesions, patellofemoral dysplasia or patellar maltracking might be poor prognostic factors for this type of implant.

Subscapularis tenotomy vs. lesser tuberosity osteotomy during total shoulder arthroplasty: When less is more

Mobilization of the subscapularis is necessary during total shoulder arthroplasty, but high rates of subscapularis dysfunction have been reported postoperatively. Two methods are commonly used: subscapularis tenotomy with tendon-to-tendon repair and lesser tuberosity osteotomy with bone-to-bone repair. There is conflicting data as to which of these methods provides superior results. This article reviews the literature to date and provides the preliminary results from a prospective randomized controlled trial comparing subscapularis tenotomy to lesser tuberosity osteotomy. Our results show that lesser tuberosity osteotomy and subscapularis tenotomy both provide a reliable, consistent healing method for subscapularis management with comparably excellent outcomes.

The Anterior-posterior Distance Between the Tibial Tuberosity and Trochlear Groove

Objectives:Tibial tuberosity osteotomy is often performed to correct excessive lateralization of the tuberosity in patients with patellar instability. An anteriorizing component has been recommended in the setting of chondral pathology, yet the ideal anterior-posterior relationship of the tibial tuberosity to the trochlear groove is unknown.Methods:Patients with symptomatic patellar instability underwent static CT imaging, and were compared to age- and gender-matched controls. All knees were imaged in full extension. Tibial-tuberosity-trochlear-groove (TTTG) distance was measured to quantify lateralization of the tuberosity, as well as the anterior-posterior distance between these two points (APTTTG distance). Lateral trochlear inclination (LTI), sulcus angle (SA) and trochlear depth (TD) were measured as indicators of trochlear dysplasia. Measurements were compared between the symptomatic and control groups using paired t-tests. Correlations between APTTTG with LTI, SA and TD were assessed using linear regression analyses.Results:22 knees in 18 patients with symptomatic patellar instability were included in the study group, with 22 control knees. TTTG and APTTTG distances were 19.9 mm and 8.3 mm in the symptomatic group, versus 16.8 mm and -0.5 mm in the control group, with a difference of 3.1 mm (p=0.002) and 8.8 mm (p<0.0001) respectively. The symptomatic group displayed greater trochlear dysplasia with lower LTI (13.0° vs 21.9°, p<0.0001), higher SA (152.7° vs 137.7°, p<0.0001) and lower TD (1.3mm vs 6.0mm, p<0.0001). There was strong correlation between APTTTG and TD (r=0.62, R2=0.39, p<0.0001).Conclusion:Our findings demonstrate that the trochlear groove is almost 9mm more anterior to the tibial tuberosity in patients with symptomatic instability, and this distance correlates with measurements of trochlear dysplasia. While further studies are needed to determine the relationship between APTTTG distance and patellar instability, these findings suggest that the anterior-posterior relationship between the trochlea and tuberosity may be a factor to consider when planning for tibial tuberosity osteotomy in patients with trochlear dysplasia.

Complications of Tibial Tuberosity Osteotomy.

It is important to understand potential complications of tibial tuberosity osteotomies (TTOs) and how to avoid them. TTO is associated with a 1% to 3% rate of tibial fracture and 1% rate of nonunion. Early weight-bearing and complete detachment of the distal tuberosity may increase these risks. Painful screws requiring removal occur in 3% to 77% of cases. Use of small (3.5- mm diameter), countersunk screws reduces this risk. Recurrent instability occurs in ∼5% of cases at 5 years. The risk of deep-vein thrombosis (4%) after TTO is higher than that associated with other sports surgeries (1% to 2%). The risk of wound complications is ∼1% and can be reduced with meticulous handling of soft tissues and avoidance of large medial incisions. The risk of deep infection is <1%. Severe complications such as compartment syndrome and pulmonary embolism are rare.

When and How Far to Move the Tibial Tuberosity in Patients With Patellar Instability.

The many factors contributing to patellar instability have led to various surgical techniques that are used commonly today. When surgery is deemed necessary, the operation should be tailored to the patient's specific pathoanatomy. Patients with malalignment can often be stabilized by moving the tibial tuberosity to a more medial, anteromedial, or distal position. Subsequent changes in the forces acting on the patellofemoral joint will depend on the direction and distance of the tuberosity repositioning. When planning tuberosity osteotomies, it is crucial to understand how to use clinical and imaging modalities to measure and quantify tuberosity position accurately to achieve the desired degree of realignment.

Paper #26 - Subscapularis repair using subscapularis peel and a novel through-implant suture technique achieves equivalent biomechanical strength to traditional lesser tuberosity osteotomy fixation

Paper #26 - Subscapularis repair using subscapularis peel and a novel through-implant suture technique achieves equivalent biomechanical strength to traditional lesser tuberosity osteotomy fixation

How should I fixate the subscapularis in total shoulder arthroplasty? A systematic review of pertinent subscapularis repair biomechanics.

The present study aimed to review the biomechanical outcomes of subscapularis repair techniques during total shoulder arthroplasty (TSA) to assist in clinical decision making. A systematic review of multiple databases was performed by searching PubMed, Scopus, Cochrane Library, Google Scholar, and all databases within EBSCOhost to find biomechanical studies of subscapularis repair techniques in cadaveric models of TSA. Nine studies met the inclusion criteria. In the majority of studies, lesser tuberosity osteotomy (LTO) techniques had greater load to failure and less cyclic displacement compared to subscapularis tenotomy or peel methods. LTO repairs with sutures wrapped around the humeral stem demonstrated superior biomechanical outcomes compared to techniques using only a tension band. In terms of load to failure, the strongest repair of any study was a dual-row fleck LTO using four sutures wrapped around the stem. Several cadaveric studies have shown superior biomechanical outcomes with LTO techniques compared to tenotomy. In the majority of studies, the strongest subscapularis repair technique in terms of biomechanical outcomes is a compression LTO. Using three or more sutures wrapped around the implant and the addition of a tension suture may increase the biomechanical strength of the LTO repair.

Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction.

Medial patellofemoral ligament reconstruction (MPFL-R) is the standard surgical intervention for patella instability. However, limited knowledge exists concerning the causes for failure, and outcome after revision MPFL-R. The purpose of this study is to evaluate the causes of primary MPFL-R failure and clinical outcomes after revision MPFL-R. Twenty-three patients (6 males and 17 females) with failed primary MPFL-R underwent isolated revision MPFL-R or combined revision MPFL-R with tibial tuberosity osteotomy (TTO). The mean age was 23 (SD 8.6). Prior to surgery, dysplasia of the patellofemoral joint, sulcus angle, Insall-Salvati index, cartilage lesions, tibial tuberosity trochlear groove (TTTG) distance, and tunnel placement were evaluated by magnetic resonance imaging (MRI). Their scores on the Kujala Anterior Knee Pain Scale and pain scores were assessed prior to surgery, 1 year post-operatively and at final follow-up. The mean follow-up time was 44 months (median range 39). The radiographic characteristics and clinical outcomes were compared with a 224 primary MPFL-R patient cohort (240 knees). Non-anatomical fixation of the graft at the medial femoral condyle after primary MPFL-R was seen in 67% of revision patients with anterior/proximal misplacement in most cases. Severe trochlear dysplasia Dejour types C and D were seen in 36% of the patients compared to 30% of primary MPFL-R patients (NS). The mean Kujala Anterior Knee Pain Scale score at final follow-up was 61.7 (SD 18.8) compared to 80.3 (SD 18) in primary MPFL-R patients (P < 0.01). The mean pain score at rest was 2.3 (SD 2.5) for revision MPFL-R patients compared to 1.7 (SD 2.5) in primary MPFL-R patients (NS) and their mean pain score during activity was 5.0 (SD 3.2) compared to 1.3 (SD 2.2) in primary MPFL patients (P < 0.001). Although revision MPFL-R establishes acceptable patellar stability, the subjective outcomes after revision MPFL-R do not improve significantly, and are poorer than after primary MPFL-R. Non-anatomical graft position can be an important cause of MPFL-R failure. The clinical relevance of this study is that it shows that it may be difficult to improve self-reported outcomes in revision MPFL-R patients. III.

Proximal ingrowth coating decreases risk of loosening following uncemented shoulder arthroplasty using mini-stem humeral components and lesser tuberosity osteotomy

Mini-stem humeral component (MSHC) use during total shoulder arthroplasty (TSA) provides bone preservation and ease of revision. MSHCs rely solely on proximal metaphyseal fixation; some early reports have demonstrated an unacceptably high rate of early loosening. To our knowledge, no study analyzing the effect of proximal porous coating on MSHCs has been performed. We performed a retrospective review of consecutive patients who underwent anatomic TSA using coated or uncoated MSHCs with minimum 2-year follow-up. Postoperative radiographs were assessed for risk of or frank stem loosening, subsidence, and presence of radiolucencies. Range of motion, outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation), and any complications were noted. We analyzed 68 shoulders with a mean follow-up of 27.3 months (range, 24-50 months). Of these, 34 had proximal coating and 34 were uncoated. In the coated group, no stems loosened, 1 (2.9%) subsided, and 7 (20.6%) developed radiolucencies. In the uncoated group, 1 stem (2.9%) became aseptically loose (requiring revision after 26 months), 7 (20.6%) were judged at risk of loosening (2 because of subsidence), and 15 (44.1%) developed radiolucencies. There was also an increased risk of proximal medial humeral radiolucencies among uncoated MSHCs. There were no significant differences in final range of motion or outcome scores. MSHC use is appropriate for TSA, achieving desired pain relief and functional improvement. Overall, component loosening appears uncommon at early follow-up; however, uncoated stems appear to be at greater risk of loosening and developing radiolucencies. Selecting an MSHC with proximal porous coating may decrease the risk of implant-related complications.

Maquet Osteotomy, Results

Objectives:The objectives are to assess the results and to discuss the indications for Maquet osteotomy in patients with patellofemoral osteoarthritis.Methods:Retrospective study of a series of 32 patients (4 bilateral, that is to say, 36 knees) operated between March 1999 and October 2013 in " Arthroscopy Private Center ", 12 male and 20 female, average age 59 years with an average postoperative surgery outcomes of 53 months. The technique consists of an arthroscopic procedure to treat joint lesions and a tibial tuberosity osteotomy of 5 cm long, by embedding a 1cm subsequent graft taken from the same metaphysis and fixed with 2 screws.Results:All patients had significant improvement, evaluated with Kujala’s score (54 points preop to 86 points postop) and Guillamon Ferguson’s criteria (27.2 very good and 60.7 good). The complication rate was acceptable.Conclusion:The available technics are surgeries on proximal soft structures, osteotomies of tibial tuberosity and patellofemoral arthroplasty. Maquet osteotomy is an excellent procedure when the patient’s selection is right. Obtaining the graft from the same metaphysis simplified the procedure.

Management of Complex Intercondylar Fractures of Lower End of Femur by Extensile Anterolateral Approach Using Tibial Tuberosity Osteotomy

Management of Complex Intercondylar Fractures of Lower End of Femur by Extensile Anterolateral Approach Using Tibial Tuberosity Osteotomy

Lesser tuberosity osteotomy and subscapularis tenotomy repair techniques during total shoulder arthroplasty: A meta-analysis of cadaveric studies

BackgroundNumerous techniques have been used to mobilize and repair the subscapularis tendon during total shoulder arthroplasty. The purpose of this study is to perform a detailed comparison of subscapularis tenotomy and lesser tuberosity osteotomy repairs during total shoulder arthroplasty. MethodsTwo independent reviewers searched two databases (PubMed and the Cochrane Library) to find cadaveric studies comparing the biomechanical strength of various subscapularis repair techniques following total shoulder arthroplasty. Articles that compared at least two repair techniques with similar biomechanical methods were included. FindingsAn initial literature search resulted in 145 studies. A title and abstract review resulted in five studies which analyzed outcomes of subscapularis tenotomy (total n=29) or lesser tuberosity osteotomy using a single- or dual-row suture technique (total n=46). Load to failure was significantly higher in the lesser tuberosity osteotomy group (M 443, SD 231N) than the tenotomy group (M 350, SD 113N) (p=0.047). Tenotomy (n=19) and lesser tuberosity osteotomy (n=31) had average cyclic displacements of 1.7mm (SD 1.3) and 2.1mm (SD 1.6), respectively (p=0.34). Mode of failure was significantly different between the two groups (p<0.0001), with soft tissue failure accounting for most tenotomy repairs (97%) and bone failure accounting for the majority of lesser tuberosity osteotomy repairs (72%). InterpretationBased on current biomechanical data, lesser tuberosity osteotomy is a stronger repair than a subscapularis tenotomy at “time-zero” in terms of load to failure. However, cyclic displacement did not differ statistically between the two techniques.

Immediate versus delayed passive range of motion following total shoulder arthroplasty

The goal of this study was to compare immediate with delayed range of motion (ROM) following total shoulder arthroplasty (TSA). The hypothesis was that ROM gains would occur earlier with immediate motion but that there would be no difference in ultimate ROM or functional outcome. Sixty patients were randomized to immediate motion (IM) or delayed motion (DM) following TSA. A lesser tuberosity osteotomy was performed in all cases. ROM and functional outcome were compared at 4 weeks, 8 weeks, 3 months, 6 months, and 1 year postoperatively. Compared with preoperative values, in the IM group, forward flexion improved from 106° to 141° at 1 year postoperatively, external rotation improved from 21° to 65°, and internal rotation improved by 2 spinal levels (P < .05). In the DM group, forward flexion improved from 104° to 144°, external rotation improved from 20° to 53°, and internal rotation improved by 4 spinal levels (P < .05). The 2 groups regained motion differently, but there were no significant differences in final ROM or functional outcome scores between the 2 groups. The IM group had higher functional outcome scores initially, but by 3 months postoperatively, there was no difference. The rate of osteotomy healing was 81% in the IM group compared with 96% in the DM group (P = .101). Immediate ROM provides a more rapid return of function compared with a delayed ROM protocol following TSA. However, there are no differences in ultimate ROM or functional outcome between the 2 groups. Moreover, immediate ROM may lower the healing rate of a lesser tuberosity osteotomy.

Survival and clinical results of a modified "crosse de hockey" procedure for chronic isolated patellofemoral joint osteoarthritis: mid-term follow-up

BackgroundThe optimum treatment for isolated patellofemoral joint osteoarthritis (PFJ-OA) remains controversial. The aim of this study was to assess the mid-term clinical results of a modified crosse de hockey procedure for the treatment of isolated PFJ-OA.Materials and methodsWe assessed 37 knees in 31 patients treated by a modified crosse de hockey procedure. The mean age was 57.6 years (range, 46–75 years) and mean follow-up was 90.1 months (range, 24–216 months). We evaluated clinical and radiographic outcomes, as well as complication rates at the mid-term follow-up.ResultsThe Kujala score (mean improvement of 46.7, P < 0.001) and the Fulkerson score (mean improvement of 19, P = 0.001) were significantly higher compared to preoperative values. Overall clinical results rated excellent in 24.3 %, very good in 21.6 %, good in 35.1 %, fair in 13.5 %, and poor in 5.4 % of knees. Patellar tilting (P = 0.015) and congruence angle (P = 0.018) significantly improved postoperatively. On the other hand, the Insall-Salvati index decreased at the time of follow-up, although it remained in the physiologic range. Postoperatively, consecutive disease progression in the tibiofemoral joint and patellofemoral joint osteoarthritis were 18.9 and 5.4 %, respectively. The operative complication rate was 5.4 % in this case series. These percentages were lower than those of alternative tibial tuberosity osteotomy techniques.ConclusionIn most patients with chronic isolated PFJ-OA, tibial tuberosity osteotomy by modified crosse de hockey is a reliable procedure that provides good/excellent mid-term clinical results.Level of evidenceLevel IV.

Biomechanical Study of a Subscapularis Repair Technique for Total Shoulder Arthroplasty.

Secure subscapularis repair is an essential element of total shoulder arthroplasty. Some surgeons prefer subscapularis peel because of ease of use, but some evidence suggests that lesser tuberosity osteotomy provides better fixation. The authors developed a novel, through-implant repair technique and performed a biomechanical study of its strength with cadaveric specimens. The authors obtained 20 matched pairs of cadaveric shoulders and inserted an uncemented short-stemmed humeral prosthesis that facilitates through-implant repair in all specimens. For each cadaver, the subscapularis was repaired with lesser tuberosity osteotomy and standard suture technique on 1 side, and the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Displacement of the subscapularis footprint, ultimate load to failure, and stiffness of each repair were measured and compared between fixation groups. Mean±SD displacement of the lesser tuberosity osteotomy group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles. Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were noted between the lesser tuberosity osteotomy group and the subscapularis peel group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88). In a biomechanical testing model, through-implant subscapularis repair provided secure fixation relative to currently accepted subscapularis repair techniques in total shoulder replacement. [Orthopedics. 2016; 39(5):e937-e943.].

The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study

ObjectiveTo prospectively study the outcome of surgically treated split depression lateral tibial plateau fractures extending into the posterior column using the extended posterolateral approach. MethodsTwenty-one patients with split depression lateral tibial plateau fractures (AO: 41-B3) with extension into the posterior column were treated with open reduction and internal fixation through an extended posterolateral approach with osteotomy of the fibular neck±Gerdy tubercle. Follow up radiographs was assessed for quality of articular reduction and limb axis. Functional assessment was performed at last follow up using the Tegner–Lysholm score. Complications pertaining to the surgical approach were recorded. ResultsThe approach was performed in 15 patients with a fibular neck osteotomy alone and 6 patients required a Gerdy's tubercle osteotomy also. All fractures and osteotomies had united. Anatomical articular reduction was achieved in 16 patients. Radiological limb alignment was restored in all patients except for a reversed posterior slope in 1 patient. Arthritic changes were seen in 3 patients. The mean Tegner–Lysholm score was 87.3 (range: 76–95) at last follow up. No specific complications related to the surgical approach like common peroneal nerve injury and lateral instability of the knee was encountered. ConclusionThe extended posterolateral approach offers excellent exposure posterior to the fibular head to perform articular reduction and fixation achieving satisfactory radiological and functional results in split depression lateral tibial plateau fractures extending into the posterior column.

Stemless shoulder prosthesis for treatment of proximal humeral malunion does not require tuberosity osteotomy.

When the proximal humeral anatomy is altered because of malunion, shoulder arthroplasty is a challenge for the orthopaedic surgeon, and tuberosity osteotomy should be avoided whenever possible. The purpose of this study was to investigate the clinical and radiological outcomes of anatomic stemless shoulder arthroplasty in cases of malunion. We hypothesized that a stemless prosthesis can be implanted without performing tuberosity osteotomy. We conducted a continuous, single surgeon, retrospective case series study with a minimum follow-up of twoyears (mean of 44months, range 24-80). The Constant-Murley score, active range of motion and X-rays were evaluated in 27 patients (mean age of 60years, range 37-83) with proximal humeral malunion who were treated with a stemless anatomic shoulder prosthesis. In all patients, the prosthesis was implanted without the need for tuberosity osteotomy. The Constant score improved from 27 to 62 (p ≤ 0.001), active anterior elevation from 81° to 129° (p ≤ 0.001), and external rotation from 5° to 40° (p ≤ 0.001). There was no evidence of radiological loosening. Use of a stemless anatomic shoulder prosthesis avoids the need for tuberosity osteotomy and certain surgical difficulties, even in cases of severe tuberosity malunion, and leads to good functional outcomes in the short term.