A simple and effective implant for displaced fractures of the greater tuberosity: the "Bamberg" plate

Comparison Study Among Three Surgical Methods in the Treatment of Isolated Fractures of the Greater Tuberosity of the Humerus

Introduction

This study aimed to compare the efficacy of three methods for isolated greater tuberosity fractures of the humerus.

Methods

A retrospective review of patients with isolated humeral greater tuberosity fractures between January 2013 and June 2021 in our institution. We recorded data on patient demographics, injury characteristics, preoperative and postoperative imaging findings, length of incision, operative time, and intraoperative blood loss.

Results

A total of 107 patients met the inclusion criteria and were divided into three groups. 50 patients in group A were administered a proximal humeral internal locking system (PHILOS) plate fixed using the deltopectoral approach, 26 patients in group B were administered a PHILOS plate fixed using the deltoid-splitting approach, and 31 patients in group C were administered a novel anatomical plate fixed using the deltoid-splitting approach. No significant differences were identified in sex, age, injury mechanism, type of fracture, dominant side limb, or shoulder anterior joint dislocation. However, the operative time, blood loss, and the length of incision was shorter than in Group C. Moreover, pain was evaluated on the third and fifth days after surgery; pain was lower in Group C, and pain at the last follow-up was not different between the groups. No significant differences were identified in the Constant score, DASH score, and ROM at the last follow-up. 2 patients were diagnosed with subacromial impingement, 1 in Group A one in Group B, and 1 patient in Group B experienced axillary nerve injury after surgery.

Conclusion

The novel anatomical plate fixed using the deltoid-splitting approach can achieve good results in the treatment of isolated humeral greater tubercle fractures with less blood loss, shorter operative time, and shorter surgical incisions, and can relieve pain in the early postoperative period.

Novel calcaneal plate versus traditional philos plate for treating split fractures of humeral greater tuberosity

Purpose

To compare the effect of two internal fixation methods of calcaneal plate fixation and Philos plate fixation in treating split fractures of humeral greater tuberosity.

Patients and methods

A total of 37 patients with split fractures of humeral greater tuberosity were retrospectively analyzed from September 2016 to April 2021. Enrolled patients were divided into Group A (calcaneal anatomical locking plates), and Group B [Proximal Humeral Internal Locking System (PHILOS)]. The demographics, injury-related variables, surgery-related variables, Constant-Murley score, and postoperative complication between the two groups were compared.

Results

There were 16 in Group A and 21 in Group B. Fracture union was achieved in all patients, with an average of 11.9 months. The mean length of incision was significantly different between groups (Group A, 6.16 cm ± 1.07 cm; Group B, 9.09 cm ± 1.30 cm, p < 0.05). Significant difference was observed by comparing bleeding loss between Group A and Group B (Group A, 45.41 ± 11.19 ml; Group B, 106.06 ± 11.12 ml, p < 0.05). After 6 months of treatment, the average Constant-Murley score of Group A was significantly higher than that of Group B (p < 0.05). In terms of operation, no significant difference was observed between groups. In addition, two patients had shoulder impingement syndrome in Group B, and none in Group A.

Conclusion

Calcaneal anatomical locking plate fixation is superior to Philos plate fixation in surgical trauma and bleeding loss. Our study provides an alternative technique for treating split fractures of humeral greater tuberosity.

Additional cuff suture provides mechanical advantage for fixation of split-type greater tuberosity fracture of humerus

PURPOSE

Split type of greater tuberosity fracture has variety of surgical treatment options. This study aimed to compare the biomechanics property of additional cuff suture and other fracture fixation techniques.

METHODS

Fifteen porcine humeri were categorized into three groups of fixation techniques those were proximal humeral internal locking system (PHILOS) plate with 2 cuff sutures, nonlocking (conventional, 3.5 mm) T-plate with 2 cuff sutures and T-plate with washer that had additional cuff suture (novel technique). Fracture was created by greater tuberosity osteotomy with 50˚ inclination to the line of surgical neck and then fixed with different prescribed techniques. Displacement of fracture site was measured with universal testing machine. The maximum forces to produce 3 mm, 5 mm of displacement and load to failure were recorded.

RESULTS

The average loads to reach 3 mm, 5 mm displacement and failure were 30.8 N, 45.4 N and 161 N for nonlocking T-plate; 76.6 N, 99.2 N and 144 N for PHILOS plate; 95.8 N, 120 N and 197 N for novel technique. The differences among three groups were significant in load to displacement at 3 and 5 mm (but not significant in load to failure). For load to reach 3- and 5-mm displacement, PHILOS plate and novel technique were significantly stronger than nonlocking T-plate (P < 0.05). For load to reach 3 and 5 mm displacement, novel technique was stronger than PHILOS plate but not significant (P > 0.05). For load to failure, novel technique was stronger than nonlocking plate and PHILOS plate but not significant (P < 0.05).

CONCLUSION

The important factors affecting the strength of fracture fixation are type of plate and numbers of suture augmentation that tie to the plate. Fixation with additional cuff suture showed the superior biomechanics of load to reach 3 mm, 5 mm displacement with better load to failure compared with PHILOS plate and conventional T-plate alone.

Surgical fixation of isolated greater tuberosity fractures of the humerus- systematic review and meta-analysis

OBJECTIVES

A systematic review was undertaken based on PRISMA guidelines to study the results of surgical treatment of Greater Tuberosity fractures of the Humerus by different techniques (Open, Percutaneous or Arthroscopic) and using different fixation devices (Sutures, Screws and Plates).

DATA SOURCES

Literature searches were performed for studies in English on four online databases (MEDLINE®, Embase®, Ovid® Emcare and CINAHL®) using a pre-planned search strategy.

STUDY SELECTION

Studies were screened against pre-decided inclusion and exclusion criteria. 24 articles were eligible for inclusion involving 562 patients in all.

DATA EXTRACTION

A template was used for collection of relevant data regarding the study design, demographics, fracture characteristics, surgical techniques and implants used, outcomes, complications and re-operations. Methodological quality was assessed using a modified Coleman Methodology Score.

DATA SYNTHESIS

Pooled analysis was conducted for (1) complications/reoperations of different devices; and (2) reported results using standard outcome measures of various techniques. Results were pooled using inverse variance method. When pooling proportions, we used arcsine transformation to account for zero events.

CONCLUSION

Use of screws was associated with higher rates of total complications (23.7%) as well as reoperations (13.2%), compared to sutures (14.2%; 2.6%) and plates (10.6%; 4.1%). In a subgroup analysis, use of low-profile plates (LPPs) was associated with the lowest rates of total complications (4.97%). The superiority of any surgical technique could not be established using the pooled Constant or ASES scores because there was lack of uniformity in the reporting of outcome measures. Our analysis of complications of the various fixation devices dissuades the use of screws and favours the use of low-profile plates. There is a need for prospective studies comparing arthroscopic suture fixation with open low-profile plate fixation of GT fractures.

Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method

Backgroud

The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications.

Methods

We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion.

Results

Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12–20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and Constant-Murley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively).

Conclusions

The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable. Therefore, second surgery for implant removal is necessary after bone union is achieved.

Dual Locking Plate Osteosynthesis for 3- or 4-Part Proximal Humeral Fractures Combined with Multiple Fractures of the Greater Tuberosity

BACKGROUND

This retrospective study was conducted to evaluate the efficacy of dual locking plate osteosynthesis for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

METHODS

From January 2012 to December 2018, 19 skeletally mature patients, who suffered 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity, were treated with open reduction and internal fixation using a dual locking plate technique through a delto-pectoral approach. Indexes for evaluation included fracture healing, quality of reduction, and incidence of complications (infections, screw perforation into the glenohumeral joint, subacromial impingement, hardware failure, avascular necrosis, and loss of reduction). Shoulder function was evaluated using Constant-Murley scoring.

RESULTS

The patients were assessed at a mean time of 25.3 months after surgery. Union of fractures was radiographically confirmed for all 19 patients. The mean Constant-Murley patient score was 85.2 points, and complications were identified in two patients during follow-up evaluations.

CONCLUSIONS

The method of using dual locking plate osteosynthesis through a delto-pectoral approach resulted in a satisfactory union rate, excellent fracture reduction, low complication rate and good shoulder function for patients with complex proximal humeral fractures. The method is effective for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

Plate Fixation versus Arthroscopic-Assisted Plate Fixation for Isolated Medium-Sized Fractures of the Greater Tuberosity: A Retrospective Study

Objectives

To compare the clinical outcomes of plate fixation and arthroscopic‐assisted plate fixation in patients with displaced isolated medium‐sized fractures of the greater tuberosity.

Methods

From July 2013 to October 2017, patients with displaced isolated medium‐sized fractures of the greater tuberosity who underwent arthroscopic‐assisted plate fixation (ASPF group) or open reduction and internal plate fixation (ORIF group) were retrospectively reviewed and analyzed. There were 19 patients in the ASPF group and 27 patients in the ORIF group, with comparable demographic characteristics. The average age of patients was 49.4 ± 12.1 years in the ASPF group and 46.9 ± 11.4 years in the ORIF group. The shoulder function reflected by the Constant–Murley (CS) scores, the American Shoulder and Elbow Surgeons (ASES) scores, and the range of motion (ROM) in the both groups at the last follow‐up were analyzed in the study. Surgery time, postoperative pain, and postoperative complications were also reviewed.

Results

A total of 46 eligible patients were included in this study. The mean follow‐up was similar for the ASPF (19.4 ± 3.7 months) and the ORIF (18.2 ± 3.2 months) groups (P = 0.372). All patients had achieved primary incision healing in both groups at the last follow‐up. The surgery time was 96.8 ± 11.7 min and 64.2 ± 8.3 min in the ASPF group and the ORIF group, respectively (P < 0.01). All the CS scores (P = 0.278), ASES scores (P = 0.426), and ROM were slightly better in the ASPF group than in the ORIF group, but they did not attain significant differences. In addition, there was no significant difference in the postoperative complication rate between the ASPF group (10.5%) and the ORIF group (18.5%) (P = 0.522). In the ASPF group, there was only one patient with postoperative shoulder stiffness and one case of fracture malunion. In the ORIF group, there were two cases of postoperative shoulder stiffness, two cases of fracture malunoin, and one case of subacromial impingement. Other major postoperative complications, such as fracture nonunion, pullout of the suture anchor, and screw penetration, were not observed in either group.

Conclusion

Arthroscopic‐assisted plate fixation is effective and may be an alternative in the treatment of displaced isolated medium‐sized fractures of the greater tuberosity.

[Effectiveness of open reduction and locking compression hook plate in treatment of isolated humeral greater tuberosity fractures]

Objective

To observe the effectiveness of locking compression hook plate in treatment of humeral greater tuberosity fractures.

Methods

Between March 2014 and September 2017, 16 patients with isolated humeral greater tuberosity fractures were terated with open reduction and internal fixation with locking compression hook plates. There were 11 males and 5 females, with an average age of 38.4 years (range, 22-67 years). The cause of injury was falling injury in 13 cases and sport injury in 3 cases. All patients were closed fractures. Of all patients, 14 patients accompanied with shoulder joint dislocations. CT scan showed the average displacement of fragment was 12.6 mm (range, 8-21 mm) after reduction. All patients began passive functional exercise at 3 days after operation.

Results

Primary healing of the incisons achieved in all patients, without complications such as infection and nerve injury. All patients were followed up 12-20 months (mean, 15.3 months). At 3 months after operation, X-ray film showed that all fractures achieved bone union, all of which met the imaging anatomical reduction standard. According to the Neer scoring criteria, 11 cases were excellent and 5 cases were good at last follow-up. One patint presented slight pain of shoulder joint and mild activity limitation, which relieved after 1 year.

Conclusion

The method of open reduction and locking compression hook plate internal fixation for isolated humeral greater tuberosity fractures has advantages, such as less intraoperative hemorrhage, mild postoperative pain, firm fixation, and allowing patients to perform functional exercise earlier, which is conducive to shoulder functional recovery and obtain satisfactory effectiveness.

Displaced isolated greater tuberosity fractures of elder adults treated with plate osteosynthesis

BACKGROUND

We elucidated the effect of open reduction and internal fixation with locking plate for acute isolated displaced greater tuberosity fractures of humerus in elder adults (aged >60 years).

METHODS

From 2009 to 2015, data from 32 patients, aged between 60 and 88 years, who had acute unilaterally displaced greater tuberosity fractures of humerus were collected and evaluated retrospectively. All the fractures were managed with open reduction and internal fixation with locking plate. The follow-up period was 50.8 months on an average (range 22-80 months). Finally, 25 patients were available for final evaluation of radiographic and functional results.

RESULTS

All the 32 fractures had union with the average union time of 14 weeks (range 10-18 weeks) and with no complications. The average of preoperative Visual Analogue Scale (VAS) was 6.2 (range 4-8), ASES was 30.4 (range 13-45), and Constant score was 30.4 (range 20-45). At the last follow-up, the mean VAS was 1.3 (range 0-2.5), the mean ASES score was 90.1 (range 72-100), and the mean Constant score was 90.3 (range 80-100). There were statistically significant differences between preoperative and final follow-up in VAS, ASES, and Constant score. Hundred percent of patients had good or excellent results by Constant score, with excellent results (86-100) in 17 (68%) patients and good result (71-85) in 8 (32%).

CONCLUSION

In conclusion, open reduction and internal fixation with locking plate is an effective treatment for acute displaced greater tuberosity fractures of humerus in elder adults.

Biomechanical Analysis of the Fixation Strength of a Novel Plate for Greater Tuberosity Fractures

Background

The incidence of isolated greater tuberosity fractures has been estimated to be 20% of all proximal humeral fractures. It is generally accepted that displaced (>5 mm) fractures should be treated surgically but the optimal surgical fixation of greater tuberosity fractures remains unclear.

Objective

The goal of this study was to simulate the environment of application of a new plate system (Kaisidis plate, Fa Königsee) for fractures of greater tuberosity, and to demonstrate the stability of the plate.

Methods

A Finite Element Method (FEM) simulation analysis was performed on a Kaisidis plate fixed with nine screws, in a greater tuberosity fracture model. Solid Works 2015 simulation software was used for the analysis. The Kaisidis plate is a bone plate intended for greater tuberosity fractures. It is a low profile plate with nine holes for 2,4 mm diameter locking screws, eight suture holes and additional K-wire holes for temporary fixation of the fragment.The supraspinatus tendon has the greatest effect on the fracture zone, and as such, was the primary focus for this study. For this study, we performed only linear calculations.

Results

The calculations were performed in a way so that the total applied force resulted in a maximum stress of 816 N/mm². The findings indicated that the most critical points of the Kaisidis system are the screws that are connected to the bone. The maximal force generated by the supraspinatus tendon was 784 N, which is higher than the minimal acceptable force.The results of the FEM analysis showed that the maximal supraspinatus force was 11.6% higher than the minimal acceptable force. As such, the load would exceed twice the amount of maximal force required to tear the supraspinatus tendon, before the screw or the plate would show first signs of plastic deformation.

Conclusion

Based on the results of this analysis and the fulfilment of our acceptance criterion, the FEM model indicated that the strength of the Kaisidis plate exceeded that of the proposed maximum loads under non-cycli loading conditions.

Application of pre-contoured anatomic locking plate for treatment of humerus split type greater tuberosity fractures: A prospective review of 68 cases with an average follow-up of 2.5 years

OBJECTIVES

Although various implants exist for 3- and 4-part proximal humerus fractures, few implants are appropriate for humerus split type greater tuberosity fractures. The goal of this study was to assess the efficacy of pre-contoured anatomic locking plate for humerus split type greater tuberosity fractures.

METHODS

A retrospective review of 68 patients with humerus split type greater tuberosity fractures treated with open reduction and internal fixation using anatomic locking plates between January 2014 and October 2016. Postoperatively, patient radiographs, functional results, and complications were reviewed.

RESULTS

All patients got a mean follow-up of 30.5 months (range 14-46 months). Average fracture healing time was 9.4 weeks (range, 8-14 weeks). Overall mean Constant score was 86.8% (range, 70%-96%). The result was rated as excellent in 25 patients (Constant score: 92.1%), good in 38 patients (Constant score: 85.3%) moderate in 5 patients (Constant score: 71.8%) and poor in 0 cases. The excellent-good rate was 92.6%. No recurrence of dislocation occurred in the 30 cases with shoulder dislocation. All fractures healed without the complications of wound infection, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening.

CONCLUSION

Pre-contoured anatomic locking plate is a reliable option in treating humerus split type greater tuberosity fractures as it provides stable fixation with an early return to function. The surgical technique is easy and efficient.

Isolated fractures of the greater tuberosity: When are they treated conservatively?: A baseline study

Background

This study analyzed the indications for conservative management of isolated greater tuberosity (GT) fractures. The rate of secondary interventions for failed conservative treatment was also assessed.

Methods

A retrospective data evaluation of isolated GT fractures was performed from the clinical database of two level-I trauma centers from January 2010 to June 2017. Conservatively treated GT fractures were identified and subdivided according to etiology, morphology, and amount of initial displacement. Secondary surgical interventions were recorded and subcategorized into fracture-associated interventions and interventions for associated soft tissue lesions.

Results

We identified 114 fractures. Nine cases were excluded because patients refused surgery or their comorbidities ruled it out. Only two of the remaining 105 patients had an initial displacement >3 mm. All other GT fractures (n = 103, 98%) were not displaced or only slightly displaced (0–3 mm). The fracture was associated with an anterior shoulder dislocation in 39 cases (37%); 17 patients (16.2%) underwent surgery after primary conservative treatment. Four of these 17 patients presented with a secondary displacement of the GT fragment. In all other cases (76.5%), an associated soft tissue lesion necessitated revision surgery. Young age, anterior shoulder dislocation, and concomitant injuries were risk factors for revision surgery after primary conservative treatment.

Conclusion

Secondary interventions are required more frequently after shoulder dislocation. Surgery is most likely required for associated soft tissue lesions rather than for secondary displacements. Thus, detailed physical examination and magnetic resonance imaging should be used to screen for concomitant soft tissue injuries accompanying GT fractures to prevent revision surgeries.

Titanium mini locking plate with trans-osseous sutures for the treatment of humeral greater tuberosity fracture osteosynthesis versus PHILOS: a retrospective view

PURPOSE

Greater tuberosity fractures (GTFs) account for 17 to 21% of proximal humerus fractures, most of these fractures are treated conservatively, but treatment for displaced fractures is still controversial. The aim of this study is to compare intra-operative clinical conditions and post-operative outcomes when displaced GTFs are treated with either proximal humeral internal locking system (PHILOS) or mini locking plate with trans-osseous sutures.

METHODS

This is a retrospective study conducted in Shanghai Tenth People's Hospital. A total of 60 patients (22 males and 38 females) with displaced humeral GTF between May 2013 and March 2017 were included, of whom 43 underwent PHILOS implant treatment and 17 underwent titanium mini plate implant with trans-osseous suture treatment. Intra-operative (incision size, intra-operative blood loss, operative duration) and postoperative (Constant-Murley score (CMS) and implant cost) variables were recorded for the comparison.

RESULTS

Mini locking plate with trans-osseous sutures shows better results. Operative duration (PHILOS mean 77.0 minutes vs mean 63.7 minutes, p value < 0.05), blood loss during surgery (PHILOS mean 111.5 vs 66.5 ml, p value < 0.05), incision size (PHILOS mean 7.2 vs 4.6 cm, p value < 0.05), CMS (PHILOS mean 81.0 vs 87.3, p value < 0.05), and implant costs (PHILOS mean 26,192.6 renminbi (RMB) vs mean 21,358.8 RMB, p value < 0.05). On the other hand, 9.30% of impingement in the PHILOS group was observed to have no complications compared to the mini locking plate group.

CONCLUSIONS

Mini locking plate with trans-osseous sutures shows better efficacy in reducing the incision size, operative duration, intraoperative blood loss, and implant cost and in improving CMS. No complication was found with its use. Our data can provide rationale and inform sample- size calculations for such studies. Larger, control studies are needed for better understanding.

An alternative technique for greater tuberosity fractures: use of the mesh plate

INTRODUCTION

Isolated greater tuberosity (GT) fractures (AO 11-A1) tend to occur in the younger patient population and are poorly managed by most precontoured proximal humerus locking plates. The goal of this study was to identify and assess an alternative treatment strategy for greater tuberosity fractures.

MATERIALS AND METHODS

A retrospective review of all cases of isolated greater tuberosity fractures treated with a 2.4/2.7 mesh plate (Synthes) between 2010 and 2015 was conducted. Patient demographics, operative reports, and clinical notes were reviewed. The time to radiographic union was assessed. Clinical outcomes were retrieved from patients at their follow-up visits or via mailed Disabilities of the Arm, Shoulder, Hand (DASH) questionnaires.

RESULTS

Ten patients with isolated GT fractures treated with mesh plating were identified with an average age of 47.1 years. The average radiographic follow-up was 7.2 months and the average clinical follow-up was 8.0 months. The mean time to union was 8.5 weeks. Two patients underwent elective hardware removal. The mean DASH at final follow-up was 28.2 (±22.4), while the mean DASH work was 13.6 (±19.1).

CONCLUSION

We have identified a viable alternative treatment option for the surgical management of isolated greater tuberosity fractures using a mesh plate that can be contoured to the patient's anatomy. Surgeons should be aware of this option for select patients.

Arthroscopic-assisted plate fixation for displaced large-sized comminuted greater tuberosity fractures of proximal humerus: a novel surgical technique

PURPOSE

The purpose of the present study was to describe the use of a novel hybrid surgical technique-arthroscopic-assisted plate fixation-and evaluate its clinical and anatomical outcomes in the management of large, displaced greater tuberosity (GT) fractures with comminution.

METHODS

From 2009 to 2011, this novel technique was performed in 11 patients [2 men and 9 women; median age, 64 years (range 41-83 years)] with large, comminuted GT fractures, with fragment displacements of >5 mm. The preoperative mean posterior and superior migration of the fractured fragment, as measured on computed tomography (CT), was 19.5 and 5.5 mm, respectively. Two patients had shoulder fracture-dislocation, and three had associated undisplaced surgical neck fracture. The mean duration between injury and surgery was 4 days. The mean follow-up duration was 26 months.

RESULTS

At the final follow-up, the mean postoperative ASES, UCLA and SST scores were 84, 29, and 8, respectively. The mean range of motion was as follows: forward flexion, 138°; abduction, 135°; external rotation at the side, 19°; and internal rotation, up to the L2 level. The mean posterior and superior displacements of fracture fragments on postoperative CT scan [0.7 ± 0.8 mm (range 0-2.1 mm) and 2.8 ± 0.5 mm (range 3.4-5.3 mm), respectively] were significantly improved (p < 0.05). On arthroscopy, a partial articular-side supraspinatus tendon avulsion lesion was identified in 10 of 11 patients (91 %), and 1 of these patients had a partial tear of the biceps and 1 had a partial subscapularis tear, respectively (9 %). Intraoperatively, 1 anchor pullout and 1 anchor protrusion through the humeral head were noted and corrected. Postoperatively, the loss of reduction in the fracture fragment was noted in 1 patient at 4 weeks, after corrective reduction and fixation surgery.

CONCLUSIONS

The novel arthroscopic-assisted anatomical plate fixation technique was found to be effective in reducing large-sized, displaced, comminuted GT fractures and in allowing concurrent management of intra-articular pathologies and early functional rehabilitation. Compared with the conventional plate fixation or arthroscopic suture anchor fixation technique, arthroscopic-assisted plate fixation enabled accurate restoration of the medial footprint of the GT fracture and provided an effective buttress to the large-sized GT fracture fragments.

LEVEL OF EVIDENCE

Retrospective clinical study, Level IV.

A Retrospective Study in the Treatment of a 2-Part Greater Tuberosity Fracture Using the F3 Biomet Plate

The purpose of this study was to evaluate the clinical efficacy of the F3 Biomet plate in the treatment of 2-part displaced humeral greater tuberosity fractures. We compared the clinical outcomes of patients with displaced greater tuberosity fractures who underwent surgical treatment using an F3 plate with those of patients who were treated nonsurgically. Eleven patients with 2-part displaced humeral greater tuberosity fractures were surgically treated with use of an F3 Biomet plate, whereas 12 patients with equal injuries were treated nonsurgically. Each patient underwent follow-up for at least 1 year. We retrospectively collected data and analyzed the clinical outcomes. The Constant score and DASH score were used to assess the shoulder function, and X-rays were taken to evaluate the fracture healing. X-rays of the patients in both groups showed that the fractures achieved union after the 1-year follow-up. Patients treated surgically with an F3 plate and open reduction internal fixation had better Constant score and DASH score results for shoulder function than those treated nonsurgically. In the present study, surgical treatment of displaced humeral greater tuberosity fractures with the use of an F3 plate led to a 100% union rate and good clinical outcomes. The F3 Biomet plate can be considered an effective implant for the treatment of displaced humeral greater tuberosity fractures. The level of evidence is therapeutic III.

Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be successfully treated nonsurgically in most patients. However, as little as 3 to 5 mm of superior greater tuberosity displacement may adversely affect rotator cuff biomechanics and lead to subacromial impingement in patients who are active. In these cases, surgical treatment is recommended. Multiple surgical techniques include open and arthroscopic options tailored to fracture morphology, and strategies for repair include the use of suture anchors, transosseous sutures, tension bands, and plates/screws. Three classification systems are commonly used to describe greater tuberosity fractures: the AO, Neer, and morphologic classifications. Several hypotheses have been discussed for the mechanism of greater tuberosity fractures and the deforming forces of the rotator cuff, and the use of advanced imaging is being explored.

Locking plate fixation provides superior fixation of humerus split type greater tuberosity fractures than tension bands and double row suture bridges

BACKGROUND

This paper aims to determine the strongest fixation method for split type greater tuberosity fractures of the proximal humerus by testing and comparing three fixation methods: a tension band with No. 2 wire suture, a double-row suture bridge with suture anchors, and a manually contoured calcaneal locking plate.

METHODS

Each method was tested on eight porcine humeri. A osteotomy of the greater tuberosity was performed 50° to the humeral shaft and then fixed according to one of three methods. The humeri were then placed in a testing apparatus and tension was applied along the supraspinatus tendon using a thermoelectric cooling clamp. The load required to produce 3mm and 5mm of displacement, as well as complete failure, was recorded using an axial load cell.

FINDINGS

The average load required to produce 3mm and 5mm of displacement was 658N and 1112N for the locking plate, 199N and 247N for the double row, and 75N and 105N for the tension band. The difference between the three groups was significant (P<0.01). The average load to failure of the locking plate (810N) was significantly stronger than double row (456N) and tension band (279N) (P<0.05). The stiffness of the locking plate (404N/mm) was significantly greater than double row (71N/mm) and tension band (33N/mm) (P<0.01).

INTERPRETATION

Locking plate fixation provides the strongest and stiffest biomechanical fixation for split type greater tuberosity fractures.

A new morphological classification for greater tuberosity fractures of the proximal humerus: validation and clinical implications

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique.

AO X-shaped midfoot locking plate to treat displaced isolated greater tuberosity fractures

Although various implants exist for 3- and 4-part fractures, few implants are appropriate for isolated greater tuberosity fractures. This retrospective study evaluated the efficacy of AO X-shaped midfoot locking plates for greater tuberosity fractures. Between May 2008 and September 2009, nineteen patients with displaced greater tuberosity fractures were treated with open reduction and internal fixation using AO X-shaped midfoot locking plates. Postoperatively, radiographs, functional results, and complications were evaluated. All patients were followed up for a mean 33.2 months (range, 24-42 months). Mean healing time was 9.4 weeks (range, 8-14 weeks). Mean Constant score was 90.6±4.0 points (range, 77-95 points). Excellent results were obtained in 16 cases, good in 2 cases, moderate in 1 case, and poor in 0 cases. The excellent-good rate was 94.7%. No recurrence of dislocation occurred in the 11 cases with shoulder dislocation. All fractures healed without the complications of wound infection, skin numbness, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening. The described technique is an effective, simple, and inexpensive method with a short learning curve.