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

Arthroscopic Tri-anchor Double-Pulley Suture-Bridge Reduction of Greater Tuberosity Fracture

Currently, cannulated screws, plates, and suture bridges are widely applied in the treatment of greater tuberosity fracture; however, further fragmentation of the fracture, risk of loss of fracture reduction, implant impingement, and anchor pullout are the drawbacks. Therefore, we present a pragmatic surgical technique called the arthroscopic tri-anchor double-pulley suture-bridge technique that uses a double-loaded metallic anchor as a lateral-row anchor. In the treatment of greater tuberosity fracture, this hybrid repair including 4 sets of double-pulley suture bridges and 2 sets of single rows can obtain powerful stiffness of the suture construct, the metallic anchor used as a lateral-row anchor can significantly reduce the risk of anchor pullout, the single-row process can lessen the overall surgical time, and implant impingement will not occur postoperatively.

Therapeutic effect of titanium locking plate combined with suture anchor repair in proximal humeral fractures

Objective

To explore the therapeutic effect of titanium locking plate combined with suture anchor (SA) repair in the treatment of proximal humeral fractures (PHF).

Methods

This retrospective study was conducted by analyzing the clinical data of 113 patients with PHF admitted to Wuhan Fourth Hospital from March 2021 to October 2023. Among them, 55 patients underwent open reduction and internal fixation (OR/IF) using titanium locking plate (OR/IF group), and 58 patients underwent surgery with titanium locking plate combined with SA (SA group). Perioperative condition, treatment success rate, shoulder joint function before and after the surgery, shoulder joint range of motion, and incidence of complications were compared between the groups.

Results

Surgery duration and the length of hospital stay of patients in the SA group were significantly shorter than those in the OR/IF group, and the intraoperative blood loss was significantly lower in the SA group than in the OR/IF group (P<0.05). In terms of treatment effect, the SA group was significantly higher than the OR/IF (P<0.05). After the surgery, muscle strength, pain levels, daily living activities, and shoulder joint range of motion scores of both groups improved, and the improvement was more significant in the SA group compared to the OR/IF group (P<0.05). After the surgery, the degrees of internal rotation, forward flexion, backward extension, and external rotation of the shoulder joints in both groups increased compared to pre- surgery levels, and were greater in the SA group compared to the OR/IF group (P<0.05). The incidence of complications in the SA group was lower than that in the OR/IF group (P<0.05).

Conclusions

In patients with PHF, the combination of titanium locking plate and SA has a more significant therapeutic effect than that of titanium locking plate alone, which is associated with improved shoulder joint function and range of motion, and reduced incidence of complications.

Comparison between arthroscopic suture anchor fixation and open plate fixation in the greater tuberosity fracture of the proximal humerus

INTRODUCTION

The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing open reduction and internal fixation (OR/IF) using a plate or patients undergoing an arthroscopic suture anchor fixation for the greater tuberosity (GT) fracture of the proximal humerus. The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing OR/IF or an arthroscopic suture anchor fixation for the GT fracture.

MATERIALS AND METHODS

Between January, 2010 and December, 2020, 122 patients with GT fracture underwent operative fixation. Either OR/IF using proximal humeral locking plate (50 patients) or arthroscopic suture anchor (72 patients) fixation was performed. Fourteen patients were lost to follow-up and finally, 108 patients were enrolled in this study. We divided these patients into two groups: (1) OR/IF group (Group I: 44 patients) and arthroscopic anchor fixation group (Group II: 64 patients). The primary outcome was subjective shoulder function (shoulder functional scale). Secondary outcomes were range of motion, and complications including GT fixation failure, fracture migration, or neurologic complication. Also, age, sex, BMI, operation time, shoulder dislocation, fracture comminution, AP (anteroposterior), SI (superoinferior) size and displacement were evaluated and compared between two groups.

RESULTS

Both groups showed satisfactory clinical and radiological outcomes at mid-term follow-up. Between 2 groups, there were no significant differences in age, sex, BMI, presence of shoulder dislocation or comminution. Group II showed higher clinical scores except VAS score (p < 0.05) and longer surgical times (95.3 vs. 61.5 min). Largest fracture displacement (Group I vs. II: SI displacement: 40 vs. 13 mm, and AP displacement: 49 vs. 11 mm) and higher complication rate (p = 0.049) was found in Group I.

CONCLUSIONS

Both arthroscopic anchor fixation and open plate fixation methods showed satisfactory outcomes at mid-term follow-up. Among them, OR/IF is preferred for larger fracture displacement (> 5 mm) and shorter operation time However, arthroscopic anchor fixation group showed better clinical outcomes and less complications than the OR/IF group.

LEVEL OF EVIDENCE

Level 4, Case series with subgroup analysis.

A Transosseous Suture as an Alternative to Suture Anchor on Anterior-Avulsion Greater Tuberosity Fragment Fixation in Neer Three-Part Proximal Humeral Fracture: A Biomechanical Study

OBJECTIVE

Greater tuberosity (GT) fragments were communicated, and additional techniques to increase the GT fragment stability after the locking plate fixation was necessary. This study aimed to analyze the reinforcement effects on the anterior-avulsion GT fragment in Neer three-part proximal humeral fractures (PHFs) using transosseous suture and suture anchor techniques.

METHODS

Eighteen fresh-frozen human cadaveric shoulder specimens were used in the study. Standardized fracture of the GT and surgical neck was created in 18 human cadaveric proximal humerus. The GT fragments were reinforced with transosseous suture (TS), suture anchor (SA), and suture in addition to the PHILOS plate fixation. The fixed humerus was tested by applying static loading to the supraspinatus tendon. Load forces and fragment displacement were evaluated by a biomechanical testing machine, and the load to 3- and 5-mm displacements, load to failure, and mode of failure were recorded for all specimens. Nonparametric variables were examined by the Kruskal-Wallis test, and the Bonferroni post hoc test was used to analyze the mean loads to create 3- and 5-mm displacements as well as the failure load.

RESULTS

The age, female proportion, and bone mineral density showed no statistically significant differences between the three groups. The mean loading force to create 3-mm and 5-mm displacement in the TS group (254.9 ± 77.4, 309.6 ± 152.7) were significantly higher than those in the suture group (136.1 ± 16.7, 193.4 ± 14.5) (P = 0.024, P = 0.005). For the SA group, the force to create 3- and 5-mm displacement (204.3 ± 60.9, 307.8 ± 73.5) were comparable to those in the TS group (P = 0.236, P = 0.983). Moreover, the loading force to failure in the TS group (508.6 ± 217.7) and SA group (406.6 ± 114.9) was significantly higher than that in the suture group (265.9 ± 52.1) (P = 0.021, P = 0.024). In the TS group, three failed due to tendon-bone junction rupture; bone tunnel broken occurred in two specimens; suture rupture could also be seen in one specimen. All specimens in the suture group failed because of suture rupture. In the SA group, three specimens failed due to suture rupture; two failed secondary to tendon-bone junction rupture; and one failed because of shaft fracture.

CONCLUSIONS

Transosseous suture is a new type of reinforcement for GT fragment in Neer-three part PHFs. The transosseous suture was superior to the suture only in the reinforcement of the anterior-avulsion GT fragment of Neer three-part PHFs, and it had comparable biomechanical strength to the suture anchor.

Arthroscopic Parachute Technique for Split-type Greater Tuberosity Fractures

Over the past years, several arthroscopic fixation procedures have been adopted for fractures of the greater tuberosity. Although they offer advantages over open approaches, especially for avulsion-type fixation, split-type fractures are usually treated with open reduction and internal fixation. However, suture constructs can result in a more reliable fixation system for multifragment or osteoporotic split-type fractures. Currently, the use of arthroscopic techniques in these more complex fractures is questionable due to inherent limitations of anatomic reduction and stability concerns. The authors report a technically simple and reproducible arthroscopic procedure based on anatomic, morphologic, and biomechanical concepts, which offers advantages over traditional open approaches or double-row arthroscopic techniques in the treatment of most split-type greater tuberosity fractures.

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.

A Mid-Scapular Portal for Arthroscopic-Assisted Fixation of Severe Retraction Greater Tuberosity Avulsion Fracture

Chronic displaced greater tuberosity avulsion fracture of the humerus causes severe retraction of the rotator cuff and resorption of the avulsion fragment. Many treatment options can be considered to solve this problem and return the patient to function. The arthroscopic technique is very challenging to achieve a reduction of the rotator cuff and fixation of greater tuberosity with minimized soft-tissue damage. This Technical Note describes a portal for arthroscopic-assisted reduction and fixation in severe retracted greater tuberosity avulsion fracture. The technique is easy to release and fix chronic displaced greater tuberosity and could avoid unnecessary open surgery.

Arthroscopic Management of Displaced Greater Tuberosity Fractures

Displaced greater tuberosity fractures of the humerus require anatomic reduction with stable fixation to optimize rotator cuff function and prevent subacromial impingement. A wide variety of surgical approaches and fixation constructs have been reported, largely with favorable results. Arthroscopic management of these fractures allows excellent visualization with strong suture anchor fixation while minimizing soft tissue disruption, blood loss, and radiation exposure. The purpose of this article is to describe an arthroscopic technique for reduction and suture-anchor fixation of displaced greater tuberosity fractures.

Tuberosity Repair in Reverse Total Shoulder Arthroplasty for Fracture Using a Stem-based Double-row Repair: A Cadaveric Biomechanical Study

INTRODUCTION

The optimal tuberosity repair method in reverse total shoulder arthroplasty for fracture is unknown.

METHODS

Eight matched pairs of cadaver shoulders were randomly assigned to a stem-based tuberosity repair technique or a nonstem-based repair (Boileau technique) and mechanically tested with a 10 kN load cell. Cyclic loading was performed between 10 and 100 N for 500 cycles at 1 Hz, followed by static pull to failure at 33 mm/s. Ultimate load was determined from the maximum load reached during the pull to failure. A paired Student t-test was used to compare the means of the ultimate load and average cyclic displacement of the two sample groups.

RESULTS

The ultimate load to failure for the stem-based tuberosity repair technique was significantly higher than the nonstem-based technique (668 ± 164 N versus 483 ± 67 N; P = 0.032). The average cyclic displacement for the stem-based tuberosity repair technique was significantly less than the nonstem-based technique 0 (0.83 ± 0.67 mm versus 3.36 ± 2.36 mm; P = 0.017).

CONCLUSION

The stem-based tuberosity repair technique afforded higher ultimate load to failure with less average cyclic displacement than the nonstem-based technique. Consideration to the stem-based technique should be given when performing a tuberosity repair in the setting of reverse total shoulder arthroplasty for fracture.

LEVEL OF EVIDENCE

Level III.

Different suture anchor fixation techniques affect contact properties in humeral greater tuberosity fracture: a biomechanical study

Background

Suture anchor-based fixations of humeral greater tuberosity (GT) fractures have yielded good outcomes in both clinical and biomechanical studies. Be that as it may, the interface contact properties of these fixations have yet to be elaborated. In response, the contact characteristics of two double-row suture anchor fixations for the management of GT fracture were compared.

Methods

Two suture anchor-based fixation techniques, namely the Double-Row Suture Anchor Fixation (DR) and Suture-Bridge Technique (SB), were used to repair humeral GT fractures in 12 fresh-frozen human cadaveric shoulders. A Tekscan pressure sensor placed between the repaired tuberosity and humerus recorded continuous data points directly after repair and for 60 min at set time intervals. The constructs were then cyclically loaded until 100 N, and the shoulders tested at 0°, 30°, and 60° of abduction. Under an applied force, the contact pressure and contact area of the interface were determined.

Results

Although both fixation configurations showed decreased contact pressure and area over time, the SB group had higher contact pressure right after fixation and at all time points thereafter. In contrast, the DR group demonstrated significantly more contact pressure and area at each abduction position with the applied load. Nevertheless, contact pressure and area decreased in response to increasing abduction position for both fixation constructs.

Conclusion

Findings suggest that despite the SB construct having superior interface contact immediately after fixation, the DR construct offered better contact performance at all abduction angles with applied force.

Level of evidence

Basic Science, Biomechanics.