Isolated Greater
Medial transfer of the tibial
INTRODUCTION –
Purpose: The three dimensional position of the tuberosity and the tension of the rotator cuff influence the structural changes of the rotator cuff and their influence on clinical results of reversed trauma prostheses. We propose this technique with it of a biological support, the fractured humeral head, adequately modeled, in order to give again the just tension to the cuff. Method: from February 2007 and February 2009 we treated 29 patients with a reversed trauma prostehes, in 7 cases we have practiced the bony necktie, for giving a support to the correct reconstruction of the tuberosity. The patients have an average of 71,5 years and was evaluated with Constant score and radiographic study with mean follow-up of 18,6 months. Results: Improvement of postoperative Constant score and radiographic good results were correlated with satisfactory subjective results. However, these results will have to be confirmed with more cases and later revision. Conclusion:
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 >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.
The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome.Aims
Methods
Shoulder arthroplasty procedures continue to increase in prevalence and controversy still remains about the optimal method to manage the subscapularis. Scalise et al. performed an analysis of 20 osteotomies and 15 tenotomy procedures, and found the tenotomy group had a higher rate of abnormal subscapularis tendons on ultrasound examination. There was one tendon rupture in the subscapularis tenotomy group and no ruptures in the osteotomy group. Jandhyala et al. retrospectively examined 26 lesser tuberosity osteotomies and 10 subscapularis tenotomies for arthroplasty, and their study demonstrated a significant improvement in the belly press test for the osteotomy group. Lapner et al. performed a randomised controlled trial assigning patients to either a lesser tuberosity osteotomy or a subscapularis peel procedure. They evaluated 36 osteotomies and 37 subscapularis peels. The outcomes evaluated were Dynamometer internal rotation strength, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score and American Shoulder and Elbow Surgeons (ASES) score, and in a subsequent paper they evaluated the healing rates and Goutallier grade. Their studies illustrated no difference in the internal rotation strength between groups. Both groups significantly improved WOOS and ASES scores postoperatively, but the difference was not significant between groups. Goutallier grade increased significantly in both groups, but there was no significant difference between the groups. Overall, the different approaches have not demonstrated a meaningful clinical difference. Further studies are needed to help understand issues leading to subscapularis complications after arthroplasty.
Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries. 188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery.
Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery.
Subscapularis tenotomy (SST) has been the preferred approach for shoulder arthroplasty for decades but recent controversy has propelled lesser tuberosity osteotomy (LTO) as a potential alternative. Early work by Gerber suggested improved healing and better outcomes with LTO although subscapularis muscular atrophy occurred in this group as well with unknown long-term implications. However, we previously performed a biomechanical study showing that some of the poor results following tenotomy may have been due to historic non-anatomic repair techniques. Surgical technique is critical to allow anatomic healing – this is true of both SST or LTO techniques. A recent meta-analysis of biomechanical cadaveric studies showed that LTO was stronger to SST at “time-zero” with respect to load to failure but there were no significant differences in cyclic displacement. A recent study evaluated neurodiagnostic, functional, and radiographic outcomes in 30 patients with shoulder arthroplasty who had SST. The authors found that the EMG findings were normal in 15 patients but abnormal in the other 15 and that these abnormalities occurred in 5 muscle groups (not just the subscapularis). In another study, patient outcomes were inferior in those patients who had documented subscapularis dysfunction following SST compared to patients who had LTO (none of whom had subscap dysfunction). The literature is not clear, however, on ultimate outcomes based on subscapularis dysfunction post-arthroplasty with some studies showing no difference and others showing significant differences.
Previous studies describing drill trajectory for single incision distal biceps tendon repair suggest aiming ulnar and distal (Lo et al). This suggests that the starting point of the drill would be anterior and radial to the anatomic insertion of the distal biceps tendon. Restoration of the anatomic footprint may be important for restoration of normal strength, especially as full supination is approached. To determine the safest drill trajectory for preventing injury to the posterior interosseous nerve (PIN) when repairing the distal biceps tendon to the ANATOMIC footprint through a single-incision anterior approach utilising cortical button fixation. Through an anterior approach in ten cadaveric specimens, three drill holes were made in the radial tuberosity from the centre of the anatomic footprint with the forearm fully supinated. Holes were made in a 30º distal, transverse and 30º proximal direction. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction leaving adequate bone on the ulnar side to accommodate an eight-millimetre tunnel. Proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole and the distance between the PIN and K-wire measured for each trajectory. The PIN was closest to the trajectory K-wires drilled 30° distally (mean distance 5.4 mm), contacting the K-wire in three cases. The transverse drill trajectory resulted in contact with the PIN in one case (mean distance 7.6 mm). The proximal drill trajectory appeared safest with no PIN contact (mean distance 13.3 mm). This was statistically significant with a Friedman statistic of 15.05 (p value of 0.00054). When drilling from the anatomic footprint of the distal biceps tendon the PIN is furthest from a drill trajectory aimed proximally. The drill is aimed radially to minimise blowing out the ulnar cortex of the radius. For any reader inquiries, please contact
We performed an advancement and medial transfer of the tibial tuberosity based on Fulkerson's principle to treat intractable anterior knee pain associated with patellofemoral maltracking diagnosed by dynamic MRI. Between January 1998 and July 2000 twenty-two patients had 28 knees operated for anterior knee pain. There were 4 men and 18 women with a mean age of 28 years (range 18-41). Indications for surgery were [a] failure to improve after six months of physiotherapy and [b] patellofemoral maltracking evident in dynamic MRI. Mean follow-up was for 37 months (23 – 42). Knee instability score modified by Fulkerson was employed for objective and subjective assessment. Objectively 22 (79%) knees achieved good to excellent results. Four knees (14%) had fair, and two (7%) had poor results. Excellent and very good results were seen in 20 knees. These patients were a younger age group (mean age 21 years) and had minimal degeneration (grade I-II) of the patellofemoral joints. Two patients achieved good results. One of them had moderate (grade III) and one minimal (II) arthritis. Three knees with fair results had advanced (grade IV or V) and one had moderate (grade III) arthritis. Out of two patients who had a poor result, one had advanced degeneration (grade V) that later required a patellofemoral joint resurfacing. The other was a 24 year old woman with grade II changes. She was treated by the pain therapy team. Anterior displacement of the tuberosity in the presented study was kept to 5 mm to avoid the possible complications of wound break down. The overall length and depth of the osteotomy was also reduced to minimise risk of fracture and commence early mobilisation. Based on our results there is a strong case of justification for Anteromedialisation of tibial tuberosity using a smaller length of osteotomy and lesser degree of anteriorisation in carefully selected patients with Patellofemoral arthralgia associated with maltracking patella.
Tibial tuberosity and trochlear groove (TT-TG) distance has been investigated for the patients with primary patellofemoral subluxation/dislocation. To date, TT-TG distance after TKA has not been evaluated, and the effect of postoperative TT-TG distance on patellar tracking is unknown. The purpose of the current study was to investigate the effect of TT-TG distance and rotational position of the femoral and tibial components on patellar tilt after TKA. Consecutive 115 knees for the diagnosis of osteoarthritis were included in the current study. TKA was performed using posterior cruciate ligament sacrificed prosthesis. A total of 17 men and 96 women with an average age of 75.3 years were included at the time of the surgery. Computed tomography (CT) was taken after TKA in full extension. Postoperative TT-TG distance was measured as a reference of surgical epicondylar axis (SEA) of the femur. Patellar tilt was defined as the angle of the patellar component relative to SEA. Femoral and tibial component rotation was measured as the angle relative to SEA and tibial antero-posterior (AP) axis. Tibial AP axis was defined as the line connecting medial one-third of the tibial tuberosity and center of medial-lateral width. Pearson correlation coefficients were calculated to determine the correlations between patellar tilt and TT-TG distance and between patellar tilt and femoral and tibial component rotation.Introduction
Methods
Isolated greater tuberosity fractures make up 17–21% of proximal humeral fractures, 30% are associated with shoulder dislocation. Conservative management of minimally displaced fractures (<5 mm) is recommended. There are few guides to which and how many fractures displace over time. A retrospective analysis of isolated greater tuberosity fractures presenting to a shoulder fracture clinic over 1 year was performed. Patients were identified from shoulder fracture clinic lists and a bluespier database. Radiological fracture displacement was measured from the edge of the defect in the humeral head to the closest edge of the greater tuberosity. All measurements were performed by three oberservers on two occasions. Data was analysed to study the relationship between initial displacement and fracture stability and between concurrent dislocation and fracture stability. Inter-observer analysis was performed.Aims
Methods
The aim of the study was to assess the rate of greater tuberosity non union in reverse shoulder arthroplasty performed for proximal humerus fractures and to assess if union is related to type of fracture or the intraoperative reduction of the greater tuberosity. All cases of reverse shoulder arthroplasty for proximal humerus fractures at our institution over a three year period were retrospectively reviewed from casenotes and radiologically and the position of the greater tuberosity was documented at immediate post op, 6 months and 12 months. Any malunion or non union were noted. A total of 27 cases of reverse shoulder arthroplasty for proximal humeral fractures were identified. 4 cases did not have complete follow up xrays and were excluded from analysis. The average age at operation of the cohort of the 23 remaining patients was 79 years (range 70–91). The greater tuberosity was anatomically well positioned intraoperatively in 17 of the 23 cases. At the end of 12 months there were 4 cases of tuberosity non union (17%), all except one occurring in poorly intraoperatively positioned greater tuberosity. 50% (3 out of 6) of greater tuberosities displaced further and remained ununited if the intraoperative position was poor. Only 6% (1 out of 17) greater tuberosities did not unite if the greater tuberosities was reduced anatomically. Intra operatively position of the greater tuberosity was strongly associated with their union (Fischer's exact test p<0.05). Union of greater tuberosity was not statistically associated with fracture pattern (Fischer's exact test p=0.48). Our case series show a low rate of tuberosity malunion after reverse shoulder arthroplasty for proximal humerus fracture. Good positioning and fixation of the greater tuberosity intra operatively is a strong predictor of their uneventful union to shaft.
Proximal fifth metatarsal fractures distal to the tuberosity, also known as Jones’ fractures, are troublesome fractures to manage with a high incidence of delayed union and nonunion. We conducted a retrospective study of 32 patients with fractures of the fifth metatarsal distal to the tuberosity over a three year period. The aim was to assess healing with non-weight bearing and variations of weight bearing mobilization including minimal, partial and full weight bearing. This is one of the largest reported series of such fractures. These fractures were classified as acute fractures (14 fractures), fractures with features of delayed union (15 fractures) and fractures with features of nonunion (three fractures) at presentation according to the radiological classification used by Torg in 1984. These patients were treated in a plaster cast and mobilised either non-weight bearing or with variations of weight bearing. These patients were followed up for a mean of 16 months. Our findings correspond with those observed by Torg and we describe a correlation between the radiological appearance of the fracture at presentation and the clinical course. Prevailing guidelines for the management of these fractures are ambiguous. A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. It is important that radiological features are correlated with clinical features and appropriate treatment instituted. The treatment of choice for acute fractures is immobilization of the limb in a below-knee non-weight bearing plaster for 6 to 8 weeks. Fractures with delayed union may eventually heal if treated non-operatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic nonunion require surgery.
The aim of our biomechanical study was to find out whether the prosthetic design, especially of the metaphyseal part, and the type of tuberosity fixation influences the primary stability in shoulder arthroplasty.
Series 1: The intertuberosity motion was significantly lower in the cable prosthesis. The tuberosity-shaft motion was significantly lower in the cable group for greater and lesser tuberosity. The metaphysis - shaft motion did not significantly differ in both groups. Series 2: The intertuberosity motion was significant lower when the tuberosities were fixed by cable. The tuberosity-shaft motion was significantly lower when cable fixation was used. The metaphysis-shaft motion was not significantly diverse.
Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this multicentre randomized double-blind study was to compare the functional outcomes and healing rates of the lesser tuberosity osteotomy (LTO) to the subscapularis tenotomy (ST). Patients undergoing shoulder arthroplasty were randomized to receive either a LTO or ST. The primary outcome was to compare subscapularis strength, as measured by an electronic hand-held dynamometer at 12 months. Secondary outcomes included range of motion, WOOS, Constant and ASES scores. A sample size calculation determined that 80 patients provided 80% power with a 50% effect size to detect a significant difference between groups.Purpose
Method
The purpose of this study is to evaluate the results of the treatment of displaced greater-tuberosity fractures by open reduction and stable fixation with heavy non absorbable sutures and early passive motion. Thirty-six patients, 21 male (average age 50 years) and 15 female (average age 62 years) underwent open reduction and internal fixation for a displaced greater-tuberosity fracture of the proximal humerus, between 1992–2000. Main indication for operative treatment was at least 1 cm displacement of the tuberosity. Reduction and stable fixation of the greater tuberosity with its rotator-cuff attachments, was performed by a lateral approach using heavy transosseous nonabsorbable sutures. Passive motion was started at the second postoperative day followed by active range of motion after the fifth postoperative week. All patients were examined periodically using clinical and radiological criteria. All fractures were healed without any displacement within 3 months. Final assessment was performed according to Neer’s criteria for pain, motion, function, strength and patient’s satisfaction, in a mean follow-up period of 4 years. Twenty seven patients (75%) rated excellent, without pain, showing active forward elevation at 160 to 180°, external rotation at 60 to 80° and internal rotation up to tiq level. Nine patients (25%) rated very good, had only minor pain problems. We conclude that, if displaced fractures of the greater tuberosity are not diagnosed and treated promptly, may result in limitation of motion and functional disability. To our experience open reduction and stable fixation with transosteal suturing, allowing early passive motion of the joint, gives excellent to very good final results.
We conducted a prospective evaluation of patients with anterior dislocation of the shoulder associated with a fracture of the greater tuberosity. Thirty-four anterior dislocations of the shoulder with greater tuberosity fractures were reviewed with a minimum follow-up of one year from the time of injury. Eight required open reduction. The final outcome with regard to pain, range of movements, and function was assessed in 34 patients. In open reduction, there were five good results, one fair, one poor and one patient died. In the non-operative group, results were good in 11 patients, fair in eight, poor in one, not assessed in five and one patient died. Two patients have died in this series, one in the open reduction group. Associated injuries are: axillary nerve damage (three), brachial plexus injury (one), loose fragment under the acromion (one) and stiffness of the shoulder (three) Anterior dislocations of the shoulder with fracture of the greater tuberosity do not always lead to good results. Close observation after reduction is important to check for later displacement of the fractures.
Surgical fixation of greater tuberosity fractures in the shoulder is the choice of treatment even if the fragment is minimally displaced. This helps to reduce the incidence of impingement secondary to a malunited tuberosity fragment especially in younger patients. We evaluated the functional outcome of our patients treated with open reduction and internal fixation of these fractures using cancellous screws. 19 patients with a mean age of 57.1 years (range 27–84) with 19 isolated greater tuberosity fractures treated with cancellous screws were included. These patients were evaluated after an average follow up period of nearly four years (range 66–444 weeks) using the DASH score and the Constant and Murley score. They were also clinically assessed to check for signs of impingement.Introduction
Materials and Methods
1- To introduce a new graft technique for ACL reconstruction using the patellar tendon with its attachment on the tibial tuberosity as bone-tendon (B PT) auto graft sparing the patella. 2-To assess the above described technique prospectively in a group of patients with ACL deficient knees. Prospective case series of a newly describedACL graft technique.Purpose of Study
Type of study
Patella recurrent dislocation and patellofemoral pain syndrome instability many young people and especially athletes. In the present study we present the results of the extension mechanism realignment through the Fulkerson oblique osteotomy of the tibial tuberosity and soft tissue balancing. During the last two years 10 patients (7 men, 3 women, mean age 29.3/ range 20–39) were treated operatively for recurrent dislocation of the patella using the Fulkerson procedure. All patients underwent knee arthroscopy for the treatment of potential chondral damage or loose bodies and for lateral retinacular release. After that we performed oblique tibial tuberosity osteotomy, medialization and internal fixation with 2 cortical screws. This oblique osteotomy allows also the anteriorization of tibial tuberosity as we move it medially. In addition, we performed medial placation. All the patients used functional knee brace locked to 0° right after the operation and with gradual ROM increase till the 8th p.o. week. The patients had no initial or long term complication. During their last follow up examination had a painless knee with full ROM and marked improvement of the patella tracking. The mean Lysholm score was 90.5. No patella dislocation was referred. Our findings show that the Fulkerson osteotomy procedure, with an additional intervention on the lateral and medial patella retinacular, is an excellent option for the treatment of recurrent patella instability and relief of the patellofemoral pain.
The purpose of this study was to evaluate the effect on movement under load of different techniques of reat-tachment of the humeral tuberosities following 4-part proximal humeral fracture. Biomechanical test sawbones were used. 4-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used – 1)tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis, 2)as 1 without cerclage suture, and 3)tuberosities attached to the prosthesis and to the shaft. All methods used a number 5 ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two Digital cameras formed an orthogonal photogrammetric system allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured. Techniques 1 and 2 were the most stable constructs with technique 3 allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique 3 (p<
0.05). The cerclage suture used in technique 2 added no further stability to the fixation. In conclusion, our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.
5 cases of subacromial impingement secondary to protrusion of the proximal portion of the GT; 2 of them associated with Pasta lesion 3 cases of unstable – non united bony fragments at subacromial level 4 cases of isolated Pasta lesions, 2 pure tendinous and 2 “bony” with unstable osteocondral fragments. All lesions were arthroscopically treated: GT tuber-oplasty, repair of Pasta lesions, suture fixation of GT fragments. After minimum follow-up of one year, Constant and Simple Shoulder Test scores were significantly improved.
The frequent association of patellofemoral pain and malalignment of the extensor mechanism is well known. In our experience, lateral hypertorsion of the tibial metaphysis (enough to cause excessive compression on the external facet of the patella) is a common finding in patients with anterior knee pain, and is even observed with computed tomography (CT). Many surgical procedures have been described, both for the realignment of the extensor apparatus and for the reduction of the excessive patellar compression. The technique of tibial tuberosity derotation consists of a distal realignment on the frontal plane with consequent reduction of the external patellofemoral pressure. This latter, based on studies on anatomic preparations, can achieve a reduction of about 50% if the tibial extra-torsion is reduced surgically. In our study, the results obtained with this surgical procedure in the medium term have been evaluated in a group of 26 patients with patellar maltracking. Our study concerned 10 men and 16 women, aged 17–42 years. These patients were affected by a painful patellar syndrome that had persisted for a period between 8 and 18 months. They underwent surgery during the period between September 1992 and June 1995. Preoperatively, each patient underwent a cycle of physiokinesiotherapy, for at least 6 months. The pain disappeared in 15 patients; it developed after moderate activity in four patients and appeared only occasionally in five patients. In only two cases did the pain remain unchanged. Seven patients reported difficulty in assuming or maintaining a kneeling position. After surgery, the Lysholm score increased from 43 to 79. When questioned about the degree of satisfaction with the corrective surgery, 16 patients declared themselves to be very satisfied, six patients were fairly satisfied, and four patients were not satisfied. We propose this procedure as a treatment for anterior knee pain resistant to conservative therapy, in young patients with external hypertorsion of the proximal tibial metaphysis and without significant chondro-pathology.
A case report of an 11 year old boy who underwent tibial osteotomy to prevent angulation of his right tibia. As a 7 year old, LH sufered a minor injury to his right tibia. A lump appeared at the same site. Soon the lump grew to be similar to “a second knee cap”. However, it only caused him pain when he traumatised it. He and his parents were disturbed by the lump, and the fact that it was creating an anterior-posterior bowing of his tibia. They sought medical advice. His original hospital carried out X rays that demonstrated the deformity and a cloud like lump at the tibial tuberosity. A bone scan confirmed a solitary osseous lesion. In July 2002 he was referred to the RNOH, where the decision was taken to resect the tibial tuberosity and undertake a corrective osteotomy. Post surgery in August 2002, LH was mobilised in a full cast for 9 weeks and graduated slowly from non to full weight bearing. Histology revealed a probable endchondroma, or unusual growth plate reaction. A year after the procedure LH is a symptom free, happy and active boy. Radiographs confirm normal angulation of his Tibia. In conclusion an osteotomy can be a very successful treatment for a childhood lesion that leads to progressive deformity.
isolated descent (n=15), isolated medial shift (n=19), and descent and medial shift (n=95). The degree of the medial shift and the descent depended on the distance from the tibial tuberosity to the trochlear notch and the Caton-Deschamps index measured preoperatively. Patients who underwent surgery for chronic anterior laxity and/or meniscal lesions were excluded (n=3). All patients were free of osteoarthritis before surgery. A complete radiographic series was available for 102 knees. Unilateral periodic dislocation of the patella was present in 60 patients whose knee x-rays were obtained bilaterally.
The literature indicates that the tibial component in total knee arthroplasty (TKA) should be placed in internal rotation not exceeding 18 to the line connecting the geometrical center of the proximal tibia and the middle of the tibial tuberosity. These landmarks may not be easily identifiable intraoperatively. Moreover, an angle of 18 is difficult to measure with the naked eye. The angle at the intersection of lines from the middle of the tibial tuberosity and from its medial border to the tibial geometric center was measured in 50 patients with normal tibia. The geometric center was determined on an axial CT slice at 10mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were performed in 25 patients after TKA in order to simulate the intra operative appearance of the tibia after making its proximal resection.Purpose
Method
Subscapularis function following Total shoulder joint replacement has been a concern in recent literature. It has been postulated that lesser tuberosity osteotomy approach may have better Subscapularis function than transtendonous approach. To assess whether lesser tuberosity osteotomy vs. subscapularis tenotomy is better for post-operative function of subscapularis in total shoulder replacements done by a single surgeon in a District general hospital. 117 shoulder replacements performed by the senior author (TH) at Waikato district general hospital between years January 2002 to January 2010 were reviewed retrospectively. Revision replacement, inverse shoulder replacement & acute traumatic hemiarthroplasty were excluded. Patients with previous rotator cuff problems, previous surgery to subscapularis, rheumatoid arthritis and post-trauma sequelae were also excluded from the study. Inclusion criteria were normal subscapularis function and intact subscapularis on MRI pre-operatively. 41 shoulders were eligible to participate in study of which 1 pt died (bilateral TSR), 1 pt unfit to participate due to cervical disc problems. Of remaining 38 shoulders 11 shoulders had transtendonous and 27 shoulders had lesser tuberosity osteotomy approach. 37 shoulders were reviewed clinically for range of motion of the shoulder and subscapularis strength. Range of motion and subscapularis strength was significantly higher in the osteotomy group. All osteotomies were united on axillary radiograph. Lesser tuberosity osteotomy approach result in better subscapularis function than transtendonous approach.
Referencing the tibial rotation on a line from the lateral border of the medial third of the tibial tubercle to the center of the tibial tray resulted in a better femoro-tibial alignment than using the medial border of tibial tubercle as landmark. Surgeons using fixed bearings with a high conformity between the inlay and the femoral component should be aware of this effect to avoid premature polyethylene wear.
There are multiple proximal prosthetic geometries available for a surgeon to select when humeral head replacement is indicated for four-part proximal humerus fractures. We compared different proximal prosthetic geometries in stable and unstable fracture patterns, with a standard tuberosity fixation method. Simulated four-part fractures were created with an oscillating saw in six synthetic shoulder models. Three different proximal prosthetic geometries used polymetylmethacrelate (PMMA) – a smooth circular shape (SCS), a diamond shape (DS) and an irregular multiple fin shape (IMFS) prostheses. A standardised fixation method using vertical, and horizontal straps along with a medial based cerclage strap was performed. Passive motion was then carried out using a robotic articulator. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to shaft using mercury strain gauges. The least amount of interfragmentary motion occurred when an IMFS was used in a stable fracture pattern. This geometry provided more interfragmentary stability even with the unstable fracture pattern than the DS or SCS. The least stable construct was the SCS prosthesis with an unstable fracture pattern. Prosthetic geometry does affect stability of tuberosity reconstruction in proximal humerus fractures. An irregular shaped prosthesis augments the fixation construct. When using a smooth prosthetic design a stable fracture pattern must be achieved to prevent excessive interfragmentary motion. A smooth prosthetic design for tuberosity reconstruction is not recommended.
We dissected 12 fresh-frozen leg specimens to
identify the insertional footprint of each fascicle of the Achilles tendon
on the calcaneum in relation to their corresponding muscles. A further
ten embalmed specimens were examined to confirm an observation on
the retrocalcaneal bursa. The superficial part of the insertion
of the Achilles tendon is represented by fascicles from the medial
head of the gastrocnemius muscle, which is inserted over the entire
width of the inferior facet of the calcaneal tuberosity. In three
specimens this insertion was in continuity with the plantar fascia
in the form of periosteum. The deep part of the insertion of the
Achilles tendon is made of fascicles from the soleus tendon, which
insert on the medial aspect of the middle facet of the calcaneal
tuberosity, while the fascicles of the lateral head of the gastrocnemius
tendon insert on the lateral aspect of the middle facet of the calcaneal
tuberosity. A bicameral retrocalcaneal bursa was present in 15 of
the 22 examined specimens. This new observation and description of the insertional footprint
of the Achilles tendon and the retrocalcaneal bursa may allow a
better understanding of the function of each muscular part of the
gastrosoleus complex. This may have clinical relevance in the treatment
of Achilles tendinopathies. Cite this article:
In the dynamic study, the suture placed between the greater tuberosity and the diafisis is the one significantly receives more tension. The breakage of the suture happens more frequently when the prosthesis is placed in a lower position and in a lower more retroverted position.
The worst positions of the hemiarthroplasty as far as over tensioning sutures is concerned are the low position and the low more retroverted position.
Lateralisation of the tuberosity tibia causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking patella (LTP), resulting in anterior knee pain, or objective patellar instability (OPI), resulting in recurrent luxations. For a precise preoperative diagnosis the tuberositas tibia (TT) trochlear groove (TG) distance was measured on a CT scan. A distance of more than 15 mm was considered to be pathological. In a prospective study, the clinical results of a subtle, CT-guided medial tuberosity transfer for LTP and OPI were evaluated. 30 Consecutive patients with LTP and 30 patients with OPI and an increased TT TG were included. Outcomes were documented at 3, 12 and 24 months follow-up using the Lysholm scale, the Kujala score, and a visual analogue pain score. Postoperatively all but one patient reported good improvement in stability (no persistent subluxations or luxations). All patients had a marked improvement in pain and functional scores at follow up. Complications seem to be related to the peroperative technique. CT-guided TT transfer appears to be satisfactory and safe method for treating patients with an increased TT TG leading to either LTP or OPI.
The results of displaced three part fracture of the proximal humerus treated by retro grade nailing +/− cannulated cancellous screws for fixation of the greater tuberosity was analysed. Displaced three part fractures of the humerus are unstable and difficult to fix. Different methods of operative treatment available for this type of fracture are Kirschner wires, tension band wiring, hemiarthroplasty and open reduction and internal fixation with plate and screws. The Halder Humeral Nail was introduced through the olecranon fossa into the head of the humerus, to stabilize the neck of humerus fracture. The displaced greater tuberosity was reduced with a minimal stab incision and fixed with cannulated screws. Compared to other open procedures the proximal exposure was minimal. 47 Patients with displaced three part proximal humeral fractures have been surgically treated since January 1995. 22 Were treated with proximal screws and 25 without proximal screw fixation. There were 32 females and 15 males. The average age was 67.68 years. Early passive movements were encouraged in the shoulder. Pain was relieved in almost all the patients. 41 Fractures united. 3 Patients had a malunion, 2 had humeral head collapse, and 1 developed AVN of the humeral head. The authors concluded that displaced three part proximal humeral fractures can be treated using the Halder Humeral Nail, and that this is a simple method of treatment which avoids major surgical exposures.
Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3.
Aims. Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. Methods. A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid
The majority of 5th metatarsal fractures are successfully treated conservatively, with few patients requiring surgical fixation for symptomatic non-union.
The complications of prostheses for fractures of the proximal humerus are understudied because the experience of each shoulder surgeon is limited and a standardised registration protocol is not yet available. A prospective study on complications in shoulder arthroplasty for fracture is, therefore, essential to explore variables that influence outcome. The purpose of this study is to report our experience with complications following arthroplasty for proximal humeral fractures. In a multicenter study, four hundred and six patients treated with arthroplasty for proximal humeral fracture were prospectively followed during a nine year period; three hundred patients with a minimum of two years follow-up, at an average of forty-five months (range, 24–117), were available for review. Objective results were graded with the Constant score and range of motion. Subjective results were reported according to patient satisfaction. At follow-up, the average Constant score was fifty-four points (range, 14–95) and active forward elevation was 103° (range, 10°–180°). Eighty-one percent of patients were satisfied or very satisfied. We observed a 59% rate of late (after three months) complications, including a high rate of tuberosity-related complications (72% malunion or nonunion). Initial tuberosity malposition was present in 35% of the patients. Secondary migration despite initial good positioning was observed in 24%.
Introduction: Treatment strategies for management of proximal humeral fractures are assisted by an understanding of the fracture morphology, and in particular the viability of the humeral head. Although widely accepted, the AO and Neer classification systems show poor interobserver reproducibility, and generally do not provide a basis to guide treatment regimens. Hertel described a comprehensive binary (Lego) classification system, which defines fracture plane and parts, as well as incorporating calcar length, attachment and angulation that is vital in predicting humeral head ischemia. The sequential numerical form of the classification makes it complex, and prone to categorisation error. Sandow has extended this to a more descriptive system by naming proximal humeral parts (H-head, G-Greater
Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the axillary nerve due to traction, manipulation of the arm, aberrant retractor placement, or relative lengthening of the arm. Intraoperative fractures are relatively uncommon but include the greater tuberosity, acromion, and glenoid.
Management of 4-part fractures of the proximal humerus continues to challenge orthopaedic surgeons, shoulder surgeons, and trauma surgeons. Truly displaced 4-part fractures typically require surgery if the patient is medically able to undergo a surgical procedure. However, outcomes following surgery are not always as predictable as we would like. Results following hemiarthroplasty have led to more predictable pain relief than predictable functional recovery relying exclusively on the fate of tuberosity healing.