Isolated Greater Tuberosity (GT) fractures were described as separate entities from proximal humeral fractures more than 100 years ago. However, there is limited literature available about the functional outcome of the two different types of GT fractures: avulsed and comminuted. To compare functional outcomes of the 2 different types of Greater Tuberosity fractures; simple and comminuted and to determine how these outcomes were affected by associated injuries such as shoulder dislocation and rotator cuff tear. We also looked at the acceptable post fixation displacement of GT fracture and when to consider it mal-reduction (malunion due to over or under reduction) and the acceptable time frame to delay the fixation and still get satisfactory results. We looked at Greater Tuberosity fractures of the humerus in Waikato Hospital between 1999–2009. Radiographs were reviewed by senior Author to classify them into simple and comminuted. Measurements were done by senior Author for post fixation displacement. Operative notes checked by the authors, when in doubt, double-checked by senior author. Outcome scores used: UCLA, ASES and oxford scores to compare functional outcome. We also measured the time off work and time on ACC (Physiotherapy), as well as period of follow up. A total of 35 patients were included in the final analysis were treated operatively. Mean age of the patients was 51 years. M/F ratio was 3/2. Mechanism of injury was predominantly direct force applied to that shoulder. Shoulder dislocation was found in around 77% of patients. Methods of fixation included tension band wiring with or without screws, rotator cuff repair and one T-plate. Follow up time was shorter for simple comminuted fractures (22 v 44 weeks respectively). Outcome scores for patients who sustained simple fractures were slightly higher than those with comminuted fractures but the difference did not reach statistical significance. The groups with dislocation and rotator cuff tear did worse than the other groups in all aspects of the study. Post fixation displacement of GT of less than 5 mm led to a significantly better outcome than displacement of 5mm plus. Better results were obtained when the time between injury and operation was less than 2 weeks. The comminuted group had similar functional outcome to the other group but required much longer follow up. Worse outcome should be expected with dislocation and rotator cuff tear associated with GT fracture. Satisfactory results relate to degree of displacement post fixation of <5 mm. Delay of fracture fixation of >2 weeks results in a less favourable outcome

Medial transfer of the tibial Tuberosity remains the treatment of choice for skeletally mature patients with patellar malalignment (recurrent dislocation, subluxation with or without patellar tilt). As many patients with patellar malalignment have patellar articular cartilage lesion or patella alta, anteriorisation and distalisation of the tibial tuberosity is advised. Material and Methods: Tibial tuberosity transfer was performed in our center on 80 knees in 66 patients (40 females, 26 males) during the past 13 years (mean age 23 range 15 – 52). One surgeon supervised all the operations. The average follows-up was 6.2 years (one to thirteen years). All patients were examined clinically for the purpose of this study. The Lisholm and Karlsson scoring system were used to evaluate the results. Radiographs of both knees were also taken. Fifteen knees had no dislocation of the patella prior to the operation, seventeen knees had 1 to 10 eleven knees had 10 to 50, ten knees 50 to 100, and twenty-seven knees had more than hundred dislocations of the patella prior to surgery. Ten of these knees had daily dislocations of the patella. All operations were done either by selective epidural anesthesia (only sensory and not motor) or general anesthesia without muscle relaxant using quadriceps muscle stimulation. The mean tibial tuberosity medialisation, anteriorisation and distalisation was 1.4 cm (0–2.5 cm) 0.4cm (0–1.1cm) and 0.87cm (0–1.2cm) respectively. Results: When interviewed by an independent examiner 87% of the patients reported improvement and only 4.3% (3 patients) reported worsening of their condition after the operation. 84% of the patients stated they would have the operation again. All patients had full active range of motion on both knees without extension lag. At the final evaluation visit the Lisholm and Karlsson scores were good and excellent in 72% and 72.5%, 18.8% and 23.5% had fair results and only 8.7% and 4.4% had poor results respectively. The poor results correlated well with the degree of the patella cartilage damage found during surgery, poor selection of patients and extreme ligamentous laxity. There were two complications: one non-union of the tibial tuberosity treated successfully with bone grafting and one non displaced fracture bellow the osteotomy, treated conservatively. Both had excellent results. Conclusion: We conclude that distal patella re-alignment done by tibial tuberosity transfer is a reliable technique for the treatment of patello femoral pain secondary to mal-alignment

INTRODUCTION – Tuberosity fractures of the calcaneum are rare injuries. The traditional operative treatment involves open reduction and internal fixation with a tension band wire construct. We have developed a new technique of fixing these fractures with internal fixation using cannulated screws and a figure of eight wire. This paper describes the new technique outlining its advantages and compares the 2 methods of fixation biomechanically to determine their properties with respect to fracture fixation. METHOD – 20 sections of bovine bone were taken to act as an experimental model for the calcaneum. They were osteotomised to create the posterior process fracture model. 10 were fixed using a traditional tension band wire construct and 10 were fixed using the cannulated screw and wire construct. Each construct was subjected to biomechanical testing to identify the stiffness, energy to failure and load to failure. RESULTS – During loading the cannulated screw and wire constructs showed a significant increase in stiffness and energy to failure compared to the tension band wire constructs. CONCLUSION – The increased stability of the cannulated screw construct demonstrated by the testing offers biomechanical benefit over the traditional tension band wire construct. This, as well as the improved technical aspects of the cannulated screw fixation, may be beneficial for clinical use

Tuberosity ‘avulsion’ fractures to the base of the fifth metatarsal respond well to symptomatic treatment. The purpose of this study was a prospective comparison of clinical and radiological outcome with treatment in a plaster slipper, compared to a tubigrip support. Ethical approval was obtained and written consent with an information sheet issued at the first fracture clinic appointment. Forty three patients with this fracture were allocated to one of our two treatment groups and followed up at regular intervals over a 12 week period or until they were suitable for discharge. A combined foot score (maximum 100 points) was used at each follow up appointment to measure levels of pain (40 points) and function (60 points). A check radiograph was taken prior to discharge to assess union. A repeated measures analysis was used to assess any difference between the two treatment groups and whether this changed with time. Results indicated no overall significant difference between the two treatment groups with a mean foot score of 73.5 for the tubigrip group and 80.3 for the plaster slipper group over the entire treatment period. At 2 weeks post injury the plaster group (70.9) had a significantly (p< 0.01) better combined foot score at assessment in comparison to the tubigrip group (54.1).By the 5–8 week stage, the mean combined foot scores had improved and were comparable at 89.5 (tubigrip) and 90 (plaster slipper). Radiographs taken prior to discharge indicated two patients in each treatment group with significant fracture site displacement. One patient remained clinically symptomatic and underwent surgical fixation. In this small cohort of patients the eventual clinical and radiological outcomes were comparable. During the initial 2 week treatment phase the plaster slipper group recorded a significantly better mean foot score

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: Tuberosity position and healing is critical for clinical and radiographic outcome in shoulder arthroplasty in trauma. In particular the rate resorption of the tuberosity in Reverse Trauma Prostheses still is elevated. we propose a new surgical technical in order to give again the just position to the tuberosity fractured and therefore to give tension to the rotator cuff

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.

Aims

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.

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 QuickDASH and Oxford Shoulder Score (OSS), were collected.

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 QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%).

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.

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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.

Introduction

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.

Aims

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.

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.

Purpose: To present the results of the tibial tuberosity osteotomy as part of the surgical approach for total knee replacement. Material and Methods: Tibial tuberosity osteotomy was performed during TKR for better exposure in 19 knees corresponding to 19m patients (9 male, 10 female), with average age 76 years (68–80). Four of the procedures were revisions. Fifteen were primary TKR, ten of which had been subjected to high tibial osteotomy previously. The rest þve patients had excessive valgus deformity (over 20 degrees), and they were approached through a lateral parapatelar incision. In two cases screws only were used to stabilize the osteotomised tubercle, and wire loops in the rest of them. Patients were instructed for partial weight bearing for six weeks postoperatively. Results: All osteotomies united in less than four months. In three cases (including the two with only screw þxation), proximal migration of the tuberosity was noted, but less than 2cm. No skin problems were encountered. Three patients,(22%), complained for anterior knee pain. Preoperative mean range of movement was 75 degrees, and improved to 90 degrees postoperatively. Average blood loss was 850 cc. Conclusions: The tibial tuberosity osteotomy offers excellent exposure in the revision and difþcult primary TKR, but it lengthens the operative time, and the blood loss is higher.

Purpose: Consolidation of the tuberosity is the key to success of shoulder arthroplasty for fracture. The purpose of this study was to assess the number and causes of tuberosity complications in order to find solutions for this problem.

Material and methods: This retrospective multicentric study included 334 shoulder prostheses implanted for fracture between 1991 and 2000. Two different prostheses were used: 300 standard Aequalis prostheses implanted between 1991 and 1997 (mean follow-up four years) and 31 Aequalis Fracture prosthesis between 1999 and 2000 (mean follow-up nine months). Radiological results were assessed on the postoperative and last follow-up x-rays. The Constant score was used for clinical assessment.

Results: For the 300 standard prostheses, the Constant score was 54 points with active anterior elevation = 104°. For the 31 fracture prostheses, the Constant score was 58 points with active anterior elevation = 114°. According to the operator’s assessment, 49% of the postoperative radiological results were fair or poor and objectively 35% of the tuberosities were poorly positioned with the standard prosthesis and 22% with the fracture prosthesis. Twenty-six percent of the good or poorly positioned tuberosities migrated secondarily with the standard prosthesis and 10% with the fracture prosthesis. Statistically significant prognostic factors limiting tuberosity complications were: satisfactory initial osteosynthesis with correct prosthesis height and retroversion facilitated by use of the fracture system, rehabilitation in a specialised centre, relative immobilisation during the first postoperative month limiting exercises to balancing movements which divided the number of secondary migrations by two compared with immediate moblisation (14% versus 27%).

Discussion: A precise analysis of the radiograms revealed a very high rate of tuberosity complications (50%). There has been little study of these complications which are underestimated in the literature. The Aequalis fracture prosthesis can reduce these tuberosity complications two-fold. Postoperative immobilisation also reduces two-fold tuberosity migrations. These observations are against the early passive motion advocated by Neer. Finally, the quality of tuberosity fixation is crucial for success. The surgeon must concentrate on this element, searching to achieve a perfectly positioned prosthesis on the peroperative x-ray.

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.

Materials and Methods: 16 fresh frozen human cadaveric humeri were dissected until only the rotator cuff remained. A four-part fracture was simulated by osteotomy. In a first step two types of shoulder prosthesis (open stem versus closed stem) were used. The Tornier Aequalis prosthesis (open stem) using suture fixation and the Mathys Affinis fracture prosthesis (closed stem) using cable fixation were implanted according to standard techniques. The specimens were then loaded into a servo-pneumatic testing device in 25° of abduction. In 20 consecutive cycles traction of 40 Newton was alternating exerted on the subscapularis and infraspinatus tendon, while a continuous force of 40 Newton was exerted on the greater tuberosity to simulate the pull of the m. supraspinatus. The motion of the fragments was recorded by 2 high speed cameras. The following parameters were investigated : Failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. After completing the first series the cable fixation exposed to be more stable. In a second series we compared cable versus suture fixation in the Affinis fracture prosthesis to find out whether the stability was depending on the prosthesis design.

Results:

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.

Conclusion: Highest primary stability of tuberosity fixation in trauma-arthroplasty of the shoulder was measured in cable fixation and closed stem. We proved that the kind of fixation was the most important factor determing the stability. Metaphyseal design was less important.

Purpose of the study: The form of the anterior tibial tuberosity (ATT) has not been described in anatomy studies. Insertion of the patellar tendon can, by its form, modify the lever arm of the extensor system and induce pathological conditions having an impact on the form of the apex or tip of the patella. The purpose of this work was to analyse the types of tibial tuberosities observed on the radiographs of 50 patients.

Material and method: Fifty patients were included in this prospective study. The form of the ATT was defined by two angles. These angles were measured on the strictly lateral x-ray. The ATT-shaft angle (ATT-d) was defined by the intersection between the anatomic axis of the tibial diaphysis and the anterior cortical of the ATT which corresponds to the insertion of the patellar tendon. The ATT-metaphysis angle (ATT-M) was defined by the angle between the tangents of the anterior metaphyseal cortical and the anterior cortical of the ATT. The height of the patella was also measured as described by Caton and Deschamps. The form of the patella on the lateral was described according to the Grelsamer criteria, and its form on the 30° axial view according to the Wiberg classification. The presence of trochelar dyplasia was determined using the Dejour method. The statistical analysis accepted p < 0.05 as significant. The coefficients of correlation R were calculated with a ½ log covariance matrix [1+R]/[1−R].

Results: The form of the ATT was given by the minimal value between the ATT-D and the ATT-M. This angle measurement revealed major variation. Three types of ATT were defined: type I 0≤ATT-M≤15 and ATT-D≤5, type II 15 < ATT-M < 20 and 5 < ATT-D < 10 and type III 20≤ATT-M 10≤ATT-D. There was an obvious correlation with the form of the patellar apex. The type III form of the patella was always associated with a type I ATT; there was a significantly association between patella type I and ATT type II and patella type III and ATT type I. There was no correlation with the height of the patella or with the form of the trochlea or the patella.

Conclusion: The form of the ATT is quantifiable and becomes a parameter to consider in the analysis of patellofemoral osteoarthritis.

Purpose

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).

Purpose: Classically reported, degenerative femorotibial remodelling after meniscectomy results from different biomechanical mechanisms depending on the compartment considered. Occurring in the medial compartment, the most frequent situation, the lesions result from punctual contact compression of the cartilage. In the lateral compartment the mechanism involves increased relative instability of the structures controlling mobility. Lateral meniscectomy disrupts femorotibial kinetics of the meniscotibial gliding articulation leading to horizontal instability and subsequent generation of osteoarthritic degeneration which explains the development of lateral decompensations without genu valgum. Based on work by Grammont and Rudy, we proposed a method to limit this horizontal instability and transfer part of the stress to the medial compartment by medial translocation of the tibial tubercle.

Material and methods: Eighteen patients, mean age 44 years, underwent treatment for disabling degeneration without major misalignment (mean HKA 181°) a mean ten years after lateral meniscetomy. Degenerative remodelling of the lateral compartment was observed on the AP views in 30% of the knees and on the tangent views in 57% Five patients had early-stage lesions of the medial compartment and femoropatellar degradation was observed in 53%. Involvement of the lateral compartment was confirmed by systematic articular exploration and patellofemoral chondropathy was observed in eight knees. Translocation of the anterior tibial tubercle was associated with section of the lateral patellar wing in all knees associated with tension plasty medially.

Results: In 88% of the knees, the postoperative period was uneventful. Weight-bearing supported with a Zimmer cast was maintained for 21 days. Functional outcome was assessed at mean 28 months. Eleven patients had a new clinical and radiographic work-up (mean 34 months). Pain was improved in 88% of the knees, allowing sustained resumption of occupational activities at three months (four knees completely forgotten). Radiographically, at mean 34 months, the lateral cartilage lesions had stabilised with no impact on the medial compartment.

Discussion: In light of these results, we have decided to continue this therapeutic approach, reserving the technique for cases of symptomatic lateral decompensation in young subjects without major valgus malalignment.

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.

Introduction

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.

Purpose of Study

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.

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.

Purpose: The aim of this study was to evaluate the arthroscopic findings and treatment of chronic shoulder pain after minimally displaced greater tuberosity (GT) fractures.

Material and Methods: Arthroscopy was performed in 12 patients (8m, 4f; mean age of 36 years) with more than 6 months of shoulder pain after sustaining a minimally displaced GT fracture (inferior to 5 mms). 4 cases were associated with anterior shoulder dislocation.

Results: Varied pathologic findings, some of them unsuspected, were observed in all cases, both at subacromial and glenohumeral level:

5 cases of subacromial impingement secondary to protrusion of the proximal portion of the GT; 2 of them associated with Pasta lesion

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.

Conclusions: Arthroscopy proved to be very useful to assess the varied etiologic factors for chronic shoulder pain in undisplaced GT fractures. Arthroscopic techniques are effective in managing GT malunions and tendinous and bony Pasta lesions.

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.

Purpose of the study: Transposition of the anterior tibial tuberosisty (ATT) is often performed during the treatment of periodic dislocation of the patella. The purpose of this retrospective study was to evaluate the rate of medial femorotibial osteoarthritis and medial patellofemoral osteoarthritis after ATT transfer.

Material and method: We reviewed 129 knees in 106 patients who underwent surgery from 1988 to 2004. The patients were reviewed at mean 9 years follow-up, minimum 2 years. Three groups were defined:

isolated descent (n=15),

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.

Results: All patients in group 2 were free of osteoarthritis. In group 2, the rate of medial femorotibial osteoarthritis was 10.5%; the rate of medial patellofemoral osteoarthritis was 21%. In group 3, the rate of medial femorotibial osteoarthritis was 7% and that of medial patellofemoral osteoarthritis 14%. For patients with unilateral periodic patellar dislocation, only the operated knees exhibited medial patellofemoral osteoarthritis (12%). The rate of medial patellofemoral osteoarthritis was significantly greater for knees with a medial shift of the ATT. The rate of medial femorotibial osteoarthritis was 6.8% for knees with medial shift versus 8.3% for the index knees. There was no significant difference between the medial shift knees and the index knees for medial femorotibial osteoarthritis.

Discussion: Biomechanical studies have shown increased stress forces on the medial compartment after medial shift of the ATT. However, these studies were performed with normal knees free of the morphological anomalies generally present in knees exhibiting periodic patellar dislocation (abnormally high tibial tuberosity femoral notch distance, trochlear dysplasia. In our series, regarding the rate of medial femorotibial osteoarthritis, there was no significant difference between the knees which underwent a medial shift of the ATT and healthy knees. Consequently, medial shift of the ATT should be avoided when unnecessary; the morphology of the trochlea (depth, morphology of the medial component) can induce increased medial stress on the patellofemoral joint.

Purpose

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.

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.

Aim: The aim of the study was to investigate the influence of bone density of the greater tuberosity on mechanical strength of different bone anchors for rotator cuff surgery. Especially in osteopenic bone the metal bone anchors and transosseus sutures are still the “gold-standard” in rotator cuff surgery.

Material and Methods: Four bone anchors, each standing for a specific group of bone anchor, and two suture materials were tested. One of them was the metallic Super Revo screw 5.0 (Linvatec), the absorbable screw Spiralok 5.0 (Mitek), the absorbable press-fit anchor Bioknotless RC (Mitek) and the absorbable Ultrasorb RC (Linvatec). The suture materials tested was the well known V-37 (Ethicon) and the new Orthocord (Mitek) both USP 2. All fixations systems were tested on a) 6 pairs of fresh-frozen human shoulders from young adults (range 20–50 yrs.) and b) 6 pairs of fresh frozen human shoulders from elderly (range 60–93 yrs.). Cyclic loading was performed, as it was considered the best way to simulate the postoperative conditions in a manner similar to those used in prior studies until the system failed. The maximum tensile strength, the failure mode, and the displacement of the fixation device (system displacement) under load at the first cycle at 75 N and at the maximum tensile strength were recorded.

Results: The absorbable Spiralok 5 mm screw anchor showed the highest failure load with a mean of 171 N in osteopenic bone. The suture material Orthocord and V-37 had the lowest mechanical strength in osteopenic bone with a mean of 125 N resp. 114 N. The remaining anchors had an almost identical failure load with means of 150 N (Super Revo 5 mm and Bioknotless RC) and 151 N (Ultrasorb RC). No statistical significance was found though. Comparing the mechanical strength of each fixation system in healthy and osteopenic bone no statistical significant difference was found except for the V-37 suture. In healthy bone the failure load of V-37 suture had a mean of 204 N and in osteopenic bone of 114 N.

Discussion: The absorbable Spiralok 5 mm screw showed a good performance in healthy and osteopenic bone when compared with standard bone anchor like the titan Super Revo 5 mm screw or transosseous sutures. Absorbable anchors have certain advantages, besides that usually they are more expensive. They can easily be overdrilled in case of rupture of the suture material, and they do not interfere during later revision surgery or for imaging studies such as magnetic resonance imaging.

Background: Correct rotational alignment of the femoral and tibial component is an important factor for successful TKA. The transepicondylar axis is widely accepted as a reference for the femoral component. There is no such reference for the tibial component. CT scans were used in this study to measure which tibial landmark most reliably reproduces a correct femoro-tibial rotational alignment in TKA. Furthermore, the impact of computer-assisted navigation on rotational alignment is investigated.

Materials and Methods: After informed consent, 80 patients were randomized to receive either navigated or conventional TKA. All patients received a cemented, unconstrained, cruciate-retaining TKA with a rotating platform. CT scans were performed 5–7 days postoperatively but before discharge. The rotational variance between the femoral and tibial components was measured.

Results: There was notable rotational variance between the femoral and tibial components in both groups. In the navigated group, the median variance was 1.2° relative external rotation of the femur (range: 16.2° relative external to 12.7° relative internal rotation of the femur). In the conventional group, the median variance was 1.7° relative internal rotation of the femur (range: 9.0° relative external to 14.4° relative internal rotation of the femur). Using the medial third of the tuberosity as reference for tibial rotational alignment, 67.5% of all TKA had a femoro-tibial variance within ± 5°, 85% within ± 10° and 97.5% within ± 20°. Using the medial border of the tibial tubercle as reference this variance was greater, 3.8% had a femoro-tibial variance within ± 5°, 15% within ± 10° and 68.8% within ± 20°.

Conclusion: Using fixed bone landmarks for rotational alignment leads to a notable variance between femoral and tibial component. Computer-assisted navigation did not reduce this variance.

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: Bone Joint J 2014; 96-B:1344–8

Introduction: Functional results of hemiarthroplasties in proximal humeral fractures are unpredictable. The correct consolidation of the tuberosities back to the prosthesis seem to be of capital importance in the functional outcome. The objective of the study is to analyze the changes of the tension registered in the sutures passed through the tuberosities when changing the height and version of the prosthesis in a static model and in a dynamic model.

Material and Method: Prosthesis positioning: in both static and dynamic model, the prosthesis was placed in anatomical position, anatomical increasing 20° retroversion, increasing height in 1cm and anatomical version, decreasing height in 1 cm and anatomical version, increasing height in 1cm and increasing 20° retroversion, decreasing height in 1 cm and increasing 20° retroversion,

Static study: a 4-part fracture was reproduced in four fresh-frozen shoulder specimens. Sutures were placed between lesser tuberosity and diafisis (sensor 1) between both tuberosities (sensor 2) and between greater tuberosity and diafisis (sensor 3). Traction was performed through supraspinatus, infraspinatus and subescapularis attachments until the breakage of the suture or 1 cm gap between bony fragments. Tensions registered in a computer model.

Dynamic study: a 4-part fracture was reproduced in a humeral saw bone. Sutures placed in the same position that in the static model. Saw bone fixed at a robotic arm reproducing cycles of 90° anterior elevation, 30° lateral rotation, 30° internal rotation and retropulsion to starting point. Registering of the tensions. Quantitative values studied through t-student and non parametric values studied through U-Mann-Whitney and Kruskal-Wallis test.

Results: In the Static study, the suture placed between the tuberosities is the one that 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.

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.

Conclusions: When planning sutures between tuberosities in proximal humeral fractures treated with hemiarthroplasty postoperative rehabilitation program has to be considered because different sutures are at risk depending on static or dynamic model.

The worst positions of the hemiarthroplasty as far as over tensioning sutures is concerned are the low position and the low more retroverted position.

Aims: There are multiple proximal prosthetic geometries for humeral head replacement for treatment of four-part proximal humerus fractures. We compared four proximal prosthetic geometries in stable and unstable fracture patterns with a standard tuberosity þxation method. Methods: Twelve synthetic shoulders and 4 cadaver shoulders had a simulated four-part fracture created with an oscillating saw. The following proximal prosthetic geometries were used: smooth circular shape (SCS), diamond shape (DS), irregular multiple þn shape (IMFS), and IMFS with deeper þns (IMSDF). A standardized þxation method using vertical sutures, horizontal sutures and medial based cerclage straps was performed. Passive motion from 0–45 degrees was carried out using a robotic articulator at a rate of 10 degrees per second. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to the shaft using mercury strain gauges. This was repeated for stable and unstable fracture patterns. Results: When comparing interfragmentary motion between the four different geometries the greatest amount of motion occurred with the SCS in a stable fracture (0.69mm, p< 0.0001) and unstable fracture (0.71 mm, p< 0.0001). The geometry that provided the most stability was the IMFSDF in stable (0.08mm) and unstable (0.09 mm) fracture patterns. Conclusion: The geometry of the prosthetic device does affect the stability of the tuberosity reconstruction. A smooth circular prosthetic design in a stable or unstable fracture pattern does not prevent excessive interfragmentary motion, while an irregular multiple þn shaped prosthesis with deep þns augments the þxation construct even in an unstable fracture pattern.

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. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

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 Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. Results. Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. Conclusion. During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881–889

The majority of 5th metatarsal fractures are successfully treated conservatively, with few patients requiring surgical fixation for symptomatic non-union. Tuberosity avulsion fractures are generally considered benign injuries with more distal fractures showing a propensity to develop delayed/non-union. We studied a cohort of patients who underwent surgery as treatment for non-union. We reported on outcome, rate of complications and requirement for additional surgery. All patients who required surgery to their 5th metatarsal from June 2008 to May 2018 were included. Demographic, clinical outcome data and radiographic classification of fracture types were collected, reviewed and analysed. 35 patients had undergone surgery for 5th metatarsal fractures during this time period and 31 of these had been operated on for a painful non-union. 12 were tuberosity avulsion fractures (Lawrence and Botte Type1) and 23 were Type 2/3. 5 patients (14.3%) experienced a further symptomatic non-union after initial surgery; Type 1 fractures were 11 times more likely to result in non-union (p=0.0375). 22.9% of the group required some form of further surgery, with a significant association between Type 1 fractures and the need for further surgery (p=0.0107). This study is the first of its kind, reporting specifically on the outcome after surgical fixation of a non-union of 5th metatarsal fractures. Overall, surgery had a good outcome with a low complication rate, though it is interesting to note that Type 1 fractures, which traditionally have a low non-union rate after conservative treatment, are associated with a significantly increased incidence of non-union if operated 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%. Tuberosity complications were associated with poor final Constant score, poor range of motion and shoulder pain (p=0.001 for all items). A re-operation was performed in 5.3% of the cases. Patients who were mobilised according to the ‘early passive motion’ concept had double the incidence of secondary tuberosity migration, compared to those that were initially immobilised (14% versus 27%, p=0.004). Tuberosity complications are the most frequent late complication and they are associated with poor functional results. It is, therefore, incumbent upon the surgeon to maximise healing with adequate fixation of the tuberosities, followed by sufficient immobilization

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 Tuberosity, L-lesser Tuberosity, S-shaft), recording the fracture plane, and optionally incorporating calcar length and head angulation or displacement.: The aim of this study was to compare the inter- and intraobserver reliability of this new classification system with the AO and Neer Classification, and its usefulness as a guide to management. Patients and Methods: 49 proximal humeral fractures in 49 consecutive patients treated at the department of orthopaedics and trauma, Royal Adelaide Hospital were identified in the period of July 2007 till January 2008. All fractures of the proximal humerus were examined using AP, lateral and axial radiographs. Three independent reviewers, looking specifically at interobserver correlation and the indication of humeral head viability, classified the fractures using the AO, Neer and “HGLS Classification”. Results: The median age of patients was 72 (range 50 to 85). Based on the interobserver correlation analysis, the AO (κ-value 0.47) and Neer κ-value (0.44) classification systems were graded as poor and were consistent with values published in articles in the past. The HGLS Classification” showed good interobserver agreement for all three examiners (κ-value 0.73). Similar κ-values were also seen for intraobserver agreement. Conclusion: While the parts system of Neer and AO-system can still provide a general impression of the fracture form, the “HGLS classification” for proximal humeral fractures provided a more precise description of the fracture pattern which has important prognostic and therapeutic implications. It is quick to apply and easy to use as it does not require the memorising of a numerical classification. Our study showed a good reliability for the classification system, however further studies seem necessary to assess validity of the HGLS-system

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. Tuberosity fracture can be repaired intraoperatively with suture techniques, glenoid fractures may be insignificant rim fractures or jeopardise baseplate fixation and require abandoning RSA until glenoid fracture ORIF heals and then a second stage RSA. Periprosthetic infection after RSA ranges from 1 to 10% and may be higher in revision cases and frequently is Propionibacterium acnes and Staphylococcus epidermidis. Dislocation was one of the most common complications after RSA approximately 5% but with increased surgeon experience and prosthetic design, dislocation rates are approaching 1–2%. An anterosuperior deltoid splitting approach has been associated with increased stability as well as subscapularis repair after RSA. Scapular notching is the most common complication after RSA. Notching may be caused by direct mechanical impingement of the humerosocket polyethylene on the scapular neck and from osteolysis from polyethylene wear. Sirveaux classified scapular notching based on the defect size as it erodes behind the baseplate towards the central post. Acromial fractures are infrequent but more common is severely eroded acromions from CTA, with osteoporosis, with excessive lengthening, and with superior baseplate screws that penetrate the scapular spine and create a stress riser. Nonoperative care is the mainstay of acromial and scapular spine fractures. Recognizing preoperative risk factors and understanding component positioning and design is essential to maximizing successful outcomes

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. Tuberosity healing failure leads to nearly universal catastrophic results with pain, dysfunction, and pseudoparalysis. Furthermore, conversion of failed hemiarthroplasty to reverse total shoulder arthroplasty leads to the highest incidence of complications and poorest outcomes of all groups of patients undergoing reverse total shoulder replacement. This is countered by the knowledge that if tuberosity healing occurs the outcome can be reliable with regard to pain relief and functional restoration. Reverse total shoulder arthroplasty, on the other hand, has emerged as a preferred surgical option for many surgeons due to the issues following hemiarthroplasty. The increased prevalence of RTSA for the management of 4-part fractures has come without overwhelming evidence that outcomes are superior especially in light of the increased cost, life-time weight bearing restrictions, and uncertain long-term durability. Long-term follow-up of patients treated with RTSA for 4-part fracture has shown concerning degradation of function and outcomes and remains a valid concern about the long-term durability. We must remain diligent therefore in continuing to better understand which fractures should be treated non-operatively and those that may be amenable to anatomic hemiarthroplasty and finally those which may be better served by using a reverse total shoulder replacement