Purpose of study. The outcomes of conservatively managed minimally displaced isolated greater tuberosity fractures are sparsely reported and the aim of this study was to look at the outcome of these fractures. patients and methods. Twenty-seven patients who had sustained a greater tuberosity fracture were identified. They were all managed by a single surgeon. All patients had a regime of initial immobilisation for 3 weeks followed by physiotherapy and range of motion exercises. They were all x-rayed at 1 week and 3 weeks after injury to monitor for any displacement. Four fractures occurred with an anterior dislocation. In seven patients the fracture was not visible on x-ray but was diagnosed on Ultrasound or MRI. Twenty-three of 27 patients were available for follow-up. For this follow up, the patients were telephonically contacted and the Oxford Shoulder Score (OSS) was completed to assess their outcome. Results. There were 12 males and 11 females in the review. The average age was 44 yrs (6–71 yrs) and the average follow up was 26.2 months (6–43 months). The OSS for the 23 patients ranged from 22–48 (average 44, median 47, mode of 48). Fourteen patients had LASI as part of their management after they started to develop pain and impingement symptoms. The ones with LASI had a slightly lower median OSS (46) compared to those without (48) but the modal scores were the same (48). One patient needed surgery after the initial fracture displaced at 3 weeks while another patient needed an acromioplasty at 10 months for impingement. Three patients developed a frozen shoulder but subsequently settled and had excellent outcome scores. Summary. In this study, 30% (7) of the fractures were not visible on the x-rays but diagnosed on ultrasound or MRI. Nearly half the patients required subacromial steroid injections to improve recovery. In only one patient did the fracture displace and require fixation. Conclusion. Conservative management of minimally displaced greater tuberosity fractures yields good functional results though a high percentage of patients require subacromial steroid injections. Secondary displacement is rare, however close vigilance of fracture is advised with x-rays done at 1 and 3 weeks postoperatively. NO DISCLOSURES

Background. The purpose of this retrospective study was to examine the functional outcomes of patients treated for isolated fracture of the greater tuberosity (GT) and to determine how their outcomes were affected by fracture pattern, treatment choices, associated shoulder injuries, the post fixation displacement of GT fragment and the time delay between injury and fixation. Methods. Forty-eight (28 male and 20 female) patients (mean age 45 years) treated at our institution between 1999–2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 conservatively. Functional outcome was assessed using Oxford scores (OS), University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow surgeons (ASES). The outpatient follow up time required and the presence of other shoulder injuries, time delay to surgery and the time off work were also recorded. Results. Outcome scores for patients who sustained simple vs comminuted fractures were not significantly different (OS = 41.8 vs 41, ASES 23.8 vs 23.4, UCLA 26.6 vs 26.3). Time taken off work was less in those who had a comminuted vs a simple fracture (21 vs 30 weeks). Shoulder dislocation was present in 77% and patients had a significantly worse outcome than those with no dislocation (OS = 40.6 vs 44, ASES 22.9 vs 26). Rotator cuff repair was required in 21% of patients and was also associated with a worse outcome (OS 42.8 vs 36.8, ASES 24.5 vs 20.5). Post fixation displacement of the GT fracture of < 5 mm led to a significantly better outcome than displacement >5mm (OS = 43 vs 37, ASES = 25.6 vs 17.7, UCLA 28.2 vs 21.3). Conclusion. Isolated fractures of the greater tuberosity have a worse outcome if they are associated with shoulder dislocation, rotator cuff tear and post fixation displacement of >5mm

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

Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

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

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

Abstract. Introduction. There is little literature exploring clinical outcomes of secondarily displaced proximal humerus fractures. The aim of this study was to assess the rate of secondary displacement in undisplaced proximal humeral fractures (PHF) and their clinical outcomes. Methods. This was a retrospective cohort study of undisplaced PHFs at Royal Derby Hospital, UK, between January 2018-December 2019. Radiographs were reviewed for displacement and classified according to Neer's classification. Displacement was defined as translation of fracture fragments by greater than 1cm or 20° of angulation. Patients with pathological, periprosthetic, bilateral, fracture dislocations and head-split fractures were excluded along with those without adequate radiological follow-up. Results. In total, 681 patients were treated with PHFs within the study period and out of those 155 were excluded as above. There were 385 undisplaced PHFs with mean age 70 years (range, 21–97years) and female to male ratio of 3.3:1. There were 88 isolated greater tuberosity fractures, 182 comminuted PHFs and 115 surgical neck fractures. Secondary displacement occurred in 33 patients (8.6%). Mean time to displacement was 14.8 days (range, 5–45days) with surgical intervention required in only 5 patients. In those managed nonoperatively, three had malunion and one had nonunion. No significant differences were noted in ROM between undisplaced and secondarily displaced PHFs. Conclusion. Undisplaced fractures are the most common type of PHF. Rate of secondary displacement is low at 8.6% and can occur up to 7 weeks after injury. Displacement can lead to surgery, but those managed conservatively maintain their ROM at final follow up

Purpose. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77(68–87)years old and mean follow-up period was 15.2(12–26)months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included. We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion(ROM). Results. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103°(30°–135°) in forward flexion, 93°(30°–135°) in abduction, 21°(0°–45°) in external rotation and L4 level in internal rotation. The complications were not shown in any cases except for resolved heterotropic ossification. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusions. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results

Background:. Currently, there are a variety of different reverse shoulder implant designs but few anatomic studies to support the optimal selection of prosthetic size. This study analyzed the glenohumeral relationships of patients who underwent reverse shoulder arthroplasty (RSA). Methods:. Ninety-two shoulders of patients undergoing primary RSA for a massive rotator cuff tear without bony deformity or deficiency and 10 shoulders of healthy volunteers (controls) were evaluated using three-dimensional CT reconstructions and computer aided design (CAD) software. Anatomic landmarks were used to define scapular and humeral planes in addition to articular centers. After aligning the humeral center of rotation with the glenoid center, multiple glenohumeral relationships were measured and evaluated for linearity and size stratification. The correction required to transform the shoulder from its existing state (CT scan) to a realigned image (CAD model) was compared between the RSA and control groups. Size stratification was verified for statistical significance between groups. Generalized linear modeling was used to investigate if glenoid height, coronal humeral head diameter and gender were predictive of greater tuberosity positions. Results:. All 92 shoulders were grouped into three different categories based on glenoid height. The humeral head size, glenoid size, lateral offset, and inferior offset all increased linearly (r. 2. > 0.95), but the rate of increase varied (slopes range from 0.59 to 1.9). Translations required to normalize the shoulder joint were similar between healthy and pathologic cases except for superior migration. Glenoid height, coronal humeral head diameter and gender predicted the greater tuberosity position within 1.09 ± 0.84 mm of actual position in ninety percent of the patient population. Morphometric measurements for each stratified group were all found to be statistically significant between groups (p ≥ 0.05). Conclusion:. Patients who undergo RSA with minimal bony deformity have superior subluxation of the glenohumeral joint. Predicting the anatomic position of the greater tuberosity is dependent on gender, glenoid height and coronal humeral head diameter. This anatomic data provides a guide to avoid inadvertent mismatch of prosthetic and patient shoulder size. If the surgeon is able to measure glenoid height and coronal humeral head diameter preoperatively, accurate planning of the position of the greater tuberosity can be accomplished

Purpose:. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods:. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77 years old and mean follow-up period was 15.2(12–26) months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included (Fig. 1, Fig. 2, Fig. 3). We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion (ROM). Results:. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103° in forward flexion, 93° in abduction, 21° in external rotation and L4 level in internal rotation. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusion:. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results. Key words: Shoulder, Proximal humerus fracture, Reverse total shoulder arthroplasty

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. Materials and Methods. 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. Results. The median age in our study was 59. The mean Constant and Murley score was 75 (range 35–98) and the mean DASH score was 15.7 (0.8–45.0) which is a good result. Most patients had trouble in performing overhead activities (as per the DASH scoresheet) inspite of surgery. Impingement signs were also positive in nearly half of our patients (9 patients). Conclusions. Greater tuberosity fracture fixation using cancellous screws is a simple procedure associated with good results. However comparision needs to be made with the outcomes following fixation using suture anchors which is also a popular technique

Aim. Review causes of anchor fixation failures in patients who underwent arthroscopic rotator cuff repair. Methods. Between 2003 and 2006, 650 arthroscopic rotator cuff repairs were performed by the senior author. Of these, anchor fixation failure occurred in fifteen patients. A retrospective review was undertaken to find out the reasons for their failure. Results. There were ten women and five men, age range 46-84 (mean age 64). Thirteen underwent repair with metallic knotless anchors (Arthrocare), and two with 5.5mm biodegradable screw anchors (Arthrotek). Knotless anchors were used to repair six massive, one large, three medium and three small tears. The two patients with biodegradable anchor repair had only small tears, each held with a single anchor. All but one failure was apparent at six weeks. One metallic anchor failed at four months. Twelve knotless anchors failed through pull-out and one broke. Both biodegradable anchors broke at the eyelet. Discussion. The increasing strength of suture material has shifted the weak point away from the suture-tendon interface towards the anchor-bone interface. Arthroscopic techniques permit a wider age range of patients suitable for surgery, each with varying degrees of osteoporosis in the proximal humerus, increasing risk of anchor pull-out. Multiple anchor insertions to reduce stiff, retracted tears may also lead to weakening of the bone table in the footprint area of the greater tuberosity. Incomplete anchor deployment, commonly at the curved cortical bone edge of greater tuberosity can also lead to failure. Conclusion. Anchors failed if tension in the repair exceeds the bones capacity to retain the anchor, if the anchor is incompletely deployed or if one anchor is stressed beyond its tension capability. We recommend that consideration is given to spreading the tension of the tissue repair amongst the anchors placed in the greater tuberosity

Removal of a well-fixed humeral component during revision shoulder arthroplasty presents a challenging problem. If the humeral component cannot be extracted simply from above, an alternate approach must be taken that may include compromising bone architecture to remove the implant. Two potential solutions to this problem that allow removal of the well-fixed prosthesis are making a humeral window or creating a longitudinal split in the humerus. A retrospective review was performed at the Mayo Clinic to determine the complications associated with performing humeral windows and longitudinal splits during the course of revision shoulder arthroplasty. This study included 427 patients from 1994–2010 at Mayo Clinic undergoing revision shoulder arthroplasty. From this cohort, those who required a humeral window or a longitudinal split to assist removal of a well-fixed humeral component were identified. Twenty-seven patients had a humeral window produced to remove a well-fixed humeral component. Six intra-operative fractures were reported from this group: 5 were in the greater tuberosity and 1 was in the distal humeral shaft. At the latest radiographic follow-up, 24 of 27 windows healed, 2 patients had limited inconclusive radiographic follow-up (1 and 2 months), and 1 did not have follow-up at our institution. Twenty-four patients underwent longitudinal osteotomy to extract a well-fixed humeral component. From this group, 1 had intra-operative fracture in the greater tuberosity. At most recent radiographic follow-up, 22 of 24 longitudinal splits healed, 1 had short follow-up (1 ½ months) with demonstrated signs of healing, and 1 did not have follow-up at our institution. In both groups, there were no cases of window malunion and no components have developed clinical loosening. Data from this study suggests humeral windows and longitudinal splits can assist with controlled removal of well-fixed humeral components with a high rate of union and a low rate of intra-operative and post-operative sequelae

Purpose:. To determine the insertion of the different layers of the rotator cuff and apply it to rotator cuff tears. Anatomical insertion of the rotator cuff holds the key to a proper anatomical repair. Method:. A study of the rotator cuff insertion was done in conjunction with MSc student department Anatomy. The rotator cuff consists of a capsular and tendinous layer. They have different mechanical properties. The capsular layer inserts ± 3 mm more medially on the tuberosity and the tendinous layer more laterally. It was shown that the superficial layer extends beyond the greater tuberosity and connects the supra-spinatus tendon to the sub-scapularis tendon via the bicepital groove. This connection was called the “rotator hood”. The “rotator hood” has a mechanically advantageous insertion, is a strong structure with a compressive force on the proximal humerus. Conclusion:. 1. The rotator cuff inserts on the greater tuberosity as two separate entities. 2. The capsular layer inserts on the more medial 2–3 mm. 3. The tendinous layer is attached over a broader more lateral area giving it a mechanical advantage. 4. The tendinous layer of supra-spinatus extends beyond the tuberosity to connect to the sub-scapularis tendon providing an even greater mechanical advantage

Surgical reattachment of torn rotator cuff tendons can lead to satisfactory clinical outcome but failures remain common. Ortho-R product is a freeze-dried formulation of chitosan (CS) that is solubilized in platelet-rich plasma (PRP) to form injectable implants. The purpose of the current pilot study was to determine Ortho-R implant acute residency, test safety of different implant doses, and assess efficacy over standard of care in a sheep model. The infraspinatus tendon (ISP) was detached and immediately repaired in 22 skeletally mature ewes. Repair was done with four suture anchors in a suture bridge configuration (n = 6 controls). Freeze-dried formulations containing 1% w/v chitosan (number average molar mass 35 kDa and degree of deacetylation 83%) with 1% w/v trehalose (as lyoprotectant) and 42.2 mM calcium chloride (as clot activator) were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (n = 6 with a 1 mL dose and n = 6 with a 2 mL dose). Acute implant residency was assessed histologically at 1 day (n = 2 with a 1 mL dose and n = 2 with a 2 mL dose). Outcome measures included MRI assessment at baseline, 6 weeks and 12 weeks, histopathology at 12 weeks and clinical pathology. MRI images and histological slides were scored by 2 blinded readers (veterinarian and human radiologist, and veterinarian pathologist) and averaged. The Generalized Linear Model task (SAS Enterprise Guide 7.1 and SAS 9.4) was used to compare the different groups with post-hoc analysis to test for pairwise differences. Ortho-R implants were detected near the enthesis, near the top of the anchors holes and at the surface of ISP tendon and muscle at 1 day. Numerous polymorphonuclear cells were recruited to the implant in the case of ISP tendon and muscle. On MRI, all repair sites were hyperintense compared to normal tendon at 6 weeks and only 1 out 18 repair sites was isointense at 12 weeks. The tendon repair site gap seen on MRI, which is the length of the hyperintense region between the greater tuberosity and tendon with normal signal intensity, was decreased by treatment with the 2 mL dose when compared to control at 12 weeks (p = 0.01). Histologically, none of the repair sites were structurally normal. A trend of improved structural organization of the tendon (p = 0.06) and improved structural appearance of the enthesis (p = 0.1) with 2 mL dose treatment compared to control was seen at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. Ortho-R implants (2 mL dose) modulated the rotator cuff healing processes in this large animal model. The promising MRI and histological findings may translate into improved mechanical performance, which will be assessed in a future study with a larger number of animals. This study provides preliminary evidence on the safety and efficacy of Ortho-R implants in a large animal model that could potentially be translated to a clinical setting

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

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

The treatment of proximal humerus fractures remains controversial. The literature is full of articles and commentary supporting one method over another. Options include open reduction and internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. Treatment options in an active 65-year-old are exceptionally controversial given the fact that people in this middle-aged group still wished to remain active and athletic in many circumstances. A hemiarthroplasty offers the advantage of a greater range of motion, however, this has a high incidence of tuberosity malunion or nonunion and this is a very common reason for revision of that hemiarthroplasty for fracture to a reverse shoulder replacement. One recent study showed a 73% incidence of tuberosity malunion or nonunion in shoulders that had a revised hemiarthroplasty to a reverse shoulder replacement. Progressive glenoid wear and erosion is also a risk after a hemiarthroplasty in the younger patient, especially someone who is young and active. In addition, studies show shorter operative time in hemiarthroplasty. The range of motion is highly dependent on proper tuberosity healing and this is often one of the most challenging aspects of the surgical procedure as well as the healing process. A reverse shoulder replacement in general has less range of motion compared to a hemiarthroplasty with anatomically healed tuberosities, however, the revision rate is lower compared to a hemiarthroplasty. (This is likely related to few were options for revision). The results after a reverse shoulder replacement may not be as dependent on tuberosity healing, however, importantly the tuberosities do need to be repaired and the results are significantly better if there is healing of the greater tuberosity, giving some infraspinatus and/or teres minor function to the shoulder. Complete lack of tuberosity healing forces the shoulder into obligate internal rotation with attempted elevation and this can be functionally disabling. Academic discussion is beginning surrounding the use of a reverse shoulder replacement in the setting of glenohumeral joint arthritis in a primary setting as it is believed that the glenosphere and baseplate may have greater longevity than a polyethylene glenoid. Along with this discussion, we will likely see greater application of the use of a reverse shoulder replacement in the setting of fracture for younger patients. In general, open reduction internal fixation should still remain the treatment of choice in the setting of a fracture that can be fixed. However, a strong argument can be made that if an arthroplasty is necessary, a reverse shoulder replacement is the implant of choice

Despite reverse total shoulder arthroplasty (RTSA) being primarily indicated for massive rotator cuff tears, it is often possible to repair portions of the infraspinatus and subscapularis of patients undergoing this procedure. However, there is disagreement regarding whether these tissues should be repaired, as their effects remain unclear. Therefore, we investigated the effects of rotator cuff repair and changes in humeral and glenosphere lateralisation (HLat & GLat) on deltoid and joint loading. Six shoulders were tested on an in-vitro muscle driven active motion simulator. Cuff tear arthropathy was simulated in each specimen, which was then implanted with a custom adjustable RTSA fitted with a six axis load sensor. We assessed the effects of 4 RTSA configurations (i.e. all combinations of 0&10mm of HLat & GLat) on deltoid force, joint load, and joint load angle during abduction with/out rotator cuff repair. Deltoid and joint loads recorded by the load cell are reported as a % of Body Weight (%BW). Repeated measures ANOVAs and pairwise comparisons were performed with p<0.05 indicating significance. Cuff repair interacted with HLat & GLat (p=0.005, Fig. 1) such that with no HLat, GLat increased deltoid force without cuff repair (8.1±2.1%BW, p=0.012) and this effect was significantly increased with cuff repair (12.8±3.2%BW, p=0.010). However, adding HLat mitigated this such that differences were not significant. HLat and GLat affected deltoid force regardless of cuff status (−2.5±0.7%BW, p=0.016 & +7.7±2.3%BW, p=0.016, respectively). Rotator cuff repair did significantly increase joint load (+11.9±2.1%BW, p=0.002), as did GLat (+13.3±1.5%BW, p<0.001). The increases in deltoid and joint load caused by rotator cuff repair confirm that it acts as an adductor following RTSA and increases deltoid work. Additionally, cuff repair's negative effects are exacerbated by GLat, which strengthens its adduction affect, while Hlat increases the deltoid's abduction effect thus mitigating the cuff's antagonistic effects. Cuff repair increases concavity compression within the joint; however, Hlat produces a similar effect by wrapping the deltoid around the greater tuberosity – which redirects its force – and does so without increasing the magnitude of muscle and joint loading. The long-term effects of increased joint loading due to rotator cuff repair are unknown, however, it can be postulated that it may increase implant wear, and the risk of deltoid fatigue. Therefore, RTSA implant designs which improve joint compression without increasing muscle and joint loading may be preferable to rotator cuff repair

Optimal surgical management of proximal humeral fractures remains controversial. We report our experience and the study on our surgical technique for proximal humeral fractures and fracture-dislocations using locking plates in conjunction with calcium sulphate augmentation and tuberosity repair using high strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. We retrospectively analysed 22 proximal humeral fractures in 21 patients. 10 were male and 11 female with an average age of 64.6 years (Range 37 to 77). Average follow-up was 24 months. Fractures were classified according to Neer and Hertel systems. Pre-operative radiographs and CT scans in three and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were 5 two-part, 6 three-part, 5 four-part fractures and 6 fracture-dislocations (2 anterior and 4 posterior). Results were assessed clinically with DASH scores, modified Constant & Murley scores and serial post-operative radiographs. The mean DASH score was 16.18 and modified Constant & Murley score was 64.04 at the last follow-up. 18 out of 22 cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients