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Abstract

Objective:

The purpose of the study was to evaluate the clinical and radiographic outcomes of treatment in patients with isolated greater tuberosity (GT) fractures of humerus using arthroscopic percutaneous inverted mattress suture fixation technique.

Materials and methods:

We attempted to use the arthroscopic percutaneous inverted mattress suture fixation technique in 17 consecutive cases with isolated displaced GT fractures. Fourteen patients were successfully treated without switching to other methods and were available for follow-up at a mean of 22 months (range: 17–38 months) after surgery. For assessment of clinical outcomes, we evaluated the range of motion and the visual analog scale (VAS) score, the shoulder index of the American Shoulder and Elbow Surgeons (ASES), and the Korean Shoulder Scale (KSS).

Results:

At the final follow-up, the VAS improved to 1.0 points (range: 0–3), the mean ASES score improved to 86.9 points (range: 78.3–100) and the KSS improved to 88.6 points (range: 82–100) postoperatively. Mean union time was 10 weeks. Mean forward flexion was 167.8° (range: 140–180°), mean external rotation in neutral position was 36° (range: 20–70°), and mean internal rotation was at the 12th thoracic level (range: T6–L3) at final follow-up. Three cases were switched to open surgery after attempted arthroscopic technique due to large fragment or osteoporosis.

Conclusion:

In select cases, the arthroscopic percutaneous inverted mattress suture fixation of GT fracture is a simple and reproducible technique with encouraging early results.

Keywords

arthroscopic treatment greater tuberosity fracture proximal humerus

Introduction

Isolated greater tuberosity (GT) fractures of the humerus account for 17–21% of all proximal humerus fractures.^1
–3 These injuries can result from impaction, avulsion, and shearing injury of the shoulders.² Even minor displacement can alter the point of attachment of the rotator cuff and lead to subsequent deterioration of shoulder functions.^3,4 Isolated fractures of the GT differ greatly within populations and hence their classification and management must be considered separately from other proximal fractures of the humerus.⁵ Even with minor displacement (i.e. 3–5 mm), surgical management should be considered, especially for athletes and individuals who perform overhead activities. Therefore, although isolated GT fractures may seem trifling, they are difficult to deal with in terms of decision-making for optimal treatment and surgical technique.

Many fixation techniques have been described for displaced GT fractures which include the use of screws, tension bands, and sutures.^1,6,7 With the advent of arthroscopic techniques, surgeons have advocated arthroscopic treatments of GT fractures to minimize dissection and the associated morbidity. However, arthroscopic techniques are not without technical difficulties and can result in suboptimal reduction in tuberosities.^4,8,9 Most arthroscopic GT fixation techniques use a double-row or suture bridge configuration.^4,10,11 However, these techniques can be more technically demanding, require more surgical time, and use an unnecessary number of anchors.

This study evaluated the clinical and radiographic outcomes of patients with displaced GT fractures who were treated with the novel arthroscopic percutaneous inverted mattress fixation of the greater tuberosity (PIG) technique using two knotless anchors. We believe that the optimal fixation of isolated GT fractures can be achieved using this technique.

Materials and methods

We performed a retrospective case series analysis after obtaining approval from the ethics review committee. Between 2011 and 2014, the arthroscopic PIG technique was used to treat isolated GT fractures in 17 consecutive cases. All the patients had GT fractures of the proximal humerus with displacement exceeding 5 mm. The patients with minimal displacement (i.e. <5 mm) were treated conservatively. All fractures were assessed using true anteroposterior views, anteroposterior views in 30° of external rotation, supraspinatus outlet views, and axillary views initially and throughout follow-up. Computed tomography (CT) with three-dimensional (3-D) reconstruction was performed for all patients to assess the exact location and orientation of the fracture fragment. Preoperative assessment using 3-D CT is essential for assessing the location, orientation, amount of displacement, and degree of comminution of the GT fragment before arthroscopic surgery.

Inclusion criteria were patients with isolated GT fractures with displacement exceeding 5 mm, who had been followed up for more than 18 months. Exclusion criteria were large GT fractures that extended to or over the surgical neck of the humerus or severely displaced fragments (>2 cm) and fractures with an associated rotator cuff tear or other fracture of the shoulder. If the fracture fragment was not amenable to arthroscopic fixation owing to its large size or comminution, it was excluded. A single sports-medicine-trained arthroscopic surgeon performed all the surgeries.

Fourteen patients were treated successfully without switching to other methods and had been followed up for a mean of 22 (range: 17–38) months after surgery, including 8 men and 6 women with a mean age of 46.5 (range: 23–72) years. Of these, six patients had falling injuries, four patients were in motor vehicle accidents, and four patients suffered from sports injuries. The mean time interval between the injury and surgery was 5 (range: 1–16) days. The arthroscopic examinations of the included patients revealed two superior labrum anterior and posterior (SLAP) tears, four partial biceps tears, and two anterior labral tears. The patients with associated rotator cuff tears were excluded from this study as the arthroscopic PIG technique is not applicable in these patients.

Radiological assessments were performed successively after the surgery and at the final follow-up and involved measuring the amount of displacement relative to the contralateral shoulder. A true anteroposterior view of both shoulders was obtained to determine the amount of superior or inferior displacement of the GT relative to the humeral head.

At the final follow-up visit, all patients underwent a physical examination including the range of motion (ROM) and completed a questionnaire, a visual analog scale (VAS) score, the Korean shoulder scale (KSS), and the shoulder score of the American Shoulder and Elbow Surgeons (ASES).

Surgical technique

All patients were under general anesthesia during surgery and were placed in the beach-chair position, with longitudinal traction on the affected limb. A standard arthroscopic examination of the intra-articular joint was performed through the posterior portal. Through the anterior portal, blood clots and hemarthrosis were removed and were examined for any additional injuries. The arthroscope was then moved into the subacromial space, and after assessing the intact rotator cuff, debridement and a bursectomy were performed, particularly around the fracture fragment and the adjacent metaphyseal area. Visualization throughout the procedure was improvised and suturing was assisted. The arthroscope was moved back into intra-articular space through the posterior portal and a spinal needle loaded with no. 2 polydioxanone (PDS) (Figure 1) was inserted from 3 to 5 mm lateral to the anterolateral corner of the acromion intra-articularly passing through the bone–tendon junction of the fractured GT fragment (Figure 2). The no. 2 PDS was inserted and subsequently retrieved through the anterior portal. After removing the spinal needle, FiberWire was passed by shuttle relay in a retrograde manner. By placing the spinal needle approximately 2–3 mm from the previously passed suture, the parallel technique was used to create two inverted mattress sutures at the bone–tendon junction of the fractured GT. Then, with the arthroscope in the subacromial space, a lateral portal was made and a cannula of 7 mm diameter was inserted. The arthroscope was moved to the posterolateral portal to better visualize the reduction in the fracture. The sutures were retrieved through the lateral portal. The passed FiberWire sutures were used to reduce the fracture fragment in the subacromial space. After reduction, the FiberWire sutures were fixed using two knotless SwiveLock anchors (Arthrex, Naples, Florida) at least 5 mm below the fracture site to prevent cracking and subsequent extension of the fracture to the anchor site. If the displacement of the GT fragment was considerable, the fragment was reduced to its native position with a probe through the anterior portal while anchor fixation was performed. Depending on the adequacy of the reduction, either both strands or one strand of Fiberwire from each inverted mattress suture were placed in a separate anchor, and the anchors were also placed at least 5 mm apart (Figure 3).

Figure 1.

With the arthroscope in the standard posterior portal, a spinal needle loaded with no. 2 PDS is inserted percutaneously from 3 to 5 mm lateral to the anterolateral corner of the acromion. PDS: polydioxanone.

Figure 2.

(a) The needle is directed intra-articularly passing through the bone–tendon junction of the fractured GT. Two strands of FiberWire are used to make an inverted mattress configuration. (b) The fracture fragments are reduced using the passed FiberWires in the subacromial space and two knotless anchors are used for fixation. The subacromial (c) and intra-articular (d) views of the reduced GT. GT: greater tuberosity.

Figure 3.

Schematic illustration of arthroscopic percutaneous inverted mattress fixation of the greater tuberosity (PIG) reduction and fixation. GT: greater tuberosity.

The amount of compression was assessed by direct visualization and a probe was used to guide fracture reduction. When the quality of reduction was questionable, intraoperative fluoroscopy was used. The final reduction was confirmed from postoperative radiographs (Figure 4).

Figure 4.

Preoperative radiograph (a) and 3-D CT evaluation (b) showing the superiorly displaced GT fracture. The radiographs obtained after arthroscopic PIG fixation showing a well-reduced GT (c, d). 3-D: three-dimensional; CT: computed tomography; GT: greater tuberosity; PIG: percutaneous inverted mattress fixation of the greater tuberosity.

Aftercare

The initial postoperative rehabilitation protocols for these patients were similar to those of patients undergoing arthroscopic rotator cuff repair. For the first 3 weeks postoperatively, the shoulder was supported with an abduction brace. Passive forward flexion was allowed and progressed gradually after 1 week. Three weeks later, the brace was removed, and the patients were allowed to start painless passive ROM exercises. At 6 weeks, active ROM shoulder exercises were performed, especially if it can be tolerated and is without pain. Progressive strengthening exercises and gradual return to sports activities were permitted when fracture healing was evident on the radiographs.

Results

There were no associated rotator cuff tears in any patient. An arthroscopic biceps tenotomy was performed in four elderly patients who showed degenerative fraying or tears of the long head of the biceps tendon. Concomitant SLAP repair was performed in two cases and a Bankart repair was performed in two cases (Table 1).

Table 1.

Demographic data and final clinical results.

Patient no.	Age (years)	Sex	Follow-up period (months)	Displacement of GT on true AP at final follow-up^a	Final follow-up clinical results			Final follow-up ROM (°)			Associated lesion
Patient no.	Age (years)	Sex	Follow-up period (months)	Displacement of GT on true AP at final follow-up^a	ASES	Constant	VAS	FE	ER	IR	Associated lesion
1	60	M	19	−1.5	83	82	1	160	60	T7	None
2	35	M	20	1.7	71.5	76	3	170	40	T12	Bankart
3	25	M	24	0.5	93	98	0	180	70	T5	SLAP tear
4	59	F	23	1.0	86	89	0	180	40	T7	None
5	23	M	18	0	91	92	0	180	70	T7	None
6	45	F	19	0.7	80	79	2	160	60	L3	Biceps tear
7	31	F	19	−1.4	78.5	82	2	170	40	T12	SLAP tear
8	53	M	21	2.1	88.5	94	1	155	40	L3	None
9	72	F	17	−3.5	70.5	72	3	150	30	L-S	Biceps tear
10	58	M	22	0	97	95	0	180	90	T5	Biceps tear
11	65	F	18	2.0	96	98	0	170	70	T7	Biceps tear
12	46	F	19	1.5	93.5	93	0	170	40	T7	None
13	43	M	38	−2.2	87.5	84	1	180	40	T7	None
14	36	M	30	0.5	92	89	1	180	30	T7	Bankart

AP: anteroposterior; ASES: American Shoulder and Elbow Surgeons; VAS: visual analog scale; ROM: range of motion; GT: greater tuberosity; SLAP: superior labrum anterior and posterior; FE: forward elevation; ER: external rotation; IR: internal rotation.

^aAssessment of adequacy of reduction with negative values showing inferior displacement of greater tuberosity compared to contralateral radiograph.

No reduction loss was evident on the radiographs immediately after surgery and at every follow-up for all patients who had successful arthroscopic reduction and fixation of the GT. In all cases, bony union of the GT seen on follow-up radiographs was achieved between 7 and 12 weeks after surgery. Clinically, the mean ASES score improved to 86.9 points (range: 78.3–100) and the KSS improved to 88.6 points (range: 82–100) postoperatively. The mean union time was 10 weeks. At the final follow-up, the mean forward flexion was 167.8° (range: 140–180°), mean external rotation in the neutral position was 36° (range: 20–70°), and mean internal rotation was at the 12th thoracic level (range: T6 to L3).

Three cases were switched to open surgery after the arthroscopic technique was attempted due to an unexpectedly large fragment (male of age 51 and female of age 60) or osteoporosis (female of age 69). The most common complication was mild stiffness (forward elevation < 160°), which was observed in four cases. At the final follow-up, no loosening of the anchors or nonunion was observed. No patients underwent surgery for complications such as impingement or stiffness (Table 1).

Discussion

This study showed that successful arthroscopic fixation of selected GT fractures can be achieved using the PIG technique. The fractured fragment could be reduced securely without using any medial anchors or tying; optimal reduction and fixation were obtained with two inverted mattress sutures and two knotless anchors distal to the fracture site.

Fractures of the GT have been described as a subclass of proximal humeral fractures or as an injury resulting from the anterior dislocation of the shoulder joint.^12,13 These are commonly described as an avulsion fracture resulting from the traction force of the rotator cuff tendon. Healing of a GT fracture in slight displacement may cause disability, altering the point of the attachment of the rotator cuff. Some authors recommend that displacement greater than 5 mm should be reduced surgically.^14,15

Cannulated screws are used most commonly for surgery in GT fractures.⁸ However, the screws cannot engage in small fracture fragments and may lead to further comminution or migration and are therefore not suitable for fixing the osteoporotic bone. In addition, the prominent hardware may impinge against the acromion when placed in the subtle GT area.

It has been hypothesized that the intact rotator cuff acts as a distracting force placing tension on the fractured fragment of GT, and the sutures placed around the tendon–bone junction act as anchors across the fracture site, thereby reducing it, and may behave in a manner similar to the “tension band” principle.^16,17 Placing sutures on the “tension side” of the fracture may counterbalance the distraction and the tension forces may be converted into compression forces. An intact “compression” cortex (no comminution) and intact rotator cuff may be the prerequisites for this principle to work. Further biomechanical validation of this hypothesis is required in the future.

The technique used in this study is very similar to the biceps soft tissue tenodesis procedure described by Sekiya et al.¹⁸ which is called the percutaneous intra-articular transtendon technique. It involves placing a spinal needle from the anterior aspect of the shoulder intra-articularly through the transverse ligament piercing the biceps tendon. The main procedure requires an intra-articular view, while shuttle relaying the sutures extra-articulary and precisely inserting sutures, which is comparable to our arthroscopic PIG technique.

Reported arthroscopic techniques for GT reduction and fixation are usually analogous to the techniques that have been used for rotator cuff repair.^4,10,11,19 However, applying medial row fixation may injure the intact rotator cuff and may also detach periosteal tissues that may be helpful when reducing the fragment. Unnecessary placement of anchors and subsequent manipulation of the rotator cuff can be avoided using our technique in appropriate cases of GT fracture. In our opinion, the optimal time for arthroscopic surgery for GT fracture is 2–3 days after injury when the active bleeding from the fracture site has subsided. Prolonging the time of surgery to more than 2 weeks is not recommended because the fractures were difficult to reduce arthroscopically in some delayed cases.

There were some limitations to our study. First, a small number of patients were enrolled and there was no control group in whom conventional screw fixation or open fixation could be performed. Second, the levels of adequacy of reduction and the rotator cuff were not assessed using postoperative magnetic resonance imaging or CT. We used only simple radiographs to assess the reduction postoperatively. Third, there were no biomechanical research to substantiate our novel fixation method. Future studies to validate our technique are mandated.

Conclusion

The arthroscopic PIG fracture is a simple, reproducible technique in selected cases and gives encouraging early results.

Footnotes

Author’s note

Research was performed at Seoul Paik Hospital, Inje University.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Suk-Hwan Jang

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Arthroscopic percutaneous inverted mattress suture fixation of isolated greater tuberosity fracture of humerus