REPAIRING SHOULDER FRACTURES AND TEARS
| PERCUTANEOUS REDUCTION AND FIXATION OF PROXIMAL HUMERUS FRACTURES —Evan L. Flatow,
MD, Lasker Professor and Chair, Department of Orthopaedic Surgery, Mount Sinai School of Medicine, New
York, NY
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| Percutaneous pins for fractures: used within past decade for valgus impacted 4-part fracture and some 3-part
fractures; ideal indication 2-part fracture in good bone; does not work well when bone loss present; especially
good for impacted valgus fractures; avascular necrosis better tolerated when reduction anatomic
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 | Two-part surgical neck fracture: almost any device works; complex cases require more versatility (plate option)
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| Impacted valgus fracture: position of tuberosities almost normal; head knocked down; after hitting head up, almost
stable even before pins placed
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| Split-head fracture: not ideal for percutaneous fixation; rotation may be difficult
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| Classic 4-part fracture: head in axilla, with nothing attached, several inches from tuberosity; not good indication for
percutaneous fixation; percutaneous pins option
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| Technique: room setup important; bring image in from top or side of table; use portals, as with arthroscopy (portal
should be available at fracture level; use for manipulating tuberosities, head, and neck); remember retroversion
of humerus (ultimate goal restoration); measuring distance in head diameters good general rule; avoid arteries;
on axillary computed tomography (CT), 4-part impacted valgus fracture with medial hinge and head pointing up
may be mistaken for minimally displaced fracture; nonoperative treatment “terrible terrible tragedy”; CT
projects side of round head down on glenoid, when almost none of articular surface actually near glenoid; restore
by knocking head up; bear retroversion in mind; place elevator anterolaterally to restore retroversion (otherwise,
may create iatrogenic lesser tuberosity head overlap), then pin neck; reduce tuberosities and place cannulated
pins; avoid over-reducing greater tuberosity; reduction of lesser tuberosity more difficult, and less necessary if
retroversion restored, but if left displaced, may block internal rotation and cause stiffness if head fragment remains
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| Three-part fractures: challenging, due to head rotation with intact lesser tuberosity; comminution often present;
percutaneous reduction possible, but plate fixation better option for most patients; split-head fracture also challenging;
percutaneous reduction not recommended in routine practice
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| Pearls: have tools easily available; if head penetrated, make new track to avoid future penetration; always cut pins
below skin to prevent infection; always use soft tissue protector; use hand turner for last few turns to anticipate
subchondral plate; 2 pins usually sufficient for low-impact injuries; 3 to 5 pins may be necessary for unstable
high-impact fractures; obtain axillary view; joystick in head permits greater control (not always necessary); percutaneous
pins yield reliable reproducible results, without undue stiffness; avascular necrosis may occur several
years out
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| PROXIMAL HUMERUS FRACTURES: HEMI- VS INVERSE ARTHROPLASTY —Jon J.P. Warner, MD, Professor,
Department of Orthopaedics, Harvard Medical School, and Chief, Harvard Shoulder Service, Massachusetts
General Hospital, Boston
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| Preoperative planning: essential for measuring restoration length and knowing height at which to place prosthesis;
knowledge of tuberosity offset, head size, and version also critical; top of pectoralis to top of humeral head always
5.4 cm ±0.3 cm, regardless of patient size; use as guide for restoring head to proper position; fix tuberosities
in circular fashion to lock them around prosthesis; new component designs permit highly accurate placement of tuberosities;
lesser and greater tuberosities perpendicular to each other; maintain angle when placing; candidates for
reverse inverse prostheses relatively few
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| Technique: fix tuberosities securely and place bone graft adequately; bone quality deteriorates with age; repair tuberosities
and posterior cuff when using reverse prosthesis to reestablish integrity of posterior cuff; reverse prosthesis
particularly indicated when patient poor candidate for hemiarthroplasty
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| Outcomes: published studies small and associated with high rates of complications; experience essential to good results
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| Speaker’s current approach: reconstruct anatomically; allow tuberosity to heal; important to use modular stem
from inverse prosthesis (in case of failure, can remove proximal component immediately and switch to inverse
prosthesis; spares patient future morbidity)
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| EVALUATION OF PULLEY LESIONS, BICEPS INSTABILITY, AND CUFF INTERVAL PROBLEMS —
Jeffrey S. Abrams, MD, Clinical Associate Professor, Seton Hall University School of Graduate Medical Education,
Medical Director, Princeton Orthopaedic and Rehabilitation Associates, and Attending Surgeon, University Medical
Center at Princeton, NJ
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| Pulley lesions: sometimes called “hidden” lesions (not always detected on open surgery for articular-side partial-
thickness tear; hidden by intact portion of rotator cuff); may be associated with biceps instability and rotator cuff
problems; patients often left with persistent pain and decreased likelihood of accurate diagnosis, treatment, and
successful healing
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| Biceps pulley: lateral—capsular portion of supraspinatus undersurface; medial—combination of superior glenohumoral
ligament and deep fibers of coracohumeral ligament reflecting on top of subscapularis tendon; capsular tissue
rarely tears without associated tear in adjacent tendon; roof disruption due to tear in coracohumeral ligament
or supraspinatus may result in biceps subluxation superficial to subscapularis, obscuring view of torn pulley
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| Mechanisms of biceps instability: most tears begin at anterior margin of supraspinatus; tear usually runs anteriorly
to posteriorly off tuberosity before it begins to dilate; tear occasionally extends anteriorly to superior border of
subscapularis, dissecting biceps between humeral head and subscapularis; stitching subscapularis will not help
because biceps block view of pulley
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| Tear patterns in rotator cuffs: tears, including subscapularis and supraspinatus, associated with damage to ≈40% of biceps;
abrasions of humeral head associated with biceps instability; posterior approach provides view of subscapularis
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| Clinical presentation: shoulder pain; clicking sensation in shoulder, except when arm at side (placing arm in
throwing position reproduces biceps subluxation); magnetic resonance imaging (MRI) with gadolinium sometimes
helpful, especially if biceps out of groove, with visible disruption of subscapularis; however, MRI and CT sometimes
misleading because middle cuts through humeral head keep biceps in groove; instability more apparent with
more superior cuts; patient also may keep arm by side in scanner; CT arthrography and MRI workable, but should
not be sole method of diagnosis; movement of damaged biceps tendon not detected during open surgery but apparent
on arthroscopy if arm taken out of traction and humerus rotated; biceps usually subluxes under subscapularis or
superior border
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| Treatment: when biceps well out of groove, choices either tenotomy or tenodesis
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| Tenodesis: partial-thickness tear—consider soft-tissue procedure (suture anterior margin of supraspinatus or interval
through biceps tendon; divide at superior glenoid; tie under direct visualization in subacromial space); full-
thickness tear—place stay suture in biceps tendon to prevent retraction down arm; incorporate biceps tendon
into rotator cuff repair, with biceps extending to posterior quadrant of repair to avoid pulling on suscapularis,
which may place traction on repair; repair pulley if patient too young for rotator cuff repair; after cuff repair, patient
requires sling for ≈3 wk; recovery slower after pulley repair (sling for 6 wk); start pendulum exercises early;
limit external rotation based on needs of subscapularis repair (limit to 0° external rotation for first 4-6 wk); introduce
strengthening exercises and physical activities slowly; younger patients should wait 4 mo before returning
to sports
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| Conclusion: pulley lesions usually associated with rotator cuff tears, even if not immediately apparent; keep debriding
tissue until cuff tear found; biceps often difficult to stabilize; tenodesis or tenotomy most reliable procedures
for virtually all patients; consider pulley repairs in very young patients
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| TRIANGLE DOUBLE-ROW CUFF REPAIR —Sumant G. Krishnan, MD, Clinical Assistant Professor, University
of Texas Southwestern Medical Center, and Attending Orthopaedic Surgeon, Shoulder and Elbow Service, W.B. Carrell
Memorial Clinic, Dallas, TX
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| Background: goal to restore full cuff integrity, not just function; to date, technique performed on >1200 repairs
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| Basic principle of triangle repair: place one anchor medially for every 2 anchors placed laterally
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| Technique: medial anchors placed just off margin of greater tuberosity; lateral anchors placed off face of greater tuberosity,
in area that allows for tensioning footprint of lateral rotator cuff back to bone; with anchors placed, sutures
passed medially; goal point-to-point fixation of rotator cuff, providing sufficient compression to allow
tendon to heal to bone; modified beach-chair position used (“dinner-chair” position, with acromion parallel to
floor); use posterior viewing portal at slightly higher than standard position; anterolateral portal 2 cm off anterolateral
corner of acromion at junction of anterior and middle raphe of deltoid; coracohumeral ligament released
from acromion; any bony excrescences on acromion removed (area flattened); arthroscope then moved to anterolateral
portal, bursectomy begun, and rotator cuff evaluated; portal placed between middle and posterior thirds of
cuff to provide same view as that obtained in open surgery with arm rotation; cuff requires juxtaglenoid mobilization
off capsule and superior surface mobilization off scapular spine and coracohumeral ligament; preparation
of bony bed; restoration of tendon to tendon (use classic McLaughlin repair) before restoring tendon to bone;
technique requires only 5.5-mm cannula sewn into place to eliminate need for holding during surgery; surgeon
needs only one assistant; during margin conversions repair, replace tendon anatomically by driving sliding knot
down, restoring tendon to normal length
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| Anchors: place medial anchors through anterior portal, by extending and internally rotating arm, as in open surgery;
retrieve sutures, and pass at musculotendon junction; important to repair all cuff laminations for complete
integrity; lateral suture anchors placed through anterolateral portal just off tuberosity tip; anchor inserter left in
place (guides sutures to surgeon); retrograde retrieval device used to retrieve sutures; place medial sutures in
mattress fashion, lateral sutures in simple fashion; all sutures and anchors placed before tying; with posterior-superior
cuff repair, stitch from posterior to anterior; after restoring tendon to bone, retrieve sutures from same anchor;
tie from posterior to anterior for posterior-superior cuff repair; keeping other sutures under tension (clipped
to drape) can reduce tension while reducing cuff to bone; tie 3 half-hitches in one direction, followed by 3 alternating
half-hitches; after lateral row repair restored, attach medial sutures; entire footprint then restored
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| Evidence-based support for triangle double-row repair: in cuff tears <5 cm, degree of MRI integrity 93% to 95%;
biomechanical strength superior to that achieved with single-row repair; also superior for decreased motion to
prevent initial gap formation, footprint restoration, and biologic healing
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| NATURAL HISTORY OF CUFF DISEASE: WHEN TO OPERATE —Dr. Flatow
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| Fate of shoulders in elderly patients with large rotator cuff tears
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| If not repaired: many painless; affected arm may be weaker, but patient adjusts; not symptomatic in classic sense;
in study of natural history of asymptomatic longitudinal tears, Yamaguchi found that 50% of tears symptomatic
within 3 yr; in one cohort, ≈50% of tears progressed and none healed; tears often progressed to severe atrophy,
with loss of tendon substance
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| If repaired: success rate (with variable strength and function, depending on degree of muscle atrophy) ≈85% in
most series; overall, function better when tendon repaired; in study by speaker and colleagues sponsored by International
Center for Health Outcomes and Innovation Research, repair associated with good return of function,
resolution of pain, and improved quality of life comparable to results obtained with total hip and knee replacements;
good cost-effectiveness; face validity—determines whether repair works as intended; cuff integrity not as
good as expected; risk for reinjury high; evidence suggests that atrophy and fatty infiltration stop when tendon
repaired and progress if tendon re-tears
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| Interpretation of data: from natural history combined with expected results of repair, Yamaguchi identified 3
groups of patients; group 1—intact cuffs or those with partial thickness or small full-thickness tears may not require
surgery (no harm in delaying surgery; chances of success with nonoperative treatment high); group 2—patients
younger, have small- to medium-sized tears or acute tears of any size, and candidates for early surgery
(results predictable; atrophy may progress while waiting); group 3—elderly patients; those with irreversible
change; presence of large chronic tears; chronic superior migration; nonoperative treatment recommended
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| Conclusion: tears often asymptomatic; usually do not heal; often progress, and become symptomatic and harder to
treat; cuff repair cost-effective, and despite risk of re-tearing, leads to better function and strength; atrophy and
fatty infiltration difficult to reverse, but may be slowed with repair
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| Indication for repair: pain; otherwise, nonoperative treatment possible as long as some muscle remains, with head
centered (except after recent trauma), and patient can comply with rehabilitation
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Suggested Reading
Beaudreuil J et al: Natural history or outcome with conservative treatment of degenerative rotator cuff tears. Joint
Bone Spine 74:527, 2007; Dimakopoulos P et al: Transosseous suture fixation of proximal humeral fractures. J
Bone Joint Surg Am 89:1700, 2007; Doornberg JN et al: Surgical treatment of intra-articular fractures of the distal
part of the humerus. Functional outcome after twelve to thirty years. J Bone Joint Surg Am 89:1524, 2007; Gladstone
JN et al: Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate
with poor functional outcome. Am J Sports Med 35:719, 2007; Iannotti JP et al: Nonprosthetic management of
proximal humeral fractures. J Bone Joint Surg Am 85-A:1578, 2003; Ji JHet al: Arthroscopic double-row suture anchor
fixation of minimally displaced greater tuberosity fractures. Arthroscopy 23:1133, 2007; Lafosse L et al: The
outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique.
J Bone Joint Surg Am 89:1533, 2007; Matsen FA et al: The reverse total shoulder arthroplasty. J Bone Joint
Surg Am 88-A:660, 2006; Milano G et al: Comparison between single-row and double-row rotator cuff repair: a
biomechanical study. Knee Surg Sports Traumatol Arthrosc 16:75, 2008; Robinson CM et al: Complex posterior
fracture-dislocation of the shoulder. Epidemiology, injury patterns, and results of operative treatment. J Bone Joint
Surg Am 89:1454, 2007; Sachs RA et al: Can the need for future surgery for acute traumatic anterior shoulder dislocation
be predicted? J Bone Joint Surg Am 89:1665, 2007; Vitale MA et al: Rotator cuff repair: an analysis of
utility scores and cost-effectiveness. J Shoulder Elbow Surg 16:181, 2007.
Educational Objectives
| The goal of this program is to improve management of humerus fractures and rotator cuff injuries. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Identify the indications for percutaneous fixation of humerus fractures.
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| 2. Choose hemi- or inverse arthroplasty to repair a humerus fracture.
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| 3. Manage pulley lesions appropriately for the patient’s age.
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| 4. State the goals and the reasoning behind the triangle double-row repair of torn rotator cuffs.
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| 5. Describe the natural history of a torn rotator cuff with and without surgery.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, the following has been disclosed:
Dr. Flatow—royalties and financial support from Zimmer; Dr. Warner—royalties from Zimmer; Dr. Abrams—
consultant and royalties from Conmed Linvatec, consultant for and stock in Arthrocare Medical, and consultant for
Wright Medical; Dr. Krishnan—consultant for and research and institutional support from Tornier and DepuyMitek.
The planning committee reported nothing to disclose.
Acknowledgments
Drs. Flatow, Warner, Abrams, and Krishnan were recorded at Arthroscopy, Arthroplasty, Fractures, held June 20-23,
2007, in San Diego, CA, and sponsored by San Diego Shoulder Institute. The Audio-Digest Foundation thanks the
speakers and the sponsor for their cooperation in the production of this program.
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