Aims. This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA). Methods. This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA. Results. The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001). Conclusion. This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation. Cite this article: Bone Jt Open 2024;5(10):929–936

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

Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

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

Rotator cuff repair has excellent clinical outcomes but continues to be a challenge when it comes to large and massive tears as well as revision procedures. Reported symptomatic retear rates are still too high to be acceptable. The purpose of the present study was to evaluate the effectiveness of a combination of augmentation techniques consisting of microfractures of the greater tuberosity, extracellular matrix (ECM) patch graft and subsequent platelet concentrate (PC) subacromial injections in revision rotator cuff repair. The study was designed as a retrospective comparative study on prospectively collected data from a consecutive cohort of patients. All patients who underwent arthroscopic revision rotator cuff repair for symptomatic failure of previous posterosuperior rotator cuff repair were considered eligible for the study. Symptomatic failure had been diagnosed according to clinical examination and confirmed by magnetic resonance imaging (MRI). Structural integrity had been assessed on MRI and classified according to Sugaya classification. Only patients affected by stage IV-V were considered eligible. Tear reparability was confirmed during arthroscopy. Only patients with a minimum 2 years follow-up were included. Patients were divided in two groups. In group 1 (control group) a standard arthroscopic revision and microfractures of the greater tuberosity were performed; in group 2 (experimental group), microfractures of the greater tuberosity and a ECM patch graft were used to enhance tendon repair, followed by postoperative PC injections. Minimum follow-up was 12 months. Primary outcome was the Constant-Murley score (CMS) normalized for age and gender. Subjective outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score in its short version (Quick-DASH). Tendon integrity was assessed with MRI at 6 months after surgery. Comparison between groups for all discrete variables at baseline and at follow-up was carried out with the Student's t-test for normally distributed data, otherwise Mann-Whitney U-test was used. Within-group differences (baseline vs follow-up) for discrete variables were analyzed by paired t-test, or by Wilcoxon signed-rank test in case of data with non-normal distribution. Differences for categorical variables were assessed by chi-squared test. Significance was considered for p values < 0.05. Forty patients were included in the study (20 patients for each group). The mean follow-up was 13 ± 1.6 months. No patients were lost at the follow up. Comparison between groups did not show significant differences for baseline characteristics. At follow-up, mean CMS was 80.7 ± 16.6 points in group 1 and 91.5 ± 11.5 points in group 2 (p= 0.022). Mean DASH score was 28.6 ± 21.6 points in group 1 and 20.1 ± 17.4 points in group 2 (p= 0.178). Post-operative MRI showed 6 healed shoulders in Group 1 and 16 healed shoulders in Group 2 (p<0.004). No postoperative complications were reported in both groups. The combination of microfractures of the greater tuberosity, ECM patch graft, and subsequent PC subacromial injections is an effective strategy in improving tendon healing rate

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

Recent studies on animal models focused on the effect of preserving tendon remnant of rotator cuff on tendon healing. A positive effect by combining tendon remnant preservation and small bone vents on the greater tuberosity in comparison with standard tendon-to-bone repair has been shown. The purpose of the present clinical study was to evaluate the efficacy of biologic augmentation of arthroscopic rotator cuff repair by maintaining tendon remnant on rotator cuff footprint combined with small bone vents of the greater tuberosity. A retrospective study was conducted. All patients who underwent arthroscopic rotator cuff repair associated with small bone vents (nanofractures) and tendon footprint preservation were considered eligible for the study. Inclusion criteria were: diagnosis of full-thickness rotator cuff tear as diagnosed at preoperative magnetic resonance imaging (MRI) and confirmed at the time of surgery; minimum 24-month of follow-up and availability of post-operative MRI performed not earlier than 6 months after surgery. Exclusion criteria were: partial thickness tears, irreparable tears, capsulo-labral pathologies, calcific tendonitis, gleno-humeral osteoarthritis and/or previous surgery. Primary outcome was the ASES score. Secondary outcomes were: Quick-DASH and WORC scores, and structural integrity of repaired tendons by magnetic resonance imaging (MRI) performed six months after surgery. A paired t-test was used to compare pre- and postoperative clinical outcomes. Subgroup analysis was performed according to tear size. Significance was set at p < 0.05. The study included 29 patients (M:F = 15:14). Mean age (+ SD) of patients was 61.7 + 8.9 years. Mean follow-up was 27.4 ± 2.3 months. Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Subgroup analysis for tear size showed significant differences in the QuickDASH score (0.04). Particularly, a significant difference in the QuickDASH score could be detected between medium and large tears (p=0.008) as well as medium and massive lesions (p=0.04). No differences could be detected between large and massive tears (p= 0.35). Postoperative imaging showed healed tendons in 21 out of 29 (72%) cases. Preservation of tendon remnant combined with small bone vents in the repair of medium-to-massive full-thickness rotator cuff tears provided significant improvement in clinical outcome compared to baseline conditions with complete structural integrity in 72% of the cases

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

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

This study aims to investigate the mechanical properties of a rotator cuff tear repaired with a polypropylene interposition graft in an ovine infraspinatus ex-vivo model. Twenty fresh shoulders from skeletally mature sheep were used in this study. A tear size of 20 mm from the tendon joint was created in the infraspinatus tendon to simulate a large tear in fifteen specimens. This was repaired with a polypropylene mesh used as an interposition graft between the ends of the tendon. Eight specimens were secured with mattress stitches while seven were secured to the remnant tendon on the greater tuberosity side by continuous stitching. Remaining five specimens with an intact tendon served as a control group. All specimens underwent cyclic loading with a universal testing machine to determine the ultimate failure load and gap distance. Gap distance increased with progressive cyclic loading through 3000 cycles for all repaired specimens. Mean gap distance after 3000 cycles for both continuous and mattress groups are 1.7 mm and 4.2 mm respectively (P = .001). Significantly higher mean ultimate failure load was also observed with 549.2 N in the continuous group, 426.6 N in the mattress group and 370 N in the intact group. The use of a polypropylene mesh as an interposition graft for large irreparable rotator cuff tears is biomechanically suitable and results in a robust repair that is comparable to an intact rotator cuff tendon. When paired with a continuous suturing technique, it demonstrates significantly resultant superior biomechanical properties that may potentially reduce re-tear rates after repairing large or massive rotator cuff tears

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

Introduction: The goal of this study is to report the clinical and radiographic results of 2 types of implants used to treat 3 and 4 parts fractures of the proximal humerus. Patients: Sixty-three patients (64 shoulders) were reviewed in this retrospective series. Forty women and 23 men were included, the mean age was 64 ± 12 (39–86). A group of 31 patients was managed with a ‘standard’ implant, a second group of 32 patients (33 shoulders) was managed with a ‘fracture’ implant. The delay between initial trauma and the surgical procedure was less than 4 weeks (1–30 days) for all patients. Methods: All the procedures were carried out by a senior surgeon. The patients were reviewed by an independent observer with a mean follow-up of 59 ± 38 months (12–138) for a clinical and radiographic evaluation. Results: In the ‘standard implant’ group; 84% of the patients were satisfied or very satisfied regarding the outcome of surgery. The subjective evaluation (SSV score) was 69% (30–100%). The active anterior elevation (AAE) was 117° ± 43° (30–180°), the active external rotation (AER) was 24° ± 20° (0–60°), the active internal rotation (AIR) was up to the T12 vertebra (buttocks-T8). The mean Constant score was 60 ± 20 points (24–95). The radiographic analysis revealed a greater tuberosity that was considered migrated, not healed or lysed in 65% of cases. The acromion – implant height was ≤ 7mm in 52% of the patients. In the ‘fracture implant’ group; all the patients were satisfied or very satisfied regarding the outcome of the surgery. The SSV score was 70% (20–100%). The AAE was 132° ± 36° (45–180°), the AER was 34° ± 16° (0–60°), the AIR was up to the L3 vertebra (buttocks-T8). The mean Constant score was 66 ± 16 points (33–95). The radiographic analysis revealed a greater tuberosity that was considered migrated, not healed or lysed in 33% of cases. The acromion – implant height was ≤ 7mm in 30% of the patients. The patients with a healed greater tuberosity in an adequate position had better Constant scores: 71 points versus 54 points for those with a greater tuberosity not healed/lysed or in a bad position (p=0.03). A healed greater tuberosity in an adequate position was obtained more constantly for the patients in the ‘fracture implant’ group (p=0.02). Conclusion: A healed greater tuberosity in an adequate position is a significant parameter influencing the outcome of hemiarthroplasty for proximal humerus fractures. A fracture designed implant allows better greater tuberosity positioning and healing

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

Objective: Analysis of the influence in shoulder function of restoring total humeral length (THL) in proximal humeral fractures (PHF) treated with hemiarthroplasty and comparing the data with a control group of proximal fractures treated with osteosynthesis. Material and method: Prospective study involving 56 patients, twenty-nine 2 and 3 part PHF treated with osteosynthesis and twenty-seven 3 and 4 part fractures treated with hemiarthroplasty. Clinical assessment through Constant Score and radiological exam of the THL of both humerus as well as CT scans to analyze position of the tuberosities at 1-year follow-up. Results: Osteosynthesis group: mean Constant Score of 77.37. In all cases greater tuberosity consolidated in good position. When differences in THL were higher than 2 cm Constant Score values significatively decreased to mean of 67, when ranging from 0 to 2 cm did not differ significatively from mean Constant Score. Hemiarthroplasty group: mean Constant Score of 55.76. In 5 cases THL was increased (mean 0.87 cm) with a mean Constant Score of 63.5 and among them the greater tuberosity consolidated in place in 3 cases and posteriorly in 2. In 20 cases THL was decreased (mean 1.03 cm) with a mean Constant Score of 54.25 and among them if the difference was minor than 1 cm the greater tuberosity consolidated in place in 3 cases, consolidated posteriorly in 4 and absent in 1 case, and if the difference was greater than 1 cm, the greater tuberosity consolidated in place in 4 cases, consolidated posteriorly in 6 and absent in 2 cases . In 2 cases no differences in THL. Conclusions: In PHF treated either with osteosynthesis or hemiarthroplasty, the greater tuberosity can be properly reattached if THL differences are less than 2 cm. Constant Score correlates with greater tuberosity position at any difference of THL less than 2 cm

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. Methods. A retrospective analysis of isolated greater tuberosity fractures presenting to a shoulder fracture clinic over 1 year was performed. Patients were identified from shoulder fracture clinic lists and a bluespier database. Radiological fracture displacement was measured from the edge of the defect in the humeral head to the closest edge of the greater tuberosity. All measurements were performed by three oberservers on two occasions. Data was analysed to study the relationship between initial displacement and fracture stability and between concurrent dislocation and fracture stability. Inter-observer analysis was performed. Results. 64 (m:32; f:32; mean age 53) patients were identified. 37 were displaced 0–5 mm at presentation, 18 were displaced 5–10 mm, 9 were displaced >10 mm. Of those displaced less than 5 mm on presentation, 22% (n8) further displaced to greater than 5 mm and 5% (n2) to >10 mm at follow-up. Of those displaced 5–10 mm on presentation, 17% (n3) displaced to >10 mm. 42% (n27) of fractures were associated with dislocation; they had greater displacement at presentation. In the 0–5 mm displacement group that displaced >5 mm, 88% (n7) had concurrent dislocation. Inter-observer analysis of the x-ray measurement showed moderate agreement (0.684). Conclusion. Isolated greater tuberosity fractures displaced less than 5 mm at presentation and that are not associated with dislocation are stable. Concurrent dislocation is associated with both greater fracture displacement at presentation and ongoing fracture instability

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

Objective: To evaluate the functional outcome of the shoulder following Neer reconstruction with a conservative rehabilitation regime. Background data: Fractures of the proximal humerus following major or minor trauma are very common. The management of 3 and 4 part fractures of the shoulder with or without dislocation presents a challenging problem to the Orthopaedic Surgeon. Neer reconstruction remains a gold-standard operation. Standard rehabilitation regime is early mobilization to prevent the development of stiffness of the shoulder. However, an aggressive early rehabilitation may lead to non-healing of the greater tuberosity. Methods: Between Dec 96 to Jun 03, 40 patients with three or four part fracture of shoulder underwent Neer reconstruction and a conservative rehabilitation regime at our centre (age range of 39–87 with a mean of 66). Patients were kept in a sling for 3 – 4 weeks before physiotherapy was commenced. They were reviewed at least 1 year postoperatively for assessment of pain and range of movement. X-Rays were taken to investigate union of the greater tuberosity. For the purpose of this study all patients were recalled and reassessed with Constant-Murley scoring system. Results: Three patients died after the one year review, one patient lost to follow up. In 12.8% of the patients (mainly elderly, with mean age of 78.8) the greater tuberosity failed to heal. In those who the greater tuberosity healed mean elevation was more than 130, and mean external rotation was 40. Conclusion: Postoperative immobilization did not result in excessive stiffness and excellent functional results were achieved, especially in those younger than 70 years of age. However tuberosity union could not be guarantied in very old patients

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