[Bilateral posterior shoulder dislocation with associated reverse Hill-Sachs lesions after electrical injury].

After workers suffer electric shock, the ankylosis and contraction of muscle groups around the shoulder joint are more likely to lead to posterior dislocation and fracture, of which 80% are complicated with reverse Hill-Sachs injury of humeral head. This paper reports a case of bilateral posterior dislocation of shoulder joint combined with Hill-Sachs injury caused by electric shock in the Department of Orthopedics, Affiliated Huzhou Hospital, Zhejiang University School of Medicine in August 2020. The diagnosis of left posterior shoulder dislocation was clear, and the diagnosis of right posterior shoulder dislocation was missed. The patient successfully reconstructed the stability of the shoulder joint by actively performing shoulder arthroscopic surgery to repair the joint capsule. After 6 months of follow-up, there was no further dislocation and the function was good.

Atypical biceps-related complication of proximal humerus fracture leading to internal shoulder impingement due to tendon stump dislocation.

Non-displaced proximal humerus fractures are usually managed non-operatively despite of minor malalignment. Biceps tendon rupture due to attrition after malunion is rare around the proximal humerus. Rupture of the long head of biceps (LHB) tendon usually occurs inside the joint close to the origin at the labrum. Treatment is usually non-operative with good outcomes. We report a rare case of a 48-year-old female patient with persistent locking and internal impingement 8 months after a proximal humerus fracture with anterior angulation leading to extra-articular reversed LHB tendon rupture with intra-articular dislocation of the proximal stump. Interposition of the tendon (3.5 cm) between the glenoid and the humeral head was confirmed on MRI arthrogram. Arthroscopic proximal tenotomy and stump removal resulted in immediate relief with improved function (subjective shoulder value 95%; Constant Score: 96). False interpretation of symptoms as posttraumatic stiffness should be avoided by a thorough examination and complementary MRI arthrogram investigation.

Subtraction osteotomy of the humeral head in posterior shoulder dislocation: a case report.

Locked posterior dislocations of the shoulder with an impacted fracture of the humeral head and an articular surface defect greater than 35-40% are generally treated with a femoral head bone graft or prosthesis. We present a case in which a subtraction osteotomy with osteoclasia on the impacted zone was performed to try to make the articular surface of the humeral head congruent and continuous. With a 42-month follow-up, the clinical outcome, in terms of mobility and pain, was very good; X-rays show there was no avascular necrosis of the humeral head nor signs of articular arthrosis. The aim of this work is to present a detailed description of our procedure, which can be a therapeutic option for this type of pathology.

Complex humeral head fractures treated with blocked threaded wires: maintenance of the reduction and clinical results with two different fixation constructs.

BACKGROUND: Locking plates are the gold standard for treatment of 3-part humeral head fractures, although major complications range from 9% to 36%. Percutaneous techniques may allow vascular supply preservation, maintenance of fracture hematoma, scarce blood loss. Many configurations with Kirschner wires can be performed, generating confusion on result interpretation. We studied the correlation between system configuration, stability, and clinical results in patients with 3-part humeral head fractures treated with the same fixation system but with 2 different biomechanical constructs. MATERIALS AND METHODS: There were 52 consecutive patients (19 men, 33 women; mean age, 63.1 [standard deviation, 5.6] years; range, 48-82 years) with Hertel 7 humeral head fractures. Two fixation constructs composed of 3 couples (construct A) or 4 couples (construct B) of blocked threaded wires were used in 17 and 35 patients, respectively. At the final follow-up, the individual relative Constant Score (irCS) and visual analog scale were measured. Radiographic evaluation according to the Bahr criteria was performed. Statistical analysis was performed. RESULTS: The mean follow-up was 22 months. The mean irCS at the final follow-up was 89.7%. The mean irCS in patients treated with construct A and construct B was 86% and 93%, respectively (P = .043). One nonunion and 2 superficial infections occurred (6%). The postoperative reduction was excellent in 97% of patients and remained excellent in 89%. The mean postoperative neck shaft angle was 135.0° (construct A: 134.7°; construct B: 135.1°), and the final neck shaft angle was 132.9° (construct A: 131.3°; construct B: 133.8°; P = .047). CONCLUSIONS: The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. Results of percutaneous fixation depend on the biomechanical construct.

A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory.

BACKGROUND: This study regards a volumetric analysis of proximal humeral fractures. The main purpose was to investigate the head displacement in relation to the shaft and its link to volume reductions ("bone loss") of the anatomic segments interposed between the head and the shaft: the tuberosities and the calcar. We call this area "control volume." METHODS: In 20 fractures, we used 3-dimensional virtual reconstruction to create a reference system that divides geometrically the control volume and allows the evaluation of displacement angles of the humeral head. We calculated the volumetric reduction of control volume segments for each fracture through a specific mathematical protocol. RESULTS: The measurement of the head displacement angles in 20 fractures led to following results: in the coronal plane, 10 varus, 6 valgus, 4 neutral; in the sagittal plane, 6 anterior tilt, 9 posterior tilt, 5 neutral position. There was a reduction of control volume in 19 of 20 fractures. Only in 1 fracture was the control volume intact and the fracture was nonimpacted. In 19 impacted fractures, the volume reduction was variable (4% minimum loss, 98% maximum loss). In head varus position, loss was greater in the medial area than in the lateral area. There was generally a clear correspondence between the positions assumed by the head and the volumetric losses of the respective control volume segments. CONCLUSIONS: The control volume is an important anatomic and functional area of the proximal humerus. A morphovolumetric 3-dimensional approach improves knowledge about pathomorphology of proximal humeral fractures.

Humeral head inferior subluxation in proximal humerus fractures.

PURPOSE: The objectives of this study are to propose a reliable radiologic method for detecting static inferior subluxation of humeral head, to calculate the relative intra- and inter-observer reliability, and to evaluate its presence pre- and post-surgery. METHODS: This is a retrospective observational study of patients surgically treated for a fracture of the proximal humerus. Fractures were classified using Codman-Lego criteria (radiographic, CT images), osteoporosis was assessed. To identify inferior subluxation, an original method is proposed. This measurement was done pre-operatively, at three and 12 month post-operatively. Clinical evaluation was recorded at final follow-up using Constant Score. RESULTS: One hundred fifty fractures surgically treated were studied. Intra- and inter-observer reliabilities were excellent and high, respectively. In pre-operative x-rays, a significant inferior subluxation was noted in 17/150 cases (11.3%), with significant correlation with fracture pattern (p=0.045), female sex (p=0.038), age older than 70 (p=0.003), obesity (BMI>30, p=0.03), and local osteoporosis (p=0.002). At three month of follow-up, 22 cases (14.6%) had inferior subluxation, with significant correlation with female sex (p=0.04), age older than 70 (p=0.002), obesity (p=0.02), pin or screw articular surface perforation (p<0.001). At 12 month of follow-up, seven cases showed persistent inferior subluxation, with significant correlation with age older than 70 (p=0.032), obesity (p=0.041), screw joint perforation and lower Constant Score (p<0.001). DISCUSSION: Inferior subluxation was mostly found in osteoporotic fractures of the elderly, obese, and of female sex both pre- and post-operatively. The intra- and inter-observer reliabilities of proposed radiographic measurement were high and excellent, respectively. CONCLUSIONS: In the early postoperative months, we found a high correlation between inferior subluxation and articular surface perforation; when persisting at later follow-ups, we might speculate that it could represent an early phase of avascular necrosis of the humeral head. LEVEL OF EVIDENCE: Level III, observational study.

Balloon humeroplasty reconstruction for acute Hill-Sachs injury: A technical note.

Posterior Hill-Sachs humeral defects are present in 80% to 100% of cases of anterior shoulder dislocation and are a factor in recurrent instability. Several techniques have been described to fill the defect and avoid recurrence. We developed a percutaneous technique to fill the newly created defect in which a percutaneous balloon, analogous to the one used in vertebral kyphoplasty, is used to reduce the defect, which is then filled with calcium phosphate cement. One patient with an acute anterior dislocation of the shoulder with no previous history was treated using this method. Early imaging results showed adequate reduction of the defect and no cement resorption. The patient was followed for 12 months; he had normal function of the shoulder and no recurrent dislocation. Shoulder computed tomography (CT) arthrography with contrast after 3 months showed an intact capsule and no recurrence of the defect. While this technique is certainly in its infancy, we have demonstrated that emergency reduction of the defect in acute first occurrence anterior shoulder dislocation is feasible, helps to restore normal anatomy of the humeral head and leads to good clinical results. Whether it can improve clinical results and prevent recurrent shoulder dislocation remains to be evaluated.

Accurate application of a precontoured-locking plate for proximal humeral fractures in Asians: a cadaveric study.

OBJECTIVES: The purpose of this study was to identify the optimal position for a precontoured-locking plating (PHILOS(®)) of the proximal humerus in Asians in terms of conformity and to determine the prevalence of screw exits in the position of the highest conformity. METHODS: Twenty adult humeri and 14 cadaveric shoulders were included in this study. After placing the precontoured plate in the well-fitted position on the humerus, we measured the distance between the upper margin of the plate and the tip of greater tuberosity (GT) (distance A) and the distance between the anterior margin of the plate and lateral border of the bicipital groove (BG) (distance B). The prevalence of K-wire exits was assessed. In the 14 cadaver shoulders, the mutual relation between the most inferior locking sleeve of the optimally positioned plate and the axillary nerve was evaluated to assess the potential for axillary nerve injury. RESULTS: The precontoured plate was well-fitted and remained in a relatively constant position in all specimens. Distance A was an average of 3.6 mm (range 1.4-5.5 mm), and distance B was an average of 2.5 mm (range 0-4.6 mm). The K wire closest to the BG pierced it in four cases (20 %), and most inferior K wires exited at an average distance of 3.8 mm (range 1.6-9.0 mm) from the inferior articular margin of the humeral head. Regarding involvement of the BG, articular width was the only significant variable in the logistic regression model, with an odds' ratio of 0.610. The axillary nerve was located at an average vertical distance of 59.7 mm (range 51.8-66.9 mm) from the tip of the GT in a vertically neutral position. The results did not differ between the left and right sides (t = 0.326, p = 0.755). Although the axillary nerve was slightly inferior to the most inferior locking holes of the proximal humerus, it was located in the path of their locking sleeves on the deltoid muscle. CONCLUSION: The optimal position for the highest conformity led to ideal fixation of the proximal humerus and inferomedial support screw in Asians. However, the precontoured plate sometimes had screw exits that involved the BG, and articular width had a large impact on involvement of the BG. If locking sleeves for the most inferior holes were introduced on the deltoid muscle in a neutral position, there was high potential for injury to the axillary nerve in Koreans.

Critical Findings on Magnetic Resonance Arthrograms in Posterior Shoulder Instability Compared With an Age-Matched Controlled Cohort.

BACKGROUND: Posterior shoulder instability is less common and potentially more difficult to diagnose clinically and radiographically compared with anterior shoulder instability. Radiographic findings including posterior labral tears, increased retroversion, presence of glenoid dysplasia, and increased capsular area are associated with symptomatic recurrent posterior shoulder instability. PURPOSE: This study aimed to determine the prevalence and severity of associated radiographic parameters found on magnetic resonance arthrograms (MRAs) in patients with arthroscopically confirmed isolated posterior labral tears and symptomatic recurrent posterior shoulder instability, compared with an age-matched cohort of patients without posterior instability or labral injury confirmed with shoulder arthroscopy. STUDY DESIGN: Cross-sectional study, Level of evidence, 3. METHODS: Patients who received a preoperative standard shoulder MRA at an academic institution over a 5-year period and had symptomatic posterior instability and received a repair of an arthroscopically confirmed posterior labral tear (n = 63) were identified. These patients were compared with an age-matched control group of patients without posterior instability (n = 49) who underwent an isolated arthroscopic distal clavicle resection that included an arthroscopic glenohumeral joint evaluation. Glenoid version, posterior humeral head subluxation, glenoid dysplasia, and linear and capsular area measurements were evaluated between the 2 groups. Interobserver reliability for continuous and categorical variables was assessed for all measurements. RESULTS: Multivariate logistic regression revealed that the presence of increased glenoid retroversion (P = .0018), glenoid dysplasia (P = .03), and increased axial posterior capsular cross-sectional area (P = .05) were significantly associated with posterior labral tears and symptomatic posterior shoulder instability compared with the age-matched control group. Posterior humeral head subluxation was found to be a statistically significant variable with univariate analysis (P = .001) for posterior shoulder instability but not with multivariate logistic regression (P = .53). Interobserver reliability was good to very good for all measurements (intraclass correlation coefficient [ICC] = 0.74-0.85; κ = 0.64) but was moderate for total capsular area and sagittal capsular area measurements (ICC = 0.43-0.56). CONCLUSION: The presence of increased glenoid retroversion, glenoid dysplasia, and increased posterior capsular area on MRA are significantly associated with posterior labral tears and symptomatic posterior shoulder instability. Identification of these critical radiographic variables on magnetic resonance arthrography assists in the accurate diagnosis and management of clinically significant posterior shoulder instability.

[EFFECTIVENESS OF OPEN REDUCTION AND INTERNAL FIXATION WITH LOCKING ANATOMICAL PLATE FOR TREATING VALGUS IMPACTED PROXIMAL HUMERUS FRACTURE].

OBJECTIVE: To investigate the effectiveness of open reduction and internal fixation with locking anatomical plate for treating valgus impacted proximal humerus fracture. METHODS: A retrospective analysis was made on the clinical data of 38 patients with valgus impacted proximal humerus fracture who underwent open reduction and internal fixation with locking anatomical plate between January 2009 and January 2014. There were 25 males and 13 females, aged from 47 to 63 years (mean, 52.3 years); the left and the right sides were involved in 18 and 20 cases, respectively. The causes of fracture included high falling injury in 10 cases, traffic accident injury in 15 cases, and falling injury in 13 cases. The time between injury and operation was 5-10 days (mean, 7.5 days). The collodiaphyseal angle was 160-200 degrees (mean, 176 degrees) on X-ray films. RESULTS: All incisions healed by first intention, and there was no early complication related to operation. All these patients were followed up 12-30 months (mean, 18 months). X-ray film showed that clinical healing time of fracture was 10-16 weeks after operation (mean, 12 weeks); at 12 months after operation, the collodiaphyseal angle recovered to 120-145 degrees (mean, 135 degrees). During follow-up, no loss of fracture reduction and no loosening of internal fixation were observed. At 10-12 months, osteonecrosis of the humeral head occurred in 3 cases (7.9%), including 2 cases of Cruess stage III and 1 case of Cruess stage IV. At last follow-up, the Constant shoulder joint scores were 56-95 (mean, 82.6); the results were excellent in 10 cases, good in 15 cases, fair in 9 cases, and poor in 4 cases, with an excellent and good rate of 66%. Visual analogue scale (VAS) scores were 0-6 (mean, 0.9). CONCLUSION: It can achieve a comparatively satisfactory clinical result to use open reduction and internal fixation with locking anatomical plate for treating valgus impacted proximal humerus fracture.

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly.

PURPOSE: The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures. METHODS: Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences. RESULTS: Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision. CONCLUSIONS: There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions. LEVEL OF EVIDENCE: Level III - Case controlled study.

Greater Tuberosity Fractures: Does Fracture Assessment and Treatment Recommendation Vary Based on Imaging Modality?

BACKGROUND: For greater tuberosity fractures, 5-mm displacement is a commonly used threshold for recommending surgery; however, it is unclear if displacement can be assessed with this degree of precision and reliability using plain radiographs. It also is unclear if CT images provide additional information that might change decision making. QUESTION/PURPOSES: We asked: (1) Does interobserver agreement for assessment of the amount and direction of fracture-fragment displacement vary based on imaging modality (radiographs only; 2-dimensional [2-D] CT images and radiographs; and 3-dimensional [3-D] and 2-D CT images and radiographs)? (2) Does the likelihood of recommending surgery vary based on imaging modality? (3) Does the level of confidence regarding the decision for treatment vary based on imaging modality? METHODS: We invited 791 orthopaedic surgeons to complete a survey on greater tuberosity fractures. One hundred eighty (23%) responded and were randomized on a 1:1:1 basis in one of the three imaging modality groups and evaluated the same set of 22 fractures. We described age, sex, mechanism of injury, days between injury and imaging, and that patients had no comorbidities or signs of neurovascular damage for every case. One hundred sixty-four of the 180 respondents completed the study and there was an imbalance in noncompletion between the three groups (two of 67 [3.0%] in the radiograph only group; nine of 57 [16%] in the 2-D CT and radiograph group; and five of 56 [8.9%] in the 3-D CT, 2-D CT, and radiograph group; p = 0.043 by Fisher's exact test). Participants assessed amount (in millimeters) and direction (posterosuperior/posteroinferior/anterosuperior/anteroinferior/no displacement) of displacement; recommended treatment (surgical or nonoperative); and indicated their level of confidence regarding the recommended treatment on a scale from 0 to 10 for every case. Overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the amount of cases they would operate on by the total number of cases (n = 22) and presented as a percentage. Confidence regarding the decision for treatment was calculated by averaging the confidence score per surgeon, ranging from 0 to 10. We compared interobserver agreement using kappa for categorical variables and intraclass correlation (ICC) for continuous variables. We used multivariable linear regression to assess difference in surgery score and confidence level between imaging groups, controlling for surgeon characteristics. RESULTS: Interobserver agreement for assessment of amount (radiographs: ICC, 0.55, 2-D CT + radiographs ICC, 0.53, 3-D CT + 2-D CT + radiographs ICC, 0.57; p values on all comparisons >0.7) and direction (radiographs: kappa, 0.30, 2-D CT + radiographs kappa, 0.43, 3-D CT + 2-D CT + radiographs kappa, 0.40; p values for all comparisons >0.096) of displacement did not vary by imaging modality. 2-D CT and radiographs (ß regression coefficient [ß], 3.1; p = 0.253) and 3-D CT, 2-D CT and radiographs (ß, 1.6; p = 0.561) did not result in a difference in recommendation for surgery compared with radiographs alone. 2-D CT and radiographs (ß, 0.40; p = 0.021) and 3-D CT, 2-D CT and radiographs (ß, 0.44; p = 0.011) were associated with slightly higher levels of confidence compared with radiographs alone. CONCLUSIONS: Imaging modality, with the numbers evaluated, does not influence interobserver agreement of greater tuberosity fracture assessment, nor did it influence the recommendation for surgical treatment. However, surgeons did feel slightly more confident about their treatment recommendation when assessing CT images with radiographs compared with radiographs alone. Our results therefore suggest no additional value of CT scans for assessment of greater tuberosity fractures when displacement seems to be minimal on plain radiographs. CT scans could be helpful in borderline cases, or in case other fractures can be expected (eg, an occult surgical neck fracture). LEVEL OF EVIDENCE: Level III, diagnostic study.

Magnetic resonance imaging and short-term clinical results of severe frozen shoulder treated with manipulation under ultrasound-guided cervical nerve root block.

BACKGROUND: We evaluated the magnetic resonance (MR) imaging findings and short-term clinical outcomes of severe idiopathic frozen shoulder treated with manipulation under ultrasound-guided cervical nerve root block (MUC). METHODS: The subjects were 30 patients (average age, 55.2 years; 12 men, 18 women) with severe frozen shoulder. Severe idiopathic frozen shoulder was defined as follows: a range of motion (ROM) of ≤ 100° in forward flexion, ≤ 10° in external rotation, and at or below the fifth lumbar vertebral level in internal rotation. Before the manipulation, all patients had continued global ROM loss for at least 6 months. Before and after manipulation, they underwent MR imaging. MR images and clinical results were evaluated 1 month after the procedure. RESULTS: In terms of the capsule tear pattern, MR imaging showed 14 midsubstance tears and 15 humeral avulsions of glenohumeral ligament-like lesions. An anterior labrum tear occurred in 4 shoulders, whereas 15 shoulders showed a bone bruise in the posterosuperior and anteromedial portions of the humeral head despite no humeral shaft fracture. There were significant improvements in the ROM, Constant-Murley score, American Shoulder and Elbow Surgeons score, and Numeric Rating Scale score from before treatment to 1 month after the procedure. CONCLUSION: MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head. Approximately 50% of patients are likely to experience bone bruising after MUC. Long-term follow-up of these patients should be performed carefully.

Bipolar bone defect in the shoulder anterior dislocation.

In the anterior shoulder instability with glenoid bone loss among 25 % or more of the inferior glenoid diameter (inverted-pear glenoid), the consensus of recent authors is that glenoid bone grafting (Latarjet procedure) should be performed. The engaging Hill-Sachs lesion has been recognized as a risk factor for recurrent anterior shoulder instability. We have developed a method using radiographic and arthroscopic studies and the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, whether or not there is concomitant anterior glenoid bone loss. If the Hill-Sachs lesion engages, it is called an "off-track" Hill-Sachs lesion; if it does not engage, it is an "on-track" lesion. On the basis of our quantitative method, we have developed a treatment paradigm with specific surgical criteria for all patients with anterior shoulder instability (first dislocation or recurrent dislocation), both with and without bipolar bone loss.

Osseous Defects Seen in Patients with Anterior Shoulder Instability.

Shoulder surgeons need to be aware of the critical size of the glenoid or humeral osseous defects seen in patients with anterior shoulder instability, since the considerable size of osseous defect is reported to cause postoperative instability. Biomechanical studies have identified the size of the osseous defect which affects stability. Since engagement always occurs between a Hill-Sachs lesion and the glenoid rim, when considering the critical size of the Hill-Sachs lesion, we have to simultaneously consider the size of the glenoid osseous defect. With the newly developed concept of the glenoid track, we are able to evaluate whether a large Hill-Sachs lesion is an "on-track" or "off-track" lesion, and to consider both osseous defects together. In case of an off-track Hill-Sachs lesion, if the glenoid defect is less than 25%, no treatment is required. In this case, the Latarjet procedure or arthroscopic remplissage procedure can be a treatment option. However, if the glenoid defect is more than 25%, treatment such as bone grafting is required. This will convert an off-track lesion to an on-track lesion. After the bone graft or Latarjet procedure, if the Hill-Sachs lesion persists as off-track, then further treatment is necessitated. In case with an on-track Hill-Sachs lesion and a less than 25% glenoid defect, arthroscopic Bankart repair alone is enough.

One-stage surgical treatment of neglected simultaneous bilateral locked posterior dislocation of shoulder: a case report and literature review.

Simultaneous bilateral locked posterior dislocation of the shoulder is a rare injury. Herein, we present a 59-year-old male case with a three-month history of an irreducible locked bilateral posterior dislocation of the shoulders with an associated large impression fracture on the anteromedial aspect of both humeral heads after a grand mal type epileptic seizure. Plain X-ray and computed tomograph revealed a defect on the right side more than 40% of the articular surface, and on the left side, 30%. He was treated with a one-stage operation with a reconstruction of femoral head osteochondral allograft on the right side and transfer of the osteotomized tuberculum minus with its attached subscapularis tendon into the defect (modified McLaughlin technique) on the left side. At 14 months during follow-up, the patient was pain-free with stable shoulder joints and satisfactory functionality.

Locked plate osteosynthesis of humeral head-splitting fractures in young adults.

BACKGROUND: Humeral head-splitting fractures occur in younger patients and can be associated with poor outcome. We decided to study the functional outcome and complications in simple and complex humeral head-splitting fractures. We hypothesized that simple head-splitting fractures will perform better compared with complex head-splitting fractures. PATIENTS AND METHODS: Records of 16 patients <55 years who underwent locked plating for humeral head-splitting fractures were reviewed. Five fractures were classified as simple (isolated head-splitting fractures) and 11 as complex fractures (associated tuberosity fractures). Union and quality of articular and tuberosity reduction were assessed radiologically. Shoulder and upper limb function was assessed by Constant and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Complications such as osteonecrosis, nonunion, and arthritic changes were also recorded. RESULTS: Of 15 fractures, 13 had united at a mean follow-up of 34 months (25-47 months). No osteonecrosis or nonunion was seen in simple fractures. In complex fractures, osteonecrosis was seen in 4 patients (P = .01), nonunion in 2 patients, and glenohumeral arthritis in 1 patient. The mean Constant score (66.5 [56-77]) and DASH score (21 [7.5-35.8]) showed significantly better outcomes in simple fractures (Constant score, P = .02; DASH score, P = .029). CONCLUSION: Locked plating achieves satisfactory results in simple head-splitting fractures. Complex fractures are associated with higher rates of nonunion, avascular necrosis, and inferior shoulder function.

Outcomes of arthroscopic Hill-Sachs remplissage and anterior Bankart repair: a retrospective controlled study including ultrasound evaluation of posterior capsulotenodesis and infraspinatus strength assessment.

BACKGROUND: Hill-Sachs lesions are compression fractures that result from shoulder dislocation. They involve "engaging" the humeral head on the anterior glenoid rim when the arm is abducted and externally rotated. The defect grows as the number of dislocations increases. HYPOTHESIS: Arthroscopic remplissage and anterior Bankart repair do not significantly affect infraspinatus strength while ensuring healing of the capsulotenodesis. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Sixty-one patients with traumatic anterior shoulder instability treated by arthroscopic Bankart repair and Hill-Sachs remplissage at least 24 months previously were compared with a control group of 40 healthy participants. Preoperative imaging included magnetic resonance imaging for Bankart lesion identification and computed tomography to quantify the humeral head defect. Active range of motion and clinical scores (Walch-Duplay, Constant-Murley, and Rowe) were assessed. External rotation (ER) and internal rotation (IR) were measured with arm at the side (ER1 and IR1) and abducted at 90° (ER2 and IR2). Infraspinatus strength was assessed with the scapula free (infraspinatus strength test [IST]) and retracted (infraspinatus scapula retraction test [ISRT]). Infraspinatus tenodesis and posterior capsulodesis healing were evaluated by ultrasound (US). RESULTS: The follow-up median was 39.5 months (range, 24-56 months). One patient experienced a recurrence of instability at 34 months. In the remplissage patients, ER1 was significantly lower in the affected compared with the unaffected shoulder (P < .001). Mean IST and ISRT strength values did not show differences between sides. The mean Constant-Murley score rose from 62.9 ± 7.1 to 90 ± 5.2 (P < .0001). The Walch-Duplay and Rowe scores were excellent in 23 (78.6%), good in 6 (17.8%), and poor in 1 patient (both scores). The remplissage group had significantly lower ER1 (P < .001), ER2 (P < .001), and IR2 (P < .01) values compared with the control group. Differences in IST and ISRT between the groups were not significant. Capsulotenodesis healing and filling of the Hill-Sachs defect were confirmed by dynamic US in all subjects. CONCLUSION: Arthroscopic remplissage is a reliable approach to Hill-Sachs lesions. The ER and IR restriction does not significantly affect quality of life. Infraspinatus strength recovery is satisfactory even compared with healthy subjects. Ultrasound examination allows accurate evaluation of capsulotenodesis healing.

Variations of the micro-vascularization of the greater tuberosity in patients with rotator cuff tears.

PURPOSE: The aim of the study was to analyse greater tuberosity's (GT) micro-vascularization in the context of rotator cuff tear and to identify factors that could affect the rate and distribution of micro-vessels. METHODS: Eighty-seven patients with supraspinatus and/or infraspinatus tendon tears were included in a prospective study. Mean age at surgery was 58 years (41-78) and clinical symptoms were lasting from an average of 20 months before surgery. A bone core of 1-cm depth was obtained from the GT during rotator cuff repair at two localizations, medial and lateral within tuberosity. Micro-vascularization was then analysed with an immunohistochemistry technique based on CD34 antigen tracking endothelial cells at two levels of depth for each sample (more and less than 5 mm). Epidemiologic and pathologic data were correlated with the rate of micro-vascularization measured. RESULTS: Median rate of GT's micro-vascularization was 9.8 %, which ranged from 0.13 % to 33.4 %. This rate decreased with preoperative steroid injection (7.4 % vs 11.2) and with localization close to the cartilage of the humeral head (8.7 % vs 11.9 %). However, it remains almost homogenous along the depth's core. Moreover, no significant correlation was found regarding age at surgery, gender, context of previous trauma, smoking habits, duration of symptoms, and specific data regarding the tendon tear. CONCLUSIONS: This study highlighted the variability of GT's micro-vascularization in case of rotator cuff tear. A greater rate was observed at the lateral part of the footprint, whereas medical history of steroid injection has a negative influence on micro-vascularization.

Hill-sachs lesions in shoulders with traumatic anterior instability: evaluation using computed tomography with 3-dimensional reconstruction.

BACKGROUND: In patients with traumatic anterior shoulder instability, a large Hill-Sachs lesion is a risk factor for postoperative recurrence. However, there is no consensus regarding the occurrence and enlargement of Hill-Sachs lesions. PURPOSE: To investigate the influence of the number of dislocations and subluxations on the prevalence and size of Hill-Sachs lesions evaluated by computed tomography (CT) with 3-dimensional reconstruction. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The prevalence and size of Hill-Sachs lesions were evaluated preoperatively by CT in 142 shoulders (30 with primary instability and 112 with recurrent instability) before arthroscopic Bankart repair. First, the prevalence of Hill-Sachs lesions was compared with the arthroscopic findings. Then, the size of Hill-Sachs lesions confirmed by arthroscopy was remeasured using the previous CT data. In addition, the relationship of Hill-Sachs lesions with the number of dislocations and subluxations was investigated. RESULTS: Hill-Sachs lesions were detected in 90 shoulders by initial CT evaluation and were found in 118 shoulders at arthroscopy. The Hill-Sachs lesions missed by initial CT were 15 chondral lesions and 13 osseous lesions. However, all 103 osseous Hill-Sachs lesions were detected by reviewing the CT data. In patients with primary subluxation, the prevalence of Hill-Sachs lesions was 26.7%, and the mean length, width, and depth of the lesions (calculated as a percentage of the diameter of the humeral head) were 9.0%, 5.3%, and 2.1%, respectively, while the corresponding numbers for primary dislocation were 73.3%, 27.7%, 14.8%, and 7.0%, all showing statistically significant differences. Among all 142 shoulders, the corresponding numbers were, respectively, 56.3%, 20.7%, 11.2%, and 4.8% in patients who had subluxations but never a dislocation; 83.3%, 33.4%, 19.1%, and 7.6% in patients with 1 episode of dislocation; and 87.5%, 46.8%, 22.2%, and 10.2% in patients with ≥2 episodes, all showing statistically significant differences. There were no differences in lesion measurements in relation to the number of subluxations. CONCLUSION: Computed tomography is a useful imaging modality for evaluating Hill-Sachs lesions except for purely cartilaginous lesions. Hill-Sachs lesions were more frequent and larger when the primary episode was dislocation than when it was subluxation. Among patients with recurrent episodes of complete dislocation, the prevalence of Hill-Sachs lesions is increased, and the lesions are larger.