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Cirigliano G, Altorfer C.S. F, Meisterhans M, Borbas P, Wieser K, Grubhofer F. Anterior shoulder dislocation with avulsion fracture of the greater tuberosity results in reliable good outcomes after closed reduction. JSES Int 2024; 8:423-428. [PMID: 38707548 PMCID: PMC11064708 DOI: 10.1016/j.jseint.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the GT typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment. Methods All patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons score and subjective shoulder value, instability assessed with the Western Ontario Shoulder Instability score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements. Results A total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n = 4, 14%) or impingement symptoms (n = 3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n = 7) and neuropraxia of the axillary nerve (n = 3) were observed temporarily and resolved during the follow-up period. The American Shoulder and Elbow Surgeons and subjective shoulder value of the conservatively treated patients at the last follow-up was 89.2 ± 19.1 respectively 86 ± 18.2%. No recurrent glenohumeral dislocation was documented. The mean Western Ontario Shoulder Instability score at last follow-up was 8(0-71). The mean GTI decreased from 1.2 ± 0.1 after ASD to 1.1 ± 0.1 at the last follow-up (P = .002). The mean II decreased from 0.6 ± 0.5 after ASD to 0.4 ± 0.3 at the last follow-up (P = .110). Conclusion The GT avulsion fragment reduces typically into a close to anatomic position after closed reduction and the GTI even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.
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Affiliation(s)
- Gabriele Cirigliano
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Franziska Altorfer C.S.
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Michel Meisterhans
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Paul Borbas
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Florian Grubhofer
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
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Ryu S, Park S, Kim E, Woo H, Jeon CY, Yoon J, Choi J. Fast field echo resembling a CT using restricted echo-spacing (FRACTURE) sequence for shoulder joint in normal dogs. Front Vet Sci 2024; 11:1298133. [PMID: 38352037 PMCID: PMC10861672 DOI: 10.3389/fvets.2024.1298133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Shoulder disease is a common cause of forelimb lameness in dogs. Determining the precise underlying cause of shoulder lameness can be challenging, especially in veterinary practice. Computerized tomography (CT) is often the preferred imaging modality for bone evaluation; however, it uses ionizing radiation and provides limited soft tissue contrast. Conversely, magnetic resonance imaging (MRI) offers excellent soft tissue contrast but has limitations in bone imaging. This study aimed to introduce a new technical innovation that enhances cortical and trabecular bone contrast on MRI, which we refer to as Fast Field Echo Resembling a CT Using Restricted Echo-Spacing (FRACTURE). In this prospective pilot study, we aimed to evaluate the use of FRACTURE, CT, and conventional MRI sequences in assessing the normal canine shoulder using a 3.0 Tesla MRI scanner. Five research beagle dogs were included, and the following pulse sequences were acquired for each dog (1): three-dimensional (3D) FRACTURE, (2) T2-weighted (T2W) images using 3D turbo spin echo (TSE), (3) T1-weighted (T1W) images using 3D TSE, (4) PD-weighted (PDW) images using 3D TSE, and (5) CT. Various parameters, including the delineation of cortical bone (intertubercular groove, greater tubercle, and lesser tubercle), conspicuity of the trabecular bone, shoulder joint visualization, and image quality, were measured for each dog and sequence. In all sequences, the shoulder joint was successfully visualized in all planes with mild motion artifacts. The intertubercular groove was best visualized on CT and FRACTURE. Both the greater and lesser tubercles were easily identified on the CT, FRACTURE, and PDW images. The trabecular pattern scored significantly higher in the CT and FRACTURE images compared to the T1W, T2W, and PDW images. Overall, the visualization of the shoulder joint was excellent in all sequences except for T1W. The use of FRACTURE in combination with conventional MRI sequences holds promise for facilitating not only soft tissue evaluation but also cortical and trabecular bone assessment. The findings from this study in normal dogs can serve as a foundation for further FRACTURE studies in dogs with shoulder diseases.
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Affiliation(s)
- Sanghwa Ryu
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Soomin Park
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Eunjee Kim
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hyeonjae Woo
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Chang-yeop Jeon
- National Primate Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju, Republic of Korea
| | - Junghee Yoon
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jihye Choi
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
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Ryan DJ, Zuckerman JD, Egol KA. Fact or fiction: the "5 mm Rule" in greater tuberosity fractures of the proximal humerus. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03427-4. [PMID: 36346475 DOI: 10.1007/s00590-022-03427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE The purposes of this study were 1) to assess the outcome of nonoperative management of GT fractures with > 5 mm of displacement and 2) to assess whether there is a correlation between degree of displacement and outcome. METHODS This study was a retrospective review of consecutive low-energy GT fractures from 2011 to 2020. Radiographs from all visits were reviewed. The direction of maximal displacement was assessed. Subjects were stratified based on the amount of maximal displacement: Group 1: 0-5 mm, Group 2: 5-10 mm, Group 3: > 10 mm. Range of motion (ROM) at the time of final follow-up was assessed. The presence of persistent shoulder pain after healing was noted, as well as whether supplemental subacromial corticosteroid injection was provided as part of long-term treatment. RESULTS A cohort of 93 fractures comprised the study group. Mean age was 62 years. Mean follow-up was 20 months. All fractures went on to union. Mean displacement was 6.2 mm. There were 43 patients in Group 1, 43 in Group 2, and 7 in Group 3. Maximal displacement was most commonly inferolateral or lateral, accounting for a combined 77% of all patients. There was no difference in final ROM between displacement groups, with at least 155 degrees of forward elevation and 45 degrees of ER in all three groups. There was no difference between Group 1 and Groups 2/3 in frequency of persistent pain or likelihood of receiving a steroid injection. CONCLUSION Our findings do not support a discrete 5 mm displacement threshold for surgical repair of isolated greater tuberosity fractures.
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Affiliation(s)
- Devon J Ryan
- Department of Orthopedic Surgery, New York University (NYU) Langone Orthopedic Hospital, New York, NY, 10003, USA.
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, New York University (NYU) Langone Orthopedic Hospital, New York, NY, 10003, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, New York University (NYU) Langone Orthopedic Hospital, New York, NY, 10003, USA
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Furuhata R, Tanji A, Oki S, Kamata Y. Inferior subluxation of humeral head after osteosynthesis for greater tuberosity fracture. J Orthop Surg Res 2022; 17:476. [PMID: 36329462 PMCID: PMC9632016 DOI: 10.1186/s13018-022-03379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/30/2022] [Indexed: 11/05/2022] Open
Abstract
Background Inferior subluxation of the humeral head is frequently observed immediately after surgery for proximal humerus fractures; however, the incidence and risk factors of inferior subluxation after osteosynthesis for isolated greater tuberosity fractures remain unsolved. Additionally, the postoperative course of inferior subluxation has not been elucidated. The purpose of the present study is to identify the predictors for the occurrence of postoperative inferior subluxation by multivariate analysis and investigate the postoperative shift of inferior subluxation and its effect on surgical outcomes.
Methods We retrospectively identified 68 patients who underwent surgery for isolated greater tuberosity fractures. The dependent variable was the inferior subluxation at 1 week postoperatively. The explanatory variables were age, sex, affected side of the shoulder, body mass index, history of smoking, local osteoporosis, time period to surgery, axillary nerve injury, inferior subluxation before surgery, fracture dislocation, surgical approach, surgical method, operative time, amount of blood loss, and postoperative drainage. Baseline variables that were statistically significant in the univariate analyses were included in the logistic regression analysis. The patients were further categorized into two groups according to the presence of inferior shoulder subluxation exhibited 1 week postoperatively: patients with inferior subluxation (+ IS group) and patients without inferior subluxation (− IS group). We compared the incidence of postoperative complications between the two groups.
Results Of 68 patients, 17 (25.0%) had inferior shoulder subluxation observed 1 week postoperatively. Multivariate analysis showed that long operative time was a risk factor for postoperative subluxation (odds ratio = 1.03; P = 0.030). In all cases, inferior subluxation disappeared within 3 months of surgery. No significant difference in complication rate was observed between the + IS and − IS groups. Conclusions The present study provides novel information regarding postoperative inferior subluxation of fractures of the greater tuberosity. Inferior subluxation occurred in 25% of patients immediately after surgery. Long operative time contributes to the onset of postoperative inferior subluxation; however, this was temporary in all cases and had no significant effect on the surgical outcomes. Level of Evidence: Level III.
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Affiliation(s)
- Ryogo Furuhata
- grid.413981.60000 0004 0604 5736Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284-1 Yobe-Cho, Ashikaga-Shi, Tochigi 326-0843 Japan
| | - Atsushi Tanji
- grid.413981.60000 0004 0604 5736Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284-1 Yobe-Cho, Ashikaga-Shi, Tochigi 326-0843 Japan
| | - Satoshi Oki
- grid.416684.90000 0004 0378 7419Department of Orthopaedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya-Shi, Tochigi Japan
| | - Yusaku Kamata
- grid.416239.bDepartment of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Meguro-Ku, Tokyo, Japan
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Rakowski DR, Ruzbarsky JJ, Woolson TE, Horan MP, Nolte PC, Millett PJ. Open Fixation of Displaced Greater Tuberosity Fractures Yields Similar Patient-Reported Outcomes to Acute Arthroscopic Rotator Cuff Repair at 2 Years: A Matched Cohort Analysis. Arthrosc Sports Med Rehabil 2022; 4:e687-e694. [PMID: 35494255 PMCID: PMC9042898 DOI: 10.1016/j.asmr.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To evaluate and compare patient-reported outcomes (PROs) after isolated greater tuberosity (GT) fracture fixation versus acute rotator cuff repair (RCR) at a minimum of 2 years. Methods Patients who underwent isolated GT fracture fixation were compared in a 1-to-3 fashion with patients who underwent arthroscopic RCR for an acute rotator cuff tear by a single surgeon from January 2006 and to July 2018. Data were prospectively collected and retrospectively reviewed. PROs were compared pre- and postoperatively as well as between groups (American Shoulder and Elbow Surgeons [ASES], General Health Short Form-12 Physical Component [SF-12 PCS], Single Assessment Numerical Evaluation [SANE], Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], and satisfaction). Reoperation rates were analyzed. Results A total of 57 patients (14 with isolated GT fracture fixation, mean age 45.7 years; and 43 who underwent ARCR for acute tears, mean age 56.6 years) were evaluated (P = .050). ASES scores significantly improved from 39.7 to 94.1 (P = .018) in the isolated GT fracture fixation group and from 51.0 to 95.2 (P < .001) in acute RCR group. At final follow-up, mean QuickDASH scores were 8.9 and 7.9 (P = .677) and SANE scores were 91.1 and 87.3 (P = .616) for the GT and acute RCR groups, respectively. The median satisfaction was 10/10 for the GT group and 10/10 for the RCR group. Additional comparison of patients who underwent double-row repair for an acute rotator cuff tear or isolated GT fracture revealed no significant difference in outcomes (P > .404). Conclusion Minimum 2-year PROs after fixation of isolated GT fractures show relatively high outcome scores whether treated by open reduction and internal fixation or arthroscopic fixation using a double-row bridging technique. The improvements in PROs are similar to those achieved with acute rotator cuff tears that were fixed arthroscopically with RCR. Further analysis of these results suggest that the functional outcomes of tendon-to-bone healing with linked, double-row rotator cuff repairs are similar to those of bone-to-bone healing as seen with GT fractures. Level of Evidence III, retrospective comparative study.
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Hoogervorst LA, Spek RWA, van den Bekerom MPJ. Comments to: "Outcomes of surgical fixation of greater tuberosity fractures: A systematic review" by S.R. Huntley, E.J. Lehtonen, J.X. Robin, A.M. Arguello, D.M. Rouleau, E.W. Brabston, B.A. Ponce, A.M. Momaya published in Orth Traumatol Surg Res. 2020;106(6):1119-1126. Orthop Traumatol Surg Res 2021; 107:102919. [PMID: 33836281 DOI: 10.1016/j.otsr.2021.102919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/02/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Lotje A Hoogervorst
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 Leiden, The Netherlands.
| | - Reinier W A Spek
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Michel P J van den Bekerom
- Shoulder and Elbow Expertise Centre, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands; Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Momaya AM, Paul KD, Rouleau DM, Brabston EW, Ponce BA. Reply to the letter by L.A. Hoogervorst, R. W.A. Spek and M. P.J. van den Bekerom. Orthop Traumatol Surg Res 2021; 107:102921. [PMID: 33836283 DOI: 10.1016/j.otsr.2021.102921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/02/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Amit M Momaya
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Kyle D Paul
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Dominique M Rouleau
- Faculty of Medicine, université de Montréal, 2900, boulevard Edouard-Montpetit, H3T 1J4 Montréal, QC, Canada; Hôpital du Sacré-Coeur, C2095-5400, boulevard Gouin O., H4J 1C5 Montréal, QC, Canada
| | - Eugene W Brabston
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brent A Ponce
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
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Fracture Avulsion of the Greater Tuberosity: Arthroscopic Transosseous Augmented Technique. Arthrosc Tech 2021; 10:e1233-e1238. [PMID: 34141537 PMCID: PMC8185574 DOI: 10.1016/j.eats.2021.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023] Open
Abstract
The fracture avulsion of the greater tuberosity (GT) represents 2% of all humerus fractures, but the true incidence is likely to be higher, being challenging the initial diagnosis on radiograph. The fracture avulsion of the GT could have different treatments: nondisplaced or minimally displaced fractures are treated conservatively, whereas for displaced or comminuted fractures surgical treatment is preferred. The most important finding of this study is the employment of an all-arthroscopic transosseous augmented technique for the treatment of a displaced humeral GT fracture avulsion. This technique shows all the advantages of the transosseous fixation and arthroscopic approach.
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