Arthroscopically treated proximal humeral fracture malunion

Articles describing the treatment of proximal humerus malunion are limited. Although in most of the cases, shoulder arthroplasty is the treatment of choice, when the articular surface of the humeral head is intact, other techniques can be considered and successfully used as well. Using arthroscopic techniques for proximal humerus malunion treatment is rarely reported in the literature. We could find only a few cases in which arthroscopic subacromial decompression was used to treat greater tuberosity malunion. Arthroscopic debridement and capsulotomy are also considered in the treatment of proximal humeral malunion cases with shoulder joint stiffness. This case report describes the completely arthroscopic treatment of a 4-part proximal humeral fracture malunion associated with pain and restricted range of motion. The main deformity in our case was medially displaced malunited lesser tuberosity that was blocking the internal rotation of the humerus. Isolated displaced lesser tuberosity fractures are rare injuries. Open techniques are usually the treatment of choice. We did not find any reports of arthroscopic treatment of lesser tuberosity malunion as a separate entity or as a component of a proximal humerus malunion. The early result in our case strongly encourages using arthroscopic techniques for lesser tuberosity malunion treatment as well as expanding the indications for shoulder arthroscopy in proximal humerus malunion cases.     

Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture.

Arthroscopic reduction and percutaneous external fixation is a well-known technique for treating selected fractures. This is the first report of a method of treating intra-articular glenoid rim fracture using shoulder arthroscopy and percutaneous external fixation. The surgical trauma associated with open operative treatment of these fractures can be minimized using minimally invasive techniques under arthroscopic control. This technique not only allows for anatomic reduction with minimal surgical trauma but provides a valid diagnostic and treatment alternative for associated injuries. Arthroscopic reduction and percutaneous external fixation yielded excellent results with no complications. The authors describe the principles of the procedure and discuss its advantages compared with traditional surgery.     

Fractures of the greater tuberosity of the humerus

Isolated fractures of the greater tuberosity of the humerus can occur in anterior shoulder dislocations or as the result of an impaction injury against the acromion or superior glenoid. Greater tuberosity fractures may be associated with partial-thickness rotator cuff tears and labral tears, which may be the cause of persistent pain after fracture healing. Nondisplaced and minimally displaced fractures are typically treated successfully nonsurgically. Surgical fixation is recommended for fractures with >5 mm of displacement in the general population or >3 mm of displacement in active patients involved in frequent overhead activity. Open surgical repair is performed with suture or screw fixation. Recently, arthroscopic techniques have produced promising results. Careful follow-up and supervised rehabilitation optimize results after both nonsurgical and surgical treatment.     

肩关节镜下张力带缝合技术治疗肱骨大结节骨折早期疗效分析

目的探讨肩关节镜下张力带缝合技术治疗肱骨大结节骨折的临床疗效。 方法回顾性分析2015年5月至2017年6月采用肩关节镜下张力带缝合技术治疗15例患者的临床资料及随访结果,其中男性9例、女性6例。年龄31 ~ 68岁,平均46.7岁。受伤原因：交通伤3例、高坠伤2例、摔伤10例。根据Mutch分型：Ⅰ型5例,Ⅱ型10例。15例患者中7例合并肩袖损伤,其中冈上肌腱4例、冈下肌腱1例、小圆肌腱1例、肩胛下肌腱损伤1例。2例肱二头肌长头腱损伤;2例Bankart损伤;3例肩关节上盂唇前后部（superior labrum anterior and posterior,SLAP）损伤。受伤至手术时间为平均4 d（2 ~ 7 d）。所有患者均在肩关节镜下完成,末次随访采用视觉模拟评分（visual analogue scale,VAS）、Constant-Murley评分和肩关节活动范围进行肩关节功能评估。 结果所有患者术后均获得随访,随访时间19.8个月（10 ~ 36个月）。所有骨折均获得骨性愈合,平均愈合时间为（2.7±1.5）个月。术后12个月VAS评分1分,Constant-Murley评分为92.1分,美国肩肘外科协会评分（rating scale of the American shoulder and elbow surgeons,ASES）为89.5分。肩关节活动度：前屈170°（140° ~ 180°）,体侧平均外旋38.7°（20° ~ 70°）,内旋达T12水平。本组无一例出现内固定失效、骨折移位、神经血管损伤等并发症。 结论肱骨大结节骨折是一种复位和固定要求极高的疾病,关节镜下张力带缝合技术治疗单纯肱骨大结节骨折是一种微创、安全有效的方法,可以获得很好的临床效果。     

肩关节镜下简化双滑轮双排缝合锚技术治疗肩盂前缘大块骨折

目的探讨肩关节镜下简化双滑轮(double-pulley)双排缝合锚技术治疗肩盂前缘大块骨折的临床疗效。方法回顾性分析2014年1月至2017年7月,采用肩关节镜下简化double-pulley双排缝合锚技术治疗24例肩盂前缘骨折患者资料,男13例,女11例;年龄(50.14±10.60)岁(范围,34~67岁);均为IdebergⅠa型骨折。其中单纯肩盂前缘骨折8例,伴肱骨大结节骨折4例,伴肩袖损伤5例,伴肩关节前脱位、肱骨大结节骨折4例,伴肩关节前脱位、肩袖损伤2例,伴肩关节前脱位、同侧桡骨远端骨折1例。肩盂前缘骨块面积占肩盂面积的28.91%±5.35%(范围,25.1%~38.5%)。肩关节镜下根据骨块大小,以1枚内排缝合锚置于肩盂前缘骨折床的内缘,2~4枚外排缝合锚置于肩盂关节面边缘,从低到高依次置入缝合锚,通过简化double-pulley技术复位固定。术后观察骨折复位及愈合情况、并发症发生情况。采用Constant-Murley评分、上肢功能障碍评分量表(Disability of Arm,Shoulder and Hand,DASH)对上肢功能进行评价,采用视觉模拟评分(visual analogue scale,VAS)评估疼痛程度。结果24例患者均获得满意骨折复位及内固定,均获得随访,随访时间19.5个月(范围,12~36个月)。手术切口均一期愈合,无一例发生感染、切口愈合不良等;骨折均愈合,愈合时间(2.7±0.6)个月(范围,2.1~3.2个月)。末次随访时,VAS评分为(0.8±0.8)分(范围,0~2分)。术后患肩关节活动度:前屈上举161.00°±5.77°(范围,145°~180°);体侧外旋46.43°±6.63°(范围,35°~60°);内旋拇指触及棘突水平为L3~T10。Constant-Murley评分(88.1±3.7)分(范围,81~93分),DASH评分(8.4±4.7)分(范围,0~40.4分)。除1例患者术后6周CT检查显示肱骨头向前下略移位外,其余患者肩关节对应正常,无脱位和不稳定表现。术后即刻及术后3、6、12个月CT检查均未见骨折块移位。CT检查评价关节面复位情况,术后即刻19例关节面台阶<2 mm,5例2~4 mm;末次随访时19例关节面台阶<2 mm,4例2~4 mm,1例>4 mm。术后6周,1例患者CT检查示肱骨头向前下略移位,但术后3个月CT检查示盂肱关节对应关系基本正常,关节面台阶5 mm。末次随访时,24例患者均未见严重骨关节炎表现,其中1例67岁患者存在轻度骨关节炎表现。2例伴肩关节前脱位及肩袖损伤者肩关节活动明显受限。结论对于大的肩盂前缘骨折,采用肩关节镜下简化double-pulley双排缝合锚固定技术治疗,创伤小,术中镜下视野清晰,骨折显露安全、充分,复位、固定稳定可靠,可获得满意疗效。     

关节镜下双排锚钉缝线桥技术治疗肩关节前脱位合并Mutch Ⅰ型肱骨大结节骨折

目的 分析关节镜下双排锚钉缝线桥技术治疗肩关节前脱位合并Mutch Ⅰ型肱骨大结节骨折的临床疗效.方法 回顾性分析自2016-06-2019-06采用关节镜下双排锚钉缝线桥技术治疗的16例肩关节脱位合并Mutch Ⅰ型肱骨大结节骨折,术中关节镜探查损伤情况并对症处理,进入并清理肩峰下间隙,Ⅲ型肩峰行肩峰成形术.复位大结...     

A Shearing Osteochondral Fracture of the Humeral Head Following an Anterior Shoulder Dislocation in a Child

A dislocation of the shoulder joint is rare in children with an open physis. The fractures associated with an anterior dislocation generally reported in the literature have been Hill-Sachs lesions, avulsions of the greater tuberosity and glenoid fractures. We present a case of a previously unreported shearing osteochondral fracture, which is distinct from a classic Hill-Sachs lesion of the humeral head, in 12-year-old boy. The patient suffered a traumatic anterior shoulder dislocation with a spontaneous reduction along with this associated fracture. The fracture subsequently healed with no further evidence of persistent instability.     

Periprosthetic fractures in total shoulder replacement

Periprosthetic fracture is an uncommon complication of shoulder arthroplasty. Over an 18-year period, we identified 38 fractures occurring either during or subsequent to a shoulder arthroplasty. Among intraoperative fractures, the humeral shaft was involved in nine cases, the greater tuberosity in five, the proximal humeral metaphysis in two, the glenoid in four, and the coracoid process in two. Postoperative fractures involved the humeral shaft in 15 cases and the coracoid process in one. Thirty-three fractures occurred in women compared with five in men. Rheumatoid arthritis was the most common diagnosis. Our results suggest that intraoperative shaft fractures occurring at or below the stem tip can be successfully managed by using a long stem implant to bypass the fracture. Supplementary cerclage wires or cables are added if additional stabilization is needed. Eleven of the 15 postoperative shaft fractures were initially treated with a cast or brace. Nonoperative treatment led to union in 6 of the 11 (54.5%), but failed in 5. We recommend a trial of closed treatment if a satisfactory reduction can be obtained and maintained. If acceptable alignment cannot be achieved, or if delayed or nonunion develops, recommended surgical options include internal fixation with a plate if the prosthesis is well fixed, or revision with a long-stem prosthesis. Three of the four intraoperative glenoid fractures precluded glenoid resurfacing. Except for a nonunion in one case, greater tuberosity fractures did not impact the ultimate clinical outcome. Coracoid process fractures were also not clinically significant.     

Arthroskopischer Korakoidtransfer

Recurrent anterior shoulder instability is a frequent and severe problem for patients. The Bankart operation with reconstruction of the labrum, capsule and ligament is the established treatment method, which is usually performed arthroscopically. However, the results of the Bankart operation deteriorate if there is significant bone loss at the glenoid or humerus and also when there is structural damage to the anteroinferior glenohumeral ligament and labrum. In 1954 Latarjet described the technique of coracoid transfer to the anterior glenoid. This procedure has become popular for the treatment of anterior shoulder instability especially in France and is performed in an open technique.In this paper we describe the indications, operative technique and early results of coracoid transfer in a completely arthroscopic technique.     

Bony avulsions of the rotator cuff : Arthroscopic concepts

Bony avulsions of the rotator cuff and isolated greater or lesser tuberosity fractures are rare injuries and a clear consensus regarding classification and therapy does not yet exist. Conservative therapy is limited, especially in injuries with displaced fragments and in these cases surgical treatment is frequently indicated. The ongoing development of arthroscopic techniques has led to quite a number of reports about arthroscopically assisted or total arthroscopic techniques in the treatment of these injuries. The advantages and disadvantages of arthroscopic concepts for the treatment of bony avulsions of the rotator cuff are presented with reference to the current literature.     

Kn?cherne Rotatorenmanschettenausrisse

Bony avulsions of the rotator cuff and isolated greater or lesser tuberosity fractures are rare injuries and a clear consensus regarding classification and therapy does not yet exist. Conservative therapy is limited, especially in injuries with displaced fragments and in these cases surgical treatment is frequently indicated. The ongoing development of arthroscopic techniques has led to quite a number of reports about arthroscopically assisted or total arthroscopic techniques in the treatment of these injuries. The advantages and disadvantages of arthroscopic concepts for the treatment of bony avulsions of the rotator cuff are presented with reference to the current literature.     

肩胛骨骨折的手术治疗

肩胛骨骨折相对少见,多因高能量创伤致肩背部遭受直接暴力所致。常伴有合并伤,高达80%～95%,应注意检查臂丛神经、血管以及同侧肢体损伤。骨折治疗的目的是恢复肩关节无痛性有效的肩关节活动功能。移位性关节盂骨折﹑肩部悬吊复合体联合损伤﹑浮肩损伤以及移位性肩胛颈骨折均应行手术治疗,内固定必须牢固可靠,能耐受早期肩关节活动。康复训练是手术成功的重要因素,术后患者应坚持肩关节活动至骨折牢固愈合。     

Therapie von Glenoid- und Skapulafrakturen

Fractures of the scapula are caused by direct or indirect trauma and can be isolated or associated with multiple injuries. Most such fractures can be diagnosed in plain X-rays of the shoulder in the a-p plane. In the case of more complex injuries computer tomography is a great help in deciding whether or not surgery is indicated. As the shoulder blade is surrounded by powerful muscles, which give adequate stability in the case of bone fracture, conservative treatment of scapular fractures is usually possible. If dislocated fracture of the joint or shoulder instability with fracture of the clavicle is present or the movement in the thoracoscapular joint is impaired surgical stabilization is necessary. Anterior access is used mainly in the case of rim fractures. When a dorsal or combined access route to the shoulder is used the particular anatomical conditions in this region must be borne in mind to avoid iatrogenic vascular and/or neural injuries. The triangular bony structure of the shoulder blade with its almost paper-thin centre allows the fixation of devices for osteosynthesis only at the edges and in the glenoid region (Kirschner wires, fragment screws, plates). A wide variety of classification systems take account of anatomical and functional aspects and those suggesting what treatment is indicated. Carrier bags and the Gilchrist and Desault bandage are both suitable for the initial immobilization. Physiotherapy is started when posttraumatic or postoperative pain fades away.     

Painless reduction of acute anterior shoulder dislocations without anesthesia

In 1938, Dr Henry Milch described a maneuver for the reduction of acute anterior shoulder dislocations consisting of shoulder abduction and external rotation with "pulsion" of the humeral head. Although many methods may be used to reduce the dislocated glenohumeral joint, the Milch technique is unique because of its gentle, effective, and relatively painless nature. This article studied the effectiveness of this technique on 76 consecutive acute anterior shoulder dislocations in 75 patients seen in our institution's two campuses over an 18-month period. Twelve shoulders had concomitant fractures of the greater tuberosity. All 76 shoulders were reduced on the first attempt. No anesthesia was used, and no complications were reported from the reduction maneuver. The Milch method is an ideal first line treatment for all acute anterior shoulder dislocations including those associated with fracture of the greater tuberosity.     

Schulterendoprothetik bei posttraumatischen Deformitäten durch Frakturfolgen

The sequelae of fractures of the proximal humerus can be of considerable clinical significance. Careful classification of the sequelae allows precise determination of whether correction osteotomy, reconstruction, or implantation of one of the various prostheses available is indicated. The integrity of the greater tuberosity, its position and continuous osseous integration to the metaphysis of the proximal humerus is the most important predictive factor for a good outcome following implantation of an anatomical shoulder prosthesis. When there is some incongruence of the glenohumeral joint while the greater tuberosity remains intact, shoulder arthroplasty can give a better clinical outcome than is seen after arthroplasty for a primary fracture. In the case of nonunion of subcapital fractures the results achieved by reconstruction, i.e. bone grafting and internal fixation using plates with fixed-angle blades, are superior to those possible with an anatomical prosthesis. Reverse shoulder arthroplasty gives better results than anatomical prostheses in the treatment of severe tuberosity malunion. The results of reverse shoulder arthroplasty for the sequelae of fractures are also influenced by the integrity of or damage to the soft tissues, the muscles of the rotator cuff (teres minor muscle), and bone. Secondary interventions for the sequelae of fractures of the proximal humerus are complex and involve high rates of complications and revisions.     

Infraglenoid tubercle avulsion and greater tuberosity fracture resulting from traumatic glenohumeral anterior dislocation: a case report

Traumatic anterior shoulder dislocation can be associated with anteroinferior glenoid bone loss causing potential recurrent instability. We report on a 62-year-old man with a first-time traumatic anterior dislocation of the right shoulder, resulting in both an infraglenoid tubercle triceps avulsion fracture and a greater tuberosity fracture. After reduction, nonsurgical management was chosen. No inferior-oriented apprehension was noticed during follow-up, which might necessitate surgical treatment of the inferior glenoid rim. At latest follow-up, the patient had recovered his shoulder function. Avulsion fractures of the infraglenoid tubercle are uncommon lesions after an anterior shoulder dislocation and, without signs of instability, can be treated conservatively.     

肱骨近端骨折肱骨头置换假体高度的控制

目的:评估利用大结节骨折片复位的方法,确定肱骨近端骨折肱骨头置换假体高度的临床疗效。方法:回顾性研究2015年1月至2019年12月收治并获得随访的肱骨近端骨折患者,符合肱骨头置换指征19例,男7例,女12例;左侧8例,右侧11例;年龄58~84(71.5±5.8)岁;受伤至手术时间3~18(7.9±4.3) d。根据Neer分型,3部分骨折伴脱位2例,4部分骨折17例,其中伴肱骨头脱位6例,肱骨头劈裂2例。19例采用组配式肱骨头假体,在手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离作为假体高度的标准。术后1年采用Constant-Murley评分,美国加州大学洛杉矶分校(University of California,Los Angeles,UCLA)肩关节评分评价肩关节功能状况及患者满意度。结果:19例均获随访,时间12~58(31.9±14.2)个月。测量手术后上臂长度26~32 cm,双侧比较误差<0.5 cm。术后3个月肩关节正侧位X线片示骨折均愈合。术后1年Constant-Murley评分(80.8±8.9)分,UCLA评分(27.9±4.8)分。术后1年患者满意度89.5%(17/19)。结论:肱骨近端骨折肱骨头假体置换手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离确定假体高度,方法简单准确,临床效果良好。     

Current aspects in the arthroscopic treatment of shoulder instability

With regard to postoperative stability of the shoulder joint, the results yielded by the various arthroscopic refixation techniques are not as good as those obtained after open operation. The aim of this paper is to analyze the reasons for this and to present a new procedure which it is hoped will improve the arthroscopic results. The main reason for the high postoperative recurrence rate after arthroscopic joint stabilization seems to be that refixation of the capsule is not performed at the level of the lesion, but above it, because of the position of the subscapularis tendon. Another reason for the poor results of arthroscopy is that the enlarged capsule cannot be shortened as desired, because the glenoid labrum is used for refixation of the capsule. To improve the arthroscopic results we suggest basic changes of the procedure in cases with severe damage to the soft tissue at the antero-inferior aspect of the glenoid and/or in cases with an enlarged capsule: refixation of the capsule should not be carried out from inside the joint but from outside the capsule. To this end, we applied the so-called extraarticular screwing technique. Refixation is achieved by inserting small cannulated titanium screws by means of a special screwdriver. No metal is placed inside the joint. This technique requires a new portal, namely the so-called antero-inferior portal, which is placed 1.5 cm inferior to the coracoid process. If the precautionary measures described are duly observed, the musculocutaneous nerve cannot be damaged. The technique allows stable refixation of the capsule in the desired length by placement of one or two small screws in the center of the Bankart lesion. Our preference is based on experience with 83 patients with recurrent shoulder instability who were operated on by arthroscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arthroscopic Reduction and Repair of a Locked Posterior Shoulder Dislocation

Locked posterior shoulder dislocations are an uncommon but difficult problem for the orthopaedic clinician. Furthermore, they are often missed on initial presentation, resulting in significant delays in treatment. Traditional treatment has involved formal open reduction, most commonly from an anterior approach, followed by transfer of the lesser tuberosity or subscapularis tendon into the anterior humeral head defect. We present the case of a patient with locked posterior shoulder dislocation, who was treated with arthroscopically assisted reduction followed by arthroscopic posterior stabilization. Use of this technique allows the surgeon to reduce the dislocation without performing an open arthrotomy, thereby decreasing the patient’s overall morbidity. Furthermore, an arthroscopic technique used for stabilization allows visualization of the entire glenohumeral joint and enables the surgeon to directly address posterior disease, rather than compensating for the defect with an anteriorly based transfer.