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Arthroscopic Reduction and Fixation With Suture-Bridge Technique for Displaced or Comminuted Greater Tuberosity Fractures
Technical Note
Arthroscopic Reduction and Fixation With Suture-Bridge Technique for Displaced or Comminuted Greater Tuberosity Fractures Hyun Seok Song, M.D., and Gerald R. Williams Jr., M.D.
Abstract: The arthroscopic suture-bridge technique (transosseous equivalent technique) was initially described for increasing the footprint size during arthroscopic rotator cuff repair. We describe a method in which the same principles are used to fix a displaced or comminuted greater tuberosity fracture. The technique involves reducing the displaced fragment with two medially placed, transtendinous anchors and compressing the greater tuberosity using the sutures from these medial anchors in two laterally placed anchors. The two medial anchors are inserted through the junction of the cuff and fragment. The anchor driver can be used as a joystick to reduce the fragment into position. One suture limb of each anchor is passed back through the tendon 5 mm from the original anchor insertion point in the tendon. With the scope in the subacromial space, the sutures from the medial anchors are tied in a mattress configuration. The four suture ends are passed distally over the greater tuberosity and incorporated into two PushLock anchors (4.5 mm; Arthrex, Naples, FL) using the suture-bridge technique. The postoperative rehabilitation protocol is similar to that for rotator cuff repairs. Key Words: Anchor fixation—Greater tuberosity fracture—Shoulder arthroscopy—Suture-bridge technique—Transosseous equivalent technique.
I
solated greater tuberosity fractures constitute 17% to 21% of proximal humeral fractures.1 Greater tuberosity fractures occur in 15% to 30% of the glenohumeral dislocations.1 Reported results of open reduction and internal fixation have been good. Arthroscopic management may offer better visualization and mobilization of the fragment, as well as visualization and treatment of any associated intra-articular pathol-
From the Department of Orthopedic Surgery, St. Paul’s Hospital, The Catholic University of Korea (H.S.S.), Seoul, Korea; and The Rothman Institute of Orthopedics at Thomas Jefferson University (G.R.W.), Philadelphia, Pennsylvania, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Hyun Seok Song, M.D., Department of Orthopaedic Surgery, St. Paul’s Hospital, The Catholic University of Korea, 620-56 Jeonnong-dong, Dongdaemun-gu, Seoul 130-709, Korea. E-mail: hssongmd@ yahoo.com © 2008 by the Arthroscopy Association of North America 0749-8063/08/2408-7593$34.00/0 doi:10.1016/j.arthro.2008.01.009
956
ogy. Open or arthroscopic2 screw fixation techniques may have some limitations with regard to the management of comminuted fragments. The arthroscopic suture-bridge technique (transosseous equivalent technique) has been recently used for double row repair of rotator cuff tears.3 This technique can compress the cuff with several sutures interconnecting two anchors across the broader area. The present report describes application of the arthroscopic suture-bridge technique for displaced or comminuted greater tuberosity fractures of the humerus. SURGICAL TECHNIQUE A typical patient may present with a two-part greater tuberosity fracture-dislocation and the greater tuberosity may be one large fragment (Fig 1A) or a series of comminuted fragments (Fig 2A). In many cases, reduction of the humeral head will result in anatomic reduction of the greater tuberosity. How-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 8 (August), 2008: pp 956-960
SUTURE-BRIDGE TECHNIQUE FOR TUBEROSITY FRACTURES
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FIGURE 1. Case 1. (A) Anteroposterior radiograph of right shoulder of a 47-year-old male showing a displaced greater tuberosity fracture, without comminution, following anterior glenohumeral dislocation. (B) Postreduction magnetic resonance image, T1 obliquecoronal view, showing a displaced fragment. Treatment involved 2 medial metal anchors and 2 lateral bioabsorbable anchors using the suture-bridge technique. (C) Radiograph showing the anatomic healing 7 months postoperatively.
ever, residual displacement of the fragment may be encountered (Fig 1B). With the patient in the beach chair position, a standard posterior portal is used to examine the glenohumeral joint. Pump pressure should be carefully monitored to prevent soft tissue swelling. A routine examination of the joint is undertaken to identify any labral, chondral, or rotator cuff lesions. The displaced greater tuberosity fragment attached to the supraspinatus can be easily identified. The
edge of the fragment and the crater of the fractures are debrided. The arthroscope is moved into the subacromial space and a bursectomy is performed, particularly around the lateral margin of the fracture and the adjacent intact metaphyseal cortex, in order to improve visualization and ease insertion of the lateral anchors. The arthroscope is reinserted into the glenohumeral joint through the posterior portal. After localization with a spinal needle, a suture anchor (5.0 mm Cork-
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H. S. SONG AND G. R. WILLIAMS
FIGURE 2. Case 2. (A) Anteroposterior postreduction radiograph of left shoulder of a 29-year-old man showing a comminuted, displaced fracture of the greater tuberosity. He had had 3 previous dislocations requiring reduction before this episode. Treatment involved 2 medial bioabsorbable anchors and 2 lateral bioabsorbable anchors using the suture-bridge technique. (B) Postoperative anteroposterior radiograph showing reduction of comminuted fragments of the greater tuberosity.
screw or Bio-Corkscrew FT; Arthrex) is passed percutaneously into the joint through the supraspinatus tendon–tuberosity junction 5 mm posterior to the most anterior extent of the fragment. After approximately half the length of the anchor is passed through the cuff, the anchor driver can be used as a joystick to reduce the fragment into an anatomic location. Care should be taken to avoid over-reduction in the region of the bicipital groove, as this can cause pain from bicipital tendon irritation.4 After reduction of the fragment, the anchor is inserted into the articular margin of the humerus (Fig 3A). To make a medial mattress suture configuration, a spinal needle is passed percutaneously through the tendon– bone junction of the fragment 5 mm posterior to the entry hole of the anchor. A No. 2 monofilament (nylon) or suture-relaying device (Shuttle Relay Suture Passer; Conmed Linvatec, Largo, FL) is used to shuttle the suture that was retrieved through the anterior portal back through the tendon. A second medial anchor is inserted 1.5 cm posterior to the first one using a similar technique. The arthroscope is then moved back into the subacromial space. The posterior portal is usually adequate. However, if visualization of the most anterior extent of the fragment is difficult, the scope can be
moved to a posterolateral portal. The medial mattress sutures are then tied under direct visualization. One strand of each suture from each medial anchor is retrieved through the lateral cannula. After punching the intact lateral cortex of the humerus distal to the fragment, a PushLock anchor (4.5 mm; Arthrex) is inserted using the suture-bridge technique. The insertion point of the lateral anchor should be more than 5 mm from the fracture margin to prevent cracking the cortex and loosening of the anchors. The degree of compression is adjusted under direct visualization. Reduction of the fragment can be seen from both the bursal and articular surfaces (Fig 3B) and confirmed using postoperative radiographs (Fig 2B). The postoperative rehabilitation protocol is similar to that for rotator cuff repairs. Pendulum exercise, passive elevation, and external rotation (to 20°) exercises are commenced within the first 7 to 10 postoperative days. Active exercise and strengthening are delayed until the sixth postoperative week. DISCUSSION Controversy exists regarding the amount of displacement that requires operative reduction and stabilization. Neer5 suggested open reduction and internal
SUTURE-BRIDGE TECHNIQUE FOR TUBEROSITY FRACTURES
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FIGURE 3. Case 1. (A) Arthroscopic findings of the displaced greater tuberosity fracture seen in Fig 1 as visualized from the posterior portal during reduction. (B) The anatomic restoration of the articulo-tendinous junction by the correct placement of the medial anchors and the proper knotting of the medial mattress sutures. (Abbreviations: BLH, long head of the biceps; C, corkscrew anchor; HH, humeral head; P, probe; S, shaver; SSP, supraspinatus tendon).
fixation for greater tuberosity fractures displaced more than 1 cm. Park et al.6 suggested that fractures with 3 mm of displacement should be reduced in athletes and heavy laborers who are involved in overhead activity. Green and Izzi Jr.1 also suggested that even small amounts of displacement could affect shoulder function. Moreover, symptomatic greater tuberosity malunion may cause a substantial number of symptoms that might require surgical intervention.6,7 Two fixation techniques using suture anchors in a double row configuration have also been reported. In both methods, a medial row of anchors is placed in a fashion similar to our method. The methods differ from one another in the manner in which the lateral row of anchors is incorporated into the fixation construct. In one method, the sutures from the lateral (i.e., distal) row of anchors are passed through the bone– tendon junction of the fragment lateral to the mattress sutures from the medial row using an open incision4 or an arthroscopic technique using C-arm guidance.8 In the other method, the suture from the medial anchor that was shuttled through the eyelet of the lateral anchor was tied over the tuberosity.9 In the first method, the fragment is “buttressed” by the lateral sutures. In the second method, the fragment is compressed directly into the fracture bed by the overlying sutures. The modification of the arthroscopic suture-bridge technique that we describe is really a two-stage technique. In the first stage, the fragment is reduced; in the second stage, the fragment is compressed into the
fracture bed. Reduction is obtained by partially passing the suture anchor through the tendon and using the anchor driver as a joystick to position the fragment before driving the anchor into the intact humerus. Once the medial row sutures have been tied, thereby reducing the fragment, they are crossed over the fragment and incorporated into a second row of anchors distal to the fragment. This accomplishes the second stage of the procedure; namely, compression of the fragment into its fracture bed. The method that we describe is similar to the previously reported suture anchor techniques in that it uses a double row anchor configuration characterized by a medial row at the articular margin and a lateral row distal to the greater tuberosity fragment. However, it is different from these previously described techniques in at least two ways. First, our technique uses the anchor driver as the reduction tool, obviating the need for traction sutures or other assistive devices. Second, the lateral (i.e., distal) row of anchors allows for differential tensioning of the sutures from different medial row anchors without the need for knot tying. The crossed sutures compress a broader area. This latter step is time efficient and may provide for a more even distribution of forces with each lateral anchor. The described arthroscopic suture-bridge technique for displaced greater tuberosity fractures is quick, reproducible, and versatile. It allows anatomic reduction and fixation of greater tuberosity fractures with an all-arthroscopic technique. In addition, it is especially well suited for comminuted fractures, because fixation
960
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is dependent on the bone at the articular margin and lateral metaphysis of the humerus and not on the fragment itself. REFERENCES 1. Green A, Izzi Jr J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg 2003;12:641649. 2. Carrera EF, Matsumoto MH, Netto NA, Faloppa F. Fixation of greater tuberosity fractures. Arthroscopy 2004;20:e24. 3. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy 2006;22:1360.e1-1360.e5. 4. Bhatia DN, van Rooyen KS, du Toit DF, de Beer JF. Surgical treatment of comminuted, displaced fractures of the greater
5. 6.
7. 8. 9.
tuberosity of the proximal humerus: A new technique of double-row suture-anchor fixation and long-term results. Injury 2006;37:946-952. Neer CSI. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Joint Dis 1997;56:171-176. Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 2000;16:695-700. Ji JH, Kim WY, Ra KH. Arthroscopic double-row suture anchor fixation of minimally displaced greater tuberosity fractures. Arthroscopy 2007;23:e1131-e1134. Cadet ER, Ahmad CS. Arthroscopic reduction and suture anchor fixation for a displaced greater tuberosity fracture: A case report. J Shoulder Elbow Surg 2007;16:e6-e9.
Arthroscopic Reduction and Fixation With Suture-Bridge Technique for Displaced or Comminuted Greater Tuberosity Fractures Hyun Seok Song, M.D., and Gerald R. Williams Jr., M.D.
Abstract: The arthroscopic suture-bridge technique (transosseous equivalent technique) was initially described for increasing the footprint size during arthroscopic rotator cuff repair. We describe a method in which the same principles are used to fix a displaced or comminuted greater tuberosity fracture. The technique involves reducing the displaced fragment with two medially placed, transtendinous anchors and compressing the greater tuberosity using the sutures from these medial anchors in two laterally placed anchors. The two medial anchors are inserted through the junction of the cuff and fragment. The anchor driver can be used as a joystick to reduce the fragment into position. One suture limb of each anchor is passed back through the tendon 5 mm from the original anchor insertion point in the tendon. With the scope in the subacromial space, the sutures from the medial anchors are tied in a mattress configuration. The four suture ends are passed distally over the greater tuberosity and incorporated into two PushLock anchors (4.5 mm; Arthrex, Naples, FL) using the suture-bridge technique. The postoperative rehabilitation protocol is similar to that for rotator cuff repairs. Key Words: Anchor fixation—Greater tuberosity fracture—Shoulder arthroscopy—Suture-bridge technique—Transosseous equivalent technique.
I
solated greater tuberosity fractures constitute 17% to 21% of proximal humeral fractures.1 Greater tuberosity fractures occur in 15% to 30% of the glenohumeral dislocations.1 Reported results of open reduction and internal fixation have been good. Arthroscopic management may offer better visualization and mobilization of the fragment, as well as visualization and treatment of any associated intra-articular pathol-
From the Department of Orthopedic Surgery, St. Paul’s Hospital, The Catholic University of Korea (H.S.S.), Seoul, Korea; and The Rothman Institute of Orthopedics at Thomas Jefferson University (G.R.W.), Philadelphia, Pennsylvania, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Hyun Seok Song, M.D., Department of Orthopaedic Surgery, St. Paul’s Hospital, The Catholic University of Korea, 620-56 Jeonnong-dong, Dongdaemun-gu, Seoul 130-709, Korea. E-mail: hssongmd@ yahoo.com © 2008 by the Arthroscopy Association of North America 0749-8063/08/2408-7593$34.00/0 doi:10.1016/j.arthro.2008.01.009
956
ogy. Open or arthroscopic2 screw fixation techniques may have some limitations with regard to the management of comminuted fragments. The arthroscopic suture-bridge technique (transosseous equivalent technique) has been recently used for double row repair of rotator cuff tears.3 This technique can compress the cuff with several sutures interconnecting two anchors across the broader area. The present report describes application of the arthroscopic suture-bridge technique for displaced or comminuted greater tuberosity fractures of the humerus. SURGICAL TECHNIQUE A typical patient may present with a two-part greater tuberosity fracture-dislocation and the greater tuberosity may be one large fragment (Fig 1A) or a series of comminuted fragments (Fig 2A). In many cases, reduction of the humeral head will result in anatomic reduction of the greater tuberosity. How-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 8 (August), 2008: pp 956-960
SUTURE-BRIDGE TECHNIQUE FOR TUBEROSITY FRACTURES
957
FIGURE 1. Case 1. (A) Anteroposterior radiograph of right shoulder of a 47-year-old male showing a displaced greater tuberosity fracture, without comminution, following anterior glenohumeral dislocation. (B) Postreduction magnetic resonance image, T1 obliquecoronal view, showing a displaced fragment. Treatment involved 2 medial metal anchors and 2 lateral bioabsorbable anchors using the suture-bridge technique. (C) Radiograph showing the anatomic healing 7 months postoperatively.
ever, residual displacement of the fragment may be encountered (Fig 1B). With the patient in the beach chair position, a standard posterior portal is used to examine the glenohumeral joint. Pump pressure should be carefully monitored to prevent soft tissue swelling. A routine examination of the joint is undertaken to identify any labral, chondral, or rotator cuff lesions. The displaced greater tuberosity fragment attached to the supraspinatus can be easily identified. The
edge of the fragment and the crater of the fractures are debrided. The arthroscope is moved into the subacromial space and a bursectomy is performed, particularly around the lateral margin of the fracture and the adjacent intact metaphyseal cortex, in order to improve visualization and ease insertion of the lateral anchors. The arthroscope is reinserted into the glenohumeral joint through the posterior portal. After localization with a spinal needle, a suture anchor (5.0 mm Cork-
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H. S. SONG AND G. R. WILLIAMS
FIGURE 2. Case 2. (A) Anteroposterior postreduction radiograph of left shoulder of a 29-year-old man showing a comminuted, displaced fracture of the greater tuberosity. He had had 3 previous dislocations requiring reduction before this episode. Treatment involved 2 medial bioabsorbable anchors and 2 lateral bioabsorbable anchors using the suture-bridge technique. (B) Postoperative anteroposterior radiograph showing reduction of comminuted fragments of the greater tuberosity.
screw or Bio-Corkscrew FT; Arthrex) is passed percutaneously into the joint through the supraspinatus tendon–tuberosity junction 5 mm posterior to the most anterior extent of the fragment. After approximately half the length of the anchor is passed through the cuff, the anchor driver can be used as a joystick to reduce the fragment into an anatomic location. Care should be taken to avoid over-reduction in the region of the bicipital groove, as this can cause pain from bicipital tendon irritation.4 After reduction of the fragment, the anchor is inserted into the articular margin of the humerus (Fig 3A). To make a medial mattress suture configuration, a spinal needle is passed percutaneously through the tendon– bone junction of the fragment 5 mm posterior to the entry hole of the anchor. A No. 2 monofilament (nylon) or suture-relaying device (Shuttle Relay Suture Passer; Conmed Linvatec, Largo, FL) is used to shuttle the suture that was retrieved through the anterior portal back through the tendon. A second medial anchor is inserted 1.5 cm posterior to the first one using a similar technique. The arthroscope is then moved back into the subacromial space. The posterior portal is usually adequate. However, if visualization of the most anterior extent of the fragment is difficult, the scope can be
moved to a posterolateral portal. The medial mattress sutures are then tied under direct visualization. One strand of each suture from each medial anchor is retrieved through the lateral cannula. After punching the intact lateral cortex of the humerus distal to the fragment, a PushLock anchor (4.5 mm; Arthrex) is inserted using the suture-bridge technique. The insertion point of the lateral anchor should be more than 5 mm from the fracture margin to prevent cracking the cortex and loosening of the anchors. The degree of compression is adjusted under direct visualization. Reduction of the fragment can be seen from both the bursal and articular surfaces (Fig 3B) and confirmed using postoperative radiographs (Fig 2B). The postoperative rehabilitation protocol is similar to that for rotator cuff repairs. Pendulum exercise, passive elevation, and external rotation (to 20°) exercises are commenced within the first 7 to 10 postoperative days. Active exercise and strengthening are delayed until the sixth postoperative week. DISCUSSION Controversy exists regarding the amount of displacement that requires operative reduction and stabilization. Neer5 suggested open reduction and internal
SUTURE-BRIDGE TECHNIQUE FOR TUBEROSITY FRACTURES
959
FIGURE 3. Case 1. (A) Arthroscopic findings of the displaced greater tuberosity fracture seen in Fig 1 as visualized from the posterior portal during reduction. (B) The anatomic restoration of the articulo-tendinous junction by the correct placement of the medial anchors and the proper knotting of the medial mattress sutures. (Abbreviations: BLH, long head of the biceps; C, corkscrew anchor; HH, humeral head; P, probe; S, shaver; SSP, supraspinatus tendon).
fixation for greater tuberosity fractures displaced more than 1 cm. Park et al.6 suggested that fractures with 3 mm of displacement should be reduced in athletes and heavy laborers who are involved in overhead activity. Green and Izzi Jr.1 also suggested that even small amounts of displacement could affect shoulder function. Moreover, symptomatic greater tuberosity malunion may cause a substantial number of symptoms that might require surgical intervention.6,7 Two fixation techniques using suture anchors in a double row configuration have also been reported. In both methods, a medial row of anchors is placed in a fashion similar to our method. The methods differ from one another in the manner in which the lateral row of anchors is incorporated into the fixation construct. In one method, the sutures from the lateral (i.e., distal) row of anchors are passed through the bone– tendon junction of the fragment lateral to the mattress sutures from the medial row using an open incision4 or an arthroscopic technique using C-arm guidance.8 In the other method, the suture from the medial anchor that was shuttled through the eyelet of the lateral anchor was tied over the tuberosity.9 In the first method, the fragment is “buttressed” by the lateral sutures. In the second method, the fragment is compressed directly into the fracture bed by the overlying sutures. The modification of the arthroscopic suture-bridge technique that we describe is really a two-stage technique. In the first stage, the fragment is reduced; in the second stage, the fragment is compressed into the
fracture bed. Reduction is obtained by partially passing the suture anchor through the tendon and using the anchor driver as a joystick to position the fragment before driving the anchor into the intact humerus. Once the medial row sutures have been tied, thereby reducing the fragment, they are crossed over the fragment and incorporated into a second row of anchors distal to the fragment. This accomplishes the second stage of the procedure; namely, compression of the fragment into its fracture bed. The method that we describe is similar to the previously reported suture anchor techniques in that it uses a double row anchor configuration characterized by a medial row at the articular margin and a lateral row distal to the greater tuberosity fragment. However, it is different from these previously described techniques in at least two ways. First, our technique uses the anchor driver as the reduction tool, obviating the need for traction sutures or other assistive devices. Second, the lateral (i.e., distal) row of anchors allows for differential tensioning of the sutures from different medial row anchors without the need for knot tying. The crossed sutures compress a broader area. This latter step is time efficient and may provide for a more even distribution of forces with each lateral anchor. The described arthroscopic suture-bridge technique for displaced greater tuberosity fractures is quick, reproducible, and versatile. It allows anatomic reduction and fixation of greater tuberosity fractures with an all-arthroscopic technique. In addition, it is especially well suited for comminuted fractures, because fixation
960
H. S. SONG AND G. R. WILLIAMS
is dependent on the bone at the articular margin and lateral metaphysis of the humerus and not on the fragment itself. REFERENCES 1. Green A, Izzi Jr J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg 2003;12:641649. 2. Carrera EF, Matsumoto MH, Netto NA, Faloppa F. Fixation of greater tuberosity fractures. Arthroscopy 2004;20:e24. 3. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy 2006;22:1360.e1-1360.e5. 4. Bhatia DN, van Rooyen KS, du Toit DF, de Beer JF. Surgical treatment of comminuted, displaced fractures of the greater
5. 6.
7. 8. 9.
tuberosity of the proximal humerus: A new technique of double-row suture-anchor fixation and long-term results. Injury 2006;37:946-952. Neer CSI. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Joint Dis 1997;56:171-176. Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 2000;16:695-700. Ji JH, Kim WY, Ra KH. Arthroscopic double-row suture anchor fixation of minimally displaced greater tuberosity fractures. Arthroscopy 2007;23:e1131-e1134. Cadet ER, Ahmad CS. Arthroscopic reduction and suture anchor fixation for a displaced greater tuberosity fracture: A case report. J Shoulder Elbow Surg 2007;16:e6-e9.