Irreducible Posterior Shoulder Dislocation With Concomitant Fracture of Both the Greater and Lesser Tuberosity: An Extremely Rare Shoulder Injury.

Posterior shoulder dislocation is a relatively rare injury representing only 5% of all shoulder dislocations. It is usually the result of a high-energy trauma or an epileptic seizure. Diagnosis is challenging with half of these injuries missed in the emergency room (ER). Often the dislocation is accompanied by a lesser tuberosity fracture as a result of the impact between the posterior glenoid and the proximal humerus. Additionally, fractures of the greater tuberosity or even the metaphysis are extremely rare, and their treatment remains challenging. We present a rare case of posterior locked shoulder dislocation with a concomitant lesser and greater tuberosity fracture in a young patient. A 29-year-old male was brought to the ER following a motor vehicle accident. The patient reported significant pain and inability to move his left shoulder. The arm was locked in an internal rotation and was neurovascularly intact. Simple radiographs revealed a locked posterior dislocation with fractures of both the lesser and greater tuberosity. The CT scan confirmed the fracture pattern and excluded metaphyseal fracture. Surgical treatment was decided. Under general anesthesia and a classic thoracodeltoid approach, both tuberosities were recognized and the dislocation was gently reduced. Fixation of the tuberosities with an anatomic plate and Ethibond No. 5 sutures was performed. He was discharged the next day with a 30-degree abduction sling cast. He was instructed to perform passive shoulder and scapula exercises once a day. After one month, the sling was removed and active elevation and rotation exercises were started. Plane X-rays were performed at one, six, and twelve months. The reduction remained stable and the patient recovered full range of motion with a slight loss of external rotation (10 degrees) compared to the contralateral limb. He returned to his previous activities without any complications. Posterior shoulder dislocations with additional fractures of the tuberosities are rare and severe injuries requiring open surgery as the humeral head may remain locked prohibiting closed reduction. Even after the reduction, the stable fixation of the tuberosities is crucial for shoulder stability and postoperative clinical and functional results.

Bilateral Divergent Fracture Dislocations in a COVID-19 Patient Following a Hyponatremia-Induced Seizure.

Bilateral divergent fracture dislocations of the shoulder are very rare. Caution with regards to seizure development in COVID-19 patients must be taken to avoid such injuries. This is the case of a male COVID-19 patient who sustained hyponatremia-induced seizure that resulted in bilateral divergent shoulder fracture dislocations. The patient suffered a lesser tuberosity fracture on his left shoulder which was posteriorly dislocated, and a greater tuberosity fracture on his right, which was anteriorly dislocated. The patient underwent bilateral open reduction and internal fixation, with suture anchor fixation for the lesser tuberosity fracture on the left side, and a proximal humerus locking plate for the greater tuberosity fracture on the right side. Education on postoperative complications and expectations were provided to the patient.

The effect of integrity of lesser tuberosity-medial calcar on postoperative outcome in the proximal humeral fracture.

BACKGROUND: In proximal humeral fractures, the medial calcar is often considered an important stabilizing structure. When the medial calcar is disrupted, some patients may have accompanying humeral lesser tuberosity comminution that has not been noticed. To investigate the impacts of comminuted fragments of lesser tuberosity and calcar on postoperative stability, CT results, number of fragments, cortical integrity, and the variation of neck-shaft angle were compared in patients with proximal humeral fractures. MATERIALS AND METHODS: From April 2016 to April 2021, this study included patients with senile proximal humeral fractures diagnosed by CT three-dimensional reconstruction with lesser tuberosity fractures and medial column injuries. The number of fragments in the lesser tuberosity and the continuity of medial calcar were evaluated. Postoperative stability and shoulder function were evaluated by comparing changes in neck-shaft angle and the DASH upper extremity function score from 1 week to 1 year after the operation. RESULTS: A total of 131 patients were included in the study, and the results showed that the number of fragments of the lesser tuberosity was related to the integrity of the medial cortex of the humerus. That is, when there were more than two lesser tuberosity fragments, the integrity of humeral medial calcar was poor. The positive rate of the lift-off test was higher in patients with lesser tuberosity comminutions 1 year after surgery. In addition, patients with more than two lesser tuberosity fragments and continuous destruction of the medial calcar had large variations in the neck-shaft angle, high DASH scores, poor postoperative stability, and poor recovery of shoulder joint function 1 year postoperatively. CONCLUSION: The number of humeral lesser tuberosity fragments and the integrity of the medial calcar were associated with the collapse of the humeral head and the decrease in shoulder joint stability after the proximal humeral fracture surgery. When the number of lesser tuberosity fragments was greater than two and the medial calcar was damaged, the proximal humeral fracture had poor postoperative stability and poor functional recovery of the shoulder joint, which required auxiliary internal fixation treatment.

Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use.

BACKGROUND: This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing. METHODS: An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively. RESULTS: A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037). CONCLUSION: A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Is lesser tuberosity morphology related to subscapularis tears and anterior shoulder instability?

PURPOSE: Although the morphological relationship of the scapula and the humeral head has been claimed to be related to shoulder pathologies, few studies examined the relationship between subscapularis (Ssc) tears and lesser tuberosity (LT)-humeral head (HH) and between Ssc tears and HH-glenoid. This study aims to evaluate the relationship of LT with HH and glenoid in patients with Ssc tears and anterior shoulder instability (ASI). We hypothesized that the glenoid, HH, and their combined relationship with LT may impact Ssc tears and ASI. MATERIAL AND METHODS: The study included 34 patients with ASI, 28 patients with isolated Ssc tears, and 40 patients as the control group. The radius of HH (Hr), the distance between the center of HH and LT (LTr), and the glenoid radius (Gr) were measured in shoulder magnetic resonance (MR) images. The LTr to Hr (LTr/Hr) ratio was defined as the lesser tuberosity-humeral head index (LTHHI), whereas the LTr to Gr (LTr/Gr) ratio was defined as the lesser tuberosity-glenoid index (LTGI). The three groups were compared regarding LTHHI, LTGI, LTr, Hr, and Gr. RESULTS: There was a significant difference between each group concerning LTGI (p < 0.001). LTGI values below 1.99 showed 93.1% sensitivity and 93.3% specificity for Ssc tears, while values above 2.24 showed 86.7% sensitivity and 86.2% specificity for ASI. Also, there was a significant difference when the groups were compared for LTHHI (p < 0.001). This rate was lowest for Ssc tears, and LTHHI values below 1.17 showed 82.8% sensitivity and 80.1% specificity. CONCLUSION: LTGI may be a new predictive factor showing 93.1% sensitivity and 93.3% specificity for Ssc tears and 86.7% sensitivity and 86.2% specificity for ASI. In addition, LTHHI may be a new predictive factor showing 82.8% sensitivity and 80.1% specificity for Ssc tears. LEVEL OF EVIDENCE: III retrospective comparative study.

The rate and predictors of healing of repaired lesser tuberosity osteotomy in reverse total shoulder arthroplasty.

Background: Evidence is building that a functional subscapularis improves function-specifically internal rotation tasks-following reverse total shoulder arthroplasty (rTSA). However, the optimal method for subscapularis repair during rTSA remains unknown with variable healing rates reported. This study aims to investigate the rate of and predictors for healing a lesser tuberosity osteotomy (LTO) following rTSA. Methods: Following local institutional review board approval, patients with at least one-year follow-up for rTSA managed with an LTO and subsequent repair between March, 2017 and March, 2020 were retrospectively identified. Shoulders were selected for LTO repair based upon preoperative imaging and intraoperative assessment of subscapularis quality. All patients were implanted with a system consisting of a 150° or 155° (constrained) humeral neck-shaft angle and 2.5 to 4.5 millimeters (mm) of glenoid lateralization (Trabecular Metal Reverse Shoulder System; Zimmer Biomet, Warsaw, IN, USA). At a minimum of six months, radiographs were reviewed for an assessment of LTO healing by three independent reviewers. Healing was classified as displaced, fibrous union, or ossified union. For assessing predictors, the repair was considered intact if the LTO fragment was not displaced (fibrous union or ossified union). Results: Sixty-five rTSA with LTO repair were performed in 64 patients. These patients had an average age of 67.2 years (range, 31-81) and 36 (55.4%; 36/65) were female. At an average follow-up of 15.2 months (range, 8-38), 50 cases (76.9%; 50/65) were classified as having an ossified union. The radiographic healing could not be assessed in a single case. Of the 14 cases without ossific union, 8 (12.3%; 8/65) were displaced and 6 (9.2%; 6/65) were classified as a fibrous union. In logistic regression, only combined humeral liner height predicted LTO displacement (odds ratio = 1.4 [95% confidence interval = 1.1-1.8]; P = .01). Humeral loosening was not found in any cases following LTO. Conclusion: This analysis demonstrates that radiographic healing of LTO repair is more favorable than published rates of healing after subscapularis tenotomy or peel in the setting of rTSA. Subscapularis management with LTO provides the ability to monitor repair integrity with plain radiographs and a predictable radiographic healing rate. The integrity of subscapularis repair may be influenced by the use of thicker humeral liners. Further investigation is needed to determine the functional impact of a healed subscapularis following rTSA.

Simultaneous isolated avulsion fractures of the lesser tuberosities of the humeri: A rare occurrence secondary to alcohol withdrawal seizures.

Fractures of the lesser tuberosity of the humerus are typically traumatic in nature, most commonly occurring in association with multi-part fractures of the humeral head, often in the setting of a posterior shoulder dislocation. Isolated fractures of the lesser tuberosity are considerably more rare and are difficult to diagnose on standard shoulder radiographs without an axillary view. These fractures have been associated with 3 main types of injury: acute abduction/external rotation injury, acute injury or repetitive stress injury in adolescent overhead or throwing athletes, and rarely as a seizure associated injury. The mechanism of injury in these cases has been posited to relate to the subscapularis tendon, either resisting forced abduction/external rotation in the setting of trauma, exerting chronic or acute avulsive traction in the setting of adolescent overhead or throwing athletes, or violently contracting and avulsing the lesser tuberosity in the setting of seizures. We present an unusual case of a 27-year-old male with a history of alcohol use disorder with bilateral shoulder pain after minor trauma and observed seizure-like activity. Clinical work-up revealed bilateral isolated avulsion fractures of the lesser tuberosities, which was thought to be on the basis of seizure-related violent contraction of the subscapularis muscles. The clinical relevance of this case is that a high clinical index of suspicion is needed in order to detect lesser tuberosity avulsion fractures and avoid the consequences of untreated injury such as instability or impingement.

Combined Greater and Lesser Tuberosity Fracture of Proximal Humerus with Intact Humeral Head and Shaft - A Case Report.

Introduction: Combined fracture of greater and lesser tuberosity is an extremely rare injury. Such fracture pattern has not been described in the Neer's, AO Muller, and Jakob's classification system. Case Presentation: We report a unique fracture pattern consisting of combined greater and lesser tuberosity of the proximal humerus (PH) with intact humeral head and shaft in a 32-year-old female. Routine radiographs and computed tomography scan with three-dimensional reconstruction were advised for better understanding of the fracture pattern, later managed by open reduction and fixation with PH locking plate. The patient has excellent clinical, radiological, and functional outcome at the end of 2 years follow-up. Conclusion: This is one among the few case reports highlighting this unique variant of PH fracture, not much has been described in the literature about this injury. Anatomic reconstruction of the fractured tuberosities combined with stable construct by PH locking plate facilitates optimum bone healing and aggressive shoulder rehabilitation.

Functional internal rotation is similar between lesser tuberosity osteotomy and subscapularis peel in total shoulder arthroplasty: short-term follow-up.

INTRODUCTION: Lesser tuberosity osteotomy (LTO) and subscapularis peel (Peel) are 2 common techniques used to mobilize the subscapularis tendon during anatomic total shoulder arthroplasty (TSA). The literature is inconclusive over which technique is optimal; thus, controversy exists over which technique should be performed. The purpose of this study was to compare specific functional internal rotation tasks and general outcome scores in TSA patients who received either an LTO or Peel. METHODS: A retrospective review of 563 patients treated with primary TSA using either an LTO (n = 358) or Peel (n = 205) with a minimum 2-year follow-up was performed. Subjective internal rotation, active internal rotation, and specific questions related to functional internal rotation isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons functional questionnaires were reviewed. Other outcome scores including visual analog scale pain and function, Single Assessment Numerical Evaluation, SST, American Shoulder and Elbow Surgeons, and revision rates were compared between the 2 groups. RESULTS: The study found no difference in postoperative functional internal rotation and range of motion between LTO and Peel. Patients who received a Peel were shown to have a slightly greater improvement in the ability to perform toileting and a higher average change in SST score that did not reach clinical significance. There was no difference in the percentage of maximal improvement, revision rate, or need for revision between the 2 groups. CONCLUSION: No difference was found between the LTO and Peel techniques in regard to functional tasks of internal rotation at short-term follow-up.

Fractura aislada de troquín. Presentación de un caso y revisión bibliográfica / Isolated troquin fracture. Presentation of a case and bibliographic review

La fractura avulsión de la tuberosidad menor humeral aislada es extremadamente rara.Es una lesión difícil de diagnosticar pasando, muchas veces, desapercibida.Se presenta el caso de una paciente de 64 años con una fractura aislada de troquín.El tratamiento que se decidió en esta paciente fue quirúrgico mediante reducción abierta y os- teosíntesis con tornillos además de suturas quirúr- gicas de los fragmentos.Existe evidencia a favor de que cualquier des- plazamiento es susceptible de tratamiento quirúr- gico con el fin de evitar un desplazamiento ma- yor de la misma, la pseudoartrosis del fragmento avulsionado, un pinzamiento anteromedial y una posible luxación del tendón del bíceps, además de la limitación funcional para la rotación interna del brazo. (AU)

Isolated humerus lesser tuberosity avulsion fracture is extremely rare.It is a difficult injury to diagnose, often going unnoticed.The case of a 64-year-old patient with an iso- lated troquin fracture is presented.The treatment that was decided in this patient was surgical by means of open reduction and oste- osynthesis with screws in addition to surgical su- turing of the fragments.There is evidence that any displacement is susceptible to surgical treatment in order to avoid further displacement of the displacement, pseu- doarthrosis of the avulsed fragment, an anterome- dial impingement and a possible dislocation of the biceps tendon, in addition to functional limitation for the internal rotation of the arm. (AU)

Cow-hitch fixation in fracture hemiarthroplasty.

BACKGROUND: The treatment of complex proximal humerus fractures with hemiarthroplasty is associated with a high failure rate due to secondary displacement of the tuberosities. It was the aim of this in-vitro study to compare the mechanical stability of tuberosity reattachment obtained with the so-called "Cow-Hitch" (CH) cerclage compared with conventional tuberosity reattachment. METHODS: A 4-part proximal humerus fracture was created in 10 fresh-frozen, human cadaveric shoulders. The greater and lesser tuberosity were reattached to the hemiarthroplasty stem with in total 4 CH Cerclages in the Cow-Hitch group. The conventional technique-recommended for the tested implant-was used in the control group using 6 sutures. A total of 5000 loading cycles with forces of 350N were applied, while motion (in mm) of the tuberosities was recorded in 3 directions (anteroposterior = AP, mediolateral = ML, inferosuperior = IS) with a telecentric camera. RESULTS: After 5000 loading cycles, the CH group showed less fragment displacement (AP: 2.3 ± 2.3 mm, ML: 1.8 ± 0.9 mm, IS: 1.3 ± 0.5 mm) than the conventional group (AP: 9.8 ± 12.3 mm, ML: 5.5 ± 5.6 mm, IS: 4.5 ± 4.7 mm). The differences were not statistically significant (AP: P = .241; ML: P = .159; IS: P = .216). The lesser tuberosity fragment displacement in the CH group after 5000 cycles was less in the AP (2.3 ± 3.3 vs. 4.0 ± 2.8, P = .359) and IS (1.9 ± 1.2 vs. 3.1 ± 1.8; P = .189) directions but higher in the ML direction (7.2 ± 5.7 vs 6.3 ± 3.6, P = .963). CONCLUSIONS: In-vitro, "Cow-Hitch" cerclage results in mean greater tuberosity displacements of 2 mm and reliably prevents displacements greater than 5 mm. In contrast, the conventional fixation technique yields unreliable, variable stability with low to complete displacement upon cyclical loading.

Arthroscopic Fixation of Avulsion Fractures of the Lesser Tuberosity of the Humerus: Clinical Outcomes With a Mean 3.5-Year Follow-up.

BACKGROUND: Avulsion fracture of the lesser tuberosity (AFLT) of the humerus has traditionally been treated with open reduction internal fixation using screw fixation. The clinical outcomes of arthroscopic repair with suture anchors remains unknown. HYPOTHESIS: It was hypothesized that arthroscopic fixation with suture anchors would result in good clinical outcomes for the treatment of AFLT. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 15 patients who underwent arthroscopic repair of AFLT of the humerus between January 2014 and October 2017. All patients had 3-dimensional computed tomography scans and magnetic resonance imaging to evaluate the avulsed fracture and concomitant injuries before surgery. The arthroscopic double-row and suture-bridge techniques were used based on the morphology of the avulsion fractures. Functional outcomes were assessed with range of motion, the visual analog scale (VAS) for pain, the Subjective Shoulder Value (SSV), the American Shoulder and Elbow Surgeons (ASES) score, and the University of California, Los Angeles (UCLA) shoulder score. The bear-hug test, liftoff test, and internal rotation resistance test at 90° abduction and external rotation (IRRT 90°) were used to evaluate subscapularis tendon integrity. RESULTS: The mean follow-up time was 3.5 years (range, 3-5 years). Comminuted fractures with 1 large part and ≥1 small pieces were seen in 12 cases, partial tear of the supraspinatus in 2 cases, Bankart lesion in 2 cases, and superior labrum anterior to posterior injury in 2 cases. There was a statistically significant improvement from the baseline to the final follow-up in the VAS (from 6.9 ± 1.5 to 1.1 ± 1), SSV (from 30.7 ± 5.1 to 90.5 ± 11.6), ASES (from 28.5 ± 7.7 to 92.3 ± 4.5), and UCLA (from 29.5 ± 6.3 to 94.2 ± 8.3) scores (P < .001 for all). All patients showed full range of shoulder motion and bilateral symmetric strength on physical examination with the bear-hug test, liftoff test, and IRRT 90° test. CONCLUSION: The arthroscopic repair of AFLT resulted in excellent reduction and healing of the displaced fragment. At the final follow-up, clinical and functional results were good. Associated injuries occurred in 40% of patients but did not affect outcomes.

What are the patient-reported outcomes, functional limitations, and complications after lesser tuberosity fractures? a systematic review of 172 patients.

BACKGROUND: Lesser tuberosity fractures are relatively rare, with an incidence of 0.46 per 100,000 persons per year. This systematic review was performed to address patient-reported outcomes (PROMs), shoulder function, and complications after lesser tuberosity fractures in pediatric and adult patients, as well as patients with an associated posterior shoulder dislocation. Within these groups, identical outcomes were evaluated for nonoperative, surgical, acute and delayed treatment. METHOD: A comprehensive search was carried out in multiple databases. Articles were included if patients sustained a lesser tuberosity fracture without a concomitant proximal humerus fracture. There were no restrictions on age, type of treatment, fragment displacement, time to presentation, or associated injuries. RESULTS: One thousand six hundred forty-four records were screened for eligibility of which 71 studies were included (n = 172). Surgical treatment was provided to 50 of 62 (81%) pediatric patients, 49 of 66 (74%) adults, and 34 of 44 (77%) patients with an associated posterior shoulder dislocation. In the pediatric group, the mean of PROMs was 94 (range 70-100) and among adults 89 (range 85-100). In the posterior shoulder dislocation group, 89% did not regain full range of motion and the complication rate was 17%. In pediatric patients, surgery was associated with fewer complications (P = .021) compared to nonoperative treatment. CONCLUSION: Pediatric patients have excellent outcomes after lesser tuberosity fractures and respond well to surgical treatment. Adults have acceptable outcomes but patients with an associated posterior shoulder dislocation have impaired range of shoulder movement and are more likely to develop complications.

Humeral lesser tuberosity avulsion fractures - magnetic resonance imaging characteristics in the pediatric population.

BACKGROUND: Avulsion fractures of the humeral lesser tuberosity are rare injuries in skeletally immature patients and can pose a diagnostic challenge that often leads to delayed identification. OBJECTIVE: To describe the demographics, mechanism of injury and magnetic resonance imaging (MRI) findings of lesser tuberosity avulsion fractures in children. MATERIALS AND METHODS: A retrospective search of children with lesser tuberosity avulsion fractures on MRI was done. Available radiographs were evaluated. Demographics, mechanism of injury, MRI characteristics and treatment were recorded. RESULTS: Thirteen children, all male, were included (median age: 13.8 years, range: 12.5-16.8 years). The most common mechanism was blunt, overhead or hyperextension traumatic injury related to sports. All patients were skeletally immature and 10/13 demonstrated isolated avulsion fractures at the footprint. Only one patient had associated osteochondral injury to the humeral head and labral tear. Two children demonstrated medial dislocation/subluxation of the biceps tendon. The median size of the avulsed fragment was 15 mm (range: 5-29 mm), median anteroposterior displacement was 3 mm (range: 0-6 mm) and medial displacement was 1 mm (range: 0-20 mm). There was no correlation between age and the size of the avulsed fragment (P=0.29). Common injury patterns were complete avulsion of the subscapularis footprint (6/13) and partial avulsion of inferior footprint (6/13). Two-thirds of the radiographs were initially reported as normal, but retrospectively showed two missed fractures. One of the initial radiographs raised concern for bone tumor. The best view for identifying an avulsion fragment was the axillary view. Seven patients of the 13 patients underwent internal fixation. CONCLUSION: Avulsion fractures of the lesser tuberosity are rare, challenging to diagnose and often radiographically occult. MRI can identify the injury at the subscapularis tendon footprint with variable size and displacement. The long head of the biceps tendon is usually normal in location. Although this entity is rare, radiologists should be aware of it to allow for correct and prompt diagnosis and prevent unnecessary biopsy or contrast administration.

Distal tibia allograft glenoid reconstruction for shoulder instability: outcomes after lesser tuberosity osteotomy.

BACKGROUND: Distal tibia allograft reconstruction of the glenoid in shoulder instability has garnered significant attention over the last decade. Prior studies demonstrate significant improvement in all reported patient outcomes albeit the approach is through a subscapularis split. There have not been prior studies evaluating outcomes after lesser tuberosity osteotomy which provides excellent exposure to the anterior glenoid.We hypothesize there is significant improvement in functional outcomes and no deleterious effects after lesser tuberosity osteotomy for distal tibia allograft reconstruction of the glenoid for shoulder instability. METHODS: A retrospective review was performed from 2016 of 2019 of patients undergoing distal tibia allograft reconstruction of the glenoid through a lesser tuberosity osteotomy. Patients were indicated if they had recurrent anterior shoulder instability with >20% glenoid bone loss and evidence of an off-track lesion. Clinical, imaging, and operative data were evaluated. Objective follow-up data evaluated at minimum 2 years included radiographs, range of motion, DASH, SANE, VAS, SST, ASES, and Constant scores. RESULTS: A total of 12 patients were available with average follow-up 28 months, average age 26 years old, and average glenoid bone loss of 33%. The patients demonstrated significant improvement in their clinical outcomes at final follow-up: DASH 42.9-8.9 (P = .004), SANE 32.2-85 (P = .00005), VAS 4.6-1.1 (P = .003), SST 7-11.4 (P = .01), ASES 50.2-90.5 (P = .001), and Constant 37.6-86.2 (P = .01). Range of motion at final follow-up was forward flexion to 161.4° (135-170°), external rotation 49.5° (40-65°), and internal rotation to T12-L1 (T7-L2) vertebral body. CONCLUSION: The present study demonstrates the effectiveness of a lesser tuberosity osteotomy in exposure of the glenoid for reconstruction with a distal tibia allograft. The functional integrity of the subscapularis is maintained and the patient-reported outcomes are comparable with current literature.

Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures-A Retrospective, Observational Study.

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.

Prediction of the anterior shoulder pain source by detecting indirect signs for partial articular subscapularis tendon tears through conventional magnetic resonance imaging.

PURPOSE: To evaluate the diagnostic efficacy of indirect signs for proximal articular-positioned, partial (< 50%), subscapularis tendon tears (facet 1 tears) via conventional magnetic resonance imaging (MRI). METHODS: A retrospective study was conducted on 67 patients of Yoo's type 1 or 2A tears. Forty-five arthroscopic subacromial decompression and acromioclavicular resection cases served as controls. Indirect signs indicating a facet 1 tear included small defects, superior subscapularis recess (SSR), long head of the biceps (LHBT) configurations, bone edema or cyst formation on lesser tuberosity (LTBEC), and fatty infiltration of subscapularis muscle. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were checked. RESULTS: SSR was the most sensitive sign (90%). The sensitivities and NPV of LHBT configurations and LTBEC were low (sensitivity: 42.9% and 17.9%, NPV: 56.4% and 44.4%, respectively). The specificities of all indirect signs were relatively high (> 90%). The Chi-squared test and multinomial logistic regression confirmed the significance of small defects, SSRs, and fatty infiltrations for facet 1 tears (p ≤ 0.014). The combined sensitivity and specificity were up to 97.7% and 92.3%, respectively, in the presence of either a small defect or an SSR. CONCLUSIONS: Conventional MRI alone can detect facet 1 tears through indirect signs (small defects, SSR, and fatty infiltrations of the subscapularis muscle), predicting unspecified anterior shoulder pain due to concealed biceps instability, and facilitating preoperative diagnosis for a facet 1 tear. LEVEL OF EVIDENCE: III.

Pedicled-lesser tuberosity osteotomy for glenohumeral joint exposure: a technical note and case report highlighting its use in allograft reconstruction of a large engaging reverse Hill-Sachs lesion after posterior shoulder dislocation.

Exposure of the humeral articular surface through an anterior approach to the shoulder for grafting humeral bone defects requires partial or complete detachment of the subscapularis tendon and traditionally is achieved through a subscapularis tenotomy, peel tuberosity osteotomy, or lesser tuberosity osteotomy. This case report presents a technique of performing a pedicled-lesser tuberosity osteotomy to allow adequate access for allograft reconstruction of a large reverse Hill-Sachs lesion after a traumatic posterior dislocation, to restore humeral head sphericity and prevent recurrent glenohumeral joint instability. The inferior subscapularis insertion is left intact leaving a periosteal sleeve and preserving the blood supply to the lesser tuberosity and humeral head, with the aim of improving healing of the osteotomy and preventing graft-related complications, such as resorption. Successful union of the pedicled-lesser tuberosity osteotomy and allograft was seen on a 6-month follow-upcomputed tomography scan, with adequate restoration of subscapularis function.

Lesser Tuberosity Avulsion Fracture: A Rare Case Report.

Introduction: Lesser tuberosity avulsion fractures are rare and often missed. Patients often complain only of heaviness around the shoulder and some loss in range of motion. Case Report: This is a rare case of a lesser tuberosity avulsion fracture with displacement. The patient was a 29-year-old male who suffered an injury to the right shoulder due to a fall. Post-fall, the patient developed typical heaviness and restrictions in the range of motion of his right shoulder. Radiographs initially taken were not true anteroposterior (AP) views. The fracture was primarily missed by another surgeon, after which on opting for a true AP radiographs, the fracture was diagnosed. The fracture was managed by an open deltopectoral approach. Fracture fragment was reduced to its footprint and was fixed using 2 × 4.0 mm cancellous screws. Post-surgery, the patient was advised 3 weeks of immobilization after which mobilization was started. By monitored physiotherapy, consistent results can be obtained without loss of reduction. In this case too, full ranges with strength were achieved by 3 months postoperatively. Conclusion: Such fractures often missed may cause loss of external rotation movements in the patient and eventually malunion of the fragment if displaced. Watchfulness and timely management of the fractures can give excellent results. This case report aims at increasing the awareness among the budding shoulder surgeons in identifying such injuries at the earliest, and the means of managing them.

Systematic review and network meta-analysis of subscapularis management techniques in anatomic total shoulder arthroplasty.

BACKGROUND: Controversy exists regarding the optimal subscapularis management technique in patients undergoing anatomic total shoulder arthroplasty. The purpose of this study was to compare clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (SP) techniques. METHODS: We performed a level III systematic review and network meta-analysis comparing ST, LTO, and SP in patients undergoing anatomic total shoulder arthroplasty. Our primary collection endpoints included range of motion, subscapularis function, subscapularis healing, functional patient-reported outcomes, complications, and revision surgery. Data were pooled and network meta-analysis was performed owing to the comparison of 3 groups. RESULTS: Eight studies met our inclusion criteria for meta-analysis. There was no difference in sex or primary diagnosis between the 3 cohorts. No significant difference was found in postoperative external rotation or forward flexion between the groups. Meta-analysis found the SP cohort to have significantly greater internal rotation strength than the ST cohort. The belly-press test results were negative most commonly in the LTO group, and there was a significant difference compared with the ST or SP group (P < .0001). The weighted-mean healing rate for the LTO site was 98.9% on radiographic imaging. There was a significantly higher ultrasound healing rate in the LTO cohort than in the ST and SP cohorts. All groups had good postoperative patient-reported outcome scores (average American Shoulder and Elbow Surgeons score range, 78.6-87) and a relatively low rate of complications (3%). CONCLUSION: This network meta-analysis demonstrates that the LTO group has superior healing and postoperative subscapularis-specific physical examination test results compared with the ST and SP groups. However, no difference in postoperative range of motion was found between the groups, and all techniques demonstrated good functional patient-reported outcomes, with a low rate of postoperative complications. These findings provide evidence-based support that ST, SP, and LTO all demonstrate similar outcomes; therefore, selection should be based on surgeon experience and comfort.