Greater Tuberosity Fracture of the Humerus: Arthroscopic Fixation

Abstract

Isolated fractures of the greater tuberosity are a relatively uncommon pathology and can lead to issues in strength, range of motion, and pain if not adequately reduced and fixed. Treatment decision mainly depends on the displacement of the fragment but most of the time it requires surgery because of the mechanics of the cuff that pulls on the fragment, making it unstable. If mistreated or unrecognized, the patients could develop chronic pain and limitations in range of motion that can lead to diminished function of the shoulder. Surgical alternatives include close reduction and percutaneous fixation, open or arthroscopic-assisted reduction, and internal fixation. In recent years, the advancements in shoulder arthroscopy have yielded arthroscopically assisted fixation techniques with encouraging results. The purpose of this Technical Note is to describe a suture bridge arthroscopic technique for treating a comminuted fracture of the greater tuberosity using multiple suture anchors. This technique has been found to be helpful in cases of greater tuberosity comminution to bridge the bony fragments.

Isolated fractures of the greater tuberosity (GT) of the humerus account for approximately 18% of isolated proximal humerus fractures.¹ Controversy still exists regarding the best treatment algorithm for proximal humerus fractures, especially in the elderly patient, but a surgical treatment is generally needed for young patients with a displaced fracture.² The rationale of surgery is to achieve an anatomic reduction with adequate fixation to restore the functionality of the rotator cuff. Fracture-specific parameters that determine the need for surgery are mainly related to displacement and comminution. McLaughlin et al.³ suggest surgical treatment when the fragment has 5 mm or more of displacement, whereas Park et al.⁴ report that in high-demand patients also a displacement as little as 3 mm is sufficient to deserve a surgical approach. Multiple surgical options are available to treat GT fractures, including closed reduction and percutaneous fixation, open reduction and internal fixation, and arthroscopic-assisted reduction and internal fixation. Open approaches are preferred for more comminuted fractures or largely displaced fractures, as reduction could be demanding to achieve arthroscopically. Nevertheless, shoulder arthroscopy, even if it could appear more demanding, can provide a more complete evaluation of the shoulder pathology and associated lesions.5, 6, 7 Moreover, it allows for different fixation techniques, such as using a suture bridge with multiple anchors, that are less invasive, do not require additional surgeries for removal, and have shown excellent results for the treatment of displaced GT fractures.⁸

In this Technical Note, we describe an all-arthroscopic technique for GT reduction and fixation using a suture bridge, double-row configuration with knotless suture anchors (Video 1). The advantages and disadvantages of this technique are outlined in Table 1.

Table 1.

Advantages and Disadvantages of the Arthroscopic Reduction and Internal Fixation of Greater Trochanter Fractures

Advantages	Disadvantages
Minimally invasive	Requires arthroscopy skills
Possibility to address concomitant lesions	Costs are greater than a traditional open technique
Better visualization of the fragments	Limited visibility in cases with severe bleeding
No hardware removal needed when using suture anchors

Surgical Technique

Preoperative Evaluation

Preoperative evaluation with standard anteroposterior, Grashey, scapular-Y, and axillary radiographs are obtained in the acute setting. Attention should be paid to evaluate possible associated fractures and fracture characteristics. However, it is often difficult to understand the fracture pattern only with radiographs and a magnetic resonance imaging or a computed tomography scan usually is needed. Magnetic resonance imaging helps evaluating rotator cuff integrity and the other soft-tissue structures around (Fig 1), whereas computed tomography scan can help to evaluate humeral head bone stock and defects as well as study the possible fracture comminution, which is quite common in GT fractures.

Fig 1.

Preoperative magnetic resonance imaging of a left shoulder including coronal T2 fat suppressed (A) and sagittal proton density fat-suppressed sequences (B), demonstrating the avulsion fracture of the greater tuberosity with multiple fragments (arrow). (G, glenoid; HH, humeral head.)

Patient Positioning and Portal Placement

Before positioning, the patient receives an interscalene nerve block, a single-shot PEC-II block, and general anesthesia with laryngeal mask airway. The patient is placed in beach-chair position and the arm is then prepped and draped in a sterile fashion and the operative extremity is placed in a commercially available arm holder. A standard posterior viewing portal is established with a 30° arthroscope, positioned 2 cm distal and in line with the posterolateral border of the acromion. Subsequently, a standard anterosuperior working portal is established under direct visualization. A diagnostic arthroscopy is performed in a standard fashion to evaluate the integrity of the intra-articular structures. The arthroscope is then placed in the subacromial space through the posterior portal, and a midlateral working portal (50-yard line portal) is established 2 to 3 cm lateral to the acromion, in line with the posterior edge of the acromioclavicular joint.

Arthroscopic Reduction and Internal Fixation

After addressing subacromial pathologies, the GT fracture is evaluated to determine the fracture pattern and the best possible suture configuration for fixation. Carefully, the fragment(s) are elevated and the bed gently debrided form the scar tissue or initial callus formations present with an arthroscopic shaver and a high-speed burr (Fig 2). This first part of the procedure is crucial in order to have a clear visualization of the fracture site and to achieve fracture healing exposing a vital bone surface. A second anterolateral portal is established against the lateral edge of the acromion, at about the 40-yard line, and an 8-mm PassPort cannula (Arthrex, Naples, FL) is introduced. Thereafter, the reducibility and mobility of the fragments are assessed with an arthroscopic grasper (Fig 3) and sequential scar releases are performed inferiorly and superiorly until an anatomic reduction of the fragments is achieved. It is then possible to proceed with the fixation of the fracture using suture anchors in a double-row or, in this case, a triple-row configuration, starting with three 4.75-mm PEEK (polyether ether ketone) SwiveLock anchors (Arthrex) medially spaced 1.5 cm apart. These are all placed far medially but just on the edge of the fracture bed and each limb of the suture tape from each anchor are passed through the rotator cuff just medial to the bony fragment. Moreover, the posterior limb of the posterior medial anchor is then passed through a lateral 4.75-mm PEEK knotless anchor positioned approximately 5 mm lateral to the posterior edge of the GT fracture to reduce the fragments into the fracture bed (Fig 4). After that, the following 2 lateral anchors are designed to achieve compression and are positioned sequentially from posterior to anterior in order to achieve a self-reinforcing interconnected construct (Fig 5). Furthermore, in the case that one of the fragments is not perfectly reduced, a fourth lateral anchor can be useful anteriorly, just lateral to the biceps groove, to provide anatomical reduction and compression (Fig 6). This bridging construct provides excellent compression and anatomic reduction of the fracture. The shoulder is then taken through a range of motion to check for the stability of the fracture. Pearls and pitfalls of the procedure are outlined in Table 2.

Fig 2.

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope. (A) Clear visualization of the fracture site and the fragments is critical before fixation. (B) An arthroscopic shaver is used to accurately debride the fracture site from any scar tissue or initial callus formations present. (FB, fracture bed; FG, fragment.)

Fig 3.

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope, an arthroscopic grasper is introduced from the accessory anterolateral portal. The mobility and reduction of the fracture fragments and rotator cuff are tested. (FB, fracture bed; FG, fragment; GT, greater tuberosity.)

Fig 4.

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) The first medial anchor is positioned medially within the fracture site. (B) Using a Scorpion suture passer (Arthrex, Naples, FL) the 2 limbs of the suture tape are passed through the rotator cuff, just medial to the fragment. (C) Next, one of the suture limbs is passed through a lateral anchor positioned posteriorly in the greater trochanter thus keeping the fragments reduced. (FB, fracture bed; FG, fragment; GT, greater tuberosity.)

Fig 5.

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) The remaining 2 medial anchors are positioned, and the suture tapes are passed through the rotator cuff in the same fashion previously described. Then the suture limbs are separated with an arthroscopic suture retriever and passed through 2 lateral anchors in the following order: one limb of each medial anchors is passed to the second lateral anchor (B) and one limb from the second and third medial anchors is passed to the third lateral anchor (C). ∗Second lateral anchor; ∗∗third lateral anchor. (AM, articular margin [medial-row fixation]; LR, lateral row fixation; RC, rotator cuff; SL, SwiveLock anchor [Arthrex]; SP, suture passer.)

Fig 6.

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) Fixation is completed as the remaining anterior deformity of the fracture (∗) is addressed. (B) After passing a suture tape through the deformity, the repair is competed with a final knotless suture anchor. (C) The final construct was probed and noted to achieve an excellent anatomic reduction and compression of the fracture fragments. ∗∗∗Fourth lateral anchor. (FB, fracture bed; RC, rotator cuff; SL, SwiveLock anchor [Arthrex]; SP, suture passer.)

Table 2.

Pearls and Pitfalls of Arthroscopic Reduction and Internal Fixation of Greater Trochanter Fractures

Pearls	Pitfalls
Fluoroscopy is not always needed, but keep it in the operating room, as it can be a very helpful tool in difficult cases	Obtain a good visualization of the fragments and the fracture site in the early stage
Perform the surgery in beach-chair position always, as it allows easy open conversion when needed	Check the correct reduction from different prospectives and portals
The first part of the procedure is critical! Carefully debride the fracture site from any soft tissue interposed	Be familiar with multiple accessory portals that may be required to allow for appropriate suture passage around the fragments
Use the first lateral row anchor to hold the fracture fragment in anatomical reduction while using the other anchors for compression	Anchors mispositioned or poorly spaced may result in fracture malreduction

Rehabilitation Protocol

The shoulder is immobilized in an abduction sling with neutral rotation for 6 weeks, and patients are instructed to perform daily passive range of motion limited to 30° of external rotation, no internal rotation, 90° of forward flexion, and 60° of abduction in the scapular plane. Active range of motion of the wrist, elbow, and fingers is initiated immediately. Active shoulder range of motion begins at 4 to 6 weeks from the surgery, depending on clinical examination at follow-up visits. Strengthening exercises for the shoulder begin at 8 weeks postoperatively, and full activities are resumed at 3 to 4 months postoperatively, while assessing for healing on postoperative radiographs.

Discussion

The main advantages of using an arthroscopic technique for GT fixation are less trauma to the soft tissues, lower risk of postoperative infection and adhesions, reduced intraoperative blood loss, better visualization of the fragments, and better detection of associated pathology.⁹ Only one study has compared the outcomes between open and arthroscopic GT fracture fixation, with the authors reporting significantly better American Shoulder and Elbow Surgeons scores in arthroscopic fixation.¹⁰ A recent study from Rakowski et al.¹¹ compared patient-reported outcomes (PROs) after isolated GT fracture fixation to acute rotator cuff repair at a minimum of 2 years follow-up. They reported that linked, double-row repairs for isolated GT fractures yield excellent PROs similar to those of patients who undergo acute cuff repair. Ji et al.¹² evaluated 16 patients who underwent arthroscopic fixation of isolated comminuted, displaced GT fractures using a similar configuration to the one described in this Technical Note. They reported a significant improvement at 2-year follow-up of PROs, with only 1 patient with a postoperative complication involving stiffness after inadequate fracture reduction. Kokkalis et el.¹³ studied 11 patients who underwent arthroscopic reduction and double-row suture anchor fixation for isolated, displaced GT fracture at an average of 1-year follow-up. Overall, all patients improved their pain scores from 8.4 points to 0.9. Mean forward flexion was 153°, abduction 149°, external rotation 42°, and internal rotation between the T10 and L3 spinal level. Moreover, 3 of the patients had a residual displacement of <3 mm as a result of nonanatomic reduction intraoperatively. This has also been tested biomechanically and the double row was found to be very strong fixation.¹⁴

Overall, arthroscopic reduction and internal fixation of GT fractures with suture anchors in a double-row or triple-row configuration have provided satisfactory clinical outcomes and proved to be a safe and reproducible technique that allows for an excellent reduction and compression of the fragments on the fracture site. Surgeons familiar with shoulder arthroscopy and rotator cuff repair may perform this technique straightforwardly but in order to achieve excellent results, it is important to know and understand the basic principles of traumatology that are needed to achieve an anatomical reduction and compression of the fracture.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M.T.D. reports editorial board member of Arthroscopy and board or committee member with the American Academy of Orthopaedic Surgeons and Society of Military Orthopaedic Surgeons. M.T.P. reports board or committee member with the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, San Diego Shoulder Institute, and Society of Military Orthopaedic Surgeons; IP royalties, paid consultant, research support from Arthrex; editorial board member of Arthroscopy; IP royalties from Arthrosurface; publishing royalties, financial or material support from Elsevier; paid consultant for Joint Restoration Foundation (AlloSource); editorial or governing board of Knee and Orthopedics; and editorial or governing board, publishing royalties, financial or material support from SLACK Incorporated. All other authors (M.A., B.T.P., R.J.W., N.J.D., R.d.P.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

This technique video describes arthroscopic fixation of a greater tuberosity fracture of the humerus using a suture anchor minimally invasive approach. This case was performed at the Steadman Clinic in Vail, Colorado. Our patient is a 51-year-old right-hand−dominant woman who presents with complaints of left shoulder pain and stiffness after sustaining a remote fall on outstretched extremity while skiing. On examination, she demonstrates limited active range of motion in abduction, as well as 3 of 5 strength of the rotator cuff unit with positive O'Brien and hornblower's tests. Initial injury films demonstrated no acute osseous abnormality. However, because of her persistent shoulder pain with difficulty performing overhead activities, a magnetic resonance imaging scan was obtained, which demonstrated an isolated greater tuberosity impaction fracture with comminution and tears of the supraspinatus and infraspinatus tendons. As she did not respond to an appropriate trial of nonoperative management and activity modification with worsening symptoms specifically with overhead activity, the plan was to proceed with arthroscopic-assisted greater tuberosity open reduction internal fixation with an all-suture anchor technique. Within the subacromial space the greater tuberosity fracture is evaluated and the fracture fragment is elevated in order for the fracture bed to undergo gentle debridement of scar tissue and initial callus formation. The mobility and reducibility of the fracture fragment and associated rotator cuff tear is assessed with an arthroscopic grasper. Next, fixation of the fracture proceeds with a triple row configuration beginning with three 4.75-mm PEEK SwiveLock anchors to form the medial row, spaced approximately 15 mm apart. The suture tape from each of the SwiveLock anchors are passed through the rotator cuff just medial to the bony fragment. Next, the posterior limb of the posteromedial anchor is passed through a lateral 4.75-mm PEEK knotless anchor, positioned 5 mm lateral to the posterior edge of the greater tuberosity fracture to reduce the fracture fragment to the fracture bed. The 2 remaining lateral knotless anchors are designed to achieve compression interposition sequentially from posterior to anterior approximately 15 mm apart in order to achieve a self-reinforcing construct. If needed, a fourth anchor can be added to the lateral row and placed anteriorly just lateral to the biceps groove. This can aid in additional compression with the goal of an anatomic reduction at the fracture site. This technique has been found to be helpful specifically in cases of greater tuberosity comminution to bridge the bony fragments.