Is Arthroscopic Technique Superior to Open Reduction Internal Fixation in the Treatment of Isolated Displaced Greater Tuberosity Fractures?

Abstract

Background: Arthroscopic double-row suture-anchor fixation and open reduction and internal fixation (ORIF) are used to treat displaced greater tuberosity fractures, but there are few data that can help guide the surgeon in choosing between these approaches.

Questions/purposes: We therefore asked: (1) Is there a difference in surgical time between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures? (2) Are there differences in the postoperative ROM and functional scores between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures? (3) Are there differences in complications resulting in additional operations between the two approaches?

Methods: Between 2006 and 2012, we treated 79 patients surgically for displaced greater tuberosity fractures. Of those, 32 (41%) were considered eligible for our study based on inclusion criteria for isolated displaced greater tuberosity fractures with a displacement of at least 5 mm but less than 2 cm. During that time, we generally treated patients with displaced greater tuberosity fractures with a displacement greater than 1 cm or with a fragment size greater than 3×3 cm with open treatment, and patients with displaced greater tuberosity fractures with a displacement less than 1 cm or with a fragment size less than 3×3 cm with arthroscopic treatment. Fifty-three underwent open treatment based on those indications, and 26 underwent arthroscopic treatment, of whom 17 (32%) and 15 (58%) were available for followup at a mean of 34 months (range, 24-28 months). All patients with such fractures identified from our institutional database were treated by these two approaches and no other methods were used. Surgical time was defined as the time from initiation of the incision to the time when suture of the incision was finished, and was determined by an observer with a stopwatch. Patients were followed up in the outpatient department at 6, 12, and 24 weeks, and every 6 month thereafter. Radiographs showed optimal reduction immediately after surgery and at every followup. Radiographs were obtained to assess fracture healing. Patients were followed up for a mean of 34 months (range, 24-48 months). At the last followup, ROM, VAS score, and American Shoulder and Elbow Surgeons (ASES) score were used to evaluate clinical outcomes. All these data were retrieved from our institutional database through chart review. Complications were assessed through chart review by one observer other than the operating surgeon.

Results: Patients who underwent arthroscopic double-row suture anchor fixation had longer surgical times than did patients who underwent ORIF (mean, 95.3 minutes, SD, 10.6 minutes vs mean, 61.5 minutes, SD, 7.2 minutes; mean difference, 33.9 minutes; 95% CI, 27.4-40.3 minutes; p < 0.001). All patients achieved bone union within 3 months. Compared with patients who had ORIF, the patients who had arthroscopic double-row suture anchor fixation had greater ranges of forward flexion (mean, 152.7°, SD, 13.3° vs mean, 137.7°, SD, 19.2°; p = 0.017) and abduction (mean, 146.0°, SD, 16.4° vs mean, 132.4°, SD, 20.5°; p = 0.048), and higher ASES score (mean, 91.8 points, SD, 4.1 points vs mean, 87.4 points, SD, 5.8 points; p = 0.021); however, in general, these differences were small and of questionable clinical importance. With the numbers available, there were no differences in the proportion of patients experiencing complications resulting in reoperation; secondary subacromial impingement occurred in two patients in the ORIF group and postoperative stiffness in one from the ORIF group. The two patients experiencing secondary subacromial impingement underwent reoperation to remove the implant. The patient with postoperative stiffness underwent adhesion release while receiving anesthesia, to improve the function of the shoulder. These three patients had the only reoperations.

Conclusions: We found that in the hands of surgeons comfortable with both approaches, there were few important differences between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures. Future, larger studies with consistent indications should be performed to compare these treatments; our data can help inform sample-size calculations for such studies.

Level of evidence: Level III, therapeutic study.

Fig. 1A–D

Preoperative imaging examinations were used to evaluate the fracture. (A) A radiograph showed a displaced greater tuberosity fracture. (B) CT and (C) three-dimensional CT scans confirmed the configuration of the greater tuberosity fragment. (D) An MR image showed a displaced greater tuberosity fracture with no concomitant injuries, including rotator cuff tear.

Fig. 2A–F

The schema of arthroscopic double-row suture anchor fixation is shown. (A) A displaced greater tuberosity fragment was detected under arthroscopy. (B) A medial-row anchor was inserted at the articular margin of the humeral head and its strands were retrieved from the joint through the anterior portal using a suture grasper. (C) An 18-gauge spinal needle was used to confirm the exact location. (D) The strands of the medial-row anchor were shuttled through the intact cuff with a prolene suture. (E) The strands of the medial-row anchors were tied with a sliding knot in the subacromial space under direct observation. (F) The suture bridge was created for greater tuberosity fracture fixation.

Fig. 3A–D

For open reduction and internal fixation, (A) the fragment edge was exposed and a heavy braided suture was placed in the rotator cuff as traction suture. (B) A locking plate was placed at the lateral aspect of the humeral shaft, and K-wires were inserted for temporary fixation of the plate. (C) An intraoperative radiograph showed a satisfactory reduction. (D) Locking screws were inserted for permanent fixation of the plate.

Fig. 4A–F

(A) A preoperative radiograph showed a displaced greater tuberosity fracture in a patient from the arthroscopic double-row suture anchor fixation group. (B) The immediate postoperative radiograph showed accurate fracture reduction, and (C) a radiograph showed bony union at 12 weeks postoperatively. (D) A preoperative radiograph showed a displaced greater tuberosity fracture in a patient from the ORIF group. (E) The immediate postoperative radiograph showed accurate fracture reduction and (F) at 12 weeks postoperatively, a radiograph showed bony union.