Shoulder:Trauma - Revision history

Alexandre.laedermann at 12:04, 6 July 2021

2021-07-06T12:04:50Z

Alexandre.laedermann at 12:00, 6 July 2021

2021-07-06T12:00:02Z

Alexandre.laedermann at 11:57, 6 July 2021

2021-07-06T11:57:08Z

Alexandre.laedermann at 11:23, 6 July 2021

2021-07-06T11:23:06Z

Alexandre.laedermann at 11:18, 6 July 2021

2021-07-06T11:18:41Z

Alexandre.laedermann at 11:08, 6 July 2021

2021-07-06T11:08:02Z

Alexandre.laedermann at 10:58, 6 July 2021

2021-07-06T10:58:10Z

Alexandre.laedermann at 10:00, 6 July 2021

2021-07-06T10:00:26Z

Alexandre.laedermann at 21:40, 5 July 2021

2021-07-05T21:40:05Z

Alexandre.laedermann at 21:30, 5 July 2021

2021-07-05T21:30:18Z

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 In non-pathologic conditions, the greater tuberosity is never above the top of the humeral head. As little as 5 mm of displacement not only creates impingement, but also insufficiency in the posterosuperior rotator cuff due to lack of tension relative to the Blix curve (''Figure 1''). Malunion can result in a mechanical block to shoulder abduction or external rotation and altered rotator cuff mechanics causing weakness. Consequently, surgical fixation is recommended for fractures with residual displacement greater than 5 mm, or 3 mm in active patients involved in frequent overhead activity. Similarly, a greater tuberosity that is too low will also harm the rotator cuff.<ref name=":0">Lädermann A, Denard PJ, Burkhart SS. Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning. Arthroscopy. 2012;28:1220-9.</ref><ref>Blix M. Die lange und die spannung des muskels. Skand Arch Physiol 1892;3:295-318.</ref>
-[[File:1562909015149-lg.jpg|center|thumb|500x500px|''Figure 1.'' Different situations or pathological position of the greater tuberosity cause impingement and loss of strength: A) Type II cephalotubercular valgus impacted fracture and B) displaced fracture of the greater tuberosity resulting in decreased mobility and loss of strength through relaxation of the cuff. Reproduce from<ref name=":0" />, with permission.|alt=]]
+[[File:1562909015149-lg.jpg|center|thumb|400x400px|''Figure 1.'' Different situations or pathological position of the greater tuberosity cause impingement and loss of strength: A) Type II cephalotubercular valgus impacted fracture and B) displaced fracture of the greater tuberosity resulting in decreased mobility and loss of strength through relaxation of the cuff. Reproduce from<ref name=":0" />, with permission.|alt=]]
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-[[File:1562909015961-lg.jpg|center|thumb|450x450px|''Figure 2''. Role of the lateral offset: A) Superomedial malposition of the greater tuberosity after a subtubercular varus impacted fracture. Reproduced from <ref name=":0" />, with permission.|alt=]]
+[[File:1562909015961-lg.jpg|center|thumb|400x400px|''Figure 2''. Role of the lateral offset: A) Superomedial malposition of the greater tuberosity after a subtubercular varus impacted fracture. Reproduced from <ref name=":0" />, with permission.|alt=]]
 Every effort should be made to restore this relationship intraoperatively whether by anatomic reconstruction with osteosynthesis (''Figure 3'') or during arthroplasty surgery. In the setting of chronic non-union, allograft reconstruction has also been described.<ref name=":1">Lädermann A, Denard P, Abrassart S, Schwitzguébel A. Achilles Tendon Allograft for an Irreparable Massive Rotator Cuff Tear with Bony Deficiency of the Greater Tuberosity: A Case Report. Knee Surg Sports Traumatol Arthrosc. 2017;25:2147-50</ref><ref>Vandenbussche E, Peraldi P, Naouri JF, Rougereau G, Augereau B. Four part valgus impacted fractures of the upper extremity of humerus: ilium graft reconstruction. Apropos of 8 cases. Rev Chir Orthop Reparatrice Appar Mot. 1996;82:658-62.</ref><ref>Levy JC, Badman B. Reverse shoulder prosthesis for acute four-part fracture: tuberosity fixation using a horseshoe graft. J Orthop Trauma. 2011;25:318-24.</ref>
-[[File:1562909015770-lg.jpg|center|thumb|600x600px|''Figure 3''. Restitution of the offset by allograft: A) Coronal CT Scan of a right shoulder. Note the loss of bone from the greater tuberosity. B) Radiograph of the same patient after allograft reconstruction of the humeral head and reinsertion of the rotator cuff. Reproduced from<ref name=":1" />, with permission.]]
+[[File:1562909015770-lg.jpg|center|thumb|500x500px|''Figure 3''. Restitution of the offset by allograft: A) Coronal CT Scan of a right shoulder. Note the loss of bone from the greater tuberosity. B) Radiograph of the same patient after allograft reconstruction of the humeral head and reinsertion of the rotator cuff. Reproduced from<ref name=":1" />, with permission.|alt=]]
 Lastly, the head-shaft relationship must be restored. The neck-shaft angle, posterior tilt and retroversion are key factors.<ref>Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br.1997;79:857-65.</ref>
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 [[File:Video @ tuberosity.mp4|thumb|''Video 1.'' An arthroscopic greater tuberosity repair (left shoulder) ''reproduced from XX with the permission''|center]]
-[[File:1562909631408-lg.jpg|center|thumb|660x660px|''Figure 14.'' Arthroscopic treatment of a humeral head fracture: A) Anteroposterior radiograph and B) CT scan of the left shoulder, revealing a humeral head fracture. ''Check the legend for C and D''. Six months after arthroscopic reduction without fixation, the Lamy frontal and lateral radiographs confirm a perfect reduction. The rotator cuff and tuberosities are intact, so secondary displacements are limited. Reproduce from <ref name=":5">Godeneche A, Freychet B, Gunst S, Daggett M, Viste A, Walch G. Arthroscopic Reduction of Acute Traumatic Posterior Glenohumeral Dislocation and Anatomic Neck Fracture Without Internal Fixation: 2-Year Follow-up. Orthop J Sports Med. 2017;5:2325967117745486</ref>, with permission.|alt=]]
+[[File:1562909631408-lg.jpg|center|thumb|550x550px|''Figure 14.'' Arthroscopic treatment of a humeral head fracture: A) Anteroposterior radiograph and B) CT scan of the left shoulder, revealing a humeral head fracture. ''Check the legend for C and D''. Six months after arthroscopic reduction without fixation, the Lamy frontal and lateral radiographs confirm a perfect reduction. The rotator cuff and tuberosities are intact, so secondary displacements are limited. Reproduce from <ref name=":5">Godeneche A, Freychet B, Gunst S, Daggett M, Viste A, Walch G. Arthroscopic Reduction of Acute Traumatic Posterior Glenohumeral Dislocation and Anatomic Neck Fracture Without Internal Fixation: 2-Year Follow-up. Orthop J Sports Med. 2017;5:2325967117745486</ref>, with permission.|alt=]]
 ====Surgical technique====

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 [[File:Cure malunion small.mp4|thumb|''Video 1. Reproduced from XX with permission.''|center]]
-The referenced article by Cheung et Sperling<ref>Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82</ref> reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain-relieving procedure.
+The referenced article by Cheung et Sperling<ref>Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008;39:475-82</ref> reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain-relieving procedure.
 ==References==
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 ROBERTS, S. M., Fractures of the Upper End of the Humerus; End Result Study, which shows Advantages of Early Active Motion. J. A. M. A. 98; 367-373. Jan. 30, 1932.
 This is the best article to which I can refer as to the present status of treatment of these fractures in progressive hospital clinics in America, for there is always some degree of progress that has not yet taken its place in the text books. It is a careful study of a series of cases treated at the Massachusetts General Hospital, where much attention has been devoted to fractures, during the last decade, by an active "fracture committee," so that the results may be assumed to be better than the average, even though they include a considerable number of instances where there was long delay in seeking hospital treatment. Nevertheless, it is evident that even in these carefully treated cases, the results are by no means perfect. Although appointed consulting surgeon to this hospital in 1929, I have had nothing to do with the treatment of these cases, nor have my principles of reduction, illustrated on page 324, Fig. 61, ever been tried out. The excellence of the results obtained by Dr. Roberts and his colleagues has in no way been dependent on the theories expounded in this chapter, which in many respects differ from those on which treatment was based in their cases. Are my theories sound enough to be tested? If so, by whom? At any rate, the economic loss in their series of fractures was evidently far less extravagant than would have been incurred in an equivalent number of cases of unrecognized complete ruptures of the supraspinatus.

← Older revision		Revision as of 11:57, 6 July 2021
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	==References==		==References==
		+	<references />

	=What would Codman have thought about this?=		=What would Codman have thought about this?=

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 ===Surgical Technique (Operative Treatment)===
 Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with fixation when possible (''Figure 1 and Video 1''). Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, and treatment of soft tissue contractures. Attempts at anatomic total shoulder arthroplasty have failed. Reverse shoulder arthroplasty is generally recommended when the fracture has eroded enough to prevent successful fixation, if the tuberosities have resorbed, if the rotator cuff is torn, or other findings are present that would limit the success rate of fixation.
-[[File:Cure_malunion.png|700x700px|A 69-year-old male presented a fracture of the left proximal humerus treated conservatively 15 months ago. Pre (anteroposterior and Neer) and postoperative X-rays show no shoulder arthritis or significant osteopenia. Surgical treatment consisted of an intramedullary fibular allograft and iliac crest autograft augmentation with a Bilboquet technique and a plate osteosynthesis.]]<br />
+[[File:Cure_malunion.png|alt=|center|thumb|700x700px|''Figure 1. Reproduced from XX with permission. Add labels A, B, C'']]
-[[File:Cure malunion small.mp4|thumb|none|''Video 1. Reproduced from XX with permission.'']]
+[[File:Cure malunion small.mp4|thumb|''Video 1. Reproduced from XX with permission.''|center]]
 The referenced article by Cheung et Sperling<ref>Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82</ref> reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain-relieving procedure.

@@ Line 334: / Line 334: @@
 ===Surgical Technique (Operative Treatment)===
-Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with fixation when possible (Figure and Video). Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, and treatment of soft tissue contractures. Attempts at anatomic total shoulder arthroplasty have failed. Reverse shoulder arthroplasty is generally recommended when the fracture has eroded enough to prevent successful fixation, if the tuberosities have resorbed, if the rotator cuff is torn, or other findings are present that would limit the success rate of fixation.
+Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with fixation when possible (''Figure 1 and Video 1''). Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, and treatment of soft tissue contractures. Attempts at anatomic total shoulder arthroplasty have failed. Reverse shoulder arthroplasty is generally recommended when the fracture has eroded enough to prevent successful fixation, if the tuberosities have resorbed, if the rotator cuff is torn, or other findings are present that would limit the success rate of fixation.
-[[File:Cure malunion.png|thumb]|700x700px|A 69-year-old male presented a fracture of the left proximal humerus treated conservatively 15 months ago. Pre (anteroposterior and Neer) and postoperative X-rays show no shoulder arthritis or significant osteopenia. Surgical treatment consisted of an intramedullary fibular allograft and iliac crest autograft augmentation with a Bilboquet technique and a plate osteosynthesis.]]
+[[File:Cure_malunion.png|700x700px|A 69-year-old male presented a fracture of the left proximal humerus treated conservatively 15 months ago. Pre (anteroposterior and Neer) and postoperative X-rays show no shoulder arthritis or significant osteopenia. Surgical treatment consisted of an intramedullary fibular allograft and iliac crest autograft augmentation with a Bilboquet technique and a plate osteosynthesis.]]<br />
-[[File:Cure malunion small.mp4|thumb]]
+[[File:Cure malunion small.mp4|thumb|none|''Video 1. Reproduced from XX with permission.'']]
 The referenced article by Cheung et Sperling<ref>Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82</ref> reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain-relieving procedure.

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 ===Displaced tuberosity fractures with a stable epiphyseal-diaphyseal union===
-Surgical management is considered in fractures where the greater tuberosity is displaced >5 mm. If the fragment is small and considered to be a type A1 bony rotator cuff lesion then arthroscopic reinsertion or open osteosuture give similar results. A large and solid fragment lends itself to screwing and nailing, while osteosuture will be preferred in cases of porous and split bone.<ref>Liao W, Zhang H, Li Z, Li J. Is Arthroscopic Technique Superior to Open Reduction Internal Fixation in the Treatment of Isolated Displaced Greater Tuberosity Fractures? Clin Orthop Relat Res. 2016;474:1269-79.</ref><ref>Lädermann A, Burkhart SS, Hoffmeyer P, Neyton L, Collin P, Yates E, Denard PJ. Classification of full-thickness rotator cuff lesions: a review. EFORT Open Rev. 2017;1:420-30.</ref>
+Surgical management is considered in fractures where the greater tuberosity is displaced >5 mm. If the fragment is small and considered to be a type A1 bony rotator cuff lesion, then arthroscopic reinsertion or open osteosuture gives similar results. A large and solid fragment lends itself to screwing and nailing, while osteosuture will be preferred in cases of porous and split bone.<ref>Liao W, Zhang H, Li Z, Li J. Is Arthroscopic Technique Superior to Open Reduction Internal Fixation in the Treatment of Isolated Displaced Greater Tuberosity Fractures? Clin Orthop Relat Res. 2016;474:1269-79.</ref><ref>Lädermann A, Burkhart SS, Hoffmeyer P, Neyton L, Collin P, Yates E, Denard PJ. Classification of full-thickness rotator cuff lesions: a review. EFORT Open Rev. 2017;1:420-30.</ref>
 ===Type II-IV cephalotubercular in the young===
-It seems acceptable to restore anatomy in young or biologically healthy patients. Epiphyseal plate osteosynthesis and antegrade nailing give similar results. The first is preferred in cases where the medial hinge is preserved. Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).<ref>Erasmo R, Guerra G, Guerra L. Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate. Injury 2014;45 Suppl 6:S43-8</ref> Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients<ref>Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006;88:502-8.</ref>. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results were achieved with fixation methods.
+It seems acceptable to restore anatomy in young or biologically healthy patients. Epiphyseal plate osteosynthesis and antegrade nailing give similar results. The first one is preferred in cases when the medial hinge is preserved. Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).<ref>Erasmo R, Guerra G, Guerra L. Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate. Injury 2014;45 Suppl 6:S43-8</ref> Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients<ref>Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006;88:502-8.</ref>. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results were achieved with fixation methods.
 Hemiarthroplasty is justified when there is a high risk of humeral head necrosis.<ref>Gadea F, Favard L, Boileau P, Cuny C, d'Ollone T, Saragaglia D, Sirveaux F, SoFCOT. Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthop Traumatol Surg Res (OTSR) 2016;102:963-70.</ref>
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 ===Isolated sub-tubercular fractures===
-Closed nailing or plate osteosynthesis are coeval. Plates are preferred in young patients to conserve their rotator cuff and facilitate their removal, and nails are used on older patients for whom removal of material is debatable. Fasciculated nailing are reserve for paediatric cases as it has not been proven in adults in comparative studies.<ref>Lee W, Park JY, Chun YM. Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration. J Orthop Trauma. 2017;31:e270-e4.</ref><ref>Milin L, Sirveaux F, Eloy F, Mainard D, Mole D, Coudane H. Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases. Orthop Traumatol Surg Res (OTSR) 2014;100:265-70. </ref>
+Closed nailing or plate osteosynthesis are coeval. Plates are preferred in young patients to conserve their rotator cuff and facilitate their removal, and nails are used in older patients for whom removal of material is debatable. Fasciculated nailing is reserved for paediatric cases as it has not been proven in adults in comparative studies.<ref>Lee W, Park JY, Chun YM. Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration. J Orthop Trauma. 2017;31:e270-e4.</ref><ref>Milin L, Sirveaux F, Eloy F, Mainard D, Mole D, Coudane H. Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases. Orthop Traumatol Surg Res (OTSR) 2014;100:265-70. </ref>
 ==References==

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 The simple humeral implant is a remedy in cases of technically impossible osteosynthesis or fractures posing a risk of significant necrosis in young patients. It is restricted to cephalotubercular fractures of types III to IV in young patients. Reconstruction requires restoration of the humeral length, correct implant retroversion, restoration of the epiphyseal width, stable implant fixation, and a robust osteosynthesis of the tuberosities.
-Functional results vary depending on the patient’s age, and especially the anatomical consolidation of the tuberosities. They can be excellent when it comes to mobility and pain. But, if the tuberosities are not consolidated then mobility results are poor, with an average anterior elevation of 90°. They do, however, remain acceptable for pain.<ref>Boileau P, Winter M, Cikes A, Han Y, Carles M, Walch G, Schwartz D.G. Can surgeons predict what makes a good hemiarthroplasty for fracture? J Shoulder Elbow Surg. 2013;22:1495-506.</ref>
+Functional results vary depending on the patient’s age, and especially the anatomical consolidation of the tuberosities. They can be excellent when it comes to mobility and pain. But if the tuberosities are not consolidated, then mobility results are poor, with an average anterior elevation of 90°. They do, however, remain acceptable for pain.<ref>Boileau P, Winter M, Cikes A, Han Y, Carles M, Walch G, Schwartz D.G. Can surgeons predict what makes a good hemiarthroplasty for fracture? J Shoulder Elbow Surg. 2013;22:1495-506.</ref>
 ====Surgical technique====
 The approach is most commonly deltopectoral. The joint is accessed by working through the fracture fragments in the setting of a 4-part fracture, or dividing the lesser and greater tuberosities in the setting of a 3-part fracture. The humeral head fragment is extracted. As with plate fixation, the rotator cuff is tagged with multiple sutures for subsequent fixation of the tuberosities.<ref>Collin P, Laubster E, Denard PJ, Akuè FA, Lädermann A. The Nice knot as an improvement on current knot options: A mechanical analysis. Orthop Traumatol Surg Res (OTSR) 2016;102:293-6.</ref>
-Correct positioning of the implant and the tuberosities is an essential step, which will determine the quality of the functional result (''cf above?->see above''). The lateral offset is restored either by introducing a graft between the implant and the greater tuberosity if the implant does not fill the space, or by using a wide metaphyseal implant with no graft.<ref>White JJ, Soothill JR, Morgan M, Clark DI, Espag MP, Tambe AA. Outcomes for a large metaphyseal volume hemiarthroplasty in complex fractures of the proximal humerus. J Shoulder Elbow Surg. 2017;26:478-83.</ref>
+Correct positioning of the implant and the tuberosities is an essential step, which will determine the quality of the functional result (''cf above?->see above''). The lateral offset is restored either by introducing a graft between the implant and the greater tuberosity, if the implant does not fill the space, or by using a wide metaphyseal implant with no graft.<ref>White JJ, Soothill JR, Morgan M, Clark DI, Espag MP, Tambe AA. Outcomes for a large metaphyseal volume hemiarthroplasty in complex fractures of the proximal humerus. J Shoulder Elbow Surg. 2017;26:478-83.</ref>
 Height can be assessed fluoroscopically by restoring a Gothic arch appearance or by locating the insertion point of the pectoralis major.<ref name=":6" /><ref>Krishnan SG, Bennion PW, Reineck JR, Burkhead WZ. Hemiarthroplasty for proximal humeral fracture: restoration of the Gothic arch. Orthop Clin North Am. 2008;39:441-50.</ref>
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 ====Surgical (Operative) Technique====
-Apart from time spent on the glenoid, implantation is in all respects similar to hemiarthroplasty. Exposure of the glenoid is easy given the absence of the proximal humerus. The glenoid cartilage is then removed using a curette and carefully milled by hand, given the absence of osteoarthritis. The glenoid baseplate should be placed so that the glenosphere is flush or slightly overhangs the lower edge of the glenoid (''Figure 27'') to avoid frictional impingements.<ref>Lädermann A, Gueorguiev B, Charbonnier C, Stimec BV, Fasel JHD, Zderic I, Hagen J, Walch G. Scapular Notching on Kinematic Simulated Range of Motion After Reverse Shoulder Arthroplasty Is Not the Result of Impingement in Adduction. Medicine (Baltimore). 2015;94:e1615.</ref> Jain et al. performed a systematic review to compared clinical and functional outcomes of reverse shoulder arthroplasty in proximal humeral fractures with and without tuberosity healing. They reported that reverse shoulder arthroplasty with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity. Repairing tuberosities improve rotations and anterior stability.<ref>Jain NP, Mannan SS, Dharmarajan R, Rangan A. Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis. J Shoulder Elbow Surg 2019;28:e78-e91</ref><ref name=":7">O'Sullivan J, Lädermann A, Parsons BO, Werner BC, Steinbeck J, Tokish JM, Denard PJ.A Systematic Review of Tuberosity Healing and Outcomes following Reverse Shoulder Arthroplasty for Fracture According to Humeral Inclination of the Prosthesis. J Shoulder Elbow Surg. 2020; 29:1938-49</ref> Reverse shoulder arthroplasty for fracture with a 135° prothesis inclination is associated with higher tuberosity healing rates compared to 145° or 155°.<ref name=":7" /> Cemented stems are usually preferred to cemented stems due to poor bone quality and lower revision rate according to the Australian registry.
+Apart from time spent on the glenoid, implantation is in all respects similar to hemiarthroplasty. Exposure of the glenoid is easy given the absence of the proximal humerus. The glenoid cartilage is then removed using a curette and carefully milled by hand, given the absence of osteoarthritis. The glenoid baseplate should be placed so that the glenosphere is flush or slightly overhangs the lower edge of the glenoid (''Figure 27'') to avoid frictional impingements.<ref>Lädermann A, Gueorguiev B, Charbonnier C, Stimec BV, Fasel JHD, Zderic I, Hagen J, Walch G. Scapular Notching on Kinematic Simulated Range of Motion After Reverse Shoulder Arthroplasty Is Not the Result of Impingement in Adduction. Medicine (Baltimore). 2015;94:e1615.</ref> Jain et al. performed a systematic review to compare clinical and functional outcomes of reverse shoulder arthroplasty in proximal humeral fractures with and without tuberosity healing. They reported that reverse shoulder arthroplasty with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity. Repairing tuberosities improve rotations and anterior stability.<ref>Jain NP, Mannan SS, Dharmarajan R, Rangan A. Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis. J Shoulder Elbow Surg 2019;28:e78-e91</ref><ref name=":7">O'Sullivan J, Lädermann A, Parsons BO, Werner BC, Steinbeck J, Tokish JM, Denard PJ.A Systematic Review of Tuberosity Healing and Outcomes following Reverse Shoulder Arthroplasty for Fracture According to Humeral Inclination of the Prosthesis. J Shoulder Elbow Surg. 2020; 29:1938-49</ref> Reverse shoulder arthroplasty for fracture with a 135° prothesis inclination is associated with higher tuberosity healing rates compared with 145° or 155°.<ref name=":7" /> Cemented stems are usually preferred to cemented stems due to poor bone quality and lower revision rate according to the Australian registry.
 The glenosphere should preferably be neutral or only minimally lateralized. In our experience lateralized and inferior eccentric glenospheres are associated with lower rates of tuberosity healing (unpublished data). The implant is then reduced and the tuberosities reinserted according to the technique described by Boileau et al.<ref name=":9" /> Higher rates of tuberosity healing have been reported with 135 degrees stems as opposed to 155 degrees stems, but no study has directly compared these to date.
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 ===Non-stable osteosynthesis and implants===
-Fasciculated retrograde nailing, insertion, partial fixation and implants are usually immobilized for 1 month to allow consolidation of the fragments. Physiotherapy is deferred until later.
+Fasciculated retrograde nailing, insertion, partial fixation and implants are usually immobilized for one month to allow consolidation of the fragments. Physiotherapy is deferred until later.
 ==Decision Making==
-Successful treatment depends on not only technical but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated to the success of the surgery.<ref>Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11:CD000434.</ref><ref>LaMartina J, 2nd, Christmas KN, Simon P, Streit JJ, Allert JW, Clark J, Otto RJ, Abdelfattah A, Mighell MA, Frankle MA. Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg. 2018;27:470-7.</ref> Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced. Surgical management is also considered in proximal humerus fractures associated with humeral shaft fractures.
+Successful treatment depends not only on technical, but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated with the surgery success.<ref>Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11:CD000434.</ref><ref>LaMartina J, 2nd, Christmas KN, Simon P, Streit JJ, Allert JW, Clark J, Otto RJ, Abdelfattah A, Mighell MA, Frankle MA. Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg. 2018;27:470-7.</ref> Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced. Surgical management is also considered in proximal humerus fractures associated with humeral shaft fractures.
 ===Humeral head fractures===
 It is difficult to codify the treatment of such a rare fracture. The following guidelines, though not based on experience, have the merit of common sense. In the elderly, the risk of humeral head necrosis immediately invokes reverse shoulder arthroplasty. In young patients, simple reduction, with or without associated osteosynthesis using screws or pins, seems valid.<ref name=":5" />

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 It is minimally invasive and therefore decreases the risk of vascular compromise. Another advantage of this technique is that it can be converted, at any time, if adequate reduction or stability cannot be obtained. Fractures are primarily stabilized with ascending fasciculated pins, using at least three diverging ‘palm tree’ pins in the epiphysis (Hacketal, Kapandji). Superior to inferior pins may also be used for greater tuberosity stabilization.
-The percutaneous approach has been difficult to establish as a reference technique due to its many disadvantages. Firstly, it is contraindicated for type 2 to 4 articular fractures, with low bone density and significant comminution, all conditions often found elderly patients. Secondly, the variable mechanical quality of the synthesis obtained can lead to long periods of postoperative immobilization and therefore stiffness. Moreover, the reduction technique and pin placement are very demanding. Lastly, many complications such as migration or joint penetration by pins, as well as potential neurological lesions have been reported.<ref name=":9">Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. J Shoulder Elbow Surg. 2011;20(2 Suppl):S47-60.</ref><ref>Yoon TH, Choi CH, Choi YR, Oh JT, Chun YM. Clinical outcomes of minimally invasive open reduction and internal fixation by screw and washer for displaced greater tuberosity fracture of the humerus. J Shoulder Elbow Surg 2018;27:e173-e177.</ref><ref>Keener JD, Parsons BO, Flatow EL, Rogers K, Williams GR, Galatz LM. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16:330-8.</ref><ref>Kamineni S, Ankem H, Sanghavi S. Anatomical considerations for percutaneous proximal humeral fracture fixation. Injury 2004;35:1133-6.</ref><ref name=":4">Rowles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am. 2001;83:1695-9.</ref> Moreover, there is a risk of injury to important anatomic structures about the shoulder. Lateral pins should be distal enough to avoid injury to the anterior branch of the axillary nerve, and multiple fluoroscopic views should be obtained to avoid penetration of the humeral head cartilage. There may be a risk of injury to the cephalic vein, the biceps tendon, and the musculocutaneous nerve with use of anterior pins, and these pins should be employed with caution. Greater tuberosity pins should be placed with the arm in external rotation, should be aimed for a point 20 mm from the inferior aspect of the humeral head, and should not overpenetrate the cortex.<ref name=":4" />
+The percutaneous approach has been difficult to establish as a reference technique due to its many disadvantages. Firstly, it is contraindicated for type 2 to 4 articular fractures, with low bone density and significant comminution, all conditions are often found in elderly patients. Secondly, the variable mechanical quality of the synthesis obtained can lead to long periods of postoperative immobilization and therefore stiffness. Moreover, the reduction technique and pin placement are very demanding. Lastly, many complications such as migration or joint penetration by pins, as well as potential neurological lesions have been reported.<ref name=":9">Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. J Shoulder Elbow Surg. 2011;20(2 Suppl):S47-60.</ref><ref>Yoon TH, Choi CH, Choi YR, Oh JT, Chun YM. Clinical outcomes of minimally invasive open reduction and internal fixation by screw and washer for displaced greater tuberosity fracture of the humerus. J Shoulder Elbow Surg 2018;27:e173-e177.</ref><ref>Keener JD, Parsons BO, Flatow EL, Rogers K, Williams GR, Galatz LM. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16:330-8.</ref><ref>Kamineni S, Ankem H, Sanghavi S. Anatomical considerations for percutaneous proximal humeral fracture fixation. Injury 2004;35:1133-6.</ref><ref name=":4">Rowles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am. 2001;83:1695-9.</ref> Moreover, there is a risk to injure important anatomic structures in the shoulder. Lateral pins should be distal enough to avoid injury to the anterior branch of the axillary nerve, and multiple fluoroscopic views should be obtained to avoid penetration of the humeral head cartilage. There may be a risk of injury of the cephalic vein, the biceps tendon, and the musculocutaneous nerve by anterior pins, and these pins should be employed with caution. Greater tuberosity pins should be placed with the arm in external rotation, should be aimed for at 20 mm from the inferior aspect of the humeral head, and should not overpenetrate the cortex.<ref name=":4" />
 A special case, which immediately contraindicates osteosynthesis, is the external fixator used during polytrauma or open fractures with skin damage (''Figure 15'').
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 ====Surgical Technique====
-The patient is placed in a beach-chair position. The arm must be free, allowing the use of fluoroscopy installed close to the patient's head. The main objective is not necessarily a perfect anatomical reduction, but to align the fragments using gentle and non-traumatic manipulation. Closed reduction and percutaneous fixation of proximal humeral fractures, with or without screws, is based on external manoeuvres using ligamentotaxis.<ref>Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg Br. 1993;75(1):132-6.</ref>
+The patient is placed in a beach-chair position. The arm must be free, allowing the use of fluoroscopy installed close to the patient's head. The main objective is not necessarily a perfect anatomical reduction, but alignment of the fragments using gentle and non-traumatic manipulation. Closed reduction and percutaneous fixation of proximal humeral fractures, with or without screws, is based on external manoeuvres using ligamentotaxis.<ref>Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg Br. 1993;75(1):132-6.</ref>
 For ascending pinning, the pins must be curved at the end to allow for epiphyseal divergence. Pin insertion can be supraepitrochlear, supracondylar, median supraolecranean, or at the tip of the deltoid V. Each approach carries neurological risks related to the local anatomy or joint stiffness in the elbow.
-For direct pinning, if the reduction proves to be insufficient, a short superoexternal incision is made under fluoroscopic control at the lateral edge of the acromion. A deltoid split is performed, without detachment from the acromion. A spatula or Rochet punch pressed against the epiphysio-metaphyseal hinge enables careful removal of the humeral head (''Figure 16'').
+For direct pinning, if the reduction proves to be insufficient, a short superoexternal incision is made under fluoroscopic control at the lateral edge of the acromion. A deltoid split is performed without detachment from the acromion. A spatula or Rochet punch pressed against the epiphysio-metaphyseal hinge enables careful removal of the humeral head (''Figure 16'').
 [[File:1562910051222-lg.jpg|center|thumb|400x400px|''Figure 16.'' A spatula is used to elevate the humeral head (''reproduced with permission from XX'')|alt=]]
-This surgical action often results in a spontaneous reduction of the tuberosities. Repositioning may also be facilitated by a bone hook placed in the subacromial space holding the greater tuberosity, while the arm is rotated externally. At this stage, the primary stability of the assembly is completed by pinning between the diaphysis and humeral head and between the tuberosity(s) and humeral head. Cannulated screws of 4.0 mm or 4.5 mm diameter with washers can then be inserted. Alternatively, threaded pins (which reduce the risk of recession compared to smooth pins) are cut, bent and left subcutaneously (''Figure'' ''17'').
+This surgical action often results in a spontaneous reduction of the tuberosities. Repositioning may also be facilitated by a bone hook placed in the subacromial space holding the greater tuberosity, while the arm is rotated externally. At this stage, the primary stability of the assembly is completed by pinning between the diaphysis and humeral head and between the tuberosity(s) and humeral head. Then cannulated screws of 4.0 mm or 4.5 mm diameter with washers can be inserted. Alternatively, threaded pins (which reduce the risk of recession compared to smooth pins) are cut, bent and left subcutaneously (''Figure'' ''17'').
 [[File:1562910051757-lg.jpg|center|thumb|534x534px|''Figure 17.'' Diagram showing the final pin assembly. With permission from Pierre Hoffmeyer.|alt=]]
 <br />
@@ Line 164: / Line 164: @@
 ====Surgical technique====
-This is a procedure performed under fluoroscopic guidance, in the beach-chair position. The incision is anterior or posterior (Neviaser's portal) at the acromioclavicular interval for valgus or varus misaligned fractures respectively. The nail must be inserted medially so as to pierce the head in a vascularized muscular, and not tendinous, area. It must therefore pierce the humeral head in the cartilaginous area and not at the tuberosity. Distal locking (diaphyseal) is performed first, which enables compression of the fracture site by retrograde impaction using a weight. Compression is maintained by two or three proximal screws locked into the nail.
+This procedure is performed in the beach-chair position under fluoroscopic guidance. The incision is anterior or posterior (Neviaser's portal) at the acromioclavicular interval for valgus or varus misaligned fractures respectively. The nail must be inserted medially so as to pierce the head in a vascularized muscular, but not tendinous area. Therefore, it must pierce the humeral head in the cartilaginous area and not at the tuberosity. Distal locking (diaphyseal) is performed first, which enables compression of the fracture site by retrograde impaction using a weight. Compression is maintained by two or three proximal screws locked into the nail.
 ===Osteosuture===
@@ Line 175: / Line 175: @@
 ===Plate osteosynthesis===
-Modern proximal humerus plating employs locking plates which have improved the biomechanical properties of fixation compared to traditional compression plates. This is particularly important for achieving fixation in the humeral head, where fixation must be unicortical. The angulation of the solid screws can be fixed or variable and various mechanisms are used for locking the screw in the plate (i.e. locking in its housing by a threaded lock nut, or threads in the screw head which lock into the plate).
+Modern proximal humerus plating employs locking plates with improved biomechanical properties of fixation compared with traditional compression plates. This is particularly important for achieving fixation in the humeral head, where fixation must be unicortical. The angulation of the solid screws can be fixed or variable and various mechanisms are used for locking the screw in the plate (i.e. locking in its housing by a threaded lock nut, or threads in the screw head which lock into the plate).
 The plate permits 1) anatomic reduction, 2) surgery on the long head of the biceps, 3) transplant options (humeral head, or Bilboquet in cases of osteoporosis), and 4) a firm assembly stabilized by locked screws (i.e. not free anteroposterior screws) for the treatment of tuberosities and the humeral head in cases of ‘head split’ (''Figure 21''), and lastly, tension-band suturing of the rotator cuff/tuberosities to the plate. It is therefore preferred for type II to IV complex cephalotubercular fractures where osteosynthesis has been opted for (''Video 2'').
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-Distally, the anterior insertion of the deltoid is elevated using a periosteal elevator and the plate is slipped-in subperiosteally. The plate is temporarily secured with one cortical screw and then the height is adjusted as needed to ensure the that the inferior locking screws are at the medial calcar. In order to limit the length of the incision the distal screw is inserted obliquely. The sutures from the rotator cuff tendon may need to be passed through the plate prior to securing to the diaphysis depending on the plate design (''Figure 25'').
+Distally, the anterior insertion of the deltoid is elevated using a periosteal elevator and the plate is slipped-in subperiosteally. The plate is temporarily secured with one cortical screw and then the height is adjusted as needed to ensure the that the inferior locking screws are at the medial calcar. To limit the length of the incision the distal screw is inserted obliquely. The sutures from the rotator cuff tendon may need to be passed through the plate prior to securing to the diaphysis depending on the plate design (''Figure 25'').
 [[File:1562916648057-lg.jpg|center|thumb|700x700px|''Figure 25.'' Osteosynthesis of a type II cephalotubercular fracture. Four sutures have been passed through the rotator cuff tendon (A). The sutures are then passed through the plate before fixation. Once osteosynthesis is completed, the next step is to tension the sutures, thereby reinforcing the assembly (B). ''Reproduced with permission from XX.'' ]]
@@ Line 205: / Line 205: @@
 A so-called mini-invasive transdeltoid variant is an option. The patient is placed in a half-seated position. A 4-5 cm approach is used in line with the acromion. The axillary nerve is isolated and the plate is then slipped between the cortex and the nerve (''Figure 26'').
-However, the authors of this article have stopped performing this approach because we have observed a higher rate of postoperative stiffness with this approach. Furthermore, implant removal for or conversion to arthroplasty (either at the initial surgery or for failure of fixation) is more easily performed through a deltopectoral approach.
+However, ''the authors of this article'' have stopped performing this approach because we have observed a higher rate of postoperative stiffness with this approach. Furthermore, implant removal for or conversion to arthroplasty (either at the initial surgery or for failure of fixation) is easier performed through a deltopectoral approach.
 [[File:1562924744090-lg.jpg|center|thumb|700x700px|''Figure 26.'' A) Locating the axillary nerve. B) Reduction of the fracture, support by pins and introduction of the plate. C-E) Fluoroscopic images and final result (F). ''Reproduced with permission from XX.'']]
 <br />
@@ Line 215: / Line 215: @@
 |-
 !'''Complication'''
-!Header text
+!Rate
 |-
 |'''Screw penetration'''

@@ Line 114: / Line 114: @@
 ===Arthroscopy===
-The treatment of tuberosity (''Figure 13'' and Movie/''Video 1'') or humeral head fractures(''Figure 14''), with or without extension to the surgical neck, is now validated.
+The treatment of tuberosity (''Figure 13'' and Movie/''Video 1'') or humeral head fractures (''Figure 14''), with or without extension to the surgical neck, is now validated.
 <br />
@@ Line 124: / Line 124: @@
 ====Surgical technique====
-This technique has many advantages including being minimally invasive and having both intra-articular and subacromial reduction control. However, it is technically demanding, and not an option for all surgeons and for all fractures. As a general guideline, arthrosopic fixation of the greater tuberosity is generally possible if the thickest part of the fragment if less than 10 mm. Fractures with more distal extension can be challenging to secure laterally if anchor-based fixation is attempted. Surgery is performed with the patient’s arm in light traction and placed in a half-seated or lateral decubitus position. The posterior approach is used, except in cases of posterior dislocation of the humeral head. Other approaches (lateral, anterior, ...) are performed on demand, depending on the type of fracture. The hematoma is drained, and a suction pipe is connected directly to the trocar, allowing the joint to be filled and emptied until a satisfactory view is obtained. An intra-articular and then subacromial assessment is performed after a bursectomy. The type of fracture and its dimensions are assessed and the fractures reduced. Joint fractures do not necessarily require stabilization (concept of the egg cup). Several types of repair are recommended to obtain an anatomic reduction of the tuberosities (single point, double row or tension band).
+This technique has many advantages including being minimal invasiveness and intra-articular and subacromial reduction control. However, it is technically demanding, and not an option for all surgeons and for all fractures. As a general guideline, arthrosopic fixation of the greater tuberosity is possible, if the thickest part of the fragment is less than 10 mm. Fractures with more distal extension can be challenging to secure laterally, if anchor-based fixation is attempted. Surgery is performed with the patient’s arm in light traction and placed in a half-seated or lateral decubitus position. The posterior approach is used, except posterior dislocation of the humeral head. Other approaches (lateral, anterior, ...) are performed on demand, depending on the fracture type. The hematoma is drained, and a suction pipe is connected directly to the trocar, allowing the joint to be filled and emptied until a satisfactory view is obtained. An intra-articular and then subacromial assessment is performed after a bursectomy. The type of fracture and its dimensions are assessed and the fractures reduced. Joint fractures do not necessarily require stabilization (concept of the egg cup). Several types of repair are recommended to obtain an anatomic reduction of the tuberosities (single point, double row or tension band).
 ===Percutaneous Pinning or Screw Fixation===

@@ Line 106: / Line 106: @@
 ===Long head of the biceps===
-The consequences of proximal humerus osteosynthesis are characterised by the development of rotator interval fibrosis and adhesions at the long head of the biceps. These result in reduced joint mobility which may explain the postoperative stiffness that is sometimes observed. Moreover, the tendon can become unstable and even interpose between fragments, preventing its reduction. Lastly, trauma causes tendinopathy and even lacerations that can lead to persistent pain. Therefore, it is recommended to routinely perform a tenodesis of the long head of the biceps.<ref>McGahan PJ, Patel H, Dickinson E, Leasure J, Montgomery W, 3rd. The effect of biceps adhesions on glenohumeral range of motion: a cadaveric study. J Shoulder Elbow Surg. 2013;22:658-65.</ref><ref>Visser JD, Rietberg M. Interposition of the tendon of the long head of biceps in fracture separation of the proximal humeral epiphysis. Neth J Surg. 1980;32:12-5.</ref><ref>Kim JM, Jupiter JB. Traumatic laceration of the long head of the biceps brachii from a displaced surgical neck fracture of the humerus: case report. Journal of surgical orthopaedic advances. 2011;20:252-4.</ref><ref>Soliman OA, Koptan WM. Proximal humeral fractures treated with hemiarthroplasty: does tenodesis of the long head of the biceps improve results? Injury 2013;44:461-4.</ref><ref>Tosounidis T, Hadjileontis C, Georgiadis M, Kafanas A, Kontakis G. The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective. Injury 2010;41:273-8.</ref>
+The consequences of proximal humerus osteosynthesis are characterised by the development of rotator interval fibrosis and adhesions at the long head of the biceps. These result in reduced joint mobility which may explain the postoperative stiffness that is sometimes observed. Moreover, the tendon can become unstable and even interpose between fragments, preventing its reduction. Lastly, trauma causes tendinopathy and even lacerations that can lead to persistent pain. Therefore, it is recommended to routinely perform a tenodesis of the long head of the biceps by opening the rotator interval to explore the long head of the biceps tendon.<ref>McGahan PJ, Patel H, Dickinson E, Leasure J, Montgomery W, 3rd. The effect of biceps adhesions on glenohumeral range of motion: a cadaveric study. J Shoulder Elbow Surg. 2013;22:658-65.</ref><ref>Visser JD, Rietberg M. Interposition of the tendon of the long head of biceps in fracture separation of the proximal humeral epiphysis. Neth J Surg. 1980;32:12-5.</ref><ref>Kim JM, Jupiter JB. Traumatic laceration of the long head of the biceps brachii from a displaced surgical neck fracture of the humerus: case report. Journal of surgical orthopaedic advances. 2011;20:252-4.</ref><ref>Soliman OA, Koptan WM. Proximal humeral fractures treated with hemiarthroplasty: does tenodesis of the long head of the biceps improve results? Injury 2013;44:461-4.</ref><ref>Tosounidis T, Hadjileontis C, Georgiadis M, Kafanas A, Kontakis G. The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective. Injury 2010;41:273-8.</ref>
-This is done by opening the rotator interval to explore the long head of the biceps tendon. This exposes the biceps and also provides a landmark to define the greater and lesser tuberosities for subsequent anatomic reduction. A tenotomy-tenodesis is performed with sutures joining the fibrous “roof” of the bicipital groove to the tendon. Alternatively, tenodesis may be performed lower to the pectoralis major tendon. This location facilitates visualization of the bicipital groove which can be used to assess version during the reconstruction. The intra-articular part of the tendon is then resected. The rotator interval is left open, so as to control reduction of the humeral head and tuberosity, and to limit mobility loss.
+This exposes the biceps and also provides a landmark to define the greater and lesser tuberosities for subsequent anatomic reduction. A tenotomy-tenodesis is performed with sutures joining the fibrous “roof” of the bicipital groove to the tendon. Alternatively, tenodesis may be performed lower to the pectoralis major tendon. This location facilitates visualization of the bicipital groove which can be used to assess version during the reconstruction. The intra-articular part of the tendon is then resected. The rotator interval is left open, so as to control reduction of the humeral head and tuberosity, and to limit mobility loss.
 ==Osteosynthesis==