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Shoulder Videos: Fracture
Latarjet Procedure to Restore Glenohumeral Stability in a Patient With a Postage Stamp Fracture
The “postage stamp fracture” is an anterior glenoid rim fracture following arthroscopic repair of a Bankart lesion. Often occurring at the time of an acute trauma, a fracture line propagates though the previous Bankart repair anchor sites, resulting in recurrent anterior instability of the glenohumeral joint. The resultant glenoid rim fracture edge gives a similar appearance as the edge of a stamp, with the osseous edge having the classic “perforation” pattern. When patients present with a postage stamp fracture, even in the setting of subcritical glenoid bone loss, we believe that additional soft-tissue stabilization procedures and/or fracture fixation pose a significant risk of failure.Arthroscopic Coracoclavicular Ligament Reconstruction Using Graft Augmentation and Titanium Implants
Several techniques have been introduced to treat acromioclavicular separation with coracoclavicular ligament reconstruction using graft augmentation. A modified arthroscopic technique for coracoclavicular ligament reconstruction was used based on a previous technique where the supportive device and tendon graft share the clavicular and coracoid drill holes. A notable problem with the previous technique was large protruding suture knots on the washer and clavicle, which could predispose to wound infection.Arthroscopic Posterior Glenoid Fracture Fixation Using Knotless Suture Anchors
Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid.Repair of an Isolated Coracoid Fracture With Suture Anchor Fixation
Coracoid fractures are rare injuries, which may occur in isolation or in association with other shoulder pathology. The mechanism of trauma consists of a strong contraction of the conjoint tendon as a result of direct trauma. The diagnosis is usually difficult and many times overlooked, thereby requiring a high level of suspicion. In many cases, standard trauma series shoulder radiographs are unable to provide a definitive and reliable diagnosis. Therefore, other imaging modalities may be necessary to confirm the diagnosis.Arthroscopic Lateral Border Resection in Medialized Scapula Neck Fractures
Scapula neck fractures are rare injuries, leaving several treatment options. Standardized markers for operative treatment are a decreased glenopolar angle ≤22°, lateral border offset (LBO) of the glenoid ≥20 mm, angular deformity ≥45°, or LBO ≥15 mm plus angular deformity ≥35°. If operative treatment is not performed before union, the fracture heals malaligned with possible mechanical complications due to a medialized glenoid and the protruding lateral border. Common operative treatment comprises a corrective osteotomy for the anatomic correction of the malunited fracture, leaving intra-articular pathologies like adhesive capsular stiffness unaddressed.Arthroscopic Treatment of Greater Tuberosity Avulsion Fractures
Isolated fractures of the greater tuberosity of the humerus are an uncommon and frequently missed diagnosis. Mistreated and unrecognized, these fractures can cause chronic pain and diminished shoulder range of motion and function. Operative treatment options include open reduction and internal fixation, as well as arthroscopic-assisted reduction and internal fixation. The purpose of this Technical Note is to describe a bridging arthroscopic technique for the treatment of bony avulsions of the supraspinatus tendon.Surgical Technique for Open Reduction–Internal Fixation of an Unstable Displaced 3-Part Proximal Humeral Fracture Using a Proximal Humeral Locking Plate
The proximal humeral locking plate (PHLP) is a recently developed fixed-angle implant that is an option for open reduction–internal fixation of an unstable displaced proximal humeral fracture. Various articles have reported successful outcomes using the PHLP when compared with other implant designs. However, many complications still occur with use of the PHLP, such as avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. These complications are related to the difficulty in fixation of this particular type of fracture, as well as ineffective surgical technique.Arthroscopic Reduction and Fixation of Transverse Intra-articular Glenoid Fractures With Scapular Extension
The most common procedure to address transverse glenoid fractures that are characterized by intra-articular step-off or gapping is open reduction and internal fixation. Disadvantages of open surgery are delay in regaining full range of motion, increased approach morbidity, neurovascular complications, and the need for capsulotomy, which delays healing and increases the risk of stiffness. An arthroscopically assisted fracture fixation, as described in this article, is characterized by better visualization of the glenoid articular surface and reduction of the intra-articular fragments under direct vision, which diminishes the chances of residual step-off after fixation.Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation
Currently, open reduction–internal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.Arthroscopic Removal of Symptomatic Proximal Humerus Locking Plates With Bone-Void Filler Augmentation
Open reduction internal fixation of proximal humerus fractures is often accomplished with proximal humerus locking plates. While these plates have a good track record, they can become symptomatic and require removal once the fracture has healed. Open hardware removal is associated with a number of additional risks to the patient, including infection, scarring, nerve damage, and blood loss. In addition, the recovery time after open hardware removal may be prolonged, thereby predisposing the patient to postoperative stiffness.Arthroscopic Fixation of Glenoid Rim Fractures After Reduction by Labral Repair
Surgical fixation of displaced, intra-articular glenoid fractures represents a clinical challenge. These fractures have traditionally been treated through open approaches to the glenohumeral joint; however, the morbidity associated with open surgery may be reduced with arthroscopic techniques. Previously described arthroscopic methods commonly use clamps and/or Kirschner wires to obtain and maintain provisional fixation. We describe our technique for minimally invasive, arthroscopic fixation of glenoid rim fractures using labral repair as an indirect reduction maneuver, followed by final fixation with an extra-articular screw.Arthroscopic Reduction and Internal Fixation of an Inferior Glenoid Fracture With Scapular Extension (Ideberg V)
Arthroscopic reduction and internal fixation of glenoid fractures have been well described, especially for glenoid rim (Bankart) fractures, as well as for scapular body fractures with extensions into the articular surface. This approach has the advantage of decreasing comorbidities associated with a standard open approach, but it can be technically challenging and may not be amenable to all fracture patterns. Arthroscopic fixation of scapular fractures incorporating a transverse pattern along the inferior aspect of the glenoid is particularly challenging because of difficulty in accessing this space.Arthroscopic Repair of a Posterior Bony Bankart Lesion
Posterior bony defects of the glenoid rim, particularly those associated with instability, are often a frustrating challenge for arthroscopists because of the defects' inaccessibility from standard portals. This challenge is enhanced when the lesion is chronic and fibrous malunion of the fragment makes mobilization difficult. We present our technique for arthroscopic repair of the relatively uncommon chronic posterior bony Bankart lesion. By use of lateral positioning and a standard anterior viewing portal and posterior working portal, as well as a strategically placed posterolateral accessory portal, the lesion is first freed from its malreduced position and ultimately repaired using suture anchor fixation of the bony fragment along with its associated labrum directly to the remaining glenoid rim.Extra-articular Synovial Chondromatosis Eroding and Penetrating the Acromion
Synovial chondromatosis of the shoulder is an uncommon disorder. It usually affects the glenohumeral joint and is characterized by metaplasia of the synovium leading to the formation of osteochondral loose bodies. Few cases of extra-articular subacromial synovial chondromatosis involving the rotator cuff tendon have been reported in the literature. The treatment of previously reported cases consisted of open bursectomy and removal of loose bodies. We report a case of subacromial synovial chondromatosis without rotator cuff involvement but with severe erosion and fracture of the acromion.Arthroscopic-Assisted Fixation of Ideberg Type III Glenoid Fractures
Operative treatment of scapular fractures with extension into the glenoid can be a challenging clinical scenario. Though traditionally addressed in an open fashion, the morbidity of this approach, complemented by advancements in arthroscopic technique and instrumentation, has led to increasing use of arthroscopic-assisted fixation. We describe our technique, including pearls and pitfalls, for minimally invasive fixation of Ideberg type III glenoid fractures. This approach minimizes morbidity, allows optimal visualization and reduction, and provides good functional results.Open Reduction Internal Fixation of Distal Clavicle Fracture With Supplementary Button Coracoclavicular Fixation
Distal clavicle fractures are common, and no standard treatment exists. Many different surgical modalities exist. This report describes an open reduction internal fixation technique that achieves both plate and coracoclavicular stabilization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drill bit is drilled across the clavicle and coracoid, passing through 4 cortices. The button is loaded onto an insertion device, passed across the 4 cortices, and captured on the undersurface of the coracoid under fluoroscopic guidance.Arthroscopic Transtendinous Modified Double-Row Suture Bridge Repair of a Bony PASTA Lesion
Surgical and conservative management of partial tears of the rotator cuff has long been a controversial topic for many generations of shoulder surgeons. These tears frequently occur on both the articular and bursal surfaces and within the intrasubstance of the rotator cuff. The term “PASTA lesion” describes the partial articular supraspinatus tendon avulsion–type injury. A less common variant of this injury is the bony PASTA lesion or partial articular bony avulsion of the supraspinatus tendon (PABAST).Arthroscopic Treatment of Comminuted Distal Clavicle Fractures (Latarjet Fractures) Using 2 Double-Button Devices
Complex distal clavicle fractures associated with a rupture of the coracoclavicular ligaments (Latarjet fractures) can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces an arthroscopic technique for treating distal clavicle fractures associated with ruptured coracoclavicular ligament using 2 double-button devices. By use of posterior and anterior standard arthroscopic portals, the base of the coracoid process is exposed through the rotator interval.The “Double-Pulley” Technique for Arthroscopic Fixation of Partial Articular-Side Bony Avulsion of the Supraspinatus Tendon: A Rare Case of Bony PASTA Lesion
We report the use of the double-pulley technique for arthroscopic fixation of the bony PASTA (partial articular surface tendon avulsion) lesion. Arthroscopic examination documented a 15-mm-long and 8-mm-wide comminuted bony avulsion with 2 main fragments. Two double-loaded suture anchors were placed with a transtendinous technique at the anterior and posterior edges of the lesion respecting the tendon insertion to the avulsed fragment. The medial sutures were retrieved through the intact supraspinatus tendon medially to the fracture.
