A novel “7 sutures and 8 knots” surgical technique in reverse shoulder arthroplasty for proximal humeral fractures: tuberosity healing improves short-term clinical results

Troiano et al. Journal of Orthopaedics and Traumatology (2023) 24:18 https://doi.org/10.1186/s10195-023-00697-4 ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access A novel “7 sutures and 8 knots” surgical technique in reverse shoulder arthroplasty for proximal humeral fractures: tuberosity healing improves short‑term clinical results Elisa Troiano1,2, Giacomo Peri1,2, Irene Calò1,2, Giovanni Battista Colasanti2, Nicola Mondanelli1,2*    and Stefano Giannotti1,2 Abstract Background Complex proximal humeral fractures (cPHFs) represent an important public health concern, and reverse shoulder arthroplasty (RSA) has emerged as a feasible treatment option in the elderly with high functional demands. Recent studies have shown that tuberosity healing leads to better clinical outcomes and an improved range of motion. However, the best surgical technique for the management of the tuberosities is still a topic of debate. The purpose of this retrospective observational study is to report the radiographic and clinical outcomes of a consecutive series of patients who underwent RSA for cPHFs using a novel “7 sutures and 8 knots” technique. Materials and methods A consecutive series of 32 patients (33 shoulders) were treated with this technique by a single surgeon from January 2017 to September 2021. Results at a minimum follow-up of 12 months and a mean ± SD follow-up of 35.9 ± 16.2 (range 12–64) months are reported. Results The tuberosity union rate was 87.9% (29 out of 33 shoulders), the mean Constant score was 66.7 ± 20.5 (range 29–100) points, and the mean DASH score was 33.4 ± 22.6 (range 2–85) points. Conclusions The “7 sutures and 8 knots” technique, which relies on three sutures around the implant and five bridging sutures between the tuberosities, is a relatively simple procedure which provides a reliable means for anatomic restoration of the tuberosities and allows functional recovery of the shoulder in elderly patients with cPHFs treated with RSA. Level of evidence: IV; retrospective atudy. Trial registration: At our institution, no institutional review board nor ethical committee approval is necessary for retrospective studies. Keywords Reverse shoulder arthroplasty, Tuberosity reconstruction, Tuberosity repair, Proximal humeral fracture, Surgical technique, Fragility fracture *Correspondence: Nicola Mondanelli Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Troiano et al. Journal of Orthopaedics and Traumatology (2023) 24:18 Introduction Proximal humeral fractures (PHFs) are the seventh most commonly observed fractures in adults and account for 4–10% of all fracture types. A bimodal distribution has been described: PHFs occur in elderly patients with decreased bone strength after low-energy traumas, while most high-energy injuries involve patients under the age of 55 [1]. PHF incidence is rising in the elderly, especially in women, and it now constitutes the third most common osteoporotic fracture [2–4]. The choice of the most effective treatment option for PHFs should take into account the fracture morphology, patient co-morbidities and functional expectations, and it should aim to achieve a pain-free functional shoulder [2, 5]. Also, since PHFs in the elderly are fragility fractures, regardless of the treatment option, a multidisciplinary approach such as a fracture liaison service is fundamental in order to reduce the risk of further fractures [6]. A variety of surgical options can be employed, including closed reduction and percutaneous fixation, closed or open reduction and internal fixation [7], and arthroplasty [3]. Non-operative treatment is generally accepted for undisplaced or minimally displaced PHFs, or for displaced fractures in the elderly with low functional demands or who are not cleared for surgery [3, 4, 8]. The most appropriate treatment for complex PHFs (cPHFs) in the elderly is still a topic of debate, as concomitant osteoporosis and significant comminution prevent the achievement of stable fixation, so they may benefit from arthroplasty rather than osteosynthesis [2, 9, 10]. Historically, hemiarthroplasty (HA) was considered the preferred choice for operative treatment of cPHFs [11, 12]; nevertheless, its outcomes are heterogeneous, so reverse shoulder arthroplasty (RSA) has emerged as an alternative treatment option [12–18]. The main theoretical advantage of RSA is that tuberosity healing and cuff rotator integrity are not prerequisites for a satisfactory outcome since RSA primarily depends on the deltoid muscle to restore shoulder function [3, 14, 15, 17, 19–21]. Nevertheless, it has been shown that tuberosity healing leads to better functional results and active motion, even in RSA [21–26]. This is due to the influence of the volume of the greater tuberosity in restoring the lateral offset, improving the deltoid wrapping over the RSA, and maintaining the function of the subscapularis. As a result, recent efforts to enhance the tuberosity healing rate have been made [24, 27–35], but a gold standard technique has not been identified. In the present paper, we present the results of a retrospective observational study conducted on patients older than 65 years of age who underwent RSA for cPHFs with the application of a novel “7 sutures and 8 knots” tuberosity fixation technique to achieve better tuberosity healing. Page 2 of 9 Materials and methods Study design A retrospective and observational study was performed. Inclusion criteria were as follows: (1) a cPHF categorized as a Neer three- or four-part fracture, a head-splitting fracture, or with more than 40% of the joint surface head involved; (2) a cPHF occurring in a patient over 65 years of age; (3) a cPHF treated with RSA, a fracture-specific stem, and a standardized novel technique of tuberosity fixation including bone grafting between the metaphyseal part of the stem and the tuberosities performed by a single surgeon; and (4) a minimum clinical and radiological follow-up of 12 months. Patients with previous failed open reduction and internal fixation for PHFs, patients undergoing (...truncated)