A Modified Rotator Cuff Sparing Approach to the Proximal Humerus in Antegrade Nail Osteosynthesis with Transosseous Supraspinatus Tendon Refixation

Abstract

Background Due to the approach within antegrade humerus nail osteosyntheses, lesions of the supraspinatus tendon with a consecutive functional limitation of the rotator cuff (RC), insufficiencies, adhesions and chronic shoulder pain in the long term can result. The evidence respectively the study data situation is limited regarding the evaluation of this issue. Patients/Material and Methods We are the first to present by means of a case report with a geriatric female patient and a dislocated diaphyseal humerus fracture a rotator cuff sparing osseous approach to the proximal humerus in antegrade nail osteosynthesis without harming the vulnerable supraspinatus tendon (SSP). This is possible through a limited osteotomy of the greater tubercle with the preparation of a 10 mm deep and 15 to 20 mm wide osseous SSP base. The medullary cavity is then opened for inserting the nail in an antegrade manner and closed after fracture stabilization through reposition of the attached osteotomy of the greater tubercle by means of a suture anchor, for example. The procedure also includes a biceps tenodesis. Besides the description of the intraoperative approach and procedure, the clinical and functional results were recorded by established scores as well as radiologically respectively sonographically 6 weeks (T1) and 3 months (T2) postoperatively. Results The patient was very satisfied regarding pain and function after the modified operative procedure. The rotator cuff tests were negative and there were no impingement like symptoms or indications for an adhesive capsulitis. Range of motion as well as the Constant and (Quick) DASH-Score showed a very good function in the course. The implant was located regularly in the radiological control and the fracture showed a good osseous consolidation. A bland joint without effusion or periarticular fluid and no adhesion with the delta fascia could be presented by sonography. The RC and especially the SSP showed a normal sonographic separation. The functional results are comparable to the other publications so far. Conclusion The described surgical technique shows a significantly less invasive approach for the implantation of an antegrade humerus nail in the case of a humerus shaft fracture with an excellent function of the affected shoulder in a short-term follow-up. This novel approach should be evaluated by means of prospective studies regarding the functional outcome to justify the establishment of this modified procedure in the long term. Other modified approaches have been depicted but are essentially differing from our described procedure with regards to the invasiveness of the vulnerable tendinous structure of the SSP respectively RC.