Arthroplasty Shoulder

Product

Reproducible. Simple. Strong.
<ul>
 <li>Three distinct suture colors aid in suture management for a simple, reproducible repair</li>
 <li>FiberTape™ suture provides more resistance to tissue pull-through compared to round suture1</li>
 <li>FxBridge technique facilitates anatomic tuberosity reduction, which increases tuberosity healing and improves postoperative range of motion2</li>
 <li>135° humeral inclination increases tuberosity healing rate and stability3-5</li>
</ul>
References
1. O'Sullivan J, Lädermann A, Parsons BO, Werner B, 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 Sep;29(9):1938-1949. doi: 10.1016/j.jse.2020.03.032. Epub 2020 Jun 9. PMID: 32815808.
2. Erickson BJ, Shishani Y, Bishop ME, Romeo AA, Lederman E, Gobezie R. Tuberosity repair in reverse total shoulder arthroplasty for fracture using a stem-based double-row repair: a cadaveric biomechanical study. J Am Acad Orthop Surg. 2020;28(23):e1059-e1065. doi:10.5435/JAAOS-D-19-00667
3. Schmalzl J, Jessen M, Holschen M, et al. Tuberosity healing improves functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis. Eur J Orthop Surg Traumatol. 2020;30(5):909-916. doi:10.1007/s00590-020-02649-8
4. Jo O, Borbas P, Grubhofer F, et al. Prosthesis designs and tuberosity fixation techniques in reverse total shoulder arthroplasty: influence on tuberosity healing in proximal humerus fractures. J Clin Med. 2021;10(18):4146. doi:10.3390/jcm10184146
5. O’Sullivan J, Lädermann A, Parsons BO, et al. 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(9):1938-1949. doi:10.1016/j.jse.2020.03.03

This animation provides an overview of the FxBridge™ tuberosity repair system and the surgical technique used in conjunction with Univers Revers™ implants to treat proximal humeral fractures.

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FxBridge™ Tuberosity Repair System: Reverse Total Shoulder Arthroplasty

Identify the proximal humeral fracture pattern. The humeral head fragment is removed from the wound. Begin the repair by passing the blue number two FiberLink inside out through the infraspinatus tendon at the bone tendon junction. Repeat this process with the white black number two. Tigerlink going through the inferior portion. Next, pass the number two FiberLink inside out through the superior portion of the subscapularis tendon. Repeat this process with the number two TigerLink through the inferior portion. Prepare the glenoid per the specific glenoid system surgical technique being used. Then prepare and trial the humeral components. Remove the humeral trials and drill two holes in the lateral side of the bicipital groove with the 2.0mm drill bit. Drill the holes 1 to 2cm distal to the humeral shaft. Fracture line. Pass the black blue 1.7mm FiberTape in an outside in, then inside out fashion. Repeat this with a second 1.7mm FiberTape. After assembling the suture cup and humeral stem, Pass the white black 1.7mm TigerTape through the two distal row eyelets of the SutureCast. Then pass the blue 1.7mm FiberTape through the proximal two eyelets. Repeat the suture passing for the posterior eyelets. Implant the humeral prosthesis and place the final humeral insert on the posterior side. Take the suture tails from the blue FiberTape and feed them into the blue FiberLink looped end. Repeat the previous steps for the TigerTape and TigerLink, then shuttle the sutures through the greater tuberosity. Reduce the shoulder on the anterior side. Take the suture tails from the blue FiberTape and feed them into the blue FiberLink looped end. Repeat the previous steps for the TigerTape and TigerLink. Shuttle the suture through the subscapularis. Take one limb of the blue FiberTape from the lesser tuberosity, and one limb of the blue FiberTape from the greater tuberosity, and tie them together. Note the strands are free moving and won't tension when being tied together. Take one limb of the white black TigerTape from the lesser tuberosity and one limb of the white black TigerTape from the greater tuberosity and tie them together. Take the remaining blue FiberTape from the lesser tuberosity and the remaining white black TigerTape from the greater tuberosity, and tie them together. These remaining strands allow for the construct to be tensioned when tied. Take the remaining white black TigerTape from the lesser tuberosity, and the remaining blue FiberTape from the greater tuberosity, and tie them together after the suture construct has been tied. Pass and tie the vertical tension band sutures starting with the anterior whole. Pass one limb of the black blue FiberTape up through the superior aspect of the subscapularis, and then through the superior aspect of the infraspinatus. Take one limb of suture from the posterior whole and tie it to the past suture. Repeat the process for the remaining black blue FiberTape working posterior to anterior.

Sri Pinnamaneni, MD (St Louis, MO), highlights his technical tips for reconstructing tuberosities in complex proximal humerus fractures with the stem-based FxBridge™ tuberosity repair system.

Reducing Complex Proximal Humerus Fractures With the FxBridge™ Tuberosity Repair System

Hello everyone. My name is Doctor Sri Pinnamaneni. I'm an orthopedic surgeon from Saint Louis, Missouri who specializes in shoulder elbow surgery. I practice at the Orthopedic Center of Saint Louis. Today we will be talking about reverse fractures, specifically tuberosity reconstruction. To give you a roadmap on how I'm going to approach this talk, we're going to talk about why it's important to repair the tuberosities in reverse fracture. And I'm going to go over some technical tips that help me do this surgery efficiently. We know that tuberosity healing improves functional outcome scores and clinical outcomes after reverse fracture. We know that tuberosity repair is important. We know that prosthesis design, coding texture and suture cup allows for stable tuberosity repair. A 135 neck shaft angle allows for better tuberosity repair in my hands. The fracture bridge tuberosity repair system allows for the simplest, strongest, more reproducible, the quickest and most efficient repair system for the Tuberosities. When I'm doing a reverse fracture. This is a 74 year old status post fall three weeks ago. As you can see on these X-rays, there's a four part displaced proximal humerus fracture. I typically get CT scans on these patients. On these axial CT scans, you can truly identify the level of comminution and displacement of this fracture. I typically use the CT scan for pre-operative planning to understand the greater tuberosity and the lesser tuberosity fracture fragments, and the bone windows that I'll be working through. Intraoperatively. Here you can truly understand the level of comminution, but also understand where the fracture exits on the surgical neck. Here you can identify where the fracture exits on the surgical neck. I use the CT scan to preoperatively plan the bone windows, including the greater and lesser tuberosity fractures. I also identify where the surgical neck fracture is. My technical tips overall from a 10,000 foot view is understanding the three phases of my surgery. The first one is the approach identification of the lesser and greater tuberosity fractures and removal of the humeral head. The next is to mobilize the lesser and greater tuberosity fractures and the shaft, and the third is placement of the humeral stem and reconstruction of the tuberosities. So I go through this process where it's extremely tight and I expose, then it's loose, and then I place the plant and it's tight again. I use a deltopectoral interval. I expose the pec tendon first, which allows me to get to the deltoid and maintain the integrity of the deltoid. I place a Hohmann retractor on the lateral portion of the humerus. I make sure to stay on bone to avoid the axillary nerve. Laterally, I identify the biceps tendon, and I follow that all the way up into the intertubercular groove. This allows me to identify the lesser tuberosity. Once I identify this, I go back. As you can see here, the large osteotomy is on the bicipital groove. But as you know from this pre-operative plan, as demonstrated here on the CT scan, the fracture exits lateral to the bicipital groove, and so you can see me move the osteotomy into the bone window to elevate the lesser tuberosity fracture. My next step is to identify and remove the humeral head. As you can see here, it's 180 degrees angulated. My next step here is to mobilize the lesser tuberosity. I use a coker clamp to do a 360. Release the lesser tuberosity fracture I next do this for the greater tuberosity fracture. Some technical tips is you have to make sure that you release the inferior portion and the inferior adhesions of the lesser tuberosity off the surgical neck. The next step is releasing the inferior portion of the greater tuberosity adhesions. Oftentimes, even when the fracture is two weeks old, you can have significant amount of callus formation, attaching the greater tuberosity inferiorly to the lateral portion of the humeral shaft. I do this with a Cobb elevator to provide a 360 release. Additionally, you can release the superior capsule using a heavy mayo scissors, allowing you to release the rotator interval all the way to the glenoid. This allows you to get mobilization, as demonstrated here. So my tips to mobilize the humeral shaft is going from known to unknown. So I typically start laterally on the bicipital groove, release the pec and go medial onto the surgical neck. In terms of sphere sizing and placement, I typically use VIP. I look at the back table, look at the native head that was removed to understand the size of the patient, and then subsequently I typically use a more medium sized gleniffer than I would when I'm using reverse or shoulder replacement for fracture. And the reason why I do that is it allows for less tension on my tuberosity reconstruction at the end of the case. Oftentimes, I will use a trial sphere to help during the reduction and trialing process. I use the CT scan to identify where the surgical neck fracture is. Oftentimes when I'm placing the broach, it sits nicely on the surgical neck and the medial shelf of the surgical neck. As long as the mediocalcar is intact. Now oftentimes I'm looking at metaphyseal fixation and not diaphyseal fixation. If the medial calcar is comminuted, I do use the measurement from the top of the pec insertion to identify my height. I rarely need to cement 90% of the time I'm doing this uncemented, and 10% of the time I'm needing to use cement. In terms of trialing with my trial implants, I typically do this with traction and less tuberosity fracture with no traction on the greater tuberosity. This should ReDeuce nice and easy. If needed, use a skid. If the reduction is extremely tight, typically that's because the greater tuberosity is tuberosity is getting in the way and you have not released this enough. So I would go back to release the greater tuberosity. Additionally, it could be that the brooch is too proud or the height is not accurate. If it's too loose, typically the stem or the brooch has subsided or the sphere is too small. As you can see here, the suture cup allows for nice placement of the suture. Tape around the suture cup through the holes. 90% of the time I'm doing this in an uncemented technique 10% of the time when I do cement, I use a black and tan type technique where I place cement down into the humeral canal and remove the proximal portion of the cement. Now, as I place the implant, oftentimes the implant and the medial portion of the stem usually sits nicely on the surgical neck. And again, 90% of the time I'm doing this uncemented in terms of the tuberosity reconstruction, I usually reduce and pass the sutures after I reduce. This allows me to have control over the greater and the lesser tuberosity. After I reduce the reverse shoulder replacement before I close the book and I repair the greater to lesser tuberosity, I will take bone graft from the humeral head and fill any bone voids between the greater and lesser tuberosity and at the lateral femoral shaft. After I placed the bone graft, then I'll repair the stitches on top. Closing the book. I take the black sutures that were in the humeral shaft and go around the world. I go through the lesser tuberosity twice and greater tuberosity twice. As I'm going through the lesser and greater tuberosity, I typically use a bovie on my needle to help pass through the soft, greater and lesser tuberosity bone. Here you can see the final product where you have an excellent robust repair of the lesser and greater tuberosity. These are X-rays. Immediately post-operatively. You can see the excellent greater tuberosity reconstruction on the lateral portion of the humeral shaft. When I'm looking at the X-rays from my reverse fractures, I'm comparing them to my reverse for arthritis or cuff tear arthropathy. And you can see that these are examples of my patients with reverse for arthritis. And these are my patients for reverse for fracture. They look extremely similar. And this is a credit to the fracture bridge system helping me create a more reproducible greater tuberosity reconstruction.

This animation presents the features and benefits of the Univers Revers™ humeral implants.

Univers Revers™ Total Shoulder System—Versatility. Simplicity. Performance.

Justin W. Griffin, MD, (Virginia Beach, VA) demonstrates the surgical technique for the Univers Revers™ Modular Glenoid System.

Univers Revers™ Modular Glenoid System

At this point, we've obtained our glenoid exposure, and we're going to use the scrape pat to remove the remaining cartilage. So this tool is very helpful for identifying the bony anatomy in the setting where we're using a VIP guide, or in settings where there's increased wear. This will allow us to make sure that we appreciate the inclination and retroversion if there's variable wear on the glenoid. So at this point we'll take our sizer and pin guide for our base plate. This is a 24. There's also a 28 in the system. We're going to place this through the neutral hole. But there's also a ten degree offset holes that will allow you to correct inclination. On our Pin. You can see that we have laser etchings to estimate the depth so that we can get our screw size. So in this case we're going to place this through the central hole. So we reach the back cortex and we'll penetrate there. And we can stop for a second and check our size which in this case is a 25. And we can remove our guide at that point. So alternatively, if we're not sure about the size of our central screw or post, we can use this sizer just to be sure that the length is appropriate. And in this case, that confirms that we are in fact at a 25 depth. So this is our Glenister sizer. This is going to allow us to judge the size of the Glenister intraoperatively in relationship to the pin. Alternatively, if you're using a VIP guide that will allow you in three dimensions to really see your anatomy. So we can place this over the pin at this point, and you can see that the inferior rim in relationship to this will give us a very nice 36 size Glenister in this case, so that we have a little bit of inferior overhang. So next we have our primary reamer. This has no positive stop on it. And we're going to look for a congruent surface on the back so that this matches the implant geometry of our base plate. So at this point it looks like we have good contact so we can stop there. So this does have a positive stop. And this will allow us to clear out the out the peripheral bone so that we can get good seating for our sphere. So this is specific to a 36 glenyce sphere in this case. So next we have our ten millimeter drill. In this case we're going to use a screw type base plate. And so this drill will prepare for the BioSync collar. So we've chosen a 25 screw. And so as you can see here we have a tap. So we're going to bring this down to the positive stop. And as is typical with our screw length being appropriate we have bicortical fixation here. And the pin comes out with the tap. So our next step is to assemble the base plate. We have our 24 base plate. And we also have our modular 25 screw. You can see that there's a hex component to this. And so as we bring these two these two together, we want to ensure that the hex component on the end of the taper aligns. So once we've assembled the two components, we need to place those into our press. The press has a min and a max line, and we have to ensure that we get between those two when we assemble the base plate. As you can see, we can place the four holes on the back of the base plate into our press. We can bring this down in contact with the screw. And then viewing the min max line will compress the base plate until we're between those two lines. So as you can see, we've brought the laser line below the minimum amount to be sure that the base plate is properly assembled. So at this point, we've ensured that our soft tissue is all clear and we're ready to place our base plate. So we get really a nice, very nice bite on that and we can align the screws. My preference is to put one superior one Superior, one inferior. So next we'll place our locking guide. I'll typically place my inferior screw first. We can read our depth, which in this case is a 24. And we can drill all of our screws and choose our lengths as we go for efficiency. So our locking screws, when we place them, these are in a fixed divergent angle. We could choose compression screws as well. Sometimes if you're placing these in the front or back of the glenoid, it's nice to have the sixteens available. So we have our sphere and we'll just check to make sure it's fully seated on the sphere. Inserter. And we'll just place our hand here to ensure that the sphere stays fully seated as we remove our inserter. We'll take our impactor. This is our sphere locking screw. And as we place this, we just want to make sure that it fully seats into the sphere. And that's our check. Just to make sure that this is fully seated with the sphere on the base plate. So as we're seeding the locking screw, we just want to be sure that on our torque adapter we're between the three and the five. We have our final assembly of our sphere. And we can check to make sure this is secure. But if the central screw is seated entirely, it should be a nice check for being sure that we're seated.

This animation highlights the features and benefits of the Univers Revers™ Modular Glenoid System.

Trauma Upper Extremities

Anthony Romeo, MD, (Chicago, IL) performs reverse total shoulder arthroplasty for a proximal humerus malunion using the Univers Revers™ Total Shoulder System.

Proximal Humerus Malunion Management with the Univers Revers Total Shoulder System

FxBridge™ Tuberosity Repair System

Child (D)

Procedure

The Arthrex Proximal Humeral Plating System is designed to treat a variety of fractures of the proximal humerus. The system offers lateral proximal humeral plates in 3- to 17-hole configurations, corresponding to lengths from 91 to 309 mm. All plates accept 3.5 mm reinforced variable-angle locking (VAL), 3.5 mm reinforced VAL KreuLock™ or cortical screws, and 4 mm cancellous screws. Additionally, 3.5 mm FiberTape® cerclage buttons can be used in the shaft of the plates.

Arthrex Proximal Humeral Plating System

Trauma Lower Extremities

The Arthrex Humeral Nail System provides two distinct options for humeral nailing. The short nail is designed to quickly and efficiently treat proximal third humeral fractures and features a self-reaming trocar tip to further reduce operative time and four screw options proximally. The long nail has 3 proximal screw options and is available in diameters of 7 mm, 8 mm, and 9 mm with lengths from 20 cm to 30 cm. An internal compression screw in the long nail aids in fracture reduction and compression. Each nail includes screws that thread into the nail to prevent screw backout and create a locking construct for added stability. Simplified instrumentation helps make the process efficient and repeatable.

Shoulder

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Humeral Nail System

The Arthrex Humeral Plating System is a comprehensive solution for proximal humerus fracture management. Three plate options include a 95° greater tuberosity buttressing plate, a 130° PHP to limit subacromial impingement, and the anatomically designed ALPHA plate to preserve the deltoid insertion point. All plates accept 4.0 partial and fully threaded locking screws and 3.5 locking and nonlocking screws distally in the shaft. Color-coded instrumentation and a simplified tray layout allow quick and repeatable fixation of all types of fracture patterns.

Proximal Humerus Plating System

The Proximal Humerus Plating System provides three distinct plate offerings for treating a variety of fracture patterns. The ALPHA plate incorporates side-specific anatomic contours that helps spare the deltoid attachment site and a crossing screw pattern proximally. The system also features the 95° greater tuberosity buttress plate and the 130° PHP for limiting subacromial impingement.

The Arthrex proximal humerus plating system is intended to treat a variety of fractures of the proximal humerus. The system features the alpha anatomic plate, 95 degree buttress plate, and the 130 degree proximal humeral plate. The alpha plate is a unique, site specific, anatomically designed option featuring crossing screws for increased screw length in the humeral head, suture holes for cuff repair, a choice of 4.0mm fully or partially threaded, locking screws proximally, and interior bend to avoid the deltoid insertion site, an oblong hole that allows up to five millimeters of compression and accepts 3.5mm locking or non-locking screws in the shaft. The blue and yellow color coded screw configurations can be used interchangeably proximally, while the green and gray screws are interchangeable distally. Begin the procedure by positioning the plate on the bone with the alignment guide attached. Using the 2.8mm multiple drill guide, drill bicortical through the slotted hole with the 2.8mm calibrated drill bit. Using the laser markings on the drill to determine screw length, insert a non-locking screw through the hole using a t15 driver and handle. Verify the proximal screw trajectory by inserting K-wires through the aiming block and verifying using fluoroscopy. Insert the screw sheath into the alignment guide followed by the 3.5mm drill guide. Advance the 3.5mm step. Drill through the sleeve until the drill tip reaches subchondral bone. Unthread and remove the drill guide from the sleeve using the depth guide. Measure to determine the desired screw length to be inserted. Insert a 4.0mm partially threaded locking screw through the sleeve. Repeat the steps for the for the remaining proximal screws. The choice of fully or partially threaded 4.0mm screws is based on surgeon preference. Once all proximal screws are inserted, remove the alignment guide for the distal holes. Begin by threading the 2.8mm locking drill tower into the screw hole. Drill bicortical using the 2.8mm drill, and use the calibration lines on the drill bit to determine screw depth. Unthread and remove the locking drill tower and insert a 3.5mm locking screw using the hex driver. Repeat the previous steps to fill the remaining holes with 3.5mm screws to complete the plate. Fixation SutureLasso technology allows for repair of the rotator cuff to the plate after the plate is applied.

Charles J. Jordan, MD (Miami, FL), demonstrates the surgical technique for the ALPHA plate, the 95° plate, and the 130° plate.

ALPHA Proximal Humeral Plate System Operative Technique

So today we're going to talk about the proximal humerus plating system. I think you'll notice that this is a very comprehensive system. It's probably as comprehensive as you'll ever need for any solution. There's three basic categories of plate. One is a straight plate with 95 degree screws approximately. Another one is a straight plate as well with 130 degree screws. And then there's the alpha plate, which has variable angles to each of the screws as far as inclination and trajectory, as well as dedicated bends in order to adapt the plate to the anatomy of the humerus. So we'll start off by talking about the 95 degree plate. I tend to choose this plate when I want the plate to sit a little bit higher, i.e. when there's a large greater tuberosity fragment, the proximal portion of the screws have a 95 degree trajectory, and that allows for a longer profile from superior to inferior. You'll notice that there are five proximal options, the screws of which run at 95 degree trajectories. And then there's two there's two calcar options below. This makes for a longer profile from superior to inferior, and allows a little bit more superior positioning of the plate. I tend to choose this type of plate when fixing fractures that involve primarily a large greater tuberosity component. In order to be able to buttress the tuberosity and avoid superior migration. Next is the straight 130 degree plate. You'll see that because it sits a little bit lower on the humerus, the profile from superior to inferior both tapers down and is a little bit shorter in length. I think that ideal indications for this plate include simple two part fractures, fractures in which the surgical neck is the primary fracture line. And in a situation where I'm going to use a deltoid splitting approach for those who prefer a straight plate option, even in extensile fractures, there's a 14 hole option as well. This plate sits on the lateral border of the humerus all the way down. And finally there's the alpha plate. The alpha plate was designed originally with complex and extensile fractures in mind. As you can see, as one extends down into the humerus, the plate has an anterior bend in order to avoid the deltoid insertion, and then has a secondary bend with a twist in order to become essentially an anterolateral humeral shaft plate. The screw trajectories in all three plates are very different. Like I previously mentioned, the 95 degree plate is intended to provide a solution for situations in which you need a plate that sits further superior and creates essentially a 95 degree fixed angle construct. Whereas the 130 degree plate essentially creates the so-called hat on a hook construct, which helps to neutralize various stresses. The 95 degree and 130 degree plates have a diverging screw pattern, whereas the alpha plate screws converge. There's a couple of reasons for this. Number one, as the screws converge, the point at which they all converge creates an intramedullary point of resistance, or an intramedullary strut that allows the blockage or the prevention of subsidence and settling of settling of the humeral head, especially in comminuted fracture patterns. Also, the paths in this converging design tends to create for longer screws and more threads in bone. And finally, this converging pattern also creates a construct in which each screw is a Czech grain to the screw above it to resist any varus displacement or various failure. The instrumentation for the set is very straightforward. Each plate comes with its own targeting block that fits the superior portion of the plate, and they allow for ease in insertion of the locking towers. This becomes especially important with the alpha plate because of the convergent pattern of the screws. Sometimes it can be a little more difficult to thread the locking towers onto the plate without the use of the guide. Okay, so just to mention about the deltoid split. One thing that's important to remember is that the deltoid splitting approach starts at the anterolateral border of the acromion and extends distally. You have about 4 or 5cm worth of area to work with here before you enter the window where you need to avoid the axillary nerve. You can always extend the incision beyond that, but generally you work in two windows. Today we're going to be focusing mostly on the deltopectoral approach, because this tends to be the workhorse approach for the majority of fractures, especially with complex fractures. So I'm just feeling for the coracoid process. And my incision tends to start just lateral to the point of the coracoid process and extends longitudinally and laterally along the deltopectoral interval and down towards where my anterolateral approach would be for the humerus. The anterolateral approach to the humerus, which is the natural extension of the deltopectoral approach, tends to go along the anterolateral border just lateral to the belly of the biceps. So we're going to make a skin incision. Along the deltopectoral interval. And it's going to extend down to the anterolateral approach for the humeral shaft. Today we're going to going to implant one of the longer alpha plates, just so I can show you as many of the features as possible with regards to the design of this plate, especially as you extend into more complex fracture patterns and into more distal fractures. So the first major landmark that we look for is the cephalic vein. And here, although with this specimen, for obvious reasons, the vein is very collapsed and may not be as straightforward to find. It tends to be a very large landmark that really points out the deltopectoral interval. So I'll deepen my retractor a little bit here and actually put it into the deltoid muscle laterally, just in order to be able to bring the vein further into my field of view. This is basically the space between the deltoid and the pec. And now we've started to develop the interval here. And as we develop this interval you can start to see the border of the deltoid and the sub deltoid space, which I'll usually develop bluntly. And the pec major. I'll usually put in a deltoid retractor. Retract back the deltoid. Now you can really visualize the proximal humerus, the lateral border of the proximal humerus, and the biceps tuberosity. Depending on the fracture and depending on the amount of exposure needed. I'll sometimes take down a portion of the pec insertion, but it's not always necessary. And a retractor is often useful once you've developed the space underneath the coracobrachialis. So the bicipital groove runs right in between the greater and lesser tuberosity. And that's generally a huge landmark for the placement of this plate. We're going to dissect distally now. So as I complete my dissection here let me point out some anatomic landmarks for clarity. The deltoid is sitting behind this retractor. Here's the strap muscles, the coracobrachialis tendon, and the pec major insertion. We're looking here at the biceps muscle belly and deep to the biceps. Muscle is brachialis and just distal is brachioradialis. Distally, we retract medially, the biceps muscle belly always keeping in mind that the musculocutaneous nerve and neurovascular bundle are deep to biceps and slightly medial. This entire portion here of the humerus represents the entirety of the deltoid insertion. It's a big, long, broad insertion and just distal to where the deltoid insertion ends. We split brachialis at the lateral one third medial two third junction, taking advantage of its dual innervation. Okay. So here's the deep dissection. And like I showed you before here's the pec insertion I've basically only taken down about a centimeter of it. It's all completely intact. We've now reflected brachialis off of the humerus. And as we come down to Brachioradialis, we've also dissected out and found the radial nerve. So, as you already know, the radial nerve courses posteriorly along the spiral groove and then emerges approximately 10 to 14cm proximal to the lateral epicondyle of the humerus. And you generally tend to find it in the lateral border of your surgical field inside the brachioradialis musculature. Before I retract or reflect any portion of the deltoid, let me point it out to you just inferior to this retractor. We're basically reaching the bottom of the sub deltoid space. And this is the entirety of the insertion of the deltoid. Now as well, you'll see that as we release it and retract it further. It's also a very broad insertion that takes up almost the entire lateral cortex when placing an alpha plate. The block that guides your locking towers has a little peg on it that mates with the plate and allows you to find the right position for it. Next you screw on the guide. And then I'll oftentimes put the inferior most locking sleeve in. So remember there's two sleeves. There's an outer sleeve and then there's the inner locking tower. And the purpose of that is to be able to have a guide for your screw trajectory, even when you remove the locking tower. And I'll use this as my guide in order to determine the height of my plate. Okay. So when placing the plate, I'll oftentimes if I have this entire surgical field dissected, I'll retract the radial nerve, slide my plate down inferiorly, and then place it basically using the superior portion of the plate behind the deltoid into the sub deltoid space. And generally you can feel a feel a natural spot where it belongs. Lateral to the pec. Insertion. Medial to the deltoid. Insertion and distally. Almost directly anterior on the humerus. I've placed my plate directly underneath the deltoid and just medial to the deltoid insertion. You can see that the first anterior bend of the plate completely avoids the proximal portion of the deltoid insertion. The second bend basically creates an anterolateral plate that allows you to plate all the way down the humerus. Being able to avoid all of the lateral soft tissues, including the radial nerve, which I'll show you once again. Besides the deltoid insertion and the pec major insertion, the most important bony landmark is the bicipital groove. In this specimen, we haven't dissected off the soft tissues to show the bicipital groove, but the lateral border of the groove can be palpated quite easily, and by placing the inferior stem of the plate up against the lateral portion of the bicipital groove, you're usually able to find your spot along the proximal humerus and therefore along the sub deltoid space fairly easily. Additionally, that's where the contour of the plate kind of allows the plate to sit right where it's supposed to go. Once we found this sweet spot, so to speak, of the plate, I'll generally shoot a wire in the inferior most hole of the proximal segment, and I'll shoot a K-wires in and take an x ray and make sure that that trajectory of the wire is aiming right at the calcar, or the inferior most bone of the surgical neck. After we get our wire in and we're confident that the height of our plate is correct, this is where I fine tune my reduction. You may have already at this point used some traction, some manual manipulation, maybe even some K-wires peripherally. I'll oftentimes use a large pointed reduction clamp skirt underneath the strap muscles and through the subscapular in order to be able to adjust my position of the humeral head relative to the plate. A lot of times I'll use this K-wires hole and actually either twist and give myself more valgus, or even just give myself more compression, or rotate and give myself more apex anterior or apex posterior angulation. So I use this in order to get my reduction. And then I'll go ahead and finish my fixation. In this case, I've fine tuned my reduction and used one of the superior suture holes as a counterpoint in order to be able to reduce my fracture. And at that point, we'll hold the reduction using some K-wires. You'll see that there's K-wires holes Along the proximal guide block. As well as outside the block. Once you've gotten your proximal reduction, depending on the fracture pattern, you can either complete the fixation proximally or distally. Oftentimes, I'll come back down distally and use another reduction clamp in order to ensure that my positioning distally is correct. Distally, you may or may not choose to use a reduction forceps in order to fine tune the positioning of the plate if necessary. But in general it should sit well. Medial and anterior to the radial nerve. So now we're going to start completing our fixation. And I'm using the blue locking towers which have these outer sheaths as well. And everything is color coded. I'm using the blue locking towers in order in order to place the four fully threaded screws proximally. So in this case, we're going to put in 4.0 cancellous fully threaded locking screws there. The blue screws, which means you're going to use the blue tower and the blue drill. The drills are calibrated. So you're usually able to tell your screw length off of the drill. However, there's also a depth probe that can be used, which is a blunt tipped device that inserts into the sheath. And we'll also give you a depth measurement. It's blunt, so you can place it up against subchondral bone and get an accurate measurement. After getting a couple of points of fixation, usually 2 to 3 screws, I like to start pulling K-wires out in order to give myself more room to complete the fixation. And generally, at this point, what I'll do is I'll remove the k wire that's through the tower and go ahead and drill for that screw. There's a laser line on the screwdriver shaft that I use as a guide to know when I'm about to lock into the plate, and that's the point at which I use a hand screwdriver in order to final tighten. We're also going to demonstrate the use of the gold screws. They are for a partially threaded screws. I tend to use them when I want a little bit of a larger caliber screw. We'll use the yellow locking tower and the yellow drill. So one other thing that I wanted to show you about the positioning of the plate. The biceps tendon is right here. And this is just medial to the proximal border of the plate. So this is another guide that you may want to use to guide your positioning. So here we're using the 3.5 conical or stepped drill once again in order to place another four partially threaded screw. Once you've got enough points of fixation in, you can also internally rotate the arm without losing your reduction, and it'll make it much easier to work without having to fight the deltoid consistently. So I pass my drill across the fracture to the point where I feel subchondral bone. So at this point, presumably any extensions into the shaft are reduced and fixed as well. You may even choose to put some lag screws in. I happen to have a clamp holding my plate in place, but if you feel more comfortable, you can use any of the K-wires holes that go along the plate. And we're just going to use a couple of non-locking and a couple of locking screws to finish our fixation distally. So there's two options. There's a locking tower and there's also a handheld soft tissue Protector. And there's two sides. One is for non locking screws and one is one is for locking screws. The locking screw side conforms to the hole and allows you to drill at the nominal angle. The non locking side allows you to vary your angle and for non locking screws. I like to use this guide because it allows me to change my angle, especially because this is a plate that changes angles itself. It allows me to be able to shoot into the shaft at whatever angle I want. The non locking screws are gray and the locking screws for the shaft are green. At this point we've completed our proximal fixation and removed our aiming block. You'll notice that there are oblong holes along the curvatures of the plate. And you can use these for a couple of different uses. Number one, if there's a situation in which you want to fix the plate to the humerus first through an oblong hole and then fine tune the position of the plate. That's a very good use for that. Additionally, you'll notice that the oblong holes themselves, at their superior and inferior extents have threads in order to insert locking screws. In this example, we've put a locking tower into one of the oblong holes at the inferior most extent, and I'm placing a locking screw. These are green. Here we've placed locking towers along the shaft and the drill bit is calibrated, which will allow me to quickly measure and place the last few screws. So to recap, we have a retractor in. But essentially the proximal portion of the plate goes laterally right over the deltoid. The entirety of the deltoid insertion remained intact as our plate curves anteriorly. To avoid the deltoid insertion medially, you have the pec major insertion, as well as the biceps tendon, and distally we're anterior on the humerus, and this allows us to avoid the not only the deltoid insertion, but stripping of all the lateral soft tissues and involvement of the radial nerve in the surgical field. When deciding on plate height and plate position, it's much more reliable to go with relative position to where the calcar screw is going to go, rather than where the plate is going to sit relative to the greater tuberosity, which can be a lot more variable with regards to positioning of 130 degree straight plate proximally, it's very similar to the alpha plate and any other proximal humerus plate, with exception to the fact that you'll often have to take down a little bit of the deltoid in order to be able to get it at a proper lateral position. So if necessary, you may need to release a little bit of the deltoid. You'll notice that I've released a small amount of deltoid in order to place the plate, and there's also a locking screw in the inferior most hole of the proximal segment. And that's in order to use the calcar Corkscrew as a reference for plate positioning, and not necessarily the position of the greater tuberosity. For me, the 95 degree plate is really a plate, used mostly when I have a fracture pattern that involves a large greater tuberosity fragment because of the trajectory of the screws. I can place my plate as superiorly as I want with relation to the greater tuberosity. Knowing that I'll get screws into the head and not superior to it. Now the alpha plate comes in variable lengths, and the purpose of its anterior bend, even with a short plate, is such that there's no removal of the deltoid necessary and no release of the deltoid insertion. So even when using it for a proximal humerus fracture that doesn't require a long plate, the positioning is very similar to that of a long plate with regards to its position proximally, and the use of a locking tower in one of the holes in order to judge positioning.

Humeral Plating System

The Humeral SuturePlate™ is an anatomically designed polyaxial locking plate and screw system designed for the treatment of proximal humeral fractures. These low profile plates with polyaxial bushings provide freedom to direct the locking screws within the anatomical template, based on the fracture pattern and bone quality for better fixation. Multiple chamfered suture eyelets along the margin of the plate allow the surgeon to pass FiberWire® suture after the plate is fixed to bone. FiberWire® Suture Kits which contain color-coded #2 or #5 FiberWire® sutures, with needles on each end, are available to facilitate suturing the soft tissue to the plate after it is in place.

Humeral SuturePlate™

Reconstruction of proximal humerus fractures is often complicated by the loss of anatomic orientation features and the inability to adequately reduce and securely fix the displaced tuberosity fragments. With its uniquely designed implant and instrumentation, the Univers Shoulder Fracture System addresses issues relating to stabilizing the humeral prosthesis and accurately positioning the humeral head. Accurately reduce and fix the tuberosities with this system's straightforward, reproducible protocol.
The system includes:
<ul>
 <li>An intraoperative adjustable humeral head prosthesis for secondary correction of the implant head height in situ.</li>
 <li>A preoperative and intraoperative measure guide to accurately set the humeral head height without need for technically demanding and complicated fracture jigs.</li>
 <li>Lateral fin positions with suture eyelets for anatomic reconstruction of the tuberosities.</li>
 <li>Multiple suture eyelets on the trunnion to prevent secondary displacement of the tuberosities.</li>
 <li>Smooth chamfered dimples in the medial aspect of the humeral stem to allow suture fixation of the tuberosity fragments without causing suture fraying and breakage.</li>
 <li>Variable eccentric adjustment of the humeral head for anatomic reconstruction.</li>
</ul>
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