Recession Wedge Osteotomy of the Greater Tuberosity for Proximal Humeral Varus

Abstract

Proximal humeral varus has multiple etiologies and may lead to impingement and reduced shoulder range of motion, particularly abduction and forward elevation. Valgus osteotomies have been described at the level of the surgical neck yielding acceptable results. This article describes a case of a male electrician who was treated for symptoms associated with proximal humeral varus of the right shoulder. He underwent an osteotomy of the greater tuberosity designed to reduce impingement and improve range of motion. The patient had previously undergone two separate surgical procedures for a simple bone cyst, but continued to have reduced shoulder function secondary to a prominent greater tuberosity. Preoperative and follow-up radiographs, physical examinations, and shoulder function were retrospectively reviewed for 32 months. Following treatment, active forward elevation improved from 130° preoperatively to 170°, abduction from 90° to 170°, external rotation from 45° to 70°, and internal rotation from T10 to T7. The patient reported relief of pain, impingement-free range of motion, and full symmetric function equal to that of his contralateral shoulder. Radiographs demonstrated osteotomy union, improved greater tuberosity/acromial clearance, and no impingement with abduction. Postoperative stiffness was the only complication noted for which a shoulder manipulation was performed under anesthesia. Thus, recession wedge osteotomy of the prominent greater tuberosity may serve as a viable surgical approach to reducing impingement and improving clinical function in proximal humeral varus.

Proximal humeral varus is characterized by a decreased humeral neck-shaft angle and is thought to arise from a growth deformity in the medial region of the proximal humeral physis.¹ In 1935, Kohler defined this condition on radiographs as (1) an anatomic neck-shaft angle less than 140°, (2) a greater tuberosity elevated above the superior margin of the humeral neck, and (3) a reduced distance between the articular surface of the humeral head and the lateral cortex of the humerus.²

Clinically, proximal humeral varus is associated with limitations in shoulder movement, particularly forward elevation and abduction, in addition to upper limb-length discrepancies. Treatment options reported in the literature for this deformity include acromionectomy and more recently, proximal humeral valgus osteotomy. Most notably, Gill and Waters³ performed a valgus osteotomy with tension-band fixation of the humeral neck in a skeletally immature patient, which led to significant improvements in range of motion. Similar results were reported by Ugwonali et al⁴ in a series of 6 patients. Benegas et al⁵ used a valgus osteotomy to successfully treat functional limitations in skeletally mature patients with varus deformities after 2-part humeral fractures.

We suggest recession wedge osteotomy of the greater tuberosity as an alternative approach to proximal humeral varus. The purpose of this case report is to present the strategic rationale, surgical technique, and clinical outcome associated with this procedure.

Case Report

A 22-year-old man presented with longstanding right shoulder pain exacerbated by overhead activities and restricted range of motion associated with popping and pain at extremes. He reported a history of a simple bone cyst of his right proximal humerus treated twice before with ablation, curettage, and bone grafting, most recently 2 years prior.

On physical examination, the patient demonstrated decreased active and passive right shoulder forward elevation and abduction compared to the contralateral side associated with pain and mechanical impingement. Specifically, active forward elevation was 130° compared to 175°, abduction was 90° compared to 170°, internal rotation was to T10 compared to T7, and external rotation was to 45° compared to 80° on the contralateral side. Pain was reproducible with both Hawkins’ and Neer’s testing.

Radiographs demonstrated an expanded metaphysis with radiographic findings consistent with humeral varus, including a greater tuberosity measuring 6 mm above the articular surface, a reduced distance between the medial joint surface and the lateral margin of the humerus, and a reduced anatomic neck-shaft angle of 112°. The glenohumeral joint was congruent with a well-maintained joint space. Irregularities of the proximal shaft and humeral head were also noted, consistent with sclerosis and scarring from prior curettage and bone grafting (Figure 1).

Figure 1: AP radiograph of the affected right shoulder, demonstrating a prominent greater tuberosity 6 mm above the level of the humeral articular surface. The humeral head is noted to have a more ovoid spherical articular surface than varus surface angulation relative to the humeral shaft, but with a well-maintained joint space. The humeral metaphysis and proximal shaft have opacities and morphology consistent with scarring and expansile deformity from prior surgical debridement and ablation of a simple bone cyst. No abnormalities of the glenoid are noted.

After conservative treatments including activity modification, physical therapy, and nonsteroidal antiinflammatory medications had failed, surgical treatment was offered. Humeral neck osteotomy templating was performed to position the greater tuberosity at or below the articular surface; however, this was felt to cause an excessive angular deformity of the proximal humerus. As the prominent greater tuberosity appeared to be the most obvious cause of symptoms, recession osteotomy of the tuberosity was planned to improve subacromial clearance. Preoperative radiographic tracings were created and used to guide planned osteotomies to avoid articular cartilage and respect rotator cuff insertions. Templating was performed using various osteotomy cuts on the tracings to obtain an osteotomy fragment that could be distalized to a position inferior to the articular surface of the humeral head.

A standard deltopectoral approach was performed avoiding a prior lateral incision. The humerus was freed of considerable adhesions to the overlying deltoid, and the tendon of the long head of the biceps was visualized in the rotator interval to facilitate its protection during the procedure. Percutaneous K-wires were placed in the base of the greater tuberosity and checked with fluoroscopy to obtain the proper angle for the osteotomy. Special care was taken not to penetrate the anterior and posterior cortex when using the small oscillating saw. Cortical cuts were then completed with small osteotomes to avoid soft tissue damage from the oscillating saw. K-wires were placed to guide the second osteotomy according to preoperative templating. This reduced the stable humerus by a wedge approximately 8 mm wide at the lateral humeral surface (Figure 2).

Figure 2: Sequential surgical steps of a recession wedge osteotomy with distalization of the greater tuberosity including: the preoperative humerus (A); first osteotomy of the greater tuberosity (B); second osteotomy of the stable humerus and removal of wedge osteotomy (C); fragment distalized and recessed (D); refixation of the greater tuberosity fragment in a recessed and distalized position (E).

Once the wedge osteotomy was removed, fluoroscopic visualization was used to guide screw length and positioning as well as advancement of the greater tuberosity fragment to a position below the superior articular surface of the stable humerus. Two fully-threaded, small fragment cancellous screws with washers were placed with a lag technique. Pre- and postosteotomy fluoroscopy images were compared demonstrating a marked increase in the subacromial space with abduction of the shoulder (Figures 3, 4).

Figure 3: Preosteotomy AP fluoroscopic image with shoulder abduction demonstrating evidence of bony impingement of the prominent greater tuberosity and the acromion. Figure 4: Postosteotomy AP fluoroscopic image with shoulder abduction demonstrating recessed greater tuberosity and improved subacromial clearance.

Postoperatively, the patient was placed in an immobilizer and instructed to perform passive range of motion exercises 3 times daily. Organized physical therapy was incorporated 6 weeks postoperatively including active range of motion and a strengthening regimen. A shoulder manipulation under anesthesia was performed at 10 weeks postoperatively when a plateau in shoulder range of motion occurred. Shoulder range of motion rapidly improved thereafter with no additional complications noted.

At 32-month follow-up, the patient reported that his shoulder function was equal to that of his contralateral shoulder, including heavy lifting and symptom-free, repetitive overhead activity. Range of motion was nearly symmetrical with the contralateral shoulder and rotator cuff strength was grossly symmetrical. Specifically, active forward elevation improved from 130° preoperatively to 170° postoperatively, abduction from 90° to 170°, external rotation from 45° to 70°, and internal rotation from T10 to T7.

Radiographic evidence of bony healing was present at 6 weeks, and full union occurred prior to manipulation under anesthesia at 10 weeks postoperatively (Figure 5). The anatomic neck-shaft angle did not change as the humeral joint surface was not altered.

Figure 5: Postoperative AP radiograph in external rotation demonstrating union of the osteotomy, height of the greater tuberosity below the superior articular surface, and improved subacromial clearance.

Discussion

Proximal humeral varus is a condition that leads to limitations in shoulder function, especially overhead activity. The most common cause in the skeletally immature is trauma. A variety of etiologies have been previously reported in the skeletally immature including infectious, traumatic, idiopathic, congenital, and systemic causes such as thalassemia and pseudohypoparathyroidism.^1,6-12 Additionally, bone lesions, including simple bone cysts, have been shown to cause deformity and growth abnormalities of the proximal humerus.^13-15

Many of the above conditions can lead to a proximal humeral varus deformity in the skeletally immature through interference with growth at the medial proximal physis. As the deformity continues to develop, forward elevation and abduction become limited due to impingement of the greater tuberosity on the acromion, a mechanically disadvantaged supraspinatus muscle, and a flattened humeral articular surface (reduced shaft/medial joint surface distance).⁵

Historically, valgus osteotomy of the proximal humerus has been used for the treatment of proximal humeral varus. Gill and Waters³ reported the use of tension-band fixation with a valgus closing-wedge osteotomy at the humeral neck for a 13-year-old boy with proximal humeral varus secondary to birth trauma. They reported significant improvements in range of motion and function. Ugwonali et al⁴ performed the same procedure on 6 skeletally immature patients and noted average improvements of 61° and 57° in forward elevation and abduction, respectively.

Solonen and Vastamaki¹² reported good results in 5 of 7 adult patients originally treated nonoperatively for 2-part fractures of the proximal humerus. Valgus osteotomy and fixation with a T-plate led to increases in range of motion. Complications included fracture through the anatomic neck in 1 patient and muscle atrophy and shoulder contractures in another. Similarly, Benegas et al⁵ reported good to excellent results for valgus osteotomy stabilized with a side plate in a series of 5 adult patients with prior 2-part humeral fractures.

Beredjiklian et al¹⁶ reported clinical outcomes of proximal humerus malunions treated according to a surgical algorithm. Their algorithm directed 7 shoulders with congruent glenohumeral joints but impinging greater tuberosities to osteotomy of the greater tuberosity with success. Several studies have reported poor outcomes of tuberosity osteotomies for malunions in the setting of shoulder arthroplasty with complications including nonunion, malunion, and resorption.^17-19 However, these shoulders, by definition, had altered proximal humeral bone quality further undermined by the simultaneous arthroplasty, which together make healing of osteotomies tenuous.

Our patient presented with limited shoulder function and painful subacromial impingement caused by a prominent greater tuberosity secondary to surgical procedures used to treat a simple bone cyst. To correct the primary deformity, the source was directly addressed: the prominent greater tuberosity.

In an attempt to address the patient-specific pathomorphology, a recession wedge osteotomy of the greater tuberosity was performed. A wedge of the greater tuberosity was removed instead of the humeral neck, providing several advantages. First, this mitigated impingement of the greater tuberosity on the acromion as the tuberosity was debulked and distally advanced below the level of the superior articular surface. Second, the greater tuberosity osteotomy did not change the alignment of the glenohumeral articulation. Additionally, there is minimal hardware prominence using a screw-washer combination compared to a side plate for valgus osteotomies. While fixation with screws was adequate in our young patient, who has excellent bone, using this technique in older patients with inferior bone should be discouraged. Clinical and radiographic results were excellent in the one patient we treated with recession wedge osteotomy of the greater tuberosity. The patient returned to near-normal motion and strength, and postoperative radiographs demonstrated early union of the osteotomy and improvement in the subacromial space. It should be noted, however, that stiffness recalcitrant to physical therapy was observed, resulting in a manipulation under anesthesia at 10 weeks postoperatively.

Regarding limitations to our study, longer clinical and radiographic follow-up with a larger series of patients is necessary to assess consistency of satisfactory clinical outcomes, including avoidance of complications and development of early osteoarthritis. Possible complications include nonunion and necrosis of the tuberosity. Secondly, the greater tuberosity osteotomy did not alter the reduced head-shaft angle and therefore, may not optimize the alignment of the glenohumeral articulation. Additionally, this procedure requires significantly greater care to protect the soft tissues, including the rotator cuff and biceps, compared to a humeral valgus osteotomy. Finally, the effectiveness of a recession wedge osteotomy for treatment of the spectrum of morphologies associated with proximal humeral varus remains to be seen.

Recession wedge osteotomy of a prominent greater tuberosity may serve as a viable surgical approach for reducing impingement and improving clinical function in proximal humeral varus. Further studies are needed with additional patients to elucidate the extent of its usefulness for treating the various deformities associated with the proximal humeral varus.

References

1. Ellefsen BK, Frierson MA, Raney EM, Ogden JA. Humerus varus: a complication of neonatal, infantile, and childhood injury and infection. J Pediatr Orthop. 1994; 14(4):479-486.
2. Kohler A. Roentgenology. 2nd edition. London, England: Balliere, Tindall, and Cox; 1935.
3. Gill TJ, Waters P. Valgus osteotomy of the humeral neck: a technique for the treatment of humerus varus. J Shoulder Elbow Surg. 1997; 6(3):306-310.
4. Ugwonali OF, Bae DS, Waters PM. Corrective osteotomy for humerus varus. J Pediatr Orthop. 2007; 27(5):529-532.
5. Benegas E, Zoppi Filho A, Ferreira Filho AA, et al. Surgical treatment of varus malunion of the proximal humerus with valgus osteotomy [published online ahead of print November 16, 2006]. J Shoulder Elbow Surg. 2007; 16(1):55-59.
6. Cho TJ, Choi IH, Chung CY, Yoo WJ, Yang SW. Humerus varus in a patient with pseudohypoparathyroidism. J Korean Med Sci. 2005; 20(1):158-161.
7. Paavolainen P, Bjorkenheim JM, Slatis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand. 1983; 54(3):374-379.
8. Lawson JP, Ablow RC, Pearson HA. Premature fusion of the proximal humeral epiphyses in thalassemia. AJR Am J Roentgenol. 1983; 140(2):239-244.
9. Ogden JA, Weil UH, Hempton RF. Developmental humerus varus. Clin Orthop Relat Res. 1976; (116):158-165.
10. Lucas LS, Gill JH. Humerus varus following birth injury to the proximal humeral epiphysis. J Bone Joint Surg Am. 1947; 29(2):367-369.
11. Lloyd-Roberts GC. Humerus varus; report of a case treated by excision of the acromion. J Bone Joint Surg Br. 1953; 35(2):268-269.
12. Solonen KA, Vastamäki M. Osteotomy of the neck of the humerus for traumatic varus deformity. Acta Orthop Scand. 1985; 56(1):79-80.
13. Haims AH, Desai P, Present D, Beltran J. Epiphyseal extension of a unicameral bone cyst. Skeletal Radiol. 1997; 26(1):51-54.
14. Capanna R, Van Horn J, Ruggieri P, Biagini R. Epiphyseal involvement in unicameral bone cysts. Skeletal Radiol. 1986; 15(6):428-432.
15. Pritchett JW. Growth plate activity in the upper extremity. Clin Orthop Relat Res. 1991; (268):235-242.
16. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am. 1998; 80(10):1484-1497.
17. Antuna SA, Sperling JW, Sanchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral nonunions. J Shoulder Elbow Surg. 2002; 11(2):114-121.
18. Mansat P, Guity MR, Bellumore Y, Mansat M. Shoulder arthroplasty for late sequelae of proximal humeral fractures. J Shoulder Elbow Surg. 2004; 13(3):305-312.
19. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg. 2001; 10(4):299-308.

Authors

Drs Aoki and Anderson are from the Department of Orthopedics, University of Utah, Salt Lake City; and Mr Marchese is from The Commonwealth Medical College, Scranton, Pennsylvania.

Drs Aoki and Anderson and Mr Marchese have no relevant financial relationships to disclose.

Correspondence should be addressed to: Stephen Aoki, MD, Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 (Stephen.Aoki@hsc.utah.edu).

doi: 10.3928/01477447-20110317-24