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.
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
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
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
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
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
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
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.
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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