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  • RSU is advertising for shoulder fellowship to start in August-September 2019 and begining of 2020
    a post-CCT shoulder fellowship for Two years. please send CV to Prof. Levy's PA Charlotte Bourne and arrange a visit to meet Prof Levy and Mr Sforza. [Read more]
  • For Patients, GPs & Physiotherapies - New!!! NHS Choose & Book
    The Unit at Berkshire Independent Hospital is open for NHS patients through Choose & Book (Extended Choice Network).
    Book online
    or contact the secretaries. [Read more]
  • Excellent clinical results over more than 13 years with the Verso rTSA.
    Very high patient satisfaction and return to full activities including sports. [Read more]
  • The least complications with the Verso shoulder compared with other reverse shoulder systems
    From the Royal National Orthopaedic Hospital, Birmingham, UK
    S. Robati, M.K. Shahid, J. Allport, A. Ray and G. Sforza
    Bone & Joint Journal 2013, Vol. 95-B Supp. 25-27

    Complication Rates From Three Commonly Used Reverse Polarity Total Shoulder Replacements: A Minimum Two Year Follow-Up Of 64 Cases
     
  • Excellent results with the Verso TSA were published in Italy! 
    A group of oorthopaedic surgeons from northern Italy from Piacenza and Verona published their first few years experience with the stemless reverse TSA - The VERSO. 
    They present Excellent clinical and radiologic results that mirror the results of the designing centre!
    (Read more) [Read more]
  • Applications for the Reading shoulder fellowship
    starting in late 2019 and for 2020
    is now open.
    Please apply by visiting the Unit and sending your CV to Jan Barker
    Visits to the Reading shoulder unit are welcome - Please liaise with Prof. Levy's PA Charlotte Bourne
    [Read more]
  • IDO Isometer Shoulder Muscle Strength Gauge.

    Available to buy online in idorth.com - Innovative Design Orthopaedics - [Read more]
  • Groundbreaking research from the Reading Shoulder Unit by Prof. Ofer Levy and his team regarding Propionibacterium Acnes and shoulder arthritis. 
    Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?

    This is a very important article in that it suggests the presence of propionibacterium in previously unoperated shoulders with arthritis and furthermore that 'aseptic' failures of shoulder arthroplasty may, in fact, be related to indolent infections with this slow growing organism.
    Read comments by Dr Frederick A. Matsen III, M.D.
    [Read more]
  • Listen to the BBC Radio4 programme - a day in the operating theatre at the Reading Shoulder Unit at the Royal Berkshire Hospital - Case Notes with Dr Mark Porter on Regional anaesthesia for shoulder surgery [Read more]
  • Art at the Reading Shoulder and Elbow Centre
    Original fine art prints all dealing with human body in different situations by four artists are exhibited in the Reading Shoulder and Elbow centre 

    The prints on display are available to buy, with the artist contributing a donation to research. For more information please contact the secretaries in the unit.

    [Read more]
  • The Verso stemless rTSA is approved in Australia & New Zealand by the TGA.
    and it was launched and in increase use in Australia. 

Palm Tree Technique for Proximal Humeral Fractures

Introduction

Proximal humeral fractures account for 4–5 % of all fractures. Several classification systems exist, the most commonly referred to is the Neer classification, which describes the site of fracture and thenumber of parts involved based displacement.

 

Undisplaced fractures are usually treated conservatively. Operative treatment is recommended for the displaced fractures, as non-operative management often results mal-union, non-union and stiffness.

Various surgical techniques and implants are available, each with their own set of advantages and disadvantages. The main concern in the majority of those cases is the amount of soft tissue dissection involved, increasing the risk of avascular necrosis

 

The Palm Tree technique was developed as a minimally invasive percutaneous approach for the fixation of 2 and 3 part proximal humeral fractures, using three wires inserted retrograde. This technique was later extended to include 4 part fractures and fracture dislocation.

 

Technique

 

The patient is positioned in the beach chair position with the arm draped free. The fracture is reduced closed under image intensifier control. This is usually achieved by reducing the humeral shaft onto the rotated humeral head with abduction and external rotation.

Fig1: Closed reduction technique

A stab incision is then made just distal to the deltoid insertion within a 3-4cm window of safety between the axillary and radial nerves.

The instruments needed for this procedure are minimal as seen in the figure below.

 

Fig 2: Instruments for palm tree fixation

The lateral cortex is approached by blunt dissection and an oblique hole is made in the lateral cortex using a 4.5mm drill.

Three divergent pre-bent 1.8mm wires are introduced through the drill hole across the fracture into the humeral head as follows.

 

Fig 3: Insertion of Wire

The blunt end of the first wire is bent and a gentle curve is made in the wire. Mounted on a T handle on a Jacob's chuck, the wire is introduced into the medullary cavity via the drill hole and is passed in a retrograde direction towards the humeral head. By introducing the blunt end of the wire there is smooth passage of the wire proximally as it "bounces off" the medial cortex. The direction of the wire is dictated by the rotation of the T handle. The wire is then impacted into the subchondral bone. The second wire is bent in a similar fashion, introduced blunt end first through the same drill hole and is made to diverge from the first by controlling rotation of the T handle. The third wire is introduced sharp end first by sliding it on the two wires in situ. Atight interference fit is achieved at the lateral cortex. This third wire is made to diverge from the other two by controlling rotation of the T handle. The wires are cut and buried but remain fairly superficial.

Fig 3: Fixation completed

 

With 4-part fractures, the fracture is approached through an antero-superior approach (Neviaser-Mackenzie). The head fragment and the tuberosities are reduced. The tuberosities are reapproximated and held with sutures against the reduced head ('Closing the book') and if there is a significant void, this is filled with bone graft substitute. By this, we transform the 4-part fracture into a '2-part' fracture. The reconstructed proximal fragment is then reduced onto the shaft of the humerus and the pre-bent wires are inserted in the manner described above.

 

Post-operatively, the patient is immobilised in a sling for three weeks at which point radiographs are taken. If there is any sign of callus formation at this stage, passive mobilisation is begun. If there is not, the patient is immobilised for a further three weeks. The wires are removed under general anaesthetic at six weeks and rehabilitation programme commence.

This method of fixation works on the basis of achieving good angular stability but maintaining axial elasticity. There is no or minimal disruption of the soft tissue envelope.

 

Three-point fixation is achieved for each of the wires: laterally at the tight-fit entry point in the lateral cortex, medially where the wire "bounces off" the medial cortex, and superiorly where the wire is impacted into the subchondral / subcortical bone.
 

Stemmed Verso - reverese TSA for fractures