To reduce the GT, the proximal humerus was reduced into the glenohumeral joint capsule. The fourth suture was passed around the greater and lesser tuberosity (see Fig. 2C). The suture was passed through the drill holes before the prosthesis was implanted (see Fig. 2B). The third suture was passed around the greater tuberosity in a vertical fashion and through humeral bone drill holes of the prosthesis. The first suture was passed around the greater tuberosity and through the lateral prosthetic stem hole the second suture was passed around the greater tuberosity and through the medial prosthetic stem hole (see Fig. 2A). For each shoulder specimen of this group 4 MaxBraid sutures #5 were used for the fixation of the greater tuberosity. The for the tested implant system recommended fixation technique (ZimmerBiomet® Anatomical Shoulder™ Fracture System's Manual) was used to serve as the control group (see Fig. 2). The aim of this study was to investigate whether the “cow hitch” cerclage technique could improve the biomechanical stability of greater tuberosity fixation over the conventional (CON) fixation technique described originally by Frankle et al 5 and which is also recommended for the tested implant (ZimmerBiomet® Anatomical Shoulder™ Fracture System). 11 The use of the cow hitch cerclage for GT fixation during the implantation of a fracture RTSA has never been investigated biomechanically regarding GT fragment stabilization.

11 Different double loop suture cerclage techniques (“cow hitch”, “nice knot”, half hitch,) were compared in a biomechanical study regarding stability properties and the “cow hitch” cerclage showed superior results. 1 The technique of tuberosity fixation differs between authors, but heavy, nonabsorbable single stranded suture loops or single wire cerclage are constantly used for fixation of the tuberosities.ĭouble suture loop cerclage techniques achieve higher fixation strength than single-stranded loops in vitro. Baumgartner has provided a comprehensive compilation of the existing fixation methods.

Depending on the implant system, various techniques are recommended. There is currently no standard fixation technique. 3, 4, 6, 7, 8, 14 For this reason, various GT refixation techniques have been studied and applied to improve the mechanical fixation of the GT, with the ultimate goal of achieving increased bony healing of the GT. 9 Greater tuberosity (=GT) healing in patients treated with RTSA is associated with better clinical outcome than if the GT does not heal. Reverse total shoulder arthroplasty (RTSA) has become an established treatment option for elderly patients with complex proximal humeral fractures.

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