Aims. Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically. Methods. Eight pairs of three-part humeral fractures were randomly assigned for pairwise instrumentation using either a prototype gliding plate or a standard PHILOS plate, and four pairs were fixed using the gliding plate with bone cement augmentation of its proximal screws. The specimens were cyclically tested under progressively increasing loading until perforation of a screw. Telescoping of a screw, varus tilting and screw migration were recorded using optical motion tracking. Results. Mean initial stiffness (N/mm) was 581.3 (. sd. 239.7) for the gliding plate, 631.5 (. sd. 160.0) for the PHILOS and 440.2 (. sd. 97.6) for the gliding augmented plate without significant differences between the groups (p = 0.11). Mean varus tilting (°) after 7500 cycles was comparable between the gliding plate (2.6; . sd. 1.9), PHILOS (1.2; . sd. 0.6) and gliding augmented plate (1.7; . sd. 0.9) (p = 0.10). Similarly, mean screw migration(mm) after 7500 cycles was similar between the gliding plate (3.02; . sd. 2.85), PHILOS (1.30; . sd. 0.44) and gliding augmented plate (2.83; . sd. 1.18) (p = 0.13). Mean number of cycles until failure with 5° varus tilting were 12702 (. sd. 3687) for the gliding plate, 13948 (. sd. 1295) for PHILOS and 13189 (. sd. 2647) for the gliding augmented plate without significant differences between the groups (p = 0.66). Conclusion. Biomechanically, plate fixation using a new gliding screw technology did not show considerable advantages in comparison with fixation using a standard PHILOS plate. Based on the finding of telescoping of screws, however, it may represent a valid approach for further investigations into how to avoid the cut-out of screws. Cite this article: Y. P. Acklin, I. Zderic, J. A. Inzana, S. Grechenig, R. Schwyn, R. G. Richards, B. Gueorguiev. Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures. Bone Joint Res 2018;7:422–429. DOI: 10.1302/2046-3758.76.BJR-2017-0356.R1

The author rates his experience of using PHILOS plate for two years for fractures of the proximal humerus. The advantage of LCP plates is the angular stability of osteosynthesis, which is the assumption for an early mobilisation and rehabilitation of shoulder joint. The poor functional result of the treatment of proximal humerus fractures is caused by difficulties and complications by osteosynthesis with the PHILOS plate and it arises from several factors:. - inexperienced operator. - insufficient reposition of the fracture and poor reconstruction of fracture of humeral tuberculi and rotator cuff of the humerus. - incorrect localisation and implantation of PHILOS plate. - neurological deficit – lesion of axillaris nerv. - deficient rehabilitation and poor functional after-treatment. Author looks upon the causes of failures by osteosynthesis of fractures of proximal humerus. In the years 2003 – 2004 there were operated 34 fractures of proximal humerus with the PHILOS plate. The functional results – the evaluation of subjective difficulties and clinical evaluation show 56% excellent, 23% good, 11% satisfactory and 10% poor results. All these complications can be prevented especially by through judgment of X-rays and CT scans, by precise depiction of the type of fracture and by the preoperative preparation of the surgeon. The perfect reposition of the fragments with the use of the X-ray control and good localisation of the plate ensures good stability of osteosynthesis. The functional after treatment involving the use orthesis or braccing and early mobilisation and rehabilitation depending on the well technically performed osteosynthesis ensures a good functional result

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures. Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate. Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted. Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing

Our aim was to analyse radiological outcome of proximal humerus fractures treated with Philos plate and to assess its usefulness in treatment of malunion and non-union. Seventy-seven patients were treated with Philos plate (24 men and 53 women). Mean age was 61 years (15–88). There were 66 acute fractures, 6 nonunion, 4 mal-union and one periprosthetic fracture. Acute fractures included 29 two part, 30 three part and five 4 part fractures. Seven had associated dislocation. There were two head splitting fractures. Deltopectoral approach was used in all. No acute fractures were bonegrafted however all nonunions had bonegraft. Postoperative radiographs were available for review for 59. Average union time was 12 weeks (8–24). Satisfactory union occurred in 51 (86.4%). Twenty-three (39 %) fractures had inadequate reduction. Malplacement of plate was observed in 25 (42%) leading to significant malunion in 11.8%. Satisfactory union was occurred in all of last 30 patients. Nonunion occurred in 2 with infection in one. Other complications included screw penetration into glenohumeral joint, avascular necrosis, screw backing out and tuberosity detachment. Philos plate fixation was used for treatment of 6 nonunions, 4 malunions and one periprosthetic fracture with satisfactory outcome in all. Relatively high rate of complications was observed in early cases in this series. This could be attributed to the steep learning curve with this technique. Emphasis should be put on careful and adequate reduction of fracture and optimal placement of plate (about 8 mm from the tip of tuberosity) to avoid impingement and to achieve correct screw placement in the humeral head. In conclusion, Philos plate has been of benefit in management of complex fractures as well as management of non-union of proximal humerus. Quality of reduction and optimal placement of plate appear to be the two most important parameters for a successful outcome

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions. Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant. 11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery. All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function. A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems

Aim: To assess the clinical and functional outcome of proximal humeral fractures (2,3 and 4 parts) fixation with PHILOS (Proximal Humeral interlocked Osteosynthesis) plate using Oxford and DASH scoring system. Methods: Forty-eight consecutive patients were treated with PHILOS plate from the complex proximal humeral fractures. One senior surgeon, using PHILOS plates, operated all patients. The patients were regularly assessed clinically, and plain radiographic evaluation was performed for fracture healing, avascular necrosis, and implant failure. Clinical outcome was measured using Oxford shoulder scores and DASH (Disability of the arm, shoulder, and hand) scores. Patients, who died, lost the follow up or the follow up was less than 3 months were excluded from the study. Results: There were nine male patients (Age: 29–89 yrs) and twenty-nine female patients (Age: 35–93 yrs). Average age: 65 yrs. 74% were two part and three part fractures. Five patients died and four were lost in follow-up. These patients were excluded from the study. Mean follow-up time: 21.7 months (range: 6–44 months). Mean oxford shoulder scores: 41.8 (range: 14–60), Mean DASH scores: 30.2 (range: 0–83.3). There were no cases of non-union. Two plates were removed after fracture healing for complications of impingement and screw cutout. Discussion & conclusion: Proximal humeral fractures constitute 5–7% of all fractures and 26% of humeral fractures.13–16% of proximal humeral fractures are 3 & 4 parts. Proximal humeral fractures have been a challenge to acquire stable fixation. Difficulties have been multifactorial, including osteoporotic bone, angular instability and non-availability of the low-profile implant to avoid impingements. PHILOS plate having locking screws provides angular stability and better hold in osteoporotic bone. It is low profile, which avoids subacromial impingement. Multiple holes in the proximal part of plate for suture anchors helps for soft tissue augmentation. PHILOS plate can provide an excellent stable construct even in multifragmented Osteoporotic proximal humeral fractures. Our study has shown that PHILOS plates are reliable implants for internal fixation of proximal humerus fractures. An inverse correlation was seen between oxford shoulder scores and DASH scores. Patients with higher oxford scores indicating a good outcome had lesser disability scores. Comminuted fractures (four part fractures) had less than satisfactory shoulder scores and higher disability scores. In general, younger patients did better than older patients. This study demonstrates that PHILOS plates provide stable internal fixation for proximal humerus fractures. Age and fracture configuration play a significant role in the clinical outcome of these fractures after internal fixation

Introduction: Proximal humeral fractures are common in the elderly osteoporotic population. Surgical management of such fractures with traditional internal fixation techniques is often challenging due to poor bone quality. Fixation with intramedullary devices theoretically offers better fixation, but with increased risk of shoulder pain and decreased range of motion. We undertook a study to compare outcome following fixation of such fractures with either an intramedullary nail (Polarus), standard Clover Leaf plate (AO), or Philos Locking plate (AO). Method: All patients admitted for surgical management of a proximal humeral fracture were entered into the study. 10 patients were treated using a Philos plate (Group 1), 5 with a Clover Leaf plate (Group 2), and 10 with a Polarus nail (Group 3). Post-operative assessment included radiological evaluation, clinical assessment of range of motion compared to the non-injured arm, assessment of pain severity (visual analogue scale), and functional assessment (DASH score). Non-parametric statistical techniques were used to analyse results. Results: There was no significant difference in age or sex distribution between the three groups. (Mean ages: Group 1: 54.6 yrs, Group 2: 45.2 yrs, Group 3: 59.7 yrs) Mean patient follow-up was 22 months (range 5–52 months). All patients in Group 1 and 2 went on to satisfactory radiological and clinical union. A higher complication rate was noted in the Polarus nail group, with 3 patients requiring removal of metal due to soft tissue or subacromial impingement. In addition one patient developed a non-union and required Philos plate fixation. All groups demonstrated a significant decrease in shoulder range of motion following injury, however this was less marked in Group 1 (Philos plate). In addition, patients in group 1 (Philos plate) demonstrated a more rapid recovery in terms of severity of pain, functional impairment and range of motion in the early postoperative phase. However, no significant long-term difference was noted in terms of post-operative pain or functional deficit between group 1 and 2. The poor outcome in group 3 was associated with a high incidence of shoulder pain and secondary procedures. Conclusion: Intramedullary fixation of proximal humeral fractures resulted in a high level of complications requiring secondary procedures in many cases. Our study supports the safety and efficacy of plate fixation techniques in the operative management of proximal humeral fractures

Purpose of study : – To highlight possible complications following Philos plating of proximal humeral fractures. Methods : – 10 patients with proximal humeral fractures operated upon in period 2003–2004 were reviewed. Analysis was undertaken with observer xray review and using radiograph analysis software. Results : – In 3 cases the fracture had collapsed significantly resulting in cut out of the proximal screws. One case required implant removal within a month following initial surgery. In another case the radiographs were not standardised views to compare the amount of collapse. The other cases went onto healing without any complication. Conclusions : – As the Philos plate is a fixed angle implant the degree of collapse expected must be accounted for when fixing the implant this is especially important in osteoporotic patients or in those with a high degree of comminution. In these circumstances high placement of the plate and long proximal screws should be avoided

Aims: Does PHILOS (Proximal Humeral Internal Locking system) construct provides better þxation than Clover leaf plate and T-plate in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model?Materials and Methods: Biomechanical laboratory study. Third generation composite Humerus model was used, with short e-glass epoxy þbres forming cortex and polyurethane cancellous core. Low density polyure-thane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were randomised to receive one of the implants. Following þxation samples were placed in a custom made jig to þx proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, Torque to failure, Cyclical compression and Compression loading to failure. Results were entered in a database. Results: PHILOS provided signiþcantly better þxation in ÔTorque to failureñ experiment. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression. Locking screws did not Ôback offñ in any of the experiments involving PHILOS construct, however ordinary screws did back off both in Ôtoque and compressionñ testing. Conclusions: PHILOS construct provides better stability in Torque and compression as compared to conventional plating devices, in an osteoporotic bone model

Introduction: The surgical management of proximal humeral fractures continues to be an unsolved problem for the orthopaedic surgeon. Disagreement remains over how best to fix the more challenging complex fractures in younger patients where the ultimate goals of treatment are restoration of a painless shoulder, adequate function, and preservation of humeral head viability. The PHILOS plate attempts to improve on previously designed implants by preserving the biological integrity of the humeral head articular fragment. The minimally invasive technique minimises soft tissue damage whilst at the same time securing the reduction using multiple locking screws with angular stability, thus allowing early mobilisation. Methods: Retrospective review of the notes and x-ray images of 54 fractures treated with the PHILOS plate between Jan 2000 and Aug 2005. Data including baseline demographics, the presence of any complications and the need for reoperation were collected. In addition 43 (81%) patients were contacted and Oxford (OSS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were calculated to assess functional recovery. All patients were contacted at a minimum of 6 months following fixation with an average follow up of 18 months (Range 6–41 months). We also present a cost analysis relating to the use of the PHILOS plate in practice. Results: 54 fractures in 53 patients (25F:28M). Average age 54.4. There were 26 2-part, 15 3-part and 13 4-part fractures. A total of 11 (20%) patients had complications of which 7 (13%) required reoperation. These complications included deep infection (3 cases), AVN (4), Non Union (3) and plate impingement (1). Mean OSS and DASH at follow up were 24.8 (S.D 11.6) and 28.0 (S.D 26.9) respectively. Worse scores were seen in those patients who had complications (OSS 39.4 Vs 22.6, DASH 58.2 Vs 23.4) although this difference was not statistically significant. There was also a trend for poorer scores with increasing fracture complexity and better scores in those patients operated upon by surgeons with a specific interest in the upper limb and in patients whose surgeon had performed more than 5 fixations. Conclusion: Our series reports a much higher complication rate (20%) than that previously published. Whilst those patients who do not suffer complications reported good functional outcomes the presence of postoperative complications was associated with poorer results. Outcomes following surgery were affected by patient, implant and surgeon related factors. Given the high rate of serious complications and their detrimental affect on outcome surgeons should give serious consideration to the appropriateness of using such implants. To clarify these issues, further prospective randomised trials are needed

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes. From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1). The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature

Aim: To compare of strength of constructs using the newer and part specific nail systems: Polarus and European Humeral Nail with that using PHILOS and Conventional plate systems in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model. Materials and Methods: A Biomechanical laboratory study was undertaken. Third generation composite Humerus model was used, with short e-glass epoxy fibres forming cortex and polyurethane cancellous core. Low-density polyurethane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were fixed using one of the implants- the Polarus nail, the European Humeral Nail, PHILOS Plate, Clover Leaf Plate or T-Plate. Following fixation samples were placed in a custom made jig to fix proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, torque to failure, cyclical compression and Compression loading to failure. Results: The two Nail systems that are specifically designed for fixation of proximal humerus fracture provided significantly better fixation in all the test modalities. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression when compared to the other plates but the 2 nail systems were far superior. Locking screws did not ‘back off’ in any of the experiments involving the Polarus, European Humeral Nail and PHILOS construct, however ordinary screws used with the conventional plates did back off both in ‘torque and compression’ testing. Conclusions: Polarus and European Humeral Nail constructs provide better stability in torque and compression as compared to PHILOS, which in turn is a more stable construct in comparison to conventional plating devices

Background: Complex tibiotalar (TT) and tibiotalocalcaneal (TTC) fusions are performed for significant ankle and hindfoot arthritis and/or deformity. Literature suggests several methods of fixation including crossed screws, plates, nail and external fixation. These are technically difficult operations with reported complication rates as high as 30–80%. We present a retrospective cohort study of angle blade plate and PHILOS plate fixation for these patients in our hospital. Methods: This study describes 21 consecutive patients with 22 TT or TTC fusions between December 2005 and May 2009. The surgery was performed for severe deformity or arthritis as a result of: osteoarthritis(2), post-traumatic arthritis(4), rheumatoid arthritis (7), Charcot arthropathy (5), avascular necrosis(1), and post traumatic avascular necrosis (3). The senior author performed all of the operations. In the first ten cases (two TT and eight TTC) an angle blade plate was used, A PHILOS plate was used in the subsequent ten cases (three TT and seven TTC). One patient had bilateral TTC fusions with a blade plate on one side and a PHILOS plate on the other. There were eight male and 13 female patients. All the procedures were performed through a lateral transfibular approach. The patients were followed up regularly with clinical and radiological evaluation until union or otherwise. Results: Fusion was achieved in 19 out of 21 patients (90.5%) and 20 out of 22 arthrodeses (90.9%). All five TT fusions went on to union (100%). Fifteen out of 17 TTC fusions united (88.2%). One TTC fusion using an angle blade plate needed revision surgery for non-union of subtalar joint. In the PHILOS group one patient developed MRSA infection of the surgical site leading to non-union. This necessiated removal of metal and prolonged treatment with intravenous antibiotics. The patient now has a relatively painless fibrous ankylosis. Conclusion: TT and TTC fusions are complex operations performed for severe arthritis and deformity, often on patients with significant co-morbidities. It is a salvage procedure to relieve pain and/or correct deformity of the foot and ankle. This study suggests that both the angle blade plate and PHILOS plate provide a stable fixed angle construct, which achieves a high rate of bony union with alignment correction

Fractures of proximal humerus account for nearly 5% of all fractures. Majority of these fractures are minimally displaced and can be treated non-operatively with good functional results. However, treatment of unstable, displaced and comminuted fractures remains a challenge and optimal treatment continues to be controversial. This study was undertaken to evaluate the results of proximal humeral internal locking system (PHILOS) plating done for treatment of displaced three- and four-part fractures of the proximal humerus. Between November 2003 and February 2008, a total of 36 patients with displaced three- and four-part fractures of the proximal humerus had an open reduction and internal fixation using a PHILOS plate. Data was collected retrospectively and clinical and radiological outcomes were assessed. The mean follow up was 18 months. 35 (97.2%) united clinically and radiologically, with a mean neck/shaft angle of 127.1 degrees. One patient (2.8%) had revision procedure for implant failure, with a longer PHILOS plate and bone graft. The mean time to union was 9 weeks (7 to 20). The mean Constant score at final review was 72.1 (36 to 96). A total of 16 patients (44.4%) had excellent outcome, 16 (44.4%) had satisfactory outcome, but in four (11.2%) the outcome was poor. The PHILOS plate provides good fracture stability early-on allowing early mobilisation without compromising fracture union. It requires minimal soft tissue dissection, does not need contouring and angular screw fixation gives good stability. We stress the importance of minimal soft tissue dissection to preserve the vascularity of the head, indirect methods of reduction and early mobilization

Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate. We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up. At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation. Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures

The study of effectiveness of PHILOS plate in the internal osteosynthesis of humeral head fractures. Since 2006 23 patients with 24 humeral head fractures ere treated in our clinic. 10 of them were men (43,48%) and 13 women (56,52%). The average age was 50,4 years (range 16–89 years). Fractures of the surgical neck of humerus were 8 of these (33,33%), 12 were 3 parts fractures according to Neer classification (50%) and finally in 3 cases there was a 4 part fracture (16,66%). Shoulder of dominant upper limb was injured in most of the cases (68%). 19 patients (82,6%) were examined periodically in an average follow-up period of 19 months (range 13–26 months). All the fractures were healed. In 4 cases (16,66%) insufficient reduction was detected postoperatively. Constant score was calculated 12 months post-operatively up to 82,05 by mean (range 62–100). Differentiation was observed between the patients of age less than 60 years (12 patients with average constant score 91,25 with range from 78 until 100) and these of age of 60 years or more (7 patients with average constant score 71,43 with range from 62 until 81). Internal osteosynthesis humeral head fractures with PHILOS plate is a reliable method of treatment not only for simple head fractures but also for them of 3 or even 4 parts, without complications and with very good functional results

Fractures of the proximal humerus account for 4–5% of all fractures with 80% requiring no surgical treatment. However, the management of the other 20% remains controversial. Multiple surgical modalities have been examined with no consensus as to which if any is the most effective. This study followed a series of 27 patients who had PHILOS plate fixation of their proximal humeral fractures. All patients were followed up clinically and radiologically for at least one year to a mean of 27.6+/−7.8 months. We reviewed 27 patients with a mean age of 62.2 years (16 patients were aged at least 60 years). The patients were classified as per the AO system into type A (n=11), type B (n=12) and type C (n=3) fractures. The mean DASH score was 51.8. The mean SF-36 scores for physical and social functions were 68.7 and 88.0 respectively. The mean Constant score was 50.5%. These results how that the PHILOS plate offers good functional outcomes across a spectrum of fracture severities and in an older population group. Its use should be considered where appropriate in the management of displaced proximal humeral fractures

The Proximal Humeral Internal Locking System (PHILOS) is being used increasingly in the treatment of proximal humeral fractures. Improvements in operative technique since its first use may represent improved functional results. We analysed 28 cases performed in the two years following October 2006. There were 22 females and 6 males. Mean age was 65 years (Range 37–79 years). There were five 2-part, nineteen 3-part, and four 4-part fractures. Functional results were measured using the Oxford Shoulder Score, American Shoulder and Elbow Surgeons’ Score (ASES) and Constant Score (Age and sex matched). This provided objective and subjective scores of function after a mean follow-up period of 15 months (Range 3–27 months). These results were compared to the patient’s non-operated shoulder to determine loss in function. Following PHILOS fixation, function of the operated arm was decreased both subjective and objective scoring. This change was significant for all three scores (p-values < 0.01). Sub-analysis comparing patients aged < 60 years with those > 60 years and 2-part fractures with 3- and 4-part fractures showed no significant difference. We conclude that our results show that function in the operated arm is lost. Our data confirms previously published function scores and shows no impact of the patient’s age and fracture configuration on the results of this implant

Proximal humeral fractures are common injuries but there is no general agreement on the best method for fixing unstable and displaced 3 & 4 part fractures. A new implant – Proximal Humeral Internal Locking System (PHILOS) – has recently been introduced to fix these fractures. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of these fractures. We operated upon 36 patients between March 2002 and December 2004. 33 of them were available for follow up, which ranged from 12–45 months. Assessment at follow up included radiological review, Constant and DASH scoring. While recovery of movements and relief in pain was satisfactory, the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate. 4 patients have shown radiological signs of avascular necrosis of humeral head. The plate was removed in 4 patients due to impingement and / or mechanical block in abduction. Another 2 patients had to undergo arthroscopic subacromial decompression for the same reasons. We encountered the problem of cold welding and distortion of screw heads, while removing the PHILOS plate. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure. The PHILOS plate does have inherent advantages over other implants for fixation of 3 and 4 part proximal humeral fractures but we are not convinced about its strength. Design of its proximal screws also appears less than satisfactory. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy

Introduction: At EFORT 2007 – Thomazeau, Duparc and Hertel excellently formulated principles that may help to decide which types of comminuted dislocated fractures should be resolved by osteosynthesis and which ones by arthroplasty – regarding blood supply of the humeral head. In following section Baker, Shahid, Biberthaler, Farron and Kääb presented results of treatment of complicated fractures by Philos plate. The fact that emerging from these presentations is that using of angular stable implants may lead in many cases to the failure of osteosynthesis, especially in osteoporotic humeral head and/or small size of head. In their presented work authors summarize the results of using Philos plate in ultimate indications. These are – dislocated proximal humeral fractures with abruption of the head in anatomical neck, where head fragment is so much thin and eventually osteoporotic, that fixation of any osteosynthetic component would be technically impossible. These cases include even situations where head fragment is then splitted into two major fragments. Method: In our Clinic we have used the Philos plate in 54 cases during last four years. 11 cases of it were indications for arthroplasty according to general principles. In four of 11 cases head was abrupted into two major fragments, and in four of 11 cases head was completely separated from soft tissues and deprived of blood supply. Despite of that, there was performed a reconstruction by Philos plate considering low age of patients/range of age 26 to 54 years/as an attempt for humeral head preservation. Procedure was performed entirely by most experienced surgeons. Results: Evaluation was performed 1 to 2 years after osteosynthesis. In all eleven cases full healing was found. In 4 cases there is clear remodelling of the head without any collapse of it. Also function of operated shoulder articulations enables the return of extremity functioning. We monitored no significant pain of the joint in any patients. Conclusion: Angular stable implant allows an attempt for salvage of anatomical head even in cases with head disruption and devitalized fragment. Presentation supported by grants MSMT CR 57/226010NPV, GA CR 106/04/1118 and FT–TA3/131