Aims. Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods. A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results. The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion. The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. However, the failure rate of this fixation is high, ranging between 10 and 35%. Numerous variables are thought to affect the performance of the fixation used, including the length and configuration of screws used and the plate position. However, there is currently limited quantitative evidence to support concepts for optimal fixation. The variations in surgical techniques and human anatomy make biomechanical testing prohibitive for such investigations. Therefore, a finite element osteosynthesis test kit has been developed and validated - SystemFix. The aim of this study was to quantify the effect of variations in screw length, configuration and plate position on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures using the test kit. Twenty-six low-density humerus models were selected and osteotomized to create a malreduced unstable three-part fracture AO/OTA 11-B3.2 with medial comminution which was virtually fixed with the PHILOS plate. In turn, four different screw lengths, twelve different screw configurations and five plate positions were simulated. Each time, three physiological loading cases were modelled, with an established finite element analysis methodology utilized to evaluate average peri-screw bone strain, this measure has been previously demonstrated to predict experimental fatigue fixation failure. All three core variables lead to significant differences in peri-screw strain magnitudes, i.e. predicted failure risk. With screw length, shortening of 4 mm in all screw lengths (the distance of the screw tips to the joint surface increasing from 4 mm to 8 mm) significantly (p < 0 .001) increased the risk of failure. In the lowest density bone, every additional screw reduced failure risk compared to the four-screw construct, whereas in more dense bone, once the sixth screw was inserted, no further significant benefit was seen (p=0.40). Screw configurations not including calcar screws, also demonstrated significant (p < 0 .001) increased risk of failure. Finally, more proximal plate positioning, compared to the suggested operative technique, was associated with reduced the predicted failure risk, especially in constructs using calcar screws, and distal positioning increased failure risk. Optimal fixation constructs were found when placing screws 4 mm from the joint surface, in configurations including calcar screws, in plates located more proximally, as these factors were associated with the greatest reduction in predicted fixation failure in 3-part unstable proximal humeral fractures. These results may help to provide practical recommendations on the implant usage for improved primary implant stability and may lead to better healing outcomes for osteoporotic proximal fracture patients. Whilst prospective clinical confirmation is required, using this validated computational tool kit enables the discovery of findings otherwise hidden by the variation and prohibitive costs of appropriately powered biomechanical studies using human samples

A reverse shoulder arthroplasty has become increasingly common for the treatment of proximal humerus fractures. A reverse shoulder arthroplasty is indicated especially in older and osteopenic individuals in whom the osteopenia, fracture type or comminution precludes fixation. However, there are many other ways to treat proximal humerus fractures and many of these are appropriate for different indications. Percutaneous pinning remains an option in certain surgical neck or valgus impacted proximal humerus fractures with minimal or no comminution at the medial calcar. In general, a fracture that is amenable to open reduction and fixation should be fixed. Open reduction and internal fixation should be the gold standard treatment for three-part fractures in younger and middle-aged patients. Four-part fractures should also be fixed in younger patients. Hemiarthroplasty results are less predictable as they are very dependent on tuberosity healing. While a reverse shoulder replacement may be considered in patients with severe comorbidities, patients always have better outcomes in the setting of an appropriately reduced and stably fixed proximal humerus fracture

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

Proximal humeral fractures account for approximately 4–5% of all fractures seen in the emergency departments. Of all shoulder injuries they account for aproximatelly 53%. In 1970 Neer published his classic study, in which he described a new method of classification, and gave recommendations for treatment. Neer recommended ORIF for three-part fractures, and prosthetic replacement for four-part fractures and fracture-dislocations. However there is still disagreement on the management of the displaced humeral fractures. Diagnosis. Accurate radiographic evaluation, is essential in order to make a correct classification of the proximal humeral fractures. The radiographic examination consists of films from three different views. The anterio-posterior (AP), lateral (Y view of the scapula), and the axillary one. The AP view will assess the fracture position, and by centring it 30 degrees posteriorly and obliquely, clearly image the glenohumeral joint space. The lateral view is taken perpendicular to the scapular plain. The head overlaps the glenoid, and projects on the centre of a “Y“, formed by acromion, the coracoid superiorly, and the scapular body inferiorly. In this projection any large avulsed greater tuberosity fragments are usually easy to visualise posteriorly, and the lesser tuberosity is visualised medialy. The axillary view is the most useful in assessing the relationship between the humeral head and the glenoid. Fracture dislocations, and true posterior dislocations can be easily distinguished in the axial view. Computer tomography, plain or with three dimensional reconstruction-views might also help the surgeon to make an accurate diagnosis and in preoperative planning. Classification. A valid classification system can be useful as a tool to select the optimal treatment. The system should be comprehensive enough to reflect the complex fracture pattern, and specific enough to allow an accurate diagnosis. The classification should be useful as a tool for identifying those fractures which should be operated upon. In 1935, Codman proposed a new classification system based on four different anatomical fragments of the proximal humerus. The anatomical head, the greater tuberosity, the lesser tuberosity and the humeral shaft. Codman stressed that the musculotendinous cuff attachment to each fragment was of major significance to the fracture pattern. In 1970 Neer further developed Codmans classification, stressing the importance of the biomechanical forces, and the degree of displacement for more complex fractures. When any of the four major segments is displaced over 1 cm or angulated more than 45 degrees, the fracture is considered to be displaced: Group 1: all fractures regardless of the level or number of fracture lines, in wich NO segments are displaced. Group 2: a two-part fracture is one in which one fragment is displaced in reference to the other three fragments. Group 3: a three-part fracture is one in which two fragments are displaced in relationship to each other and the other two are undisplaced fragments, but the head remains in contact with the glenoid. Group 4: a four-part fracture is one in which all four fracture fragments are displaced; the articular surface of the head is out of contact with the glenoid and angulated either laterally, anteriorly, posteriorly, inferiorly, or superiorly. Furthermore it is detached from both tuberosities. Neer has also emphasised the term fracture dislocation. It exists when the head is displaced outside the joint space rather than subluxated or rotated and there is, in addition, a fracture. The degree of displacement is directly related to the clinical outcome and the choice of treatment. In the 1970’s the AO group from Switzerland, emphasised the importance of the blood supply to the articular surface of the humeral head. Since the risk for avascular necrosis was high, they based their classification on the vascular anatomy of the proximal humerus. The system classified the fractures into three different categories:. Group A: Extra-articular, unifocal fracture. Group B: Partially extra-articular, bi-focal fracture. Group C: Articular fracture. Each group is sub-divided into three categories, from less to more serious lesions. This gave us 27 different sub-groups to analyse and interpret. The AO system is easy to use for the diaphyseal segments of the femur, tibia and humeral shaft, but applying it to the proximal humerus is confusing, and makes it more difficult to use than the Neer system. Consequently the AO classification system has not gained general acceptance among shoulder surgeons. The reliability and the reproducibility of these classifications have been questioned Unfortunately, we do not have a better classification system on hand and therefore the Neer system is still widely used. Treatment. Many methods of treatment of proximal humeral fractures have been proposed during the past 50 years, creating a great deal of controversy and confusion. There are two main treatment options: Non-operative treatment and operative. Conservative treatment. Approximately 80% of all proximal humeral fractures are non-displaced, or only minimally displaced, and the clinical outcome is satisfactory after conservative treatment. After some days of rest, early mobilisation with gentle physiotherapy is of great importance. Operative treatment. Various types of osteosynthesis have been suggested. Semitubular straight or angulated plates, screws, Rush pins, external fixators, cerclage wires, tension band technique or K-wires with bone grafting have been used. The results reported range from excellent to poor. In cases of three- and four- part fractures, most authors have used open reduction with internal fixation. Because of poor bone quality, and a torn cuff, especially in elderly patients, osteosynthesis is not always the best choice. Hemiarthroplasty is reported to give an excellent outcome in many studies. In fracture dislocations, when closed reduction is not possible, the only way to restore the dislocated shoulder joint is to perform an open reduction and stabilise the fracture with an osteosynthesis implant, or replace the humeral head with a hemiarthroplasty. Scoring systems for evaluation of the end results. There are two rating systems generally used. The Neer system from 1970 has been widely used in a number of studies, all over the world, and the Constant-Murley system from 1987 has been recommended for use in Europe. Neer’s rating system from 1970 is used to assess shoulder function, after fractures, arthroplasty and dislocations. It is based on a 100 units scale, with points for pain (35), function (30), range of motion (25), and anatomy (10). In 1987 Constant and Murley designed a European scoring system, claiming it to be applicable for measuring shoulder function regardless of diagnosis. This system is also based on a 100 point scale. The degree of pain, activities of daily living, strength, and active range of movement are assessed. The results are then related to gender, age and activity level of the patient. Both systems has recently been questioned because of its low reliability. Confusion remains because different authors from the USA and Europe continue to use their own criteria for evaluation. Consequently, it is not unusual that the reported results after fracture treatment vary, depending on which rating system was used

The aim of this study was to determine the biomechanical behavior of two different implants used in the fixation of proximal humerus fractures. The two implants in this study are specifically designed for the fixation of proximal humerus fractures and both utilize the concept of fixed angle locking screws. Bone densitometry was performed prior to fracture production and fixation. A reproducible three-part fracture was created in paired human cadaveric bone and then fixed using the locking screw implants. Stress/strain curves for the bone-implant construct were created for loads applied in cantilever bending and torsion to determine the relative stiffness below the yield point. Following this each construct was tested to failure with a valgus bending load. The locking nail implant provided a significantly stiffer construct in torsion, valgus, extension and flexion at loads below failure threshold. The valgus load to failure was significantly higher for the nail. The mode of failure was different between implants

Introduction. We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications. Methods. Between July 2010 & April 2012, 39 isolated closed intra-articular calcaneal fractures were admitted to St Mary's Hospital. All Sanders type 2 and type 3 fractures were included. Undisplaced fractures (13) were treated non-operatively and comminuted type 4 fractures (4) were treated with primary arthroscopic fusion. Surgery was performed on the next list with no delay for swelling. All patients had pre and post op CT scans. Patients were discharged in a temporary cast with routine follow up at 2, 6 and 12 weeks. Technique. Arthroscopy was performed in the lateral position with a 4.0mm arthroscope, using two sinus tarsi portals and a posterolateral portal. The fracture fragments were reduced percutaneously, held with wires before definitive fixation. Results. There were 10 three-part fractures (Sanders 3AB) and 12 two part (Sanders 2A/2B). Bohler's angle improved from 9.9 (7–18) to 27.7 (23–32) P <0.001. The mean time to surgery was 4 days (1–7), mean post-op stay was 1.9 days. Mean articular step of 0.9mm (0.4–1.9mm) on post-op CT. There were no deep wound infections. Conclusions. PACO is an accurate and reliable technique for fixation of calcaneal fractures, with a low complication rate, and minimal pre and post-operative delay

Two-part surgical neck fractures, two-part greater tuberosity fractures and three- and four-part fractures of the proximal humerus represent a frequently encountered clinical problem. Many types of conservative treatments have been proposed, with a poor functional outcome, however; when the fracture fragments are displaced, surgery is required. Because the open reduction and the internal fixation disrupts soft tissue and increases the risk of avascular necrosis of the humeral head, closed or minimally open reduction and percutaneous pin fixation should represent an advantage. We report on 31 patients affected by fractures of the proximal humerus (n=6, two-part surgical neck fractures; n=5, with two-part greater tuberosity fractures; n=10, three-part fractures; and n=11, four- part fractures) treated with minimally open reduction and percutaneous fixation. The average age was 57 years. Most of the four-part fractures were of the valgus type with no significant lateral displacement of the articular segment. A small skin incision was performed laterally at the shoulder and a rounded-tipped instrument was introduced to obtain the fracture reduction; this latter was stabilised by percutaneous pins and cannulate screws. A satisfactory reduction was achieved in most cases. The average follow-up was 24 months (range 18–47). Only one patient, with four-part fractures associated with lateral displacement of the humeral head, showed avascular necrosis and received a prosthetic implant. Minimally open reduction and percutaneous fixation is a non-invasive technique with a low risk of avascular necrosis and infection. This surgical technique allows a stable reduction with minimal soft tissue disruption and facilitates postoperative mobilisation

Purpose: To present the results of the use of shoulder prosthesis in multifragmented displaced humeral head fractures. Material-methods: 19 patients with comminuted and severely displaced fractures of the upper humeral epiphysis were treated with shoulder hemiar-throplasty. Their age varied from40 to 81 years (av:71). Seven patients had severely displaced four-part fracture; eight patients had four- part fracture-dislocation and four patients, three-part fracture dislocation with extended damage to humeral head articular surface. In 16 cases the arthroplasty was performed within 10 days, and in three, 6 weeks or more after the injury. The glenoid was not replaced in any of the cases. Results: The follow-up period was 16–84 months (av: 51). None of the patients had been reoperated, and none of the prosthesis was regarded ÒlooseÒ. The clinical assessment was done using the Constant-Murley scale. The score varied from 50 to 89 points, (av: 79). The average score for ÒpainÒ was 13(max 15) and for ÒmobilityÒ29(max 40). Average abduction reached 100 degrees and forward ßexion 110 degrees. At the last examination, 15 out of the 19 patients had returned to the previous social and occupational activities. Conclusions: The shoulder replacement offers satisfactory results in cases with comminuted and badly displaced fractures, but is a technically demanding procedure, and the time interval between injury and operation, strongly affects the result. Long lasting physiotherapy, patient compliance and cooperation are necessary for a satisfactory outcome

Three and four part fractures of the proximal humerus can prove difficult to treat and results are generally poor. We used a Polarus Nail technique to treat seven consecutive patients who had sustained an isolated fracture to the proximal humerus. According to Neers classification, four patients had sustained a three-part fracture and three patients a four-part fracture. One patient had a fracture dislocation. At review, six of the seven patients were assessed using the Constant and Dash scoring systems. One patient had died, but at last review had been discharged with a satisfactory result. The average age of the patients reviewed was 62 years (range 48–79). The dominant hand was affected in 2 patients. All six patients were followed up to fracture union and were happy with the result of treatment. All patients had mild or no pain. The average Constant score was 83 (range 59–98) and average Dash score was 131 (range 8–300). When comparing our results to other methods of treatment already described, we found that fixation using a Polarus nail provided a satisfactory alternative method. In fact, our patients appeared to have less pain and a higher score to all elements of the Constant score. We conclude therefore that the use of the Polarus Nail should be considered as a treatment option in this group of patients

Objectives and Material: The authors have evaluated 78 patients with fractures of the proximal humerus that have been interned in the Orthopedics’ Service at Hospital de Santa Maria since the 1st January of 1995 until the 31st December of 1999 with the objective of evaluating different factors influencing the final results and concluding to the best therapeutic conduct in the different cases. Method: The following parameters have been evaluated: sex, age, accident type (low/high energy), associated injuries, fracture’s classification, type of treatment and results achieved. The Constant score have been used for the functional evaluation. Due to reduced number of patients in each class a non-parametric test has been used – Qui-square test (X2). SPSS program has been used to run the calculations. Results: It has been verified that sixty four percent of the cases happened due to low energy accidents and the three-part fractures prevailed (46%), followed by four-part fractures (34%). The fracture of the proximal humerus occurred isolated and prevailed in women above 60 years old. Patients’ age was not a factor of bad prognostic. The number of bad results depended on the fracture’s type. Open reduction and internal fixation has been the most frequently used technique in all fracture types and the one with the best results. Open reduction and Kirschner pinning should be used only in very specific cases and with limited functional objectives. Humeral head reconstruction has not been a valid option to four-part fractures treatment, allowing concluding that, in many cases of very fragmented fractures, the option for the humeral head substitution by prosthesis should be better than trying its reconstruction

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications

Aim: The authors report a new ostheosinthesis device(Prysmatic Threeangular System P.T.S.) designed for the treatment of complex fractures of the proximal part of the humerus. Methods: From May 2005 to February 2006 we treated ten patients, four patients were female and six male. The average age was 45.1 years (max. 69, min. 27). Cases included nine fresh fractures and a malunion of three-part fracture treated three months after the trauma. All patients had closed fractures; one was worsened by a partial and temporary lesion of the brachial plexus. All patients underwent a standard X-ray and a Ct scan. In all patients, some homologous spongy bone was inserted in the titanium structure; moreover, in five cases (the youngest patients) autologous blood-derived growth factors were added. All patients were kept immobilized by means of a brace with internal rotation for 4 weeks. Results: In 6 cases the follow-up period ranged from 3 months to a 10 months in 6 cases. In these cases the CT scan allowed as to determine that the integration of the bank bone with the receiver took place after 3–4 months, while the check performed at 6 months did not show any peri-metallic lysis and showed that the P.T.S. had perfectly integrated with the metaepiphysis. No cases of nervous or vascular secondary lesions were detected. No infections, either superficial or deep, were noticed even after a long period. Discussion: The best surgical treatment of three- or four-part, dislocation and unclassifiable complex fractures of the humerus is still debated, the results achieved with other system or a shoulder prosthesis are not constant. The Authors report a new system consisting of a prismatic threeangular titanium structure which, allows to modulate the reduction of the parts and open a window from the fracture rim through which the surgeon can directly observe the lesion and the relevant parts

Introduction and purpose: The results of hemiarthroplasty for the treatment of complex proximal humerus fractures are controversial since there are wide variations across series. In what follows, we shall present our experience and results with the implants we use, with a minimum follow-up of one year. Materials and methods: 87 prostheses were revised (hemiartroplasty with cemented Neer II endoprosthesis) with a minimum follow-up of one year (1 to 10); 74 females and 13 males, 53 right and 34 left, with a mean age of 73.3 years (range: 51 – 82). Indications included three-part fractures (15 cases), four-part fractures (66) and fracture-dislocation (6). All patients were put on a postop customized standardized physical therapy program. Results: The Constant test was performed after 3, 6 and 12 months postop, with a mean result of 44.57 points after 3 months, 49.52 after 6 months and 64.37 after 12 months. 90% of patients had either no pain or occasional pain and 85% of them subjectively described their condition as very good. Two patients were revised: one as a result of a lysis in his lesser tuberosity and the other because of a painful implant. There were two instances of a periprosthetic fracture and three infections (2 late ones and a post-fracture one). Conclusions: Although these results might seem poor, it should be emphasized that heimarthroplasty led to a predictable absence of pain and to a perception by the patient that the result obtained was very good. Even if it is true that certain limitations were observed in terms of function and strength, patients were able to perform many of their daily life activities and gain a substantial degree of independence, albeit with certain restrictions. For this reason we consider the technique described as the procedure of choice for these types of fractures

Introduction and purpose: The treatment of proximal humerus fractures is still controversial in terms of the surgical approach to be used and even of whether surgery is indeed necessary or not. The purpose of this study is to assess the functional result and the patients’ perception of their general health condition after treatment of displaced humerus fractures by means of transosseous sutures with or without the support of modified Ender nails. Materials and methods: The study comprised a series of 40 patients (mean age: 66.21 years); 82% females /18% males. The patients had the following fracture types: 27% had two-part fractures, 60% had three-part fractures and 12% had four-part fractures and fracture-dislocations. The mean follow-up was 55.83 months (12.83-97). The final functional evaluation was carried out using the Constant score and the health perception was measured on the EuroQol-5D scale. All patients were submitted to a final radiological exam (AP and profile radiographs on the scapular plane). Results: The mean value obtained on the Constant Scale was 74.18 in the involved arm and 84.06 in the contralateral one. As regards pain, the mean obtained was 12.57, while the value for forward arm elevation was 8.24. When comparing two age groups (> 70 vis-á-vis < 70 year olds) a significant difference was obtained with respect to Constant Scale’s global value (p 0.022). Furthermore, a significant difference was detected between the result of the EuroQol-5D scale, the global result of the Constant Scale (p 0.061), abduction (p 0.05), internal rotation (p 0.05) and strength (p 0.007). The rate of postop complications was 6% (2 surgical wound haematomas). The final radiological control revealed losses in reduction and necrosis in 9.37% and 3.03% of patients respectively. Conclusions: (1) Good global functional results on he Constant Scale. (2) Significant differences in functional results based on patients’ age. (3) Difference in quality of life perceptions on the basis of the amount of mobility and strength obtained postoperatively. (4) Low complications rate

A series of 116 patients surgically treated, with exclusion of arthroplasty, between December 1996 and December 2002 for a fracture of the proximal humerus, was retrospectively reviewed. Only 44 patients (45 shoulders) were available for clinical and radiological follow-up, 21 were deceased, 36 refused to participate and 14 could not be traced. The mean age was 60 y (15–93 y), the mean follow up was 44 months (15–78 m.); 28 were women, 16 men. The fractures were classified according the Neer-classification but also according the different types of surgery they underwent: percutaneous or retrograde pinning without opening the fracture site, osteosynthesis with plate and screws, osteosynthesis with screws alone, bone-graft and osteosutures or a combination of two or more methods. Two-part fractures (10 out of 13 fractures), but also 9 of the 15 three-part fractures, were treated by pinning, whereas the remaining 2 and 3-part, the isolated fractures of tuberculi and two 4-part fractures needed open surgery and fixation. A plate was used in only 3 cases, screws alone in 6 cases, a cortical bone-graft with osteosutures in 4 cases and a combination of open fixation in 8 cases. Whenever possible a minimal invasive technique was thus preferred. 16 patients (35,7%) had complications: 6 were minor (pin migration, slight secondary displacement or impingement as a consequence of protruding hardware), but one non-union, 4 CRPS and 5 avascular necrosis occurred. Only one of the latter underwent shoulder-arthroplasty at time of review. Major complications occurred mainly in the more complex fracture types (3 or 4 part fractures). Mean values of Constant score, ASES-score, Neerscore, UCLA score and Simple Shoulder test were not statistically different, neither between fracture types nor between surgical techniques. Using a correlation analyses we found a negative correlation between age and scoring systems: the older the patient, the lower the score. Patient satisfaction was higher in the percutaneous or retrograde pinning group than the other types of open surgery. We can conclude that although no statistical differences could be observed in our series, minimal invasive surgical techniques, less prone to complications, are preferable in the treatment of two and three part fractures of the proximal humerus and 4-part fractures of the younger population

The purpose of this study is the assessment of the shoulder function after a proximal humeral nail insertion for trauma, using a minimal invasive approach. Material and methods: 22 patients had osteosynthesis for proximal humeral fractures using the Telegraph Nail. 15 patients underwent percutaneous osteosynthesis. The indication for the percutaneous procedure was determined at the per-operative control under fluoroscopy when the fracture was reducible by external manoeuvres. 12 of the fractures involved the surgical neck and 3 fractures were three-part fractures of the proximal humerus. The proximal interlocking was made using two screws in all the cases. The distal static interlocking was made with a single screw in all the cases. All the patients followed a standardised rehabilitation protocol including early mobilisation and passive and active assisted muscular activity. The shoulder function was assessed using the Simple Shoulder Test (SST) and the Constant score. The mobility was assessed using the flexibility ratio described by Harryman as compared to the opposite healthy arm. The patients were assessed at 6, 12, 26 and 52 weeks after surgery. Results: All the fractures showed consolidation within 6 weeks. Two fractures united with internal rotation and presented at controls with limited external rotation. Stable results were obtained at an average of 3 months. Return to previous activities was possible between 8 and 10 weeks after surgery in all the cases excepting two. In one case subacromial conflict between the nail and the rotator cuff was due to malpositioning of the proximal part of the nail and of the screws and required early removal and cuff repair. Average forward elevation was 12O25. Average external rotation was 4515. The SST score reached an average of 8.2/12 within 6 months and practically was unchanged at 12 months for all the series. The pondered Constant score was 76.7/1OO at six months. All the patients were improved after surgery. Conclusion and discussion: The percutaneous insertion of a proximal humeral nail for shoulder fractures is a minimally invasive alternative to heavy open surgery. The results are acceptable for the patients and stable in time. The advantage of minimal bleeding and short hospital stay recommend this technique in all the cases when reduction is possible without opening, as showed by the fluoroscopy

Introduction. The treatment of complex fractures of the proximal humerus still raises controversy, particularly in those 3 or 4 part fragments fractures, which are at risk for osteosynthesis (poor fixation in poor bone) or for secondary avascular necrosis. Conventional hemi-arthroplasty has currently remained the most common surgical treatment, but the recovery of active mobility remains incomplete and disappointing. Inverted shoulder arthroplasty has been initially proposed for the treatment of omarthrosis secondary to deficient rotatory cuffs, however its use in acute traumatology has not been yet investigated. Material and Medthod. We hereby present the results obtained in 43 consecutive patients (41 women and 2 men) which were retrospectively reviewed with a mean follow-up of 21 months (5–58). The mean age was 78 years-old (64–97). There were 5 three-part fractures, 26 four-part fractures and 12 four-part fracture dislocations. All patients were clinically and radiologically assessed, except two, who deceased with incomplete follow-up data. Results. The clinical outcome was satisfactory with a mean active forward elevation of 97° and a mean active external rotation in abduction (ER 2) of 30°. The mean Constant score was 44 points (16–69). The mean ponderate score was 66% (25–97%). The mean pain score was 12.5/15, the mean activity score was 10.9/20, the mobility score was 17.6/40 and the strength score was 3.6/25. The mean ponderate score of the controlateral shoulder was 105 %(80–130). The mean ASES score was 9 points (0–19) out of 24. The mean DASH score was 44 points (0–92) out of 100. Post-operative complications included 3 reflex sympathetic dystrophies, 5 regressive neurological complications, 1 loosening of the deltoid suture, 1 anterior dislocation and 1 acromion fracture. There was no infection. Radiographs at last follow-up showed peri-prosthetic calcifications in 36 cases, displacements of the tuberosities in 19 cases and scapular notches in 10 cases (1 type III, 3 type II and 6 type I notches). No migration of the prosthetic components was observed. Discussion. Satisfactory mobility scores can be obtained in the treatment of complex shoulder fractures in the elderly, despite frequent deficiencies of the rotator cuff, whatever their causes, degenerative or traumatic (secondary displacement). Conclusion. Inverted shoulder arthroplasty might constitute an interesting alternative in the treatment of displaced 3 or 4 part fragment fractures in the elderly over 70. Long term results are required before extending the indications to younger patients or to other types of fracture