Aim: The treatment of the fractures to three and four fragments of the humerus still represents a challenge. The authors describe the surgical technique and results with a modular prosthesis that permits an anatomical reconstruction of the proximal humerus from the calcarside, that becomes the point reference of reconstruction with the “Puzzle-Pieces” technique.

Methods: From February 2000 to February 2007 41 patients were treated with modular prosthesis. They were 8 males and 33 females aged between 56 and 79 years. In 23 cases the interested shoulder has been the right, in 18 the left. All fractures were diagnosed with X-ray and CT-scan. The type of fracture includes: 20 fractures of four fragments, 15 pluri-fragmentary fractures, and 6 fracture\dislocations. At the follow-up we evaluated 26 patients.

Results: The functional results were evaluated in 26 patients by Constant score with a mean follow-up of 4 years. All the patients reviewed have executed a X-Ray, while in 18 cases we also have evaluated the reconstruction of the tuberosities with CT-scan. In one case there has been had a complete resorption of the tuberosities with insufficiency of rotator cuff. The mean of forward elevation was 132° Conclusion: The plant of a humeral pros-thesis for fractures is a very complex intervention. The technique, for modular prostheses it’s not very codified. Moreover the results from the Literature are inconstant in particular as to function of the shoulder, not predictable and often were it accompanied by complications.

The technique we described consists in the identification and reconstruction of the medial part of calcar that becomes “the thread conductor” for restoration of the height and the retrotorsion of the humeral head.

Purpose: The three dimensional position of the tuberosity and the tension of the rotator cuff influence the structural changes of the rotator cuff and their influence on clinical results of reversed trauma prostheses.

We propose this technique with it of a biological support, the fractured humeral head, adequately modeled, in order to give again the just tension to the cuff

Method: from February 2007 and February 2009 we treated 29 patients with a reversed trauma prostehes, in 7 cases we have practiced the bony necktie, for giving a support to the correct reconstruction of the tuberosity. The patients have an average of 71,5 years and was evaluated with Constant score and radiographic study with mean follow-up of 18,6 months

Results: Improvement of postoperative Constant score and radiographic good results were correlated with satisfactory subjective results. However, these results will have to be confirmed with more cases and later revision

Conclusion: Tuberosity position and healing is critical for clinical and radiographic outcome in shoulder arthroplasty in trauma. In particular the rate resorption of the tuberosity in Reverse Trauma Prostheses still is elevated. we propose a new surgical technical in order to give again the just position to the tuberosity fractured and therefore to give tension to the rotator cuff

Introduction: Twenty-four proximal humeral fractures were treated by surgical internal fixation with locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes after treatment with antegrade humeral nail inplanted with an interval rotator split.

Material and Methods: We present a consecutive series of 24 patients with proximal and diaphyseal humeral fractures treated with the Telegraph^® nail inserted trough the interval rotators.

There were six proximal, seven bifocal interesting the third proximal and shaft and eleven diaphyseal humeral fractures fracture.

Results: The mean follow-up was 22 months with a range from 12 to 32 months, nineteen of the 24 patients were available for follow-up. All but two fractures progressed to healing. The mean Constant score were 80, Relative Constant score were 94,6%.

Conclusion: Intramedullary antegrade nail insert trough the interval rotator without violating rotator cuff results in good clinical outcomes and with certain fracture types can be an effective and satisfactory device.

Purpose: The purpose of this study is to report the preliminary outcomes after open reduction and internal fixation of displaced proximal humerus fractures with a new device called “Da Vinci System^® (Arthrex)”. It is a triangle-shaped titanium cage whose opposite faces are pierced and represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients.

Material and methods: Between May 2005 and May 2008 we treated 54 patients (26 males and 28 females), even though we included in our study 36 patients who had a minimum follow-up of 12 months. The mean age was 60.3 years. The fractures were classified according to Neer. According to the technique, the Authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage and are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures.

Results: The functional results were evaluated by the Constant score; with a mean follow-up of 22 months (minimum 12, maximum 36 months), the results were excellent or good in 34 cases, bad in 1 case; the mean active anterior elevation was 165 degrees, while in one case a polar necrosis is present but clinical asymptomatic.

All fractures but one healed; in one case, 80 days after the operation, we had a deep infection treated with a self-customed cement spacer.

Discussion: Surgical management of displaced proximal humerus fractures is still a challenge to surgeons. Optimal fixation system remains controversial, especially in complex fractures with instable fragments and osteoporotic bone. The Authors underline it is important to reconstruct the medial part of the surgical neck, to fill the bone defect, and to provide stable osteosynthesis. The “Da Vinci System” is an interesting innovation to treat difficult problems such as fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization.

Aim: The treatment of the fractures to three and four fragments of the humerus still represents a challenge.

The authors describe a surgical technique with a modular prosthesis that permits an anatomical reconstruction of the proximal humerus from the calcar-side, that becomes the point reference of reconstruction with the “Puzzle-Pieces” technique.

Methods: From February 2000 to February 2007, 41 patients were treated with modular prosthesis. They were 8 males and 33 females aged between 56 and 79 years. In 23 cases the interested shoulder has been the right, in 18 the left. All fractures were diagnosed with X-ray and CT-scan. The type of fracture includes: 20 fractures of four fragments, 15 pluri-fragmentary fractures, and 6 fracture\dislocations. At the follow-up we evaluated 26 patients.

Results: The functional results were evaluated in 26 patients by Constant score with a mean follow-up of 4 years. All the patients reviews have executed a X-Ray, while in 18 cases we also have evaluated the reconstruction of the tuberosities with CT-scan. In one case there has been had a complete resorption of the tuberosities with insufficiency of rotator cuff. The mean of forward elevation was 132°

Conclusion: The plant of a humeral prosthesis for fractures is a very complex intervention. The technique, for modular prostheses it’s not very codified. Moreover the results from the Literature are inconstant in particular as to function of the shoulder, not predictable and often were it accompanied by complications.

The technique we described consists in the identification and reconstruction of the medial part of calcar that becomes “the thread conductor” for restoration of the height and the retrotorsion of the humeral head.

Aim: To describe a new surgical technique for the reconstruction of complex fractures of the proximal humerus that can be used in both young and elderly patients. It consists in the anatomical reconstruction of fragments as puzzle with used of bone block and small fragment bone between the methaepiphiseal and head before a minimal osteosinthesis with K.-wire and or cannulated screws and or surure bone.

The goal of this technique is to restore normal anatomy of proximal humerus around a bone bridge inside the head and the metaphysis.

Methods: From 2003 to 2005 we treated 25 patients (17 males and 8 females), average 49.6, with a 3- or 4-part fractures and fracture\dislocations. The surgical technique requires a medial reconstruction with bone block insert and osteosyntesis with minimal encumbrance(k-wire and cannulated srews). In eleven cases we used autologus platelet growth factor

Results: All cases were submitted X-ray at 3months 6 months and 1 years. ten cases, also had TC scan. The functional results were evaluated according to the Constant score. With a mean follow-up of 24 months (range from 12 to 36 months), the results were excellent or good in 24 patients; the mean active forward elevation was 160 degrees. In one case we found a sintomatic avascular necrosis that was resolved with a hemiarthroplasty.

Discussion: Surgical management of acute complex proximal fracture of the humerus is still a challenge to the surgeons, both in young and in elderly patients.

The Authors report the goal of this technique is to restore normal anatomy of proximal humerus around a triangle-shaped bone block positioned inside between the head and the metaphyseal. The fragments are then stabilized with a minimal osteosynthesis by K- wires, screws or bone sutures.

The results of our study show that the technique we propose has good clinical and functional outcomes, with a low percentage of 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.

Aim: In this work we report mild term clinical results of a consecutive series of 104 arthroscopic stabilizations for traumatic or non traumatic anterior-inferior shoulder instability treated using for the stabilization always poly- L-lactic acid Bioknotless anchors (Mitek, Nor-wood, Mass., USA) and surgical technique described by Thal, and the clinical results of 74 patients reviwed

Methods: From 2000 to 2005, 104 consecutive patients underwent arthroscopic capsuloplasty repair using bio-knotless anchors.14 cases were performed SLAP II by original reconstruction with bioknotless anchors. All the patient underwent preoperative a clinical examination and valued Constant and Rowe score, and subjected a X-Ray study and MRI o TC\ arthroTC scan. All patients were operated by same surgical team. 74 patients (55 male, 19 female) were reviewed with at least 20 months follow-up (20 – 60 months). Average age was 25 (18–45).

Results: Recurrence rate for instability was 6,7% (5/74). All recurrence, was associated with a large Hill-Sachs lesion and poor quality of capsular tissue. Overall, the results were good or excellent in 91,5% using the Rowe score. At X-ray study 28 cases have not show Samilson’s arthrosis, in 4 (14,7%) cases we observed geoid on glenoid side.

Conclusion: The improvement in the results, to use absorbable anchor, obtained could be related to the development of materials and in particular at use of PLLA (poly-L- lactic polymer) and PGACP (polygluconate co-polimer), at surgical techniques carried out, to the different fixation methods and not least to the different inclusion criteria used for the selection of patients.

Arthroscopic capsulolabral stabilization for the treatment of recurrent anterior shoulder instability repair using absorbable Knotless offers reliable results with respect to failure rate, range of motion, and shoulder function also at 4 years follow-up.

The percentage of rate for instability is 6,7% and is in accord with the International Literature on non resorbable anchors.