Summary Statement

In this study, massive rotator cuff tears were treated using an absorbable collagen-based patch or a non-absorbable synthetic patch. Results demonstrated the efficacy of the use of the synthetic prolene patch especially for elderly patients

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up.

For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period.

The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome.

PURPOSE OF THE STUDY: We reported of eleven cases of early spontaneous osteonecrosis (SO) of the knee successfully treated with an extracorporeal shock-wave treatment (ESWT).

Traumatic and vascular theories have been proposed as the cause of the SO, lack of blood in some critical areas, such as subchondral bone of femoral condyles or tibial plateaus, has been considered the underlying condition of this pathology.

ESWT can be suggested as an effective conservative treatment for SO of the knee.

MATERIALS AND METHODS: Ten patients with medial femoral condyle osteonecrosis of the knee (one bilateral) were evaluated. Exclusion criteria was evidence of a structural collapse of subchondral bone. Two patients had received a femoro-popliteal by-pass within the last year, while others five presented a deficit of the vascular axis of the homolateral lower limb documented by an eco-colordoppler. A clinical evaluation was taken at the diagnosis using KSS, PPI, NRS and VAS. Plain radiographs and MRI confirmed the diagnosis of osteonecrosis.

Patients were treated with a cycle of three ESWT performed with 2000 pulses of 0,28 mJ/mm2 with Wolf Piezoson 300 with 6,5 MHz ultrasounds for three times in a month.

Clinical evaluation was performed at first and at third month after treatment and a MRI evaluation was performed at fourth month after treatment.

RESULTS: Clinical evaluation showed a significant improvement of symptoms and articular functionality. MRI of all cases revealed the continuity of the cartilage with a reduction in bone marrow edema and no collapse of lesion.

DISCUSSION: In our study, a single cycle of ESWT produced an improvement of the clinical and MRI aspects in eleven cases of SO of the knee. The neo-angiogenetic effect of the ESWT appears to accelerate the time for the symptom remission.

ESWT might have the potential to avoid the need for surgical treatment.

The shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion.

Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms.

The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear.

We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls.

Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient.

The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group.

This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear.

The aim of the study is to evaluate the results obtained in patients older than 70 years who were treated with open surgical repair for massive ruptures of the rotator cuff and the functional outcome.

This is a retrospective analysis of a consecutive series of 280 patients who underwent open repair of a massive rotator cuff tear between 1999 and 2003. The inclusion criteria were: age 65 or over, symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size > = 5 cm, minimum follow-up of 2 y since surgery. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views) and nmr of the shoulder. Patients were assessed with the Costant score, Simple Shoulder test, UCLA score before and after surgery. Pain was assessed by use of a visual analog scale. The mean age of patients was 75b years (range 65–91). There were 41 men and 28 women. The mean duration of symptoms before repair was 18 months (range 1–58). The dominant arm was affected in 54 patients (78%). The change in UCLA scores, SST, Costant score and their subcomponents were analyzed with the paired Student’s test, assuming a normal distribution of the total score. In an exploratory analysis trying to identify preoperative variables that could be associated with a good surgical outcome, a multivariate logistic regression analysis was performed including the following variables: age equal or more than 80 years, sex history, shoulder different affected, UCLA score, SST, costant score and use of formal physical therapy. Satisfactory results were achieved in 250 patients: the mean preoperative UCLA score was 9.3, Costant score 45, and the mean score after surgery was 16.9 and 65 rispectively. The mean preoperative function score was 2.4, after surgery was 8.1. The UCLA preoperative score for active forward flexion averaged 1.3 (30°–90°), and postoperative rating increased to 4.5 points (p=0,0001)corresponding to an active forward flexion between 120° and 150°.

The purpose of this study was to analyse the long-term results of prosthetic joint replacement in patients suffering from metastatic bone disease. The treatment was performed in order to prevent or treat pathological fractures, to control the pain and improve the functionality of the lower limb.

120 patients suffering from metastatic disease of the lower extremities were treated with prosthetic replacement between 1992 and 2004

The patients, 80 females and 40 males, having an age at the time of surgery ranging from 32 to 83 years, were treated by the same equipe in the San Raffaele Hospital in Milan.

The primary tumor included breast carcinoma (66), lung carcinoma (19), kidney tumor (17), prostatic tumor (7), plasmocytoma (5), non identified tumor (5), melanoma (1). The metastasis was located in the proximal femur in 112 cases, in the distal femur in 3, in proximal tibia in 5. In 8 out of 120 patients, the metastatic lesion was the first sign of carcinoma, 25 patients had a pathological fracture and the bone metastases were detected from 6 mounth to 13 years after the diagnosis of the primary tumor.

Knee: in our casuistry 8 patients with a metastasis in proximal tibia or distal femur were operated with modular prostheses: in 1 case of this group (single lesion of kidney tumor), we have implanted an allograft-prosthesis-composite.

Proximal femur: for the treatment of this site, we have included also those patients having a life expectancy inferior to 1 month. In 30 cases the lesion was located in the epiphysis and neck and we have implanted 5 endoprosthesis, 5 total hip prostheses and 20 bipolar prostheses. In 82 patients with a metastasis located in the metaphysis we used a modular prosthesis with a femoral resection up to 16 cm.

69 patients are alive with a follow-up ranging from 6months to 12 years. 5 patients died in early post surgical period. 13 patients developed local recurrence. These latest have suffered from a pathological fracture, which had occurred before the first surgical treatment. Pain relief was achieved in all patients after surgery with acceptable functionality of the operated limb.

We considered the risk of pathological fractures more important than life expectancy. Moreover, we believe that the surgery to these patients should be definitive. In fact, the use of prostheses allow for a wide resection of the lesion. This condition represents also an advantage in those cases where radio- or chemiotherapy can not be performed. Moreover, the prostheses permit an immediate weight bearing, a good functional recovery and also, in patients with critical general condition, a more easy assistance. In conclusion, for patients with metastatic bone disease, we consider a correct approach the radical excision of the lesion and the implant of a prosthesis.

Introduction: The purpose of this work is to create an in vitro model of engineered osteochondral composite by combining a cylinder of calcium phosphate and cartilage tissue produced by isolated swine articular chondrocytes seeded onto fibrin glue.

Methods: Swine articular chondrocytes were enzimatically isolated and seeded onto fibrin glue. Immediately before gel polymerization, the fibrin glue was placed in contact with the cylinders of calcium phosphate. The osteochondral composites were left in standard culture conditions for 1,3,6 weeks. At the end of experimental times the samples were macroscopically analysed and processed for histological evaluation.

Results: Preliminary data showed a macroscopically integrity of the osteochondral samples. Histology showed cartilage like tissue maturing within the fibrin glue scaffold.

Discussion: The results demonstrate that isolated chondrocytes, seeded onto fibrin glue, produce a cartilage-like matrix that integrates with a cylinder of calcium phosphate.

This tissue engineered osteochondral composite could represent a valuable model for further in vivo studies on the repair of osteochondral lesions.

Three cases of patients affected with massive bone defects are reported, in which over 50% of the segments are involved. The treatment options considered were original and not yet described in literature. The patients were affected with: partial agenesia of the tibia, congenital hypoplasia and pseudoarthrosis of the femur, and massive post-traumatic bone defect. In all these cases the Ilizarov’s method was applied. In the first case, instead of carrying out an osteotomy and callotasis of the residual bone tissue, an osteotomy was performed close to the tibiofibular syndesmosis and a distraction at this level was executed. In the second case of pseudoarthrosis with antecurvatum of the proximal femur of 135°, varus of 100°, length discrepancy of 63%, a multiplanar gradual correction of the proximal deformity of the femur was carried out followed by a distal lengthening.

The third case concerning the pluri-fragmented exposed diaphyseal fracture of the tibia and fibula, with massive bone loss, was treated by restoring all the small fragments, even those without periosteal connections, to increase the proximal and distal bone mass. Once the fusion of the fragments occurred, a proximal osteotomy and callotasis was performed to rejoin the fracture’s segments.

Renal neoplasm is the most frequent cause of metastases, after prostatic and breast carcinoma.

Lesions are aggressive and expansive with cortical destruction and soft tissue extension. Pathological fracture is very common, up to 50%. The most frequent localizations are long bones, spine and pelvis.

Aim of this work is to evaluate the usefulness of surgical treatment of soft tissue and skeletal metastases in kidney neoplasm.

Between 1995 and 2005 66 patients (40 males, 26 females) were submitted to surgical treatment at San Raffaele Hospital, Milano. Most common localizations were femur, humerus, spine, pelvis, metatarsus. We report 3 cases of soft tissue metastases of lower limb.

Twenty-five patients had single localization, 10 pathological fracture and in 5 diagnose was bioptical.

Surgical treatment was performed with large resection and in 15 patients the lesion was embolized.

Twelve patients had local relapse and in 3 we performed a new surgical treatment.

We had no infections nor fatal outcome in the post-surgical period.

Objective: The purpose of this study is to evaluate the functional performance of patients who underwent to two different types of total knee prosthesis replacement (TKR).

Methods: Kinematics and kinetics of the knee and ankle and electromyography activity of the lower limb muscles were obtained from 16 patients who underwent a TKR. 8 patients had received a fixed bearing prosthesis while the other 8 patients had received a mobile bearing prosthesis. The functional performance of the patients was evaluated using two tests, the gait and the squat. As control, 8 normal subjects, matched by age, were also evaluated.

Results: During the stance phase of gait, patients with TKR showed a reduced knee extensor (internal) moment as compared to normal controls. During the squat test, patients with TKR exhibited a knee ROM that was reduced with respect to normal patients. Moreover, all patients with TKR showed a low velocity of execution of the both tests. There were no significant differences between patients who had received a fixed vs. mobile bearing prosthesis.

Discussion: The results showed that after TKR, the functional performance of the patients is different from that of the normal subjects, regardless of the type of prosthesis implanted.

In the past the prevailing view believed that there was an inverse relationship between osteoarthritis and osteoporosis; a recent study showed that elderly women with advanced osteoarthritis requiring total hip replacement had an evidence of osteoporosis and vitamin-D deficiency. An altered metabolic bone status as induced by low level of vitamin D could be one of the major causes of aseptic bone loosening and consequently failure of the implant. We studied the bone mineral metabolism of thirty elderly women with osteoarthritis undergoing total hip replacement in order to identify whether or not there were a bone metabolic alterations.

All the subjects included in the study were over than 70 years old (mean age 74 ± 2.5). The results showed that six (20%) subjects had a hypovitaminosis D status and eighteen (60%) had a vitamin D deficiency status. Five subjects (16%) had a secondary iperparathyroidism. The bone mineral metabolism of elderly women with osteoarthritis undergoing total hip replacement is characterised by a high prevalence of vitamin D deficiency and in a less percentage of the cases by a secondary iperparathyroidism. Both of these metabolic conditions could compromise the bone integration of the implant and lead to aseptic bone loosening.

Background: The aim of this study is to evaluate the efficacy of extracorpereal shock wave therapy (ESWT) in some of most frequent muscularskeletal pathologies.

Material and methods: From July to October 2004 310 patients were treated with ESWT, suffering from the following pathologies: 96 symptomatic calcific tendonitis of the shoulder, 53 symptomatic sub-acromial impingement, 48 humeral epichondylitis, 52 plantar fasciitis, 24 pertrochanteric bursitis, 15 Achilleous tendinopathy and 22 patellar tendinopathy.

Patients were evaluated clinically and instrumentally before the first application and at one and three months of follow-up. Three disability scales we utilized (NRS, Mcgill Pain Questionnaire e Chronic Pain Grade Questionnaire).

Results: We observed a reduction of the pain and an increase of the articular functionality in 83% of calcific tendonitis of the shoulder, in 55% of sub-acromial impingement, in 76% of epichondylitis, in 74% of palantar fasciitis, in 90% of pertrochanteric bursitis, in 82% of Achilleous tendinopathy and in 86% of patellar tendinopaty.

Discussion: The data confirm the therapy with ESWT is efficient in some of most frequent musculoskeletal pathologies, with variable outcome in the various pathologies under investigation.

The fibrocartilaginous labrum acetabulare enlarges the acetabular socket and contributes to the stability of the femoral head. In DDH the labrum is everted and pushed upward by the femoral head. In the dislocated hip the labrum is often inverted into the acetabular cavity and obstructs anatomic reduction. In the past, excision of the labrum was performed to allow the reduction of the femoral head. The aim of this study was to evaluate the position of the labrum in early detected decentered hips and its role in the early treatment of DDH. During the eleven-year period from 1992–2002, 21,709 neonates (43,418 hips) were examined both by ultrasound and by Ortolanis test to establish the diagnosis of DDH. According to Grafs classification the following hips were present: 298 type D-hips, 252 type IIIa, 4 type IIIb and 20 type IV. Therefore 431 of the patients (356 females and 75 males) showed 574 sonographically unstable hips affected by DDH (1.32%). Due to its echogenic structure, the fibrocartilaginous labrum is clearly visible by ultrasound. In type D, type IIIa, and type IIIb it was always located cranially to the femoral head; in type IV it was located medially to the femoral head. The average age of the children at the time of the diagnosis was 42 33 days (mean value SD). Ortolanis test was positive in 61 hips (10.63%) and negative in the remainder of the hips (89.37%). 21.5 % of the cases were diagnosed within the second week of life, 52.9 % between the third and the eighth week, and 25.5 % after the eighth week. The labrum was not inverted in any of these cases, nor was an open reduction necessary in order to remove it as an obstacle to the closed reduction. Only the ultrasound examination allowed the early diagnosis of the unstable decentered hips. The importance of the labrum decreases when an early diagnosis can be made and an early treatment can be performed.

After gaining experience from 1990 to 2003 using the Cincinnati incision in the surgical treatment of congenital clubfoot, we were able to extend its use to the early surgical treatment of congenital vertical talus (CVT). Eight of the 172 feet were affected by CVT; four were idiopathic, three were associated with arthrogriposis and one with cerebral palsy. The average age of the six children at the time of the operation was 13.5 months (range 6–27 months). We performed a posterior, medial and lateral release of the subtalar joint and of the talona-vicular joint. The reduction of the talus was performed using a K-wire placed through the posterolateral aspect of the talus in its longitudinal axis. After the calcaneus was reduced from its everted position, a second K-wire was placed through the calcaneus and into the talus. The medial talonavicular joint capsule was opened and the redundant capsule reconstructed. Peroneal tendon lengthening was performed in five cases. The radiological evaluation, according to Hamanishi, showed preoperatively a talo-first metatarsal angle of 94° (NV: 3.3 ± 6.4 SD) and a calcaneal-first metatarsal angle of 54° (NV: −9 ± 4.5 SD); postoperatively the values were 24° and 7°, respectively. There were no wound complications or avascular necrosis of the talus.

With the Cincinnati incision we were able to visualise the talo-calcaneal and talo-navicular dislocation in all three spatial planes. It also allowed us to correct the deformity in all three mentioned planes and in a single-step procedure.

The surgical technique for treatment of massive rotator cuff tears, more than 5 cm, with loss of substance and tendon retraction, is still not well defined by the international orthopaedic community. A specific rehabilitation regimen or arthroscopic débridement may be insufficient in active patients who continue to suffer from pain and muscular fatigue in active forward elevation. We treated 20 patients, 14 men and 6 women, with an average age of 52 years (range 40–69) with the surgical technique consisting in acromion decompression, stabilisation of the cuff lesion with anchors, application of a prolene membrane and using a deltoid muscular flap as reinforcement. Deltoid flap is created by splitting the deltoid muscular fibres in front of the anterior border of the acromion. The inferior part of deltoid is sutured to the tendon above the synthetic membrane.

The mean patient follow-up was 24 months. The pain was completely relieved in 85% of subjects, The joint mobility increased significantly in flexion, abduction and external rotation; however, the internal rotation did not improve.

We propose this surgical technique as the procedure of choice for treating retracted ruptures of the supraspinatus associated with lesions of the supra- and the infra-spinatus.

The purpose of this work was to create an in vitro model of tissue-engineered cartilage structure produced by isolated swine articular chondrocytes, expanded in culture and seeded onto a biological scaffold.

Swine articular chondrocytes were enzymatically isolated from pig joints and expanded in monolayer culture. When confluence was reached, cells were resuspended and seeded in vitro onto biological collagen scaffolds for 3, 4 and 6 weeks. Samples were retrieved from the culture and analysed macroscopically and biomechanically by compressive test. Gross evaluation was performed by simple probing, sizing and weighing the samples at all time periods. A baseline of the values was also recorded at time 0. Then, samples were biomechanically tested by unconfined compression and shear tests. Finally, the samples were fixed in 4% paraformaldehyde and processed for histological evaluation. Some samples were stained with Safranin-o, and some others subjected to immunostaining analysis for type II collagen.

Upon retrieval, samples showed dimensional enlargement and mass increase over time and gross mechanic integrity by simple probing. A biomechanical test demonstrated an initial reduction in the values of compressive and shear parameters, followed by a consistent increase throughout the tested time points. Histology showed cartilage-like tissue maturing over time within the biological scaffold.

The results from this study demonstrate that isolated chondrocytes could be seeded onto a biological collagen scaffold, producing cartilage-like matrix with tissue-specific morphology and biomechanical integrity. This tissue-engineered cartilage structure is easily reproducible and it could represent a valuable model for studying the behaviour of different variables on the newly formed cartilage.

From 1990 to 2003 the Ilizarov technique was used to treat 41 patients affected by the following congenital or acquired deformities : post-poliodeformity (n=8), hemimelia (n=6), pseudoachondroplasia (n=5), idiopathic genu valgum/varum (n=5), hypoplasia (n=3), osteomyelitis with growth arrest (n=3), DDH (n=2), rickets (n=2), Blount disease (n=2), Ollier disease (n=1), Perthes disease (n=1), arthrogryposis (n=1), hypochondroplasia (n=1) and congenital genu flexum (n=1). Post-traumatic deformities and simple leg-length discrepancies were excluded. The majority of the patients (26/41) presented with multi-planar deformities with the following average degrees: varus 22°, valgus 21°, internal rotation 36°, external rotation 42°, antecurvatum 20° and recurvatum 15°. The average leg-length discrepancy was 6 cm (range 2–10 cm). In total, 66 segments (30 femurs and 36 tibias) in 50 limbs were treated. The rotational corrections were performed at a rate of 4 mm/day; the angular corrections at the rate of 1.5 mm/day on the concave side and 0.75 mm/day on the convex side. The rotational correction occurred on the regenerate. The average correction time was 44 days, the healing time 86 days.The results were: excellent (correct mechanical axis, normal ROM and no limping) in 14 cases, good (correct mechanical axis, limping and reduced ROM) in 24 cases, fair (residual deformity, limping and joint contracture) in three cases, poor (residual deformity, limping and rigid joints) in none. The complications were: five pin tract infections and three fractures.

Maintenance of the bone stock is a primary goal in hip surgery. The idea of a resurfacing hip prosthesis had already been proposed in the past without success. The improvement in prosthetic materials, however, has mades it possible to reconsider the use of resurfacing prostheses. We report our experience with the Birmingham hip resurfacing (BHR) prosthesis.

We operated on 58 patients (60 hips, two bilaterally), 31 men, 27 women, with a mean age of 47.9 years (25–76) and a mean follow-up of 27 months (1–42). We used the posterolateral approach with the patient in lateral decubitus. We performed a clinical and radiographic examination before surgery and at 1 and 6 months postoperatively. We recorded a statistically significant improvement in the clinical score at 6 months after surgery, with respect to the preoperative examination. Major complications were two fractures of the femoral neck and one infection. We recorded also peri-prosthetic calcifications in two patients, calcifications of the ileopsoas in two and ileopsoas tendinitis in one.

In conclusion, in our experience, the BHR prosthesis reproduced the biomechanics of the hip and minimised the risk of luxation. The preliminary clinical results are encouraging, also for difficult cases.

Nowadays it is well known that both a clinical examination and an imaging investigation (MRI/CT scans) are useful in order to provide surgeons with complete informations about the proposed treatment for shoulder pain. The purpose of this study was to evaluate the diagnostic sensitivity of the Neer, Hawkins, Jobe, Lift-off and Infraspinatus tests in diagnosing rotator cuff tears and compare this with what was found during surgery.

From 2001 to 2003, data from 430 patients who underwent shoulder open surgery, performed by a single surgeon, were documented. The results showed that the Jobe test has a sensitivity of 97.5% and positive prognostic value (PPV) of 80.3% and negative prognostic value (NPV) of 90.9% for the presence of a supraspinatus lesion; the Neer, Hawkins and Yokum tests have a sensitivity close to 95% for assessing subacromial bursitis; the Lift-off and Infraspinatus tests have a sensitivity close to 70% for assessing the degree of lesion and identify a severe lesion with a NPV over 83%. The Lift-off and Infraspinatus tests also provide information concerning muscular trophism and concerning retraction and degeneration of tendons.

According to our results, clinical evaluation of shoulder pain should be supported by imaging investigations for diagnosis of rotator cuff tear.

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.