Introduction: There is an increasing tendency for internal fixation of proximal metaphyseal fractures. Intra-medullary nailing only recently has been considered to be a valuable option in these cases. Through the development of new reliable implant types, nailing finds increasing acceptance.

Questions: Is intramedually nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures and is it combined with a good outcome?

Material and methods: A prospective international mul-ticenter study with standardized study control focused on the “Proximal Humeral Nail (PHN–Synthes Inc.), possible complications and clinical outcome. 151 fractures had been treated in 11 hospitals, where 72 were A-type, 67 B-type and 12 C-type (AO). There were 37 male, 114 female patients, median age 66 years ranging from 16 to 97 years. The outcome had been measured through Constant-Morley scores and DASH scores. 108 patients could be followed up until 1 year postoperatively.

Results: Important complications were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), dislocation of fragments (n=2), non union (n=2), humeral head necrosis (n=3) and wound infection (n=1). The Constant-Morley score shows in total mean values one year postoperatively 75.3 in the injured and 89.9 in the non-injured side. The DASH score pre-operatively was in total 5.9 and 9.3 one year postoperatively, where the best results could achieve 0 points, the worst 100 points.

Discussion: Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related the technical failure in performing nailing. Here or the nail has not been introduced profoundly enough or the length for the spiral blade was not determined exactly and probably not controlled intraoperatively. This is due to the individual accuracy of the surgeon. The development of non-union (2/108) shows a ratio equal or even better to what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments n the other side, show the limit of this procedure, where in multifragmentary fracture type one spiral blade will not be able to fix a fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach. Constant score and Dash-score results perform similar to plate osteosynthesis, where clearly C-type-fractures present the worst prognosis.

Conclusion: Proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures. Even in many B-type fractures it is still a good alternative with limited incision to the plate osteosynthesis.

In C-type fractures it is not advisable as a standard routine, only for experienced surgeons it might be a possible solution in selected cases.

Lateral tibial plateau fractures are articular fractures that can have a severe prognosis involving a joint biomechanically and functionally very important.

Osteosynthesis is very often required as the articular surface must be accurately restored.

In many cases rigid devices were implanted, often sacrificing lateral meniscus and leading to osteoarthritic changes in the following years.

In the recent years new diagnostic tools as TC and MRI and the growing role of arthroscopy have allowed a more precise diagnosis and the possible use of less invasive devices.

Considering all fractures classified as B3 according AO (or type 2 by Schatzker), we considered 10 cases treated with Barr screw and 8 cases treated with K-wires positioned as a shelf after reduction and bone grafting.

All patients underwent an accelerated rehabilitation protocol with immediate mobilization and full weight bearing within 10 weeks.

At the follow-up at 24 months, both the groups showed very good and comparable clinical, radiographical and functional results.

We can conclude that after an accurate preoperative planning also the use of less invasive devices allow a quick recovery of range of motion without compromising the stability of osteosynthesis and the morphology of knee joint.

Introduction: In order to improve functional recovery of hip fractures and to optimize the use of resources, all the patients belonging to our district have been enclosed in a specific protocol.

Material and methods: The program provides that all the patients, except contra-indications, have operated by 24 hours. Osteosynthesis or prosthesization techniques have to allow an early and complete weight bearing. At the time of the admission, an informative card is sent to house assistance team of the district. After the operation, patients are examined by a physician, who prescribes the rehabilitation protocol and estimates the possibility of a domiciliary physiotherapy. Discharging from hospital occurs usually between third and fifth day post-op, toward patient home or an intermediate structure. In the first case, the local health district provide the patient with nursing and rehabilitation services. Ambulatory controls follow the specific requirements for each kind of implant.

Results: In the period 1–9/2004 we have recruited 341 subjects aged over 65 years (mean 81,5), males 25,5%, female 74,5%. Type of fracture: femoral neck 58,4%, trochanteric region 41,6%. Surgical treatment: cephalic endoprosthesis 35,2%, arthroprosthesis 8,6%, gamma nail 43,2%, cannulated screws 9,5%, dynamic plaque 0,9%, Ender nails 0.9%, none operation 2,4%. Type of hospital discharging: previous residence 69,5%, rehabilitation structures 26,2%, intensive care unit 3%, death 0.6%, other 0,6%. Waiting time before surgery: 2,7 days. Reasons of an extended waiting are anti-coagulation therapies and hospital admission during week end. Mean time of hospitalisation: 12,1 days. Main cause of an extended time of hospitalisation is relative absence. A phone follow-up at 6 months points out that 33,3% of patients doesnt go out of home or is completely unfit, while before only 7,8%. Pain is absent or modest/tolerable in 93% of cases. Comparing to previous sample of patients (2002), we observed a reduction of the pre-surgical time (2 days), of the total hospital time (3 days) and an improvement of the final performance.

Discussion and conclusions: Modern surgical and anaesthesiological techniques reduce peri-surgical death rate to very low level. Then an aggressive, integrated treatment of patients with hip fractures allows to improve functional performance, backing to normal social life, and besides to reduce costs.

Aims: The purpose of our review is to evaluate results of surgical treatment in bone metastases and to relate the surgical indications to these results. Methods: 297 patients operated between 1980 and 1998 were reviewed. Main age of the patients was 60.9 (18–86). The involved bones were femur (169cases), humerus (77), spine (33), tibia (8), pelvis (4), cubitus (2)others (4). The primary tumours (of 215 reviewed diagnosis) were breast (80cases), lung (31), myeloma (21), kidney (18), intestine (8), thyroid (7), prostate (6), uterus (6), pharynx (4), sarcoma (4), bladder (2), liver (2), others (4), well differentiated unknown origin (14), undifferentiated (8). The operations performed were nailing (86cases), interlocked-nailing (59), prosthesis (58), spinal osteosynthesis (34), plating+cement (25) nailing+cement (17), resection (10), resection+cement (6), amputation (2). Minimal conditions for surgery were life expectancy of at least 60 days, possibility of a solid implant and acceptable blood parameters (wbc> 2,000, plt> 30,000). Most of the patients underwent postoperative radiotherapy. Results: The Karnofsky index at sixty days showed a mean improvement of 30pts% using nails and prosthesis, and 10pts% with plating+cement (performed in patients in better general conditions). After surgery, all of the patients reached a score over 70pts% and in every case pain was sensibly reduced. There were 3 perioperative deaths (1%) and 10 major complications (3.4%). Conclusions: An operation performed after an accurate planning leads to an improvement in the quality of life and self-sufþciency of these patients, thereby reducing the cost of care. The choice of technique must allow to obtain a quick result (no bone grafting) and a fast functional improvement, considering the limited life expectancy of the patients.