Multiple myeloma may be associated with extensive bone destruction, impending or present pathological fracture, and intractable pain. Chemotherapy and radiotherapy are usually effective, but surgical intervention may sometimes be required.

We analyzed the surgical technique and the functional and oncological outcomes of patients with multiple myeloma who underwent surgery in our services between 1993-2004.

There were 19 males and 15 females (age range 49– 75 years) who had destructive bone lesions located at the humerus (n=17), acetabulum (n=5), femur (n=5), or tibia (n=7). Indications for surgery included pathological fracture (n=20), impending pathological fracture (n=11), and intractable pain (n=3). Nineteen patients underwent marginal tumor resection, reconstruction with cemented hardware, and adjuvant radiation therapy and 15 patients underwent wide tumor resection with endoprosthetic reconstruction. All patients reported immediate and substantial postoperative pain relief. Function was good/excellent in 23 patients (68%), moderate in eight (23%), and poor in three (9%). Two patients (5.9%) had local tumor recurrence treated with local excision and adjuvant radiotherapy, with no evidence of further recurrence at 21 and 26 months, respectively. Thirty one (91%) patients survived > 1 year, 23 (68%) > 2 years, and 15 (44%) > 3 years postoperatively. All reconstructions remained stable at the most recent follow-ups.

The relatively prolonged survival of patients with multiple myeloma justifies an aggressive surgical approach, which is safe and associated with good local tumor control and functional outcome.

Introduction: Three and four part fractures and fracture dislocations of the proximal humerus (Neer classification) presents a technical challenge for the shoulder surgeon. The high rate of excellent and good results of shoulder hemiarthroplasty reported by Charles Neer in the past was never again achieved by other surgeons in Israel and aboard. Up to day no satiafactory method of surgical treatment was for this group of fractures.

Purpose: The intention of this study is to demonstrate that the nonsurgical conservative management of complex proximal humeral fractures gives as good results as the surgical methods if not better.

Clinical Material and Methods: Between January 1, 2003 and December 31, 2003 fifty patients with three and four part fractures and fracture dislocations of the proximal humerus was treated in our outpatient facility. 25 patients were randomly selected for nonsurgical and 25 patients for surgical treatment. Three distinct groups were separated. The first group, selected for nonsurgical management, consisted of 19 female and 6 male patients with an average age of 66 years. The second group consisted of 9 females and 3 male patients treated by closed reduction and external fixation (CREF) or by open reduction and external fixation (OREF) with an average age of 67 years. The third group consisted of 10 females and 3 males treated by shoulder hemiarthroplasty with an average age of 70 years. Constant functional assessment score with “the limited goals” correction was used to evaluate the results.

Results: No significant differences were seen among the first and second group. Slightly better results were observed at the patients treated by external fixation means, but not statistically significant. The results of the hemiartroplasty group were found worse than the two previous groups, with statistically significant differences. It is interesting to mention that in the last group a better external rotation was seen in association with significantly worse abduction and forward elevation than in the first two groups.

Conclusion: Three and four part fractures and fracture dislocations of the proximal humerus are better managed by preserving the original head of the bone, even with gross deformity, than treated by hemiarthroplasty. Conducted by the results of this study we recommend to manage complex fractures of the proximal humerus by conservative methods or as needed by minimal invasive techniques (CREF or OREF).