Our purpose was to study the functional outcome and electrophysiologically to assess the axially nerve function in patients who have undergone surgery using a deltoid-splitting approach to treat complex proximal humeral fractures. This was a prospective observational study and was carried out in the Shoulder injury clinic at a university teaching hospital. Over a one-year period we treated fourteen locally-resident patients (median age 59 years) who presented with a three- or four-part proximal humeral fracture. All patients were treated using the extended deltoid-splitting approach, with open reduction, bone grafting and plate osteosynthesis. All patients were prospectively reviewed and underwent functional testing using the DASH, Constant and SF-36 scores as well as spring balance testing of deltoid power, and dynamic muscle function testing. At one year after surgery, all patients underwent EMG and nerve latency studies to assess axillary nerve function. Thirteen of the fourteen patients united their fractures without complications, and had DASH and Constant score that were good, with comparatively minor residual deficits on assessment of muscle power. Of these thirteen patients, only one had evidence of slight neurogenic change in the anterior deltoid. This patient had no evidence of anterior deltoid paralysis and her functional scores, spring balance and dynamic muscle function test results were indistinguishable from the patients with normal electrophysiological findings. One of the fourteen patients developed osteonecrosis of the humeral head nine months after surgery and had poor functional scores, without evidence of nerve injury on electrophysiological testing. Reconstruction through an extended deltoid-splitting approach provides a useful alternative in the treatment of complex proximal humeral fractures. The approach provides good access for reduction and implant placement and does not appear to be associated with clinically-significant adverse effects

Optimal surgical management of proximal humeral fractures remains controversial. We report our experience and the study on our surgical technique for proximal humeral fractures and fracture-dislocations using locking plates in conjunction with calcium sulphate augmentation and tuberosity repair using high strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. We retrospectively analysed 22 proximal humeral fractures in 21 patients. 10 were male and 11 female with an average age of 64.6 years (Range 37 to 77). Average follow-up was 24 months. Fractures were classified according to Neer and Hertel systems. Pre-operative radiographs and CT scans in three and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were 5 two-part, 6 three-part, 5 four-part fractures and 6 fracture-dislocations (2 anterior and 4 posterior). Results were assessed clinically with DASH scores, modified Constant & Murley scores and serial post-operative radiographs. The mean DASH score was 16.18 and modified Constant & Murley score was 64.04 at the last follow-up. 18 out of 22 cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients

Background. Periacetabular osteotomy (PAO) is an effective treatment method for early or mild osteoarthritis caused by developmental dysplasia of the hip. Since the procedure is performed from late eighties of the past century it is still a very demanding procedure performed only by high skilled surgeons in high volume orthopaedic centres. The idea was to develop a custom-made surgical tool to improve the accuracy of the two osteotomies of the iliac bone and help us to avoid inadvertent intraarticular osteotomy of the acetabulum. Methods. Firstly CT scans of pelvises of two cadavers were performed. The DICOM format files were up-loaded into EBS software (Ekliptik d.o.o., Ljubljana, Slovenia), application for preoperative planning, constructing and designing different templates, where the three-dimensional (3D) model of each pelvis was created. On the virtual pelvis models the PAO lines on each of four acetabuls were placed and virtual PAOs were performed [Fig. 1]. For the execution of the two iliac bone osteotomies the osteotome or saw guiding jigs were virtually created and exported in STL format in ProJet 3500 HDPlus printer which created custom made jigs made from VisiJet Crystal biocompatible plastic material (3D systems, Rock Hill, South Carolina, USA) for each of the four acetabula. The next step was the surgery on aforementioned cadavers. Extended Smith-Petrson approach was performed on each of four cadaveric hips and Bernese PAOs were performed using custom-made jigs. After performing the acetabular correction the cadavers were carefully dissected to study any possible posterior column damage or damage of the acetabular wall. None of them were damaged and the osteotomies were performed according to the virtual plan. Next step was the real procedure on 47-years old female patient with bilateral acetabular dysplasia. The procedure was executed on right side using the extended Smith-Peterson approach. Preoperatively native X-ray of both hips and the CT scan of pelvis were performed. According the CT scan (DICOM format) the virtual 3D model of the pelvis was created and virtual osteotomy lines were decided and production of the appropriate jig was manufactured in the same manner as for the cadavers [Fig. 2]. Preoperative and postoperative centre-edge (CE) angles were measured. Results. Preoperatively the patient had a Tönnis grade I osteoarthritis of the right hip. The preoperative CE angle was 19.1° and the postoperative CE angle is 36.7° [Fig. 3] which indicates good improvement in coverage of the femoral head. Patient had an uneventful postoperative course, with no neuro-vascular damage. The intraoperative blood loss was 250 ml and the patient was discharged from hospital on seventh postoperative day, walking with crutches loading 15 kg. Conclusion. Custom-made jig for iliac bone osteotomy in PAO procedures is a helpful tool, which improves accuracy of the osteotomy lines, safety of the patient and considerably reduces surgical time. We are planning to create also jigs for screw placement and the device to verify intraoperatively the level of PAO correction