Aims. Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal
Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal
The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy.Aims
Methods
The aim of this study was to examine the implant accuracy of custom-made partial pelvis replacements (PPRs) in revision total hip arthroplasty (rTHA). Custom-made implants offer an option to achieve a reconstruction in cases with severe acetabular bone loss. By analyzing implant deviation in CT and radiograph imaging and correlating early clinical complications, we aimed to optimize the usage of custom-made implants. A consecutive series of 45 (2014 to 2019) PPRs for Paprosky III defects at rTHA were analyzed comparing the preoperative planning CT scans used to manufacture the implants with postoperative CT scans and radiographs. The anteversion (AV), inclination (IC), deviation from the preoperatively planned implant position, and deviation of the centre of rotation (COR) were explored. Early postoperative complications were recorded, and factors for malpositioning were sought. The mean follow-up was 30 months (SD 19; 6 to 74), with four patients lost to follow-up.Aims
Methods
The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH). This retrospective study reviewed patients undergoing guided growth or varus osteotomy for Kalamchi type II AVN between September 2009 and January 2019. All children who had undergone open reduction and Pemberton acetabuloplasty for DDH with a minimum two-year follow-up were enrolled in the study. Demographic and radiological data, which included the head-shaft angle (HSA), neck-shaft angle (NSA), articulotrochanteric distance (ATD), Sharp angle (SA), and lateral centre-edge angle (LCEA) at baseline, two years, and at the extended follow-up, were compared. Revision rates were evaluated. Clinical outcomes using the Harris Hip Score were assessed two years postoperatively.Aims
Methods
We compared the results of the surgical treatment of trochanteric hip fractures before and after surgeons had been introduced to the tip-apex distance (TAD) as a method of evaluating
The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error. We retrospectively identified all proximal humeral fractures treated in our institution between October 2016 and October 2018 using the hospital information system. The patients’ medical and radiological data were collected, and we divided potential risk factors into two groups: preoperative factors and intraoperative factors. Preoperative factors included age, sex, height, weight, body mass index, proximal humeral bone mineral density, type of fracture, the condition of the medial hinge, and medial metaphyseal head extension. Intraoperative factors included the grade of surgeon, neck-shaft angle after reduction, humeral head height, restoration of medial support, and quality of reduction. Adjusted binary logistic regression and multivariate logistic regression models were used to identify pre- and intraoperative risk factors. Area under the curve (AUC) analysis was used to evaluate the discriminative ability of the multivariable model.Aims
Methods
To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS). We carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included.Aims
Methods
Eight-plates are used to correct varus-valgus deformity (VVD) or limb-length discrepancy (LLD) in children and adolescents. It was reported that these implants might create a bony deformity within the knee joint by change of the roof angle (RA) after epiphysiodesis of the proximal tibia following a radiological assessment limited to anteroposterior (AP) radiographs. The aim of this study was to analyze the RA, complemented with lateral knee radiographs, with focus on the tibial slope (TS) and the degree of deformity correction. A retrospective, single-centre study was conducted. The treatment group (n = 64 knees in 44 patients) was subclassified according to the implant location in two groups: 1) medial hemiepiphysiodesis; and 2) lateral hemiepiphysiodesis. A third control group consisted of 25 untreated knees. The limb axes and RA were measured on long standing AP leg radiographs. Lateral radiographs of 40 knees were available for TS analysis. The mean age of the patients was 10.6 years (4 to 15) in the treatment group and 8.4 years (4 to 14) in the control group. Implants were removed after a mean 1.2 years (0.5 to 3).Aims
Methods
With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article:
The clinical diagnosis of a partial tear of the
anterior cruciate ligament (ACL) is still subject to debate. Little
is known about the contribution of each ACL bundle during the Lachman
test. We investigated this using six fresh-frozen cadaveric lower
limbs. Screws were placed in the femora and tibiae as fixed landmarks
for digitisation of the bone positions. The femur was secured horizontally
in a clamp. A metal hook was screwed to the tibial tubercle and
used to apply a load of 150 N directed anteroposteriorly to the
tibia to simulate the Lachman test. The knees then received constant
axial compression and 3D knee kinematic data were collected by digitising
the
We aimed to retrospectively assess the accuracy and safety of
CT navigated pedicle screws and to compare accuracy in the cervical
and thoracic spine (C2-T8) with (COMB) and without (POST) prior
anterior surgery (anterior cervical discectomy or corpectomy and
fusion with ventral plating: ACDF/ACCF). A total of 592 pedicle screws, which were used in 107 consecutively
operated patients (210 COMB, 382 POST), were analysed. The accuracy
of positioning was determined according to the classification of
Gertzbein and Robbins on post-operative CT scans.Aims
Patients and Methods
Arthroscopically controlled fracture reduction in combination
with percutaneous screw fixation may be an alternative approach
to open surgery to treat talar neck fractures. The purpose of this
study was thus to present preliminary results on arthroscopically
reduced talar neck fractures. A total of seven consecutive patients (four women and three men,
mean age 39 years (19 to 61)) underwent attempted surgical treatment
of a closed Hawkins type II talar neck fracture using arthroscopically
assisted reduction and percutaneous screw fixation. Functional and
radiological outcome were assessed using plain radiographs, as well
as weight-bearing and non-weight-bearing CT scans as tolerated.
Patient satisfaction and pain sensation were also recorded.Aims
Patients and Methods
Computer hexapod assisted orthopaedic surgery (CHAOS), is a method
to achieve the intra-operative correction of long bone deformities
using a hexapod external fixator before definitive internal fixation
with minimally invasive stabilisation techniques. The aims of this study were to determine the reliability of this
method in a consecutive case series of patients undergoing femoral
deformity correction, with a minimum six-month follow-up, to assess
the complications and to define the ideal group of patients for
whom this treatment is appropriate. The medical records and radiographs of all patients who underwent
CHAOS for femoral deformity at our institution between 2005 and
2011 were retrospectively reviewed. Records were available for all
55 consecutive procedures undertaken in 49 patients with a mean
age of 35.6 years (10.9 to 75.3) at the time of surgery.Aims
Patients and Methods
The purpose of this study was to identify factors
that predict implant cut-out after cephalomedullary nailing of intertrochanteric
and subtrochanteric hip fractures, and to test the significance
of calcar referenced tip-apex distance (CalTAD) as a predictor for
cut-out. We retrospectively reviewed 170 consecutive fractures that had
undergone cephalomedullary nailing. Of these, 77 met the inclusion
criteria of a non-pathological fracture with a minimum of 80 days
radiological follow-up (mean 408 days; 81 days to 4.9 years). The
overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex
distance (TAD) (p <
0.001), CalTAD (p = 0.001), cervical angle
difference (p = 0.004), and lag screw placement in the anteroposterior
(AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters
were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507),
fracture type (AO classification) (p = 0.381), Singh Osteoporosis
Index (p = 0.575), lag screw placement in the lateral view (p =
0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575).
In the multivariate analysis, CalTAD was the only significant measurement
(p = 0.001). CalTAD had almost perfect inter-observer reliability
(interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD
is a predictor of cut-out. The finding of CalTAD as the only significant
parameter in the multivariate analysis, along with the univariate
significance of Parker’s ratio index in the AP view, suggest that
inferior placement of the lag screw is preferable to reduce the
rate of cut-out. Cite this article:
A variety of operative techniques have been described as under
the term ‘Bristow-Latarjet’ procedure. This review aims to define
the original procedure, and compare the variation in techniques
described in the literature, assessing any effect on clinical outcomes. A systematic review of 24 studies was performed to compare specific
steps of the technique (coracoid osteotomy site, subscapularis approach,
orientation and position of coracoid graft fixation and fixation
method, additional labral and capsular repair) and detect any effect
this variability had on outcomes.Objectives
Materials and Methods
We have investigated the benefits of patient
specific instrument guides, applied to osteotomies around the knee. Single,
dual and triple planar osteotomies were performed on tibias or femurs
in 14 subjects. In all patients, a detailed pre-operative plan was
prepared based upon full leg standing radiographic and CT scan information.
The planned level of the osteotomy and open wedge resection was
relayed to the surgery by virtue of a patient specific guide developed
from the images. The mean deviation between the planned wedge angle
and the executed wedge angle was 0° (-1 to 1, Cite this article:
Penetration of the dorsal screw when treating
distal radius fractures with volar locking plates is an avoidable complication
that causes lesions of the extensor tendon in between 2% and 6%
of patients. We examined axial fluoroscopic views of the distal
end of the radius to observe small amounts of dorsal screw penetration,
and determined the ideal angle of inclination of the x-ray beam
to the forearm when making this radiological view. Six volar locking plates were inserted at the wrists of cadavers.
The actual screw length was measured under direct vision through
a dorsal approach to the distal radius. Axial radiographs were performed
for different angles of inclination of the forearm at the elbow. Comparing axial radiological measurements and real screw length,
a statistically significant correlation could be demonstrated at
an angle of inclination between 5° and 20°. The ideal angle of inclination
required to minimise the risk of implanting over-long screws in
a dorsal horizon radiological view is 15°. Cite this article:
The Gamma nail is frequently used in unstable
peri-trochanteric hip fractures. We hypothesised that mechanical failure
of the Gamma nail was associated with inadequate proximal three-point
fixation. We identified a consecutive series of 299 Gamma nails
implanted in 299 patients over a five-year period, 223 of whom fulfilled
our inclusion criteria for investigation. The series included 61
men and 162 women with a mean age of 81 years (20 to 101). Their fractures
were classified according to the Modified Evans’ classification
and the quality of fracture reduction was graded. The technical
adequacy of three points of proximal fixation was recorded from
intra-operative fluoroscopic images, and technical inadequacy for
each point was defined. All patients were followed to final follow-up
and mechanical failures were identified. A multivariate statistical
analysis was performed, adjusting for confounders. A total of 16
failures (7.2%) were identified. The position of the lag screw relative
to the lateral cortex was the most important point of proximal fixation,
and when inadequate the failure rate was 25.8% (eight of 31: odds
ratio 7.5 (95% confidence interval 2.5 to 22.7), p <
0.001). Mechanical failure of the Gamma nail in peri-trochanteric femoral
fractures is rare (<
1%) when three-point proximal fixation is
achieved. However, when proximal fixation is inadequate, failure
rates increase. The strongest predictor of failure is positioning
the lateral end of the lag screw short of the lateral cortex. Adherence
to simple technical points minimises the risk of fixation failure
in this vulnerable patient group. Cite this article:
Coronal plane fractures of the posterior femoral
condyle, also known as Hoffa fractures, are rare. Lateral fractures are
three times more common than medial fractures, although the reason
for this is not clear. The exact mechanism of injury is likely to
be a vertical shear force on the posterior femoral condyle with
varying degrees of knee flexion. These fractures are commonly associated
with high-energy trauma and are a diagnostic and surgical challenge. Hoffa
fractures are often associated with inter- or supracondylar distal
femoral fractures and CT scans are useful in delineating the coronal
shear component, which can easily be missed. There are few recommendations
in the literature regarding the surgical approach and methods of
fixation that may be used for this injury. Non-operative treatment
has been associated with poor outcomes. The goals of treatment are
anatomical reduction of the articular surface with rigid, stable
fixation to allow early mobilisation in order to restore function.
A surgical approach that allows access to the posterior aspect of
the femoral condyle is described and the use of postero-anterior
lag screws with or without an additional buttress plate for fixation
of these difficult fractures. Cite this article:
Acetabular bone loss is a challenging problem
facing the revision total hip replacement surgeon. Reconstruction
of the acetabulum depends on the presence of anterosuperior and
posteroinferior pelvic column support for component fixation and
stability. The Paprosky classification is most commonly used when
determining the location and degree of acetabular bone loss. Augments
serve the function of either providing primary construct stability
or supplementary fixation. When a pelvic discontinuity is encountered we advocate the use
of an acetabular distraction technique with a jumbo cup and modular
porous metal acetabular augments for the treatment of severe acetabular
bone loss and associated chronic pelvic discontinuity. Cite this article:
We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.
We reviewed 212 consecutive patients with adolescent
idiopathic scoliosis who underwent posterior spinal arthrodesis
using all pedicle screw instrumentation in terms of clinical, radiological
and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51
patients), the correction was performed over two rods using bilateral
segmental pedicle screws. In Group 2 (161 patients), the correction
was performed over one rod using unilateral segmental pedicle screws
with the second rod providing stability of the construct
through two-level screw fixation at proximal and distal ends. The
mean age at surgery was
14.8 years in both groups. Comparison between groups showed no significant
differences with regard to age and Risser grade at surgery, pre-
and post-operative scoliosis angle, coronal Cobb correction, length
of hospital stay and SRS scores. Correction of upper thoracic curves
was significantly better in Group 1 (p = 0.02). Increased surgical time
and intra-operative blood loss was recorded in Group 1 (p <
0.001
and p = 0.04, respectively). The implant cost was reduced by mean
35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved
excellent deformity correction in adolescent patients with idiopathic
scoliosis, which was maintained at two-year follow-up. This has
been associated with high patient satisfaction and low complication
rates.
We report the results of 62 hips in 62 patients
(17 males, 45 females) with mean age of 62.4 years (37 to 81), who underwent
revision of the acetabular component of a total hip replacement
due to aseptic loosening between May 2003 and November 2007. All
hips had a Paprosky type IIIa acetabular defect. Acetabular revision
was undertaken using a Procotyl E cementless oblong implant with
modular side plates and a hook combined with impaction allografting. At a mean follow-up of 60.5 months (36 to 94) with no patients
lost to follow-up and one died due to unrelated illness, the complication
rate was 38.7%. Complications included aseptic loosening (19 hips),
deep infection (3 hips), broken hook and side plate (one hip) and
a femoral nerve palsy (one hip). Further revision of the acetabular component
was required in 18 hips (29.0%) and a further four hips (6.4%) are
currently loose and awaiting revision. We observed unacceptably high rates of complication and failure
in our group of patients and cannot recommend this implant or technique.
Percutaneous epiphysiodesis using transphyseal
screws (PETS) has been developed for the treatment of lower limb discrepancies
with the aim of replacing traditional open procedures. The goal
of this study was to evaluate its efficacy and safety at skeletal
maturity. A total of 45 consecutive patients with a mean skeletal
age of 12.7 years (8.5 to 15) were included and followed until maturity.
The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%)
at six months and 66% (21% to 100%) at maturity. The mean efficacy
of the tibial epiphysiodesis was 46% (18% to 73%) at six months
and 66% (25% to 100%) at maturity. In both groups of patients the
under-correction was significantly reduced between six months post-operatively
and skeletal maturity. The overall rate of revision was 18% (eight
patients), and seven of these revisions (87.5%) involved the tibia.
This series showed that use of the PETS technique in the femur was
safe, but that its use in the tibia was associated with a significant
rate of complications, including a valgus deformity in nine patients
(20%), leading us to abandon it in the tibia. The arrest of growth
was delayed and the final loss of growth at maturity was only 66%
of that predicted pre-operatively. This should be taken into account
in the pre-operative planning.
We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed. At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.
Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing.
Different calcaneal plates with locked screws were compared in an experimental model of a calcaneal fracture. Four plate models were tested, three with uniaxially-locked screws (Synthes, Newdeal, Darco), and one with polyaxially-locked screws (90° ± 15°) (Rimbus). Synthetic calcanei were osteotomised to create a fracture model and then fixed with the plates and screws. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1000 cycles at 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). During cyclic loading, the plate with polyaxially-locked screws (Rimbus) showed significantly lower displacement in the primary loading direction than the plates with uniaxially-locked screws (mean values of maximum displacement during cyclic loading: Rimbus, 3.13 mm ( The increased stability of a plate with polyaxially-locked screws demonstrated during cyclic loading compared with plates with uniaxially-locked screws may be beneficial for clinical use.
With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.
We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D). The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p <
0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5Dindexscore) was significant in both groups compared with that before the fracture (p <
0.005). Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures. The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.
We describe our early operative experience with a new pelvic reduction frame and the standard of reduction of fractures of the pelvic ring which we achieved in the first 35 consecutive patients, with 34 acute fractures and one nonunion. The pre-operative and immediate post-operative radiographs were measured, using two methods, to find the maximum radiological displacement of the fracture and the quality of the reduction according to the criteria of Tornetta and Matta. There were 19 vertical shear fractures and 16 compression injuries. The mean age of the patients was 33.5 years (10 to 59) and mean delay to surgery was 4.6 days (0 to 16) in the 34 acute injuries. The mean operative time in isolated procedures was 103.4 minutes ( The frame was shown to be effective, allowing the surgeon to obtain a satisfactory reduction and fixation of acute displaced disruptions of the pelvic ring.
The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group. We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.