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BACKGROUND: Proximal humeral fractures with severe comminution and poor bone quality are among the most common injuries in the elderly population. Reverse shoulder arthroplasty (RSA) has been widely used to manage complex three- and four-part humeral head fractures. The purpose of the present study was to report the result of this technique in the demanding population of octogenarians. MATERIALS AND METHODS:  Twenty-six patients above the age of 80 years were included in the study and followed for a minimum of one-year follow-up. To assess the functional outcomes the postoperative range of motion (ROM), the Constant score, the visual analog scale for pain, and the disability of the arm and shoulder score (DASH) were measured at 6 and 12 months. Radiological assessment and potential complications were also recorded. RESULTS: The mean age of the study population was 81.9 years (81-86) at the time of surgery. There was a statistically significant improvement in all outcomes over the follow-up intervals. Shoulder ROM was 125.7o for flexion, 98.2o for abduction, 42.2o for internal rotation, and 43.2o for external rotation at 12 months. The mean Constant, DASH, and VAS scores at the last follow-up were 61.3, 31.9, and 0.5, respectively. Reported complications include one superficial surgical site infection. CONCLUSION: RSA is a safe and reliable surgical option with satisfactory outcomes to manage complex three- and four-part fractures of the humeral head as it can provide prompt pain relief and function in octogenarians.

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The condition combining a dislocated humeral head fracture and an ipsilateral humeral shaft fracture is seen to be rare in literature, which is limited to case report or case series. Furthermore, effective management of these coexistent injuries is still a subject of debate. The essential purpose of this article is to report another treatment method for this condition. We present a case of a 79-year-old female patient who suffered a three-part humeral head fracture-dislocation associated with the ipsilateral humeral shaft fracture. The combined injuries were managed by minimal invasive plate osteosynthesis (MIPO) through the deltopectoral approach with the eventual result of bone healing and good function after thirty-three months of follow-up. In conclusion, MIPO should be considered a safe and effective option, however, the risk of traumatic osteonecrosis of the humeral head is taken into account before operation decision-making.

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BACKGROUND: Posterior shoulder dislocation is an uncommon orthopaedics injury and is frequently missed or misdiagnosed, accounting for 2%-4% of all shoulder dislocations, and is associated with the reverse Hill-Sachs lesion. Once posterior shoulder dislocation develops into a chronic disease, it will bring a lot of trouble to the treatment, especially in repairing the humeral defects. Surgical strategies are also developing and innovating to deal with this injury, including transfer of subscapularis tendon or lesser tubercle, humeral rotational osteotomy, autogenous bone graft or allograft. Shoulder replacement seems to be the ultimate and only option when the injury becomes irreparable, although some studies have shown unsatisfactory follow-up results. Considering no gold-standard treatment for locked posterior shoulder dislocation, we described a novel modified McLaughlin procedure for locked chronic posterior shoulder dislocation and evaluated the functional outcomes. METHODS: This study included five locked chronic posterior shoulder dislocation patients with an associated reverse Hill-Sachs lesion, in which the compression surface covered 30-40% of the humeral head. The mean period from injury to receiving surgery was 11.6 weeks (6-24 weeks). All five patients underwent the modified McLaughlin procedure, mainly divided into three steps, including open reduction, transfer of the partial lesser tuberosity and artificial bone to repair the reverse Hill-Sachs defects. The kernel technique was to fix the transferred tuberosity with two lag screws and strengthen it with two Ethibond sutures. The Constant-Murley score (CMS), the range of shoulder motion and the complications were recorded to assess and compare the functional situation of the shoulder postoperatively and postoperatively. RESULTS: After an average of 19.8 months (12-30) of follow-up, the mean CMS improved to 85.8 ± 4.9 (79-91) compared with 46.0 ± 4.5 (40-52) preoperatively, which showed a significant difference (p = 0.001). In the final follow-up, all five patients showed no symptoms of shoulder instability, and there was no pain or limited activity in daily life, thus all patients were satisfied with the results. CONCLUSION: Repairing the reverse Hill-Sachs lesion by transferring the partial lesser tuberosity combined with artificial bone fixed by lag screws and sutures can ensure shoulder stability and provide pain relief and good function in patients with locked chronic posterior shoulder dislocation associated with the humeral head defect.

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BACKGROUND: Mini open reduction and percutaneous fixation of three-part humeral head fracture with blocked threaded wires has demonstrated functional results similar to locking plates or intramedullary nails but with significantly lower major complication rate. In the context of three-part humeral head fractures, we performed a parametric optimization through a finite element analysis of a recently published construct to verify if the encouraging clinical results can be supported by a more rigorous investigation from a mechanical viewpoint. MATERIALS AND METHODS: The 2-dimensional geometry of a three-part proximal humerus fracture synthetized with a system of blocked threaded wires was created. Tension/bending/shear and compression load tests were simulated. A parametric optimization analysis was performed considering four design parameters (height of wire couples; wire material; interdistance between two wires). Eighteen simulations were carried out. Additional analyses were performed also considering a varying diameter of the external rod. RESULTS: Four points where the largest gap occurs and three points associated with the highest stress concentration were considered. As per the tension/bending/shear loading, a slight gap increase was observed in two different points (8.494 µm; 7.540 µm), while a slight decrease was detected along the greater tuberosity fracture line (1.445 µm). The maximum von Mises stress up to 64.4 MPa was achieved in the humeral head. As per the compression loading, the gap increased along the greater tuberosity fracture line (1.445 µm; 7.545µm); the maximum von Mises stress attains the value of 64.42 MPa. The smallest gap distance (15.37µm) and the lowest von Mises stress (51.51 MPa) were obtained in two different alternative constructs. The diameter of the external rod had no significant effect. CONCLUSIONS: The studied construct is biomechanically valid; it only allows micromovements (one-thousandth of the characteristic humerus size) that are not able to cause humeral head rotation and translation. Furthermore, the construct generates acceptable pressure stresses on sensible areas of the fractured humeral head. Compared to the original construct, we propose to space the pair of horizontal wires for the great tuberosity by at least 1 cm.

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It is assumed that dorsocranial displacement of the greater tuberosity in humeral head fractures is caused by rotator cuff traction. The purpose of this study was to investigate the association between rotator cuff status and displacement characteristics of the greater tuberosity in four-part humeral head fractures. Computed tomography scans of 121 patients with Neer type 4 fractures were analyzed. Fatty infiltration of the supra- and infraspinatus muscles was classified according to Goutallier. Position determination of the greater tuberosity fragment was performed in both coronary and axial planes to assess the extent of dorsocranial displacement. Considering non-varus displaced fractures, the extent of the dorsocranial displacement was significantly higher in patients with mostly inconspicuous posterosuperior rotator cuff status compared to advanced fatty degenerated cuffs (cranial displacement: Goutallier 0-1: 6.4 mm ± 4.6 mm vs. Goutallier 2-4: 4.2 mm ± 3.5 mm, p = 0.020; dorsal displacement: Goutallier 0-1: 28.4° ± 32.3° vs. Goutallier 2-4: 13.1° ± 16.1°, p = 0.010). In varus displaced humeral head fractures, no correlation between the displacement of the greater tuberosity and the condition of the posterosuperior rotator cuff could be detected (p ≥ 0.05). The commonly accepted theory of greater tuberosity displacement in humeral head fractures by rotator cuff traction cannot be applied to all fracture types.

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INTRODUCTION: Retained bullets in joint spaces have been shown to cause both mechanical and chemical damage to the joint surfaces, leading to the risk of arthritis if untreated. CASE REPORT: A case of arthroscopic treatment for a gunshot to the shoulder with a retained bullet embedded in the glenoid is presented. The patient presented with multiple gunshots to his back and extremities, including gunshot to the left leg with popliteal vein injury, gunshot to the back with lumbar level laminar fractures and acute spinal cord injury, and gunshot to the left shoulder with a retained bullet in the posterior superior glenoid. CONCLUSION: Shoulder arthroscopy can be successfully employed to retrieve larger embedded bullet or foreign body with the help of tools such as laparoscopic graspers. Even with significant glenoid bone defect, the stability of the shoulder joint does not get compromised if the bone defects are located posterosuperiorly.

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PURPOSE: This study compared the clinical and radiological results of bone marrow mesenchymal stem cell implantation with traditional simple core decompression (CD) using a matched pair case-control design for osteonecrosis of the humeral head (ONHH) after fracture of the proximal humerus. PATIENTS: We retrospectively reviewed 64 patients who had surgery for ONHH. Thirty patients had been treated with cell therapy between 2010 and October 2015, with 18 patients at pre-collapse stage (8 stages-I, 10 stages-II), and 12 patients at post-collapse stages (7 stages-III and 5 stages-IV). Using a matched pair case-control design, these 30 study patients were compared to 34 other patients who were treated with simple core decompression (CD) without cells (control group). METHODS: The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow (BM) concentration. During a mean follow-up duration of 7years (5 to 10years), radiographs performed each year were used to evaluate the radiological results; the Constant score and visual analogue scale were chosen to assess the clinical results. We assessed stage progression, collapse and arthroplasty conversion rate. Survivor rate analysis was performed using these parameters as the primary endpoints. RESULTS: Among the 30 shoulders included in the cell therapy group, three (10%) humeral heads had collapsed at the most recent follow-up, versus 25 (74%) in 34 shoulders after simple core decompression (P<0.0001). As consequence, we observed statistically significant difference (P=0.0001) in the humeral head survival (absence of arthroplasty conversion) rate at the end time point between the cell therapy group (93% survival) and simple core decompression (26% survival). Better results were obtained for early stages (stages I and II) osteonecrosis without collapse at baseline. CONCLUSION: Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.

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PURPOSE: Angular stable implants reduced the complication rate in the treatment of humeral head fractures. But the failure rate is still high. To further reduce the risk of cut-out, cement augmentation of screws was introduced. A reason for failure of plate osteosynthesis might be the extremely high stiffness of the screw-plate interface leading to a loss of reduction and cut-out of screws. A more homogeneous distribution of the forces on all screws may avoid secondary dislocation. We hypothesize that dynamic osteosynthesis minimizes screw loosening and results in a higher load to failure than standard locking screws. METHODS: Twelve paired human humerus specimens were analysed. A standardized three-part fracture model with a metaphyseal defect was simulated. Within each pair of humeri, one was fixed with a Philos plate and standard locking screws (LS), whereas the other humerus was fixed with a Philos plate and dynamic locking screws (DLS). A cyclic varus-bending test or a rotation test with increasing loading force was performed until failure of the screw-bone-fixation. RESULTS: In the varus bending test, pairs failed by screw loosening in the humeral head. The LS-group reached 2901 (601-5201) load cycles until failure, while the DLS-group failed after 3731 (2001-5601) cycles. This corresponds to a median loading of 195 N for the LS-group and 235 N for the DLS-group (p = 0.028). In the rotation test the LS-group reached a median of 1101 (501-1501) load cycles until failure of fixation occurred, while the DLS-group failed after 1401 (401-2201) cycles (p = 0.225). CONCLUSIONS: Plate fixation using dynamic locking screws for the treatment of proximal humerus fractures demonstrated more load cycles until failure compared to standard locking plate osteosynthesis.

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BACKGROUND: Little is known about the screw design as a factor for stability of the bone-implant interface in locking plate fixation of proximal humeral fractures. Aim of the present study was to analyze if locking screws with a large core diameter and a low thread pitch provide increased stability when compared to conventional locking screws. METHODS: 3-Part proximal humeral fractures were created in ten pairs of osteoporotic human cadaveric humeri and fixed with a locking plate. Head fixation was performed with screws with a large core diameter (soft bone screws) in one humerus and with conventional cancellous locking screws in the other humerus of each donor. Specimens were loaded in the varus bending position. Stiffness, failure loads, plate bending and motion at the bone-implant interface were evaluated using mechanical sensors and an optical motion capture system. FINDINGS: The stiffness of the construct for the soft bone screws was 299.8 N/mm (IR, 72.1 N/mm) and 203.9 N/mm (IR, 37.3 N/mm) for the conventional locking screws (p = 0.005). Plate bending did not differ between the two groups. Motion at the bone-implant interface was significantly reduced in the soft bone screw group (p < 0.05). The median load-to-failure was significantly higher in the soft bone screw group (358 N vs. 313 N; p = 0.012). INTERPRETATION: The use of soft bone screws is associated with less motion at the bone-implant interface and therefore greater fixation strength when compared to fixation with conventional locking screws. Clinical studies are needed to prove these biomechanical findings in the in vivo situation. LEVEL OF EVIDENCE: Controlled laboratory study.

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BACKGROUND: Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare. OBJECTIVE: Determination of predictive factors for the failure of osteosynthesis with the loss of fixation or migration of screws in humeral head fractures. METHOD: From 1995 to 2011, 408 patients with proximal humeral fractures [mean age 66.6 years, 50.9-82.3 years] and osteosynthesis were analyzed. Two hundred and three received open reduction internal fixation (ORIF) with the PHILOS® plate. The non-locking plate was used in 80, the locking plate in 16 and humeral head prosthesis in 26 patients, in addition to 23 patients undergoing other procedures. Intraoperative reduction that achieved an anatomical alignment of the medial aspect of the humerus (humeral calcar) was assessed in 94 patients by postoperative X-ray analysis. The loss of fixation was evaluated by a follow-up of three to five X-rays and measurement of the humeral tip-apex-distance (HTAD). RESULTS: For stable fixed fractures with an intact calcar, percentual HTAD was significantly higher than for unstable fixed fractures (p=0.04). Morbidity, such as hypertension, orthopedic operations or diabetes, strongly influenced the HTAD, while postoperative passive motion treatment modestly affected the HTAD over time. CONCLUSION: The anatomic reconstruction of the calcar, leading to stable fixation of humeral head fractures, can significantly prevent an overproportioned decrease in the HTAD in postoperative X-rays and seems to be vital in multimorbid patients. Measurement of the HTAD over time delivers a tool for early detection of secondary loss of fixation.

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INTRODUCTION: Head preserving, delayed osteosynthesis five days after a luxated, multifragmentary humeral head fracture is rarely seen and a challenge for the surgeon. PRESENTATION OF CASE: This case history describes the case of a 69-year-old female with delayed head preserving treatment of a dislocated multifragmentary humeral head fracture using intramedullary nailing, avoiding a primary trauma arthroplasty after strict refusal of the patient despite poor prognosis and high risk of avascular humeral head necrosis. DISCUSSION: The treatment of the humeral head fracture is still a matter of debate, the "golden standard" does not exist, especially in the deferred luxated situation. With the use of modern implants head preserving treatment is reasonable and possible. It should therefore always be taken into account as an alternative for arthroplasty. CONCLUSION: Excellent postoperative outcome can be achieved by joint reconstruction eliminating the possible side effects of shoulder endoprosthesis.

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BACKGROUND: Shear forces at the bone-implant interface lead to a loss of reduction after locking plate fixation of proximal humeral fractures. The aim of the study was to analyze the roles of medial support screws and screw augmentation in failure loads and motion at the bone-implant interface after locking plate fixation of proximal humeral fractures. METHODS: Unstable 3-part fractures were simulated in 6 pairs of cadaveric humeri and were fixed with a DiPhos-H locking plate (Lima Corporate, Udine, Italy). An additional medial support screw was implanted in 1 humerus of every donor. The opposite humerus was stabilized with a medial support screw and additional bone cement augmentation of the 2 anteriorly directed head screws. Specimens were loaded in the varus bending position. Stiffness, failure loads, plate bending, and the motion at the bone-implant interface were evaluated using an optical motion capture system. RESULTS: The mean load to failure was 669 N (standard deviation [SD], 117 N) after fixation with medial support screws alone and 706 N (SD, 153 N) after additional head screw augmentation (P = .646). The initial stiffness was 453 N/mm (SD, 4.16 N/mm) and 461 N/mm (SD, 64.3 N/mm), respectively (P = .594). Plate bending did not differ between the 2 groups. However, motion at the bone-implant interface was significantly reduced after head screw augmentation (P < .05). CONCLUSION: The addition of bone cement to augment anteriorly directed head screws does not increase stiffness and failure loads but reduces motion at the bone-implant interface. Thus, the risk of secondary dislocation of the head fragment may be reduced.

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BACKGROUND: A radiolucent carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plate was recently introduced for fixation of proximal humerus fractures. Prospective clinical and radiographic results of patients treated with a CFR-PEEK plate are compared with those of patients treated with a conventional locking plate. METHODS: Twenty-nine patients (mean age, 66 years) were treated with a CFR-PEEK plate for a 3- or 4-part proximal humerus fracture. Patients were clinically and radiographically re-examined at 6 weeks, 6 months, 12 months, and 24 months with the Simple Shoulder Test, Constant-Murley score (CMS), and Oxford Shoulder Score (OSS) as well as with simple radiographs. In addition, results were compared with a matched group of patients treated with a conventional locking plate. RESULTS: At the final follow-up examination at 24 months, patients achieved a mean Simple Shoulder Test score of 58%, a mean CMS of 71.3 points (range, 44-97), and a mean OSS of 27.4 points (range, 8-45). Bone union was confirmed in all patients. Compared with patients treated with the conventional locking plate, patients treated with the CFR-PEEK plate achieved significantly better results with regard to the CMS and the OSS (P = .038 and .029, respectively). Furthermore, loss of reduction with subsequent varus deformity was less frequently observed in the CFR-PEEK plate group. CONCLUSION: Fixation of proximal humerus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. The results are comparable to those achieved with conventional locking plates.

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Fracture and intrathoracic displacement of the humeral head is the result of severe high energy trauma and are extremely rare. Because of the exceedingly limited number of cases, appropriate treatment modality remains unclear. Hitherto, we describe a unique case of thoracic aorta injury caused by fragmented humeral head. Purposeful medical examination and fast locating of the humeral head fragment are crucial for the selection of appropriate treatment modality. Early aggressive intervention, e.g., emergency thoracoscopy exploring, can be performed to treat potential thoracic complications.

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OBJECTIVE: Replacement of the fractured humeral head with a modular prosthesis. The procedure aims at an adequate reconstruction of shape and function of the shoulder. INDICATIONS: Displaced three- and four-part fractures of the proximal humerus that cannot be reduced and internally fixed. CONTRAINDICATIONS: Fracture can be reduced and adequately internally fixated. Noncompliant patient. SURGICAL TECHNIQUE: In beach-chair position, the fractured humeral head is removed via a deltopectoral approach. The Aequalis modular fracture prosthesis can be positioned by two methods: (i) a fracture jig optimizing height and retroversion of the prosthesis, (ii) under additional intraoperative fluoroscopy. Healing of the tuberosities can be promoted by cancellous grafts taken from the fractured head. These are fixed by four heavy sutures running horizontally and two sutures running vertically. RESULTS: 13 out of 22 patients treated by primary hemiarthroplasty (within 10 days after the fracture) and 34 out of 50 patients treated by secondary arthroplasty could be assessed after a mean follow-up of 40 (15-70) and 44 (8-98) months, respectively. The absolute Constant score amounted to 45 and 50 points, respectively, and the relative score to 56% in both groups. The majority of patients was free of pain or suffered less pain than before the operation (secondary arthroplasty; p < 0.001). In contrast to these, only satisfactory, objective results, self-assessment was good or better than before (secondary prostheses; p < 0.001). In both groups, prognostic factors were the size and position of the tuberosities (p < 0.001).

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Although shoulder surgery is usually performed during general anesthesia, the use of an interscalene block alone or in combination with other anesthetic procedures is increasing. Blockade of the suprascapular nerve is used in the diagnosis and treatment of shoulder pain and to provide temporary relief from muscle spasm or strain in the supraspinatus or infraspinatus muscle We report a case of a patient that presented with severe shoulder pain who underwent surgery for traumatic humeral head fracture. Anesthesia was provided by an interscalene block follwing suprascapular nerve block.

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