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Hypothesis: Locking plates with special configuration for the anatomic region of the proximal humerus have been introduced recently to address the difficulties of stabilizing proximal humeral fractures. The purpose of this study was to carry out a systematic review of the literature on the efficacy and early to medium term functional results of locking plates for stabilization of proximal humeral fractures. Methods: Using the PubMed database, a systematic review of the English and German literature was carried out in order to assess the efficacy and complications related to the use of these plates and the patients'' functional outcome, using the key words “locking plates proximal humeral fractures,” “angular stability plates proximal humeral fractures,” “PHILOS plate,” and “LPHP plate.” Our criteria for eligibility were clinical studies with more than ten cases followed-up, adult patients, and adequate data provided at least in terms of implant related complications. Articles written in English and German language were included. Exclusion criteria were: studies dealing exclusively with 2-part fractures (since this category has a more favorable outcome); experimental studies; case reports; and, literature other than English or German. Each one of the articles was evaluated for quality of the study using the Structured Effectiveness Quality Evaluation Scale (SEQES). Results: Twelve studies including 791 patients met the inclusion criteria. Patients in these studies continued to improve up to one year, achieving a mean Constant score of 74.3. The incidence of the reported complications was: avascular necrosis 7.9%, screw cut-out 11.6% and re-operation rate 13.7%. Discussion: The high incidence of cut-out may be secondary to the rigidity of the implant in combination with medial inadequate support, in cases compromised by severe underlying osteoporotic bone. Definition of indications for the use of locking plates and attention on technical aspects of applying them would help optimization of the results. Level of evidence: Systematic Review. [Copyright &y& Elsevier]

Summary: The ideal management of complex proximal humeral fractures continues to be debatable. Evolution of proximal humeral fracture management, during the past decade, led to the implementation of many innovations in surgical treatment. Even though the pendulum of treatment seems to swing towards new trends such as locked plating, hemiarthroplasty remains a valid and reliable option that serves the patient''s needs well. Hemiarthroplasty is indicated for complex proximal humeral fractures in elderly patients with poor bone stock and when internal fixation is difficult or unreliable. Hemiarthroplasty provides a better result when it is performed early post-injury. Stem height, retroversion and tuberosity positioning are technical aspects of utmost importance. Additionally reverse total shoulder arthroplasty is an alternative new modality that can be used as a primary solution in selected patients with proximal humeral fracture treatment. Failed hemiarthroplasty and fracture sequelae can be successfully managed with reverse total shoulder arthroplasty. Individual decision-making and tailored treatment that takes into consideration the personality of the fracture and the patient''s characteristics should be used. [Copyright &y& Elsevier]

Summary: Patients’ perspectives in clinical research have become increasingly interesting and important. Much effort has recently been made to understand, evaluate and promote the patients’ active roles in and unique views on their involvement in clinical research, and how these may help resolve old and new problems in research planning, conduct and implementation. In this article issues regarding informed consent, differences between medical care and medical research, confidentiality, conflicts of interest and disclosure of study results are considered from the patients’ point of view. [Copyright &y& Elsevier]

Summary: The advent of locking plates for the management of metaphyseal fractures, and subsequent experience of biological fracture fixation, has led to the development of minimally invasive percutaneous osteosynthesis (MIPO), which is now proven to have multiple advantages. Soft tissue stripping is minimized, with preservation of vascular pedicles, and the fracture haematoma around the site of injury remains undisturbed promoting fracture healing. While early published results are encouraging, MIPO technique is not applicable to every fracture. To avoid complications, defining the correct indications is of paramount importance. [Copyright &y& Elsevier]

Summary: PubMed and Ovid Medline were searched to investigate the role of intramedullary nailing in the treatment of diaphyseal humeral non-union. Of 474 abstracts, 9 retrieved articles fulfilled our inclusion criteria and described management in 166 cases of humeral shaft non-union using several types of intramedullary nails. Union ranged from 40 to 100%; part of the variation could be explained by the quality index of the selected articles. Exchange nailing alone was not effective. Exposure of the fracture site and use of bone grafting were key to successful treatment. The total incidence of severe complications, including radial nerve damage, was very low. Thus, intramedullary nailing in the treatment of humeral shaft non-unions can lead to successful outcomes when associated with autologous bone grafting. [Copyright &y& Elsevier]

Objective: To examine associations of major complications after surgical treatment of slipped upper femoral epiphysis (SUFE) with condition- and treatment-related risk factors. Study design: This systematic review and meta-analysis of observational studies used an electronic literature search of Embase and Medline supplemented by a manual search of bibliographies. The studies enrolled children and adolescents with SUFE, defined stable and unstable disease, and reported at least 3 primary endpoints: avascular necrosis (AVN), chondrolysis, and reoperation. Random-effects meta-regression analysis was performed when possible. Results: The weighted risk for AVN, derived from intercept-only meta-regression, was estimated as 5.3% (95% confidence interval [CI], 3.4%-7.2%). Patients with unstable slips had a 9.4-fold greater risk of developing AVN. Instability proved to be an independent predictor for AVN. The weighted risk of chondrolysis was 0.8% (95% CI, 0.2%-1.4%), associated with unstable slips and osteotomies. The risk of reoperation was estimated at 5.5% (95% CI, 1.7%-9.3%). Loss of fixation was the primary reason for reoperation. Conclusions: Current evidence indicates that unstable slips are at a significantly higher risk for AVN than stable slips, regardless of the attempted surgical approach. Little clinical information is available regarding chondrolysis and reoperation in relation to the stability of the physis. [ABSTRACT FROM AUTHOR]

Summary: Necrotising fasciitis is a rapidly progressive, life threatening soft tissue infection. In a significant proportion of patients, the extremities are involved as a result of trauma, needle puncture or extravasation of drugs, often leading to limb loss and devastating disability. In this systematic review of necrotising fasciitis of the upper and lower extremities, we report on the clinical characteristics, the predisposing factors, the associated diseases, the pathogenic bacteria, the surgical treatment and the final outcome in terms of limb loss and mortality. Data for a total of 451 patients were analysed for each parameter of interest. A percentage of 22.3% of the reviewed patients underwent amputation or disarticulation of a limb following failure of multiple debridements to control infection and the mortality rate was estimated as high as 21.9%. [Copyright &y& Elsevier]

Summary: Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov''s principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested. [Copyright &y& Elsevier]

Summary: Few data are available in the literature regarding fat embolism in cases of bilateral femoral and pathological femoral fractures. The incidence of bilateral femoral fractures ranges from 2–9.5% of the total number of patients with femoral fractures, and they usually occur in high energy trauma and multitrauma patients. Although injury severity scores tend to underestimate the severity of these injuries, fat embolism seems to occur in increased frequency ranging from 4.8–7.5%. Intramedullary nailing, which is the preferred surgical treatment, triggers a systemic inflammatory response that poses an additional burden to pulmonary function. In addition, the femur is a common site of metastatic bone disease. The treatment of impending and actual pathological fractures is complicated by increased rates of lung damage due to various factors. Fat embolism during treatment—mainly with intramedullary nails—generally seems to range from 0–10%. [Copyright &y& Elsevier]

Abstract: Aim: In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed. Patients and methods: Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis. Results: In all group A patients Singh score ≤4 and CBR>0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score ≥5 and CBR<0.48. Fractures of group A healed in 19.38±5.9 weeks (12–30) and in group B 16.19±5.07 weeks (10–28), P =0.02. Conclusions: Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process. [Copyright &y& Elsevier]

Abstract: Aims and objectives: To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury. Methods: One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover. Results: Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p <0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response. Conclusions: These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible. [Copyright &y& Elsevier]

Abstract: The ulnar coronoid process plays a central role in elbow stability due to its unique anatomic characteristics. A fracture of the coronoid, although uncommon, represents a serious injury that can adversely affect functional outcome if not treated appropriately. Several surgical interventions addressing different fracture patterns are being increasingly recognised as effective treatment options even for smaller fragments. A review of the literature was performed in order to evaluate different treatment strategies applied to clearly defined fracture configurations. 14 articles reporting data for the management of 236 coronoid fractures met our inclusion criteria and were subjected to critical analysis. The data suggest that recognition of specific coronoid fracture patterns, use of appropriate classification systems and application of staged surgical protocols can stabilise the elbow effectively and lead to favourable outcomes. [Copyright &y& Elsevier]

Summary: The characterization of the molecular mediators regulating the fracture healing response over the past decade has vastly expanded our knowledge in this area at the molecular level. It is clear today that the physiological mechanisms governing the biology of bone repair and turnover are complex and far from being well understood. Several of the molecules implicated in the healing process have become available for use in the clinical setting thanks to advances made in recombinant technology. Current evidence of their effect in accelerating fracture healing in both experimental and clinical studies is promising. However, despite these findings, several factors require further investigation, including the ideal timing to administer these molecules, which is the most effective dose, and the factors affecting the lack of consistency in the experimental designs and animal models that have been used. In addition, the available evidence lacks phase III, level I studies. Until such studies become available, the results should be interpreted with caution. [Copyright &y& Elsevier]

Abstract: Objectives: This study aims to assess whether elderly patients (>65 years) with open tibial shaft fractures (OFs) have increased mortality rates than those with closed fractures (CFs). Patients and methods: Patients admitted during 2003–2005 with open/closed diaphyseal (AO 42) fractures of the tibia were eligible to participate. Exclusion criteria: Pathological and peri-prosthetic fractures. Results: A total of 54 patients (38 females) met the inclusion criteria. Twenty-six patients had sustained CF and 28 OF (Gustilo grade I (11), grade II (five), grade IIIa (two) and grade IIIb (10)). The OF group was statistically significantly different with higher injury severity score, secondary procedures and length of hospital stay (p <0.05). A higher rate of admission/length of stay to intensive care unit and complication rate was noted in the OF group. Mortality rate between the two groups was comparable (CF=2/26, OF=3/28). Conclusions: Elderly patients with OFs of the tibial shaft have similar mortality rate to those with CFs. [Copyright &y& Elsevier]

Abstract: We have studied the histologic and immunohistochemical changes of the long head of the biceps brachii tendon (LHB) in low-energy complex proximal humerus fractures. Our objective was to detect histological features, which may be correlated to pain generation. Biopsy samples were obtained during hemiarthroplasty procedures from 11 patients who suffered a complex proximal humerus fracture. The control group consisted of 10 samples harvested from human cadavers with no history of premortem shoulder problems and no gross shoulder pathology. Histologic investigation included quantitative measurement of tendon degeneration, cellularity, neoangiogenesis, inflammation and metaplasia, as well as immunohistochemical detection of cells with neural differentiation within the tendon tissue proper with S-100 protein and neuropeptide Y (N-Y). The found lesions were significantly more in the group of tendons from fractures compared to the control group (p <0.001). These lesions were also statistically correlated to each other, indicating a possible neural differentiation of tendon stromal cells. The LHB is a potential source of pain and the routine use of tenotomy/tenodesis of this tendon in hemiarthroplasty procedures for fracture may be reinforced by the results of this study. [Copyright &y& Elsevier]

Summary: The microenvironment theory has become very popular for providing mechanisms which explain the development of often lethal posttraumatic complications such as systemic inflammatory response syndrome (SIRS), adult respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). With the recent advances in molecular biology and the ever-expanding understanding of trauma pathophysiology, immunomonitoring in trauma patients attempts to characterise and quantify novel molecules in order to predict patients at risk. This review article assesses the existing evidence on the biomarkers of endothelial injury and their potential utility as quantification parameters of endothelial dysfunction in trauma patients. [Copyright &y& Elsevier]

Abstract: Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints. [Copyright &y& Elsevier]

Summary: The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9–317 mo). Patients had undergone a median of 2 (range 0–11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3–15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute. [Copyright &y& Elsevier]