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Background: In connection with the war in Ukraine and the use of modern high-energy weapons by the enemy, the nature of injuries have changed. These changes require improvement of approaches to the treatment of patients with gunshot and mine-explosive bone defects., Case Presentation: We present the case of treatment of a 28-year-old Ukranian man with a gunshot multifragmentary fracture of the proximal humerus with a bone defect using three-dimensional printing of a polyetheretherketone frame (scaffold) for alloplastic material. The analysis of this case expands the possibilities of using three-dimensional printing technologies of polyetheretherketone scaffolds in the treatment of significant bone defects., Conclusion: Modern military trauma requires individualized treatment for each patient. The use of individual polyetheretherketone scaffolds in the treatment of a gunshot multifragmentary fracture with a bone defect has a positive clinical effect., (© 2024. The Author(s).)

Background: Plate fixation of proximal humeral fractures is usually associated with some degree of distal deltoid dissection. The purpose of this study was to quantify deltoid release with standard linear versus curvilinear plates used in the repair of proximal humeral fractures., Methods: Seven nonpaired, fresh-frozen, clavicle-to-fingertip cadaveric shoulders met the inclusion criteria for this study. Four different proximal humerus implants were tested. One of these plates was curvilinear (89 mm), and the other 3 plates were linear (85, 98, 109 mm in length). Plates were compared based on the amount of deltoid insertion released for proper plate positioning. An analysis of variance with post hoc Tukey tests was conducted to compare mean deltoid disruption across the 3 shortest plate types from each manufacturer. A linear regression analysis was conducted to analyze the effect of plate length on mean deltoid release., Results: The mean deltoid insertion length was 39.6 ± 8.6 mm (n = 7). The curvilinear plate (89 mm) required the least amount of average deltoid release at 4.1 ± 4.5 mm, or 12.1% of the deltoid insertion. Independent analysis of variance, including the 3 shortest plates from each manufacturer, found a significant effect of which plate was used on the amount of deltoid disruption that resulted (F(2, 18) = 18.0, P < 0.001, ω = 0.6). A linear regression including all 4 plates demonstrated a statistically significant direct relationship between the plate length and the mean deltoid released (y = 0.6x - 43.8, r2 = 4)., Conclusion: This study demonstrates that proximal humerus plate length has a direct relationship with the amount of deltoid released during plating. Although deltoid disruption is length dependent, plate shape (curvilinear vs. linear) could also be contributory. When comparing a curvilinear and a linear plate of similar lengths, the curvilinear plate resulted in less mean deltoid release., Competing Interests: M. McKee is a consultant for and receives royalties from Stryker, Inc. A. Shah is a consultant for and receives royalties from Arthrex, Inc. E. Lederman is a consultant for and receives royalties from Arthrex, Inc. The remaining authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report the functional results of our experience and to describe intraoperative findings and complications due to the techniques used in our service., Methods: From January 2018 to December 2022, 27 Pediatric patients aged from 8 to 16 years underwent surgery to treat proximal humerus fractures. Their demographic characteristics were evaluated, as well as their clinical characteristics on admission, type of reduction (closed/open), presence of interposition in open reductions, type of implant, complications, and functional range of movement according to two shoulder functional scores., Results: Mean age was 11.2 years (8-15), there was a predominance of males, who accounted for 70% of the cases, and sports accidents were the cause of injury in 44% of the cases. Anatomical location was balanced between patients, including 55% of physeal fractures and 45% of metaphyseal ones. Overall, 81.5% of patients required open reduction to achieve axis correction, and that 55.5% of fractures were fixed with Kirschner wires, and 44, 4% with elastic titanium nails. Mean QuickDASH score was 0.58 (0-1.7), and Constant score was 9 (3-24). There were no major complications, but 27% of cases subjected to open reduction presented a hypertrophic scar., Conclusion: Surgical treatment of severely displaced proximal humerus fractures is successful, both with closed and open reduction; type of implant does not play a key role and should be selected based on the characteristics of each case. Surgical training should prevail at the time of decision-making. When these recommendations are followed, results can be excellent and sequelae are infrequent., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures., Methods: A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle., Results: Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection., Conclusions: Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Scapular glenoid fractures, categorized based on the Ideberg classification, are commonly addressed surgically through approaches like the anterior deltoid-pectoral approach, posterior Judet approach, modified Judet approach, or posterior axillary approach. However, these methods present limitations in exposing the superior part of the glenoid. Therefore, we propose an approach for patients with concomitant acromion fractures, involving the anterior lateral flipping of the fractured acromion, allowing direct superior visualization of the superior and posterior superior parts of the glenoid., Method: Retrospective analysis was conducted on the data of five patients with shoulder fractures combined with scapular Ideberg III fractures between June 2018 and May 2023. All patients were treated using the shoulder approach above the scapular spine. There were four males and one female, aged 23-54 years with an average age of 36.6 years. One case involved the left shoulder, and four cases involved the right shoulder. X-rays and CT were taken before and after surgery to assess the location of the fractures and the healing status. Clinical evaluation included the assessment of efficacy using the Constant-Murley scoring criteria and analysis of surgical complications., Results: All five patients were followed up for a duration of 14-36 months. All fractures healed completely, with an average healing time of 4.3 months (range: 3-6 months). There were no complications such as suprascapular nerve injury, nonunion, wound infection, or shoulder joint instability observed postoperatively. At the final follow-up, the Constant-Murley shoulder joint function score ranged from 84 to 98 points, with an average of 91.4 points. Three patients achieved an excellent rating in shoulder joint function score, while two patients achieved a good rating., Conclusion: The shoulder approach above the scapular spine exhibits advantages such as easy exposure and reduction, minimal intraoperative trauma, and clear visualization., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: Rapid and effective reduction is difficult for minimally invasive plate osteosynthesis (MIPO) surgery. This study aims to introduce a bidirectional rapid reductor (BRR) designed to assist in the reduction during MIPO surgery for proximal humeral fractures (PHFs)., Methods: This retrospective study was conducted between June 2021 and February 2022 in the Third Hospital of Hebei Medical University, involving patients diagnosed with PHFs. A detailed technical approach of BRR in MIPO surgery was described, and the patients' outcomes based on postoperative radiographic results including x-ray postoperative follow-up, and clinical outcome parameters including visual analogue scale (VAS) and constant-Murley score at last follow-up were reported., Results: A total of 12 patients were included in this study, comprising three males and nine females, with an average age of 67.58 years. The mean operative time was 70.92 min (range 63-80 min). The mean blood loss was 102.27 mL (range 50-300 mL). The mean VAS and constant-Murley scores at final follow-up were 0.33 and 88, respectively. All patients had their fractures healed without secondary displacement at last follow-up. One patient experienced shoulder stiffness post-operation. There were no adverse events or complications following the use of this technique, such as acromion fracture, nerve or blood vessel injury., Conclusion: The BRR can assist MIPO for good reduction of PHFs. However, the efficacy should be validated with a large-sample randomized controlled trial and longer follow-up., (© 2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Background: Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study., Methods: This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts., Results: Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P <0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P <0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P =0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement., Conclusion: We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement., Level of Evidence: II., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature., Methods: A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007 to 2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, and reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R., Results: A total of 28 studies (1119 patients) were included with an average age of 74 ± 3.7 and mean follow-up of 32 ± 11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4 ± 0.76 weeks compared to 5.9 ± 1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126 ± 27.5), abduction (116 ± 30.6), internal rotation (5.27 ± 0.74, corresponding to L3-L1), American Shoulder and Elbow Surgeons score (71.8 ± 17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 year old with acute PHF undergoing shoulder arthroplasty (all P ≤ .05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (P = .005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (odds ratios, 0.30; P = .01 & odds ratios, 0.42; P = .05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) vs. (8.91%) in the press fit rTSA subgroups (P = .02)., Conclusion: Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM when compared to the mainstream preference-rTSA-Cement-Delayed., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: In this study, we reviewed proximal humeral fractures surgically treated with open reduction and internal fixation (ORIF) to test the null hypothesis that there is no association between fracture characteristics and surgeon characteristics in outcomes after surgical management of displaced proximal humeral fractures with ORIF., Methods: A retrospective review of surgically treated proximal humeral fractures was done at a tertiary-level hospital. The data were organized into two categories: fracture characteristics and surgeon characteristics., Results: There were 314 proximal humeral fractures treated with ORIF. In total, there were 112 failures (36%). Bivariate Pearson correlations demonstrated that the number of proximal humerus fixation surgeries performed by an individual surgeon was associated with adequate calcar reduction (r = 0.995, P < 0.001) and greater tuberosity reduction (r = 0.994, P < 0.001). Years of experience was positively associated with adequate calcar reduction (r = 0.594, P = 0.012) and greater tuberosity reduction (r = 0.589, P = 0.013). Regression analysis of two surgeons versus the rest of the cohort demonstrated significantly lower failure rates (P = 0.001)., Discussion: Complex proximal humeral fractures (3-part and 4-part) have better calcar reduction and tuberosity reduction when treated by surgeons with greater volume of proximal humeral fracture surgery. Among surgeons with high volume, there may be individuals who have the unique ability to provide markedly better results., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Insufficient tuberosity healing is the most common reason for poor outcome after treatment of proximal humerus fractures (PHFs) using hemiarthroplasty (HA). In these cases, revision to reverse total shoulder arthroplasty (RTSA) can improve function and reduce pain in the short term, however, long-term results remain scarce. Aim of this study was to evaluate the clinical and radiological mid- to long-term results in patients with a revision RTSA after failed HA for PHF., Methods: In this retrospective study all patients that received a revision to RTSA after failed fracture HA between 2006 and 2018 were included. A total of 49 shoulders in 48 patients (38 female, 10 male; mean age 82 ± 9 years) were identified in our database. A total of 20 patients (17 female, 3 male; mean age was 79 ± 9 years) were available for follow-up examination after a mean time period of approximately eight years (3-14 years) after revision surgery. At final follow-up, patients were assessed using a subjective shoulder value (SSV), range of motion (ROM), visual analogue score (VAS), the Constant Score (CS) and the 12-Item Short Form Survey (SF-12)., Results: At final follow-up, mean CS was 55 ± 19 (19-91), VAS averaged 3 ± 3 (0-8) and mean SSV was 61 ± 18% (18-90%). Mean SF-12 was 44 (28-57) with a mean physical component summary (PCS) of 38 (21-56) and a mean mental component summary (MCS) of 51 (29-67). On average active forward flexion (FF) was 104° (10-170°), active abduction (ABD) was 101° (50-170°), active external rotation (ER) was 19° (10-30°) and active internal rotation (IR) of the lumbosacral transition was reached. Three patients presented with a periprosthetic humeral fracture after RTSA implantation and underwent a reoperation (15%) during follow-up period., Conclusions: Revision RTSA results in promising clinical results in patients after initial failed HA after PHF. A complication and reoperation rate of 15% is tolerable in consideration of satisfactory functional and psychological outcome., Trial Registration: Retrospectively registered., (© 2024. The Author(s).)

Objective: To analyze the effectiveness of tuberosity suture combined with autogenous bone grafting in reverse total shoulder arthroplasty for elderly patients with proximal humerus fracture., Methods: A clinical data of 28 patients with fresh proximal humerus fractures, who met the selection criteria and admitted between June 2014 and April 2022, was retrospectively analyzed. There were 7 males and 21 females. Age ranged from 65 to 81 years, with an average of 73.8 years. The causes of injury were 21 cases of fall, 6 cases of traffic accident, and 1 case of falling from height. The time from injury to operation ranged from 5 to 20 days with an average of 9.2 days. There were 8 cases of Neer three-part fracture and 20 cases of four-part fracture. The reverse total shoulder arthroplasty was performed, and the greater and lesser tuberosities were sutered and reconstructed with autogenous bone grafting. After operation, the Constant score, American Society for Shoulder Surgery (ASES) score, and visual analogue scale (VAS) score were used to evaluate shoulder function and pain; and the active range of motion of the shoulder joint was recorded, including flexion, external rotation, and internal rotation. X-ray films were taken to observe the position of prosthesis. According to the evaluation criteria proposed by Boileau, the healing of greater tuberosity was evaluated, and the effectiveness was compared between the patients with healed and non-healed (displacement and absorption) greater tuberosity., Results: All incisions healed by first intention after operation. All patients were followed up 24-106 months, with an average of 60.9 months. At last follow-up, the VAS score of shoulder joint ranged from 0 to 6 (mean, 1.1). The Constant score ranged from 45 to 100 (mean, 80.1). The ASES score ranged from 57 to 100 (mean, 84.7). The active range of motions of shoulder joint were 60°-160° (mean, 118°) in flexion, 0°-50° (mean, 30°) in external rotation, and corresponding to reaching the S 5 -T 8 vertebral body level in internal rotation. During follow-up, no shoulder joint re-dislocation or severe shoulder instability occurred, and no revision surgery was performed. X-ray film reexamination showed that there was no loosening of the prosthesis. According to the evaluation criteria proposed by Boileau, the greater tuberosity fused in 22 cases (78.6%), displaced in 3 cases (10.7%), and absorbed in 3 cases (10.7%). The shoulder joint function and pain related evaluation indicators in the healed group were significantly better than those in the non-healed group ( P <0.05)., Conclusion: Tuberosity suture combined with autogenous bone grafting is a relatively simple procedure that provides a reliable fixation for the anatomic recovery of greater and lesser tuberosities and is beneficial for the recovery of shoulder function in elderly patients with proximal humeral fractures.

Case: Fourteen-year-old boy presented with bilateral proximal humerus lesser tuberosity avulsions after swinging between 2 desks. Injuries were not visualized on radiographs but identified on magnetic resonance imaging. He underwent bilateral open reduction and internal fixation of the bony avulsions. Following repair, he returned to full activities, including sports, without limitations., Conclusion: Lesser tuberosity avulsions are rare injuries in the pediatric population that can be missed. Our case is a low energy noncontact mechanism resulting in bilateral injury, highlighting the importance of having a high index of suspicion for this diagnosis in adolescent patients with shoulder pain with normal radiographs., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C466)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Innovation has in common the promise of benefit for patients; however, past experience has shown that this promise is not always delivered. Instead, low-value innovation might encourage treatment variation and dilute the available body of evidence. This study aims to investigate (1) whether the peer-review process is capable of filtering out low-value innovation appropriately, and (2) whether low-value surgical innovation would be preferred more often than nonoperative innovation by peer-reviewers in the treatment of proximal humeral fractures in the elderly., Materials and Methods: Two duplicated sham scientific abstracts, respectively introducing a low-value surgical innovation and a valuable nonsurgical innovation, were submitted to nineteen peer-reviewed scientific meetings worldwide for orthopedic trauma surgery with submission deadlines between 01/01/2022 and 31/12/2022. Decision regarding abstract acceptance was compared., Results: There was a high acceptance rate for the abstract introducing low-value surgical innovation (12 out of 19 (63.2 %)), which was higher than that of a nonoperative duplicate (10 out of 19 (52.6 %)), but this difference was not statistically significant ( p = 0.5). The majority of the ten meetings that accepted both abstracts placed both in equivalent programmatic tiers (oral presentation (4) and poster presentation (2)). In three meetings, the surgical abstract received superior program placement (oral presentation). In one case, it was the opposite., Conclusion: There is a high acceptance rate for low-value surgical innovation among peer-reviewed scientific meetings. However, we can not conclude that low-value surgical innovation is preferred more often than nonoperative innovation by peer-reviewers as the differences in acceptance rate were small and not statistically significant. The peer-review process may be suitable as value-based medicine emerges. Scientists should be encouraged to pursue value-based innovation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients., Methods: This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported., Results: In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures., Conclusions: Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF)., Methods: A systematic search of the literature was undertaken using the Medline ® , PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted., Results: A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p <0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p =0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p =0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p =0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group., Conclusions: This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Hypothesis and Background: Recently, the indication of reverse total shoulder arthroplasty (RTSA) has expanded beyond rotator cuff arthropathy to include treatment of complex acute proximal humeral fracture (PHF). Limited previous studies have compared the long-term clinical and functional outcomes of patients undergoing RTSA for PHF vs. elective indications for degenerative conditions. The purpose of this study was to compare implant survivorship, reasons for revision and functional outcomes in patients undergoing RTSA for acute PHF with those undergoing elective RTSA in a population-based cohort study., Methods: Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 6862 patients who underwent RTSA. Patients were categorized by preoperative indication, including PHF (10.8%), rotator cuff arthropathy (RCA) (44.5%), osteoarthritis (OA) (34.1%), rheumatoid arthritis (RA) (5.5%), and old traumatic sequelae (5.1%). Revision-free implant survival and functional outcomes (Oxford Shoulder Scores [OSSs] at the 6-month, 5-year, and 10-year follow-ups) were adjusted by age, sex, American Society of Anesthesiologists class, and surgeon experience and compared., Results: Revision-free implant survival at 10 years for RTSA for PHF was 97.3%, compared with 96.1%, 93.7%, 92.8%, and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was significantly higher for traumatic sequelae (hazard ratio = 2.3, P = .023) but not for other elective indications. The most common reason for revision in the PHF group was dislocation or instability (42.9%), which was similar to the OA (47.6%) and traumatic sequelae (33.3%) groups. At 6 months post-surgery, OSSs were significantly lower for the PHF group compared with the RCA, OA, and RA groups (31.1 vs. 35.6, 37.7, and 36.5, respectively, P < .001), and similar to traumatic sequelae (31.7, P = .431). At 5 years, OSSs were only significantly lower for PHF compared with OA (37.4 vs. 41.0, P < .001) and there was no difference between the PHF and other groups. At 10 years, there were no significant differences between groups., Conclusions: RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared with elective indications. Despite lower functional outcomes in the early postoperative period for the PHF group, implant survivorship was similar in patients undergoing RTSA for the primary indication of acute PHF compared with RCA, OA, and RA and superior compared to the primary indication of traumatic sequelae., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: If reduction images of fractures can be provided in advance with artificial-intelligence (AI)-based technology, it can assist with preoperative surgical planning. Recently, we developed the AI-based preoperative virtual reduction model for orthopedic trauma, which can provide an automatic segmentation and reduction of fractured fragments. The purpose of this study was to validate a quality of reduction model of Neer 3- or 4-part proximal humerus fractures established by AI-based technology., Methods: To develop the AI-based preoperative virtual reduction model, deep learning performed the segmentation of fracture fragments, and a Monte Carlo simulation completed the virtual reduction to determine the best model. A total of 20 pre/postoperative three-dimensional computed tomography (CT) scans of proximal humerus fracture were prepared. The preoperative CT scans were employed as the input of AI-based automated reduction (AI-R) to deduce the reduction models of fracture fragments, meanwhile, the manual reduction (MR) was conducted using the same CT images. Dice similarity coefficient (DSC) and intersection over union (IoU) between the reduction model from the AI-R/MR and postoperative CT scans were evaluated. Working times were compared between the two groups. Clinical validity agreement (CVA) and reduction quality score (RQS) were investigated for clinical validation outcomes by 20 orthopedic surgeons., Results: The mean DSC and IoU were better when using AI-R that when using MR (0.78 ± 0.13 vs. 0.69 ± 0.16, p < 0.001 and 0.65 ± 0.16 vs. 0.55 ± 0.18, p < 0.001, respectively). The working time of AI-R was, on average, 1.41% of that of MR. The mean CVA of all cases was 81%±14.7% (AI-R, 82.25%±14.27%; MR, 76.75%±14.17%, p = 0.06). The mean RQS was significantly higher when AI-R compared with MR was used (91.47 ± 1.12 vs. 89.30 ± 1.62, p = 0.045)., Conclusion: The AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times. Beyond diagnosis, classification, and outcome prediction, the AI-based technology can change the paradigm of preoperative surgical planning in orthopedic surgery., Level of Evidence: Level IV., (© 2024. The Author(s).)

BACKGROUND Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of rotator cuff deficiency and proximal humerus fractures. This single-center study aimed to evaluate the outcomes from reverse shoulder arthroplasty for rotator cuff ınsufficiency and proximal humerus fractures in 22 patients from a single center. MATERIAL AND METHODS Twenty-two patients were included in the study. The median age of the patients was 66 years (Range: 58-95). Proximal humerus fractures were diagnosed using X-ray and CT, while rotator cuff tears were diagnosed using MRI. For the assessment of joint function, the Constant-Murley score, the American Shoulder and Elbow Surgeons (ASES), and the Disabilities of Arm, Shoulder, and Hand (DASH) scores were used as patient-reported outcome measures. Kaplan-Meier analysis was conducted to evaluate implant survival. RESULTS The mean follow-up duration was 4.05±1.2 years. Significant improvements were observed: ASES Score: Increased from 35.8±2.8 to 81.3±5.4 (p<0.001). VAS Pain Score: Decreased from 7.3±1 to 2.9±0.9 (p<0.001). DASH Score: Improved from 66.3±4.3 to 32.5±3.6 (p<0.001). Constant-Murley Score: Increased from 48.3±3.5 to 74.6±7.7 (p<0.001). Kaplan-Meier analysis estimated implant survival at 6.7 years (95% CI, 6.3-7.2). CONCLUSIONS When performed with appropriate indications, RSA yields positive results, as seen in the literature and our study. Interscalene block anesthesia, advancements in implant technology, and adherence to surgical procedures can reduce RSA complications and ensure its safe application.

Case: (1) A 69-year-old man sustained a proximal humeral fracture-dislocation. During emergency surgery, copious bleeding occurred. A pseudoaneurysm was identified 30 days postoperatively. (2) A 69-year-old man sustained a proximal humeral fracture and axillary artery injury. Physical examination demonstrated a cold but pink hand. Hemiarthroplasty and bypass vein grafting were performed. (3) An 86-year-old woman sustained a proximal humeral fracture and axillary artery injury. Her hand had turned cold and pale. Reverse shoulder arthroplasty and bypass vein grafting were performed., Conclusion: In cases of proximal humeral fractures with significant displacement, concomitant axillary artery injury must be assessed and if there is a high index of suspicion, prompt advanced imaging is necessary., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C400)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Purpose: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management., Methods: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated., Results: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews., Conclusions: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes., Level of Evidence: Level III, Diagnostic Study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term., Methods: Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations., Results: Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period., Conclusions: In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions., (© 2024. The Author(s).)

Background: This study evaluated national trends in cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humerus fractures using a comprehensive national surgical database. This study aimed to compare RSA used in the treatment of proximal humerus fractures with the literature and to determine the country's trend., Methods: A cross-sectional study was conducted using the health records of individuals aged ≥ 18 years who underwent RSA for proximal humerus fractures between 2016 and 2022. Patients were divided into cemented and uncemented groups, and demographic data (age, sex), duration of hospital stay, transfusions, revisions, mortality, and Charlson Comorbidity Index (CCI) scores were analyzed., Results: A total of 618 cemented RSA and 1,364 uncemented RSA procedures were reviewed. Patients who underwent cemented RSA were significantly older than those who had uncemented RSA ( p = 0.002). Transfusion rates were higher in the cemented RSA group ( p = 0.006). The frequency of revision surgery was 6.1%. Younger age and male sex were associated with revision ( p < 0.001). CCI scores were higher among transfused patients than non-transfused patients ( p < 0.001). The incidence of cemented RSA was 11.7% and 49% in 2016 and 2022, respectively. Differences were found among hospital types and geographical regions., Conclusions: While cemented RSA has been gaining attention and increased application in recent years for proximal humerus fractures, uncemented RSA still predominates. The choice between these 2 methods is largely influenced by regional and hospital-level factors. The type of RSA and high CCI scores were found to have no significant impact on the risk of surgical revision., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2024 by The Korean Orthopaedic Association.)

Background: Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality., Methods: Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined., Results: For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment., Conclusions: Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies., Level of Evidence: III., (© 2024. The Author(s).)

Introduction: Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls., Methods: A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days)., Results: In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission., Conclusion: Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Introduction: The optimal treatment approach for Bony Bankart remains a subject of considerable debate among shoulder surgeons. Existing literature highlights low recurrence rates and high patient satisfaction with nonoperative treatment, particularly in the middle-aged population. This study aimed to evaluate the recurrence rate of dislocation, as well as the clinical and functional outcomes in middle-aged individuals treated nonoperatively following an acute bony Bankart fracture. Additionally, the impact of glenoid rim size and fragmentation on the treatment outcome was investigated., Material and Methods: A prospective analysis was conducted on 20 patients aged over 50 with nonoperatively treated bony Bankart fractures, ensuring a minimum follow-up of 24 months. The study population was categorized based on fragment size (small and medium) according to Kim classification and glenoid rim fragmentation (type 1b and 1c) according to Scheibel classification. Data including UCLA score, Rowe score, recurrence rate, clinical instability, and range of motion (ROM) were collected and analyzed., Results: The average UCLA and Rowe scores were 32.15 ± 2.85 and 93.85 ± 2.19, respectively, with no instances of dislocation recurrence. The affected shoulder exhibited no significant reductions in ROM compared to the contralateral side, except for a loss of external rotation (ER) (13.08° ± 7.51; p = 0.005). No differences were observed based on fragment size, although patients with multifragmented glenoid rims showed a greater loss of ER compared to those with a solitary fragment, albeit not reaching statistical significance., Conclusion: Nonoperative treatment appears to be a viable and effective option for middle-aged individuals with bony Bankart fractures, resulting in favorable functional outcomes and a low risk of recurrence. Additionally, a notable loss of external rotation was observed in fractures with glenoid rim fragmentation., Level of Evidence: IV., (© 2024. The Author(s).)

While several proximal humerus fractures treated nonsurgically reach satisfactory outcomes, some become symptomatic malunions or nonunions with pain and dysfunction. When joint-preserving options such as malunion or nonunion repair are not optimal because of poor remaining bone stock or glenohumeral arthritis, shoulder arthroplasty is a good option. Because of the semiconstrained design of reverse shoulder arthroplasty, it is effective at improving function when there is notable bony deformity or a torn rotator cuff. Clinical studies have demonstrated reliable outcomes, and a classification system exists that is helpful for predicting prognosis and complications. By understanding the associated pearls and pitfalls and with careful management of the tuberosities, reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

A high failure rate is associated with fracture plates in proximal humerus fractures. The causes of failure remain unclear due to the complexity of the problem including the number and position of the screws, their length and orientation in the space. Finite element (FE) analysis has been used for the analysis of plating of proximal humeral fractures, but due to computational costs is unable to fully explore all potential screw combinations. Surrogate modelling is a viable solution, having the potential to significantly reduce the computational cost whilst requiring a moderate number of training sets. This study aimed to develop adaptive neural network (ANN)-based surrogate models to predict the strain in the humeral bone as a result of changing the length of the screws. The ANN models were trained using data from FE simulations of a single humerus, and after defining the best training sample size, multiple and single-output models were developed. The best performing ANN model was used to predict all the possible screw length configurations. The ANN predictions were compared with the FE results of unseen data, showing a good correlation (R 2  = 0.99) and low levels of error (RMSE = 0.51%-1.83% strain). The ANN predictions of all possible screw length configurations showed that the screw that provided the medial support was the most influential on the predicted strain. Overall, the ANN-based surrogate model accurately captured bone strains and has the potential to be used for more complex problems with a larger number of variables., (© 2024 The Author(s). International Journal for Numerical Methods in Biomedical Engineering published by John Wiley & Sons Ltd.)

Background: Post-operative non-compliance is a risk factor for fracture fixation failure and presents a challenge for revision surgery planning. We present a patient who underwent revision surgery for a proximal humerus fracture with lateral locked plating augmented with a UV light activated intramedullary implant., Case: A 45-year-old woman with a history of alcoholism presented with a proximal humerus fracture. After undergoing open reduction internal fixation with a lateral locking plate, the patient suffered a fall secondary to delirium tremens. New radiographs demonstrated displacement of the fracture with failure of screws. Revision surgery consisting of removal of the initial construct as well as open reduction internal fixation via lateral locking plate, augmented with a UV-activated intramedullary cement implant, was performed., Conclusion: This is the first case report describing the use of a UV-activated intramedullary cement implant to augment the use of lateral locked plating for proximal humerus fractures. This case illustrates the successful management using UV-activated intramedullary cement to augment fixation, specifically in a patient with risk factors and post-operative non-compliance that predispose to fixation failure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The primary objective of this study was to investigate the association between preoperative chronic steroid use and postoperative complications following open reduction internal fixation (ORIF) for proximal humerus fractures (PHF)., Methods: The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for all patients who underwent PHF ORIF between 2015 and 2021. A total of 6,273 patients were included in this study, of which 3.4% (n = 212) were in the chronic steroid use cohort. Patient characteristics including demographics, comorbidities, and 30-day postoperative complications after PHF ORIF were collected. Bivariate logistic regression and multivariate logistic regression analysis, adjusted for all significantly associated variables, was conducted to investigate the relationship between preoperative chronic steroid use and postoperative complications., Results: Chronic steroid use was significantly associated with age ≥ 75 (p < 0.001), male gender (p =0.006), dependent functional status (p = 0.008), American Society of Anesthesiologist (ASA) ≥ 3 (p < 0.001), CHF (p = 0.007), hypertension (p < 0.001), COPD (p < 0.001), bleeding disorder (p = 0.007), ascites (p = 0.040), disseminated cancer (p< 0.001), and systemic sepsis (p < 0.001). After adjusting for all significantly associated variables, chronic steroid use was independently associated with major complication (OR 1.60, 95% CI 1.06-2.43; p = 0.026), and non-home discharge (OR 1.05, 95% CI 1.01-1.08; p = 0.014)., Conclusion: Preoperative chronic steroid use is associated with increasing rate of postoperative complications following PHF ORIF. Better understanding and characterizing chronic steroid use as a preoperative risk factor can aid physicians in risk stratification to reduce rates of postoperative complications following PHF ORIF., Level of Evidence: III. Retrospective Cohort Comparison; Prognosis Study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications., Methods: Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated., Results: A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77 years. PPHF occurred a mean of 50 months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4, stem replacement 1)., Conclusion: The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions., Level of Evidence: Level IV, epidemiologic study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients., Aims: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years., Methods: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes., Results: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed., Conclusions: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel., (© 2024. The Author(s).)

Introduction: The majority of all proximal humeral fractures (PHFs) are treated non-surgically. Due to the risk of early secondary fracture displacement patients with non-surgically treated PHFs routinely undergo serial clinical and radiological evaluations. However, the value of these routine follow-up visits is unclear. This study aimed to examine the rate of early conversion to surgery in non-surgically treated PHFs. Moreover, the associations between patient and fracture characteristics and the risk of conversion to surgery were explored in order to assess the need for routine follow-ups., Methods: Data on all patients aged ≥18 years with a non-surgically treated PHF registered between 2013 and 2021 were extracted from the Swedish Fracture Register. Early change of treatment from non-surgical to surgical is an optional treatment modality in the SFR. The rate of early conversion to surgery within 60 days from injury was analyzed in relation to age and sex of the patient, energy level at injury and fracture morphology according to the AO/OTA classification., Results: A total of 31,761 primarily non-surgically treated PHFs (mean age 70 years: 76 % female) were included in the study. The overall rate of early conversion to surgery was 3.7 %. Younger age and increasing fracture severity were associated with a higher conversion rate to surgery. Patients ≥80 years and those with the three most common fracture types (A1, A2, and B1) had <2 % early conversion to surgery. In contrast, patients with C-type fractures, unstable/displaced fractures (A3, B2, and C2), or fracture dislocations (A1.3, B3, and C3) had a substantially higher risk (5.0-20 %) of early conversion., Conclusion: The overall risk of early conversion to surgery in non-surgically treated PHFs is low and can be further predicted based on patient age and fracture morphology. These results could have implications regarding which patients are in need of routine follow-ups., Level of Evidence: Level II; Retrospective design; Prognosis study., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: 4-part proximal humerus fractures are complex injuries that are often associated with comminution of the greater tuberosity. The purpose of this study is to evaluate the functional outcomes of 4-part humerus fractures that are treated with reverse total shoulder arthroplasty (rTSA) and correlate these outcomes with the healing status of the greater tuberosity., Material and Methods: A retrospective observational study was performed including 65 patients who underwent rTSA following a 4-part proximal humerus fracture. These patients were categorized into 3 groups according to the healing status of the greater tuberosity: patients with healed greater tuberosity in an anatomical position (group A, n = 43), patients with non-union of the greater tuberosity but in anatomical position (group B, n = 14), and patients with resorption or non-union of the greater tuberosity not in anatomical position (group C, n = 8). The Constant-Murley score and range of motion were recorded for each patient at 12 months postoperatively. The clinical and radiographical outcomes of the 3 groups were compared., Results: Patients with healed greater tuberosity (group A) had higher range of motion compared to patients with greater tuberosity migration or reabsorption (group C) regarding forward flexion (130° vs 80°, p < 0.001), abduction (110° vs 65°, p < 0.001) and external rotation (20° vs 10°, p = 0.004). However, no significant changes regarding forward flexion (130° vs 125°, p = 0.67), abduction (110° vs 100°, p = 0.60) and external rotation (20° vs 25°, p = 0.37) were noted between patients with healed greater tuberosity (group A) and those with non-united greater tuberosity that remained attached to the humeral prosthesis (group B). Similarly, Constant- Murley score was similar between patients of group A and group B (65.0 vs 61.5, p = 0.53), while it was higher in patients of group A compared to those of group C (65.0 vs 39.0, p = 0.053)., Conclusions: The outcomes of this study indicate that reliable recovery regarding range of motion and functional status can be achieved in patients who undergo rTSA due to 4-part proximal humerus fractures, as long as the greater tuberosity remains in close proximity to the humeral prosthesis, even if it has signs of non-union with no continuity to the adjacent humerus., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objectives: To compare reoperation rates of acute versus delayed reverse total shoulder arthroplasty (RTSA) following a period of nonoperative treatment for proximal humerus fractures (PHFs). We also aimed to identify an optimal time interval from PHF to RTSA before the risk of reoperation significantly increased., Methods:  ., Design: Database review., Setting: Ontario, Canada., Patient Selection Criteria: Adults aged 50 years and older who sustained a PHF (OTA/AO 11A-C) between 2004 and 2019 were included. Exclusion criteria included polytrauma, open fractures, non-Ontario residents, invalid health insurance, and any operative treatment before RTSA., Outcome Measures and Comparisons: The primary outcome measure was reoperation within 2 years following RTSA. A risk-adjusted, restricted cubic spline was used to model the probability of reoperation according to the time elapsed between PHF and RTSA to identify a time point at which the risk of reoperation significantly increased. A multivariate logistics regression was used to identify predictors., Results: In total, 891 patients (685 acute, 206 delayed) underwent RTSA for PHF. The acute cohort had a significantly lower reoperation rate (3.9%) compared with the delayed cohort (8.3%) (P = 0.02). The odds of reoperation increased with a delay to RTSA greater than 28 days and continued to rise until 100 days after fracture. Patients who underwent RTSA 28 days after PHF were found to have a significantly higher odds of reoperation by 2 years (P = 0.03)., Conclusions: Among patients undergoing RTSA for acute PHFs, a delay to surgery greater than 28 days is associated with a greater odds of reoperation and may be useful when counseling patients., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT)., Methods: We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates., Results: Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases., Conclusion: Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: This study aims to evaluate the clinical application efficacy of the ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator in the treatment of difficult-to-reduce pediatric Salter-Harris II type proximal humerus fractures., Methods: A retrospective analysis was conducted on children with Salter-Harris II type proximal humerus fractures, who failed manual closed reduction from January 2018 to March 2022. The group consisted of 7 males and 2 females, aged between 10 and 14 years. The surgical method involved percutaneous leverage reduction using the ultrasound-guided Joystick technique, combined with Kirschner wires and external fixation. Throughout the procedure, ultrasound is used for monitoring, with the fracture condition being determined before surgery. An external support screw is inserted into the distal end of the humerus as an operating lever, along with 3.5 mm Kirschner wire for ultrasound-guided reduction and maintenance of position during the operation. Following fixation with Kirschner wire, a combination external fixator is applied. After fixation is completed, ultrasound is used once more to assess the quality of fracture reduction, followed by verification of the reduction status using a C-arm X-ray machine., Results: All surgeries were successfully completed with a 100 % success rate in resetting. Notably, there were no postoperative complications like nerve or vascular injury, malunion, nonunion, or bone bridge formation in the proximal humeral physis. Three cases experienced minor complications (redness and swelling at the screw sites), which improved with conservative management. The follow-up period ranged from 6 to 18 months, averaging 10.6 months, with fracture clinical healing occurring within 6 to 8 weeks (average 6.3 weeks). The final follow-up revealed excellent functional outcomes, with Neer scores ranging from 90 to 100 (average 96.3 points)., Conclusion: The ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator can effectively treat difficult-to-reduce Salter-Harris II proximal humeral fractures in children, avoiding open reduction and minimizing intraoperative radiation exposure. This approach offers good stability and facilitates early rehabilitation, aligning with the ERAS (Enhanced Recovery After Surgery) concept in fracture management, thus warranting clinical promotion., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Acute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty., Hypothesis: We tested the hypothesis that cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant Score., Methods: A prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant Score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score, American Shoulder and Elbow Surgeons Score, and EQ5D-5L up to 2 years; differences in complication rate at 1 and 2 years; differences in revision and implant failure at 1 and 2 years., Results: Eighteen patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant Score at 12 months was better in the reverse polarity shoulder arthroplasty group (mean 51.1, s.d. 14.9) compared to the hemiarthroplasty group (mean 35.0, s.d. 13.5) (P = .004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5 L patient rated health status score was significantly higher in the reverse polarity shoulder arthroplasty group compared to the hemiarthroplasty group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded., Discussion: Treatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant Score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals., Methods: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF)., Results: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001)., Conclusions: Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The calcar of the proximal humerus is a fundamental structure for medial humeral column support. This study aimed to assess the outcome of osteosynthesis across cases of unstable proximal humerus fractures (PHFs) with medial calcar comminution, following treatment with a PHILOS locking plate and medial support screw (MSS)., Methods: Between January 2010 and December 2018, we retrospectively analyzed the outcomes of 121 cases of osteosynthesis for PHFs with medial column disruption. For the medial support, at least one oblique screw was inserted within 5 mm of the subchondral bone in the inferomedial quadrant of the humeral head. All patients were categorized into two groups: 26 patients in the single MSS group, and 95 in the multiple MSS group. Follow-up after at least an year involved clinical and radiographic outcome evaluations, and correspondingly measuring the Constant-Murley score, University of California, Los Angeles (UCLA) shoulder scale, pain visual analogue scale (VAS), major complications, neck-shaft angle (NSA), humeral head height (HHH), and the eventual time to bone union. Risk factors for the major complications were assessed by multivariate logistic regression analyses., Results: The cohort's mean age was 64.4 ± 15.4 years, and the mean follow-up duration was 19.5 ± 7.6 months. At the final follow-up, between the single MSS and multiple MSS groups, no significant differences in the Constant-Murley score (p = 0.367), UCLA score (p = 0.558), VAS (p = 0.571), time to bone union (p = 0.621), NSA loss (p = 0.424), and HHH loss (p = 0.364) were observed. The incidence of complications (p = 0.446) based on the number of MSS were not significantly different. The initial insufficient reduction after surgery (of NSA < 125°) was found to be a significant risk factor for post-surgical complications., Conclusions: To treat unstable PHFs, the use of at least one MSS along with a locking plate system is sufficient to achieve satisfactory outcomes. Successful operative treatment using a locking plate for PHF treatment is inherent in anatomical fracture reduction, coupled with medial column support., (© 2024. The Author(s).)

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Background: Little is known about the frequency and results of conservative treatment of proximal humerus fractures (PHF) in older individuals., Methods: Billing data of the BARMER health insurance carrier for all patients of age ≥ 65 for the years 2005-2021 were retrospectively analyzed with multivariable Cox regression models, taking account of the patients' age, sex, and individual comorbidity profiles. The defined primary endpoints were overall survival (OS), major adverse events (MAE), thromboembolic events (TE), and complications of surgery or of trauma. Multivariable p-values for the effect of treatment on all primary endpoints were jointly adjusted using the Bonferroni-Holm method., Results: Of 81 909 patients, 54% were treated conservatively. Conservative treatment was more common in those who received their diagnosis as outpatients (79.5%, vs. 37.2% for inpatients). Operative treatment was associated with significantly longer overall survival (long-term hazard ratio [HR] 0.89, 95% confidence interval [0.86; 0.91]), fewer MAE (0.90 [0.88; 0.92]), and fewer TE (0.89 [0.87; 0.92]), but more complications due to surgery or trauma (1.66 [1,.4; 1.78]; all p < 0.001). By 6 months after diagnosis, 3.1% of the patients who were initially treated conservatively had undergone surgery. Risk factors for failure of conservative treatment were alcohol abuse, obesity, cancer, diabetes mellitus, Parkinson disease, and osteoporosis., Conclusion: The conservative treatment of PHF is associated with a lower overall rate of complications due to surgery or trauma, but also with more MAE, more TE, and higher mortality. These findings underline the need for individualized and risk-adjusted treatment recommendations.

Purpose: Few studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback., Methods: In this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively., Results: 162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration., Conclusions: Our patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.)., (© 2024. The Author(s).)

Background: The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality., Methods: Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed., Results: 48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction., Conclusions: Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result., (© 2024. The Author(s).)

Objectives: The aim of the present meta-analysis was to compare the efficacy and safety of the carbon fiber-reinforced polyetheretherketone (CFR-PEEK) and titanium plate for the treatment of proximal humeral fractures (PHFs) from clinical comparative trials., Materials and Methods: A comprehensive search of English databases was carried out, such as PubMed, Web of Science, ScienceDirect, Springer and Cochrane Library databases. The RevMan version 5.1 software was applied for statistical analysis, and the mean difference (MD) and risk difference (RD) as the combined variables, and "95%" as the confidence interval (CIs)., Results: One randomized-controlled trial and five retrospective controlled studies including 282 PHFs were considered eligible and finally included. Meta-analysis demonstrated that there were significant differences in Constant score (CS) (MD=9.23; 95% CI: 5.02, 13.44; p<0.0001), anterior elevation (MD=18.83; 95% CI: 6.27, 31.38; p=0.003), lateral elevation (MD=18.42; 95% CI: 3.64, 33.19; p=0.01) and adduction (MD=3.53; 95% CI: 0.22, 6.84; p=0.04). No significant differences were observed regarding Constant score compared to the contralateral shoulder, Oxford Shoulder Score, internal rotation, external rotation, screw perforation and cutout, varus/valgus malalignment, humeral head collapse/necrosis, implant removal, and revision surgery between the two groups., Conclusion: Compared to titanium plate, CFR-PEEK plate showed better Constant score, anterior elevation, lateral elevation and adduction in treating PHFs. The complications are comparable to those achieved with conventional titanium plates.

Background: Open reduction and internal fixation (ORIF) using locking plates is a widely adopted treatment for displaced proximal humerus fractures. Various augmentation techniques have been developed to enhance the stability of plate fixation. Among these, iliac bone autograft is notable for its advantages over allografts, such as ready availability and the elimination of costs and risks associated with disease transmission. Despite its potential benefits, data on the outcomes of iliac bone autograft augmentation (IBAA) are still limited. This study aims to present the mid- to long-term results of treating proximal humerus fractures with ORIF using locking plates and IBAA., Methods: The study included 15 patients treated with ORIF and IBAA. We classified fracture patterns using the Neer classification and estimated local bone density via the deltoid tuberosity index. We measured the neck shaft angle (NSA) and humeral head height (HHH) on both immediate postoperative and most recent X-ray images to assess the maintenance of reduction. Clinical outcomes were evaluated using the DASH (Disabilities of the Arm, Shoulder, and Hand) and Constant scores., Results: The average follow-up duration was 59.56 months, ranging from 24 to 93 months. A majority of fractures were classified as four-part (53%). The average immediate and late postoperative NSAs were 132.6±8.19 and 131.6±7.32 degrees, respectively. The average HHH on the immediate postoperative and latest follow-up images were 16.46±6.07 and 15.10±5.34, respectively. None of the patients exhibited any radiological signs of avascular necrosis or loss of reduction at the latest follow-up. The mean postoperative Constant and DASH scores at the latest follow-up were 79.6 and 11.5, respectively., Conclusion: Our findings suggest that ORIF with IBAA is an effective method for managing three- or four-part proximal humerus fractures, yielding excellent outcomes.

Objective: To compare the clinical efficacy of the minimally invasive locking plate technique (Philos plate) and interlocking intramedullary nailing technique (TRIGEN intramedullary nail) in the treatment of Neer two-part and three-part proximal humeral fractures., Methods and Materials: The clinical data of 60 patients with Neer two-part and three-part proximal humerus fractures admitted to the hospital from April 2017 to April 2021 were retrospectively analyzed. Thirty-two patients were treated with the minimally invasive locking plate technique (minimally invasive plate group), and 28 patients were treated with the interlocking intramedullary nailing technique (intramedullary nail group). The operation time, intraoperative blood loss, incision length, fracture healing time, and postoperative complications were compared between the two groups. The ASES score and Constant-Murley score were used to evaluate the shoulder joint function of the two groups one year after surgery., Results: All 60 patients were followed up for 12 to 24 months, with an average of 16 months. There was no significant difference in operation time, intraoperative blood loss, incision length, or fracture healing time between the two groups (P > 0.05). The incidence of postoperative complications in the intramedullary nail group was significantly lower than that in the minimally invasive steel plate group, and the difference between the groups was statistically significant (P < 0.05). There was no significant difference in the ASES score or Constant-Murley score between the two groups one year after surgery (P > 0.05)., Conclusion: The use of the minimally invasive locking plate technique and interlocking intramedullary nailing technique in the treatment of Neer two-part and three-part proximal humerus fractures has the advantages of a small incision, less blood loss, and a high fracture healing rate, and both can achieve satisfactory clinical effects. The internal nail technique is more convenient than the minimally invasive locking plate technique in controlling postoperative complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Isolated greater tuberosity (GT) fractures typically occur in younger patients following high-energy trauma compared to humeral neck fractures. Surgical treatment is indicated when superior displacement is > 5 mm. This study aimed to assess the complications and long-term outcomes of surgically-treated GT fractures., Methods: A retrospective review of 39 patients who underwent surgery from 2010 to 2014 was conducted. The cohort comprised 54.6% females, with an average age of 56.74 years and a median follow-up of 6.71 years. Only 25 patients returned for reevaluation, with functional outcomes assessed using Constant-Murley score., Results: Women were older than men (63.00 ± 12.15 vs. 48.65 ± 16.93, p = 0.006). 18/39 patients (46.1%) sustained avulsion-type, 1 patient out of 39 (2.6%) depression-type, and 20/39 patients (51.3%) split-type fractures. The mean Constant-Murley score was 84.08 ± 18.36, with higher scores observed in men (p = 0.021). Avulsion-type fractures were related to higher postoperative scores compared to split fractures (p = 0.069). Post-surgical complications occurred in 20.5% of patients, with no differences noted between sexes, fracture types, or procedures., Conclusion: This study enhances understanding of the long-term outcomes of surgically-treated GT fractures, aiding in treatment selection. Interfragmentary screws may be preferable in younger male patients, but are associated with the higher risk of reintervention, particularly in fragile bone. Prospective multicentric studies are warranted to further elucidate long-term results and treatment strategies., (© 2024. The Author(s).)

Background: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature., Methodology: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this., Results: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks)., Conclusion: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases., (© 2024. The Author(s).)