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Proximal humeral fractures are among the most common fractures seen in emergency departments. Accurately diagnosing and selecting the most appropriate treatment for these fractures can be challenging, and consultation with a senior orthopedic surgeon can be time-consuming for both the patient and the emergency unit. We developed a machine learning model for predicting the type of treatment based on injury radiographic images. The model distinguishes between nonoperative and operative treatment options, achieving an accuracy of 86% and an interobserver reliability (kappa) of 0.722 for test-dataset, which is more than the interobserver agreement between shoulder surgeons. This model has the potential to serve as a therapeutic decision support system for the practitioners in the emergency departments to expedite treatment decisions and to reduce patients' waiting time.

Aims: The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs., Methods: The CNN was trained and tested on radiographs sourced from 11 hospitals in Australia and externally validated on radiographs from the Netherlands. Each radiograph was paired with corresponding CT scans to serve as the reference standard based on dual independent evaluation by trained researchers and attending orthopaedic surgeons. Presence of a fracture, classification (non- to minimally displaced; two-part, multipart, and glenohumeral dislocation), and four characteristics were determined on 2D and 3D CT scans and subsequently allocated to each series of radiographs. Fracture characteristics included greater tuberosity displacement ≥ 1 cm, NSA ≤ 100°, shaft translation (0% to < 75%, 75% to 95%, > 95%), and the extent of articular involvement (0% to < 15%, 15% to 35%, or > 35%)., Results: For detection and classification, the algorithm was trained on 1,709 radiographs (n = 803), tested on 567 radiographs (n = 244), and subsequently externally validated on 535 radiographs (n = 227). For characterization, healthy shoulders and glenohumeral dislocation were excluded. The overall accuracy for fracture detection was 94% (area under the receiver operating characteristic curve (AUC) = 0.98) and for classification 78% (AUC 0.68 to 0.93). Accuracy to detect greater tuberosity fracture displacement ≥ 1 cm was 35.0% (AUC 0.57). The CNN did not recognize NSAs ≤ 100° (AUC 0.42), nor fractures with ≥ 75% shaft translation (AUC 0.51 to 0.53), or with ≥ 15% articular involvement (AUC 0.48 to 0.49). For all objectives, the model's performance on the external dataset showed similar accuracy levels., Conclusion: CNNs proficiently rule out proximal humerus fractures on plain radiographs. Despite rigorous training methodology based on CT imaging with multi-rater consensus to serve as the reference standard, artificial intelligence-driven classification is insufficient for clinical implementation. The CNN exhibited poor diagnostic ability to detect greater tuberosity displacement ≥ 1 cm and failed to identify NSAs ≤ 100°, shaft translations, or articular fractures., Competing Interests: R. W. A. Spek received payments of an amount between USD 10,000 and USD 100,000 from the Flinders Foundation (Adelaide, Australia) for the purpose of this study. During the study period, R. W. A. Spek received payments of an amount between USD 10,000 and USD 100,000 from Prins Bernhard Cultuurfonds (Amsterdam, the Netherlands), Stichting Zabawas (The Hague, The Netherlands), and with an amount of less than USD 10,000 from Michael van Vloten Foundation (Rotterdam, The Netherlands) and Anna Fonds NOREF (Mijdrecht, the Netherlands), all of which were unrelated to this specific study. B. Jadav provided paid consultations for Johnson & Johnson, unrelated to the current study. G. I. Bain received a Flinders Foundation grant for this study, paid to Flinders University, as well as royalties or licenses from Fusetec, stock or stock options in Fusetec, and speaker payments or honoraria from Depuy Synthes and Medartis, none of which are related to this study. G. I. Bain also holds fiduciary roles in the Australian Hand Surgery Society, the Shoulder and Elbow Society of Australia, the Asia Pacific Wrist Association, the International Federation for the Societies for Surgery of the Hand, and the Journal of Wrist Surgery. J. L. Jaarsma is an unpaid executive of the Australian Orthopaedic Association. B. Jadav received a one-off consultation payment and payment for teaching courses from Johnson & Johnson, unrelated to this study. M. P. J. van den Bekerom receives fellowship support from Smith & Nephew, which contributed to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Introduction: The combination of anterior large glenoid rim fractures (GRF) and proximal humerus fractures (PHF) is rare, with limited data available on specific treatments for these glenohumeral combination fractures (GCF). This study aimed to evaluate the treatment approaches for GCF, analyze patient outcomes, and outline surgical management strategies for different fracture types., Materials and Methods: This retrospective study included patients with GCF, excluding those with fossa glenoidalis fractures, isolated greater tuberosity fractures, or small glenoid rim fractures (< 5 mm). Preoperative radiographs, CT scans, and follow-up radiographs were reviewed. Clinical outcomes were assessed using the Constant-Murley Score (CMS), Western Ontario Shoulder Instability Index (WOSI), Rowe Score (RS), and Oxford Shoulder Score (OSS)., Results: Sixteen patients with 17 GCFs (mean age 62 years) were followed for an average of 39 months. PHFs were categorized into three-part (76%), four-part (12%), and two-part fractures (12%). The average medial displacement of GRF was 5 mm, with an average dehiscence of 4 mm in the sagittal plane. Fourteen patients (88%) underwent surgical treatment; 35% had only the PHF surgically addressed, while 53% had both lesions surgically treated. Two patients (12%) received non-operative treatment. Complications were observed in 29% of cases, primarily involving the humeral side. The average CMS was 68 points, WOSI was 75%, RS was 77 points, and OSS was 41 points., Conclusion: Treating GCF is complex and routinely necessitates surgical intervention, with or without GRF refixation. CT imaging is crucial for precise assessment of fracture morphology. The involvement of the minor tuberosity is critical in selecting the optimal surgical approach and managing the subscapularis muscle., (© 2024. The Author(s).)

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.)

Case: We report a case of a lesser tuberosity avulsion fracture in a 14-year-old adolescent boy who presented to Orthopaedic Urgent Care where he was promptly diagnosed after magnetic resonance imaging. The patient was successfully treated with an open transosseous equivalent suture repair 3 weeks after initial injury., Conclusion: The purpose of this case report was to advance the understanding of these injuries, enable appropriate diagnosis and treatment, and optimize patient's shoulder outcomes and return to sport., 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/C477)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

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: 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).)

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.)

Introduction: In displaced pediatric proximal humerus fractures (PHF), surgical treatment ranges from closed to open procedures. Soft tissue interposition can impede closed reduction, making open techniques necessary. While K-wire fixation and elastic stable intramedullary nailing (ESIN) lead to good results, plate fixation could be an alternative in patients with limited growth potential and highly unstable or insufficiently retained fractures. Only few studies with low sample sizes have assessed plate fixation, yet. In this study, the outcome of pediatric PHFs treated with plate fixation was evaluated., Materials and Methods: We present a retrospective case series of 18 patients with open growth plates and unilateral, displaced PHFs, treated with plate fixation. The mean age at trauma was 12.1 years (± 2.4), the mean follow-up was 6.52 years (± 4.37). A mean fracture angulation of 32.3° (± 10.89°) was seen. Postoperative assessments included range of motion, clinical scores [Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Pediatric/Adolescent Shoulder Score (PASS), Disabilities of Arm, Shoulder and Hand (DASH) Score], radiological parameters and subjective satisfaction., Results: All patients showed excellent results in SST (99.4% ± 0.02), SSV (98.3% ± 0.04), ASES-score (100% ± 0) and PASS (0.99 ± 0.01). In the DASH-score, 17 patients had excellent results, one patient showed a good outcome. Fracture healing occurred in all patients without complications. Eight patients complained about bothering scars. Age, gender and fracture morphology did not affect the outcome. Revision surgery after secondary fracture dislocation did not show a worsened outcome compared to primary plate fixation. Physeal growth plate bridging implants did not worsen the outcome. The timing of implant removal within the first 6 months postoperatively did not affect long-term function., Conclusion: Plate fixation is a safe option in pediatric patients with limited growth potential and highly displaced PHFs. Plate fixation led to a good to excellent functional outcome, regardless of fracture morphology and implant positioning. A higher invasiveness and the need for implant removal must be considered., Competing Interests: Declarations Conflict of interest The authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s).)

Purpose: Proximal humerus fractures account for 4-5% of all fractures in adults and affect females more than males. With the advent of special locking plates, the treatment trend has shifted more towards a surgical approach. These methods have produced good results but very high complications rates have been reported in the literature. This study was undertaken to analyse the radiological parameters which reflect towards a favourable long term functional outcome in order to advance the surgical fixation skills for managing fractures of the proximal part of the humerus., Materials and Methods: 83 study participants with proximal humerus fracture fixed using proximal humerus locking plates were retrospectively analysed. The radiological parameters studied were neck shaft angle, head shaft angle, head diameter, head height, greater tuberosity to articular surface distance and reduction of the medial hinge with or without placement of calcar screw. The functional parameters assessed were the Constant Murley Score and range of movements of the shoulder joint. The patients were not followed further for the purpose of the study., Results: The mean Constant Murley Score for the participants was 80.75 ± 8.09 (range 60-90). The participants with good to excellent CM Score had a significantly higher neck shaft angle (107.47 ± 9.74 v/s 124.16 ± 10.68) and (-0.28 ± 0.85 v/s 2.37 ± 2.28), head shaft angle (23.09 ± 4.82 v/s 31.76 ± 7.76), head diameter (40.08 ± 8.63 v/s 45.15 ± 4.73), head height (18.77 ± 1.96 v/s 20.69 ± 2.76) and greater tuberosity to articular surface distance (-0.28±0.85 v/s 2.37±2.28) as compared to the patients with satisfactory and worse CM Score. The patients with a higher neck shaft angle and a maintained subacromial space had a better range of shoulder abduction. A higher rate of valgus collapse was seen with an inadequate medial hinge reduction., Conclusion: The radiological parameters which can predict towards a good functional outcome are a higher neck shaft angle and head shaft angle, a larger head diameter and head height, a superior position of the greater tuberosity in relation to the articular surface and a good medial hinge reduction., Competing Interests: Declarations Ethics approval The study was conducted after taking due clearance from the Institutional Ethics Committee, Sri Ramachandra Institute of Higher Education and Research, on 10/02/2022. Informed consent Informed consent was obtained from all the participants before enrolling in the study. Consent to Publish The authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 2, 3 and 4. Competing interests The authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

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.)

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 The role of post-reduction radiography in patients with shoulder dislocation remains controversial. Therefore, this retrospective study of 1076 cases of shoulder dislocation at a single center in Türkiye aimed to evaluate the role of post-reduction radiography in the detection of clinically significant fractures. MATERIAL AND METHODS Patients with radiographically confirmed anterior shoulder dislocation were included in the study, and their demographic data, mechanism of injury, pre- and post-reduction radiograph readings, reduction method, and patient outcome were recorded. The study analyzed patients who had pre- and post-reduction anterior-posterior and axillary shoulder radiographs. RESULTS During the 44-month study period, a total of 1076 patients were examined, and their pre- and post-reduction radiographs were reviewed by an independent radiologist. Of these patients, 27 (2.6%) had a fracture on their pre-reduction radiographs, while 32 (3.1%) had a fracture on their post-reduction radiographs. The difference between the 2 groups was not statistically significant (P=0.142). The study found that patients who did not undergo a post-reduction radiograph spent an average of 106 min in the emergency department, while patients who had the radiograph and were discharged spent an average of 237 min. The hospital stay of patients who had the radiograph was also significantly longer (P<0.01). CONCLUSIONS Our study supports that routine use of post-reduction radiographs in all cases of anterior shoulder dislocation may not be necessary and could potentially expose patients to unnecessary radiation exposure and healthcare costs. Shortening the examination time in the emergency department by not taking a follow-up radiograph will help prevent overcrowding.

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.)

Aims: Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries., Methods: A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis., Results: A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae., Conclusion: The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological 'red flags' which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention., Competing Interests: None declared., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Introduction: To evaluate the relationship between initial displacement in proximal humeral fractures and fatty degeneration of the rotator cuff measured by CT according to the Goutallier classification., Material and Methods: This cross-sectional observational study evaluated patients with proximal humeral fractures over a six-month period. The study included patients ≥ 18 years old with complete radiological views (anteroposterior, lateral, and Grashey) and a CT scan of the affected shoulder; previous fracture or ipsilateral shoulder surgery were excluded. Neer's classification system and Goutallier stages were used to evaluate the patients. Demographic data were collected and, two groups were analysed according to age (≤ 50 years and > 50 years)., Results: Sixty-two patients were included (m = 36, f = 26, ratio 1.3:1); seven patients were excluded. Male patients (36, 58.1%), patients older than 50 years (33, 53.2%) and a low-energy injury mechanism (36, 58.1%) were the most frequent cases. According to the Neer system, the most common proximal humerus fracture was fracture-dislocation in 17 (27.4%) cases. The most common stage in Goutallier's classification was I (some fatty streaks) in 22 (35.4%) cases. Younger patients (≤ 50 years) had more displaced fractures with low fatty degeneration (p = < 0.001) than older patients (> 50 years), who had minimally displaced fractures with greater fatty degeneration (p = 0.567)., Conclusions: High-energy mechanisms are associated with younger patients and a more displaced fracture according to the Neer classification. Older patients had a more advanced Goutallier stage and lesser displaced fracture. We should consider a more aggressive approach in the treatment of non-displaced fractures in elderly patients, less conservative and more surgical management, to obtain a better clinical evolution after the treatment of these kinds of fractures., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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: Treatment of proximal humerus fractures remains controversial. Understanding the factors that can affect the long-term functional outcomes can aid with management choices. This primary aim of this paper is to evaluate the association of radiographic parameters with functional outcomes., Methods: Radiographic parameters [Caput-collum-diaphyseal (CCD) angles, Y-scapular angles, and humeral head height (HHH)] were studied. The patients were split into varus and valgus groups based on the CCD angles and retroverted and anteverted groups based on Y-scapular angles. Functional outcome was measured by Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), and quick Disabilities of Arm, Shoulder and Hand score at 1 year follow-up. Intra- and interrater reliability were measured with the intraclass correlation coefficients (ICCs). Receiver operator curve (ROC) analysis and logistic regression analysis defined the optimal value for abnormalities on radiographic evaluation as an outcome predictor., Results: 111 patients were recruited (mean age 69, 78% female). Median final radiographic assessment was at 7 months. Mean initial/final CCD was 119 o /111 o (varus, n = 36) and 153 o /140 o (valgus, n = 75). Mean initial/final Y-scapula angle was 27 o /27 o (retroversion, n = 101) and 70 o /40 o (anteversion, n = 9). There was a significant relationship between OSS and final Y-scapular angle in the retroverted group (adj coeff 0.034, p = 0.009) with optimum predictive retroversion angulation of 25 o predicting poor functional outcome (OSS < 40), area under the ROC curve of 0.614. Higher initial valgus and retroversion significantly predicted more change in the final angle (adj coeff - 0.349, p = 0.002, adj coeff - 0.527, p < 0.001 respectively). Both intra-rater and inter-rater reliability for the radiographic parameters were excellent (ICC > 0.9)., Conclusion: Radiographic parameters whilst having excellent reliability, have a limited ability to predict short-term functional recovery. The extent of retroversion is the most important predictor for functional recovery with 25 o a cut-off guide. Fractures with a higher initial valgus and retroversion tend to displace more., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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: 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).)

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).)

Background: Reverse shoulder arthroplasty (RSA) is a frequently used therapy for complex proximal humeral fractures and posttraumatic disorders. The present study's purpose was to assess the clinical and radiological outcome of primary and secondary RSA, and to analyze the impact of refixation of the greater tuberosity (GT)., Patients and Methods: 28 patients with primary fracture RSA and 18 patients with RSA due to posttraumatic disorders were examined with a mean clinical follow-up of 2.5 ± 1.73 years. Operative details and radiographs were retrospectively reviewed. Additional analyses were performed for healed and non-healed GT in primary RSA., Results: Patients with fracture RSA had higher Constant-Murley score (CMS) than secondary RSA without reaching significance (p = 0.104). No significant difference was present for the quality of life measured by the Short Form 36 (SF 36) and the range of motion. In primary RSA, 78.6% GT healed anatomically. Compared to non-healed GT, patients with healed GT had a significantly higher CMS (p = 0.011), external rotation (p = 0.026) and forward flexion (p = 0.083), whereas DASH score was lower without a significant difference (p = 0.268). SF 36 showed no significant difference. Patients with healed GT had a more neutral glenoid version (p = 0.009)., Conclusion: Superior range of motion and clinical outcome scores were present for anatomically healed GT. Therefore, refixation of the tuberosities is recommended. Secondary RSA can result in inferior results compared to primary RSA, so patients need to be adequately informed., (© 2024. The Author(s).)

Background: There are concerns as to the reliability of proximal humerus radiographic measurements, particularly regarding the rotational position of the humerus when obtaining radiographs., Methods: Twenty-four patients with proximal humerus fractures fixed surgically with locked plates received postoperative anteroposterior radiographs with the humerus in neutral rotation and in 30° of internal and external rotation. Radiographic measurements for head shaft angle, humeral offset and humeral head height were performed in each humeral rotation position. Intra-class correlation coefficient was used to assess inter-rater and intra-rater reliability. Mean differences (md) in measurements between humeral positions was evaluated using one-way ANOVA., Results: Head shaft angle demonstrated good-to-excellent reliability; the highest estimates for inter-rater reliability (ICC: 0.85; 95% CI: 0.76, 0.94) and intra-rater reliability (ICC: 0.96; 95% CI: 0.93, 0.98) were achieved in neutral rotation. There were significant differences in measurement values between each rotational position, with mean head shaft angle of 133.1° in external rotation, and increasingly valgus measurements in neutral (md: 7.6°; 95% CI: 5.0, 10.3°; p < 0.001) and internal rotation (md: 26.4°; 95% CI: 21.8, 30.9°; p < 0.001). Humeral head height and humeral offset showed good-to-excellent reliability in neutral and external rotation, but poor inter-rater reliability in internal rotation. Humeral head height was significantly greater using internal compared to external rotation (md: 4.5 mm; 95% CI: 1.7, 7.3 mm; p = 0.002). Humeral offset was significantly greater in external compared to internal rotation (md: 4.6 mm; 95% CI: 2.6, 6.6 mm; p < 0.001)., Conclusions: Views of the humerus in neutral rotation and 30° of external rotation displayed superior reliability. Differences in radiographic measurement values, depending on humeral rotation views, can make for problematic correlations with patient outcome measures. Studies assessing radiographic outcomes following proximal humerus fractures should ensure standardized humeral rotation for obtaining anteroposterior shoulder radiographs, with neutral rotation and external rotation views likely yielding the most reliable results., Level of Evidence: Level IV., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Context: Minimally invasive (MI) approaches are purported to present advantages for osteosynthesis when compared with conventional approaches. This study aimed to compare the medium-term clinical and radiological outcomes of patients with proximal humerus fractures treated by plate osteosynthesis with conventional and MI superolateral approaches., Method: The study carried out was a retrospective monocentric comparative analysis. Forty-three cases were followed up - 18 were treated with an MI approach and 25 with a conventional approach. Constant-Murley, DASH and SSV scores were established and standard complications were investigated., Results: No significant differences in functional scores or complications were found between the 2 groups. The only significant difference was for pain which was significantly lower for the MI group. The overall revision rate was 18.3 %. The mean adjusted Constant-Murley for the entire population was 80.1 ± 20.2; the mean DASH score was 17.8 ± 15.9 and the mean SSV was 73.2 ± 19.5., Conclusion: This study did not demonstrate any significant differences between the 2 approaches. Given the low patient population in our series, the superiority of the MI approach - as indicated in the literature - was not proven., Competing Interests: Declaration of competing interest The authors have declared no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality., Methods: Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs., Results: All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side., Discussion: A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head., Conclusion: Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results., Competing Interests: Declaration of competing interest The authors have declared no conflict of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Case: A 34-year-old man was a restrained passenger involved in a high-speed rollover motor vehicle crash. The patient sustained a type 5 AC joint separation, severely comminuted intra-articular glenoid fracture with extension to the coracoid process base, displaced open scapular body fracture, a posterior shoulder dislocation of the glenohumeral joint, and a 2-part proximal humerus fracture., Conclusion: To our knowledge, this is the first report describing this injury pattern involving the superior shoulder suspensory complex with an associated open proximal humerus fracture-dislocation., 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/C357)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Background: This systemic review and meta-analysis aimed to evaluate the clinical outcomes of proximal humeral fracture in elderly patient fixation using locked plate with or without cement augmentation., Methods: The databases of PubMed, Embase, and Cochrane Library were searched in August 2023 for literature comparing the clinical outcomes of patients with PHFs treated with locked plate alone and locked plate augmented with cement. Data describing study design; level of evidence; inclusion criteria; demographic information; final follow-up; revision rate; implant failure rate; avascular necrosis rate; total complication rate; constant score; and disability of arm, shoulder, and hand (DASH) score were collected., Results: Eight studies (one randomized-controlled trial and seven observational studies), involving 664 patients, were identified. Compared with locked plates alone, using cement-augmented locked plates reduced the implant failure rate (odds ratio (OR) = 0.19; 95% confidence interval (CI) 0.10-0.39; P < 0.0001) and total complication rate (OR = 0.45; 95% CI 0.29-0.69; P = 0.0002) and improved DASH scores (mean difference (MD) = 2.99; 95% CI 1.00-4.98; P = 0.003). However, there was no significant difference in clinical outcomes, including revision rate, avascular necrosis rate, and constant score., Conclusion: In this review and meta-analysis, fixation of the PHFs in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. Good results are expected for most patients treated with this technique., Trial Registration: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines were followed to conduct this systematic review and meta-analysis and was registered as a protocol in PROSPERO (CRD42022318798)., (© 2024. The Author(s).)

Case: A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus., Conclusion: Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors., 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/C346)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA)., Methods: Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores., Results: Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0)., Conclusion: The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis., Level of Evidence: III Retrospective Cohort Comparison Study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Acromion and scapular spine fractures (ASFs) following reverse total shoulder arthroplasty (RSA) have been reported at a rate of 3.9%. The location of the fracture has been shown to be an important factor in determining the outcomes of nonoperative treatment, with medial fractures having worse outcomes than lateral fractures. As the debate between operative and nonoperative treatment continues, a more precise understanding of the location of the fracture is necessary for effective management. The purpose of this study was to use 3-dimensional computed tomography (CT) reconstruction to characterize the exact location of ASFs after RSA., Methods: A retrospective review of 2 separate institutional shoulder and elbow repositories was performed. Patients with post-RSA ASFs documented by post-fracture CT scans were included. The query identified 48 patients who sustained postoperative ASFs after RSA between July 2008 and September 2021. CT scans of patients with ASFs were segmented using Mimics software. Eight patients were excluded because of poor image quality. Each bone model was manipulated using 3-Matic Medical software to align the individual scapula with an idealized bone model to create a view of scapular fracture locations on a normalized bone model. This model was used to classify the fractures using the modified Levy classification., Results: The study cohort consisted of 40 patients with a diagnosis of postoperative ASF after RSA. The median age at the time of surgery was 76 years (interquartile range, 73-79 years). The cohort comprised 32 women (80%) and 8 men (20%), with a median body mass index of 27.8. Only 10 patients (25%) had a previous diagnosis of osteoporosis and 6 (13%) had a diagnosis of inflammatory arthritis; 53% of patients underwent RSA owing to rotator cuff tear arthropathy. The distribution of fracture locations was similar within the cohort. However, lateral fractures were slightly more prevalent. The most common fracture location was the type I zone, with 12 fracture lines (29%). There were 11 fracture lines (26%) in the type IIa zone, 10 (23%) in the type IIb zone, 0 in the type IIc zone, and 9 (21%) in the type III zone., Conclusion: ASFs after RSA occur in 4 predictable clusters. No fractures appeared to distinctly cluster in the type IIc zone, which may not represent a true fracture zone. Understanding the distribution of these fractures will help to enable the future design of implants and devices to stabilize the fractures that require fixation., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment., Methods: A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected., Results: 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001)., Conclusion: We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Due to first promising long term outcome data, reverse shoulder arthroplasty experienced an immense increase of usage during the past decade. Moreover, the initial Grammont concept has constantly been refined and adapted to current scientific findings. Therefore, clinical and radiological problems like scapular notching and postoperative instability were constantly addressed but do still remain an area of concern.This article summarises current concepts in reverse shoulder arthroplasty and gives an overview of actual indications like cuff tear arthropathy, severe osteoarthritis, proximal humerus fractures, tumours, fracture sequelae as well as revision surgery and their corresponding clinical and radiological results., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach., Methods: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study., Results: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented., Conclusion: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible., 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.

Introduction: The purpose of this prospective study was to examine clinical results of tuberosity refixation in RSA for the treatment of displaced PHF in elderly patients. We hypothesized that tuberosity refixation would increase clinical outcome., Methods: In this prospective study, 50 patients were included after receive a primary RSA for complex proximal humeral fracture between March 2013 and December 2015 for follow-up after three, 12 and 24 months. A functional and radiological assessment was performed on the patients., Results: At final follow-up after a mean period of 25.1 months, data were available for 30 women and 6 men (74% of the included overall study collective) with a mean age of 77 years (range 55-93 years) at time of surgery. The tuberosities were refixated in 74% (n = 37) and in 26% (n = 13) resected. RSA with tuberosity refixation resulted in better clinical shoulder function compared to RSA with non-refixated tuberosities. The data show an external rotation with a significant difference (24.9° vs. 14°, p < 0.05) in favor of participants with refixation. The raw CMS was statistically significant (71.3 vs. 56.3, p < 0.05) after refixation, and SSV was significant improved (82.7% vs. 68%, p < 0.05) in the same group. Among 3 of 50 patients a total of 3 complications occurred with a total of 6% surgical revision., Conclusions: In this prospective study, tuberosity refixation as part of fracture treatment using RSA results in better external rotation, subjective assessment of shoulder recovery (measured by SSV and by raw CMS) in elderly patients, compared with tuberosity excision., Level of Evidence: II, Prospective comparative study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: Up to 59% of undisplaced greater tuberosity (GT) fractures are missed on initial evaluation. Timely diagnosis of these injuries can avoid undue morbidity, but a clinical sign to accurately identify them has not previously been described. Magnetic resonance imaging (MRI) remains the gold standard for their assessment but may not be routinely available, or difficult to organize urgently. We aimed to evaluate the diagnostic efficacy of a new clinical sign (the anterior bruise sign [ABS]), in diagnosing radiologically occult GT fractures., Methods: Over a 4-year period, 59 patients who sustained a traumatic shoulder injury with no fracture on initial radiographs were referred to a specialist shoulder clinic within a week of their injury and enrolled in a prospective observational cohort study. At initial presentation, the presence of anterior arm bruising extending to the mid-diaphysis was recorded as a positive ABS. MRI assessment of the injured shoulder was performed in all patients at first follow-up. Presenting radiographs, 2-week radiographs, and MRI scans were reviewed by a musculoskeletal radiologist. The diagnostic value of a positive ABS was compared with 2-week radiographs, and other clinical tests., Results: The mean age of the cohort was 58.5 (range 30-79) years, and 27 (45.8%) were female. The mean time from injury to first follow-up was 6.9 (standard deviation 2.4) days. MRI revealed that 25 of 59 patients (42.4%) had an undisplaced GT fracture. The overall accuracy of the ABS in identifying occult GT fractures was 98% (sensitivity = 100%, specificity = 97%, positive predictive value = 96%, negative predictive value = 100%, P < .001). In contrast, radiographs taken at 2 weeks postinjury were less accurate (71.2%) (P < .001), and other clinical assessments of cuff function had much lower accuracy., Conclusion: In patients presenting with a traumatic shoulder injury with normal radiographs, the ABS is a highly sensitive and specific clinical aid to identify patients with an occult GT fracture., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Aims of our study were to define whether the great tuberosity (GT) positioning fixation in reverse shoulder arthroplasty (RSA) after proximal humeral fracture (PHF) could predict tuberosity healing and its impact on clinical outcomes., Methods: We enrolled 59 patients treated with cementless reverse shoulder arthroplasty after PHF in our institute between 2012 and 2018. The mean follow-up was 57 months (± 23.4). We divided patients into two groups according to GT positioning after fixation: Group 1 GT in contact and Group 2 GT detached at least 1 mm from humeral diaphysis. Clinical and radiographic evaluations were conducted at last follow-up., Results: Overall GT healing rate was 64.4%, (Group 1 70.7%-Group 2 50%). A statistically significant difference (P = 0.047) was found in cortical thickness narrowing at one-third of stem length. We found a correlation between lateral cortical narrowing and GT fixation in non-anatomical position, but we observed no statistically significant differences about GT healing according to GT anatomical or non-anatomical fixation. No differences were found in shoulder function in patients whose tuberosity was healed or failed to heal., Conclusion: GT reduction is not a predictive factor for GT healing; external stress shielding, instead, seems to be decreased in patients with postoperative anatomically reduced GT. In our study, GT healing did not affect clinical outcomes or patient's satisfaction in elderly low-demanding patients., (© 2023. The Author(s), under exclusive licence to Istituto Ortopedico Rizzoli.)

Background: Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far., Methods: Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years)., Results: Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up., Conclusion: The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: Proximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study's objective is to show that preoperative planning performed while handling a three-dimensional (3D) printed anatomical model of the fracture can ensure a better understanding of trauma for both surgeons and patients., Materials and Methods: Twenty patients (group A, cases) with complex PHF were evaluated preoperatively by reproducing life-size, full-touch 3D anatomical models. Intraoperative blood loss, radiographic controls, duration of surgery, and clinical outcomes of patients in group A were compared with 20 patients (group B, controls) who underwent standard preoperative evaluation. Additionally, senior surgeons and residents, as well as group A patients, answered a questionnaire to evaluate innovative preoperative planning and patient compliance. Cost analysis was evaluated., Results: Intraoperative radiography controls and length of operation were significantly shorter in group A. There were no differences in clinical outcomes or blood loss. Patients claim a better understanding of the trauma suffered and the proposed treatment. Surgeons assert that the planning of the definitive operation with 3D models has had a good impact. The development of this tool has been well received by the residents. The surgery was reduced in length by 15%, resulting in savings of about EUR 400 for each intervention., Conclusions: Fewer intraoperative radiography checks, shorter surgeries, and better patient compliance reduce radiation exposure for patients and healthcare staff, enhance surgical outcomes while reducing expenses, and lower the risk of medicolegal claims., Level of Evidence: Level I, prospective randomized case-control study., (© 2024. The Author(s).)

Objective: Proximal humeral fracture combined with contralateral midshaft clavicle fracture is an extremely rare injury in children. Few studies focus on the injury mechanism and treatment scheme. The aim of this study is to propose the possible mechanism of this injury and present the treatment results., Methods: This retrospective study included children diagnosed with proximal humeral fractures combined with contralateral midshaft clavicle fractures from August 2016 to March 2019 in the corresponding author's institution. The patients received elastic stable intramedullary nails and external fixation as treatment. The radiological and clinical outcomes of treatments were evaluated using the imaging and the Constant-Murley score (CMS) in follow up., Results: Twelve patients (eight males and four females) with an average age of 7.83 years old (age 5-12) were included in this research. All the patients had suffered a side impact in a road traffic accident or outdoor environment. Hypothesis about the mechanism was the proximal humerus was directly impacted at first and caused the surgical neck fracture, then the contralateral shoulder hits the solid object and the contralateral midshaft clavicle was fractured. During the average 45.2 months (range 36-57) follow-up, all the patient's fractures achieved clinical and radiological union before 14 weeks without complications. Every patient had a satisfactory score (range from 92 to 100) on the CMS criteria for both shoulders., Conclusion: The hypothesis about the mechanism of this combined injury in this study sounds reasonable. It highlights the need for safety-related education about using a safety seat or wearing a seat belt to parents and caregivers, so as to avoid such injury even if the treatment with external fixation (EF) and proximal humeral and elastic stable intramedullary nailing (ESIN) showed good results., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Purpose: This study aims to determine the stress shielding and other radiological outcomes of patients who underwent an uncemented reverse shoulder arthroplasty (RSA) with an anatomic proximal coated stem for complex proximal humeral fractures (PHF) with 3 or 4 parts at 2 years postoperatively., Methods: 37 shoulders underwent an uncemented RSA for PHF from November 2015 to February 2019 and were followed up for 2 years. A radiographic assessment of stress shielding, filling ratio, stem stability (radiolucent lines/subsidence/alignment), tuberosity healing and notch was performed., Results: The mean age at the time of surgery was 72 years (range, 61-85). Stress shielding was appreciated in 31 shoulders (83.8%). The most important characteristic of stress shielding is cortical resorption: Grade 3 resorption occurred in 3 shoulders (8.1%) and grade 4 in 23 (62.2%) as per the grading system defined by Inoue et al. (Inoue et al. in J Shoulder Elbow Surg 26:1984-1989, 2017). A high occurrence of bone resorption was observed in Gruen zones 2 (Lateral Stress shielding) and 7 (Medial Stress shielding). The mean distal filling ratio in patients without stress shielding was 78,48(SD 14,9), whereas in patients with stress shielding, it was slightly higher with a mean of 81,68% (SD 4,89). Tuberosity healing was found in 94.6% (35/37) of the shoulders. No patient had any radiolucent line. No notch was observed., Conclusion: At short-term follow-up, a high rate of tuberosity healing was achieved (94.6%) even though stress shielding was found in 83.8% (31/37) of the shoulders. Bone resorption was most frequently observed externally at zone 2 (Lateral stress shielding) and internally at zone 7 (Medial stress shielding). A higher filling ratio was associated with an increased occurrence of stress shielding. The uncemented anatomic humeral component did not result in early loosening., Level of Evidence: IV; Case Series; Treatment study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Fracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae., Methods: Patients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant-Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed., Results: In total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients., Conclusion: Due to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification., Level of Evidence Iv: Case series., (© 2023. The Author(s).)

Purpose: Proximal humeral fractures cause large intramedullary bone defects after humeral-head reduction. Hydroxyapatite/poly-L-lactide (HA/PLLA) materials are widely used for various fractures. However, the efficacy of endosteal strut using a HA/PLLA mesh tube (ES-HA/PLLA) with a locking plate for treating proximal humeral fractures was not reported. The purpose of this study is to examine the efficacy of ES-HA/PLLA with a proximal humeral locking plate in proximal humeral fractures., Methods: Seventeen patients with proximal humeral fractures treated using ES-HA/PLLA with a locking plate from November 2017 to November 2021 were evaluated. The range of motion of the shoulder and postoperative complications were assessed at the final follow-up. Radiographs were evaluated to assess bone union and loss of reduction by measuring humeral-head height (HHH) and humeral neck-shaft angle (NSA)., Results: The average flexion and external rotation of the shoulder at the final follow-up were 137° (range, 90-180°) and 39° (range, - 10 to 60°), respectively. All fractures were united. The average HHH and NSA just after the surgery and final follow-up were 12.5 mm and 11.6 mm and 129.9° and 127.4°, respectively. Two patients presented screw perforation of the humeral head. One patient underwent implant removal due to infection. Avascular necrosis of the humeral head was observed in one patient with arthritis mutilans., Conclusions: The use of ES-HA/PLLA with a proximal humeral locking plate resulted in bone union in all patients and prevented postoperative loss of reduction. ES-HA/PLLA is one of the treatment options for proximal humeral fractures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN)., Methods: We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN., Results: The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head., Conclusion: Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Imaging techniques such as X-rays and 3D Computed Tomography (CT) are used to diagnose and evaluate a patient's shoulder before and after surgery. Identifying the kind, location, and severity of a shoulder fracture helps surgeons choose the right treatment and surgery., Objectives: The study examines the effectiveness of small incision reduction and superior closure pinning in treating Ideberg type III glenoid fractures identified by X-ray and CT scans., Materials and Methods: From October 2017 to June 2022, 40 patients with Ideberg type III glenoid fractures underwent mini-incision reduction and superior closed pinning fixation using the Anterior (AA) and Posterior (PA) approaches. Pre- and post-surgery shoulder scores and imaging data were analyzed. Outpatient review and shoulder anteroposterior radiographs were collected at 1, 3, 6, and 12 months after surgery. We assessed shoulder joint function using the American Shoulder and Elbow Society (ASES) shoulder score, VAS score, Constant-Murley Shoulder Outcome (Constant) score, and DASH score., Results: A total of 40 patients were monitored for 14-16 months, averaging 15.2 ± 0.3 months. All fractures were healed between 14-25 weeks from X-rays, averaging 17.6 ± 5.4 weeks. Both the AA and PA groups had similar shoulder score changes. However, the AA group did better. In all cases, ASES shoulder scores were outstanding at 80%. Radiographs demonstratedno traumatic arthritis or internal fixation failure consequences like screw loosening or breakage., Conclusion: It was concluded that Ideberg type III glenoid fracture reduction with an anterior small incision and superior closed pinning hollow lag screw internal fixation could be successful., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing open reduction and internal fixation (OR/IF) using a plate or patients undergoing an arthroscopic suture anchor fixation for the greater tuberosity (GT) fracture of the proximal humerus. The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing OR/IF or an arthroscopic suture anchor fixation for the GT fracture., Materials and Methods: Between January, 2010 and December, 2020, 122 patients with GT fracture underwent operative fixation. Either OR/IF using proximal humeral locking plate (50 patients) or arthroscopic suture anchor (72 patients) fixation was performed. Fourteen patients were lost to follow-up and finally, 108 patients were enrolled in this study. We divided these patients into two groups: (1) OR/IF group (Group I: 44 patients) and arthroscopic anchor fixation group (Group II: 64 patients). The primary outcome was subjective shoulder function (shoulder functional scale). Secondary outcomes were range of motion, and complications including GT fixation failure, fracture migration, or neurologic complication. Also, age, sex, BMI, operation time, shoulder dislocation, fracture comminution, AP (anteroposterior), SI (superoinferior) size and displacement were evaluated and compared between two groups., Results: Both groups showed satisfactory clinical and radiological outcomes at mid-term follow-up. Between 2 groups, there were no significant differences in age, sex, BMI, presence of shoulder dislocation or comminution. Group II showed higher clinical scores except VAS score (p < 0.05) and longer surgical times (95.3 vs. 61.5 min). Largest fracture displacement (Group I vs. II: SI displacement: 40 vs. 13 mm, and AP displacement: 49 vs. 11 mm) and higher complication rate (p = 0.049) was found in Group I., Conclusions: Both arthroscopic anchor fixation and open plate fixation methods showed satisfactory outcomes at mid-term follow-up. Among them, OR/IF is preferred for larger fracture displacement (> 5 mm) and shorter operation time However, arthroscopic anchor fixation group showed better clinical outcomes and less complications than the OR/IF group., Level of Evidence: Level 4, Case series with subgroup analysis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up., Methods: Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years., Results: There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years., Conclusions: Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)