Background: This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures. Methods: Between January 2016 and April 2018, 86 patients (mean age: 65.2 +/- 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n= 36) or locked plating without the lavage (group NL, n=36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up). Results: One year after open reduction and internal fixation, the mean Constant score was 70 +/- 14 (group L, n=31) compared with 73 +/- 14 (group NL, n=31, P=.272). The mean forward flexion and abduction in group L was 134 +/- 33 and 128 +/- 33 as compared with 139 +/- 32 and 135 +/- 32 in group NL, respectively (P=.538, P=.427). The mean external rotation was 40 +/- 16 (group L) compared with 44 +/- 16 (group NL) (P=.210). The overall complication rate was 9.6% and did not differ significantly between the groups (P=.321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P=.742). Conclusion: The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up. Level of evidence: Level 1; Randomized Controlled Trial; Treatment Study (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

BACKGROUND:This study compared the clinical and radiologic outcomes of screw tip-augmented locking plate osteosynthesis vs. standard locked plating in elderly patients with displaced proximal humeral fractures. METHODS:Of the 94 patients older than 65 years with displaced proximal humeral fractures, 55 underwent fixation with a locking plate only whereas 39 underwent fixation using a locking plate with fluoroscopy-controlled polymethyl methacrylate augmentation of screw tips. RESULTS:At 2 years' follow-up, the locking plate-only group showed a mean Constant score (CS) of 62.6 ± 17.4 points, mean CS as a percentage of the uninjured side of 78.2% ± 18.9%, and mean age- and sex-adjusted CS of 72.4 ± 20.5 points. Among the 39 patients who underwent locked plating with polymethyl methacrylate augmentation of screw tips, the mean CS was 63.7 ± 18.5 points (P = .28), the mean CS as a percentage of the uninjured side was 79.5% ± 20.4% (P = .36), and the mean age- and sex-adjusted CS was 76.8 ± 26.2 points (P = .11). The mean Disabilities of the Arm, Shoulder and Hand score was 26.4 ± 21.3 in the locking plate-only group compared with 23.6 ± 19.2 in the group with screw tip-augmented locking plate osteosynthesis (P = .41). The overall complication rate was 16.3% in the locking plate-only group compared with 12.8% in the group with screw tip-augmented osteosynthesis (P = .86); loss of fixation occurred in 10.9% vs. 5.1% (P = .74). The follow-up rate was 81%. CONCLUSIONS:Loss of fixation was less frequent when augmentation of screw tips was performed; however, at the 2-year follow-up, the clinical and radiologic outcomes were not significantly different compared with standard locked plating without augmentation.

IntroductionSecondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies.Materials and methodsThe databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively.ResultsOut of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II-IV and study quality was 26-70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients' clinical outcome. None of the studies showed relevant augmentation-associated complication rates.ConclusionsAugmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs' stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.

INTRODUCTION:To evaluate outcomes following open reduction and internal fixation of displaced proximal humeral fractures with regards to the surgeon's experience.MATERIAL AND METHODS:Patients were included undergoing ORIF by use of locking plates for displaced two-part surgical neck type proximal humeral fractures. Reduction and functional outcomes were compared between procedures that were conducted by trauma surgeons [TS], senior (>2 years after board certified) trauma surgeons [STS] and trauma surgeons performing ≥50 shoulder surgeries per year [SS]. Quality of reduction was measured on postoperative x-rays. Functional outcomes were assessed by gender- and age-related Constant Score (nCS). Secondary outcome measures were complication and revision rates.RESULTS:Between 2002-2014 (12.5 years) n = 278 two-part surgical neck type humeral fractures (AO 11-A2, 11-A3) were included. Open reduction and internal fixation was performed with the following educational levels: [TS](n = 68, 25.7%), [STS](n = 110, 41.5%) and [SS](n = 77, 29.1%). Functional outcome (nCS) increased with each higher level of experience and was significantly superior in [SS] (93.3) vs. [TS] (79.6; p = 0.01) vs. [STS] (83.0; p = 0.05). [SS] (7.8%) had significantly less complications compared with [TS] (11.3%; p = 0.003) and [STS](11.7%; p = 0.01) moreover significantly less revision rates (3.9%) vs. [TS](8.2%) and [STS](7.4%) (p<0.001). Primary revision was necessary in 13 cases (4.7%) due to malreduction of the fracture.CONCLUSION:Quality of reduction and functional outcomes following open reduction and internal fixation of displaced two-part surgical neck fractures are related to the surgeon's experience. In addition, complications and revision rates are less frequent if surgery is conducted by a trauma surgeon performing ≥50 shoulder surgeries per year.

Die arthroskopische Weichteilstabilisierung ist ein etabliertes Verfahren zur Therapie der posttraumatischen Schulterinstabilität. Zu den Vorteilen zählen im Vergleich zur offenen Stabilisierung die bessere Visualisierung des strukturellen Schadens und die geringere Invasivität. Technische Fortschritte haben in den letzten Jahren die arthroskopische Therapie der Schulterinstabilität weiter verbessert. In diesem Beitrag werden bewährte Techniken erläutert und neue Entwicklungen beleuchtet. Dabei werden die Grundlagen wie die Patientenpositionierung, Portale, Präparation des Glenoids, Gewebedurchstechung und Shuttle-Techniken erklärt; ebenso werden die modernen Ankersysteme zur Weichgewebsfixierung mit den jeweiligen Vor- und Nachteilen dargestellt. Darüber hinaus werden Limitationen und Langzeitergebnisse der arthroskopischen Weichteilstabilisierung diskutiert.

Arthroscopic soft tissue stabilization is a well-established and broadly accepted procedure to treat posttraumatic shoulder instability. Advantages in comparison to open stabilization procedures include improved visualization of the structural damage and a less invasive approach. Technical developments in recent years have led to further improvement of the arthroscopic technique for shoulder instability. This article presents a description of principles and new developments as it contains basic techniques including patient positioning, access portals, preparation of the glenoid bone, soft tissue handling and shuttle techniques. Modern suture anchor systems to achieve arthroscopic stabilization with the corresponding advantages and disadvantages are also presented. Furthermore, the limitations and long-term results of arthroscopic soft tissue stabilization are discussed.

Background. Aim of the study was to evaluate clinical outcomes 5 years following locked plating for proximal humeral fractures and to identify risk factors for a poor outcome.Methods. 467 patients with displaced proximal humeral fractures were treated by open reduction and locking plate fixation between 02/2002 and 02/2012. 228 patients (follow-up rate 48.8 %) were followed by use of the Constant and DASH score. Final follow-up was performed after a median of 5.7 years (95 % CI: 5.4; 6.1).Results. Of 228 patients, 68.9 % female (mean age 65.7 years, 95 % CI: 63.6; 67.7) and 31.1 % male (mean age 55.5 years, 95 % CI: 52.3; 58.6) the absolute Constant Score (CS) five years after surgery was 75.5 (95 % CI: 72.6; 78.4). The normalized CS (nCS) was 85.5 (95 % CI: 81.6; 89.3) and the CS in percentage to the contralateral side (% CS) was 84.5 % (95 % CI: 81.1; 87.9). The shoulder function was rated "excellent" (100-86 points) in 41.7 %, "good" (85-71) 24.1 %, "moderate" (70-56) 19.3 % and "poor" (< 56) 14.9 %. The CS at five years correlated negatively with patient age (r = -0.2, p < 0.01) and with the occurrence of revision surgery (r = -0.3, p < 0.01).Conclusions. Five years after locked plating of displaced proximal humeral fractures patients show good to excellent outcomes in 2/3 of cases. However, worse long-term outcomes are observed in 15 % of cases, particularly in patients of higher age that underwent revision surgery.

Ziel dieser Studie war es, das klinische Outcome bei Patienten mit dislozierter proximaler Humerusfraktur und winkelstabiler Plattenosteosynthese 5 Jahre postoperativ zu erheben und Risikofaktoren für ein schlechtes Ergebnis zu identifizieren.

The treatment of comminuted three and four part fractures of the proximal humerus in elderly patients with degenerative rotator cuff tears is challenging. Primary reverse total shoulder arthroplasty (RSA) is an alternative; however, functional outcome is still unclear due to a lack of study results. The aim of this study was to examine the functional results of RSA and to compare them with the results after reconstruction and locking plate osteosynthesis 1 year after surgery. In this study 24 patients (mean age: 77.9 +/- 9.1 years) underwent RSA as primary treatment for three and four part fractures of the proximal humerus with either head split or rotator cuff tears > Bateman type II. The results obtained at 3, 6 and 12 months follow-up included shoulder range of motion (ROM), Constant score, age-adjusted and gender-adjusted Constant score and as a percentage when compared to the uninjured side. Data were compared to patients of matching age, gender and fracture pattern from a prospectively collected database of 526 patients treated by locking plate osteosynthesis. The mean shoulder ROM 1 year after surgery was 105 +/- 29A degrees flexion, 99 +/- 31A degrees abduction, 22 +/- 23A degrees external rotation and 65 +/- 26A degrees internal rotation. In 6 patients flexion-abduction was > 130A degrees. The mean Constant score (CS) 1 year postoperatively was 62.4 +/- 14, age and gender normalized CS was 79.2 +/- 20.5, CS compared to the uninjured side was 76.1% and there were no significant differences to matched individuals treated by open reduction and internal fixation using locking plates (p=0.360). There were no infections, dislocations, vascular or neural disorders and surgical revision was not necessary in any patient. RSA should be considered as an appropriate alternative for the primary treatment of comminuted three and four part fractures of the proximal humerus with head split or large rotator cuff tears in elderly patients. Although RSA can provide immediate shoulder stability for elderly patients with severe shoulder injuries, primary RSA needs investigation with regards to long-term outcome.

Die optimale Behandlung komplexer Frakturen des proximalen Humerus stellt gerade beim älteren Patienten mit reduzierter Knochenqualität und degenerativem Rotatorenmanschettenschaden eine Herausforderung dar. Die primäre Versorgung mit der inversen Frakturendoprothese ist ein Verfahren, über das bisher noch wenige Ergebnisse vorliegen. Ziel unserer Studie war es, das funktionelle Ergebnis 1 Jahr postoperativ zu erheben und mit dem Ergebnis nach Rekonstruktion und winkelstabiler Plattenosteosynthese zu vergleichen.

Anterior fracture dislocations are among the most severe forms of proximal humeral fractures. Because of potential devascularization of the humeral head, it is unclear whether open reduction and internal fixation (ORIF) offers superior results to primary hemiarthroplasty (HAS) or reverse shoulder arthroplasty (RSA). We retrospectively compared functional outcomes, complications, and revision surgeries after ORIF, HSA, and RSA in 81 patients with anterior fracture dislocations. Functional results were assessed with the age- and gender-normalized Constant Score (nCS). Of 81 anterior fracture dislocations, 40 (49.4%) were treated by ORIF (mean age 61.5 ± 13.9 years, range 29–89), 19 (12.3%) by HSA (mean age 71.6 ± 10.1 years, range 53–85), and 22 (27.2%) by RSA (mean age 79.8 ± 10.8 years, range 58–91). Of 81 patients (75.8% women, mean age: 67.4 ± 12.5 years, range 29–91 years), the mean nCS after 3.4 ± 2.9 years of follow-up was 63.4 ± 10.3 after ORIF, 52.4 ± 12.9 after HSA, and 74.5 ± 11.1 after RSA (ANOVA, p = 0.001). The complication rate in ORIF procedures was 22.5% (secondary displacement n = 2, avascular necrosis n = 7), in HSA, 36.8% (tubercle dislocation n = 4, tubercle resorption n = 2, septic loosening n = 1), and RSA, 13.6% (acromial fracture n = 1, tubercle displacement n = 1, tubercle resorption, n = 1; p < 0.001). Avascular necrosis was observed in 17.5% of cases following a primary head-preserving treatment. Treatment of anterior fracture dislocations is demanding. Open anatomic reduction and internal fixation can lead to good and excellent functional outcomes in young patients with good bone quality and should be performed in these patients as soon as possible. Elderly and frail patients may profit from RSA as a primary treatment. HSA should be reserved for cases where anatomic reduction and stable fixation in patients <65 years has failed; however, functional outcomes are poor.