Constant Scoring System Research Articles

Functional and radiological outcome of intramedullary interlocking nail in the treatment of fracture shaft of humerus

Fracture shaft of Humerus are one of the most common injuries of the arm caused by high velocity injury. Both direct and indirect forces act on it resulting in different fracture patterns. Based on the pattern humeral shaft fractures have been treated both by operative and nonoperative methods. Closed intramedullary nailing of these fractures has been the modality of choice for both segmental and communited fractures compared to plate and screw fixation. By this closed nailing procedure fracture complication, operative and post operative complications are reduced with good functional outcome and early restoration of pre morbid functions. The main purpose of the study was to evaluate the functional outcome and the role of locked intramedullary nailing in fracture shaft of humerus with respect to bone union, shoulder function and related complications. A study population was selected and was carried out with a total of 25 patients (male: 20, female: 5) treated with with intramedullary interlocking nail. The inclusion criteria were patients with closed humerus fracture less than 2 weeks and age more than 20 years. The selected patients were assessed both clinically and radiologically at regular intervals of 6 wks, 12 wks, 24 wks and 6 months thereafter till union. The functional outcome was accessed using Constant murley's scoring system. From our selected study sample we found majority of the patients had segmental fractures (70%) and others had communited fractures (30%). Based on the union, 80 % of patients showed full union by 12 weeks and 20 % showed full union by 16 to 20 weeks. We had 20 patients with excellent functional outcome at final follow-up while 5 patients had good outcome. Intramedullary interlocking nail is a quite safe, effective procedure associated with fast healing, good shoulder movements and reduced infection rates in humeral shaft fractures. Being a closed intramedullary procedure early mobilization and rehabilitation is possible with early restoration of premorbid functions.

Functional outcome following surgical management of proximal humerus fracture in elderly

Proximal humerus fracture accounts to about 4-5% of all the fractures and is the third most common fracture in the elderly population. Though several modalities of treatment exist there are no clear guidelines or consensus to the optimal method of treatment of these fractures especially in the elderly population. This study was based in a tertiary hospital with the objectives to assess the functional outcome of surgical treatment of proximal humerus fractures in the elderly population. Patients with proximal humerus fracture aged above 51 years and fulfilling the inclusion criteria were included in the study. The fractures were classified using Neer’s classification of proximal humerus fracture. Patients were treated surgically by [ORIF] and post-operatively limb is immobilized in arm pouch; mobilization was started at the second week as per patient’s tolerance. Patients were then followed up at 3 months, 6months and 12 months.They were assessed for functional outcome using Constant scoring system [Pain, activities of daily living and range of motion]. A total of 37 patients were included in the study. The mean age of the patients was 65.2 years. The study included 18 2-part fracture, 11 3-part fractures and 8 4-part fracture. The mean Constant score at 12-month follow-up in 2-part fracture was 66.2, in 3-part fracture was 59 and in 4-part fracture was 51.4. The overall mean Constant score was 60.2. In conclusion we areof opinion that treatment of proximal humerus fractures in the elderly population is a challenge and one should not deny them a good functional outcome. Patients with 2-part fracture fared better and has a satisfactorily good functional outcome. Whereas in 3-part and 4-part fractures the outcomes do not vary significantly and patients with 4-part fracture had higher incidence of surgery related complication.

Study of operated fracture mid shaft clavicle

Introduction: It is the study of mid shaft clavicle fracture treated with anatomical locking plates. We wanted to study to study the surgical management and to assess its functional outcome in displaced mid-shaft clavicular fractures. To study the duration of union, complications and compare the results of operated cases with other operative study and conservative study. Materials and Method: The study consist of 100 patients with mid shaft clavicle fracture. We have treated patient with anatomical locking plates. Clinical outcome and function results were evaluated by Constant and Murley scoring system. Result: We have operated total 100 cases with anatomical plate in mid-shaft clavicle fractures. Average union time was 11.7 week. We have achieved 80% of excellent result. Conclusion: Anatomical plate for mid-shaft clavicle fracture are as per shape of the bone. Anatomical reduction is possible and axial alignment and rotational stability is provided. As plates have groove on inner surface so it preserves the periosteal blood supply which will help in faster healing of the bone. Rigid fixation with plate and screws for fresh displaced or comminuted middle third clavicle fracture gives immediate pain relief and prevents the development of shoulder stiffness and non union.

Factors Influencing Functional Outcome of Philos Plate Fixation for Proximal Humerus Fractures

Introduction: Displaced and unstable proximal humerus fractures are difficult to treat and they have high morbidity. The main goal is to achieve painless shoulder with full recovery of the shoulder joint motion. Impingement syndrome is one of the commonest postoperative complication. This study aim is to appreciate the functional outcomes of Philos-plate fixation for proximal humerus fractures and to establish association with high plate positioning with impingement syndrome of the shoulder after Philos-plate fixation. Materials and method: This is a retrospective study, reviewing 26 patients who had proximal humeral fractures and underwent open reduction and Philos-plate fixation between December 2010 and January 2015 in Hospital Tengku Ampuan Afzan, Kuantan. Preoperative X-rays or CT scans were inspected, follow-up visits and X-ray images were obtained at every follow-up to evaluate the plate position and bone union. Assessments of impingement syndrome and other complications were done and also functional outcome measured with Constant shoulder scoring system during final follow-up. Results: Almost 70% of patients achieved good (Constant score: 71-85) to excellence (Constant score: 86-100) outcome, with 77.54 mean Constant score. All cases achieved union. None of the cases developed complications like malunion, infection, AVN, and loosening of implant while 2 cases complicated with shoulder impingement post operatively. Among all the factors, age more than 60 years, and high plate position found to be a significant factor in the outcome of the surgery where both factors yielded significantly less mean Constant scores. Neer 3 parts fractures have higher mean of Constant score compare to Neer 4 parts fractures and high plate position is significantly associated with impingement syndrome postoperatively. Conclusion: This study showed that age, fracture type and plate position were key factors affecting shoulder function after Philos locking plate fixation surgery. We recommend that plate should be position at most 10mm from the greater tubercle to prevent impingement syndrome postoperatively and for better functional outcome.

Short term outcome of use of proximal humerus locking plate as a treatment of proximal humerus fracture using constant score

Objective: This study focuses on short term outcome of use of proximal humerus locking plating as a treatment of proximal humerus fracture using Constant Score. Introduction: Proximal humerus fractures are one of the most common osteoporotic fractures. The major goal in the treatment of this fracture is to promote complication free healing to recreate a pain free mobile, stable and functional shoulder joint. We study the outcome of these fractures treated with proximal humerus locking plate. Methodology: A cohort of 20 proximal humerus fracture, treated with proximal humerus locking plate between Sep 2015 to Sep 2016 were analysed for minimum of 6 months and final result was analysed using Constant Score. Results: 75% patients had satisfactory results. Assessment was done using Constant Scoring System. No major complication was noted whatsoever.

Is PHILOS as good as it sounds to be? Analysis of complications and functional outcome of PHILOS plating

Aim: Proximal humeral fractures have posed a challenge for internal fixation. Among several methods, most recently, PHILOS (Proximal humeral Internal Locking system) plates have been promoted as most effective method to achieve fixation and union. However, there are no enough studies evaluating the complications and outcome of PHILOS plating. Some studies have shown complication rates ranging from 3.7% to 33.5%. So with this study, we aim to analyze the efficacy and the functional outcome following open reduction and internal fixation with PHILOS plate for displaced proximal humerus fractures. Methodology: In this study, we identified 38 patients in our orthopaedic unit treated surgically by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate from January 2013 to December 2016. All those patients who had a radiographic and regular clinical follow-up for at least 6 months were included in the analysis. Surgery was done for displaced 2-part, 3-part and 4-part proximal humerus fractures (Neer’s Classification) through deltopectoral approach during the time period. Six patients who did not fit into inclusion criteria, did not attend regular follow-up or had incomplete records were excluded from analysis. The study group comprising 32 patients was analyzed for complications and functional outcome by studying patient records and x-rays. The functional outcome was measured using Constant shoulder scoring system. Results: 68% of the patients were males (22 males and 10 females) and male to female ratio was 2.2:1. The mean age of the patients was 47 ± 16 years (Range 31-63 years). Involvement of left side proximal humerus fracture was more common (58%). 55% patients had 2-part fracture according to Neer’s classification. The range of movements at first, second and third follow ups increased gradually during subsequent follow ups. According to Constant Shoulder scores, 50% of the patients had excellent outcome followed by 21.9% good, 12.5% fair and 15.6% poor outcome. Total of 7 patients out of 32 had complications (21.8%) and most common complications noted were inadequate reduction, subacroimial impingement, adhesive capsulitis and loss of varus reduction. There were no nerve injuries or infection. Conclusion: Proximal humeral internal locking system (PHILOS) plate for the treatment of proximal humerus fractures leads to a satisfactory functional outcome in majority of the patients. However, functional results depend on correct anatomical reduction of the fracture and stable fixation. Complications still occur due to fracture severity and lack of technical expertise. However, complications like inadequate reduction, varus malalignment, subacromial impingement can still occur with this system. Varus malalignment was found to be a strong predictor of poor functional outcome

Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder.

Magnetic resonance (MR) imaging is common in structural and qualitative assessment of the rotator cuff post-operatively. Rotator cuff integrity has been thought to be associated with clinical outcome. The purpose of this study was to evaluate the inter-observer reliability of cuff integrity (Sugaya's classification) and assess the correlation between Sugaya's classification and the clinical outcome. It was hypothesized that Sugaya's classification would show good reliability and good correlation with the clinical outcome. Post-operative MR images were taken two years post-operatively, following arthroscopic rotator cuff repair. For assessment of inter-rater reliability, all radiographic evaluations for the supraspinatus muscle were done by two orthopaedic surgeons and one radiologist. Rotator cuff integrity was classified into five categories, according to Sugaya's classification. Fatty infiltration was graded into four categories, based on the Fuchs' classification grading system. Muscle hypotrophy was graded as four grades, according to the scale proposed by Warner. The clinical outcome was assessed according to the constant scoring system pre-operatively and 2 years post-operatively. Of the sixty-two consecutive patients with full-thickness rotator cuff tears, fifty-two patients were reviewed in this study. These subjects included twenty-three men and twenty-nine women, with an average age of fifty-seven years. In terms of the inter-rater reliability between orthopaedic surgeons, Sugaya's classification showed the highest agreement [ICC (2.1)=0.82] for rotator cuff integrity. The grade of fatty infiltration and muscle atrophy demonstrated good agreement, respectively (0.722 and 0.758). With regard to the inter-rater reliability between orthopaedic surgeon and radiologist, Sugaya's classification showed good reliability [ICC (2.1)=0.70]. On the other hand, fatty infiltration and muscle hypotrophy classifications demonstrated fair and moderate agreement [ICC (2.1)=0.39 and 0.49]. Although no significant correlation was found between overall post-operative constant score and Sugaya's classification, Sugaya's classification indicated significant correlation with the muscle strength score. Sugaya's classification showed repeatability and good agreement between the orthopaedist and radiologist, who are involved in the patient care for the rotator cuff tear. Common classification of rotator cuff integrity with good reliability will give appropriate information for clinicians to improve the patient care of the rotator cuff tear. This classification also would be helpful to predict the strength of arm abduction in the scapular plane. IV.

A prospective comparative study in the management of Neer’s type II and type III proximal humerus fracture with proximal humerus nail versus proximal humerus internal locking system

<p><strong>Background:</strong> Proximal humerus fractures account for approximately 4-5 % of all the fractures and are next in occurrence to hip fractures and distal radius fractures in elderly population.</p><p><strong>Methods:</strong> A prospective study of 40 patients with Neer’s type II and type III proximal humerus fracture, among which 20 were treated with proximal humerus nail and 20 with proximal humerus internal locking system at two Hospitals attached to J.J.M Medical College Davangere, Karnataka, India between September 2015 to December 2016. At final follow up results were assessed with constant shoulder scoring system.</p><p><strong>Results:</strong> In the PHN group, 8 patients (40%) showed excellent outcome, 8 patients (40%) showed good outcome and 4 patients (20%) showed fair outcome. Among the PHILOS group, 12 patients (60%) showed good outcome, 6 patients (30%) showed fair outcome and 02 patients (10%) with poor outcome.</p><p class="abstract"><strong>Conclusions:</strong> Proximal humerus nail for Neer’s type II and type III proximal humerus fracture has better results compared to proximal humerus locking plate system with increased range of movements and restoring better shoulder biomechanics.</p>

Functional outcome of conservative versus plate osteosynthesis in displaced midshaft clavicle fracture in manual labours

Background: Clavicle fracture is a one of most common shoulder injury which is commonly treated conservatively. Operative methods are used for open reduction and internal fixation of displaced fracture shaft clavicle with better functional outcome preserving the shoulder biomechanics needed for overhead manual workers. This study is aimed at study of functional outcome of different modalities of treatment used in treatment of displaced fracture midshaft clavicle in manual laborers.Methods: This study was conducted with permission of ethical committee in B.R.D Medical College, Gorakhpur, Uttar Pradesh, India. This study included 36 patients with closed displaced fracture midshaft fractures. Out of 36patients, 17 were treated conservatively using clavicle brace and sling and 19 patients were treated operatively by open reduction and internal fixation using reconstruction plate or AO pre-contoured plate. All patients were followed clinically and radiologically, regularly at 1 month duration for 18 months. Functional outcome both, conservative and operatively treated patients were assessed using constant and murley scoring system. Results: 17 patients treated conservatively had good to average functional results and 19 patients treated surgically had excellent functional outcome at 4 weeks of the treatment. At 12 weeks all fractures united well in operative group patients had better functional outcome with good range of shoulder abduction than conservative group of patients where in 4 patients fractures did not united and later underwent operative treatment to achieve fracture union. Average time of fracture healing in operative group was 8 weeks, less than time average time (12 weeks) taken by fracture healing in conservatively treated patients. Complication rate in conservatively treated group was tenting of skin and formation of discharging wound later, malunion, delayed fracture healing leading to shoulder stiffness and decreased shoulder abduction. Wound infection, implant failure or wound dehiscence like common complications were not seen in operative group.Conclusions: In manual laborers, clavicle fractures treated operatively had united early with excellent functional outcome and better shoulder abduction and early return to work with no complications in comparison to fractures treated conservatively.

Arthroscopic 360 degrees capsular release for treatment of adhesive capsulitis– A study of 40 cases

Introduction: Adhesive capsulitis, better known as frozen shoulder is a common disabling musculoskeletal disease, characterized classically by pain and restriction in range of motion. Management of this condition is controversial, ranging from non-operative to operative interventions, all intending to decrease pain and restore joint function. Arthroscopic capsular release has emerged as an effective surgical procedure for treating adhesive capsulitis. The aim of this study was to evaluate the results of arthroscopic capsular release for adhesive capsulitis Methods: Between February 2013 and May 2015, 40 patients underwent arthroscopic capsular release non responsive to conservative management. Patients having rotator cuff disease, osteoarthritis, history of fracture upper end humerus and bilateral adhesive capsulitis were excluded from the study. Patients were followed up for a minimum period of 11 months. Results were evaluated using Constant score, UCLA (University of California Los Angeles) and VAS (Visual Analog Scale) scoring system. Results: The mean age of the patients was 57.1 years, with 13 male (32.5%) and 27 female (67.5.5%) patients. The right and left shoulder were affected in 31 patients (77.5%) and 9 patients (22.5%) respectively. 21 patients were diabetic (52.5%), 6 patients had a history of trauma (15%) whereas 13 patients had primary idiopathic adhesive capsulitis (42.5%). Post-operatively, the mean time to achieve maximum pain relief was 1.7 months, whereas the mean time to achieve maximum gain in range of motion was 2 months. Mean preoperative range of motion (Anterior Elevation/ Abduction/ External Rotation/ Internal Rotation) was 98.20/36.30/21.10/13.80 whereas post-operatively it increased to 178.50/166.80/55.70/48.10. The average VAS, Constant and UCLA score was 8.7, 27.5 & 12.8, which improved to 2.3, 88.8 & 31.3 respectively.Conclusion: The results of arthroscopic capsular release for adhesive capsulitis are encouraging and provide an effective treatment modality to provide pain relief restore joint function in cases resistant to conservative management

Functional outcome following external fixator (JESS) application for proximal humeral fractures

<p class="abstract"><strong>Background:</strong> Proximal humeral fractures account for 5% of all fractures. Observed frequently in older osteoporotic patients but found in young patients with high-energy trauma.About 80% of these fractures are undisplaced or minimally displaced. Non-operative method requiring immobilization of shoulder often leads to a stiff shoulder, whereas surgical procedures such as plating need excessive soft tissue dissection. It was overcome in this study by less soft tissue dissection by use of external fixator application and early mobilization.</p><p class="abstract"><strong>Methods:</strong> Total of 18 patients mean age 40.5 years, predominantly male (16/18) treated with external fixator - JESS (Joshi’s external immobilization system) for Neer’s two, three and four part proximal humeral fractures. Vehicular accidents were the most common mode of injury followed by fall. There were 8 cases each of Neer's two and three part fractures. Shoulder mobilization started within a week as postoperativelyas pain allowed. Patients followed up at 3, 6, 12 and 18 weeks for pain, function, range of motion and anatomy with check X-ray. After radiological union at 8-10 weeks JESS was removed. Cases were evaluated for functional result by constant scoring system.<strong></strong></p><p class="abstract"><strong>Results:</strong> Average score on constant scoring system was 72 after a mean follow-up of 6 months. All fractures united in mean duration of 9.33 weeks. The complications included shoulder stiffness in one case and pin tract infection in two cases.</p><strong>Conclusions:</strong> Early shoulder mobilization a prerequisite for good results can be achieved without compromising fracture union. Less soft tissue dissection required and significant cost effective.

Functional outcome in surgical management of midshaft clavicle fractures fixed with precontoured plate in adults

Background: Fractures of clavicle are one of the most common fractures in traumatic injury around shoulder girdle as the bone is sub cutaneous throughout. Fractures of middle third clavicle generally occur either by high energy or low energy impact. These fractures have been treated traditionally by non-operative methods. Although many close reduction methods have been described it has been recognised that complete reduction is practically impossible. Open reduction and internal fixation have become the mainstay of treatment for most of the midshaft fractures, as these operative methods restores the anatomy, biomechanics and contact loading characteristics of the clavicle. Objectives: To study the functional outcome of surgically managed clavicle fractures with precontoured locking plate. Methods: A prospective study of 60 cases of midshaft clavicle fractures in adults, Managed surgically by open reduction and fixation with precontoured plate during the period from May 2014 to April 2016 satisfying the inclusion and exclusion criteria were studied. The functional outcome was evaluated using the Constant and Murley scoring system. Results: In our study we achieved 93.4% excellent to good results, 5% fair results, 1.6% Poor results. The results were comparable to other studies. Interpretation & Conclusion: The operative results were satisfactory in 93.4% cases, with good to excellent functional outcome. This study shows rigid fixation with precontoured plate and screws for fresh displaced or comminuted middle third clavicle fracture gives good anatomical reduction, immediate pain relief and prevents the development of shoulder stiffness and non-union and thus on the whole shows good functional outcome by early mobilisation and hence patient to their functional activities.

Comparison of deltoid-splitting approach versus deltopectoral approach for the management of proximal humeral fractures with Philos plate

Fractures of the proximal humerus represent approximately 4% of all fractures and 26% of humerus fractures. Three and four-part fractures (13-16% of proximal humerus fractures) have been a challenge to achieve stable fixation. Difficulties have been multifactorial, including osteoporotic bone, angular instability, implant impingement, loss of reduction and backing out of screws. A total of 22 patients with proximal humeral fractures were divided in two groups, in Group A, patient’s classical deltopectoral approach utilized, while in Group B deltoid-splitting approach was used. All patients were managed by PHILOS plate fixation. Cases were followed up clinically as well as radiologically at 2 weeks , 6 weeks, 12 weeks, 3 months , 6 months and one year. Functional outcomes of patient were accessed in terms Constant Scoring System, while radiological evaluation was done by taking x-rays to access quality of reduction and union of fracture. All patients were followed for a minimum of 18 months. In Group B, reduction of greater tuberosities was better in 3 part and 4 part fractures. Mean Constant score in Group A at the end of 3 months was 46, while in Group B it was 62 and statistically significant (P = 0.02). At the end of 18 months, mean Constant score in Group A was 67, while in Group B it was 68 and statistically insignificant (P = 0.72). Complications like One fracture (open)in group A was associated with deep infection, loss of reduction of fracture in one patient in group B & primary screw perforation in one patien in group B. There were no nonunions, osteonecrosis and implant breakage. We recommend deltopectoral aproach for calcar reconstruction in 3 & 4 parts fracture and deltoid splitting for greater tuberosity reduction in 2, 3 & 4 parts fracture.

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

ObjectiveDescribe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described. Material and methodsThis retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25years±7(range, 17–49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed. ResultsAfter a mean follow up of 25±4months (range 14–38), the results of the Constant (CS) were 94.1±5,5 (range 76–100) and test ACJI 87.3±9,8 (range 65–100), showing no significant differences with the uninjured shoulder (CS 95.8±2.5, range 83–100; ACJI 94.1±3.7, range 80–100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75±1.97mm to 8,73mm±0.75 and the acromioclavicular distance (Alexander View) from 12,65mm±1.99 to 0,35±0.3mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes. ConclusionTwin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.

Locking compression plate in humeral shaft nonunion: a retrospective study of 18 cases

<p class="abstract"><strong>Background:</strong> Humeral shaft nonunions are frequently seen in Orthopaedic practice. Osteosynthesis with bone grafting is the treatment of choice. Locking compression plate (LCP) is the latest implant used in treating them. We retrospectively evaluated the outcome of use of LCP in humeral shaft non-union resulted by both conservative management and following failed internal fixations.</p><p class="abstract"><strong>Methods:</strong> Eighteen patients with nonunion of humeral shaft in which ten were treated by traditional bone setters and eight followed by failed internal fixation were included in these study. The mean duration of nonunion was 18.3 months (range 8-22). The mean follow up period was 18 months (range 12-26). The mean age of patients was 44.4 years (range 22-60). All patients underwent osteosynthesis with LCP and autologoous cortico-cancellous iliac crest graft. The outcome measures include radiographic assessment of fracture union and preoperative and postoperative function using modified constant and murley scoring system.<strong></strong></p><p class="abstract"><strong>Results:</strong> All fractures united following osteosyntesis average time for union was15 weeks (range 10-24). We did not have any delayed union or non-union. The complications were superficial infection (n=1) and wound haematoma (n=1).Three patients with preoperative radial nerve palsy recovered at the end of four months. Functional evaluation using constant-murley score showed excellent result in 14, good in 3 and fair in 1. We did not have any poor results.</p><strong>Conclusions:</strong> LCP with cancellous bone grafting is a safe reliable option for all forms of humeral shaft nonunion. We recommend it.

Long endomedullary nail in proximal third humeral shaft fractures

IntroductionProximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new “Long” humeral nail for this type of lesion and identify the best distal locking. Materials and methodsForty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four‐part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. ResultsImprovements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. ConclusionsThe results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. Study designretrospective, cohort of cases. Level of evidenceIV.

Short-term Results of Robinson Type 2B2 Clavicular Fractures Treated Conservatively or Surgically.

The most frequently treated injuries, representing approximately 82% of all clavicular fractures, involve the midshaft clavicle. Historically, most acute displaced midshaft clavicular fractures were treated nonsurgically. However, the outcomes of nonsurgical treatment have recently been thought to be not as good as expected in the past, and the trend is to treat these fractures surgically. The goal of this study was to evaluate the short-term clinical outcomes of Robinson type 2B2 clavicular fractures treated conservatively vs with locked plate fixation. Among 59 patients included in the study, 30 patients (mean age, 45±13.7 years; range, 30-62 years) treated conservatively were designated as group A, and 29 patients (mean age, 38.8±11.1 years; range, 20-60 years) treated with locked plate fixation were designated as group B. All patients were evaluated using Oxford and Constant scoring systems at final follow-up. Mean follow-up was 18 months (range, 12-24 months). In group A, mean Constant score was 70.5±15.1 (range, 98-43) and mean Oxford score was 46.6±1.3 (range, 49-44) at final follow-up. In group B, mean Constant score was 89.2±8 (range, 100-77) and mean Oxford score was 46.5±1.2 (range, 48-44) at final follow-up. Callus was detected radiographically in both groups at 6-week follow-up. Patients in groups A and B started active range-of-motion exercises at weeks 6 and 3 after treatment, respectively. Locked plate fixation of Robinson type 2B2 clavicular fractures can be the first treatment option because of good clinical results, low complication rates, and good cosmesis.

Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications

PurposeThe optimal surgical treatment of displaced type B and C fractures of the proximal humerus in the elderly remains controversial. Good clinical results have been reported by plating these fractures as well as a high rate of complications. Our retrospective study aims to evaluate clinical recovery and complications using the S3 locking plate in elderly patients. MethodsFifty-one patients older than 65 years of age, with a complex proximal humeral fracture type B or C (AO classification system), were included. Patients have been followed up for a minimum of 12 months. We assessed callus formation, radiological results, clinical outcome (according to the Constant Shoulder Score System) and complications. Any difference in the clinical recovery among the 2 types of fracture pattern (B and C) was investigated. ResultsThe mean time of fracture healing was 12.4 weeks. The mean Constant score at 3, 6 and 12 months was 68, 73 and 75 respectively. No statistically significant difference in the clinical outcome was observed between the B and C fracture patterns (p > 0.05). We noticed an overall of 5 complications (9.8%). There was no need to revision any of the implants. ConclusionAnatomic reduction and proper plate positioning are essential for minimizing implant-related complications. In our experience the S3 angular stability system offers a proper osteosyntesis and a good clinical recovery with a low rate of complications.

Posterior bone block: a reliable method to treat recurrent nonlocked posterior shoulder dislocation with engaging reverse Hill–Sachs lesion

Background Posterior shoulder dislocation was first reported in 1839 by Sir Astley Cooper. Hill and Sachs, in 1940, stated that with any dislocation event the soft bone of the humeral head impacts against the harder, sharper edge of the glenoid, leading to an impression fracture of the posterosuperior head in recurrent anterior dislocation. A reverse Hill–Sachs lesion is an impression fracture in the anterosuperior head in recurrent posterior dislocation. In 1952, McLaughlin described his surgical technique to treat an anterior impression fracture of the humerus after recurrent posterior shoulder dislocation. Hypothesis Our hypothesis is to prove that posterior bone block augmentation of the posterior glenoid is a safe and reliable line of treatment in cases of recurrent posterior instability with engaging reverse Hill–Sachs lesion. Patients and methods Between March 2009 and March 2011 five cases were referred to us with chronic recurrent posterior shoulder dislocation with engaging reverse Hill–Sachs lesion. The mean age of the patients was 28 years (range: 20–36 years). There were two left and three right shoulders. All patients were male. All patients were manual workers. All sustained traumatic dislocations through nonathletic accidents. None of the patients had epileptic fits before. Preoperatively, the mean active forward elevation was 140° (range: 130°–150°) and external rotation with the arm at the side was 35° (range: 20°–50°). Preoperative constant score average was 40 points (range: 30–50 points). The mean time interval between injury and surgery was 12 months (range: 8–16 months). All cases had engaging reverse Hill–Sachs lesion. None of the cases had significant posterior glenoid bone loss. All patients were treated with open posterior bone block augmentation of the posterior glenoid harvested from the anterior iliac crest. Results Patients were evaluated at 3, 6, 12, and 24 months. Range of motion was recorded and follow-up radiographs were taken to evaluate graft incorporation. The mean follow-up time for the five patients was 30 months (range: 24–36 months). At 6 months postoperatively, the mean forward elevation was 165° (range: 160°–170°) and external rotation with the arm at the side was 55° (range: 40°–70°). Patients were evaluated postoperatively according to the constant score system (maximum: 100 points). We found a mean postoperative constant score of 87.5 points (range: 80–95 points), a fairly good result considering the nature of bone loss. Conclusion The posterior bone block can successfully restore the stability and function of the shoulder in patients with recurrent posterior dislocations with significant engaging reverse Hill–Sachs lesion in which arthroscopic soft-tissue reconstruction is not a reasonable option. This technique can be used for combined soft tissue and bony defects as well as for revisions after previous soft-tissue reconstructions.

Impact of plate Osteosynthesis on Functional Outcome in displaced midshaft Clavicular Fractures: a prospective observational study

Introduction: Fractures of the clavicle are common, accounting for 2.6-4% of adult fractures and 35% of injuries to the shoulder girdle. Fractures of the shaft account for 69-82% of all fractures. Prevalence of non-union or mal-union in displaced midshaft clavicular fractures after conservative treatment is higher than previously presumed. Plate fixation can help obtain firm anatomical reduction in severe displaced or comminuted fracture. We have taken up this study to evaluate the functional outcome after plate osteosynthesis ofclavicular fractures. Materials and Methods: This is a prospective study done in Department of Orthopedics at tertiary care teaching hospital in central India over period of 1 year. The patients who presented with fracture clavicle and fulfilled the inclusion criteria were studied. Functional outcome was evaluated using modified Constant and Murley scoring system. Results: 24 patients of displaced midshaft clavicle fracture matching inclusion criteria were included in this study. Follow up evaluation of the patients was done at the desired interval with a minimal follow up of 6 months. 52.17% were in the age group of 20-29 years. 73.91% of patients studied were males. Type-2 middle third fracture type-2 B1 was encountered in 78.26 % of patients. The mean modified Constant Shoulder Score was 65.39 with range 48-72. In this study 17 patients (73.91 %) had very good functional outcome. Conclusion: Use of locking plates for displaced midshaft clavicle fractures results in early union with very good functional outcome and is associated with very low complication rates.