Neer Scoring Research Articles

Osteoperiosteal decortication and extracortical bone-bridging for treatment of atrophic humeral nonunions

Objective To assess the effectiveness of osteoperiosteal decortication and extracortical bone-bridging in the treatment of atrophic humeral nonunions. Methods Nineteen patients with atrophic humeral nonuninon were treated by osteoperiosteal decortication and extracortical bone-bridging between March 2008 and April 2016. They were 12 men and 7 women, aged from 23 to 68 years (mean, 36.6 years). The fracture was located at the left side in 10 cases and at the right side in 9. Before admission to our hospital, 8 had received surgery once, 6 twice and 5 thrice. The time from fracture to hospitalization ranged from 12 to 106 months (average, 26.3 months). Shoulder function was evaluated by Neer scoring and elbow function by Mayo elbow performance score (MEPS) at final follow-ups. Results All incisions healed by first intention. Two cases reported transient radial nerve symptoms of numbness. All the 19 patients were followed up for 28.9 months on average (range, from 13 to 78 months). Radiographic examinations showed signs of bone remodeling, disappearance of fracture lines and formation of extracortical bone bridge at 6 to 8 weeks after operation. All of them achieved radiographic union within 10 to 46 weeks (16.8 weeks on average). The Neer scores averaged 82.5 (range, from 70 to 98), giving 12 excellent cases, 5 good ones and 2 fair ones. The MEPS averaged 84.4 (range, from 70 to 96), giving 11 excellent cases, 5 good ones and 3 fair ones. Conclusion Osteope-riosteal decortication and extracortical bone-bridging in treatment of atrophic humeral nonunions can effectively induce osteogenesis and increase stability of broken ends, promoting bone healing. Key words: Shoulder joint; Elbow joint; Humeral fractures; Fractures, ununited; Bone graft

Minimally invasive percutaneous plate osteosynthesis for Neer three-part fractures of proximal humerus in young adults

Objective To evaluate the efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of Neer three-part fractures of the proximal humerus in young adults. Methods A retrospective analysis was performed of the 46 patients aged < 65 years with Neer three-part fracture of the proximal humerus from March 2010 to December 2016. MIPPO with locking proximal humerus plate (LPHP) was used in 23 of them who were 12 men and 11 women with an average age of 41.6±1.2 years; open reduction and internal fixation (ORIF) with LPHP was used in the other 23 patients who were 14 men and 9 women with an average age of 42.2±1.6 years. The 2 groups were compared in terms of operation time, intraoperative bleed-ing, fracture healing time and shoulder function by Neer scoring at the last follow-up. Results The average follow-up (13.4±1.2 months) for the MIPPO groups was not statistically different from that for the ORIF group (14.2±2.4 months) (P >0.05). The MIPPO group reported significantly shorter operation time (105±15 min), significantly less intraoperative bleeding (140±50 mL), significantly shorter fracture healing time(4.2±0.6 months), and significantly higher shoulder Neer scores (88.6±3.4) than the ORIF group (120±20 min, 320±40 mL, 5.4±1.2 months, and 81.6±2.2, respectively) (P 0.05). Conclusion MIPPO with LPHP may be obviously advantageous over ORIF with LPHP in the treatment of proximal humeral fractures in young adults. Key words: Shoulder fractures; Fracture fixation, internal; Bone plates; Surgical procedures, minimally invasive

A study of surgical management of distal femoral fractures in adults using locking compression plate

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The introduction of locking compression plates with option of locked screws has provided the means to increase the stability of fracture fixation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this study, 30 distal femoral fractures were treated using the distal femoral locking compression plate. All fractures were fresh, closed and operated within 12 days. Follow up duration ranged from 6 to 18 months.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this study, 20 patients were males and 10 were females. The 23 of the fractures (76.66%), were caused by road traffic accidents, 3 were due to accidental falls (10%), one was due to assault and 3 were due to fall from height.9 patients had associated injuries. All patients were treated with open reduction and internal fixation using Locking Compression Plate. 6 to 9 holed plates were used. Out of 30 patients 2 went for delayed union and 3 went for non-union. Average knee flexion was 109&lt;sup&gt;o&lt;/sup&gt; having knee range of motion more than 100 with 50% patients. Average knee extensor lag was 2.4 degrees with only 4 patients with lag more than 5. 2 patients developed 2 cm shortening. 4 patients had less than 5 degrees of malalignment. 2 patients had deep infection. Functional outcome was measured using NEER's scoring system and was done at the end of 5- 7 months (average of 6 months). Excellent results- 17 (56.66%) good results-8 (26.66%) fair results-2 (6.66%) poor results-3 (10%).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; LCP condylar plate represents an evolutionary approach to the surgical management and is an important armamentarium in distal femur fracture fixation, especially when fracture is severely comminuted and in situations of osteoporosis. &lt;/p&gt;

Treatment of Proximal Humerus Fractures using PHILOS Plate.

Treatment of proximal humerus fractures always holds a dilemma for the treating surgeon. To assess the functional outcome of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating. Fifty three consecutive patients were treated with PHILOS plating between August 2013 and August 2014. The inclusion criteria were skeletally matured patients with closed fracture proximal humerus with displacement >1 cm and varus angulation of >450. Severely comminuted fractures, open fractures and valgus impacted fractures were excluded from the study. The outcome was assessed using Neer's scoring system. The average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes. PHILOS plating has a good functional outcome. However, proper patient selection, thorough knowledge of the anatomy and biomechanical principles are the pre-requisites for a successful surgery.

Open reduction and internal fixation versus minimally invasive percutaneous plate osteosynthesis for complicated proximal humeral fractures

Objective To compare open reduction and internal fixation(ORIF)and minimally invasive percutaneous plate osteosynthesis(MIPPO)in the operative treatment of complicated proximal humeral fractures. Methods From January 2014 to October 2015, 55 complicated proximal humeral fractures were treated at our department. They were 32 men and 23 women, from 21 to 81 years of age(average, 51 years). According to Neer classification, 34 cases belonged to three-part fractures and 21 ones to four-part fractures, 14 of which were complicated with dislocation. Of them, 35 received ORIF and 20 underwent MIPPO. The 2 groups were compared in terms of operation time, intraoperative blood loss, incision length and Neer scoring of the shoulder function at the final follow-ups. The 2 groups were compatible without significant differences in preoperative demographic data(P> 0. 05). Results The 55 patients were followed up for 6 to 12 months(mean, 9 months). The operation time(100. 5 ±10. 2 min), intraoperative blood loss(80. 0 ±10. 5 mL), and incision length(7. 5 ±3. 2 cm)in the MIPPO group were significantly better than those in the ORIF group(120. 0 ±10. 1 min, 200. 5 ±10. 2 mL, and 10. 5 ±5. 3 cm, respectively)(P< 0. 05). According to the Neer scoring of the shoulder function at the final follow-ups, the good to excellent rate was 71. 4%(25/35)in the ORIF group and 85. 0%(17/20)in the MIPPO group, showing a significant difference(P< 0. 05). The incidence of humeral head necrosis was 15 in the ORIF group, significantly higher than that(3)in the MIPPO group(P< 0. 05). Conclusion In treatment of complex proximal humeral fractures, compared with ORIF, MIPPO may lead to less damage to local blood supply, less trauma, and quicker functional recovery due to early functional exercise. Key words: Shoulder fractures; Surgical procedures, minimally invasive; Fracture fixation, internal

Evaluation of Different Modalities of Osteosynthesis of Proximal Humerus Fractures in Adults

Background: Proximal humerus fractures account for approximately 4-5% of the fracture attendance at the hospital. The management of proximal humeral fractures has always been an enigma because of numerous muscles attachment and paucity of space for fixing the implant. The objective of the present study was to compare different modalities of fixation in proximal humerus fractures. Methods: This is a retrospective study done on 112 patients of acute proximal humerus fractures treated surgically. Follow up was done for 12 months and results were analyzed using Neer’s scoring system. Results: Radiological union occurred at average time of 10.1 weeks. As per Neer's scoring system, 36% patients had excellent results while 31% patients had satisfactory results. They were all pain free and successfully returned to their pre-injury work. 25% patients had unsatisfactory and 8% failure result. 2 patients required revision surgery. Conclusion: Treatment options depend on fracture pattern, bone quality, patient's goals and surgeon’s familiarity with the technique. Patients who have two part greater tuberosity avulsion fracture are best treated by closed reduction and percutaneous screws fixation. Patients who have metaphyseal comminution and/or three-part fracture with appreciable displacement of the greater tuberosity are more appropriately treated by open reduction and Internal fixation with a plate. Key Words: Osteosynthesis, Proximal humerus fractures, Internal fixation

Distal Femur Locking Plate: The Answer to All Distal Femoral Fractures.

Good results have been published by researchers with distal femur nail, dynamic condylar screw and even addition of a medial plate to a distal femur locking plate for treating distal femur fractures. By this study, we explore the capability of a distal femur locking plate to counter distal femur fractures of extra- articular, partial or intra- articular nature. Positive results have been published by various groups from all over the world. To study the functional and radiological outcome of distal femoral fractures in skeletally mature patients treated by open reduction and internal fixation with distal femur locking plate. This was a prospective study conducted from January 2012 to March 2014 at the Government Medical College and Hospital (GMCH) with a 2 year follow-up. Twenty five skeletally mature patients with post-traumatic distal femur fractures were included. Patients with open grade 3B and 3C distal femur fractures, according to the Gustilo- Anderson classification and pathological distal femur fractures were excluded from the study. Patients with any fracture other than the distal femur in the ipsilateral limb were excluded from the study. Follow-up at 3 months, 6 months, 1 year and 2 years was carried out and evaluation was done according to the Neer scoring system. The statistical data analysis was carried out using SPSS version 20 (IBM, Chicago, USA). The p-value <0.05 was considered significant. Following all principles of fracture reduction, union was achieved in all patients with mean time to radiological union being 19 weeks. The mean Range of Motion (ROM) was 109 degrees with 20 patients having a Neer score graded as excellent to satisfactory. Our study had nine cases which required additional surgeries. Out of these, all nine cases required bone grafting, three also required antibiotic cement bead insertion initially. Three patients developed complications in the form of infection (two cases) and mal-union (one case) during the course of our study, but were completely treated by the end of the study. Positive results can be obtained by distal femur locking plate alone as it is the main implant of choice for distal femur fractures of all varieties. Best outcome is expected if fracture fixation is done following all the basic principles of fracture fixation and taking benefit of the mechanical properties of a locking plate.

Open reduction and Internal Fixation of Displaced Proximal Humerus Fractures with AO Stainless Steel T-Plate.

Proximal humeral fractures are considered the last unsolved fractures in orthopaedics. The treatment is controversial and various operative modalities have been reported in the literature. The aim of the present study was to evaluate functional outcome and complication rate after open reduction and internal fixation of displaced proximal humerus fractures by proximal humerus AO stainless steel T-plate. Twenty-five (25) patients with displaced proximal humerus fractures treated with proximal humerus T-plate between May 2005 and June 2008 were included in the study. Fractures were classified according to the Neer classification into displaced 2-part, 3-part, and 4-part fractures. Patients were followed-up for a minimum period of two years. Functional evaluation was done according to the Neer scoring system. Scores were compared with other studies in the literature using similar implant. Twenty patients had 2-part fracture, four had 3-part fracture, and one had 4-part fracture. Eighty-eight [88% (n = 22)] patients had good to excellent result, eight [8% (n = 2)] had fair, and four [4% (n = 1)] had poor result. Difference in Neer's score between 2-part and 3-part fractures was not significant. Complications encountered in this series were screw backout in 8% (n = 2), superficial infection in 12% (n = 3), and avascular necrosis in 4% (n = 1) of cases. We conclude that proximal humerus AO T- plate is a cheap and easily available implant, aspects which are particularly relevant in third world countries like India. It gives reliable fixation for 2-part and 3-part fractures. Its use in more complicated fracture patterns of 4-part fractures is not recommended. Proximal humerus fractures, proximal humerus stainless steel T-plate, unstable fracture.

Treatment of comminuted fractures of the proximal humerus with locking proximal humeral plate

Objective To evaluate the efficacy of locking proximal humeral plate (LPHP) for the treatment of comminuted fractures of proximal humerus in comparison with anatomical proximal humeral plate (APHP) and T-shaped plate.Methods From August 2008 to September 2010,65 patients with comminuted fracture of proximal humerus of Neer types Ⅱ-Ⅳ were treated in our department.They were 36 men and 29 women,with an average age of 39 years (from 24 to 70 years).LPHP was used in 36 patients (group A),APHP in 19 patients (group B) and T plate in 10 patients (group C).All the operations were conducted through the deltoid-pectoral-gap,and autografts were transplanted in the cases of bone defects after reduction.Exercises were done 1 to 6 weeks postoperation to prevent shoulder anchylosis.The clinical outcomes were compared between the 3 methods,including fracture healing,Neer score and complications.Results All the patients were followed up from 12 to 18 months (14.5 months on average).Fracture union was achieved in 36 cases in group A,in 17 cases in group B and in 8 cases in group C,with significant between-group differences ( P ＜ O.05).The mean healing time was 10.1 ± 1.2 weeks in group A,12.3 ± 1.4 weeks in group B and 15.4 ±2.6 weeks in group C,with significant between-group differences ( P ＜ 0.05).Humeral head necrosis occurred in 2 cases in group B and in 2 cases in group C,with a significant difference between group A and groups B and C ( P ＜ 0.05).By Neer scoring system,the good to excellent rate of shoulder function was 97.2％ in group A,63.2％ in group B and 40.0％ in group C,with significant between-group differences ( P ＜ O.05).Conclusion LPHP can be considered as the standard-therapy for comminuted fractures of proximal humerus of Neer types Ⅲ - ⅣV,because it can firmly fixate the comminuted fractures of the proximal humerus,leading to fast fracture healing,good functional recovery and limited complications. Key words: Shoulder fractures; Fractures, comminuted; Fracture fixation, internal; Bone plates

Surgical treatment of proximal humeral fracture with external fixator

The treatment of unstable displaced proximal humeral fractures remains challenging and controversial. Reports about the application of a mini-external fixator in the treatment of proximal humeral fractures are rare. The objective of this retrospective study was to evaluate the efficacy and complications of surgical treatment of proximal humeral fractures by closed reduction and external fixation with application of a mini-external fixator. Thirty-two patients with displaced proximal humeral fractures were surgically treated by closed reduction and external fixation with mini-external fixators at our institute between March 2007 and June 2009. There were 22 men and 10 women who had a mean age of 56 years (range, 23-81 years). The Neer scoring system related to pain, function, and range of motion was used to assess the outcome. All the patients were followed up at an mean of 18 months (range, 13-27 months). The duration of surgery was 29 ± 12 minutes. The accumulative fluoroscopy time was 12 ± 3.5 exposures. The mean time of fracture union was 13 ± 3.6 weeks. The mean Neer score was 83.2 ± 12.5 points at final follow-up. The incidence of excellent and good results was 81%. Two patients had loosening of the pins. One patient had a collapsed humeral head. There was no infection and impingement. The surgical treatment of displaced proximal humeral fractures with a mini-external fixator is characterized by minimal invasion, a shorter duration of surgery, and easy manipulation, making application of the mini-external fixator a good option for some selected patients.

Humeral diaphyseal nonunions treated by interlocking or expandable intrameduilary nailing plus iliac bone grafting

Objective To discuss the efficacy of interlocking or expandable intramedullary nailing plus iliac bone grafting for treatment of humeral diaphyseal nonunion.Methods From June 1999 to May 2008, 27 cases of humeral diaphyseal nonunion, 14 males and 13 females, were treated in our department.The nonunions occurred at the upper-middle humerus in 6 cases, at the middle humerus in 16 cases and at the middle-lower humerus in 5 Cases. The patients had previously undergone operations for 1 to 4 times (average,2.3 times). Interlocking nailing was applied in 16 cases (including one case of close nailing and 5 cases of cable tension band osteosynthesis after replacement of the original nailing); expandable nailing was applied in 11 cases. Autologous iliac bone grafting was performed in 26 cases except the one case of close nailing.Results Twenty-six cases were followed up for an average of 4 years and 2 months. Bony healing was obtained in 5.4 months on average. By Neer scoring, the shoulder functions were evaluated as excellent in 12,good in 8 and fair in 6 cases, with a good to excellent rate of 76. 9％. By Mayo clinic performance scoring,the elbow functions were excellent in 23 and good in 3 cases, with a good to excellent rate of 100％. One case of radial nerve palsy recovered 6 months after operation.ConclusionInterlocking or expandable intramedullary nailing plus iliac bone grafting is an effective method to treat nonunion of humeral diaphysis. Key words: Humeral fractures; Fractures, ununited; Bone nails; Fracture fixation, internal

LPHP combined with MIPO techniques for treatment of proximal humeral fractures in elderly osteoporotic patients.

Objective A prospective study was conducted to evaluate the efficacy of LPHP combined with MIPO techniques for treatment of proximal humeral fractures in elderly osteoporotic pailents.Melhods Thirty-eight elderly patients aged from 63 to 86 years with part-three and part-four fractures of the proximal humerus Were managed with the above-mentioned method between June 2003 to June 2006.Postoperative shoulder function and complications were evaluated and analyzed.Results The follow up period of the 38 cases ranged from 15 to 50 months(average 32.1 months).There was no infection,no avasculax necrosis of the humeral head,and no incidence of implant failure.Bone union was achieved in all the cases,with the mean healing period of 38 cases ranged from 14 to 27 weeks(average 18.3 weeks).According to Neer scoring,excellent in 26 cases,good in 8 cases,and fair in 4 cases.The excellent and good result rate was 89.5%. Conclusion LPHP combined with MIPO techniques is a satisfactory and effective method for treatment of proximal humeral osteoporotic fractures. Key words: Aged; Humeral fractures; Osteoporosis; MIPO

Reconstruction and balance of soft tissue in hemi-shoulder replacement for patients with four-part fracture of the proximal humerus

To explore the effective skills of reconstruction and balance of soft tissue in hemi-shoulder replacement for patients with four-part fracture of the proximal humerus in order to avoid postoperative complications of joint instability and great tubercle displacement. From June 2002 to June 2006, 25 patients with Neer four-part fracture of the proximal humerus were adopted in the study which included 15 females and 10 males, with the mean age of 66 years (ranged from 56 years to 80 years). They were treated with humeral head replacement and should joint reparation simultaneously by modified operation approach and reconstruction and balance skills of soft tissue. The mean duration of follow-up was 2.3 years (ranged from 1 to 4.5 years). No infection, nerve damage and prosthesis loosing were found in all cases. Two cases of infra-forward dislocation or subluxation occurred due to affected limb placed on abduction splint postoperatively. One case occurred prosthesis upward displacement due to early active abduction exercise but no complains. Neither joint instability nor displacement and malunion of great tubercle were found in other patients. According to Neer scoring system, 6 cases were rated as excellent, 15 as good and 5 as fair. The good and excellent rate was 84%. In hemi-shoulder replacement for patients with Neer four-part fracture the modified operation approach and reconstruction and balance of soft tissue skills combined with rational rehabilitation exercise can prevent postoperative shoulder joint instability and displacement and malunion of great tubercle.

Internal fixation of proximal humerus fractures using the Polarus intramedullary nail

It has been stated that proximal humeral fractures are the last unsolved fractures in orthopedics. In this study, we evaluate the results of the Polarus nail, in order to constitute to the controversial problem of the treatment of proximal humerus fractures. Between 2003 and 2005, 27 patients with severely displaced proximal humeral fractures were treated with the Polarus intramedullary system. The fractures were classified according to the Neer classification system. There were 16 2-part fractures and 11 3-part fractures. At the 12-months follow up we graded the clinical outcome of the patients according to the Neer scoring system. The duration from time of injury to operation ranged from 1 to 6 days. The mean operative time was 55 min and no need of blood transfusion was recorded. Bony union was obtained in 27 patients. There were no cases of nonunion and the period from operation to the appearance of sufficient bridging callus on radiographs was 5-11 weeks (mean 6 weeks). In one patient, a backed-out proximal screw was recorded. Stiffness of the shoulder was seen in one patient and avascular necrosis of the head of humerus in another. Related to the clinical outcome, six patients had an excellent result, 15 patients had a satisfactory result, four patients had an unsatisfactory result, and two patients had a poor result. The 77.78% of the patients had an excellent or satisfactory clinical outcome. There was significant difference in the functional outcome between patients younger than 65 years (91.55) and those older than 65 years (80.22) (P < 0.05). No significant difference was recorded in the Neer score between the patients with a 2-part fracture and the patients with a 3-part fracture (80.18) (P > 0.05). The Polarus nail is designed to provide stable fixation with a straightforward insertion and targeting procedure. The fact that 77.78% of the patients had an excellent or satisfactory clinical outcome, suggest that Polarus humeral rod system can be a worthy alternative to traditional operative methods for displaced proximal fractures of the humerus.

高齢者大腿骨遠位端骨折の治療経験

We present our experience of consecutive patients of 70 years or older who underwent surgical treatment for distal femoral fracture (AO types A and C) from 1992 to 2001 in our department. In total, nine female patients with an average age of 80.2 years were followed up for more than four months. There were four type-A1, one type-A2, one type-A3, one type-C1, and two type-C2 fractures according to AO classification. Patients were divided into a simple group (AO type A1 and C1) and a comminuted group (AO type A2, A3 and C2). Three patients were treated with May anatomical plates, three with Zickel supracondylar nails, and three with intramedullary supracondylar (IMSC) nails.All fractures united in an average duration of 11.0 weeks. The operating time averaged 69 minutes in the simple group and 119 minutes in the comminuted group. After Wilde modification of the Neer scoring system, two patients were excellent and three were moderate in the simple group, while all patients except one two could not walk before injury were moderate in the comminuted group.

Minimally invasive fixation for unstable two-part proximal humeral fractures: surgical techniques and clinical results using j-nails.

To evaluate the outcome of a minimally invasive treatment of unstable two-part proximal humeral fractures using a J-nail. Retrospective case series. Forty-one unstable two-part proximal humeral fractures (thirty women and eleven men) with a mean age of sixty-five years (range 18 to 95 years) were studied. Closed reduction and internal fixation with J-nails. All fractures were classified using Neer's classification and were displaced and unstable. Forty of the two-part fractures were at the surgical neck and one at the anatomic neck. All patients had a closed reduction and intramedullary fixation using three J-nails. The mean follow-up period was twenty-nine months (range 2 to 4 years). Clinical assessment was performed by doctors who did not participate in the primary surgery and was graded according to Neer's scoring system. All patients experienced immediate pain relief. At the two-year follow-up, the mean angles of active forward elevation, abduction, and extension were 138 degrees (range 80 to 180 degrees), 132 degrees (range 80 to 170 degrees), and 65 degrees (range 40 to 85 degrees), respectively. According to Neer's criteria, the outcome was excellent in twenty-five patients, satisfactory in twelve, unsatisfactory in three, and a failure in one. The final Neer's score showed a significant negative correlation with age (p < 0.01). J-nail fixation has the advantage of being an almost closed method without the disadvantage of muscle transfixation associated with other methods. The procedure is simple and involves minimal invasion of the soft tissue. Shoulder and elbow function is not impeded because the nails are inserted just below the distal part of the deltoid muscle insertion. This surgical technique may be one of the more reliable and effective treatments for proximal humeral fractures.

Strength and motion after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1-6 years.

We evaluated 27 patients with shoulder hemiarthroplasty after displaced four-fragment fracture of the proximal humerus after mean 4 (1-6) years. Isometric strength measurements (Kintrex) and three-dimensional motion analysis (Elite-System) were performed on the operated and unoperated shoulders. Clinical assessment was based on Constant's score and Neer's scoring system. The isometric strength of the operated and unoperated sides were 22 (SD 8.6) Nm and 24 (SD 5.9) Nm in abduction and 48 (SD 14) Nm and 65 (SD 21) Nm, respectively in adduction (the latter was statistically significant). Motion analyses at follow-up showed a mean reduction in glenohumeral movement. Increases in acceleration and deceleration of the acromion at the operated side were noted, indicating a change in glenohumeral rhythm during maximal abduction. The Constant score was 45 (SD 15) points with a significant reduction in the range of motion. 15 patients had some degree of heterotopic ossification. On the basis of our findings, the impaired function seems to be caused by reduced glenohumeral mobility rather than muscle strength. We also found a better outcome after early than late hemiarthroplasty.

The retrograde intramedullary nail: prospective experience in patients older than sixty-five years.

To determine whether retrograde nailing of distal femoral fractures is beneficial for the elderly patient. Prospective study of consecutive patients, aged sixty-five years or older, whose distal femoral fractures were treated with a retrograde femoral nail between January 3, 1993, and April 30, 1996. Twenty-four of twenty-six patients were followed for more than twelve months. There were twenty AO/ASIF 33A and four AO/ASIF 33C fractures. Twenty-three were closed. There was one Gustilo type 1 fracture. All fractures healed. Six patients did not walk before injury. Using the Neer scoring system, there were ten (56 percent) excellent (85 or more points), six (33 percent) good (70 or more points), and two (11 percent) fair (55 or more points) results; none of the cases were considered as failures (less than 55 points). Retrograde intramedullary nailing makes possible a biological osteosynthesis of distal femoral fractures. It also produces good functional results in elderly patients. The two major technical problems encountered with this implant are the poor hold of the distal interlocking screws and difficulties with proximal interlocking. Early weight-bearing is not advisable.

Shoulder function after displaced fractures of the proximal humerus.

It is difficult to predict the outcome of comminuted fractures of the proximal humerus and give guidelines for optimal treatment. Different treatment modalities are available, and there are various scoring systems for postoperative evaluation. The aim of this study was to assess the functional outcome after three- and four-part fractures of the humeral head in 38 patients, with a 3-year follow-up. Twenty-eight patients were treated conservatively, seven were operated on with open reduction and internal fixation, and three received a hemiarthroplasty. All patients were examined clinically and radiographically. Neer and Constant scoring systems were used. The functional outcome after three-part fractures was generally good. Twenty-five of 26 patients with a three-part fracture could accept their shoulder situation. Range of motion was significantly lower in the four-part fracture group. Mean flexion was 89 degrees compared with 120 degrees in the three-part fracture group. Necrosis of the humeral head was found in 2 cases, both four-part fractures. Osteoarthrosis developed in 13 cases (6 with a three-part fracture, 7 with a four-part fracture). No disability was found in 16 of 24 patients with three-part fractures, and in 4 of 11 patients with four-part fractures. There was strong agreement between the Constant score and the patients' opinions.

Distal clavicular excision: a detailed functional assessment.

Distal clavicular excision is commonly performed for a number of clinical conditions. The results of the procedure are not well described. Using the Constant, American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA) and Neer scoring systems, the medium term results of distal clavicular excision were assessed. Over an 8 year period, 39 patients underwent distal clavicular excision for conditions other than acromioclavicular instability (subluxation or dislocation). A single technique was employed. A retrospective study was performed of all 18 patients who could be contacted. In those cases patient satisfaction was universal. Pre-operative pain was severe in 16 patients (89%) and moderate in two (11%). Following surgery, five (28%) were free from pain, 10 (55%) had only mild or occasional pain, and three (17%) reported moderate pain. The difference between pre-operative and postoperative levels of pain was highly significant (P < 0.001). However, continuing difficulties with work (59%), sleeping (55%) and activities of daily living (59%) were reported. Ten of 14 (71%) wishing to return to sporting activities were able to do so without restriction. Neither shoulder strength nor range of movement was fully restored following surgery, which relieved pain but did not restore normality. This series may facilitate subsequent assessment of arthroscopic distal clavicular excision.