Fracture-dislocation Of Proximal Humerus Research Articles

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations

Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P=.175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020)

The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a six-year period (2015-2020) within an insurance claims database. This retrospective database cohort study utilized data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The ICD10 data was correlated to the CPT code for shoulder arthroplasty [proximal humeral prosthetic replacement (23616), shoulder hemiarthroplasty (HA)(23470), reverse total shoulder arthroplasty (rTSA)(23472)] or open reduction internal fixation (ORIF) [open treatment of proximal humerus fracture with internal fixation (23615), open treatment of proximal humerus fracture-dislocation with internal fixation (23680)] We investigated the number of proximal humerus fracture operative cases per year, percent arthroplasty used per year, rTSA and HA per year, hospital cost information as well as percent arthroplasty per US geographic region. A total of 8,057 operative proximal humerus fractures cases were identified in 7,697 patients over 65 years of age, with 0.45% (360/8,057) being bilateral. There was a 40.8 % decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 +/- 146.6) and second half of the study period (2018-2020, 998.3 +/- 258.7). Arthroplasty accounted for 78.7% of all surgeries, and 91% of those being rTSA. The total number of cases, rTSA and ORIF performed decreased per year (p=.01). The downward trend of percent ORIF per year approached significance (p=.054). Arthroplasty was a more expensive payment for total case option by almost $850.00 (p=.001). There was a larger percentage of arthroplasty performed in the Northeast, and North central US geographic regions. Despite the rise of both the elderly population and related geriatric proximal humerus fractures, there were less operatively represented in this insurance claims database across the six-year period. There may be a trend to utilize less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, Arthroplasty was being performed at a higher percentage in the Northeast, and North central regions of the United States.

The long-term results of shoulder hemiarthroplasty in irreducible four-part fracture-dislocation of the proximal humerus without rotator cuff tear arthropathy.

Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6years old and 48.6months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen.

Fracture Dislocations of the Glenohumeral Joint.

Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment. While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.

Rare finding of axillary artery dissection secondary to a proximal humerus fracture-dislocation: A case report

Proximal humerus fractures are a relatively common injury, making up approximately 5% of all extremity fractures. Concurrent damage to the axillary artery, however, is not a commonly associated trauma. We present a unique case of a proximal humerus fracture-dislocation resulting in an axillary artery dissection and upper extremity ischemia, requiring emergent vascular intervention. Axillary artery injury secondary to a proximal humerus fracture-dislocation is a rare, but possibly devastating complication. A thorough physical examination to identify any neurovascular deficits is critical in determining an optimal and timely resolution.

PROXIMAL HUMERUS FRACTURE DISLOCATIONS: OUTCOMES OF MANAGEMENT

Proximal humerus fracture dislocations are amongst the most severe proximal humerus injuries, presenting a challenging management problem. The aim of this study was to report on the long-term outcomes of the management of proximal humerus fracture dislocations.Patients with a proximal humerus fracture dislocation managed at a Level 1 trauma centre from January 2010 to December 2018 were included. Patients with an isolated tuberosity fracture dislocation or a pathological fracture were excluded. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, non-union/malunion, and avascular necrosis.A total of 69 patients were included with a proximal humerus fracture dislocation in the study period; 48 underwent surgical management and 21 were managed with closed reduction alone. The mean (SD) age of the cohort was 59.7 (±20.4), and 54% were male. Overall patients reported a mean OSS of 39.8 (±10.3), a mean EQ-5D utility score of 0.73 (±0.20), and 78% were able to return to work at a median of 1.2 months. There was a high prevalence of complications in both patients managed operatively or with closed reduction (25% and 38% respectively). In patients undergoing surgical management, 21% required subsequent surgery.Patient reported outcome measures post proximal humerus fracture dislocations do not return to normal population levels. These injuries are associated with a high prevalence of complications regardless of management. Appropriate patient counselling should be undertaken before embarking on definitive management.

To study of functional outcome and complications of proximal humerus fracture dislocation managed with reduction internal fixation with various methods

Background: Fracture-dislocation of the humerus refers to the fracture of the proximal part of humerus associated with dislocation of the head from the humero-glenoid joint. It is occurs most commonly in elderly due direct low velocity trauma, while in younger age group, high-velocity trauma is needed.1 Management of fracture dislocation of proximal humerus needs early reduction and fixation. In or prospective study we have observed the functional outcome and complications of management of displaced proximal humerus fragments with various methods.;Methods: A two-year prospective study was conducted after getting ethical approval at tertiary care centre on cases admitted with proximal humerus fracture dislocation as per the inclusion criteria based on Neer’s classification evaluation was done after investigations like xray CT scan and surgery was performed. Postoperative follow-up was done at 1st, 6th month and 1 year and outcome were evaluated for each case based on Neer’s shoulder score of constant score.Results: 30 cases were studied which were operated according to neers classification by various methods. Mean age was 42.6 years. Constant Shoulder score was good in maximum patients (46.67%) followed by excellent in 33.67%, three patients (10%) had fair score while it was poor in 2 patients (6.66%).Conclusions: Proximal humerus fracture dislocation can be managed with various methods of treatment. Each method has its own advantage and disadvantages.

Preoperative Computed Tomography Angiography to Prevent Vascular Injuries in 4-Part Proximal Humerus Fracture-Dislocations

Cases: This study compares 2 cases of 4-part proximal humerus fracture-dislocations managed by reverse total shoulder arthroplasty: one with significant medialization and acute surgical management and another with mild medialization and delayed surgical management. Both presented with normal vascular examination; however, computed tomography angiography (CTA) revealed vascular involvement necessitating thoracic or vascular surgery consultation. Conclusion: Although vascular injuries are rare, they should be considered in patients with complex injuries, particularly those with delayed treatment or medialization of a bony structure. Our cases highlight important fracture characteristics where a preoperative CTA should be considered even with a normal vascular examination.

Proximal humerus fractures and shoulder dislocations: Prevalence of concomitant rotator cuff tear

Background: Proximal humerus fractures and shoulder dislocations are relatively common. However, an associated rotator cuff tear is often missed with these injuries. The objective of this study was to assess the prevalence of a concomitant rotator cuff tear associated with common shoulder injuries. Methods: A cross-sectional epidemiological study of three patient populations: Group 1. Proximal Humerus Fractures; Group 2. Shoulder Dislocations; Group 3. Proximal Humerus Fracture-Dislocations. All patients within these three groups presented to and underwent subsequent management of their shoulder injury at a trauma unit. Management included both non-operative and operative intervention. Patients were evaluated for associated rotator cuff tears. Results: This study included a total of 196 patients: Group 1 = 146 Proximal Humerus Fractures; Group 2 = 37 Shoulder Dislocations; Group 3 = 13 Proximal Humerus Fracture-Dislocations. Of the 196 patients in total, 23 (11.7%) sustained a concomitant rotator cuff tear. The highest number of tears was found in Group 1 ( n = 14). However, the highest percentage prevalence of tears was in Group 2 (18.9%). There was noted to be a higher prevalence of rotator cuff tears with increasing age. Twenty-two (95.7%) rotator cuff tears were detected in patients over 50 years of age. The vast majority of rotator cuff tears were detected by ultrasound (78.3%) as opposed to magnetic resonance imaging (21.7%). The majority of tears were full-thickness (60.9%). Of the 23 patients with a concomitant rotator cuff tear, 17 involved a single tendon (73.9%) and supraspinatus was most common (69.6%). Conclusions: A concomitant rotator cuff tear in association with a proximal humerus fracture, shoulder dislocation or proximal humerus fracture-dislocation is relatively common. The overall rotator cuff tear prevalence in this study was 11.9%. Rotator cuff tears are more likely to occur in patients over 50 years old and those sustaining a shoulder dislocation.

Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review.

The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF). The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded. Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%). Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.

CORR Insights®: What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

CORR Insights®: What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

SEVER INFERIOR HUMERAL HEAD SUBLUXATION FOR 3 MONTHS IN PROXIMAL HUMERUS FRACTURE DISLOCATION

Proximal humerus fracture is common fracture 4-6% of all fractures (1), third most common non vertebral fracture in elderly >65 years (2), affecting female more than males in ratios of 2:1.Approximately half (51%) of these fractures are displaced, the majority of which involve the surgical neck (77%). (3) Surgical treatment (mainly internal fixation or humeral head replacement) is being increasingly used (4).Management of each fracture is dependent of patient factors, fracture pattern, and complexity.Case scenario:33 years old female not known to has any medical illness, presented to the emergency department with right shoulder pain and inability to move it after motor cycle accident. X-rayshowed proximal humerusfracture dislocation Upon Post-operative follow up patient developed sever inferior humeral head subluxation, With intact axillary nerve sensation and motor exam.Discussion:proximal humerus fracture is common, fracture pattern and type, with patient factors will guide your management.proximal humerus fracture dislocation is more difficult and challenging to surgeon in managing such fracture, with inferior hemeral head subluxation is common can reach to 42% in the radiographic incidence among proximal humerus fracture.

Anterior proximal humerus fracture dislocation with concomitant glenoid fracture: An operative challenge! A case report

Introduction Combined proximal humerus fracture dislocation and glenoid fracture is a rare combination of injuries which presents technical operative challenges. There is little evidence to guide surgical management. Case Report We report a case of a proximal humerus fracture with anterior dislocation and glenoid fracture treated in the same sitting with open reduction and internal fixation with angular stability locking plate and cannulated screw. The surgical technique involved standard deltopectoral approach with coracoid osteotomy. Conclusion By addressing both fractures operatively at the same time, we reported a satisfactory clinical and functional outcome with bony union of the fracture sites without instability at end of 1 year. Coracoid osteotomy may open an alternative pathway to treat complex proximal humerus injuries with ipsilateral glenoid fracture.

Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations.

Proximal humeral fracture with associated glenohumeral dislocation (PHFD) is a challenging clinical problem. Outcomes of open reduction and internal fixation (ORIF) of these injuries have not been widely reported. The purpose of this analysis is to report our experience with ORIF of PHFD. A retrospective review of our 2 institutions' shoulder surgery databases was conducted to identify all PHFDs that were treated with ORIF from 2008 through 2017. Radiographs were reviewed for fracture healing by 12 weeks postoperatively. All reoperations were recorded. Patient-reported outcomes using Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores at a minimum 2-year follow-up were recorded. There were 20 PHFDs identified: they were 50% male, 55.8 ± 10.3 years old (range 31.3-66.3), and had a body mass index of 29.3 ± 8.2 (15.2-47.8). Seven (35%) patients experienced varus collapse, nonunion, or avascular necrosis and 6 (30%) patients underwent reoperation. Of the 17 patients who did not go on to revision or arthroplasty, 14 (82.3%) had patient-reported outcomes at a mean follow-up of 4.9 ± 2.2 years (2.3-8.8). These patients had an average SST 8.0±4.0 yes responses (0-12) and ASES scores of 71.6 ± 20.4 (20.2-94.9). ORIF of PHFD carries a high rate of reoperation. In patients who achieve healing, functional scores are satisfactory. This information is important for proper patient counseling prior to surgery.

Surgical Treatment of Humerus Fracture-Dislocations: Medium-Term Results

Background. Fracture-dislocation of the proximal humerus is a severe injury that equally affects both young and old people. Such injuries are often accompanied by the high risk of neurocirculatory and other complications, which defines their great medical and social importance. The purposes of this study were: 1) to compare the mid-term results of the surgical treatment of the patients with dislocation-fractures of the proximal humerus when they were managed according to the standard algorithm or the new one developed by the authors of this study; 2) to evaluate the effectiveness of the proposed protocol in relation to the patients with neurological complications in order to elaborate a universal approach to the optimal treatment tactics. Patients and Methods. The treatment results of 73 patients with proximal humerus fracture-dislocation undergone the surgery from 2012 to 2018. The patients were divided into 2 groups, which were managed according to the traditional (control group) or the new algorithms (main group), differing in the time of the surgery, a set of diagnostic methods, and an approach to the prevention and treatment of complications. The patients’ examination included taking patients’ anamnesis, their physical examination, X-rays and multispiral computed tomography of the injured shoulder, electromyoneurography, ultrasound of the upper limb blood vessels, patients’ questioning. Results. A year after the surgery, a statistically significant difference in the functional results was revealed in the patients of the main and control groups by the Constant Shoulder Score (p = 0.0063). In the control group, there was a statistically significant difference of the functional results by Constant Shoulder Score between the patients with and without neurological complications (p = 0.003). There was no statistically significant difference among such patients in the main group (p = 0.387). Conclusion. The main group patients, including those with neurological complications, achieved higher functional results in comparison with the control group. Thus, the authors’ treatment algorithm showed its effectiveness. The surgery within 6 hours from the moment of admission of the patients with humerus fracture-dislocation, as well as the earliest possible diagnosis of neurological injury and treatment of complications significantly improved the prognosis and outcome the main group patients.

A study of functional and radiological outcome of complex fracutre dislocation of proximal humerus treated with proximal humeral internal locking system (Philos) plate

Fracture dislocations of the proximal humerus are extremely rare and have poor functional and radiological outcome regardless of many available surgical interventions. There has been a wide variation in optimum modality of treatment of proximal humerus fractures ranging from conservative treatment, open reduction and internal fixation to total and reverse shoulder arthroplasty. We have evaluated the outcome of efficacy of proximal humeral internal locking system (PHILOS) plate in complex fracture dislocation of the proximal humerus. A total of 20 patients with fracture dislocation of proximal humerus were included in the study after careful inclusion and exclusion criteria. All fracture dislocations were fixed with proximal humeral internal locking system (PHILOS) plate and patients were followed up at regular intervals. Final evaluation was done based on Neer's scoring system. Open reduction and internal fixation of proximal humeral fracture dislocation with the PHILOS plate was associated with good functional and radiological outcomes provided the correct surgical technique was used.

Cases of Missed Posterior Fracture-Dislocation of the Shoulder

Proximal humerus fracture-dislocation is a rare condition that occurs mostly in young adults due to high energy trauma and about 60-79 percent of misdiagnosis is occurred in the first diagnosis. In this article, we present two patients with proximal humerus fracture-posterior dislocation the fractures of whom were diagnosed, but after the radiographic studies including x-ray and computer tomography (CT) scan, the posterior dislocation was misdiagnosed. In addition, complications, management, and avoidance of this misdiagnosis were discussed.

Regional anesthesia combined with virtual reality hypnosis for extended orthopedic surgery: two case reports

Background : Virtual reality hypnosis is a combination of visual immersion in a virtual reality environment and clinical hypnosis. It can be used in addition to conventional techniques, for sedation and pain management during wound care. Patients undergoing painful and long-lasting procedures under regional anesthesia could also benefit, from this technique alleviating the need for sedative-hypnotic medication. Case presentation : Two patients with relative contra- indications for general anesthesia underwent lengthy orthopedic surgery of the upper limbs under regional anesthesia with additional virtual reality hypnosis. Written informed consent was obtained from both patients before surgery. A 69-year-old man, with a previous medical history of severe symptomatic aortic valve stenosis (ѳ 0.69cm2, max/mean gradient of 91/58mmHg) sustained a proximal humerus fracture-dislocation and was scheduled to undergo shoulder hemi-arthroplasty. Anesthesia was provided with ultrasound-guided continuous interscalene block at the C5-C6 level (11mL levobupivacaine 0.5%) combined with a single-shot superficial cervical plexus block (6mL levobupivacaine 0.5%). The second case was a 56-year-old man suffering from rheumatoid arthritis with severe restrictive lung function due to interstitial lung disease and bilateral bronchiectasis. He received a unilateral elbow prosthesis. Continuous infra-clavicular brachial plexus block, per- formed under ultrasound guidance was provided (20 mL mepivacaine 1.5%). Both patients required prolonged immobilization on the operating table. We used virtual reality hypnosis to induce sedation and improve comfort without using medication. This was provided by headphones and head-mounted goggles, showing computer generated images of underwater scenes (Aqua module, Oncomfort ™). Both surgeries were uneventful during which time cardiorespiratory stability was maintained. Patients were comfortable during and satisfied after surgery. No sedative drugs were given before nor during the procedures. Conclusion : Non-pharmacological sedation can be achieved with virtual reality hypnosis. When com- bined with regional anesthesia, this technique provides satisfactory sedation when pharmacological methods may be hazardous.