Eur J Trauma Emerg S
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The surgical treatment of proximal humeral fractures constitutes a great challenge. Not all fracture types can be successfully reconstructed. Indications for a primary joint replacement arise from critical fracture patterns and defined ischemia-predicting criteria in the elderly. ⋯ Multicenter studies observed an averaged Constant Murlay Score of 56 to 73.5 points. 79% of the patients had no or only mild pain in the follow up, ROM was acceptable (41.9% Anteversion >90°, 34.7% Abduction >90°). Generally, subjective evaluations are much better than objective results. The incidence of complications after primary humeral head replacement is still relatively high, whereas the 10-year-survival-rate of shoulder hemiarthroplasties was found to be 100%, currently.
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Replacement of an almost completely absent medial meniscus with a collagen implant (CMI), reconstruction of form and function of the medial meniscus, delay of the development of arthrosis deformans. ⋯ 60 patients (19-68 years, average 41.6 years) with subtotal loss of the medial meniscus and varus morphotype were treated from January 2001 to May 2004 as part of a prospective, randomized, arthroscopically controlled study. The sample consisted of 30 patients with high tibial valgus osteotomy combined with implantation of a CMI, and 30 patients with valgization correction osteotomy only. The CMI had to be removed from one patient because of a dislocation. Evaluation on the Lysholm Score, IKDC (International Knee Documentation Committee), and subjective pain data revealed only slight, nonsignificant differences for 39 patients after 24 months (CMI and correction n = 23; correction only n = 16). The chondroprotective effect of the CMI in the long term remains to be seen.
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Improved imaging, updated knowledge regarding humeral head perfusion and adapted fixation techniques with implants having better purchase also in osteopenic bone, have influenced the treatment of proximal humeral fractures in recent years. Demographic evolution and a more active population even among the older age groups will increase the incidence of this fracture, which is already the third most frequent fracture after hip and distal radius fractures in elderly patients. Long-term morbidity related to the treatment of these fractures like avascular humeral head necrosis, non-union, malunion, shoulder stiffness, persistent pain and functional disability are the challenging factors to be overcome. ⋯ Even though plating of proximal humeral fractures with angular stable implants has shown promising first clinical results, there still remain elevated complication rates especially in the elderly osteoporotic patient population. Recent clinical reports using angular stable plates provided only data with a low level of evidence to help in decision-making. The comparison with historical series using non-angular stable plates in respect to the long-term morbidity should help to better evaluate the value of locked plates inserted with less-extensive soft-tissue exposure.