Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate.

We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up.

At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation.

Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures.

Aims

The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique.

Introduction

The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning.

Introduction

Surgical treatment is justified in patients with fifth metacarpal shaft fractures with angulation exceeding 30 degrees, as these patients are prone to have shortening, restriction of movements, decreased efficiency of the flexor tendons and poor cosmetic results1,2. The authors describe a new technique where these patients can be treated in the clinic non-surgically.

Background: Intraarticular loose bodies following simple dislocations can lead to early degeneration. Non concentric reduction may indicate retained loose bodies and offer a method to identify patients requiring exploration to avoid this undesirable outcome.

Methods: 117 consecutive simple dislocations of the hip presenting to the hospital from January 2000 to June 2006 were assessed for congruency after reduction by fluoroscopy and good quality radiographs. Patients with non concentric reduction underwent open exploration to identify the etiology and removal of loose bodies. The post operative results were analyzed using Thomson and Epstein clinical and radiological criteria.

Results: 12 of the 117 (10%) dislocations had incongruent reduction which was identified by a break in Shenton’s line and an increase in medial joint space in seven patients, superior joint space in three patients or a concentric increase in two patients. CT scan performed identified the origin of the osteocartilagenous fragment to be from the acetabulum in six patients, femoral head in four, from both in one and one patient had inverted posterior labrum. In addition to this a patient had posterior capsular interposition. Following debridement, congruent reduction was achieved in all patients. At an average follow up of four years and nine months (4.9 years), the functional outcome evaluated by Thompson and Epstein criteria was excellent in 11 cases and good in one case.

Conclusions: Intra articular loose bodies were identified by non-concentric reduction in 12 out of 117 patients with simple hip dislocation. Careful evaluation by immediate post reduction fluoroscopy and good quality radiographs are a must following reduction of hip dislocations.

Introduction: Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous Methods:

Methods: We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.

Results: The age of the patients varied from 10 to 27. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it is attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.

Conclusions: Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.