Search Results (65)

Background and Clinical Significance: Aneurysmal bone cyst (ABC) is a benign but locally aggressive osteolytic lesion that typically arises in the metaphysis of long bones in children and adolescents. Extension across an open proximal humeral physis into the epiphysis is uncommon and creates a diagnostic challenge because unicameral bone cyst and telangiectatic osteosarcoma may show overlapping radiological features. Case Presentation: A 12-year-old girl presented with pain and restricted motion of the left shoulder after a bicycle-related fall. Radiographs demonstrated a large expansile lytic lesion of the proximal humerus with cortical thinning and pathologic fracture. CT showed cortical ballooning, septation-like internal architecture, and extension across the open proximal humeral physis into the epiphysis. MRI demonstrated a multiloculated cystic lesion with thin internal septa and thin peripheral/septal enhancement, without nodular solid enhancement or a bulky extraosseous soft-tissue component. Curettage, bone cement filling, and elastic intramedullary nailing were performed. Histopathology, immunohistochemistry, and USP6 FISH analysis supported the final integrated diagnosis of ABC, although USP6 rearrangement was not detected. At 40 months, the patient was pain-free, had essentially normal shoulder motion, had returned to normal school and daily activities, and required no further surgery; radiographs showed stable remodeling without aggressive re-expansion. Conclusions: A focused literature review supports that frank transphyseal ABC is rare, particularly in the proximal humerus. The diagnostic contribution of this case lies in the integration of radiography, CT, MRI, histopathology, ancillary testing, and long-term clinical and radiographic follow-up. In a skeletally immature patient with a proximal humeral cystic lesion, transphyseal extension should prompt careful multimodality assessment. Imaging can substantially narrow the differential diagnosis, but integrated radiologic–pathologic confirmation remains essential when malignant mimics are possible. Full article

Background/Objectives: Reverse total shoulder arthroplasty (rTSA) is the preferred treatment for elderly patients with complex proximal humerus fractures. Accurate humeral stem positioning remains challenging in these cases due to complex fracture patterns, which may lead to postoperative complications. Virtual surgical planning (VSP) may assist in optimizing humeral stem and greater tuberosity positioning; however, its clinical impact in fracture-related rTSA has not yet been evaluated. This study aimed to assess whether VSP improves postoperative range of motion (ROM). Methods: A comparative cohort study was conducted, comprising a prospective VSP group and a retrospective control group. Patients underwent rTSA for proximal humerus fractures. Primary outcomes were ROM during forward elevation, abduction, and external rotation at two months and one year postoperatively. Secondary outcomes included complications, procedure time, greater tuberosity repositioning and healing, and postoperative deviation in humeral stem height compared with the preoperative plan. Statistical analyses included independent t-tests, Mann–Whitney U tests, and chi-square tests. Results: A total of 48 patients were included: 27 in the VSP group and 21 in the non-VSP group. At two months, abduction was significantly greater in the VSP group (76° vs. 63°, p = 0.05). Forward elevation and external rotation were numerically higher in the VSP group but did not reach statistical significance (p < 0.1). Stem height deviation was significantly lower in the VSP group (3 mm vs. 12 mm, p < 0.001). Conclusions: VSP enables more accurate humeral stem positioning in rTSA for proximal humerus fractures. Although no statistically significant improvements in ROM were observed at one year, VSP demonstrated superior accuracy in stem positioning. Full article

Purpose: The treatment of proximal humerus fractures (PHFs) remains debated, and similar fracture patterns may be managed with different strategies. The aim of this retrospective single-center case series without a control group was to evaluate clinical and radiographic outcomes after treatment of selected PHFs with the Galaxy Fixation System. The primary endpoint was functional recovery at 12 months, assessed using the Constant Shoulder Score and QuickDASH. Secondary endpoints included radiographic maintenance of reduction, quality of life, treatment-related complications, and need for revision surgery. Methods: We retrospectively analyzed 48 consecutive patients with proximal humeral fractures treated at the Orthopaedic and Traumatology Unit of Versilia Hospital, Viareggio, Italy, between November 2017 and February 2022. Fractures were assessed using trauma-series radiographs and computed tomography when required, and were classified by two senior surgeons according to the Neer, AO/OTA, and Hertel classifications. Eligible patterns included 2-part, 3-part, and selected 4-part fractures with at least two-thirds of intact metaphyseal bone stock. Results: Forty-six patients completed the 12-month follow-up; two patients died during follow-up from causes unrelated to the index procedure. The mean Constant Shoulder Score improved from 62.7 at 6 months to 69.3 at 12 months, and the mean QuickDASH improved from 9.4 to 8.1. The mean postoperative head-shaft angle was 137.2 degrees and remained substantially stable at 135.1 degrees at 12 months. Pin-tract infection occurred in 5 patients, pin migration in 4, algodystrophic syndrome in 1, and avascular necrosis requiring revision arthroplasty in 1. Conclusions: In this retrospective uncontrolled series, external fixation with the Galaxy system was associated with progressive functional recovery, satisfactory radiographic maintenance of reduction, and a low rate of revision surgery in carefully selected PHFs. These findings should be interpreted cautiously because of the retrospective design, limited sample size, absence of a control group, incomplete availability of some baseline variables, and lack of formal comparative or cost-effectiveness analyses. Full article

Background and Objective: This study aimed to evaluate the impact of early functional rehabilitation on clinical outcomes and tuberosity healing in older patients undergoing reverse shoulder arthroplasty for proximal humeral fractures. We hypothesized that early functional rehabilitation would not compromise tuberosity healing and would result in comparable or improved outcomes versus postoperative immobilization. Methods: This retrospective matched-pair analysis included patients aged 70 years or older who underwent reverse shoulder arthroplasty for proximal humeral fractures, with 12 to 24 months of follow-up. Group allocation was time-based: earlier patients received immobilization and later patients underwent early rehabilitation. Matching was based on sex, age, body mass index, fracture classification (Neer), and glenosphere size. Outcomes included patient-reported scores, range of motion, and radiographic assessment of tuberosity healing using standardized imaging. Results: Forty patients (20 per group) with a mean age of 80.7 years and a mean follow-up of 16.1 months were included. The early rehabilitation group demonstrated significantly higher Constant scores (p = 0.044), age- and sex-adjusted Constant scores (p = 0.033), and greater active external rotation (p = 0.002). Anatomical tuberosity healing was seen in 28 of 40 patients (70%). Greater tuberosity healing occurred in 75% and lesser tuberosity healing in 85% of patients with available axial imaging. One deep infection occurred in the early rehabilitation group and was successfully managed. Conclusions: Early functional rehabilitation after reverse shoulder arthroplasty in older adults with proximal humerus fractures improved functional outcomes without compromising tuberosity healing. Full article

Background: Local bone quality of the proximal humerus is a key determinant of fracture risk and implant stability in osteoporotic bone. Beyond established HU-based calibration, CT-osteoabsorptiometry (CT-OAM)-derived indices and microarchitecture-oriented workflows warrant systematic cross-modality evaluation. Methods: Twelve proximal humeral heads from six body donors (age 65–86 years; bilateral specimens) were analyzed using paired clinical CT and high-resolution micro-CT. Bone quality was quantified by (i) a HU-calibrated cancellous vBMD method (Krappinger et al.), (ii) a CT-OAM-inspired workflow reporting an ROI-averaged mean-intensity index in arbitrary units (a.u.), and (iii) a calibrated Bone Microarchitecture Analysis (BMA) workflow in Analyze 15.0. Paired tests, linear regression, and repeated-measures ANOVA after z-standardization were applied. Results: HU calibration yielded a mean trabecular vBMD of 114.37 ± 35.15 mg/cm³ on clinical CT. The BMA workflow produced higher CT-based values (207.37 ± 23.78 mg/cm³, p < 0.001) and markedly higher micro-CT values (469.34 ± 30.99 a.u.), indicating a systematic level shift between calibration frameworks. The CT-OAM index averaged 166.94 ± 40.12 a.u. on clinical CT and 455.89 ± 132.63 a.u. on micro-CT. Cross-modality agreement was very strong for CT-OAM (R² = 0.888) and moderate for BMA (R² = 0.502). After z-standardization, no significant differences were detected between the three CT-based approaches. Conclusions: A CT-OAM-inspired ROI-mean index and a BMA-based workflow provide complementary, transferable readouts of proximal humeral bone quality across clinical CT and micro-CT, with stronger cross-modality rank consistency for CT-OAM. Absolute density values differ systematically between calibration frameworks and should not be interpreted as directly interchangeable. These approaches support opportunistic, site-specific bone quality assessment from routine CT, but require prospective validation against fixation-related outcomes and robust scanner-independent standardization. Full article

Background: Reconstruction of the proximal humerus after wide tumor resection is technically demanding, and traditional methods such as allograft–prosthetic composites, reverse shoulder arthroplasty, and metal implants are limited by graft unavailability, pediatric size mismatch, their high cost, and metal-related stress shielding. Polyether ether ketone (PEEK), with its modulus closer to cortical bone and radiolucency, offers a promising alternative. Building upon the success in craniomaxillofacial surgery and its favorable physical characteristics, we applied personalized 3D-printed PEEK implants for proximal humerus reconstruction. This study reports the first evidence of applying patient-specific 3D-printed PEEK implants in the proximal humerus. Methods: A retrospective cohort study was conducted on seven patients who underwent wide resection of primary malignant bone tumors of the proximal humerus, followed by reconstruction using patient-specific 3D-printed PEEK implants. Implant design was based on preoperative computed tomography (CT) imaging, incorporating contralateral humeral mirroring and computer-aided design. The implants were fabricated using fused deposition modeling (FDM) with medical-grade PEEK under stringent thermal control (nozzle temperature > 400 °C and heated build chamber), followed by a controlled annealing process to minimize internal stress, optimize polymer crystallinity, and enhance mechanical durability. Outcomes assessed included implant survival, oncologic control, shoulder range of motion, and functional outcomes measured using the Musculoskeletal Tumor Society (MSTS) score. The mean follow-up duration was 56.3 months. Results: All patient-specific PEEK implants were successfully manufactured and implanted with satisfactory geometric accuracy. Mechanical implant survival was 85.7% at final follow-up, with one implant fracture occurring at 28 months. No cases of deep infection, dislocation, loosening, or permanent neurovascular injury were observed. Local soft-tissue recurrence occurred in two patients (28.6%), without distant metastasis or tumor-related mortality. The limb-salvage rate was 100%. At final follow-up, the mean MSTS score was 23.0 ± 1.6. Shoulder motion was limited but comparable to outcomes reported for conventional anatomic megaprosthetic reconstructions. Conclusions: Patient-specific 3D-printed PEEK implants provide a feasible and oncologically safe option for proximal humerus reconstruction after tumor resection, with acceptable midterm implant survival and functional outcomes. The favorable elastic modulus and radiolucency of PEEK offer distinct biomechanical and imaging advantages over metallic implants. Further design optimization and larger prospective studies are warranted to enhance mechanical durability and functional restoration. Full article

Background/Objectives: Avascular necrosis (AVN) of the humeral head is a severe complication after intracapsular proximal humerus fractures in the elderly. Hertel’s radiographic classification is widely used to estimate ischemic risk, yet its real-world accuracy remains debated. Methods: We retrospectively analyzed 204 patients aged ≥65 years treated between 2019 and 2022 for intracapsular proximal humerus fractures. Fractures were classified according to Hertel’s criteria and the LEGO system. The incidence of AVN and its association with radiographic predictors were assessed. Diagnostic performance metrics (sensitivity, specificity, predictive values, accuracy) were calculated for Hertel’s classification. Results: AVN developed in 22 patients (10.8%). High-risk fractures according to Hertel’s criteria showed a 24.7% AVN rate versus 0.8% in low-risk fractures (p < 0.001; OR = 38.7). Hertel’s model demonstrated high sensitivity (95.5%) and negative predictive value (99.2%) but low positive predictive value (24.7%). Medial hinge disruption and calcar extension < 8 mm were the strongest radiographic predictors (p < 0.001). Conclusions: Hertel’s classification effectively identifies elderly patients at low risk for AVN, given its high sensitivity and NPV. However, its limited positive predictive value highlights the need for integrative models combining radiographic and clinical parameters to improve ischemic risk stratification. Full article

Adding a fibular strut bone graft to locking plate fixation has been introduced to improve stability and prevent varus collapse. The purpose of this study was to perform finite element analysis (FEA) of the biomechanical characteristics of different insertion angles of the fibular strut graft in proximal humerus fractures. Proximal humerus fractures with metaphyseal comminution and instability were simulated by creating wedge-shaped osteotomies medially and laterally for varus and valgus models, respectively. Three-dimensional finite element models were reconstructed from computed tomography images. A locking compression plate with a length of 90 mm (three holes) was applied to the proximal humerus fracture model. Fibular allografts were inserted at 0° and 30° to the humeral shaft. Axial and traction forces of 70°, 90°, and 110° relative to the vertical axis were applied to each model to simulate stress on the plate and graft. At axial loads, stresses in both the plate and the graft were lower when the graft was inserted at 0° than at 30°. Under traction loads, plate stress was lower with 30° insertion. Graft stress was also lower with 30° in most experimental conditions in both the valgus and varus models. These findings suggest that oblique insertion may provide biomechanical advantages under traction forces in unstable proximal humerus fractures. Full article

Objectives: The optimal rehabilitation protocol following open reduction and internal fixation (ORIF) for Neer type-4 valgus impacted proximal humeral fractures (VIPHF) remains controversial. This study aimed to compare the long-term efficacy and safety of early active mobilization versus conventional rehabilitation in these patients. Methods: We conducted a retrospective cohort study at a single tertiary hospital involving 128 patients who underwent ORIF for Neer type-4 VIPHF between January 2018 and December 2022. Participants were divided into two groups based on the rehabilitation protocol received: the Early Active Activation (EAA) group (n = 64), which initiated controlled active exercises on postoperative day 1, and the Conventional Rehabilitation (CR) group (n = 64), which followed a delayed protocol. The primary outcome was the Constant–Murley score at 24 months. Secondary outcomes included scores at 3, 6, and 12 months, pain VAS scores, active range of motion, fracture healing time, and complications. Results: The EAA group demonstrated significantly superior outcomes, including a higher 24-month Constant–Murley score (88.7 ± 6.5 vs. 75.3 ± 9.2, p < 0.001), lower VAS scores at all time points (p < 0.001), greater range of motion (p < 0.001), and shorter fracture healing time (10.2 ± 1.8 vs. 12.5 ± 2.3 weeks, p < 0.001). Complication rates did not differ significantly (4.7% vs. 6.3%, p = 0.718). Conclusions: For patients with surgically stabilized Neer type-4 VIPHF, early active rehabilitation initiated on postoperative day 1 was associated with significantly improved functional outcomes, accelerated recovery, and a favorable safety profile. However, these findings should be interpreted with caution due to the retrospective design, single-center setting, and potential residual confounding. Further validation through prospective, multicenter studies is recommended. Full article

Background/Objectives: Hemiarthroplasty (HA) and Reverse Total Shoulder Arthroplasty (RTSA) are both reliable treatment options for complex proximal humerus fractures. The role of the subscapularis tendon is well-defined in HA, whereas it plays a controversial role in RTSA. The purpose of our study is to evaluate its role in patients with proximal humerus fractures treated with HA and RTSA and investigate its association with clinical outcomes. Methods: Sixty-eight consecutive patients with proximal humeral fracture were prospectively enrolled into the study from June 2015 to May 2020 (RTSA = 36; HA = 32). Pre- and postoperative shoulder CT scans were performed to measure the subscapularis muscle cross-sectional area (SMCSA) and the supraspinatus fossa cross-sectional area (SFCSA). The SMCSA/SFCSA ratio was employed to normalize measurements against individual patient anatomy. Patient reported outcomes (PROs) and range of motion (ROM) were evaluated at the final follow-up. Results: The RTSA group demonstrated superior patient-reported outcomes (PROs) and range of motion (ROM) compared to the HA group. Notably, the Constant Score was significantly higher in the RTSA group (58.00 vs. 38.50; p = 0.0001), as well as forward flexion (147.50° vs. 90.00°; p < 0.0001). A postoperative reduction in subscapularis size of >35% occurred more frequently in RTSA patients (55.6%) than in HA patients (25%) (p = 0.01). The loss of subscapularis surface was greater in the RTSA patients (p = 0.018). Conclusions: RTSA demonstrated better results compared to HA, providing better ROM and PROs. Postoperative reduction in subscapularis size was significantly higher in RTSA compared to HA. Subscapularis condition seems to show no correlation with functional outcome in RTSA. Full article

Background and Clinical Significance: Non-prosthetic peri-implant fractures (NPPIFs) are rare injuries occurring around internal fixation devices, and are distinct from periprosthetic fractures. While most studies focus on the femur, humeral NPPIFs remain poorly documented. This case illustrates a complex humeral NPPIF and highlights key surgical considerations. Case Presentation: A 62-year-old woman presented with a spiral humeral shaft fracture (AO 12B2) after a fall. Following closed reduction and antegrade intramedullary nailing, an intraoperative peri-implant fracture occurred at the distal interlocking screw. CT imaging revealed a complex fracture extending from the lateral condyle to the proximal humerus. Treatment included implant removal and open reduction with dual plate fixation—lateral distal and helically contoured proximal plates—plus cerclage bands and antibiotic-loaded beads. Recovery was uneventful, with a full range of motion achieved at six months. At one year, the DASH score and MEPS were 86 and 75, respectively. Conclusions: Humeral NPPIFs are challenging and require individualized, biomechanically sound strategies. This case reinforces the importance of intraoperative assessment and careful implant selection in humeral fracture management. Full article

Background: Distal humeral shaft fractures (DHSFs) pose surgical challenges due to the proximity to the elbow joint, limited bone stock, and the risk of radial nerve injury. This study compared clinical and radiographic outcomes of anterolateral and posterior triceps-sparing approaches to determine the most effective surgical strategy. Methods: This multicenter retrospective study included 75 patients who underwent surgery for a DHSF between 2015 and 2021, with a minimum one-year follow-up, a distal fragment ≥3 cm, and no preoperative radial nerve injury. Fifty patients underwent anterior plating via anterolateral approach, and twenty-five underwent posterior plating. Clinical and radiographic outcomes were evaluated. Results: Bone union was achieved in 74 patients (98.7%), with no significant difference between the groups (p = 0.21). The anterolateral approach resulted in a shorter operative time (116 ± 29.4 vs. 143 ± 31.4 min, p = 0.03). However, intraoperative blood loss (p = 0.36), Mayo Elbow Performance Score (p = 0.71), range of motion (p = 0.36), and complication rates (p = 0.21) were not significantly different. Two cases of transient radial nerve palsy occurred in the posterior group (p = 0.17), and four cases required implant removal due to discomfort (p = 0.18) in the anterolateral group. Conclusions: Both approaches effectively treat DHSFs with high union rates and comparable functional outcomes. However, the anterolateral approach significantly reduces operative time due to supine positioning, direct access, and avoiding radial nerve dissection. Posterior plating remains viable when stable anterior fixation is unachievable. Further studies should assess the long-term outcomes and factors influencing approach selection. Full article

Background: Proximal humeral fractures (PHFs) are common, especially in the elderly, and account for 4% to 10% of all fractures, with women more often affected than men. Treatments include conservative methods, internal fixation and arthroplasty, with surgical approaches increasingly being used due to technological advancements. This study analyzes the evolution of PHF treatments in Italy from 2001 to 2022, using data from the Italian Hospital Discharge Records (HDRs) Database, and includes a stratified analysis by age and sex. Methods: Using HDR data from 2001 to 2022, records with ICD9-CM codes for proximal humeral fractures (812.0 and 812.1) among diagnoses were selected and categorized into three treatment groups: arthroplasty, fixation and conservative. Time series were analyzed with stratification by sex and age. Results: The extracted data included 486,368 records of PHFs, with 223,742 cases treated surgically (arthroplasty or internal fixation) and 262,626 treated conservatively; the average patient age was 66.6 years, with a higher proportion of women, especially among arthroplasty patients. Over time, the use of fixation and arthroplasty increased from 20% of treatments in 2001 to over 60% in 2022, with fixation becoming the most common treatment method by 2014 and arthroplasty significantly increasing among women, particularly in the 65–74 and 75–84 age groups. Conclusions: The study shows that in Italy, over the past two decades, treatment for PHFs has shifted from conservative methods to a preference for internal fixation and increasingly for arthroplasty, particularly among women and patients aged 65–84, reflecting evolving trends and technological improvements. Full article

Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues. Full article

Background: Proximal humerus fractures are common fractures of the elderly population which can lead to long-term compromise of a patient’s shoulder function. Closed reduction and internal fixation with intramedullary nailing is a well-established surgical technique yielding good outcomes, as perceived by patients, obtained via Patient-Reported Outcome Measures, and objectified by clinical shoulder testing. Apart from conventional range-of-motion testing and clinical shoulder tests, strength testing of the shoulder is a yet-neglected but meaningful and standardizable outcome parameter. In this study, isometric shoulder strength is evaluated in relation to fracture morphology/postoperative reduction quality as well as with patient-reported outcomes. Methods: 25 patients (mean age 73.2 ± 10.5 years) underwent isometrics strength-testing of the shoulder joint in the scapular plane (abduction) as well as in the sagittal plane (flexion) as well as hand-grip strength-testing at 4.5 ± 1.88 years follow-up. Pre- and postoperative radiographs were analysed. Patients completed ASES and CMS questionnaires. Results: Patients exhibited a decrease in abduction and flexion force (−24.47% and −25.30%, respectively, p < 0.001) using the contralateral, uninjured arm as reference. Abduction force tended to be decreased in three- and four-part fractures. Patient satisfaction correlated negatively with the relatively reduced force of the affected arm. Varus-angulated humeral heads produced significantly lower abduction force output than valgus- or physiologic angulation (p = 0.014), whereas flexion force was unaffected (p = 0.468). The anatomical reduction had no influence on shoulder strength. Conclusions: Proximal humerus fractures may cause a significant reduction in shoulder function, both reported by patients and objectified by shoulder strength testing. Varus head angulation demonstrated the greatest loss of shoulder strength and should be avoided to ensure proper functioning. Further, strength testing seems a valuable outcome parameter for a thorough shoulder examination with easy obtainability. Full article