Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta.

There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication.

The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation.

This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study.

The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection.

Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003).

This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection.

Aims

The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures.

Fluoroscopic C-arms are operated by medical radiography technologists (RTs) in Canadian operating rooms (ORs). While they do receive formal, accredited training, most of it is theoretical, rather than hands-on. During their first encounters in the OR, new RTs can experience difficulty achieving the radiographic views required by surgeons, often needing several scout X-rays during C-arm positioning. Furthermore, ambiguous language by surgeons often inadequately conveys their request. The result is often frustration, unnecessary radiation exposure, and added OR time. The purpose of this study was to evaluate the value of artificial X-rays in improving C-arm positioning performance, with inexperienced C-arm users.

We developed an Artificial X-ray Imaging System (AXIS) that generates Digitally Reconstructed Radiographs (DRRs), or artificial X-ray images, based on the relative position of a C-arm and manikin. 30 participants were enrolled in the user study and performed four activities: an introduction session, an AXIS-guided evaluation, a non-AXIS-guided evaluation, and a questionnaire. The main goal of the study was to assess C-arm positioning performance with and without AXIS guidance. For each evaluation, the participants had to replicate a set of target X-ray images by taking real radiographs of the manikin with the C-arm. During the AXIS evaluation, artificial X-rays were generated at 2 Hz for guidance, while in the non-AXIS evaluation, the participants had to acquire real scout X-rays to guide them toward the correct view.

For each imaging task the number of real X-rays and time required per task was recorded, and the C-arm's pose was tracked and compared to the target pose to determine positioning accuracy; these were averaged for each participant and condition. Hypothesis testing on the means and paired t-tests were carried out using a significance level of α=0.05.

On average, users took significantly fewer real scout X-ray images (53% fewer (2.8 vs 6.0), p<0.001) when guided by AXIS. Lateral distance accuracy was improved by 10% for final C- arm positions and by 26% for the most accurate intermediate C-arm positions when guided by AXIS (p<0.05). There was no significant difference in average task time or angular accuracies between the AXIS and non-AXIS evaluations. Overall, we are encouraged by these findings and plan to further develop this system with the goal of deploying it both for training and intraoperative uses.

Pedicle screw fixation is a technically demanding procedure with potential difficulties and reoperation rates are currently on the order of 11%. The most common intraoperative practice for position assessment of pedicle screws is biplanar fluoroscopic imaging that is limited to two- dimensions and is associated to low accuracies. We have previously introduced a full-dimensional position assessment framework based on registering intraoperative X-rays to preoperative volumetric images with sufficient accuracies. However, the framework requires a semi-manual process of pedicle screw segmentation and the intraoperative X-rays have to be taken from defined positions in space in order to avoid pedicle screws' head occlusion. This motivated us to develop advancements to the system to achieve higher levels of automation in the hope of higher clinical feasibility.

In this study, we developed an automatic segmentation and X-ray adequacy assessment protocol. An artificial neural network was trained on a dataset that included a number of digitally reconstructed radiographs representing pedicle screw projections from different points of view. This model was able to segment the projection of any pedicle screw given an X-ray as its input with accuracy of 93% of the pixels. Once the pedicle screw was segmented, a number of descriptive geometric features were extracted from the isolated blob. These segmented images were manually labels as ‘adequate’ or ‘not adequate’ depending on the visibility of the screw axis. The extracted features along with their corresponding labels were used to train a decision tree model that could classify each X-ray based on its adequacy with accuracies on the order of 95%.

In conclusion, we presented here a robust, fast and automated pedicle screw segmentation process, combined with an accurate and automatic algorithm for classifying views of pedicle screws as adequate or not. These tools represent a useful step towards full automation of our pedicle screw positioning assessment system.

Hospital type is an indicator for structures and processes of care. The effect of hospital type on hip fracture in-hospital mortality is unknown. We determine whether hip fracture in-hospital mortality differs according to hospital type.

We retrieved records of hip fracture for 167,816 patients aged 65 years and older, who were admitted to a Canadian acute hospital between 2004 and 2012. For each hospital type we measured and compared the cumulative incidence of in-hospital death by in-patient day, accounting for discharge as a competing event.

The cumulative incidence of in-hospital death at in-patient day 30 was lowest for teaching hospital admissions (7.3%) and highest for small community hospital admissions (11.5%). The adjusted odds of in-hospital death were 12% (95% CI 1.06–1.19), 25% (95% CI 1.17–1.34), and 64% (95% CI 1.50–1.79) higher for large, medium, and small community hospital versus teaching hospital admissions. The adjusted odds of nonoperative death were 1.6 times (95% CI 1.42–1.86), and 3.4 times (95% CI 2.96–3.94) higher for medium and small community hospital versus teaching hospital admissions. The adjusted odds of postoperative death were 14% (95% CI 1.07–1.22) and 20% (95% CI 1.10–1.31) higher at large and medium community hospitals versus teaching hospitals. The adjusted odds of postoperative death were largest at small community hospitals but the confidence interval crossed 1 (OR = 1.25, 95% CI 0.92–1.70).

A higher proportion of hip fracture patients die at non-teaching compared to teaching hospitals accounting for length of stay. Higher mortality at small community hospitals may reflect disparities in access to resources and delay to treatment.

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

Purpose

The prevention of a subsequent, contralateral hip fracture is targeted as an avoidable event in the elderly. Fall prevention and bone strengthening measures have met with limited success and the urgency of their effect is undetermined. Our objective was to evaluate the time to second hip fracture (the time between a first and a subsequent, contralateral fracture) in elderly patients, using a population-based administrative health data set.

Purpose

Radiographs are the most common imaging modality used to guide orthopaedic interventions. Ultrasound (US) imaging offers potential advantages for intraoperative imaging by its portability and ability to produce real-time 2D or 3D images without radiation to either the patient or surgical team. Our objective in this study was to determine in a live emergency room setting, if a newly-developed image processing method for 3D US would allow us to accurately extract (reproduce) the surfaces of fractured bones.

Purpose

To determine whether there have been changes in the age, sex and subtype specific first hip fracture rates in Canadian province of British Columbia (BC) between 1990 and 2004.

Background

The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy.

Purpose: Problem: Tibia plateau fractures may lead to end-stage post-traumatic arthritis that requires reconstructive surgery. The incidence of this problem is unknown but has been estimated at 20–40% by studies that were limited by small sample sizes, potential follow-up bias, and the limitations of using radiographic arthritis as a chosen outcome (not correlated to function). The use of administrative data bases to follow the care of a large number patients for robust end points such as surgery, offers an opportunity to address these limitations. Purpose: to determine the minimum ten year incidence of post-traumatic arthritis necessitating reconstructive surgery following tibia plateau fractures.

Method: We queried our prospectively collected Orthopedic Trauma Data base to identify operatively treated patients with tibia plateau fractures. These cases were cross-referenced with the data from our Province’s administrative health database and tracked over time for the performance of reconstructive knee surgery. Each individual’s exposure/follow-up period was limited by end of health plan coverage on record or date of death from vital statistics data. The minimum follow-up was ten years.

Results: Between 1987 and 1994, 378 patients with a tibia plateau fracture were treated at our institution. The average age was 46 years (sd=18, range 14–87), while 56% of patients were males. Seventeen out-of-Province residents were excluded, along with forty-six others whose “Medical Services Plan” numbers could not be identified. Of which seven were WCB patients and one who was affiliated with the military. The study cohort therefore consisted of 311 patients with 314 tibia plateau fractures. Four individuals (1.3%) we treated tibia plateau fractures have required reconstructive knee surgery for end-stage post-traumatic knee arthritis at 10 years. Of these 3 of 4 were type VI fractures and 1 of 4 was open.

Conclusion: Patients who require surgical treatment of tibia plateau fractures may be counseled on their long-term risk of requiring reconstructive knee surgery for endstage knee arthritis based on a clinical study. Based on our findings, the proportion of those who have required a total knee surgery, ten years following their injury, is lower than previously published.

Purpose: Femoral and tibial shaft malunion may predispose to knee osteoarthritis but may also pose a problem for knee reconstruction; malposition of total knee prostheses being a known cause of early failure. Limb realignment may prove to be beneficial prior to proceeding with arthroplasty. The purpose of this study was to evaluate the outcome and effect of shaft osteotomy prior to total knee arthroplasty (TKA).

Method: A search of the trauma database between 1987 and 2006 was conducted. Twenty-two osteotomies were performed on 21 patients with femoral or tibial shaft malunion who had been considered for TKA. Mean age at osteotomy was 54 years and mean follow-up 86 months. Time intervals between surgical procedures and Knee Society scores were calculated. Patients were surveyed regarding pain relief and functional improvement.

Results: Femoral osteotomy improved mean Knee Society knee scores from 47 to 76 and function scores from 34 to 61. Tibial osteotomy improved knee scores from 53 to 82 and function scores from 28 to 50. Four osteotomies were complicated by nonunion and required further intervention. Osteotomy subjectively improved pain and function for a mean of 56 months. Femoral and tibial shaft osteotomy delayed TKA in 45% (10 cases) for a mean period of just over 6.5 years (89 and 73 months for femoral and tibial osteotomy respectively). Pre and post Knee society scores were: Femur: knee 56 to 88, function 41 to 72; Tibia: knee 65 to 85, function 25 to 57. One TKA was revised after 11 months due to valgus malalignment and was complicated by a wound infection. There were no other infections or wound complications. The procedure additionally relieved pain and improved function in the remaining 12 joints, not yet requiring arthroplasty.

Conclusion: Femoral and tibial shaft osteotomy may delay and possibly avoid TKA, relieve pain and improve function in patients who present with malunion and end-stage knee arthritis. The complication rate and clinical results of TKA following shaft osteotomy appear to be similar to primary TKA. This treatment strategy should be considered in younger patients with post traumatic osteoarthritis where significant femoral or tibial deformity is present.

Purpose: Decubitus ulcers and post-operative infections significantly impact patients’ outcome and resource utilization. The purpose of this study is to report incidence of post-surgical infection, decubitus ulcer and associations to 30-day in-hospital mortality among elderly Canadians admitted for hip fracture.

Method: Statistics Canada’s national Health Person-Oriented Information database of linked acute care hospital discharges was queried for fiscal 2001–02, 2002–03, 2003–04 creating a cohort of 67,434 hip fracture patients aged 60+. Demographics, comorbidities (enhanced Charlson Index), fracture type and treatment were used in logistic regression models to report odds ratios for outcomes.

Results: Women were 76% of the cohort, median age was 82 yrs. Decubitus ulcer was detected in 2.3% of hip fracture patients. Increased risk was indentified for trochanteric fractures (OR 1.14, p< .05), dementia (OR 1.25, p< .05) and increasing age (OR: 1.02, p< .05). Decubitus ulcer more than doubled to 2.9% for those with 1–2 comorbidities, increasing to 6.3% for 3+ comorbidities. Between 1.2% and 1.3% of the cohort developed a post-surgical infection/inflammatory response depending on method used to calculate 30-day follow-up. Compared to internal fixation, arthroplasty showed higher infection (OR: 1.38, p< .05). Overall cohort 30-day in-patient mortality was 7%. Selected complications were significantly associated to 30-day in-hospital mortality (decubitus ulcer OR: 1.51 p< .05, post-surgical infection/inflammatory response (OR: 1.52 p< .05). Trochanteric fractures (OR: 1.19 p< .05) and hemi-arthroplasty (OR: 1.10, p< .05) were associated to 30-day mortality. No significant variation was found between total arthroplasty and internal fixation for 30-day in-patient mortality.

Conclusion: Quantification of these rates and risk factors may offer normative values to measure health system performance and possibly reflect care strategies and delays to surgery. Results may identify target groups at risk for complications and potentially highlight the impact of clinical decisions such as performing arthroplasty for all (displaced and undisplaced) femoral neck fractures.

Purpose: Lower extremity articular fracture treatment requires acccurate diagnosis and anatomic reduction and fixation. As articular injuries, posterior malleolus (PM) fractures are still poorly defined: for example the incidence of associated PM marginal impaction and of free articular fragments is unknown. The purposes of this study were:

to define the articular injuries of PM fractures into clincially relevant groups, as complex articular injuries could require specific surgical steps;

Method: Our prospectively-collected orthopaedic trauma database (OTDB) query identified 796 ankle fractures treated operatively between 2003–2007. Of these 147 cases involved the posterior malleolus. Four were misclassified leaving 143 cases. We obtained demographic and injury data from the OTDB, and validated the OTDB coded mechanisms of injury by an individual chart review. We reviewed all radiographs to describe the PM injuries (fracture patterns and dimensions) and to identify the associated injuries.

Results: Of the 143 cases: Mean age was 50 years (sd=19), 68.5% were female, 51% were right sided injuries, and the median ISS=4 (in fact, 97.5% had ISS=4, most therefore being isolated trauma). The mean post malleolus AP size=11mm (sd=5). We identified recurrent patterns and classified the PM fracture as SIMPLE or COMPLEX (to include marginal impaction or free comminuted fragment, which should be anatomically reduced), 42% of cases (60/143) were COMPLEX (18 were impaction, 42 were free fragment). To help clinicians identify which cases could be COMPLEX we correlated (Chi-sq) the presence of a COMPLEX PM fracture to common clinical and radiographic variables. COMPLEX PM were statistically significantly associated with (p values)

an axial loading injury mechanism (.000),

For example, axial loading would result in a complex fracture in > 85% of cases. In contrast, there was a statistically significant association between a Weber C fracture and older age and the presence of a SIMPLE PM fracture. These factors being potentially “protective” from joint comminution.

Conclusion: We have defined and quantified the PM articular lesions which require anatomic reduction and fixation, beyond what has been published. We have defined clinical and radiographic criteria which, because higly associated with COMPLEX lesions, could

prompt surgeons to order further imaging (CT) to better delineate the lesion, and

Purpose: The management of pelvic fractures with urinary disruption is controversial, with potential cotamination of anterior ORIF by bladder or urethral injuries and possible deep infection and non-union. External fixation is advocated by some to avoid such problems, on theoretical grounds of limited soft tissue disruption. This advantage however has not been clearly substantiated. The purpose of this study is to describe the epidemiology of these injuries and to compare the risk of deep wound infection in patients with pelvic fractures and urinary disruption treated with ORIF versus External Fixation (EF).

Method: Retrospective review of prospectively collected data on patients treated at a tertiary trauma centre between 1999 and 2006. Demographics, Injury charateristics, Treatment and Outcomes (infection, non-union) of adults sustaining pelvic fractures with associated urinary disruption and treated by ORIF or EF were analysed. Of the 444 pelvis fractures operated over that period, 78 cases had an associated urological injury. Mean age 35 (SD13), ISS 28 (SD10), sex: 65% male, 35% female, AO/OTA #type: A 3.8%, B 48.7%, C 47.4%, 13 Open fractures (17%), Urological injuries: 64% Bladder, 22% urethra, 6% combined bladder-urethra, 8% associated pelivc organ injury. Treatment was ORIF in 49 (63%) and EF in 29 (37%).

Results: ORIF and EF groups showed no statistically significant difference (p values indicated) in: Age (.07) and ISS (.22) by T-test, or Fracture type (.92), Gustilo classification (.08), Urological injury (.11) by Chi Sq. Early Deep wound infection occurred in 2 of 48 (4.1%) ORIF cases, and in 1 of 29 (3.4%) in EF cases. The differences were not statitically significant. (Chi Sq). There were no nonunion cases and no late deep wound infection in either group. The infection rate was however significantly different than in the entire pelvis frature cohort of 433 cases, which is 0.9%.

Conclusion: External fixation showed no advantage with respect to infection rate, with the rate of deep infection in both ORIF and EF showing no statistically significant difference. Despite its statistical power limitations, this study assembles the largest cohort with this comibination of injuries and guides the orthopedic surgeon in his or her treatment decisions.

ACL deficiency can have detrimental pathological effects on the menisci in the knee. A database review in Quebec over a three-year period was previously reported (Canadian Academy of Sport Medicine, Winnipeg, 2003), which examined the relationship between waiting times for ACL surgery and the requirement of a meniscal procedure. The purpose of this study is to determine if the length of time between an index injury and ACL reconstruction (ACLR) surgery correlates with the incidence of meniscal repair and meniscectomy in Alberta, and to compare the results to those of the Quebec study.

Retrospective study, using procedure and billing codes to search the Alberta Health and Wellness databases for knees undergoing primary ACLR surgery between 2002–2005. Inclusion: Patients sixteen years or older at time of reconstruction. Exclusion: Revision ACLR, duplicate billing and coding, and insufficient database information. For each reconstructed knee, databases were searched for initial injury evaluation date with primary care physician, dates of meniscectomy or meniscal repair procedures, and date of ACLR.

Over a three-year period, there were 3382 primary ACL reconstructions performed in Alberta, 3812 ACLR in Quebec. Of these patients, 2583 in Alberta (76%) and 1722 in Quebec (45%) required a meniscal procedure. On average, Albertans waited 1389 days from injury to ACLR compared to 422 days in Quebec. In Alberta, patients not requiring a meniscal procedure waited 1212 days, patients requiring meniscal repair waited 1143 days, and patients requiring meniscectomy waited 1519 days, compared to 251, 413 and 676 days in Quebec, respectively. Three percent of patients in Alberta had ACLR < three months after injury (114 patients), with 45% requiring meniscectomy. Overall, 61% of patients in Alberta required a meniscectomy for significant meniscal injury, compared to 48% of patients in Quebec. The proportions for each province were statistically significant.

Compared to Quebec, patients in Alberta are waiting longer for ACLR, with only a small proportion of cases being treated acutely. The proportion of patients requiring surgery for significant meniscal injury is also greater in Alberta. The higher proportion of patients in Alberta requiring meniscectomy may be due to the delay in ACLR.

To determine if intraoperative positioning in the supine or lateral position affects morbidity and mortality in orthopaedic trauma patients with femur fractures.

Retrospective cohort study of 991 patients representing 1030 femoral shaft fractures admitted to our level one trauma center between the years of 1987 to 2006. Primary outcome measures included mortality and admission to ICU. Secondary outcome measures included length of stay in hospital, length of time admitted to the intensive care unit and discharge disposition. Logistic regression analysis was performed to compare to effect of intraoperative position in addition to other known dependent variables on primary and secondary outcome measures.

Intraoperative position in the supine or lateral position had no effect on morbidity or mortality in orthopaedic trauma patients with femur fractures.

There is no difference in immediate mortality or morbidity between patients with femur fractures treated with IM nails in either the lateral or supine position. We conclude that either position is safe for the surgical stabilization of femur fractures and intraoperative position should be determined by surgeon preference.

Evidence suggests that femoral neck fractures initiate in the superolateral cortex, where it is significantly thinner in older than younger individuals (Mayhew, et al. Lancet 2005). Thus, we sought to determine the relative time-course of crack initiation and propagation during a simulated hip fracture.

Four unembalmed frozen, human cadaveric specimens (mean age = 78 yrs) were loaded to failure in sideways fall configuration at a rate of 100 mm/sec using a materials testing system. Images of the fracture were captured with two high-speed video cameras at a resolution of 384x384 pixels, and sample rate of 9,111 Hz (frames/second).

Test A: The load-displacement (L-D) curve had three distinct peaks: at the first peak (4390 N), the head and neck rotated slightly. At the second peak (4607 N), a visible local compressive fracture appeared in the superior cortex of the proximal neck. At the third peak (3582 N), a neck-spanning tensile failure occurred in the inferior neck. Test B: At the first and second peak loads (1714 N and 3040 N) fluid was released from the posterior then superior and inferior surfaces. The third peak load (3361 N) corresponded to a local compressive failure in the lateral superior neck, followed by a neck-spanning tensile failure medially. Test C: The L-D curve was linear until ultimate load (3038 N). A compressive crack first appeared on the anterior-superior surface of the neck cortex, then fractured in the inferior neck. Test D: The L-D curve was linear until ultimate load. A small local crack appeared in the superior cortex of the proximal neck at ultimate load (3841 N).

We found that during ex vivo simulations of hip fracture, the femur failed initially in the superior cortex of the neck, and then failed in the inferior cortex. This is the first study to demonstrate, with high speed video data, the location of crack initiation and its propagation. These preliminary data support the hypothesis of Mayhew et al. (Mayhew, et al. Lancet 2005) in terms of fracture development and could relate to clinically relevant fracture types.

We reviewed the results of sixteen patients with three and four part proximal humerus fractures treated with the Locking Proximal Humerus Plate (LPHP) in two trauma centres. All fractures were radiographically healed by six weeks. We found a high rate of fixation failure 4/16 cases within two weeks of surgery and range of motion results similar to previously reported techniques. This device has not demonstrated its clear superiority when used in trauma centres which commonly treat proximal humerus fractures. A randomised control trial comparing it to classical techniques and using outcome-based measures would seem appropriate.

Proximal humerus fractures with poor functional outcomes are expected to increase in frequency owing to an active ageing population. New angle stable devices have been developed to address the frequently associated osteoporosis and loss of fixation.

This study reviews the early experience of fixation with an angle stable device, the LPHP (Synthes Canada).

Three and four part fractures treated with the LPHP were identified from the database of two trauma centres. Demographics, patient activity level, mechanism of injury, fracture type were collected. Early complications, maintenance of reduction, and ROM were reviewed.

Sixteen fractures treated with the LPHP. Male to female ratio was 1.3:1. Mean age was 51.5 (29–77) Activity: 12/16 sedentary, 4/16 manual labourers. Mechanism: four Low and twelve High-energy injuries. Fracture classification: Five three part, and Eleven four part fractures.

Early complications: one wound haematoma,one re-operation for intra-articular hardware, and four of sixteen pts pulled off the greater tuberosity fixation within two weeks of surgery. Union was achieved in all sixteen by six weeks. The mean forward elevation was 60° at six weeks and 80° at three months.

This review of the early experience with the LPHP shows a significant rate of fixation failure (4/16 cases) and functional ROM results similar to other previously described techniques. Although a “learning curve effect” is possible, this device has not demonstrated clear superiority with surgeons who commonly treat proximal humerus fractures. A randomised control trial comparing it to classical techniques would seem appropriate.