Rehabilitation after osteosynthesis of the humerus. Scar and care for it. Exercise therapy. Should I pull out the plate?

Osteosynthesis is a modern and effective surgical method that is used for bone fractures. During the operation, the traumatologist connects and fixes the bones together using special metal structures (plates, knitting needles, rods, screws, etc.).

The advantage of osteosynthesis over conservative treatment is that as a result of such a strong connection, anatomically correct and rapid restoration of bone integrity . For some types of injuries, osteosynthesis is the only effective way to restore the joint and maintain its mobility.

The material was prepared by orthopedic traumatologist, head of the surgical department of Euromed Clinic Suprun Konstantin Stanislavovich

Types of osteosynthesis

Depending on the type and location of the fracture, trauma surgeons at the Euromed perform osteosynthesis using various methods:

• Internal (submersible) osteosynthesis
  is a method of bone fixation using various implants that fix bone fragments inside the patient’s body.
• External osteosynthesis,
  when bone fragments are connected using compression-distraction external fixation devices (the most famous is the Ilizarov apparatus, but there are many other modifications).

To minimize the risks of complications and quickly restore bone integrity, the correct choice of osteosynthesis technique is of great importance.

Operating traumatologists-orthopedists of Euromed Clinic with extensive experience in performing operations, when choosing a method of surgical treatment, take into account the characteristics of the injury, the presence of concomitant pathology and the patient’s lifestyle.

At Euromed Clinic, when performing osteosynthesis, traumatologists use metal structures made of biologically inert materials that are absolutely safe for human health. The choice of a specific fixator depends on the location of the fracture and the severity of the injury.

In what cases are such operations carried out?

Main indications for osteosynthesis:

• fractures that cannot heal without mechanical fixation of the fragments;
• divergence of fragments;
• intra-articular fractures;
• fractures in which there is a high probability that fragments will damage the skin, that is, the injury will change from closed to open;
• the presence of soft tissue between bone fragments;
• fractures complicated by damage to a nerve or great vessel;
• secondary displacement of fragments during conservative treatment;
• inability to perform closed reduction of fragments;
• non-united or slowly healing fractures;
• false joints.

Preparing for surgery

Preparation for surgery includes a number of studies:

• markers of hepatitis C and B;
• analysis for RW and HIV;
• clinical blood test;
• blood chemistry;
• general urine analysis;
• fluorography;
• coagulogram;
• identification of blood group and Rh factor;
• ECG;
• consultation with an anesthesiologist;
• therapist's conclusion.

If necessary, a traumatologist may prescribe a computed tomography scan to establish the exact localization of the affected area.

2nd period

The starting position is to bend the torso forward.

1. “Rinse the laundry” (swing to the sides), followed by spreading and crossing the arms in front of the chest. 2. Circular pendulum movements with straight arms in both directions. 3. “Skiing” (free pendulum movements of the arms forward and backward). 4. Brushes in a lock. The lock is open to your chest, to your mouth, to your forehead, behind your head (if possible). Spread your elbows to the sides.

Starting position: bent over with a stick.

1. Bend the torso forward. A stick in the hands at shoulder width. Stick towards and away from yourself. Free pendulum swings. 2. Circular movements in both directions (arms straight). 3. Stick at the ends. Free swings to the sides. 4. Hands shoulder-width apart. Arm bending - stick to the chest, to the chin, to the forehead. 5. Circular rotation of the stick towards and away from you, bending your elbows.

Starting position: standing.

1. Circular movements of the shoulders in both directions. Hands along the body. 2. Hands slide to the armpits, along the side and down. 3. Hands to shoulders. Retracting your elbows to the sides. 4. Stroke the affected hand with the healthy one up to the shoulder blade. 5. Hand clapping in front and behind. 6. Brushes in a lock. Raising straight arms to the horizontal. 7. Place your hands on your belt (with different thumb positions). 8. Brushes in a lock. Slide your palms along the body to the chin (elbows to the sides). 9. Slide your hands up a polished surface or on a platform with wheels (along the wall).

Starting position – standing. Exercises with a gymnastic stick.

1. Different hand grips. Stick to the chest and down. 2. Raising the stick to the horizontal and down. 3. Lifting the stick towards the sore arm (stick by the ends). 4. Circular movements with the stick towards and away from you (hands shoulder-width apart). 5. The stick slides to the chin (elbows to the sides). 6. Stick from behind. Grip the hand from below, shoulder width apart. Scratch your lower back up and down. 7. Stick from the side vertically to the floor on a straight arm. Circular rotations with the affected arm in both directions.

How is the operation performed?

The operation is performed under general or local anesthesia. The incision area is treated with an antiseptic solution. Next, an incision (usually one) of the tissue with a scalpel is made over the affected area.

The trauma surgeon connects the bone fragments to each other in the correct position. Then installs and fixes the previously selected latch. Then layer-by-layer suturing of the tissues is carried out, the wounds are treated, and drainage is installed.

If additional immobilization is necessary, a cast is applied.

After the operation, the patient is transferred to a comfortable ward for approximately three days, depending on the location and extent of the intervention.

Removing pins

Pins made from conventional materials are removed after approximately 8-10 months. The exact period is determined by the doctor. If you skip this period, the structure may become overgrown with bone tissue. You cannot leave the pin inside - this can lead to complications. If you arrive on time, the pin can be removed without unnecessary injury. The hole left by the structure will fill up fairly quickly. There will be no scars left after removal - the structure will be removed by making an incision where it was last time.

Today, special biodegradable materials are also used for osteosynthesis. There is no need to remove such pins - they dissolve in the bone cavity. No additional intervention is required when performing the procedure with modern materials.

Rehabilitation after osteosynthesis

The recovery course for the patient is selected by a traumatologist taking into account the individual characteristics of the body and, as a rule, includes:

• drug treatment to accelerate bone regeneration and eliminate swelling;
• massage to improve local blood circulation and prevent bedsores;
• Exercise therapy to restore normal mobility;
• physiotherapeutic procedures;
• in some cases, anticoagulants (drugs that reduce blood clotting) are prescribed.

The duration of wearing fixing devices is determined individually and, as a rule, ranges from 3 to 12 months. A planned operation is performed to remove metal structures.

POLYTRAUMA / POLYTRAUMA

Egiazaryan K.A., Ratyev A.P., Tamazyan V.O., Glazkov K.I., Ershov D.S.

Federal State Budgetary Educational Institution of Higher Education "Russian National Research Medical University named after. N.I. Pirogov" of the Ministry of Health of Russia, Moscow, Russia State Autonomous Institution of the Moscow Region "TsGKB Reutov", Reutov, Moscow region, Russia

RESULTS OF OSTEOSYNTHESIS OF FRACTURES OF THE PROXIMAL HUMERUS WITH AN INTRAMEDULLARY PIN WITH ADDITIONAL SOFT TISSUE STABILIZATION OF THE TURBLES

Proximal humerus fracture (PHF) is the third most common fracture among older adults, second only to hip and distal radius fractures, and accounts for about 4-5% of bone fractures throughout the body [1, 2]. Such fractures are believed to be caused by osteoporosis and are mainly associated with an increasing number of injuries in older women with the fracture localized in the metaphyseal zone [3]. The main cause of injury is a common fall, which occurs in 75% of older postmenopausal women [2]. On the other hand, it can be noted that POJ fractures tend to occur most often in a subgroup of older people who are relatively healthy and physically able to work [3]. Compared with nondisplaced two-part fractures, which have a good prognosis with conservative treatment [3, 4], the treatment of displaced fractures remains controversial. Conservative treatment of these fractures can result in delayed humeral healing, pseudarthrosis, joint stiffness, and post-traumatic arthrosis, and therefore lead to significantly disabling outcomes [5]. Various fixators have been proposed for the fixation of PPJ fractures, including pins, locking plates, and intramedullary pins. Although no implant has yet achieved superiority over the others, most experts agree that minimally invasive intervention and adequate fixation should be the primary goals of any internal fixation device [6]. Currently, intramedullary osteosynthesis of the proximal humerus is gaining increasing popularity. This is due to improved technology, the evolution of implants and a better understanding of the anatomy of the shoulder joint. However, errors and complications after the use of pins continue to persist [7]. Purpose of the study -

compare the results of surgical treatment of patients with fractures of the proximal humerus using intramedullary locked osteosynthesis using the standard method with closed reduction and the proposed method of semi-open reduction with soft tissue stabilization of the tubercles.

MATERIALS AND METHODS

The study was carried out in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013), “Rules of Clinical Practice in the Russian Federation” (Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266) , with written consent from patients to participate in the study and approved by the ethics committee of the Federal State Budgetary Educational Institution of Higher Education Russian National Research Medical University named after N.I. Pirogov of the Russian Ministry of Health (protocol No. 66 of February 19, 2007). For comparison, we took two groups of patients with fractures of the proximal humerus (PHB), who were treated in the traumatology and orthopedic department of the State Autonomous Institution of Healthcare of the Moscow City Clinical Hospital in Reutov from 2010 to 2021. The first group consisted of 47 patients who underwent intramedullary osteosynthesis using a closed pin insertion technique. The second group consisted of 42 patients who also underwent intramedullary osteosynthesis, but using a semi-open reduction technique and additional soft tissue stabilization of the humeral tubercles. The first group was assessed based on retrospective data obtained during the treatment period of patients from 2010 to 2014. The results of treatment 1 year after surgery were tracked in 35 patients out of 47. Women predominated in the gender distribution in the group (26 patients - 74.3%), the average age was 52.8 years (from 22 to 79 years). According to the nature of the fracture, the group includes only 2-fragment fractures at the level of the surgical neck of the humerus, according to the Neer classification. At that time, we did not attempt to perform osteosynthesis of 3- and 4-part fractures using pins. The main characteristic of the group was the method of osteosynthesis performed, namely the standard method of closed reduction of the fracture under the control of an electron-optical converter (EOC) and antegrade insertion of the pin. In 7 cases, a universal humeral nail (UHN) was used without the angular stability of the locking screws. In the remaining 28 patients, proximal short pins of the 1st and 2nd generation with a curved proximal part of the pin were used. The operations were performed by different operating surgeons. Based on the results obtained in the first group of patients and drawing appropriate conclusions, we changed the treatment tactics for patients with POPK. Since 2014, we have stopped using closed reduction for intramedullary osteosynthesis of PPJ fractures and, to achieve favorable treatment outcomes, we have proposed using semi-open reduction, supplementing it with soft tissue stabilization of the humeral tubercles. Using this method, 2 patents for inventions of the Russian Federation were received (No. 2673115 and No. 2673146). This technique used only generation II pins with a curved proximal part with the ability to lock the proximal screws. In the second group of 42 patients, the results were also monitored in 35 people. The group was dominated by women (27 patients – 77.1%). The mean age of the group was 56.9 years (range 23 to 70 years). According to the nature of the fracture, the group included 2-fragment fractures at the level of the surgical neck of the humerus - 7 patients (20%), 3-fragment (surgical neck and greater tubercle) - 24 patients (68.6%), 4-fragment - 4 patients (11.4%) according to Neer classification. All surgical interventions were performed by one operating team. The proposed method of semi-open intramedullary osteosynthesis of PD fractures is carried out as follows. An anterolateral approach is performed [8]. A linear skin incision is made 5-6 cm from the anterolateral angle of the acromion parallel to the direction of the fibers of the deltoid muscle, not reaching the projection of the axillary nerve. After spreading the deltoid muscle, the area of ​​the intertubercular groove and, distal to it, the place of attachment of the tendon of the pectoralis major muscle to the diaphysis of the humerus are visualized. Next, parallel to the tendon of the long head of the biceps, a sequential dissection of the transverse ligament of the shoulder and the interrotator interval (joint capsule) is made between the tendon of the supraspinatus muscle and the tendon of the subscapularis muscle. Through this incision, access appears to the tendon of the long head of the biceps, which runs in the intertubercular groove. The long head tendon is sutured with non-absorbable sutures using two wraparound sutures to the proximal edge of the pectoralis major tendon (tenodesis) at its insertion to the humerus to prevent changes in the length of the biceps. Next, using curved scissors, a tenotomy is performed on the tendon of the long head of the biceps at the site of attachment to the glenoid cavity of the scapula. The resulting free end of the long head of the biceps tendon is cut off 0.5-1 cm proximal to the tenodesis. After excision of the intra-articular part of the long head of the biceps tendon, the reposition of fragments of the humerus becomes much easier and it becomes possible to visually and palpably control the articular surface of the head when it is fractured. Then the tendons of the supraspinatus and infraspinatus muscles are stitched at a distance of 1-1.5 cm from the place of attachment to the greater tubercle of the humerus with two stitches, and the tendon of the subscapularis muscle at a distance of 1-1.5 cm from the place of attachment to the lesser tubercle. By traction on the threads, the fragments are manipulated and repositioned under the control of the image intensifier. First, traction is applied in the lateral and distal directions using the threads from the tendons of the supraspinatus and infraspinatus muscles to reposition the greater tubercle. By traction on the threads from the tendon of the subscapularis muscle, you can control the rotation of the head along the axis of the humerus. While maintaining traction on the threads and rotating the head of the humerus (depending on varus or valgus displacement) in the desired direction, a 1-1.5 cm long incision is made longitudinally to the fibers of the supraspinatus tendon. The incision made provides access to the top of the humerus, where an awl is used to make a hole for inserting a pin. Despite the curved pin, we used a medial pin insertion point, which has several advantages: 1) preserves the supraspinatus tendon; 2) the medial location of the proximal part of the pin in the humeral head preserves more bone material in the lateral part (“lateral bone bridge”), further increasing the ability of the structure to resist varus displacement forces; 3) in case of fractures that include the greater tuberosity, accidental insertion of a pin into the fracture zone can be prevented; 4) with correct insertion of the pin, its proximal part can increase the stability of the structure, potentially counteracting varus forces and being the so-called “proximal anchor point”; 5) if the insertion point was chosen correctly, then the alignment of the head and diaphysis along the axis should occur automatically during insertion of the pin. Next, under the control of the image intensifier, the greater and lesser tubercles are fixed with proximal locking screws and the pin is fixed in the diaphysis with a distal locking screw. The threads passed through the tendons are fixed to the heads of the proximal screws with tension. In this case, threads passed through the tendons of the supraspinatus and infraspinatus muscles are fixed to the screws located in the area of ​​the greater tubercle of the humerus. Threads passed through the tendon of the subscapularis muscle are fixed to the screw passed through the lesser tubercle of the humerus. The ends of each thread are fixed after its eight-shaped cross. Next, the wound was sutured layer-by-layer and sutures were placed on the skin. The operated limb was fixed in a support bandage for 3-4 weeks, passive development in the shoulder joint began under the supervision of a physical therapy doctor from the 2nd day after surgery. X-ray monitoring was performed at 4, 12, 26 and 52 weeks after surgery. Treatment results were assessed 12 months after surgery. To evaluate the results, we used the CSS scale as objective (the higher the score, the better the functional result) and the Quick Dash Score - QDS as subjective (the lower the score, the better the functional result). Results on CSS were rated as excellent with more than 90 points, 90-80 points - good, 79-70 - satisfactory, less than 70 points - unsatisfactory. On the QDS scale, with a score from 0 to 14 - excellent function, 15-29 points - good, 30-59 points - satisfactory function, more than 60 points - unsatisfactory function. Statistical processing of the obtained data was carried out using the Excel program and calculators from the website www.medstatistic.ru. For quantitative characteristics, the results are presented in the form of absolute indicators, arithmetic means (M), standard deviations (σ) and the average error of the arithmetic mean (m); for qualitative ones – relative indicators expressed as percentages. The critical level of significance (α) when testing statistical hypotheses was taken equal to 0.05. When confirming the normal distribution of values, the statistical significance of differences between groups was assessed using the parametric Student's t test ( t

) for independent samples.
The differences in all cases were assessed as statistically significant at p
< 0.05.

RESULTS

The pin insertion point for all operations performed in the first group of patients was the zone in the projection of the anatomical neck of the humerus at the border between the articular surface of the head and the apex of the greater tubercle, which was the main negative feature of osteosynthesis in this group. Among the resulting complications, migration of screws due to the lack of their fixation in some models of pins stands out (4 cases, 11.4%). Subsequently, in two of these patients, this led to failure of osteosynthesis due to osteoporosis and the formation of a pseudarthrosis of the surgical neck of the humerus. The high position of the proximal end of the pin contributed to the development of impingement syndrome in 4 patients (11.4%). Instability of the pin in the proximal fragment led to secondary varus displacement of the humeral head and consolidation of the fracture in this position (7 cases, 20%). The lack of construct stability in osteoporotic bone is due to low bone density in the lateral part of the head, which is further exacerbated by the lateral entry point of the pin. The latter fact also contributed to the development of persistent pain and stiffness of the shoulder joint (3 cases, 8.6%) due to damage to the insertion site of the supraspinatus tendon during pin insertion. In the second group, we did not experience any complications characteristic of the first group. However, one complication has arisen and has been described in multi-fragment fractures of the PDAC. In the case of a 4-fragment fracture in a 42-year-old patient, one year after surgery, we observed an x-ray picture of aseptic necrosis of the head of the humerus. We associate this complication with the nature of the fracture, the mechanism of injury (road accident) and the time from the moment of injury to surgery - 11 days (the injury was received outside the Russian Federation). Despite the development of this complication, a score of 78 was obtained on the Constant Shoulder Score (CSS), and 15.9 the Disabilities of the Arm, Shoulder and Hand Score ( The proposed technique increases the accuracy of reposition and stability of the main fragments of the POJ thanks to a semi-open surgical approach. Through the anterolateral approach, the correct insertion point for the intramedullary pin can be determined and performed. Manipulation of threads with low trauma and great precision ensures reposition of the tubercles and elimination of subluxation of the head. Reposition can be facilitated by tenotomy of the long head of the biceps tendon, which after osteosynthesis prevents secondary displacement of the fragments. The stability of osteosynthesis and the neutralization of rotator muscle forces is ensured by soft tissue stabilization of the rotator tendons on the screw heads. The preservation of blood supply and bone mass of the humeral head is facilitated by soft tissue reduction of the fracture using sutures rather than metal instruments. Reposition without the use of metal devices prevents injury to the neurovascular structures, articular surfaces of the head and scapula. As a result, the duration of the operation and tissue damage are reduced, since the number of instruments used is reduced. On average, in both groups, surgery was performed 5 days after the injury. The average duration of the operation in the first group was 59.1 minutes (47-72 minutes), in the second - 55.4 minutes (40-75 minutes). The reduction in operating time in the second group is associated with semi-open reposition (and, therefore, more adequate), the lack of time spent on installing and removing temporary wires for reposition, as well as the absence of the need for radiological monitoring of some stages of reposition. Despite the fact that the second group included patients with 3- and 4-fragment fractures, this did not affect the lengthening of the operation time, which is also associated with the possibility of careful control of each stage of the operation through the anterolateral approach. In the first group, the average result on CSS was 73.6 points, on QDS – 24 points. In the second group, the average result on CSS was 93.1 points, on QDS – 4.7 points. Treatment outcome scores are presented in Table 1 and Table 2.

Table 1. Distribution of results in the first group

Table 2.
Distribution of results in the second group

When comparing the treatment results of the first and second groups according to CSS, the Student's t-test value is 7.03. The differences are statistically significant ( p

= 0.00).
When comparing the treatment results of the first and second groups according to QDS, the Student's t-test value is 6.42. The differences are statistically significant ( p
= 0.00). Thus, in the second group, significantly better results were obtained, and the proposed method is justified. Noteworthy is the greater number of excellent and good indicators on the QDS scale when compared with the CSS scale. Most likely, this fact is due to the fact that the QDS scale does not contain objective indicators, such as abduction angle, flexion angle, etc. When assessing their recovery after injury, patients are more focused on their everyday capabilities, rather than on the actual angles of range of motion.

DISCUSSION

Intramedullary pin fixation with locking screws is a fairly rational type of osteosynthesis, since it provides several theoretical advantages compared to plate fixation [9]. Kogan P.G. et al. [10] in 2013 considered closed intramedullary osteosynthesis with proximal locked rods to be one of the most promising methods for treating comminuted fractures of the proximal humerus. The appearance of a locking pin for the proximal humerus was called “a revolution in intramedullary osteosynthesis of the humerus” by V. Murylev et al. [11], but they believed that reposition should be performed closed, under X-ray control, without open restoration of the anatomy. Having obtained significantly better treatment results in patients of the second group, we have stopped using plates for osteosynthesis of POPC in our department since 2021. In our opinion, intramedullary osteosynthesis is superior in a number of parameters to external osteosynthesis in this location of fractures. In 2002, Cuny et al [12] reported the use of the Telegraph pin for proximal humeral fractures. Unlike previous designs and techniques, this one was direct, and the authors recommended an anterolateral approach through the medial and well-vascularized portion of the rotator cuff. They also reported the results of the first 64 pins placed during the first year. Outcomes were favorable, including those with 3- and 4-part fractures. As a further development of the technique, we see the introduction into practice of the separation of straight pins of the third generation together with soft tissue stabilization of the tubercles, in addition to the pins of the second generation. In 2009, Blum et al [13] introduced and emphasized the term “angularly stable intramedullary nails” for proximal humeral fractures in their report of 151 proximal humeral fractures fixed in a manner that distinguished them from standard locking. Their patients had an average Constant score of 75.3. Similar results were obtained in a study by Konrad G. et al. [14]. We consider the presence of angular stability of the screws in the pin to be an extremely important factor for achieving a good treatment result. Data obtained in the work of Bondarenko P.V. et al., indicate the high effectiveness of using a short straight intramedullary nail for 2- and 3-part fractures of the humerus [15]. In 2015, S. Cuny et al showed excellent results of surgical treatment of 3-part fractures of the proximal humerus using third-generation intramedullary fixators [16]. When comparing the results of two studies with similar numbers and patient characteristics [17, 18] with our results, we obtained a greater number of excellent and good ratings in the second group and fewer complications. With the development of minimally invasive techniques, studies have appeared that also mention the negative aspects of closed reduction of fractures. Mittlmeier WF et al [19] reported 59 complications in 115 patients. The largest number (26 out of 59) was screw migration. The authors draw attention to the need for more careful fixation of the tubercles and improved screw placement techniques to prevent this complication. A similar number of complications, which was 39% (26 out of 61 patients), was noted in a report by Witney-Lagen C. et al [20]. The largest number (7 out of 26) were due to impingement syndrome, which required removal of the pin. The second most common complication was migration of the greater tuberosity and failure to consolidate. Over time, the authors began to pay more attention to fixing the tubercle and to perform this stage of the operation more carefully. However, not only the pin itself influenced the improvement of treatment results, but also the views on the principles of stability of fragments in fractures of the hip joint that changed over time. Improved treatment results after additional fixation of the tubercles with threads are confirmed by many studies [21, 22]. Prudnikov D.O. et al. [23] emphasized that even minimal displacement of fragments is fraught with deep functional disorders, and fixation with screws alone is unreliable and gives worse results compared to a tension 8-shaped loop. According to our observations, the stability of the tuberosities after osteosynthesis allows us to begin developing movements in the shoulder joint much earlier without fear of loss of primary reposition in the postoperative period. A controversial issue remains the treatment tactics for 3- and 4-part fractures, taking into account the possible development of avascular necrosis of the head of the humerus in these patients. In modern literature, the proportion of avascular necrosis after osteosynthesis with intramedullary pins is on average 4% [17, 18, 24, 25]. If endoprosthetics is necessary in this category of patients, it is extremely important to preserve the elements of the rotator cuff viable, thereby reducing the layout of the endoprosthesis, up to a limited replacement of only the articular surface of the humeral head. However, not all patients require arthroplasty if they develop ANG, since it is often not progressive and does not cause significant pain or functional deficit [26]. In our study, the only patient with ANG is still satisfied with the achieved result and refrains from arthroplasty. It is worth noting that in the second group there were no complications such as stiffness and persistent pain, characteristic of fractures of the pelvis. We attribute these results to the stability of the tuberosities and tenodesis (or tenotomy) of the long head of the biceps tendon due to its reputation as a persistent source of pain [27, 28]. All of the above made it possible to begin early passive development of the shoulder joint in the absence of pain.

CONCLUSION

The results of the study indicate the high reliability and effectiveness of the proposed method of osteosynthesis. The use of an intramedullary pin with additional soft tissue stabilization of the tubercles is possible for all types of fractures of the cervical spine. The proposed method should be considered as the method of choice in elderly patients, since it allows achieving high stability of osteosynthesis with low tissue trauma. We consider the positive side of the study to be the presence of an extremely small number of complications in the second group of patients, which emphasizes the value of the proposed method. However, it is worth noting the small number of patients operated on using this technique. It is important to consider the currently short-term long-term results. We see a gradual transition to the use of III generation pins in combination with soft tissue stabilization of the tubercles as the future development of the study. It is safe to say that increasing the number of patients treated and tracking their long-term results will demonstrate all the positive and negative aspects of the technique in more detail.

Funding and conflict of interest information

The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

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Advantages of treating diseases of the musculoskeletal system at Euromed Clinic:

• trauma surgeons are highly qualified specialists with extensive experience in performing operations;
• Our clinic practices an individual, comprehensive approach to each patient . When choosing a method of surgical treatment, the characteristics of the injury, the presence of concomitant pathology and the physical activity of the patient are taken into account;
• the department is equipped with the most modern equipment for the diagnosis and treatment of diseases of the musculoskeletal system ;
• preparation for surgery and the entire scope of treatment are carried out in one place ;
• Orthopedic traumatologists use only certified European materials ;
• Euromed Clinic is a full-cycle clinic ; if necessary, for rehabilitation, the patient can be referred for consultation to a chiropractor or osteopathic doctor.

*Preparation for surgery, anesthesia care and hospital stay are paid separately. For details please call +

SURGICAL TECHNIQUE

PROXIMAL SHOULDER PLATE

New three-dimensional standard in shoulder osteosynthesis

• Optimal anatomical structure
• Reduced risk of subacromial impingement
• 3D subchondral support
• Lightweight soft tissue attachment

Simplified soft tissue fixation

• The unique design of the holes for the ligatures allows the tuberosity to be restored after fixation of the head of the humerus
• Holes for ligatures allow repeated threading for strong fixation of soft tissues

Guide technology

• Pre-installed disposable drill guides
• There is no need for intraoperative assembly, which significantly saves time
• The conductors are color coded for easy plate identification: red - right lime - left