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Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).

Untreated 3-and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).

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Retrospective clinical and radiographic evaluation was performed on 41 patients seen at the Salzburg General Hospital Department of Traumatology on average 2 years following ACL reconstruction. In 26 patients (61%) clinical examination revealed pain trigger points over the donor site of the midthird patellar tendon and in the patellofemoral joint. Functional pain during kneeling activities was observed in 19 patients (46%). Objective measurement of the length of the patellar tendon in bilateral radiographs demonstrated exactly equal patellar tendon length in both knees in 11 patients (27%). The radiographs showed tendon shortening following harvesting of the midthird patellar tendon by 1-3 mm in 7 patients (17%), by 4-6 mm in 16 (39%), and by 6-9 mm in 7 (17%). Average length change in the patellar tendon on the donor side was -3 mm, representing a patellar tendon shortening of 9.8%. On the basis of the OAK score, however, good and very good results were recorded in 33 patients (80%). On the whole, these good overall results were compromised only be patellar tendon defect morbidity. In addition to the local scarring problems at the donor site, shortening of the patellar tendon was observed with changes to patella position and interference with the mechanics of the patellofemoral joint. Tendon shortening can be explained on the basis of cicatricial contraction in the process of autorepair to the tendon defect. The problems affecting the patellofemoral joint are inherent in the therapy and must be treated as a negative factor. In the case of patients whose work requires mainly a kneeling position and those who make significant functional demands of the extension system of the knee, a critical assessment is required of the use of the midthird patellar tendon for anterior cruciate ligament reconstruction.