Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome.

INTRODUCTION: Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures. MATERIALS AND METHODS: In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed. RESULTS: Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals. CONCLUSION: A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs.

INTRODUCTION: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups. MATERIALS AND METHODS: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system. RESULTS: Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023). CONCLUSION: Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures. LEVEL OF CLINICAL EVIDENCE: Level 3, retrospective cohort study.

Minimally invasive plate osteosynthesis for clavicle fractures.

OBJECTIVE: Treatment of comminuted clavicle shaft fractures with minimally invasive plate osteosynthesis (MIPO). INDICATIONS: Multifragmentary (≥ 2 intermediate fragments) clavicle shaft fractures with no need for anatomical reduction (AO 15.2B and 15.2C). Even simple fractures (AO 15.2A) with significant soft tissue injuries Tscherne grade I-III are suitable. CONTRAINDICATIONS: Medial or lateral clavicle fractures as well as simple fracture pattern where anatomical reduction is indispensable. SURGICAL TECHNIQUE: Short incision over the medial and lateral end of the main fracture fragments. Either medial or lateral epiperosteal plate insertion. Under image intensifier guidance, the plate is centered either superior or anteroinferior on the clavicle and fixed with a compression wire temporarily (alternatively by a cortical screw) in one of the most lateral holes. Fracture reduction (axis, length, and rotation) over the plate and preliminary fixation medially. After correct reduction has been achieved, further cortical screws and/or locking head screws can be inserted (lag before locking screws). Relative stability is achieved by applying a bridging technique. POSTOPERATIVE MANAGEMENT: No immobilization is needed. Patients are encouraged to perform functional rehabilitation with active and passive physical therapy. Loading is increased according to radiological signs of bony consolidation. RESULTS: In a retrospective evaluation from 2001-2021, 1128 clavicle osteosyntheses were performed, of which 908 (80.5%) were treated with plate osteosynthesis and 220 (19.5%) with titanium elastic nail (TEN). Of the 908 plate osteosyntheses, 43 (4.7%) were performed with the MIPO approach. Finally, 42 patients (35 men and 7 women; mean age of 44 ± 15 years) with 43 clavicle shaft fractures were analyzed. The operation was accomplished in 63 ± 28 min, and average fluoroscopy time was 45 ± 42 s. A collective of 27 patients could be evaluated after a median follow-up of 14 months (range 1-51 months). In all, 26 fractures healed in a timely manner. In 1 patient a pseudarthrosis occurred which was treated with re-osteosynthesis and cancellous bone grafting in an open technique. Another patient revealed a wound complication with need of operative wound revision 6 weeks after the index surgery. Further postoperative course was uneventful in both patients. All were pain-free and able to return to work. After an average of 17 ± 8 months, 18 hardware removals (66.7%) were performed.

Validation of the modified AO sternum classification system.

INTRODUCTION: The Arbeitsgemeinschaft für Osteosynthesefragen (AO) foundation along with the Orthopaedic. Trauma Association (OTA) introduced a new classification for sternal fractures in 2018 aiming to provide greater uniformity and clinical utility for the surgical community. A previous validation study identified some critical issues such as the differentiation between type A and B fractures and localization of the fracture either in the manubrium or in the body. Due to the moderate agreement in inter- and intra-observer variability, some modifications were proposed in order to improve the performance of the classification. The aim of this study was to re-assess the inter- and intra-observer variability after adding modifications to the classification. Our hypothesis was that a significative improvement of inter- and intra-observer variability could be achieved. MATERIAL AND METHODS: Twenty computed tomography (CT) scans of patients with sternal fractures were analyzed by six. Junior and six senior surgeons independently. Two assessments were performed with an interval of 6 weeks. The kappa (K) value was calculated in order to assess inter- and intra-observer variability. RESULTS: The overall mean kappa value for inter-observer variability improved from 0.364 to 0.468 (p < 0.001). Inter-observer variability mean for location was 0.573 (SD 0.221) and for type was 0.441 (SD: 0.181). Intra-observer variability showed a mean of 0.703 (SD: 0.153) with a statistic significant improvement when compared to the previous study (mean 0.414, SD: 0.256, p < 0.001). CONCLUSIONS: By modifying the AO/OTA classification of sternal fractures, the inter- and intra-observer variability improved and now shows moderate to substantial agreement.

Clinical performance of the Femoral Neck System within 1 year in 125 patients with acute femoral neck fractures, a prospective observational case series.

INTRODUCTION: Osteosynthesis of femoral neck fractures (FNFs) is an important treatment option, especially for younger patients. We aimed to assess the rate of early implant-related complications in FNF osteosynthesis using the Femoral Neck System (FNS). PATIENTS AND METHODS: Consecutive patients diagnosed with displaced or nondisplaced FNFs were treated with FNS in this prospective, observational, multicenter investigation. Patients were followed up for minimally 3 months and up to 12 months if radiologic bone union and no pain was not achieved beforehand. Predefined treatment-related adverse events (AEs, defined as implant failure, loss of reduction, iatrogenic fractures, deep infection, and surgical revision), radiologic bone union, and patient-reported Harris hip score (HHS) and EQ-5D-5L index score were assessed. RESULTS: One hundred and twenty-five patients were included in the study. Thirty-eight (30.4%) fractures were displaced (Garden III and IV), and 37 (29.6%) were vertical fractures (Pauwels type III). Predefined treatment-related AE rate at 3 months was 8 patients, 6.4% (95% CI, 2.8-12.2), and at 12 months, 11 patients, 8.8% (95% CI, 4.5-15.2). Cumulative incidences of bone union were 68% at 3 months, 90% at 6 months, and 98% at 12 months. The mean changes of HHS and EQ-5D-5L index score between preinjury and at 12 months were -7.5 (95% CI, [ - 21.1] to [6.2]) and - 0.03 (95% CI, [ - 0.21] to [0.15]), respectively; neither were statistically significant. CONCLUSION: The current study on osteosynthesis of FNFs with the FNS resulted in treatment-related complication rates of 6.4% (95% CI, 2.8-12.2) at 3 months and 8.8% (95% CI, 4.5-15.2) at 12 months. On average, patients returned to preinjury function and quality of life. The current study may also indicate that the conventional wisdom of treating stable FNF in patients aged between 60 and 80 years with osteosynthesis may need to be reconsidered. REGISTRATION: The study is registered with ClinicalTrials.gov (registration number: NCT02422355).

Concept for Minimally Invasive Hook Plate Stabilisation of the Acromioclavicular Joint.

AIMS: Despite the availability of various operative procedures, hook plates are still one of the main implants used for the treatment of acromioclavicular (AC) joint dislocation. The aim of this report is to present a novel minimally invasive operation technique for AC hook plate fixation. The functional outcomes of patients operated upon with this technique are presented. PATIENTS AND METHODS: A retrospective analysis was performed for 5 patients who were operated upon with minimally invasive hook plate fixation. The QuickDASH score (QDS) and subjective shoulder value (SSV) were used to express functional outcomes, and the numeric rating scale (NRS) was used to evaluate pain. RESULTS: The mean (SD) follow-up was 30±7 months. Patients were hospitalized for a mean of 3±1 days and operated upon for a mean of 54±7 minutes. Functional outcomes measured with the QDS showed a median (IQR) of 2.3 (0 - 6.8) and a median SSV relative to the healthy side of 95% (89 - 100). The median NRS was 0 (0 - 0). CONCLUSION: Minimally invasive hook plate fixation for acromioclavicular joint dislocation led to excellent functional outcome scores without complications in a small case series of 5 patients.

Let's Agree to Disagree on Operative versus Nonoperative (LADON) treatment for proximal humerus fractures: Study protocol for an international multicenter prospective cohort study.

BACKGROUND: The proximal humerus fracture is a common injury, but the optimal management is much debated. The decision for operative or nonoperative treatment is strongly influenced by patient specific factors, regional and cultural differences and the preference of the patient and treating surgeon. The aim of this study is to compare operative and nonoperative treatment of proximal humerus fractures for those patients for whom there is disagreement about optimal management. METHODS AND ANALYSIS: This protocol describes an international multicenter prospective cohort study, in which all patients of 18 years and older presenting within three weeks after injury with a radiographically diagnosed displaced proximal humerus fracture can be included. Based on patient characteristics and radiographic images several clinical experts advise on the preferred treatment option. In case of disagreement among the experts, the patient can be included in the study. The actual treatment that will be delivered is at the discretion of the treating physician. The primary outcome is the QuickDash score at 12 months. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and QuickDash scores. DISCUSSION: The LADON study is an international multicenter prospective cohort study with a relatively new methodological study design. This study is a "natural experiment" meaning patients receive standard local treatment and surgeons perform standard local procedures, therefore high participation rates of patients and surgeons are expected. Patients are only included after expert panel evaluation, when there is proven disagreement between experts, which makes this a unique study design. Through this inclusion process, we create two comparable groups whom received different treatments and where expert disagree about the already initiated treatment. Since we are zooming in on this particular patient group, confounding will be largely mitigated. Internationally the treatment of proximal humerus fractures are still much debated and differs much per country and hospital. This observational study with a natural experiment design will create insight into which treatment modality is to be preferred for patients in whom there is disagreement about the optimal treatment strategy. TRIAL REGISTRATION: Registered in Netherlands trial register NL9357 and Swiss trial register CH 2020-00961; https://clinicaltrials.gov/.

Osteosynthesis of scapular fractures: a retrospective cohort study.

PURPOSE: In recent years a trend from conservative to operative treatment of displaced scapula fractures has evolved. The aim of this study was to assess surgical and patient-based radiological and functional outcome after open reduction and internal fixation (ORIF) of displaced scapula fractures following predefined operative indications. METHODS: We retrospectively analyzed data of a consecutive series of patients with displaced scapula fractures following operative fixation at our institution between 06/2010 and 02/2020. The primary endpoint was a functional outcome using the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), numeric rating scale (NRS) for pain, Activities of Daily Living score (ADL) and complications. RESULTS: Twenty-six male patients were treated operatively. Twenty-three of whom were available for follow-up after a median follow-up time of 33 months (interquartile range [IQR] 8-70 months). In 18 (69%) cases a standard open approach and in 8 (31%) cases a minimal invasive (MI) approach was used. The median QuickDASH was 0 (IQR 0-0) with a median SSV of 95 (IQR 90-98). Patients reported a median NRS of 0 (IQR 0-1) and a median ADL score of 1 (IQR 1-1). Radiological fracture union was 100% without the occurrence of implant failure or mal-union. Two patients (7.7%) required early correction osteosynthesis, one patient (3.8%) developed a frozen shoulder 3 months postoperatively, and one patient (3.8%) presented with a superficial wound infection. CONCLUSION: Following previously published indications for ORIF of displaced scapula body and neck fractures a good functional outcome and a low rate of complications could be achieved.

RIA versus iliac crest bone graft harvesting: A meta-analysis and systematic review.

BACKGROUND: Reamer-Irrigator-Aspirator (RIA) of long bones is increasingly being used as an alternative to iliac crest harvesting for bone-grafts. This meta-analysis compares both harvesting techniques with regard to donor site morbidity, healing potency and implantation site morbidity. METHODS: PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) with corresponding 95% confidence interval (95%CI). RESULTS: A total of 5 studies were included. RIA carries a lower risk for chronic pain (0% versus 14.2%, OR 0.08, 95% CI 0.02 - 0.35) and infection (1% versus 5.9%, OR 0.29, 95% CI 0.09- 0.9) at the donor site compared to iliac crest harvesting. Iliac crest bone-harvesting has an inherent additional risk of neuropraxia of the lateral femoral cutaneous nerve and numbness of the scar which is not encountered in RIA harvesting. Risk for other reported complications such as hematoma and iatrogenic fractures appear equal in both groups. The clinical healing potential of both bone grafts, in terms of union rate (OR 1.53, 95%CI 0.62 - 3.75) at the implantation site and time-to-union (MD 0.44 months, 95%CI -1.72 - 0.83), seems equal. CONCLUSION: The main difference between RIA and iliac crest bone graft harvesting is the considerable higher risk of chronic pain of the pelvic procedure. Although risk for infection was also higher for the iliac crest group, the absolute difference is relatively small. Evidence suggests an equal healing potential of the grafts themselves irrespective of harvesting method.

Lateral approach for intramedullary nailing of displaced midshaft clavicle fractures; a retrospective cohort study.

PURPOSE: Midshaft clavicle fractures represent about 4% of all fractures in the emergency department. Non-operative treatment of displaced midshaft clavicle fractures (DMCF) can result in a relatively high non-union rate. Several operative techniques, including intramedullary fixation (IMF) using elastic stable intramedullary nailing (ESIN), have therefore been established. IMF through the medial approach is less suitable for fractures of the lateral diaphysis. IMF of DMCF of the lateral diaphysis through a lateral approach can be an alternative approach for these fractures. The aim of this study is to describe the technique of IMF from the lateral side and to present the functional outcome and complications. METHODS: A retrospective cohort study was performed. All patients with a traumatic DMCF treated with IMF using ESIN through a lateral approach between 2014 and 2019 were included. Endpoints were the functional outcome (QuickDASH, Subjective Shoulder Value (SSV)), pain (numeric rating scale (NRS)), daily impairment (activities of daily living (ADL)), complications and implant removal. RESULTS: Forty out of 43 patients were available for follow-up. Mean follow-up was 37 months. Mean age was 24 years (range 13-70). The median QuickDASH score was 0 (IQR 0.0-0.0) and the median SSV was 100 (95-100). The median ADL score was 1 (1-4) and the median NRS was 0 (0-0). No non-union occurred. Implant related irritation occurred in 11 patients (27.5%). Implants were removed in a total of 38 (95%) patients; in 10 cases due to irritation, in 28 cases routinely or on patient's request. CONCLUSION: IMF of DMCF of the lateral diaphysis through a lateral approach leads to excellent functional results and seems to be a suitable option for internal fixation. However, as with IMF from the medial side, it is not without complications and implant-related irritation.

Pathologic femur fractures following surgery and radiotherapy for soft tissue sarcomas: A case series.

INTRODUCTION: Combined limb-sparing surgery and radiation therapy are considered the standard of care for higher grade soft tissue sarcomas (STS) of the extremities. The risk of post-radiation fracture after this treatment modality is well known, but still underestimated, and can end in serious long-term secondary problems years later. PRESENTATION OF CASE: We reviewed the records of three patients with pathological femur fractures years after wide local excision of an STS of the proximal lower extremity. All patients received more than 50 Gy (Gy) to the entire femur circumference. During surgery, all patients had bone exposure, and in two patients with stripping of the periosteum. The median time from surgery to fracture was 116 months (range from 84 to 156 months). The median age at the time of diagnosis was 66 years old. Despite standard operative fracture treatment, all three patients developed a non-union. One patient later died due to uncontrolled pulmonary metastasis independent from the femoral non-union. In the second case, an exarticulation at hip level due to an uncontrolled infected non-union had to be performed. The third patient finally achieved fracture union after two years of treatment. DISCUSSION: Our study confirms the high occurrence rate of postoperative complications and difficulties one encounters in treating these pathologic fractures. Only in one patient, following several revisions with intramedullary nailing, the fracture healed. In pathologic femur shaft fractures we recommend a minimal invasive procedure using intramedullary nailing devices. CONCLUSION: The risk of pathological fractures at the former treatment site is high, even years later. The rate of non-unions after a difficult fracture treatment in this particular clinical situation seems to be very high and may be associated with severe complications.

Clavicle fractures in adults; current concepts.

BACKGROUND: For decades, clavicle fractures have been treated conservatively. In the last 20 years, however, non-union rates after conservative treatment appear higher than previously reported and more evidence regarding operative treatment has become available. This has led to a paradigm shift towards an increase in operative treatment. The aim of this review is to present the current concepts and available evidence regarding clavicle fracture treatment. METHODS: Conservative and operative treatment options together with their indications for medial, shaft and lateral clavicle fractures are discussed. For all three anatomical locations, a treatment algorithm is proposed. CONCLUSION: In general, non-displaced fractures are treated conservatively. Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient.

Osteosynthesis of sternal fractures with double locking compression plate fixation: a retrospective cohort study.

PURPOSE: Sternal fractures are rare injuries and mostly treated non-operatively. In selected cases, internal fixation becomes necessary. No standard operative approach has been determined yet among experts. The aim of this study is to describe our treatment algorithm and results after operative stabilisation of sternal fractures with locking compression plates (LCP), mainly focusing on the functional outcome. METHODS: A retrospective cohort study was conducted. We included all patients after operative stabilisation of a sternal fracture between 2008 and 2016. Endpoints were the functional outcome using the Activities of Daily Living (ADL) score, pain analysed by the numeric rating scale (NRS), breathing ability, complications and implant removal. RESULTS: Eighteen out of 153 (12%) patients with a sternal fracture underwent operation. Three patients were lost to follow-up. Eleven out of 15 (73%) patients were treated with double straight LCP 3.5 mm implants and 4 (27%) patients with pre-countered LCP 3.5 mm implants. Mean follow-up was 57 months. The median ADL score was 1 (1-4), the median NRS was 0 (0-9), and respiratory complaints scored a median of 1 (1-4). No non-union, hardware failure or implant-related complication occurred. Post-operative complications were pneumonia (20%) and respiratory insufficiency (20%). Implants were removed in 4/15 (27%) patients; three times due to implant-related irritation, once on patient's request. CONCLUSION: Operative stabilisation of sternal fractures with double LCP 3.5 mm provides excellent long-term functional results and seems to be an appropriate option for internal fixation. The rate of post-operative complications is low; however, 27% had a second operation for implant removal.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome.

BACKGROUND: Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course. METHODS: We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview. RESULTS: From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred. CONCLUSIONS: In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study.

INTRODUCTION: Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets. METHODS: One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions. RESULTS: Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted. CONCLUSIONS: This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.

Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome.

BACKGROUND: Operative treatment is the standard for severely displaced proximal humerus fractures, but functional impairment can persist. Retaining of the implant can be a reason and in other fracture situations has proved to ameliorate patient satisfaction. The aim of this study was to analyse the functional outcome after locking plate removal in proximal humerus fractures. METHODS: In a two-year period, all symptomatic patients with plate osteosynthesis for proximal humerus fracture and hardware removal were retrospectively evaluated clinically and radiologically pre- and post-implant removal. Evaluation included Constant score, height of plate position and possible impingement, as well as intraoperative complications. RESULTS: Twenty patients met the inclusion criteria. The mean age was 56 ± 12 years. The plates were placed 6.9 ± 3 mm distal to the greater tubercle. The operation was performed in 35 ± 10 min and no intraoperative complications were reported. The Constant score improved significantly after implant removal from 71 to 76 (p = 0.008). CONCLUSION: Symptomatic patients after locked plate osteosynthesis for proximal humerus fractures showed statistically significant improvement of the Constant score after implant removal.