COVID-19 vs. Classical Myocarditis Associated Myocardial Injury Evaluated by Cardiac Magnetic Resonance and Endomyocardial Biopsy

Background: Despite the ongoing global pandemic, the impact of COVID-19 on cardiac structure and function is still not completely understood. Myocarditis is a rare but potentially serious complication of other viral infections with variable recovery, and is, in some cases, associated with long-term cardiac remodeling and functional impairment.

Aim: To assess myocardial injury in patients who recently recovered from an acute SARS-CoV-2 infection with advanced cardiac magnetic resonance imaging (CMR) and endomyocardial biopsy (EMB).

Methods: In total, 32 patients with persistent cardiac symptoms after a COVID-19 infection, 22 patients with acute classic myocarditis not related to COVID-19, and 16 healthy volunteers were included in this study and underwent a comprehensive baseline CMR scan. Of these, 10 patients post COVID-19 and 13 with non-COVID-19 myocarditis underwent a follow-up scan. In 10 of the post-COVID-19 and 15 of the non-COVID-19 patients with myocarditis endomyocardial biopsy (EMB) with histological, immunohistological, and molecular analysis was performed.

Results: In total, 10 (31%) patients with COVID-19 showed evidence of myocardial injury, eight (25%) presented with myocardial oedema, eight (25%) exhibited global or regional systolic left ventricular (LV) dysfunction, and nine (28%) exhibited impaired right ventricular (RV) function. However, only three (9%) of COVID-19 patients fulfilled updated CMR–Lake Louise criteria (LLC) for acute myocarditis. Regarding EMB, none of the COVID-19 patients but 87% of the non-COVID-19 patients with myocarditis presented histological findings in keeping with acute or chronic inflammation. COVID-19 patients with severe disease on the WHO scale presented with reduced biventricular longitudinal function, increased RV mass, and longer native T1 times compared with those with only mild or moderate disease.

Conclusions: In our cohort, CMR and EMB findings revealed that SARS-CoV-2 infection was associated with relatively mild but variable cardiac involvement. More symptomatic COVID-19 patients and those with higher clinical care demands were more likely to exhibit chronic inflammation and impaired cardiac function compared to patients with milder forms of the disease.

Fast Strain-Encoded Cardiac Magnetic Resonance for Diagnostic Classification and Risk Stratification of Heart Failure Patients

OBJECTIVES

The purpose of this study was to compare the ability of fast-strain encoded magnetic resonance (fast-SENC) cardiac magnetic resonance (CMR) to classify and risk stratify all-comer patients with different stages of chronic heart failure (Stages of heart failure A to D) based on American College of Cardiology/American Heart Association guidelines with standard clinical and CMR imaging data.

BACKGROUND

Heart failure is a major cause of morbidity and mortality, resulting in millions of deaths and hospitalizations annually.

METHODS

The study population consisted of 1,169 consecutive patients between September 2017 and February 2019 who underwent CMR for clinical reasons, and 61 healthy volunteers. In addition, clinical follow-up was performed in Stages A and B patients after 1.9 ± 0.4 years. Wall motion score and late gadolinium enhancement score indexes, left ventricular (LV) ejection fraction, and global circumferential and longitudinal strain based on fast-SENC acquisitions, were calculated in all subjects. The percentage of myocardial segments with strain ≤-17% (% normal myocardium) was determined in all subjects.

RESULTS

LV ejection fraction, global circumferential and longitudinal strain, and % normal myocardium significantly decreased with increasing heart failure stages (p < 0.001 for all by analysis of variance). By multivariable analysis, % normal myocardium remained an independent predictor of heart failure stages, exhibiting closer association than LV ejection fraction (rpartial = 0.76 vs. rpartial = 0.30; p < 0.001). Importantly, 149 of 399 (37%) with Stage A were reclassified to Stage B, that is, as having subclinical LV dysfunction based on % normal myocardium <80%. Such patients exhibited significantly higher rates of all-cause mortality and hospital stay due to heart failure during follow-up, compared with patients with % normal myocardium ≥80% (chi-square = 6.9; p = 0.03).

CONCLUSIONS

The % normal myocardium, determined by fast-SENC, enables improved identification of asymptomatic patients with subclinical LV dysfunction compared with LV ejection fraction and risk stratification of patients with so far asymptomatic heart failure. The identification of such presumably healthy patients at high risk for heart failure-related outcomes may bear important medical implications.

Interleukin-6, procalcitonin and TNF-alpha: markers of peri-prosthetic infection following total joint replacement

This prospective study evaluates the role of new laboratory markers in the diagnosis of deep implant infection in 78 patients (41 men and 37 women) with a revision total knee or hip replacement. The mean age at the time of operation was 64.0 years (19 to 90). Intra-operative cultures showed that 21 patients had a septic and 57 an aseptic total joint replacement. The white blood cell count, the erythrocyte sedimentation rate and levels of C-reactive protein, interleukin-6, procalcitonin and tumour necrosis factor (TNF)-alpha were measured in blood samples before operation. The diagnostic cut-off values were determined by Received Operating Characteristic curve analysis. C-reactive protein (> 3.2 md/dl) and interleukin-6 (> 12 pg/ml) have the highest sensitivity (0.95). Interleukin-6 is less specific than C-reactive protein (0.87 vs 0.96). Combining C-reactive protein and interleukin-6 identifies all patients with deep infection of the implant. Procalcitonin (> 0.3 ng/ml) and TNF-alpha (> 40 ng/ml) are very specific (0.98 vs 0.94) but have a low sensitivity (0.33 vs 0.43). The combination of C-reactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant. A highly specific marker such as procalcitonin and pre-operative aspiration of the joint might be useful in identifying patients with true positive C-reactive protein and/or interleukin-6 levels.

[The influence of reduced bone density on primary stability of cementless femoral stems. A biomechanical in vitro study]

OBJECTIVE

The aim of the present in vitro study is to examine the influence of bone density on the primary stability of cementless femoral stems in nine pairs of human cadaveric femurs.

METHOD

The human proximal femurs were evaluated with regard to their bone density by dual-energy X-ray absorptiometry. Two pairs of human cadaveric femurs had an osteoporotic and two pairs an osteopenic bone stock. After implantation of the cementless femoral stems, the prostheses were loaded in a physiological position. Subsidence, rotation and interface motion of the stems were measured with load cycles up to 2000 Newton.

RESULTS

There was no significant correlation between the bone density of the proximal femur and the primary stability of the femoral stem in subsidence (p=0.23) and rotation (p=0.79). Reduced bone density in the osteoporotic and osteopenic human femora did not increase the interface motion at the proximal or distal part of the prosthesis (p>0.05).

CONCLUSION

The initial stability of cementless femoral stems was not influenced by the bone density, at least in this biomechanical in vitro study. Thus, theoretical conditions exist that allow secondary osseointegration of femoral stems also in cases of reduced bone density.

Langfristiger Einfluss der anatomisch angepassten spongiösen Endoprothese auf den periprothetischen Knochen

INTRODUCTION

The anatomically shaped, cementless total hip replacement (THR) (S and G, ESKA Lübeck) has a fully porous coating for secondary osseointegration. The aim of the present study was to analyse the long-term effect of the prosthesis on periprosthetic bone remodelling.

METHODS

137 THR in 117 patients were analysed clinically and radiographically 12.8 years (10-14.9 years) postoperatively. The average age at the last follow-up was 71.8 years (range: 34-87 years). Osteodensitometric DEXA measurements of the periprosthetic bone in comparison to the contralateral non-operated femora were performed.

RESULTS

Cumulative survival rates of all implanted THR (n = 231) at 14.9 years were 86.2 % (+/-5.3 %) for the fully porous coated stem and 90.1 % (+/- 8 %) for the cup. Five stem fractures (3.6 %) at the middle part were recorded. The Harris hip score of the non-revised THR at the last follow-up averaged 88.3 (34-100) points. Bony atrophy in the proximal periprosthetic femora in Gruen zones I (16.8 %) and VII (34.6 %) confirmed a proximal stress-shielding. Osteodensitometric analyses demonstrated in comparison to the contralateral femora (BMD 1.3 g/cm (2)) a significantly reduced bone density at the calcar femoris (BMD 0.9 g/cm (2)) (p < 0.001).

CONCLUSION

The original goal of a physiological load transfer has not been realised with this fully porous, cementless THR. The anatomic S & G stem will mainly be osseointegrated by distal load transfer.

Long-term results of the metal-cancellous cementless Lübeck total hip arthroplasty: a critical review at 12.8 years

INTRODUCTION

The influence of a spongy metal surface total hip arthroplasty (THA) (S&G, ESKA, Lübeck, Germany) on the clinical, psychometric, and radiograhic long-term results were examined.

MATERIAL AND METHODS

An amount of 137 THA with the cementless spongy metal Lübeck hip prosthesis were evaluated long-term, radiographically and clinically, with a mean follow-up time of 12.8 years (range 10.1-14.9 years). The MOS SF-36 was used to assess the health-related quality of life (HRQL).

RESULTS

Cumulative survival rates were 90% (+/-8%) for the cups and 86% (+/-5%) for the stems at 14.9 years. Four stems fractured at the middle part (3%) without major trauma. In the remaining patients the clinical results expressed as Harris Hip Score (HHS) averaged 88 (range 34-100). Patients above 60 years undergoing THA had no significant difference in HRQL (MOS SF-36) in comparison to the age-matched healthy population (P>0.05). Patients younger than 60 years had scores lower than normal in the physical function domains (P<0.01), but were comparable in the mental health domains (P>0.05). Radiolucent lines and bone atrophy related to stress shielding by distal fixation were found in the periprosthetic Gruen Zone I (19.8, 16.8%) and VII (10.3, 27.1%) of the proximal femur.

DISCUSSION

Whereas the rate of aseptic cup failures of the cementless spongy metal Lübeck hip prosthesis is among the best, the failure rate of the stems is attributable to osteolysis of the proximal femur. The fractures of the stem may be attributed to the combination of the lack of proximal support, the fully porous stem made of a cast cobalt-chrome-molybdenum alloy, and the narrow dimension of the stem core. The long-term results of the spongy metal cup are good, whereas the high loosening and fracture rate of fully coated stem are a source of concern especially with regard to the difficult revision scenario with frequent massive bone loss.

Acute compartment syndrome following intramedullary pulse lavage and débridement for osteomyelitis of the tibia

The implantation of gentamicin loaded polymethylmethacrylate (PMMA) beats and other local antibiotic carriers is a common practice in the treatment of chronic osteomyelitis as is the use of local jet lavage débridement. This article presents the case of a patient with chronic osteomyelitis of the tibia, who had no complication after débridement, intramedullary reaming and pulse lavage without tourniquet but sustained a compartment syndrome 2 weeks later during a second procedure in which an intraoperative tourniquet and pulse lavage were combined.

Immobilisation after radiofrequency-induced shrinkage of tendon

Despite widespread use of radiofrequency (RF) shrinkage, there have been no animal studies on the effects of post-operative immobilisation on the histological properties of the shrunken tissue. We have therefore examined the role of post-operative immobilisation after RF shrinkage with special emphasis on the histological properties of collagenous tissue.

One patellar tendon of 66 New Zealand White rabbits was shrunk. Six rabbits were killed immediately after the operation. Twenty rabbits were not immobilised, 20 were immobilised for three weeks and 20 for six weeks. Fibroblasts, collagen and vascular quality and density were evaluated on sections, stained by haematoxylin and eosin.

Nine weeks after operation the histological properties were inferior to those of the contralateral control tendons. Shrunk tendons did not return to normal at any time after operation irrespective of whether the animals had been immobilised or not. All the parameters improved significantly between zero and three weeks after operation. Immobilised tendons tended to have a better and faster recovery.

Careful rehabilitation is imperative after RF shrinkage. Immobilisation aids recovery of the histological properties. Our findings in this animal model support a period of immobilisation of more than three weeks.

Peritoneal release of TNFalpha and IL-6 after elective colorectal surgery and anastomotic leakage

The evaluation of postoperative peritoneal drainage fluid tumor necrosis factor (TNF)alpha and interleukin (IL)-6 was studied prospectively over a 7-day period in 25 patients operated on for neoplastic colorectal diseases. In 22 cases, colon or rectum carcinoma was the reason for surgery, and in 3 patients resection was performed because of colonic adenoma. All patients received either an end-to-end colo-colonic or colorectal anastomosis. Of this group, 22 patients were free of complications defined as uneventful postoperative course without any signs of anastomotic leakage until the 14th postoperative day. All of these patients showed a significant rise in peritoneal TNFalpha with maximum on the 7th day during the study period (p <.05). In contrast, peritoneal IL-6 levels remained constant without significant change in time (p >.05). Three patients underwent relaparotomy because of anastomotic leakage. In these patients, peritoneal TNFalpha concentrations showed a rise until the day of operative confirmation of anastomotic leakage. This rise preceded the day of operative confirmation by at least 1 day but did not change significantly in time (p =.59). Peritoneal IL-6 concentrations in patients with anastomotic leakage remained constant and also did not change significantly in time (p =.21). After elective colorectal surgery, neither postoperative abdominal drainage fluid TNFalpha nor IL-6 monitoring is helpful to decide on the need for revision in patients with anastomotic leakage.

[Objective measures of gait following revision hip arthroplasty. First medium-term results 2.6 years after surgery]

AIM

The purpose of the study was to identify the functional impairments after revision arthroplasty by gait analysis.

METHODS

This retrospective study compared 33 patients (mean age 58.5 years) who have undergone revision of an acetabular component (mean follow-up 2.6 years) with a group of normal control subjects. Gait analysis including recording of the three dimensional kinetics and kinematics was performed in all patients. Surface electromyography of seven leg and trunk muscles were registered bilaterally. The vertical ground reaction forces were determined by two force plates. These data were correlated with the Harris Hip Score, the d'Aubigné Score and the radiographic analysis (centre of rotation).

RESULTS

The analysis revealed a decreased hip range of motion during gait (p < 0.0001). In the sagittal plane there was a significant decrease in the hip extension at the end of the stance phase (p < 0.0001). The control group reached a mean extension of - 7.6 degrees, the operated patients were limited by the extension deficit (+ 9.1) in step length (p < 0.0016) and velocity (p < 0.0001). Kinetic parameters indicated a reduced hip abductor moment (p < 0.0001). Compensation of gait instability was observed in an extended stance phase (p = 0.0389). The hip muscle activity was increased to stabilize the impaired hip. The changed kinematic parameters are observed with secondary impairments in knee extension and reduced dorsiflexion in ankle motion (p < 0.0001). Neither the Harris Hip score (77.8 points) nor the d'Aubigné score (14.9 points) were associated with the motion analysis (p > 0.05). Deterioration in kinematics are indicated by cranialisation of the centre of rotation (p = 0.18). However, medial movement of the centre of rotation does not influence the kinematic data (p > 0.05).

CONCLUSION

Despite sufficient satisfactory clinical data the gait analysis confirmed objective impairments of the operated hip and neighboring joints. Gait instability is revealed in a decreased hip extension and deficient hip abduction.

Peritoneal release of TNFalpha and IL-6 after elective colorectal surgery and anastomotic leakage

The evaluation of postoperative peritoneal drainage fluid tumor necrosis factor (TNF)alpha and interleukin (IL)-6 was studied prospectively over a 7-day period in 25 patients operated on for neoplastic colorectal diseases. In 22 cases, colon or rectum carcinoma was the reason for surgery, and in 3 patients resection was performed because of colonic adenoma. All patients received either an end-to-end colo-colonic or colorectal anastomosis. Of this group, 22 patients were free of complications defined as uneventful postoperative course without any signs of anastomotic leakage until the 14th postoperative day. All of these patients showed a significant rise in peritoneal TNFalpha with maximum on the 7th day during the study period (p <.05). In contrast, peritoneal IL-6 levels remained constant without significant change in time (p >.05). Three patients underwent relaparotomy because of anastomotic leakage. In these patients, peritoneal TNFalpha concentrations showed a rise until the day of operative confirmation of anastomotic leakage. This rise preceded the day of operative confirmation by at least 1 day but did not change significantly in time (p =.59). Peritoneal IL-6 concentrations in patients with anastomotic leakage remained constant and also did not change significantly in time (p =.21). After elective colorectal surgery, neither postoperative abdominal drainage fluid TNFalpha nor IL-6 monitoring is helpful to decide on the need for revision in patients with anastomotic leakage.

[Limits in cementless hip revision total hip arthroplasty. Midterm experience with an oblong revision cup]

Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. To fill the defect, a valuable option for revision arthroplasty is the cementless oblong revision cup (LOR).

METHODS

50 consecutive revisions of the acetabular component were performed in 48 patients. The mean age at the time of revision was sixty-one years (range, thirty-three to seventy-eight years). Forty-eight hips were available for follow-up, at a mean of thirty-two months (range, eighteen to sixty-one months). The acetabular defect classified according to Paprosky, the migration and the radiolucencies were followed radiologically.

RESULTS

8 hips (16 %) were revised again: two because of infection (4 %) and six because of instability (12 %). The revised hips are not associated to the preoperative degree of acetabular defect (34 % defect type III) (P > 0.05). The mean Harris Hip score was corrected from 36.5 (range, 7.5 to 92.5) to 78.2 points (range, 47.6 to 97.6) (P < 0.01). The mean d'Aubigné Score was corrected from 8.3 (range, 4 to 6) to 15 points (range, 10 to 18) (P < 0.01). Neither pre- nor postoperative results were associated to the degree of acetabular defect (P > 0.05). However, patients with multiple revisions had a significantly reduced clinical outcome than patients with the first revision (P < 0.05). The hip center of rotation, cranially placed to the contralateral side (0.92 cm) was corrected by the revision to a more normal anatomic rotation center (0.27 cm). Partial zonal radiolucencies, always smaller than 1.5 mm were seen in 30 % of the patients. The mean migration of the acetabular component was not significant (P > 0.05).

CONCLUSION

The authors support the use of the cementless oblong revision cup if contact can be made with host bone to more than 50 %. If this is not possible, acetabular bone reconstruction combined with a roof ring and a cemented cup is the component of choice.

[Long-term results of quality of life in patients with idiopathic scoliosis after Harrington instrumentation and their relevance for expert evidence]

AIM

The expert evidence of operated patients with idiopathic scoliosis is determined by functional and pulmonary restriction. The degree of deformity and the extent of fusion is crucial for grading disability. In a retrospective study on the quality of life (SF-36) and low back pain (Roland-Morris Score) of 82 patients (22 - 40 years) with idiopathic scoliosis treated with Harrington instrumentation the grading was registered.

METHOD

An average of 16.7 years after the surgery, these data were correlated with the type and size of curve and to the extension of fusion.

RESULTS

Compared to the age-matched healthy population, there was no significant difference in the physical SF-36 scale (P = 0.98). Surgically treated patients showed significantly lower scores than at baseline in the psychological SF-36 scale (P = 0.005). Sixty-five (79.3 %) of the eighty-two patients reported no or occasional back pain in the Roland Index. Five patients (6.1 %) complained of chronic back pain. 33 patients (40 %) were legally defined in their rate of disability as severely handicapped patients. The grading disability was associated with the physical SF-36 scale (P < 0.001) and the low back pain (P = 0.02). A significant correlation between the grading disability and the extent of fusion (P = 0.53) or the size of curve (p = 0.4) could not be proven.

CONCLUSION

Despite good long-term outcomes, 40 % of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons. The additional measurements of quality of life and low-back pain can improve legal assessment in orthopaedics.

[Spondylothoracic dysplasia--a case report of 2 affected sisters with 20 year follow-up]

This is a case report and review of the literature in spondylothoracic dysplasia. Spondylothoracic dysplasia is a genetically transmitted, rare entity characterized by multiple vertebral abnormalities and rib anomalies. Two siblings from one family of normal parents who have four other normal children were affected. There is no history of congenital anomalies in the family. Due to progressing deformity of the spine, a convex epiphyseodesis had to be performed in the oldest girl. The second girl, who has a healthy twin sister, was borne with an inperforated anus and a recto-vaginal fistula. An operation was performed at an early stage. Today, the mature patients are painfree and fully integrated in social life. Spondylothoracic dysplasia is discussed with regard to the hereditary nature, course, and prognosis on the basis of the pertinent literature.

[Surgical correction and stabilization of neuromuscular scoliosis--2-4-year results of dorsal and one-stage ventro-dorsal operated patients]

QUESTION

In order to evaluate the outcome of the operative treatment of neuromuscular scoliosis 45 patients were studied prospectively.

METHODS

27 Patients were operated by posterior correction and fusion using the Münster Posterior Doublerod-System (MPDS) (GI). 18 Patients were treated with one-stage ventro-dorsal procedure in combination of VDS with MPDS (GII). For all patients, medical and radiographic records were available, with a minimum follow-up of 2 years. Postoperative management, bloodloss and complications will be discussed.

RESULTS

In group I the main curve (76.3 degrees), by an average flexibility of 36.1%, were corrected by 53.5% and 52.3% at follow up. The mean pelvic obliquity (7.7 degrees) averaged 53.8%. The mean major scoliosis of group II (107.1 degrees), by an average flexibility of 25%, gets improved by 61%. At most recent follow-up, the mean correction was 61.5%. The mean pelvic obliquity (23.1 degrees) averaged 73.2% and 70.6% respectively. The mean bloodloss in group I was 1840 ml and in group II 2180 ml.

CONCLUSION

The data in the current study support the benefit of the operative treatment of patients with severe neuromuscular scoliosis. The quality of life gets improved by stability in seating and standing by correction of pelvic obliquity and trunk instability.

[Effect of Harrington instrumentation spondylodesis on scoliotic thoracic deformity. A retrospective 5-year analysis]

INTRODUCTION AND AIM OF THE STUDY

Harrington-Instrumentation (HI) was the golden standard of scoliosis surgery for more than two decades and is still frequently used. The effects of instrumentation on rib hump reduction in long term follow-up is not well documented. 104 patients with idiopathic thoracic scoliosis were studied with a minimum follow-up of five years (min. 5 y., max. 8 years).

METHODS

The rib-cage deformity was determined as rib hump index (RHi) by measuring the rib hump to the depression. The long term effect of HI was investigated using full standing AP radiographs. Measuring cobb angle (CA), translation (TA) and rotation of apical vetebra (RA) were obtained for every patient preoperatively, postoperatively and at follow-up. Patient were analysed in 3 different groups. Single curve thoracic scoliosis (n = 54) (King III and IV), double curve thoracic/lumbar scoliosis (n = 35) (King I and II) and double curve thoracic scoliosis (n = 15) (King V).

RESULTS

With an average preoperative measurement of 62.7 degrees and a postoperative measurement angle of 32.9 degrees the correction of CA achieved is 47.5% (23-73%). The mean thoracic translation improved by 50% (0-100%). Rotation of the scoliosis was not reduced significant. In follow up studies no loss of correction in frontal plane deformity was obtained. The mean RHi in all groups was seen to improve by 25-30% (min. 0%, max. 60%), depending on form of scoliosis. In group of patients King II/III scoliosis (n = 52) the mean RHi increased measurably to 11.5% (min. 0%, max. 50%) correction at long term follow up. In group of patients King I/II scoliosis average RHi was increased from 31% (5-100%) to 21% correction. The mean RHi correction in the group of patients King V scoliosis correction rate of 26% (0-50%) was unchanged at long term follow up.

CONCLUSION

HI leads to a permanent and stable improvement of the frontal plane including apical vertebral translation. HI does not have derotational capabilities. The effect of the rib-cage deformity was less impressive with loss of correction at follow up.

[Treatment of humeral shaft fracture with intramedullary procedures (Seidel nail, Marchetti-Vicenzi nail, Prevot pins)]

Humeral shaft fractures can be treated either conservatively or operatively. Plating of the humerus is the established operative method, but recently interest has also been focussed on intramedullary nailing. Fifty-nine cases of humeral fractures treated with intramedullary nailing (Seidel/Marchetti-Vicenzi/Prévot) from January 1991 to December 1995 (44 fractures after trauma, 11 pathological fractures, 3 pseudarthroses, 1 re-fracture). Closed reduction in 55/59 cases. One infection (soft tissue); 2/48 pseudarthrosis (indication for nailing: pseudarthrosis!). No iatrogenic palsy of the radial nerve. Functional postoperative treatment in all 44 cases of humeral fractures after adequate trauma. One poor functional result: periarticular ossification after retrograde nailing, possibly connected with long-term respiratory treatment after trauma. Treatment of humeral shaft fractures by intramedullary nailing is favoured in our clinic (low complication rates, excellent or good functional results, limited approaches, small scars). Proximal fractures should be treated by the Seidel nail (stable interlocking of the proximal fragment); very distal fractures need Prévot nailing (reaming of condylar canals). All other fractures of the humeral shaft can be treated by each of the implants used in our clinic. Pathological fractures are an excellent indication for intramedullary stabilization. These patients benefit from stable fixation without intense surgical trauma. Pseudarthrosis, according to our limited experience, seems to require plating plus bone grafting. Plating is also recommended if revision of the radial nerve becomes necessary.