Advertisement

Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 8, pp 1075–1099 | Cite as

Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies

  • Niklas Biermann
  • Wolf Christian Prall
  • Wolfgang Böcker
  • Hermann Otto Mayr
  • Florian HaastersEmail author
Trauma Surgery
  • 119 Downloads

Abstract

Introduction

Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies.

Materials and methods

The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively.

Results

Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II–IV and study quality was 26–70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients’ clinical outcome. None of the studies showed relevant augmentation-associated complication rates.

Conclusions

Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs’ stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.

Keywords

Humerus Augmentation Cement Allograft Autograft 

Notes

Funding

There is no funding source.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    Kannus P, Palvanen M, Niemi S, Sievanen H, Parkkari J (2009) Rate of proximal humeral fractures in older Finnish women between 1970 and 2007. Bone 44(4):656–659.  https://doi.org/10.1016/j.bone.2008.12.007 CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury 37(8):691–697.  https://doi.org/10.1016/j.injury.2006.04.130 CrossRefGoogle Scholar
  3. 3.
    Kralinger F, Blauth M, Goldhahn J, Kach K, Voigt C, Platz A, Hanson B (2014) The influence of local bone density on the outcome of one hundred and fifty proximal humeral fractures treated with a locking plate. J Bone Joint Surg Am 96(12):1026–1032.  https://doi.org/10.2106/JBJS.M.00028 CrossRefGoogle Scholar
  4. 4.
    Maier D, Jaeger M, Izadpanah K, Strohm PC, Suedkamp NP (2014) Proximal humeral fracture treatment in adults. J Bone Joint Surg Am 96(3):251–261.  https://doi.org/10.2106/JBJS.L.01293 CrossRefGoogle Scholar
  5. 5.
    Haasters F, Prall WC, Himmler M, Polzer H, Schieker M, Mutschler W (2015) Prevalence and management of osteoporosis in trauma surgery. Implementation of national guidelines during inpatient fracture treatment. Unfallchirurg 118(2):138–145.  https://doi.org/10.1007/s00113-013-2500-4 CrossRefGoogle Scholar
  6. 6.
    Palvanen M, Kannus P, Niemi S, Parkkari J (2006) Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 442:87–92CrossRefGoogle Scholar
  7. 7.
    Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20(7):1025–1033.  https://doi.org/10.1016/j.jse.2011.04.016 CrossRefGoogle Scholar
  8. 8.
    Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D, Collaborators PT (2015) Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 313(10):1037–1047.  https://doi.org/10.1001/jama.2015.1629 CrossRefGoogle Scholar
  9. 9.
    Handoll HH, Brorson S (2015) Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev.  https://doi.org/10.1002/14651858.CD000434.pub4 Google Scholar
  10. 10.
    Lill H, Bewer A, Korner J, Verheyden P, Hepp P, Krautheim I, Josten C (2001) Conservative treatment of dislocated proximal humeral fractures. Zentralbl Chir 126(3):205–210.  https://doi.org/10.1055/s-2001-12495 CrossRefGoogle Scholar
  11. 11.
    Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C (2013) Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. J Shoulder Elbow Surg 22(1):e8–e14.  https://doi.org/10.1016/j.jse.2012.04.002 CrossRefGoogle Scholar
  12. 12.
    Ockert B, Siebenburger G, Kettler M, Braunstein V, Mutschler W (2014) Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 23(8):1223–1231.  https://doi.org/10.1016/j.jse.2013.11.009 CrossRefGoogle Scholar
  13. 13.
    Jost B, Spross C, Grehn H, Gerber C (2013) Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg 22(4):542–549.  https://doi.org/10.1016/j.jse.2012.06.008 CrossRefGoogle Scholar
  14. 14.
    Haasters F, Siebenburger G, Helfen T, Daferner M, Bocker W, Ockert B (2016) Complications of locked plating for proximal humeral fractures-are we getting any better? J Shoulder Elbow Surg 25(10):e295–e303.  https://doi.org/10.1016/j.jse.2016.02.015 CrossRefGoogle Scholar
  15. 15.
    Sproul RC, Iyengar JJ, Devcic Z, Feeley BT (2011) A systematic review of locking plate fixation of proximal humerus fractures. Injury 42(4):408–413.  https://doi.org/10.1016/j.injury.2010.11.058 CrossRefGoogle Scholar
  16. 16.
    Ockert B, Biermann N, Haasters F, Mutschler W, Braunstein V (2013) Reverse shoulder arthroplasty for primary fracture treatment. Displaced three and four part fractures of the proximal humerus in the elderly patient. Unfallchirurg 116(8):684–690.  https://doi.org/10.1007/s00113-013-2410-5 CrossRefGoogle Scholar
  17. 17.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8(5):336–341.  https://doi.org/10.1016/j.ijsu.2010.02.007 CrossRefGoogle Scholar
  18. 18.
    Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 10(1):2–11CrossRefGoogle Scholar
  19. 19.
    Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M (2010) Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech (Bristol Avon) 25(7):642–646.  https://doi.org/10.1016/j.clinbiomech.2010.04.006 CrossRefGoogle Scholar
  20. 20.
    Osterhoff G, Baumgartner D, Favre P, Wanner GA, Gerber H, Simmen HP, Werner CM (2011) Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Shoulder Elbow Surg 20(5):740–746.  https://doi.org/10.1016/j.jse.2010.10.040 CrossRefGoogle Scholar
  21. 21.
    Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC (2011) The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Jt Surg Br 93(7):937–941.  https://doi.org/10.1302/0301-620X.93B7.26125 CrossRefGoogle Scholar
  22. 22.
    Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ (2012) Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg 21(7):894–901.  https://doi.org/10.1016/j.jse.2011.04.015 CrossRefGoogle Scholar
  23. 23.
    Hsiao CK, Tsai YJ, Yen CY, Lee CH, Yang TY, Tu YK (2017) Intramedullary cortical bone strut improves the cyclic stability of osteoporotic proximal humeral fractures. BMC Musculoskelet Disord 18(1):64.  https://doi.org/10.1186/s12891-017-1421-8 CrossRefGoogle Scholar
  24. 24.
    Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H (2014) Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech (Bristol Avon) 29(7):735–741.  https://doi.org/10.1016/j.clinbiomech.2014.06.008 CrossRefGoogle Scholar
  25. 25.
    Kwon BK, Goertzen DJ, O’Brien PJ, Broekhuyse HM, Oxland TR (2002) Biomechanical evaluation of proximal humeral fracture fixation supplemented with calcium phosphate cement. J Bone Jt Surg Am 84-A(6):951–961CrossRefGoogle Scholar
  26. 26.
    Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC (2013) Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma 27(7):399–404.  https://doi.org/10.1097/BOT.0b013e318278c595 CrossRefGoogle Scholar
  27. 27.
    Kennedy J, Molony D, Burke NG, FitzPatrick D, Mullett H (2013) Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a cadaveric biomechanical study. J Orthop Surg (Hong Kong) 21(2):173–177CrossRefGoogle Scholar
  28. 28.
    Unger S, Erhart S, Kralinger F, Blauth M, Schmoelz W (2012) The effect of in situ augmentation on implant anchorage in proximal humeral head fractures. Injury 43(10):1759–1763.  https://doi.org/10.1016/j.injury.2012.07.003 CrossRefGoogle Scholar
  29. 29.
    Röderer G, Scola A, Schmolz W, Gebhard F, Windolf M, Hofmann-Fliri L (2013) Biomechanical in vitro assessment of screw augmentation in locked plating of proximal humerus fractures. Injury 44(10):1327–1332.  https://doi.org/10.1016/j.injury.2013.05.008 CrossRefGoogle Scholar
  30. 30.
    Kathrein S, Kralinger F, Blauth M, Schmoelz W (2013) Biomechanical comparison of an angular stable plate with augmented and non-augmented screws in a newly developed shoulder test bench. Clin Biomech (Bristol Avon) 28(3):273–277.  https://doi.org/10.1016/j.clinbiomech.2012.12.013 CrossRefGoogle Scholar
  31. 31.
    Scola A, Gebhard F, Roderer G (2015) Augmentation technique on the proximal humerus. Unfallchirurg 118(9):749–754.  https://doi.org/10.1007/s00113-015-0061-4 CrossRefGoogle Scholar
  32. 32.
    Schliemann B, Seifert R, Rosslenbroich SB, Theisen C, Wahnert D, Raschke MJ, Weimann A (2015) Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures. J Shoulder Elbow Surg 24(12):1968–1973.  https://doi.org/10.1016/j.jse.2015.06.028 CrossRefGoogle Scholar
  33. 33.
    Kuang GM, Wong TM, Wu J, Ouyang J, Guo H, Zhou Y, Fang C, Leung FKL, Lu W (2018) Augmentation of a locking plate system using bioactive bone cement-experiment in a proximal humeral fracture model. Geriatr Orthop Surg Rehabil 9:2151459318795312.  https://doi.org/10.1177/2151459318795312 CrossRefGoogle Scholar
  34. 34.
    Walch G, Badet R, Nove-Josserand L, Levigne C (1996) Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elbow Surg 5(3):161–168CrossRefGoogle Scholar
  35. 35.
    Ring D, McKee MD, Perey BH, Jupiter JB (2001) The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus. J Shoulder Elbow Surg 10(6):501–507.  https://doi.org/10.1067/mse.2001.118414 CrossRefGoogle Scholar
  36. 36.
    Zhu L, Liu Y, Yang Z, Li H, Wang J, Zhao C, Chen X, Zhang Y (2014) Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture. Chin Med J (Engl) 127(9):1672–1676Google Scholar
  37. 37.
    Gao K, Gao W, Huang J, Wu X, Wang CS, Wang Q (2012) Treatment of surgical neck nonunions of the humerus with locked plate and autologous fibular strut graft. Med Princ Pract 21(5):483–487.  https://doi.org/10.1159/000337438 CrossRefGoogle Scholar
  38. 38.
    Gardner MJ, Boraiah S, Helfet DL, Lorich DG (2008) Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 22(3):195–200.  https://doi.org/10.1097/BOT.0b013e31815b3922 CrossRefGoogle Scholar
  39. 39.
    Badman BL, Mighell M, Kalandiak SP, Prasarn M (2009) Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft. J Orthop Trauma 23(3):173–179.  https://doi.org/10.1097/BOT.0b013e31819b0bdc CrossRefGoogle Scholar
  40. 40.
    Rollo G, Rotini R, Pichierri P, Giaracuni M, Stasi A, Macchiarola L, Bisaccia M, Meccariello L (2017) Grafting and fixation of proximal humeral aseptic non union: a prospective case series. Clin Cases Miner Bone Metab 14(3):298–304.  https://doi.org/10.11138/ccmbm/2017.14.3.298 CrossRefGoogle Scholar
  41. 41.
    Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG (2011) Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res 469(12):3300–3306.  https://doi.org/10.1007/s11999-011-1949-0 CrossRefGoogle Scholar
  42. 42.
    Matassi F, Angeloni R, Carulli C, Civinini R, Di Bella L, Redl B, Innocenti M (2012) Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury 43(11):1939–1942.  https://doi.org/10.1016/j.injury.2012.08.004 CrossRefGoogle Scholar
  43. 43.
    Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG (2012) Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma 26(4):212–215.  https://doi.org/10.1097/BOT.0b013e318243909c CrossRefGoogle Scholar
  44. 44.
    Little MT, Berkes MB, Schottel PC, Lazaro LE, LaMont LE, Pardee NC, Nguyen JT, Helfet DL, Lorich DG (2014) The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma 28(6):338–347.  https://doi.org/10.1097/BOT.0000000000000012 CrossRefGoogle Scholar
  45. 45.
    Tan E, Lie D, Wong MK (2014) Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft. Orthopedics 37(9):e822–e827.  https://doi.org/10.3928/01477447-20140825-60 CrossRefGoogle Scholar
  46. 46.
    Hinds RM, Garner MR, Tran WH, Lazaro LE, Dines JS, Lorich DG (2015) Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation. J Shoulder Elbow Surg 24(6):889–896.  https://doi.org/10.1016/j.jse.2014.10.019 CrossRefGoogle Scholar
  47. 47.
    Panchal K, Jeong JJ, Park SE, Kim WY, Min HK, Kim JY, Ji JH (2016) Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft. Int Orthop 40(3):569–577.  https://doi.org/10.1007/s00264-015-2950-0 CrossRefGoogle Scholar
  48. 48.
    Chen H, Ji X, Zhang Q, Liang X, Tang P (2015) Clinical outcomes of allograft with locking compression plates for elderly four-part proximal humerus fractures. J Orthop Surg Res 10:114.  https://doi.org/10.1186/s13018-015-0258-9 CrossRefGoogle Scholar
  49. 49.
    Cha H, Park KB, Oh S, Jeong J (2017) Treatment of comminuted proximal humeral fractures using locking plate with strut allograft. J Shoulder Elbow Surg 26(5):781–785.  https://doi.org/10.1016/j.jse.2016.09.055 CrossRefGoogle Scholar
  50. 50.
    Chen H, Yin P, Wang S, Li J, Zhang L, Khan K, Zhang L, Tang P (2018) The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People. Biomed Res Int.  https://doi.org/10.1155/2018/3130625 Google Scholar
  51. 51.
    Kim DS, Lee DH, Chun YM, Shin SJ (2018) Which additional augmented fixation procedure decreases surgical failure after proximal humeral fracture with medial comminution: fibular allograft or inferomedial screws? J Shoulder Elbow Surg 27(10):1852–1858.  https://doi.org/10.1016/j.jse.2018.03.020 CrossRefGoogle Scholar
  52. 52.
    Chen H, Ji X, Gao Y, Zhang L, Zhang Q, Liang X, Tang P (2016) Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemi-arthroplasty for repair of osteoporotic four-part proximal humerus fracture: Consecutive, prospective, controlled, and comparative study. Orthop Traumatol Surg Res 102(3):287–292.  https://doi.org/10.1016/j.otsr.2015.12.021 CrossRefGoogle Scholar
  53. 53.
    Euler SA, Hengg C, Wambacher M, Spiegl UJ, Kralinger F (2015) Allogenic bone grafting for augmentation in two-part proximal humeral fracture fixation in a high-risk patient population. Arch Orthop Trauma Surg 135(1):79–87.  https://doi.org/10.1007/s00402-014-2128-z CrossRefGoogle Scholar
  54. 54.
    Euler SA, Kralinger FS, Hengg C, Wambacher M, Blauth M (2016) Allograft augmentation in proximal humerus fractures. Oper Orthop Traumatol 28(3):153–163.  https://doi.org/10.1007/s00064-016-0446-8 CrossRefGoogle Scholar
  55. 55.
    Atalar AC, Eren I, Uludag S, Demirhan M (2014) Results of surgical management of valgus-impacted proximal humerus fractures with structural allografts. Acta Orthop Traumatol Turc 48(5):546–552.  https://doi.org/10.3944/AOTT.2014.14.0115 CrossRefGoogle Scholar
  56. 56.
    Checchia SL, Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, Nascimento LG (2009) Pseudarthrosis of the humeral neck: analysis of the results when using the technique described by walch Et Al. Rev Bras Ortop 44(3):239–246.  https://doi.org/10.1016/S2255-4971(15)30074-4 CrossRefGoogle Scholar
  57. 57.
    Kim SH, Lee YH, Chung SW, Shin SH, Jang WY, Gong HS, Baek GH (2012) Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft. Injury 43(10):1724–1731.  https://doi.org/10.1016/j.injury.2012.06.029 CrossRefGoogle Scholar
  58. 58.
    Robinson CM, Page RS (2003) Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Jt Surg Am 85-A(9):1647–1655CrossRefGoogle Scholar
  59. 59.
    Lee CW, Shin SJ (2009) Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Shoulder Elbow Surg 18(1):83–88.  https://doi.org/10.1016/j.jse.2008.06.014 CrossRefGoogle Scholar
  60. 60.
    Somasundaram K, Huber CP, Babu V, Zadeh H (2013) Proximal humeral fractures: the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates. Injury 44(4):481–487.  https://doi.org/10.1016/j.injury.2012.10.030 CrossRefGoogle Scholar
  61. 61.
    Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD (2012) Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg 21(6):741–748.  https://doi.org/10.1016/j.jse.2011.09.017 CrossRefGoogle Scholar
  62. 62.
    Russo R, D’Auria D, Ciccarelli M, Della Rotonda G, D’Elia G, Siciliano B (2017) Triangular block bridge method for surgical treatment of complex proximal humeral fractures: theoretical concept, surgical technique and clinical results. Injury 48(Suppl 3):S12–S19.  https://doi.org/10.1016/S0020-1383(17)30651-4 CrossRefGoogle Scholar
  63. 63.
    Katthagen JC, Lutz O, Voigt C, Lill H, Ellwein A (2018) Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures. Obere Extrem 13(2):123–129.  https://doi.org/10.1007/s11678-018-0440-x CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Niklas Biermann
    • 1
  • Wolf Christian Prall
    • 1
    • 2
    • 4
  • Wolfgang Böcker
    • 1
  • Hermann Otto Mayr
    • 2
    • 3
    • 4
  • Florian Haasters
    • 1
    • 2
    • 4
    Email author
  1. 1.Hospital of Trauma SurgeryUniversity of Munich (LMU)MunichGermany
  2. 2.Academic Teaching Hospital of the Paracelsus Private Medical University SalzburgSalzburgAustria
  3. 3.Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical CenterAlbert-Ludwigs-University of FreiburgFreiburgGermany
  4. 4.Department of Knee, Hip and Shoulder SurgerySchön Klinik Munich-HarlachingMunichGermany

Personalised recommendations