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Transosseous Suture Fixation of Proximal Humeral Fractures
Panayiotis Dimakopoulos, MD1; Georgios Kasimatis, MD1; Andreas Panagopoulos, MD, PhD2
1 Shoulder and Elbow Unit, Orthopaedic Department, Patras University Hospital, Rio-Patras 26504, Greece. E-mail address for P. Dimakopoulos: pa.dimakopoulos@gmail.com
2 Ipapantis and 25 Martiou 1, 26504 Kato Kastritsi, Patras, Greece
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Shoulder and Elbow Unit, Orthopaedic Department, Patras University Hospital, Patras, Greece

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Aug 01;89(8):1700-1709. doi: 10.2106/JBJS.F.00765
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Abstract

Background: The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus.

Methods: Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis.

Results: All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%.

Conclusions: The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Panayiotis Dimakopoulos, M.D.
    Posted on October 01, 2007
    Dr. Dimakopoulos responds to Dr. Edelson et al.
    Patras University Hospital, Orthopaedic Department, Rio-Patras 26504, GREECE

    We thank Professor Edeloson for his letter. To answer his comments on the "mistaken" classification regarding figure 4, careful observation of the preoperative pictures reveals a clear separation between the lesser tuberosity and the humeral head. Besides, we also had the intraoperative report that documented the true nature of the fracture.

    Nevertheless, the aim of surgical management for this type of fracture is to avoid disimpaction of the head which is fixed in place with transosseous sutures, thus minimizing the risk for avascular necrosis.

    Gordon Edelson, M.D.
    Posted on September 03, 2007
    TRANSOSSEOUS SUTURE FIXATION OF PROXIMAL HUMERAL FRACTURES
    Poriya Government Hospital, Tiberias, ISRAEL

    To The Editor:

    We note in figure 1 in the paper by Dimakopoulos et al.(1) that what the authors use as an example of a 4 part humeral head fracture is in fact a three part fracture). This mistaken classification may account in part for their pleasant surprise at the low prevalence of avascular necrosis they encountered. Three-part fractures are less likely than four part fractures to interrupt the principle blood supply to the head, i.e. the anterior circumflex artery. In contrast, in four part fractures, which we characterize as a subtype of a "Shield" fracture, both the greater and lesser tuberosity are detached and the main blood supply coming up the biceps groove is potentially disrupted.

    This type of misclassification is common (2-5) when using the Neer or other classification systems that are based only on two dimensional x-rays. In contrast, using a 3-D classification system(6) allows a global evaluation of the fracture. and helps to avoid classification errors. Figures 3A and 3B (below) illustrate a 3 part valgus impacted injuries viewed in this way.

    In a study of 63 complex fractures of the proximal humerus(7) we observed that three part valgus impacted injuries are more common than four part valgus impacted fractures. The key view for telling these two fractures apart is the 3D overhead view with the scapula removed. In three part fractures with this view one notes that the greater tuberosity alone, with or without comminution, is detached from the head. Occassionally, one may be fortunate to get a similar view with simple axillary X-ray, as the authors' have provided us in their Fig.4(see figure 1, below) – but such good luck is unusual in an acute fracture situation; in contrast,the 3D reconstruction gives this view consistently.

    We recommend that surgeons use 3D studies to better understand of the type of fracture. Advance knowledge of the major fracture lines helps avoid ideopathic damage which sometimes results from limited surgical exposure.


    Fig. 1. Modification of the authors' Fig. 4 (p. 1706) demonstrates this to be a 3, not a 4 part fracture. Note that the lesser tuberosity is intact while in a 4 part fractures the lesser tuberosity is by definition separated from the head.


    Fig. 2. A 3D classification system demonstrates the actual anatomy of 3 Part, 4 Part ("Shield" injuries) and Isolated Greater Tuberosity fractures with which this article is concerned.




    Fig. 3A and 3B. Examples of 3 part valgus impacted injuries seen in "fracture wheel" format. With views from four different directions, fractures can usually be accurately placed in a 3D classification system. 3A shows severe valgus displacement; 3B is less severe, similar to that shown by the authors' in their Fig. 4 example (our Fig. 1)..."B" is in bicipital groove.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Dimakopoulos P, Kasimatis G, Panagopoulos A. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am 2007;89:1700-1709.

    2. Brien H, Noftall F, MacMaster S, Cummings T, Landells C, Rockwood P.Neer's classification system: a critical appraisal. J Trauma 38: 257-260, 1995.

    3. Burstein AH, (ed). Fracture classification systems: do they work and are they useful? Bone and Joint Surg Am 78: 1371-5, 1996.

    4. Sidor M, Zuckerman J, Lyon T, Koval K. Cuom F, Shoenberg N. The Neer classification system for proximal humeral fractures: An assessment of interobserver reliability and intraobserver reproducibility. J Bone and Joint Surg Am 75:1745-1750, 1993.

    5. Siebenrock K, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone and Joint Surg Am 75 :1751-1755, 1993.

    6. Edelson G, Kelly I, Vigder F, Reis ND. A three-dimensional classification for fractures of the proximal humerus. J. Bone Joint Surg Br. 2004;86B:413-25.

    7. Edelson G, Safuri H, Salameh Y, Vigder F, Militianu D, Natural history of complex fractures of the proximal humerus using a 3-demensional classification system. Accepted for publication. J. Shoulder and Elbow Surg.

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