G.G. Konrad and N.P. Südkamp reply:
The authors thank Drs. Court-Brown and McQueen for their interest in our study. They raised several points which deserve further comment, and we offer the following explanations: We agree that it is important to define the indications for surgical treatment of proximal humeral fractures, especially because proximal humeral fractures are common and are getting more common as the prevalence of osteoporotic fractures increases. However, the aim of the present study was to evaluate the functional outcome and complication rate after open reduction and internal fixation of proximal humeral fractures with the Locking Proximal Humerus Plate. There was no control group for conservative treatment. Therefore, with the data available from this study, it is not possible to determine which fractures will do better with surgical treatment. In our study, all fractures either met the indications for operative treatment outlined by Neer, i.e., an angulation of the articular surface of >45° or a displacement between the major fracture segments of >1 cm, or were unstable when tested with passive motion with use of an image intensifier. Nondisplaced stable fractures and fractures with minimal displacement and adequate stability as well as fractures involving only the greater or lesser tuberosity were not considered for treatment with the plate. Therefore, the patients in our study presumably represent a selection that will end up with a lower Constant score after conservative treatment compared with the patients in the study by Court-Brown and McQueen. In their study, all patients had an impacted valgus fracture (B1.1) of the proximal part of the humerus. The distribution of fracture types according to the AO classification and sex is shown in Figure 1. Also, the results for different fracture types are mentioned in the manuscript, and there was no significant difference in the Constant score between fracture types according to the AO classification at the time of the final follow-up.
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