P. Dimakopoulos, A. Panagopoulos, and G.B. Kasimatis reply:
We thank Dr. Abboud for his interest in our article, and we appreciate the opportunity to clarify certain points regarding the transosseous suture fixation technique.
No fluoroscopic imaging is needed with this technique because it is an open one, allowing for a very good view of the operating field. We would point out that with the ability to rotate the arm in both external and internal rotation, intraoperative visualization of the fracture fragments is easily obtained both anteriorly and posteriorly. We have not found it necessary to use fluoroscopy intraoperatively with this technique.
Plates are a reasonable alternative for proximal humeral fractures but they do have disadvantages. We used proximal humeral plates extensively in the past but, in many instances, the fixation was unstable, especially in cases of three and four-part valgus impacted fractures. Although precontoured proximal humeral plates permit better osseous purchase and more stable fixation, they do not allow for as good a tensioning of the tuberosities as is provided by the sutures themselves. Our current indication for plate osteosynthesis is a two-part fracture of the surgical neck, and we use a plate that also enables the placement of sutures for even better stabilization.
The concept of non-anatomic fracture reduction obviates many of the main disadvantages of earlier techniques. Screw purchase is not always possible in the exact place that it was initially planned, hardware and tuberosities may impinge, and the final function of the rotator cuff muscles is occasionally compromised. Figure 11 in our study is a postoperative radiograph showing a four-part valgus impacted fracture that was fixed with the transosseous suturing technique. For this type of fracture, we accept a non-anatomic reduction in order to avoid disimpaction of the head part from its valgus impacted status, thus minimizing the risk of further disruption of the vulnerable blood supply to the head. In order to restore the mechanics of the rotator cuff, we pull and fix the tuberosities below the top of the head, producing a non-anatomic, yet functional, situation (as shown in Figure 8 of our article). Overall, what matters most is to provide a stable osteosynthesis with adequate tensioning of the rotator cuff, without impingement.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.