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