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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 6  |  Issue : 2  |  Page : 124-131

Transosseous suture-aided proximal humeral internal locking osteosynthesis plate in proximal humerus fractures: A prospective study


Department of Orthopaedics, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Submission25-Jun-2022
Date of Decision08-Oct-2022
Date of Acceptance21-Nov-2022
Date of Web Publication3-May-2023

Correspondence Address:
R Shibu
Department of Orthopaedics, Government Medical College, Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_52_22

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  Abstract 


Background: Fracture of the proximal humerus is the commonest fracture affecting the shoulder girdle in adults. Neer's 2, 3, and 4 part fractures are managed by operative fixation. Proximal humeral internal locking osteosynthesis (PHILOS) plate fixation is the treatment nowadays. However, accurate reduction of greater and lesser tuberosities may not be possible with a plate alone, which may lead to avascular necrosis of the humeral head. Transosseous suture fixation can accurately reduce the greater and lesser tuberosity fragments to shaft and head, but cannot maintain the reduction. A combination of transosseous suture fixation with PHILOS plate may be a viable option. Objective of Study: Our study was to evaluate functional outcome of transosseous sutures along with PHILOS plating for patients with proximal humerus fractures. Materials and Methods: The study was done as a prospective observational study of 40 consecutive patients with proximal humerus fractures, managed with transosseous suturing aided PHILOS plating. They were followed up for 6 months and evaluated using Constant Murley Scoring system. Results: The mean age of our patients was 52.86 years. The mechanism of injury was due to road traffic accident in 42.5% (17) and domestic falls in 57.5% (23). There were 20% two-part, 52.5% three-part, and 27.5% four-part fractures. Overall functional outcome was found to be good to excellent in 77.5% of our patients. The mean Constant Murley score achieved was 80.35. We found that patients with Neer's two-part and three-part fractures had the highest Constant scores (88.1 and 79.7. respectively) while patients with four-part had the lowest Constant scores (76). Patients <60 years showed better results. Conclusion: Transosseous suturing-aided PHILOS plating can be an excellent treatment option for osteosynthesis of complex proximal humerus fractures allowing early mobilization and good functional outcome. Transosseous suturing along with PHILOS plate can counteract the varus forces which can reduce complications such as late fracture displacement and avascular necrosis. There is no need for additional hardware, fibular graft, or exposure for the combined procedure to achieve a good outcome. Thorough knowledge of anatomy, proper fracture reduction and proper placement of locking plate are equally important for a superior outcome in these difficult fractures.

Keywords: Proximal humeral internal locking osteosynthesis plate, proximal humerus fracture, transosseous suture


How to cite this article:
Bhargavan V, Shyam Roy A S, Shibu R. Transosseous suture-aided proximal humeral internal locking osteosynthesis plate in proximal humerus fractures: A prospective study. J Orthop Dis Traumatol 2023;6:124-31

How to cite this URL:
Bhargavan V, Shyam Roy A S, Shibu R. Transosseous suture-aided proximal humeral internal locking osteosynthesis plate in proximal humerus fractures: A prospective study. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:124-31. Available from: https://jodt.org/text.asp?2023/6/2/124/375548




  Introduction Top


Fracture of the proximal humerus is the commonest fracture affecting the shoulder girdle in adults and the third most common fracture in people above 65 years of age, after fractures of the hip and distal radius.[1],[2] They have a bimodal distribution, in young people following high-energy trauma and in those older than 50 years with low-velocity injuries like domestic fall.[2] Females are more commonly affected than males and fracture incidence increases with age.[3] Eighty-five percent of these fractures are minimally displaced and can be effectively treated with immobilization followed by an early motion. The remaining 15% of unstable fractures require surgical treatment, especially in young patients and active elderly people.[4] Displaced Neer's[5] 2,3 and 4 part fractures are managed by operative fixation.[6] Many techniques are used for fracture fixation such as closed reduction and percutaneous K-wire fixation, open reduction and fixation with bone sutures, tension band wiring, cerclage wiring, T plate, intramedullary nailing, locking plates, shoulder arthroplasty, and proximal humeral internal locking osteosynthesis (PHILOS) plate.[6],[7],[8] Loosening or failure of the implant and nonunion are possible complications of surgery in humeral fractures.[9],[10] To decrease the high complication rates of proximal humerus fractures, the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) group developed the PHILOS plate; an internal fixation system that enables angled stabilization with multiple interlocking screws.[11] However, the accurate reduction of greater and lesser tuberosities may not be possible with plate alone. Transosseous suture fixation techniques with strong nonabsorbable suture provide the advantage of incorporating the rotator cuff insertion to increase fixation. It has got advantages like less surgical soft tissue dissection, a low rate of humeral head osteonecrosis, early passive movements and the avoidance of bulky and expensive implants. However, suture fixation alone cannot maintain the reduction and stability of the fracture fragments needed for fracture union. Hence, a combination of PHILOS plate with transosseous sutures may be tried to get the advantages of both fixation modalities in proximal humerus fractures, leading to a better functional outcome. There are no studies in literature showing PHILOS plate with transosseous sutures for the treatment of proximal humerus fractures. Our study was to evaluate the functional outcome of transosseous sutures along with PHILOS plating as a treatment modality for proximal humerus fractures.


  Materials and Methods Top


The study was conducted as a prospective observational study at the orthopedic department of a tertiary care hospital for 1 year after institutional ethics committee clearance. All consecutive patients with closed proximal humerus fracture attending the orthopedic outpatient and emergency departments, who satisfied the inclusion criteria, were enrolled in our study. There were 40 patients in our study and they were surgically treated with PHILOS plate (Depuysynthes®i Switzerland) combined with trans-osseous suture fixation. Patients were followed up for minimum 6 months. Inclusion criteria were patients above 20 years with closed fractures and with Neer's 2, 3, or 4 part fractures with >1 cm displacement and varus angulation of >45°; who gave written informed consent for the study. Exclusion criteria were patients with open fractures, pathological fractures, valgus-impacted fractures, psychological and neurological disorders, previous injury to same joint, multiple injury to the same limb and poor follow-up.

Surgical procedure

Under supraclavicular block or general anesthesia, the patient was positioned supine on a radiolucent operating table. Using the anterior deltopectoral approach, proximal part of humerus exposed. Soft-tissue attachments to the fracture fragments were carefully preserved to prevent devascularization of the humeral head. Tuberosity fragments and humeral head were mobilized from the displaced position. Transosseous suturing of tuberosities and head was done with nonabsorbable No-5 Ethibond (Ethicon®) sutures. For two-part fractures, six drill holes were made with 2.7 drill bit, two in greater tuberosity fragment, two near lesser tuberosity and another two at proximal shaft medially and laterally. 1st and 3rd sutures will allow greater tuberosity to align with the fracture bed. 2nd, 4th, and 5th Ethibond will aid to maintain reduction with shaft of humerus [Figure 1]. All sutures were tied in cruciate manner, taking care not to overtighten to prevent comminution. In three-part fractures, 8 holes were drilled and 6 Ethibond sutures were passed. Two sutures were used for approximating greater or lesser tuberosity to the fracture bed. Other two sutures from greater and lesser tuberosities were used for anchoring on the proximal shaft, directing toward opposite cortices. Greater tuberosity tightened towards medially and lesser tuberosity tightened towards lateral cortex of proximal shaft [Figure 2]. Ten drill holes are made for four-part fractures, two each for tuberosities and head; and four in proximal shaft-two medially and two laterally. From among the eight ethibonds, two used for tightening and approximating tuberosities toward the shaft. Other two sutures in each tuberosity were used for anchoring towards opposite cortices of the proximal shaft and the last two ethibonds for head-to-shaft fixation [Figure 3].
Figure 1: Two-part transosseous suture fixation

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Figure 2: Three-part transosseous suture fixation

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Figure 3: Four-part transosseous suture fixation

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Sutures were tightened in such a way as to regain the normal shape of proximal humerus. The accurate reduction of fracture fragments was confirmed with fluoroscopy. On the anteroposterior view, the PHILOS plate was placed 8-10 mm distal to the superior tip of the greater tuberosity; from the lateral view, the plate was centered against the lateral aspect of the greater tuberosity. The initial screw was then placed in the elongated hole in the humeral shaft so that the height of the plate could be adjusted and then the locked screws were inserted into the humeral head. At least three distal shaft screws were inserted. Reduction and screw placements were confirmed with C-arm, to prevent screw protrusion into the shoulder joint. The wound closed in layers over a suction drain. The limb was immobilized in a cuff and collar sling. Antibiotics were given for 3 days.

Active assisted and passive exercises were done during the first 2 weeks by a physiotherapist; and 3 weeks later active motion was started. Patients were followed up on an outpatient basis at 2 weeks at first; then after every month till 6 months. At every follow-up, patients were assessed clinically for shoulder pain, activities of daily living (ADL), strength, and range of motion (forward flexion, abduction, external and internal rotations). Constant and Murley Score[12] were calculated at 6 months from these parameters. Patients were also assessed radiographically for the progress of fracture healing; and complications such as varus collapse, loss of fixation, infection, screw cut-out, non-union, subacromial impingement, and hardware failure.

Data were collected using structured pro forma and entered into Microsoft Excel 2013. Subjective variables like pain, ADL and objective variables like strength of shoulder muscles, range of motion of shoulder-forward flexion, abduction, external rotation, and internal rotation were recorded for calculating Constant Murley scores [Table 1]. Other variables entered were – age, gender, mechanism of injury, side, associated shoulder dislocation, Neer's type, hypertension, diabetes, other bony injuries, infection, neurological deficits, vascular injury [Table 2]. Time taken for radiological union recorded in weeks. All data were analyzed with the help of SPSS Statistics 21.0 (IBM®, Armonk, NY, USA) software. The results were scored using Constant and Murley Scoring system [Table 1].[12]
Table 1: Constant Murley Scoring system

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Table 2: Variables

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  Results Top


Out of the 40 patients, 40% (n = 16) were above 60 years [Figure 4]. Female patients constituted 60%. The mean age of our patients was 52.86 years. The mechanism of injury was due to road traffic accident in 42.5% (17) and domestic falls in 57.5% (23) [Table 2]. Left side was involved in 62.5% (25). The fracture was associated with shoulder dislocation in 45% (18). As per Neer's classification,[5] there were 20% two-part, 52.5% three-part, and 27.5% four-part fractures. 35% (14) cases had other bony injuries also. 45% had hypertension and 37.5% had diabetes. There were no cases of associated neurological deficits or vascular injury. Patients with associated other bony injuries had a statistically significant P value (0.007) depending on Neer's type [Table 3]. P values of the mechanism of injury showed no statistical significance [Table 4] and [Table 5]. Associated shoulder dislocation had no statistically significant effect on Constant Murley score (P = 0.298) or on the improvement of range of motion after 6 months (P = 0.642) [Table 6]. Average time of radiological union in our study was 12+/-4.3 weeks. In 87.5% (35) cases, the range of motion showed significant improvement in 6 months [Table 7].
Figure 4: Age distribution. Sixteen patients belonged to age group more than 60 years suggesting a strong relation of proximal humerus with age related osteoporosis

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Table 3: P value based on Neer's classification

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Table 4: P value based on mechanism of injury

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Table 5: Outcome based on mechanism of injury

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Table 6: Outcome based on associated shoulder dislocation

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Table 7: Functional outcome

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Overall, the functional outcome was found to be good to excellent in 80% of our patients (40% excellent and 40% good) [Table 7]. The mean Constant-Murley score achieved was 80.35. Patients below 40 years had a mean constant score of 90 and in above 60 it was 73.3 [Table 8] and [Figure 5]. Males had a better score (85.6) compared to females (76.9) [Figure 6]. We found that patients with Neer's 2-part and 3-part fractures had the highest Constant scores (88.1 and 79.7, respectively) while patients with four-part fractures had the lowest Constant score of 76 [Table 9] and [Figure 7]. No patients underwent bone grafting. Surgical site infection was reported in 5% (2) cases. The infection subsided with 5 days of parenteral antibiotics. There were no cases of varus collapse, screw backout or shoulder impingement during the study.
Figure 5: CMS based on the age of patients. CMS: Constant Murley score. Patients below 40 years had better scores and score decreases with increasing age

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Figure 6: Constant Murley score based on gender. Males had better scores than females

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Figure 7: Constant score based on fracture patterns. Constant Murley Score: 2-part 88.1, 3-part 79.7 and 4-part 76. Score decreases with increasing complexity of fracture

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Table 8: Constant score based on age

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Table 9: Constant score based on Neer's type

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  Discussion Top


In our study, 57.5% of patients had a history of domestic fall. In young age, the common cause was mostly due to road traffic accident. 16 patients (40%) belonged to age group above 60 years suggesting a strong relation of proximal humerus with age-related osteoporosis. The mean constant score was 85.6 for men and 76.9 for females, and it may be due to the fact that most of the fractures in females occur during their perimenopausal age group. Patients below 40 years had a mean constant score of 90, but in patients above 60 the constant score was 73.3. This may be due to osteoporosis and poor implant-holding capacity in elderly. The overall mean Constant Murley score was 80.35 in 6-month follow-up. The mean Constant Murley Score of two-part fractures was 88.1, three-part fractures 79.7 and four-part fractures 76. This may be due to increasing complexity of fracture pattern and difficult fixation in four-part fractures.

A study by Cho, et al.,[13] used Tension suture fixation using two washers with PHILOS plate for proximal humeral fractures, yielded satisfactory radiographic and clinical results. They used different scoring system for functional outcome, so that comparison becomes inappropriate. In a study by Doshi et al.,[14] using PHILOS plate for fixation on 53 patients, reported 13.21% excellent and 69.81% satisfactory results using Neer's scoring system. Oldrini et al., in a systematic review and meta-analysis, concluded that fixation with PHILOS plate has high complications and reintervention rates.[15] Common complications in their study were screw cut-out, humeral head AVN, and subacromial impingement. Dasari et al. opined that in elderly patients with proximal humerus fractures, PHILOS plate should be augmented with a fibular allograft for improved outcomes.[16] Shukla et al., in their study, concluded that tension band rotator cuff suture fixation of locked plating of proximal humerus fractures resulted in lower complication rate and excellent functional outcomes.[17] To avoid the theoretical chance of suture cut-out and to attain good apposition of tuberosities to shaft, we have modified the rotator cuff sutures to transosseous sutures to supplement PHILOS plate in our study. Various techniques have been devised for the fixation of the comminuted proximal humerus, either by transosseous wiring or by PHILOS plate fixation. The uniqueness of our study is that, by providing a strong construct by combining transosseous fixation stabilized by PHILOS plating, we can prevent the late collapse when transosseous wiring is used alone and the screw cut out when PHILOS plates are used alone. The wiring technique we used was less complex and simple, by directly apposing opposite cortices of displaced tuberosity fragments which have been displaced due to opposite muscle forces, and then wiring that construct directly to the opposite cortices of the proximal shaft.

Postoperatively, only very less complications were observed in our study. Infection was found in 2 (5%) patients and was treated with oral antibiotics. In our short period of follow-up, no patients showed signs of avascular necrosis. The chances of avascular necrosis of the shoulder are directly proportional to the severity of the injury. In our combined procedure, the vascularity of fracture fragments was preserved by minimum soft tissue dissection and re-attaching tuberosities along with rotator cuff to its natural attachments by the sutures. The risk of osteonecrosis increases if the anterolateral branch of the anterior humeral circumflex artery is damaged and care should be taken while exposing the biceps tendon in the bicipital groove. Shoulder impingement was reported in 1.8%–8% of cases in literature.[18] There were no cases of shoulder impingement in our study. This may be due to the accurate reduction of greater tuberosity to shaft by the transosseous sutures and placing the PHILOS plate 8–10 mm distal to the superior tip of the greater tuberosity so that greater tuberosity or plate does not impinge on the acromion. We had no cases of screw cut-out, nonunion, or hardware failure in our study. This could be explained by the accurate reduction attained by the trans-osseous sutures before plating and accurate length of screws. Thus, with the combined technique of using transosseous sutures and PHILOS plating, we can prevent most of the complications and achieve good results in proximal humerus fracture fixation.


  Conclusion Top


Transosseous suturing-aided PHILOS plating can be an excellent treatment option for osteosynthesis of complex proximal humerus fractures allowing early mobilization and good functional outcome. This combined procedure can counteract the varus forces, which can reduce complications such as late fracture displacement and avascular necrosis. There is no need for additional hardware, fibular graft, or exposure for the combined procedure to achieve a good outcome. Thorough knowledge of anatomy, proper fracture reduction, and proper placement of locking plate are equally important for a superior outcome in these difficult fractures.

Limitations

The limitation of our study is a small sample size and short follow-up period.

Acknowledgment

The authors would like to thank Dr. I Yadev, for his contributions to statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Passaretti D, Candela V, Sessa P, Gumina S. Epidemiology of proximal humeral fractures: A detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg 2017;26:2117-24  Back to cited text no. 1
    
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Bigliani LU: Proximal humeral fractures. In: Tornetta P, Ricci W, Court-Brown CM, McQueen MM, McKee M, editors. Rockwood and Green's Fractures in Adults. Philadelphia, PA: Lippincott Williams and Wilkins; 2019.  Back to cited text no. 2
    
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Launonen AP, Lepola V, Saranko A, Flinkkilä T, Laitinen M, Mattila VM. Epidemiology of proximal humerus fractures. Arch Osteoporos 2015;10:209.  Back to cited text no. 3
    
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Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: A randomized controlled trial. J Shoulder Elbow Surg 2011;20:747-55.  Back to cited text no. 4
    
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Carofino BC, Leopold SS. Classifications in brief: The neer classification for proximal humerus fractures. Clin Orthop Relat Res 2013;471:39-43.  Back to cited text no. 5
    
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Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015;(11):CD000434.  Back to cited text no. 6
    
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Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C. 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 2013;22:e8-14.  Back to cited text no. 7
    
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Newman JM, Kahn M, Gruson KI. Reducing postoperative fracture displacement after locked plating of proximal humerus fractures: Current concepts. Am J Orthop (Belle Mead NJ) 2015;44:312-20.  Back to cited text no. 9
    
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Gavaskar AS, Karthik B B, Tummala NC, Srinivasan P, Gopalan H. Second generation locked plating for complex proximal humerus fractures in very elderly patients. Injury 2016;47:2534-8.  Back to cited text no. 10
    
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Kettler M, Biberthaler P, Braunstein V, Zeiler C, Kroetz M, Mutschler W. Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures. Unfallchirurg 2006;109:1032-40.  Back to cited text no. 11
    
12.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.  Back to cited text no. 12
    
13.
Cho CH, Kim DH, Kim BS. Radiographic and clinical results of tension suture fixation using two washers with PHILOS plate for proximal humeral fractures. Injury 2017;48:464-8.  Back to cited text no. 13
    
14.
Doshi C, Sharma GM, Naik LG, Badgire KS, Qureshi F. Treatment of proximal humerus fractures using PHILOS Plate. J Clin Diagn Res 2017;11:C10-3.  Back to cited text no. 14
    
15.
Oldrini LM, Feltri P, Albanese J, Marbach F, Filardo G, Candrian C. PHILOS synthesis for proximal humerus fractures has high complications and reintervention rates: A systematic review and meta-analysis. Life (Basel) 2022;12:311.  Back to cited text no. 15
    
16.
Dasari SP, Kerzner B, Fortier LM, Rea PM, Bodendorfer BM, Chahla J, et al. Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: A systematic review and meta-analysis. J Shoulder Elbow Surg 2022;31:884-94.  Back to cited text no. 16
    
17.
Shukla DR, McAnany S, Pean C, Overley S, Lovy A, Parsons BO. The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures. Injury 2017;48:474-80.  Back to cited text no. 17
    
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Vijayvargiya M, Pathak A, Gaur S. Outcome analysis of locking plate fixation in proximal humerus fracture. J Clin Diagn Res 2016;10:C01-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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