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Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical

Technique
Panayiotis Dimakopoulos, Andreas Panagopoulos and Georgios Kasimatis
J Bone Joint Surg Am. 2009;91:8-21. doi:10.2106/JBJS.H.01290

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COPYRIGHT © 2 009 BY THE JOURNAL OF BONE AND JOINT SURGERY, I NCORPORATED

Transosseous Suture Fixation

of Proximal Humeral Fractures
Surgical T echnique
By Panayiotis Dimakopoulos, MD, Andreas Panagopoulos, MD, and Georgios Kasimatis, MD
Investigation performed at the Shoulder and Elbow Unit, Orthopaedic Department, University Hospital of Patras, Patras, Greece

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 1700-9, August 2007

ABSTRACT FROM THE ORIGINAL ARTICLE

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 dis-
placed 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 pa-
tients 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, hetero-
topic 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 syn-
drome, 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.
ORIGINAL ABSTRACT CITATION:“Transosseous Suture Fixation of Proximal Humeral Fractures” (2007;89:1700-9).

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.

A video supplement to this article has been produced by the Video Journal of Orthopaedics (VJO). This production is included on the bound-in DVD as part of this issue
and will also be available in streaming video format at the JBJS website, [Link]. VJO can be contacted at (805) 962-3410, web site: [Link].

J Bone Joint Surg Am. 2009;91 Suppl 2 (Part 1):8-21 • doi:10.2106/JBJS.H.01290

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INTRODUCTION tuberosity, the lesser tuberosity, nonabsorbable sutures instead of

The management of displaced and the upper part of the meta- wires, which can cut through the
proximal humeral fractures is physis are sutured together in a bone, especially in osteoporotic
challenging and often reflects the cruciate fashion, and in three- patients, and can more easily fa-
personal experience of the physi- part fractures, the displaced tu- tigue, resulting in the need for
cian treating the injury. Regard- berosity is sutured to the intact the removal of broken or mi-
less of the treatment protocol one as well as through drill holes grated wire fragments in some
used, these fractures present in the metaphyseal area. Finally, patients.
challenges in restoring humeral in two-part tuberosity fractures,
alignment, joint surface congru- the displaced tuberosity is su- SURGICAL TECHNIQUE
ity, and rotator cuff function tured to the intact one and to the Preoperative evaluation includes
while maintaining humeral head adjacent metaphyseal area. Stable a thorough clinical examination,
vascularity. Over the last fifteen fixation can be obtained in each focused on the presence of any
years, we have used a technique of these fractures, allowing for neurovascular deficit, and a stan-
of transosseous suture fixation early shoulder motion with a low dard radiographic trauma series
for a large number of displaced risk of osteonecrosis and hard- of the shoulder (an anteroposte-
proximal humeral fractures. ware-related complications. rior radiograph in the scapular
These have included four-part Other techniques of transosseous plane as well as lateral and axil-
valgus impacted fractures, three- fixation of two-part or three-part lary radiographs) (Fig. 1). In or-
part fractures or fracture-dislo- fractures with use of wires, tapes, der to minimize discomfort, the
cations, and two-part fractures of or sutures have previously been axillary radiograph is usually
the greater tuberosity with or proposed by other authors1-3. Re- done with the patient in a supine
without associated dislocation of garding the method proposed by position, under the supervision
the humeral head. With use of Hawkins et al.1, our surgical tech- of the attending physician. Addi-
this technique in four-part val- nique differs in that it can also be tional radiographic views (an-
gus impacted fractures, the im- applied to four-part valgus im- teroposterior in external rotation
pacted head, the greater pacted fractures and utilizes or in internal rotation with 15° of

FIG. 1

Preoperative radiographs of a four-part valgus impacted fracture. Note the displacement of the greater tuberosity, the impaction of the hu-
meral head, and the absence of lateral displacement of the head fragment on the anteroposterior (AP) radiograph.
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FIG. 2

The patient is placed in the beach-chair position (left), and the skin incision extends no more than 6 to 7 cm distal to the anterolateral tip
of the acromion (right).

cephalic tilt) and computed to- eral tip of the acromion, the humeral head. Invariably, the
mography can be useful in se- extending laterally and distally humeral head is facing superiorly
lected patients. for approximately 6 to 7 cm (Fig. with the tuberosities displaced to
After induction of general 2). With use of blunt dissection, either side of it (Fig. 4). While
anesthesia, the patient is placed the deltoid is split for 4 to 5 cm the impacted valgus position of
in the beach-chair position with distal to the acromion (Fig. 3). the humeral head fragment is
at least 60° of flexion at the waist. Rotation and abduction of the preserved, two heavy nonabsorb-
Two folded sheets are placed be- proximal part of the humerus in able sutures are passed through
neath the medial border of the this surgical window allows ade- the bone of the head fragment, 1
scapula to bring the shoulder quate visualization of both tu- cm proximal to the fracture line
girdle forward, facilitating access berosities and the metaphyseal at both the medial and the lat-
to the glenohumeral joint. A area, thus minimizing the risk of eral border of the articular sur-
second-generation cephalosporin iatrogenic injury to the axillary face. Additional sutures are then
is administered preoperatively nerve. In patients with metaphy- passed through each tuberosity
and for the first postoperative seal extension of the fracture, the fragment (or near the site of ten-
day. The entire upper extremity nerve is identified and protected don insertion into the fragment
is prepared and draped in a man- by the surgeon’s finger. in osteoporotic bone or when in-
ner that allows full and unre- tensive comminution is present),
stricted positioning of the arm Fixation of Four-Part and the rotator cuff tendons are
during the procedure. Valgus Impacted Fractures mobilized (Fig. 5). Finally, two
The fractured area is ex- Soft-tissue attachments to the additional pairs of sutures are in-
posed with use of the lateral fracture fragments are carefully serted laterally and medially
transdeltoid approach, by devel- preserved to prevent devascular- through 2.7-mm drill holes in
oping an interval between the ization of the humeral head. The the diaphysis (Fig. 6). These su-
anterior and middle portions of fracture lines between the tuber- tures are then passed through the
the deltoid muscle. The skin inci- osities are identified and gently opposite tuberosity, near the
sion is made from the anterolat- separated, facilitating access to musculotendinous junction, and
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on to the neighboring area of the

articular segment (i.e., from the
medial diaphysis toward the
greater tuberosity and from the
lateral diaphysis toward the lesser
tuberosity as well as to the adja-
cent articular fragment). Once all
sutures are in place, the tuberosi-
ties are approximated to the dia-
physis and recessed just below
the top of the head fragment.
Then each suture is tied individ-
ually and to each other in a cru-
ciate arrangement that allows
stable fixation of all parts of the
fracture to all others (Fig. 7). Any
further loosening of the sutures,
FIG. 3
because of fracture compression,
is corrected by tying additional The split of the deltoid extends no more than 4 to 5 cm in order to avoid iatrogenic injury
to the axillary nerve.
knots between the free suture
ends once more in a cruciate
manner. A schematic representa-
tion of the surgical technique in a
four-part valgus impacted frac-
ture is shown in Figure 8 with the
appropriate order of suture pas-
sage and the final knot-tying.
When completed, eight sutures
will have been placed. Each tu-
berosity contains four suture
ends (two distinct sutures, one to
each side of the shaft fragment,
and two shared sutures to the
neighboring tuberosity), and the
head fragment contains two dis-
tinct sutures (both going
through the proximal holes in
the shaft fragment) (Fig. 8, c).
Any associated tears of the rota-
tor cuff tendons are also repaired FIG. 4
with nonabsorbable sutures.
Intraoperative photograph made after exposure of a four-part valgus impacted fracture.
Soft-tissue attachments to the fracture fragments are carefully preserved to prevent
Fixation of Three-Part devascularization of the humeral head. The fracture lines between the tuberosities are
Fractures (Fig. 9) then identified and gently separated. GT = greater tuberosity, LT = lesser tuberosity,
The same principles of fixation HH = humeral head, and HD = humeral diaphysis.

are used for three-part fractures.

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and then to each other in a cru-

ciate arrangement that allows
stable fixation of all parts, one
to the other. Loosening of the
sutures, because of fracture
compression, is corrected by ty-
ing additional knots between
the free suture ends in a cruci-
ate manner. Associated rotator
cuff tears are repaired with non-
absorbable sutures.

Fixation of Two-Part
Fractures of the Greater
Tuberosity (Fig. 10)
When anterior dislocation of
FIG. 5 the shoulder accompanies frac-
The first suture is passed through the head fragment and the greater and lesser tuberos- ture of the greater tuberosity,
ities. GT = greater tuberosity, LT = lesser tuberosity, HH = humeral head, and HD = hu- the patient is lightly sedated in
meral diaphysis. the emergency department to
facilitate reduction. Only one or
In this type of fracture, the hu- and two shared sutures to the two efforts are made to reduce
meral head is typically rotated neighboring tuberosity) (Fig. 9, the dislocation by closed means.
either internally or externally, c). Once all the sutures are in If closed reduction fails, the pa-
and care must be taken to place, they are tied individually tient is transferred to the oper-
achieve an adequate reduction
in both the frontal and sagittal
planes. Initially, two sutures are
placed through the displaced
greater tuberosity and then
through the intact lesser tuber-
osity. Two additional pairs of su-
tures are inserted laterally and
medially through 2.7-mm drill
holes in the diaphysis. These su-
tures are directed into the oppo-
site tuberosity (i.e., the medial
diaphysis toward the greater tu-
berosity and the lateral diaphy-
sis toward the intact lesser
tuberosity). When completed,
six sutures will have been FIG. 6

placed, with each tuberosity Additional sutures are placed through drill holes in the medial and lateral aspects of the
containing four suture ends humeral diaphysis (HD). The black arrows indicate the drill holes in the diaphysis. GT =
(two distinct sutures to the op- greater tuberosity, LT = lesser tuberosity, and HH = humeral head.

posite side of the shaft fragment

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ating room for open reduction of the tuberosity fragment and the rotator cuff are repaired
under general anesthesia. In our directed to the upper, middle, with nonabsorbable sutures.
series, twenty-nine (52%) of the and lower parts of the cortical Once the fracture has been
fifty-six patients with two-part bed and metaphyseal area. repaired, gentle mobilization of
fractures of the greater tuber- When completed, five sutures the humerus of up to 90° of ab-
osity had a characteristic longi- will have been placed. Two dis- duction and 30° of external and
tudinal tear in the rotator tinct sutures connect the upper internal rotation is tested intra-
interval. Complete avulsion of tuberosity fragment to the bed operatively. The intraoperative
the supraspinatus tendon was of the head and shaft, while impression of a stable construct
seen in five patients; complete three sutures secure the lower that moves as a single unit in all
avulsion of the infraspinatus part of the tuberosity fragment directions presumes the adequacy
tendon, in three; and combined to different fixation points in of fixation and avoids the need
avulsion of both tendons, in the shaft and metaphysis (Fig. for intraoperative radiographic
two patients. To repair the frac- 10, c). Once all sutures are in examination. The deltoid flaps are
tures, two sutures are passed place, the cortical edge of the then reapproximated with use of
from the upper part of the tuberosity fragment is reduced absorbable sutures in a figure-of-
greater tuberosity through the to align with the edge of the eight manner. The subcutaneous
lower part of the metaphysis fracture bed on the proximal tissue is closed with absorbable
(through a corresponding drill part of the humerus and the su- sutures, and the skin is closed
hole) and into the upper part of tures are carefully tied in a cru- with a subcuticular technique. A
the cortical bed of the humeral ciate fashion with care being Velpeau dressing secures the arm
head, near the fracture line. taken to prevent overreduction to the chest wall. It is converted to
Three additional sutures are and to avoid further comminu- a simple sling on the second post-
passed through the lower part tion. The longitudinal tears in operative day. Postoperative radi-
ographs in the recovery room
document the adequacy of reduc-
tion and fixation (Fig. 11).

REHABILITATION PROTOCOL
A closely monitored, three-phase
rehabilitation program is admin-
istered to all patients. Initially,
this consists of pendulum exer-
cises starting on the second post-
operative day and continuing
until the third or fourth postop-
erative week. The second phase
includes active-assisted range-of-
motion exercises for a period of
five to ten weeks. In the final
FIG. 7 phase, commencing at approxi-
The fixation is demonstrated just prior to final tying of the knots. There is an adequate
mately three months after sur-
reduction and balance of the involved rotator cuff tendons. The fracture site has been gery, active dynamic shoulder
closed, and both the tuberosities have been placed below the articular margin of the hu- motion and strengthening exer-
meral head. Note the cruciate nature of the sutures. cises are prescribed until the
sixth postoperative month.
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A four-part valgus impacted frac-

ture of the proximal part of the
humerus. a: Drawing showing the
drilling of the greater and lesser
tuberosities, the head fragment
in its valgus impacted position,
and the lateral and medial meta-
physeal areas. b: The sutures
are passed through the holes in
the appropriate order as indi-
cated by the numbers. c: The
sutures are in place. The tuber-
osities are pulled down below
the level of the top of the head
and are tightened not only to
each other but also to the meta-
physis overlapping the lateral
cortex. d: The postreduction ap-
pearance after tightening of all of
the knots.

b
FIG. 8
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FIG. 8 (CONTINUED)
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A three-part fracture of the

proximal part of the humerus.
a: Drawing showing the drilling
of the greater tuberosity, the
humeral metaphysis, and the
lesser tuberosity. b: The su-
tures are passed through the
holes as indicated by the num-
bers. c: The sutures are in
place. d: The postreduction ap-
pearance after tightening of all
of the knots.

b
FIG. 9
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FIG. 9 (CONTINUED)
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A two-part fracture of the

proximal part of the hu-
merus. a: Drawing showing
the drilling of the greater tu-
berosity and the humeral
metaphysis. b: The sutures
are passed through the holes
as illustrated following the or-
der of the numbers. c: The
sutures are in place prior to
knot-tying. d: The postreduc-
tion appearance after tighten-
ing of all of the sutures.

b
FIG. 10
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FIG. 10 (CONTINUED)
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FIG. 11

Postoperative radiograph of the same four-part valgus impacted fracture as seen in Figure 1. The humeral head remains in its valgus posi-
tion, and both of the tuberosities have been secured below the articular margin of the head. AP = anteroposterior.

CRITICAL CONCEPTS

INDICATIONS:
According to the classification of proximal humeral fractures proposed by Neer4, the following types of fractures are ap-
propriate for transosseous suture fixation:

• Two-part fractures of the greater tuberosity with or without an associated shoulder dislocation
• Three-part fractures or three-part fracture-dislocations
• Four-part valgus impacted fractures (with no more than 45° of rotational deformity and <6 to 7 mm of lateral displacement
of the head on the anteroposterior radiograph)

CONTRAINDICATIONS:
• Displaced four-part fractures or four-part fracture-dislocations
• Two-part surgical neck fractures (relative contraindication)
• Head-splitting or anatomical neck fractures

POTENTIAL RISKS AND PITFALLS:

• The axillary nerve, which is the major anatomical structure in danger, is located approximately 5 to 6 cm distal to the tip
of the acromion. With the transdeltoid approach, the deltoid split ends well proximal to the nerve since only 1 to 2 cm of
metaphyseal exposure is required to place the drill holes in the shaft fragment. We believe that the main advantage of the
lateral approach compared with the more standard deltopectoral approach is the preservation of the remaining blood sup-
ply of the humeral head, especially in four-part valgus impacted fractures5.
• From a technical point of view, the passage of all sutures prior to fracture reduction is essential, as doing so can balance
the deforming forces of the rotator cuff tendons and facilitate mobilization of the tuberosity fragments. The sutures are al-
ways tied in a cruciate fashion with use of a specific order of knot-tying. Loosening of the knots because of fracture com-
pression is mitigated by tying additional knots between the free sutures also in a cruciate manner. We prefer heavy
number-5 nonabsorbable sutures passed through 2.7-mm drill holes. The sutures are cut at the end of the procedure only
continued
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CRITICAL CONCEPTS

POTENTIAL RISKS AND PITFALLS (CONTINUED):

after a stable construct has been achieved. With osteoporotic or severely comminuted tuberosity fragments, the sutures
are passed near the musculotendinous junctions.
• The displaced tuberosities in four-part valgus impacted fractures are always pulled down below the top of the head frag-
ment with the shoulder in the adducted position and are sutured not only to each other but also to the head fragment as
well as to the medial and lateral aspects of the diaphysis in a manner that we believe neutralizes the deforming muscular
forces. We avoid disimpacting the head fragment from its valgus impacted position, thus minimizing the risk of further dis-
ruption of the vulnerable blood supply of the posteromedial hinge. Despite this “incomplete” fracture reduction, it seems
that the residual disturbance of normal anatomy does not affect shoulder joint mechanics. The moment arm of the rotator
cuff muscles is preserved by suturing the tuberosities below the top of the impacted head. Use of this approach is sup-
ported by the very low rate of early degenerative arthritis seen in our series.
• In three-part fractures of the greater tuberosity, the sutures are passed through the intact lesser tuberosity. This provides
a stable construct and restores the normal functional balance of the involved tendons, thus allowing for early shoulder
joint motion. In isolated two-part fractures of the greater tuberosity, the displaced tuberosity is reduced to its anatomical
position, thus avoiding a mechanical block to abduction of the shoulder or obstruction of external rotation because of pos-
terior displacement of the greater tuberosity. Our preference is for suture fixation of the greater tuberosity fragment in pa-
tients with associated dislocation of the shoulder, regardless of the extent of its postreduction displacement6. Our
decision to internally fix the greater tuberosity in its anatomical position is based on the nature of the injury rather than
the degree of postreduction displacement. Recently proposed guidelines of 5 or 10 mm of greater tuberosity
displacement as an indication for internal fixation cannot be followed because displacement often exceeds 20 mm at the
time of dislocation. Associated tears of rotator cuff tendons, noted in the majority of our patients, are an additional
indication for early surgical intervention.
• Regarding two-part surgical neck fractures, we believe that the optimal treatment is with plate-and-screw osteosynthesis.
We do not recommend transosseous suture fixation in this type of fracture as rotational instability between the large prox-
imal fragment and the narrow diaphysis can often be problematic. In such patients, stable fixation can be achieved only if
the humeral head fragment is impacted to the diaphysis.
• Finally, integral to obtaining the optimum outcome is completion of the full rehabilitation program. An important variation
of our current regimen over previous protocols is the early initiation of pendulum exercises on the second postoperative
day and their continuation for the first three to four weeks. A full range of motion is restored in this manner without exert-
ing stress on the fixation.

AUTHOR UPDATE:
No changes or modifications of the original technique have been made since its publication.

Panayiotis Dimakopoulos, MD Operative treatment. J Bone Joint Surg Am. 2002;11:389-400.

Andreas Panagopoulos, MD 1986;68:1410-4.
Georgios Kasimatis, MD 5. Panagopoulos AM, Dimakopoulos P,
Shoulder and Elbow Unit, Orthopaedic Department, 2. Park MC, Murthi AM, Roth NS, Blaine TA, Tyllianakis M, Karnabatidis D, Siablis D, Papa-
University Hospital of Patras, Papanikolaou Street, Levine WN, Bigliani LU. Two-part and three- dopoulos AX, Lambiris E, Kraniotis P, Sakella-
part fractures of the proximal humerus ropoulos G. Valgus impacted proximal
Rio-Patras 26504, Greece. E-mail address for P.
treated with suture fixation. J Orthop Trauma. humeral fractures and their blood supply after
Dimakopoulos: [Link]@[Link]. E-mail
2003;17:319-25. transosseous suturing. Int Orthop.
address for A. Panagopoulos: andpan21@[Link].
Email address for G. Kasimatis: [Link]@[Link] 3. Banco SP, Andrisani D, Ramsey M, Frie- 2004;28:333-7.
man B, Fenlin JM. Tension band fixation for
6. Dimakopoulos P, Panagopoulos A,
The line drawings in this article are the work of unstable two-part humeral fractures in
Kasimatis G, Syggelos SA, Lambiris E.
Joanne Haderer Müller of Haderer & Müller patients with osteopenic bone (parachute
Anterior traumatic shoulder dislocation
(biomedart@[Link]). technique). Tech Shoulder Elbow Surg.
associated with displaced greater tuberos-
2001;2:50-3.
ity fracture: the necessity of operative
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