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

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.