经皮顺行克氏针固定治疗肱骨近端骨折

目的：对应用经皮顺行克氏针固定治疗肱骨近端骨折的适应证、手术方法和疗效进行总结分析。方法：应用经皮顺行穿针固定治疗肱骨近端闭合骨折32例，男7例，女25例；年龄28-75岁，平均49．25岁。Neer外科颈2部分骨折20例，3部分骨折9例，4部分骨折3例。结果：32例均获随访，随访时间8-34个月，平均13．5个月。按Con—stant-Murley功能评分标准：优21例，良9例，可2例。结论：经皮顺行穿针固定治疗肱骨近端骨折，结合有计划的康复治疗，操作简单、疗效可靠。不但可用于治疗外科颈2部分骨折，而且还可选择性地应用于3、4部分骨折的治疗。     

经皮穿针固定治疗肱骨近端骨折

目的　对应用经皮穿针固定治疗肱骨近端骨折的疗效、适应证和手术方法进行总结分析。方法　随访 4 9例应用经皮穿针固定治疗的肱骨近端新鲜闭合骨折患者 ,平均随访时间 16 9个月。患者平均年龄 4 0 4岁。 2部分外科颈骨折 39例 ,2部分大结节骨折 6例 ,外展嵌插 4部分骨折 4例。最终随访时进行ASES评分、Constant Murley评分、UCLA评分以及SST(SimpleShoulderTest)问卷评估。结果　 4 9例患者ASES评分平均为 91 4 ,VAS疼痛评分平均为 1 7,肩关节活动度平均为前屈上举 14 6 7°,外旋 39 6°,内旋T8～T9水平 ;Constant Murley评分平均为 88 2 ;UCLA评分平均为 31 2 ;SST问卷中回答“是”的问题平均为 10 1个。 4 9例患者骨折均愈合 ,平均愈合时间为 8 8周。患者对于疼痛的满意度为 95 9% (4 7/ 4 9) ,对于功能恢复的满意度为 91 8% (4 5 / 4 9)。最终随访时均未出现肱骨头坏死的征象。结论　应用经皮穿针固定治疗大多数 2部分外科颈骨折、外展嵌插型的 2部分大结节骨折以及外展嵌插 4部分骨折可得到良好的治疗效果 ;结合及时、充分的术后康复 ,经皮穿针固定是治疗特定类型肱骨近端骨折的一种有效的方法     

Proximal humerus fractures in the elderly are we operating on too many?

Proximal humerus fractures in the elderly are a relatively rare injury, the treatment of which remains controversial, especially regarding Neer displaced two-part, and three-part and four-part fractures. Operative indications for most displaced proximal humerus fractures in the elderly remain poorly defined, but recent literature is actually supporting less aggressive approaches except for the most severe fractures. Recent epidemiological and larger scale retrospective studies fail to show a significant functional difference between operative and non-operative treatment of displaced two-part and three-part fractures in the elderly. Most four-part fractures appear to be best treated with hemiarthroplasty. Recent meta-analyses show a need for well-executed, randomized, prospective studies that can be used to provide evidence-based templates for appropriate management of displaced proximal humerus fractures in the elderly.     

Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results

We evaluated 74 patients with displaced proximal humeral fractures (mean age, 70.9 years) treated with closed reduction and percutaneous pinning. Fractures were classified radiographically following Neer's system, and the quality of reduction was assessed according to Kristiansen and Kofoed. Patients were also evaluated clinically with the Constant scale. Overall, the reduction was good in 72% of fractures, but the probability of obtaining a satisfactory reduction of displaced tuberosities was significantly lower in comparison to the humeral head. Four-part fractures obtained the worst radiographic results. The mean Constant scores were 65.8 +/- 18 points for the injured shoulder and 79.5 +/- 9.1 points for the opposite shoulder. Clinical results correlated with the quality of reduction. Closed reduction and percutaneous pinning should be reserved for 2-part fractures, but the technique can also be used in 3-part fractures in elderly patients, in whom an incomplete reduction can yield satisfactory clinical results.     

Percutaneous pinning for proximal humerus fractures

Proximal humerus fractures are relatively frequent. The are several possibilities for fixation of proximal humerus fractures: close reduction and fixation with percutaneous pinning or intramedullary rod, open reduction and fixation with tension band or a plate. Close reduction and percutaneous pinning have the advantage to be an easy technique, with good results and it is considered to be ideal in young patients with two-part fractures. The number and the directions of the pins depend upon the number of fragments displaced, reducibility, bone quality, patient age, other pathology associated. Some authors consider being enough the placement of 2 or 3 ascending pins, while others recommend at least 4 pins, ascending and descending. Usually we prefer the techniques in witch are used 3 ascending pins. The operative technique is presented. The most common intra-operative complication in percutaneous pinning is the possibility of damaging the adjacent neuro-vascular structures or tendons. Post-operative complications which may occur are: loosing reduction, pins migrations, aseptic necrosis of humeral head, pins infection. In conclusion percutaneous pinning for proximal humerus fractures it is an easy technique with good results. In this manner are avoided large incisions to the shoulder with can lead to aseptic necrosis of the humeral head. This technique can be used in young patients, with good bone quality, but also in elderly patients, with osteoporosis and other pathology associated. In some three or four-part fractures some reduction problems can occur, but this are rare in two-part fractures.     

Proximal fractures of the humerus in patients older than 75?years of age: should we consider operative treatment?

Background

Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.

Materials and methods

In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.

Results

Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).

Conclusion

This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.

Level of evidence

According to OCEBM Working Group, Level IV.     

Intramedullary nailing of displaced four-part fractures of the proximal humerus

BackgroundIntramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail.Designprospective monocentric cohort study.Settingsingle level 1 traumacenter.Materials and MethodsFrom February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study.ResultsAfter mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity.ConclusionsIntramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result.Level of evidenceLevel 2b – monocentric prospective cohort study.     

Rigid internal fixation of fractures of the proximal humerus in older patients

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus.     

Internal fixation of proximal humerus fractures using the T2-proximal humeral nail

Introduction

Surgical management of proximal humerus fractures remains controversial and there is an increasing interest in intramedullary nailing. Created to improve previous designs, the T2-proximal humeral nail (PHN) (Stryker^®) has been recently released, and the English literature lacks a series evaluating its results. We present a clinical prospective study evaluating this implant for proximal humeral fractures.

Method

We evaluated the functional and radiological results and possible complications. Twenty-nine patients with displaced fractures of the proximal humerus were treated with this nail. One patient was lost right after surgery and excluded from the assessment. Eighteen patients were older than 70 years.

Results

There were 21 fractures of the proximal part of the humerus and 7 fractures that also involved the shaft; 15 of the fractures were two-part fractures (surgical neck), 5 were three-part fractures, and 1 was a four-part fracture. All fractures healed in a mean period of 2.7 months. There was one delayed union that healed in 4 months. One case of avascular necrosis of the humeral head was observed (a four-part fracture), but remained asymptomatic and did not require further treatment. In one case a back-out of one proximal screw was observed. A final evaluation with a minimum 1 year follow-up was performed by an independent observer; in 18 patients, the mean Constant score was 65.7 or 76.1% with the adjustment of age and gender; in 19 patients, the mean Oxford Shoulder Score was 21.7. The results obtained with the T2-PHN nail indicate that it represents a safe and reliable method in the treatment of two- and three-part fractures of the proximal humerus. The proximal fixation mechanism diminishes the rate of back-out of the screws, a frequent complication described in the literature. Better functional results were obtained from the patients younger than 70 years, but these were not statistically significant.

     

肱骨近端解剖锁定钢板与解剖钢板治疗肱骨Neer三、四部分骨折的疗效比较

【摘要】 目的〓探讨肱骨近端解剖钢板与肱骨近端解剖锁定钢板治疗老年肱骨近端Neer三、四部分骨折的功能及疗效差异。方法〓收集有完整随访资料的151例老年Neer三、四部分骨折患者,按手术方式分为肱骨近端解剖钢板组(A组,65例)和肱骨近端解剖锁定钢板组(B组,86例),在随访过程采用Constant评分及Neer评分评价并比较两组疗效。结果〓B组平均愈合时间显著短于A组(P<0.05)。两组的术后1年和术后2年功能比较:B组Neer评分的疼痛、功能、活动度及总分均显著优于A组(P<0.05);B组Constant评分的疼痛、日常生活活动、主动活动及总分显著优于A组(P<0.05)。结论〓肱骨近端解剖钢板与肱骨近端解剖锁定钢板均可用于老年Neer三、四部分骨折,但解剖锁定钢板愈合更快,功能恢复更好,临床推荐优先使用。     

Treatment of complex proximal humeral fractures with minimally invasive fixation of the humeral head combined with flexible intramedullary wire fixation – introduction of a new treatment concept

The treatment of three- or 4-part proximal humerus fractures is still a matter of scientific discussion. The following study presents the results of a combined procedure using limited invasive fixation techniques for reconstruction of the humerus head and retrograde intramedullary wiring with elastic nails for the treatment of displaced three- or 4-part fractures. A prospective study of 24 patients with 3-part and 4-part fractures was performed from September 1995 to December 1998. Combined biologic fixation for reconstruction of the humerus head, including intramedullary wiring, was utilized. Fracture reduction was performed in an open soft-tissue-preserving technique through a limited lateral approach. Fixation of the head fragments was performed using screw and/or cerclage wire fixation. The reconstructed humerus head was stabilized to the shaft with intramedullary wires, with retrograde insertion 2 cm above the olecranon fossa. Supportive fixation of the head fragments was achieved using fully threaded cancellous screws. At the 1-year postoperative follow-up, 40% of the 18 patients had excellent results using the Neer and Constant score. Forty-five percent had satisfactory and 15% unsatisfactory results. The initial results of this study reveal that a combination of limited internal fixation of the humerus head and retrograde elastic intramedullary wiring provide stable fixation with limited soft-tissue destruction. This approach has been shown to be especially useful for the combined treatment of three- or four-part fractures of the humeral head.     

Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review

Background

While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.

Materials and methods

Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.

Results

Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.

Conclusions

Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.

Level of evidence

Level IV, Systematic review.

     

Percutaneous fixation with Schanz screws for displaced two- and three- part fractures of the proximal humerus in patients above fifty years of age

Purpose:

The aim of this study is to evaluate whether two 3.0 mm Schanz screws in two-part proximal humeral fractures (plus one additional Schanz screw or K wire in three-part fractures) can provide enough stability to allow early mobilization until healing occurs in elderly patients.

Settings and Design:

This prospective study was performed in the Orthopaedic Department of our University Hospital.

Patients and Methods:

We performed closed reduction and percutaneous pinning for thirty-three patients with proximal humerus fractures. Twenty-seven patients were available for the final follow-up. Of those 27 patients, 17 had two-part surgical neck fractures; while 10 had three-part fractures. For fixation, we used two 3.0 mm Schanz screws in patients with two-part fractures plus one additional Schanz screw or K wire in the 10 patients with three-part fractures.

Results:

The mean Constant score modified according to the age and sex was 89.8% (range: 77.3-97.2%). Fifteen patients had excellent results, 11 patients had good results, and one patient had a fair result.

Conclusion:

Closed reduction and percutaneous pinning with two Schanz screws for two-part surgical neck humeral fractures, plus an additional Schanz screw or K wire for three-part proximal humeral fractures is a useful and effective technique that provides enough stability to allow an early rehabilitation program till union occurs in elderly patients.

Level of Evidence:

IV; therapeutic study, case series.     

New intramedullary nail for the surgical neck fracture of the proximal humerus in elderly patients

Background Fractures of the proximal humerus are common and the repair of displaced fractures generally requires an operative approach. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. We have developed a new intramedullary nail (pin lock nail) for the repair of surgical neck fractures of the proximal humerus in patients with osteoporotic bones. A retrospective review is presented of the cases of 19 elderly patients with two-part or three-part fractures of the proximal humerus treated using the pin lock nail. Methods We treated 19 elderly patients with a mean age of 70.5 years. There were 13 two-part surgical neck fractures, 3 two-part surgical neck fractures with non-displaced greater tuberosity fracture, and 3 three-part surgical neck fractures with greater tuberosity fracture. All fractures were treated using the pin lock nail. Clinical results were evaluated using the Japanese Orthopaedic Association score at the last follow-up examination. On radiographic evaluation, duration to bone union of the fracture, backing out of the pin and screw, penetration of the proximal pin, and varus angulations of the humeral neck were examined. Results Mean duration of follow-up was 14 months (range 6–54 months). All fractures had united at an average of 3.3 months after surgery. No backing out of the pin and screw or penetration of the proximal locking pin was seen at the time of last follow-up. Thirteen of the 16 patients had no or minimal varus angulations of the humeral neck (≤10°). The mean overall JOA score was 84.3 points (range 65.5–100). Conclusions Our data show that using the pin lock nail for the treatment of two-part and three-part humeral fractures is a reliable procedure, providing good results with careful postoperative management.     

Outcomes after percutaneous reduction and fixation of proximal humeral fractures

The purpose of this study is to report the outcomes after closed or percutaneous reduction with percutaneous fixation of displaced proximal humeral fractures. This study included 35 patients from 3 institutions. Of these, 27 were followed up for a minimum of 1 year after surgery. The mean age at injury was 61 years. There were seven 2-part, eight 3-part, and twelve valgus-impacted 4-part proximal humeral fractures. All fractures were reduced and stabilized with percutaneous techniques only. The mean duration of follow-up was 35 months. All fractures healed after the index procedure. The mean pain score on a visual analog scale was 1.4. The mean American Shoulder and Elbow Surgeons and Constant scores were 83.4 and 73.9, respectively. Four patients healed with malunion, and in four, glenohumeral joint osteoarthritis developed. Fracture type, age, malunion, or osteoarthritis had no significance influence on measured outcomes. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications.     

Treatment of acute proximal humerus fractures with an Evans staple

The purpose of this study was to report on radiographic, objective, and functional outcomes in patients with 2- and 3-part proximal humerus fractures treated with an Evans staple. Six patients (three males and three females) who had had acute, displaced proximal humerus fractures requiring operative treatment were identified and their medical records reviewed. There were four 2-part and two 3-part fractures as described by Neer. Mean age was 68.5 (range, 57 to 73) years; mean followup was 71.1 (range, 30 to 98) months. The senior author (T.W.W.) was the treating physician who determined the treatment method. All patients were treated within 2 weeks of injury using an Evans staple (Smith & Nephew, Memphis, TN), with or without tension band. Clinical outcome measurements were fracture healing, range of motion, complications, Shoulder Pain and Disability Index (SPADI) score, and radiologic outcome. All six fractures reached clinical and radiographic union at a mean of 4.2 months without postoperative complications. Two patients required subsequent hardware removal. Mean SPADI score at last followup was 36.8 (good). Average radiologic neck/shaft angle was 110 (range, 92 to 136) degrees. The Evans staple is a valuable implant for treatment of 2- and 3-part proximal humerus fractures requiring a relatively simple surgical implantation and minimal soft tissue dissection.     

The use of intramedullary helix wire for the treatment of proximal humerus fractures

OBJECTIVE: To present the functional and radiographic outcome 1 and 6 years after application of a new intramedullary fixation device for proximal humerus fractures. DESIGN: Retrospective case series. SETTING: Level II orthopaedic surgery hospital. PATIENTS: Twenty-six consecutive patients (average age 68.9 years) with 2-, 3- and 4-part fractures of the proximal humerus were operated at a single institution. Follow-up was performed after 1 year (26 patients) and 6 years (16 patients). INTERVENTION: All patients were treated with closed reduction and intramedullary helix wires. MAIN OUTCOME MEASUREMENTS: The Constant-Murley score and the University of California Los Angeles (UCLA) score. Clinical complications and radiological posttraumatic arthritis were recorded. RESULTS: The average Constant-Murley score was 70.3 (points) and 70.7 after 1 and 6 years, respectively; the average UCLA score was 27.2 and 31.5 after 1 and 6 years, respectively. Major complications were 4 revisions for 3 secondary fragment displacements and 1 nonunion with partial avascular osteonecrosis in the first postoperative year. Complications were found predominantly in 4-part fractures (3/5, 60%). There were no further complications or progressive posttraumatic arthritis up to 6 years following surgery. CONCLUSION: The helix wire is well suited for displaced or unstable 2- and 3-part proximal humerus fractures. Adequate functional outcome, a low number of implant displacements, a low number of application morbidity, and infrequent implant removals were recorded. The use of this device is not recommended for 4-part fractures.     

锁定钢板治疗Neer 3、4部分肱骨近端骨折的病例对照研究

目的：比较运用锁定钢板治疗Neer 3、4部分肱骨近端骨折的疗效。方法：自2009年1月至2011年6月,采用锁定钢板治疗64例Neer 3、4部分肱骨近端骨折。3部分骨折组39例,男16例,女23例;平均年龄（55.12±12.52）岁。4部分骨折组25例,男9例,女16例;平均年龄（57.92±13.14）岁。随访根据美国肩肘外科医师评分（American Shoulder and Elbow Surgeons score,ASES）评估患者肩关节功能,采用视觉模拟评分法（visual analogue scale,VAS）进行疼痛评分,并评价相关并发症。结果：术后患者切口均I期愈合。64例均获随访,时间12～30个月,平均16.5个月。末次随访时,ASES评分3部分骨折（76.14±14.10）分,4部分骨折（65.93±11.82）分;VAS评分分别为2.12±1.63和3.90±2.21,以上指标两组比较差异均有统计学意义（P〈0.05）.并发症发生率分别为20.51%和36.00%,差异无统计学意义。结论：锁定钢板治疗肱骨近端3部分骨折的疗效优于4部分骨折,术中需争取解剖复位、稳定固定、选择合适长度的螺钉及钢板位置,术后合理功能锻炼以获得良好的疗效。     

Kapandji pinning and tuberosities fixation of three- and four-part fractures of the proximal humerus

Purpose

The Kapandji pinning was initially described for the treatment of surgical neck fractures of the humerus in young patients. The aim of our study was to evaluate functional and radiological outcomes of the Kapandji modified technique in displaced complex three- and four-part fractures.

Methods

From 2005 to 2009, 32 patients (23 three-part and nine four-part fractures) were included retrospectively. The mean age was 63 years old (range, 22–86), and the dominant shoulder was involved in 40 % of the cases.

Results

At a mean follow up of 25 months (12–72), the mean absolute Constant score achieved 68 points (35–98) and adjusted score 80 % (47–100). Patients had an average forward elevation of the shoulder of 132° (80°–180°), an average external rotation of 36° (0°–90°), and an average internal rotation to the level of L1 (sacrum to the level of T6). The older the patients were the worst was the active anterior elevation recovery (r = −0.3; p = 0.01). Reduction and fixation of initial varus-displaced fractures was not as reliable as in valgus. In eight cases (25 %), K-wire migrations were observed and were correlated with age over 70 years old (p = 0.001). Two partial osteolysis of the greater tuberosity and two avascular necrosis of the humeral head (one was associated with a non-union) were identified. Moreover, three patients developed adhesive capsulitis.

Conclusion

The Kapandji technique with fixation of tuberosities provides satisfactory results for the treatment of complex proximal fractures of the humerus. However, we do not recommend this technique for patients older than 70 years and in cases of varus displaced fractures.     

Transosseous suture fixation of proximal humeral fractures

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 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 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 expensive implants.