The “suture-only” fixation in the treatment of proximal humerus fractures: A narrative review

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Introduction : Surgical treatment of proximal humerus fractures (PHFs) is still associated with high complication and reoperation rates, most of them being implant related. In order to reduce such complications, a minimally-invasive technique was introduced by using only sutures for fixation of PHFs. Methods : For the arrangement of this narrative non-systematic review, an exploratory search in the MEDLINE (via PubMed) database using the keywords “proximal humeral fracture” and “sutures” was conducted. Results : The initial search in Pubmed yielded 254 studies, where only 8 were found to be possibly relevant. Following critical review, there were 6 studies that satisfied the inclusion criteria and were subject to further analysis. There were 325 patients with PHFs included in our study. The average age was 58 years (range 18–84 years). By fracture type there were 79 (24.3%) two-part greater tuberosity (GT) fractures with 36 (46%) of them associated with anterior dislocation, 9 (2.8%) two-part surgical neck (SN) fractures, 114 (35.1%) three-part fractures, and 124 (38.2%) four-part fractures, all of them being valgus impacted type. Conclusion : The “suture-only” technique obtains good clinical outcomes with lower complication and reoperation rates, but in selected types of unstable PHFs: two-part GT fractures with or without associated shoulder dislocation, and three- and four-part valgus-impacted fractures. While the indications for two-part SN fractures are contradictory, three- and four-part varus fractures, four-part fracture dislocations and split fractures are contraindicated for “suture-only” fixation. However, additional studies with a higher level of evidence are necessary to support the routine use of the “suture-only” technique in the treatment of these selected types of PHFs.