title: Review of fixation techniques for the four-part fractured proximal humerus in hemiarthroplasty.
abstract: BACKGROUND
  The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Secondary fragment dislocation may prevent bone integration; the primary stability by a fixation technique is therefore needed to accomplish tuberosity healing. Present technical comparison of surgical fixation techniques reveals the state-of-the-art approach and highlights promising techniques for enhanced stability.
  
  
  METHODS
  A classification of available fixation techniques for three- and four part fractures was done. The placement of sutures and cables was described on the basis of anatomical landmarks such as the rotator cuff tendon insertions, the bicipital groove and the surgical neck. Groups with similar properties were categorized.
  
  
  RESULTS
  Materials used for fragment fixation include heavy braided sutures and/or metallic cables, which are passed through drilling holes in the bone fragments. The classification resulted in four distinct groups: A: both tuberosities and shaft are fixed together by one suture, B: single tuberosities are independently connected to the shaft and among each other, C: metallic cables are used in addition to the sutures and D: the fragments are connected by short stitches, close to the fragment borderlines.
  
  
  CONCLUSIONS
  A plurality of techniques for the reconstruction of a fractured proximal humerus is found. The categorisation into similar strategies provides a broad overview of present techniques and supports a further development of optimized techniques. Prospective studies are necessary to correlate the technique with the clinical outcome.
authors.affiliation: Institute for Biomechanics, ETH Zurich, Wolfgang-Pauli Strasse 10, 8093 Zurich, Switzerland. baud@zhaw.ch
authors.forename: Daniel
authors.initials: D
authors.lastname: Baumgartner
authors.forename: Betsy M
authors.initials: BM
authors.lastname: Nolan
authors.forename: Robert
authors.initials: R
authors.lastname: Mathys
authors.forename: Silvio Rene
authors.initials: SR
authors.lastname: Lorenzetti
authors.forename: Edgar
authors.initials: E
authors.lastname: Stüssi
mesh_terms: D000368:Aged; D001178:Arthroplasty / Q000295:instrumentation / Q000379:methods*; D001864:Bone Wires; D005592:Fracture Fixation / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D019736:Prostheses and Implants; D011474:Prosthesis Design; D012784:Shoulder Fractures / Q000601:surgery*; D013537:Sutures