Proximal humeral fractures: Regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws

Tingart, Markus; Lehtinen, Janne; Zurakowski, David; Warner, Jon J.P.; Apreleva, Maria

doi:10.1016/j.jse.2005.09.007

Cited by 124 publications

(80 citation statements)

References 10 publications

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“…Whereas the latter has been proven to correlate well to DXA measurements of other anatomic sites (distal radius, proximal femur) [16], our study is the first, to our knowledge, to compare the Tingart measurement with local BMD measured by pQCT of the proximal humerus. A possible explanation why the Tingart measurement was at a disadvantage to the deltoid tuberosity index in this respect could be that Tingart defined different regions of interest in the proximal humerus and found the best correlation to BMD of the greater tuberosity [25,26]. We were not able to account specifically for this region of interest with the pQCT protocol used in our study [14].…”

Section: Discussionmentioning

confidence: 87%

“…There is evidence, however, that the BMD of the upper limb (distal radius) is less than that of typically measured sites (such as the proximal femur and lumbar spine) in patients with proximal humerus fractures [27]. Thus, preoperative assessment of BMD of the proximal humerus has become the focus of some studies, with methods ranging from measuring the cortical thickness on AP radiographs, to calculating BMD on peripheral quantitative CT (pQCT) scans [6,8,9,14,16,21,25,26]. Barnett and Nordin [3] were the first to invent a cortical index to assess local bone quality of the hand and femur.…”

Section: Introductionmentioning

confidence: 99%

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Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures

Spross

Kaestle

Benninger

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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Background Osteoporosis may complicate surgical fixation and healing of proximal humerus fractures and should be assessed preoperatively. Peripheral quantitative CT (pQCT) and the Tingart measurement are helpful methods, but both have limitations in clinical use because of limited availability (pQCT) or fracture lines crossing the area of interest (Tingart measurement). The aim of our study was to introduce and validate a simple cortical index to assess the quality of bone in proximal humerus fractures using AP radiographs. Questions/purposes We asked: (1) How do the deltoid tuberosity index and Tingart measurement correlate with each other, with patient age, and local bone mineral density (BMD) of the humeral head, measured by pQCT? (2) Which threshold values for the deltoid tuberosity index and Tingart measurement optimally discriminate poor local bone quality of the proximal humerus? (3) Are the deltoid tuberosity index and Tingart measurement clinically applicable and reproducible in patients with proximal humerus fractures? Methods The deltoid tuberosity index was measured immediately above the upper end of the deltoid tuberosity. At this position, where the outer cortical borders become parallel, the deltoid tuberosity index equals the ratio between the outer cortical and inner endosteal diameter. In the first part of our study, we retrospectively measured the deltoid tuberosity index on 31 patients (16 women, 15 men; mean age, 65 years; range, 22-83 years) who were scheduled for elective surgery other than fracture repair. Inclusion criteria were available native pQCT scans, AP shoulder radiographs taken in internal rotation, and no previous shoulder surgery. The deltoid tuberosity index and the Tingart measurement were measured on the preoperative internal rotation AP radiograph. The second part of our study was performed by reviewing 40 radiographs of patients with proximal humerus fractures (31 women, nine men; median age, 65 years; range, 22-88 years). Interrater (two surgeons) and intrarater (two readings) reliabilities, applicability, and diagnostic accuracy were assessed. Results The correlations between radiograph measurements and local BMD (pQCT) were strong for the deltoid tuberosity index (r = 0.80; 95% CI, 0.63-0.90; p \ 0.001) and moderate for the Tingart measurement (r = 0.67; 95% CI, 0.42-0.83; p \ 0.001). There was moderate correlation between patient age and the deltoid tuberosity index (r = 0.65; p \ 0.001), patient age and the Tingart measurement (r = 0.69; p \ 0.001), and patient age and pQCT (r = 0.73; p \ 0.001). The correlation between the deltoid tuberosity index and the Tingart measurement was strong (r = 0.84; p \ 0.001). We determined the cutoff value for Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Inte...

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Section: Discussionmentioning

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures

Spross

Kaestle

Benninger

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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“…They found that failure occurred more frequently, even with low stress, when the screws were directed toward the supero-anterior quadrant of the humeral head, since the stability of the fixation largely depends on the quality of the trabecular epiphyseal bone. Tingart et al (21) studied bone density distribution of humerus head and demonstrated that the central area has the greatest density, followed by infero-anterior, supero-posterior, infero-posterior and supero-anterior areas. For this reason, the mobilization force also varies in proportion to density.…”

Section: Discussionmentioning

confidence: 99%

Humerus axial projection. New intraoperative radiological projection proposal for proximal humeral fractures treatment by intramedullary nailing

Panella¹

2014

PER

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Background: guaranteeing humeral proximal fracture stabilization by intramedullary nailing is essential to correctly position the nail in the humeral head, being careful that proximal screws reach pluriaxially epiphysis cortices without protruding into the joint. Objectives: conventional intraoperative fluoroscopic radiography is used to verify positioning of these parts from the antero-posterior and transthoracic views. We suggest to integrate projections with an axial view, modified with regard to those proposed by Bool-Obata or Velpeau. Methods: we performed a clinical observational study in which we tested the effectiveness of this new projection. The primary endpoint was to assess the feasibility of performing this new projection. We also monitored the need for additional time. The secondary endpoint was to assess the reliability of this new projection, monitoring in how many patients the screws were in joint and were not visible to the two standard projections. Results: twenty patients undergoing intramedullary nailing surgery for proximal humeral fractures were monitored. This new projection did not cause any invasion of the working field of the other operators. Its execution required on average additional 30 seconds. It showed that a screw was in a joint in 6 patients, which was not visible with AP and TT projections (p=0.005). Discussion: we verified that it was possible to check the correct positioning of the head screws while safeguarding higher bone density areas. After an adequate learning curve, this projection could actually integrate the previous projections, since it is necessary to study the relations of the screws with the cortex and any protrusions into the joint.

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“…Es ist aber allgemein bekannt, dass deutliche lokale Unterschiede der Knochenqualität im proximalen Humerus existieren [14,15] [16].…”

Section: Biomechanikunclassified

Augmentationstechnik am proximalen Humerus

2015

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The augmentation of the screws in locked plating in a proximal humerus fracture model is effective in improving the primary stability in a cyclic varus bending test. The targeted augmentation of two particular screws in a region of low bone quality within the humeral head was almost as effective as four screws with twice the amount of bone cement. Screw augmentation combined with a knowledge of the local bone quality could be more effective in enhancing the primary stability of a proximal humerus locking plate because the effect of augmentation can be exploited more effectively limiting it to the degree required. The technique of augmentation is simple and can be applied in open and minimally invasive procedures. When the correct procedure is used, complications (cement leakage into the joint) can be avoided.

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Proximal humeral fractures: Regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws

Cited by 124 publications

References 10 publications

Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures

Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures

Humerus axial projection. New intraoperative radiological projection proposal for proximal humeral fractures treatment by intramedullary nailing

Augmentationstechnik am proximalen Humerus

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