Simple radiographic assessment of bone quality is associated with loss of surgical fixation in patients with proximal humeral fractures

Newton, Ashley W.; Selvaratnam, Veenesh; Pydah, S K V; Nixon, Matthew

doi:10.1016/j.injury.2015.12.029

Cited by 16 publications

(10 citation statements)

References 12 publications

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“…We had hypothesised that the newly described medial cortical ratio would correlate more strongly than the previously studied parameters based on data and observations from the study of Newton et al 11 These investigators showed that loss of fixation (displacement, screw cut out, or change in neck-shaft angle > 4°), as determined on follow-up radiographs, occurred in 14 patients (21.9%). Additionally, they showed that the medial cortical ratio was significantly lower in patients with failed fixation (0.170 versus 0.202, p = 0.019), and the loss of fixation was three times more likely in patients with a medial cortical ratio < 0.16 (41% versus 14%, p = 0.015).…”

Section: Discussionmentioning

confidence: 97%

“…3) has been evaluated by Newton et al 11 who used pre-operative radiographs of fractured humeri of patients who then had surgery for these fractures. The medial cortical ratio is calculated as the thickness of the medial cortex divided by the outer cortical diameter at that same location.…”

Section: Methodsmentioning

confidence: 99%

“…The medial cortical ratio is calculated as the thickness of the medial cortex divided by the outer cortical diameter at that same location. We made this measurement at the D3 location, which corresponds to the lower portion of the region designated by the method of Tingart et al 19 in accordance with Newton et al 11 …”

Section: Methodsmentioning

confidence: 99%

“…2,11 For example, as mentioned above, the canal-to-calcar ratio, which incorporates measurements resembling the cortical index relative to two diaphyseal levels, is used to distinguish differences in bone quality and mass in the proximal femur, and we speculate that it could be used in an analogous way in the proximal humerus. The ‘medial cortical ratio’ (defined below) recently described by Newton et al 11 is another parameter that warrants consideration.…”

Section: Introductionmentioning

confidence: 97%

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Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio

Skedros¹,

Mears

Burkhead³

2017

Bone & Joint Research

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ObjectivesThis investigation sought to advance the work published in our prior biomechanical study (Journal of Orthopaedic Research, 2016). We specifically sought to determine whether there are additional easy-to-measure parameters on plain radiographs of the proximal humerus that correlate more strongly with ultimate fracture load, and whether a parameter resembling the Dorr strength/quality characterisation of proximal femurs can be applied to humeri.Materials and MethodsA total of 33 adult humeri were used from a previous study where we quantified bone mineral density of the proximal humerus using radiographs and dual-energy x-ray absorptiometry (DEXA), and regional mean cortical thickness and cortical index using radiographs. The bones were fractured in a simulated backwards fall with the humeral head loaded at 2 mm/second via a frustum angled at 30° from the long axis of the bone. Correlations were assessed with ultimate fracture load and these new parameters: cortical index expressed in areas (“areal cortical index”) of larger regions of the diaphysis; the canal-to-calcar ratio used analogous to its application in proximal femurs; and the recently described medial cortical ratio.ResultsThe three new parameters showed the following correlations with ultimate fracture load: areal cortical index (r = 0.56, p < 0.001); canal-to-calcar ratio (r = 0.38, p = 0.03); and medial cortical ratio (r = 0.49, p < 0.005). These correlations were weaker when compared with those that we previously reported: mean cortical thickness of the proximal diaphysis versus ultimate fracture load (r = 0.71; p < 0.001); and mean density in the central humeral head versus ultimate fracture load (r = 0.70; p < 0.001).ConclusionSimple-to-measure radiographic parameters of the proximal humerus reported previously are more useful in predicting ultimate fracture load than are areal cortical index, canal-to-calcar ratio, and medial cortical ratio.Cite this article: J. G. Skedros, C. S. Mears, W. Z. Burkhead. Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio. Bone Joint Res 2017;6:1–7. DOI: 10.1302/2046-3758.61.BJR-2016-0145.R1

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Section: Discussionmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 97%

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Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio

Skedros¹,

Mears

Burkhead³

2017

Bone & Joint Research

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“…2 Therefore, there have been studies that have measured preoperative shoulder bone mineral density (BMD), aside from the usual central BMD, for the evaluation of osteoporosis and assessment of its effect on postoperative outcomes. 4,5,12,15,20,31 There are few clinical studies in the literature that target patients who underwent arthroscopic rotator cuff repair with all-suture anchors, which have no area of rigidity.…”

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confidence: 99%

All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium Rotator Cuff Tears

Ro¹,

Rhee

Kim

et al. 2019

Am J Sports Med

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Background: All-suture anchors are increasingly being used in rotator cuff repair. However, there are debates on the micromotion of all-suture anchors. Purpose: To perform rotator cuff repair on patients with rotator cuff tears and different shoulder bone mineral densities (BMDs) and investigate (1) where the anchor is located under the cortex, (2) if there is any anchor migration settling during follow-up, and (3) if structural outcome differs according to shoulder BMD. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively investigated 88 patients who underwent arthroscopic single-row repair for small- to medium-sized rotator cuff tears (age [mean ± SD], 58.8 ± 7.1 years) from 712 cases of rotator cuff tendon repair between November 2015 and February 2018. Inclusion criteria were as follows: use of an all-suture anchor; preoperative shoulder BMD; and magnetic resonance imaging (MRI) conducted preoperatively, 2 days after surgery, and 10 months after surgery. Patients were excluded from the study if they underwent open rotator cuff repair (n = 118), got surgery with a double-row technique (n = 178), underwent surgery with anchors other than the all-suture type (n = 273), received anchor insertion in sites other than the greater tuberosity owing to concomitant procedures such as biceps tenodesis and subscapularis repair (n = 29), did not take preoperative shoulder BMD (n = 15), had more than a large-size tear (n = 6), and were lost to follow-up (n = 5). After compression of the all-suture anchor during surgery, the strands were pulled multiple times to ensure that the anchor was fixed onto the bone with appropriate tension. BMD was measured before surgery. Depth to anchor (DA), anchor settling, and repaired rotator cuff integrity were measured with MRI. Patients were categorized into 3 groups: group A (BMD, <0.4 g/cm2; n = 31), group B (BMD, 0.4-0.6 g/cm2; n = 32), and group C (BMD, >0.6 g/cm2; n = 25). A total of 65 patients had follow-up MRI. On the basis of rotator cuff tendon integrity, patients were categorized into either a sufficient thickness group (group S, Sugaya classification grade II or lower; n = 44) or an insufficient thickness group (group I, Sugaya classification grade III or higher; n = 21). Results: On time-zero MRI, the DA differed significantly among groups (group A, 3.62 ± 2.02 mm; group B, 5.18 ± 2.13 mm; group C, 6.30 ± 3.34 mm) ( P = .001). The DA was deeper in patients with a higher BMD at time zero ( r = 0.374; P = .001), but the DA did not differ at follow-up MRI (mean, 10.3 months after surgery). On follow-up MRI, anchor settling tended to increase with deeper time-zero DA ( r = 0.769; P < .001). Anchor settling was significantly different among groups (group A, 1.33 ± 1.08 mm; group B, 2.78 ± 1.99 mm; group C, 3.81 ± 2.19 mm) ( P = .001). The proportion of patients with sufficient thickness in each group did not show a statistical difference (group A, 70.8%; group B, 72.7%; group C, 57.9%) ( P = .550). Conclusion: In conclusion, this study confirmed that the postoperative site of anchor insertion in arthroscopic single-row rotator cuff repair with all-suture anchors was located farther from the cortex in patients with higher shoulder BMD and closer to the subcortical bone in patients with lower BMD. On follow-up MRI, no further settling occurred past a certain distance from the cortex, and there was no significant difference in anchor depth or integrity of the rotator cuff tendon based on shoulder BMD. Therefore, minimal settling in the all-suture anchor did not show clinical significance.

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Proximal Humeral Fractures

Spross

Jost

2019

Textbook of Shoulder Surgery

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Simple radiographic assessment of bone quality is associated with loss of surgical fixation in patients with proximal humeral fractures

Cited by 16 publications

References 12 publications

Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio

Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio

All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium Rotator Cuff Tears

Proximal Humeral Fractures

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