Predictive Value of DeltoidTuberosity Index in PlateOsteosynthesis of ProximalFractures: Is it Better than Age?
DOI:
https://doi.org/10.82189/spot.80Keywords:
Bone Density, Bone Plates, Fracture Fixation, Internal, Fracture Healing, Humeral FracturesAbstract
Introduction: Proximal humerus fractures (PHF) are considered fragility fractures, with increasing incidence in the elderly. Several risk factors negatively influence osteosynthesis outcomes, including age, bone density and medial hinge comminution. Age ≥65 is often considered a decision threshold in treatment algorithms. The deltoid tuberosity index (DTI) is a simple, reproducible method to evaluate local bone density. This study aimed to assess whether DTI is a better predictor than age for complications and re-interventions in PHF treated with locking plates.
Methods: This retrospective study included 40 patients with PHF treated with open reduction and internal fixation with locking plates between 2021 and 2024. DTI was measured on pre-operative AP Grasey views by two independent shoulder specialists. Calcar screw-calcar distance and calcar reduction were also evaluated. Early complications (<12 weeks), late complications (>12 weeks), and the type of re-intervention were recorded.
Results: Early complications occurred in 15% (n = 6), late complications in 27.5% (n = 11), and re-intervention was required in 25% (n = 10). DTI had good accuracy for predicting complications (AUC = 0.809), with an optimal cut-off of ≤1.64 (100% sensitivity, 92% specificity; Youden Index = 0.92). DTI was significantly lower in patients with late complications (1.34 vs 1.46; p = 0.001) and re-intervention (1.31 vs 1.45; p = 0.002), but not with early complications (p = 0.309). Age was not associated with early (p = 0.668), late complications (p = 0.148), or re-intervention (p = 0.889). There was no correlation between age and DTI (r = 0.232; p = 0.150). Calcar screw-calcar distance was significantly higher in early complications (11.23 vs 7.84 mm; p = 0.018) and re-intervention (10.77 vs 7.92 mm; p = 0.036). Calcar deviation had no significant associations.
Conclusion: DTI is a valuable tool in the management of PHF, predicting complications and re-intervention more reliably than patient age.
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References
Handa A, Uchiyama Y, Shinpuku E, Watanabe M. Comparison of three plain radiography methods for evaluating proximal humerus bone strength in women. J Orthop Sci. 2019;24:243-9. doi:10.1016/j.jos.2018.09.020
Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: A systematic review. J Shoulder Elbow Surg. 2009;18:837-44. doi:10.1016/j.jse.2009.06.004
Lee JS, Kim JH, Kim KG, Yoon YC. Effect of calcar screw in locking compression plate system for osteoporotic proximal humerus fracture: a finite element analysis study. Biomed Res Int. 2022;2022:1268774. doi:10.1155/2022/1268774
Kralinger F, Blauth M, Goldhahn J, Ka ch K, Voigt C, Platz A, et al. The Influence of Local Bone Density on the Outcome of One Hundred and Fifty Proximal Humeral Fractures Treated with a Locking Plate. J Bone Joint Surg Am. 2014;96:1026-32. doi:10.2106/JBJS.M.00028.
Le TG, Bui KH, Do HP, Phan NT, Hoang CM, Pham TT, et al. Factors influencing surgical outcomes of fixation with locking plate for three- and four- part proximal humerus fractures in patients aged 50 Years and older. J Hand Microsurg. 2024;16:100127. doi:10.1016/j.jhsm.2024.100127.
Krapinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011;42:1283-8. doi:10.1016/j.injury.2011.01.017
Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open Reduction and Internal Fixation of Proximal Humerus Fractures Using a Proximal Humeral Locked Plate: A Prospective Multicenter Analysis. J Orthop Trauma. 2009;23:163-72. doi:10.1097/BOT.0b013e3181920e5b.
Willauschus M, Schram L, Millrose M, Ruther J, Loose K, Bail HJ, et al. Specific Radiologic Risk Factors for Implant Failure and Osteonecrosis of the Humeral Head after Interlocking Nailing with the Targon PH+ of Proximal Humeral Fractures in a Middle to Old Population. J Clin Med. 2022;11:2523. doi:10.3390/jcm11092523
Klug A, Harth J, Hoffmann R, Gramlich Y. Surgical treatment of complex proximal humeral fractures in elderly patients: a matched-pair analysis of angular-stable plating vs. reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2020;29:1796-803. doi:10.1016/j.jse.2020.01.073
Mazzucchelli RA, Jenny K, Zdravkovic V, Erhardt JB, Jost B, Spross C. The influence of local bone quality on fracture pattern in proximal humerus fractures. Injury. 2018;49:359-63. doi:10.1016/j.injury.2017.12.020.
Luciani P, Procaccini R, Rotini M, Pettinari F, Gigante A. Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient. Musculoskeletal Surg. 2022;106:43-8. doi: 10.1007/s12306-020-00669-5.
Padegimas EM, Chang G, Namjuyan K, Namdari S. Failure to restore the calcar and locking screw cross-threading predicts varus collapse in proximal humerus fracture fixation. J Shoulder Elbow Surg. 2020;29:291-5. doi: 10.1016/j.jse.2019.06.014.
Frank FA, Niehaus R, Borbas P, Eid K. Risk factors for secondary displacement in conservatively treated proximal humeral fractures. Bone Joint J. 2020;102:881-9. doi:10.1302/0301-620X.102B7.
Wang Q, Sheng N, Rui B, Chen Y. The neck-shaft angle is the key factor for the positioning of calcar screw when treating proximal humeral fractures with a locking plate. Bone Joint J. 2020;102-B:1629-35. doi: 10.1302/0301-620X.102B12.BJJ-2020-0070-R1.
Schnetzke M, Bockmeyer J, Porschke F, Studier-Fischer S, Grutzner PA, Guehring T. Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures. J Bone Joint Surg Am. 2016;98:1777-85. doi: 10.2106/JBJS.16.00112.
Kim DM, Park D, Kim H, Lee ES, Shin MJ, Jeon IH, et al. Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density. Geriatr Orthop Surg Rehabil. 2020;11:2151459320938571. doi: 10.1177/2151459320938571.
Spross C, Zeledon R, Zdravkovic V, Jost B. How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2017;26:1566-72. doi: 10.1016/j.jse.2017.02.026.
Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, et al. Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures. Clin Orthop Relat Res. 2015;473:3038-45. doi: 10.1007/s11999-015-4322-x.
Xiang W, Acharyya S, Huang S, Beng Kee Kwek E, Yijia Tan B. Deltoid tuberosity index for proximal humerus fracture: reliability and a predictor of systemic osteoporosis in an Asian population. J Shoulder Elbow Surg. 2025;34:e133-e140. doi:10.1016/j.jse.2024.05.018.
Razaeian S, Al Marhi O, Wiese B, Zhang D, Bouklas P, Krettek C, et al. Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score. BMC Musculoskelet Disord. 2023;24:754. doi: 10.1186/s12891-023-06883-z.
Roddy E, Kandemir U. High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment? J Shoulder Elbow Surg. 2023;32:2097-104. doi:10.1016/j.jse.2023.04.002.
Ponce BA, Thompson KJ, Raghavan P, Eberhardt AW, Tate JP, Volgas DA et al. The Role of Medial Comminution and Calcar Restoration in Varus Collapse of Proximal Humeral Fractures Treated with Locking Plates. J Bone Joint Surg Am. 2013;95:e113. doi: 10.2106/JBJS.K.00202.
Kimmeyer M, Schmalzl J, Rentschler V, Schieffer C, Macken A, Gerhardt C, et al. Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fiber-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws. J Orthop Traumatol. 2023;24:54. doi: 10.1186/s10195-023-00733-3.
Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. The calcar screw in angular stable plate fixation of proximal humeral fractures-a case study. J Orthop Surg Res. 2011;6:50. doi: 10.1186/1749-799X-6-50.
Mehtaa S, China M, Sanvillea J, Namdari S, Hast MW. Calcar screw position in proximal humerus fracture fixation: Don't miss high! Injury. 2018;49:624-9. doi:10.1016/j.injury.2018.02.007.
Taskesen A, Gocer A, Uzel K, Yaradilms YU. Effect of Osteoporosis on Proximal Humerus Fractures. Geriatr Orthop Surg Rehabil. 2020;11:2151459320985399. doi:10.1177/2151459320985399.
Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011;4:408-13. doi: 10.1016/j.injury.2010.11.058.
Brorson S, Frich LH, Winther A, Hrobjartsson A. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop. 2011;82: 475-81. doi:10.3109/17453674.2011.5 88856
Fisher ND, Bi AS, Egel KA. Predicting proximal humerus fracture mechanical complications: are computed tomography hounsfield units the answer? J Am Acad Orthop Surg. 2025;33:150-5. doi: 10.5435/ JAAOS-D-24-00594.
Jain S, Arora S, Gupta S, Sharma S, Bansal N, Ranjan S. Assessment of bone quality using radiogrammetric parameters of proximal humerus in India: defining the osteoporotic fracture risk limit value and its reliability. Indian J Orthop. 2020;54:307-15. doi: 10.1007/ s43465-020-00224-1.
Koczy-Baron A, Koczy B, Mielnik M, Stoltny T, Baczyński K, Hawranek R, et al. Influence of radiographic bone quality on the type of proximal humerus fracture. Traumatol Rehabil © MEDSPORTPRESS. 2021;23:65-77. doi: 10.5604/01.3001.0014.8136
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