Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density

Semi-automatic proximal humeral trabecular bone density assessment tool: technique application and clinical validation

PURPOSE

This study aimed to apply a newly developed semi-automatic phantom-less QCT (PL-QCT) to measure proximal humerus trabecular bone density based on chest CT and verify its accuracy and precision.

METHODS

Subcutaneous fat of the shoulder joint and trapezius muscle were used as calibration references for PL-QCT BMD measurement. A self-developed algorithm based on a convolution map was utilized in PL-QCT for semi-automatic BMD measurements. CT values of ROIs used in PL-QCT measurements were directly used for phantom-based quantitative computed tomography (PB-QCT) BMD assessment. The study included 376 proximal humerus for comparison between PB-QCT and PL-QCT. Two sports medicine doctors measured the proximal humerus with PB-QCT and PL-QCT without knowing each other's results. Among them, 100 proximal humerus were included in the inter-operative and intra-operative BMD measurements for evaluating the repeatability and reproducibility of PL-QCT and PB-QCT.

RESULTS

A total of 188 patients with 376 shoulders were involved in this study. The consistency analysis indicated that the average bias between proximal humerus BMDs measured by PB-QCT and PL-QCT was 1.0 mg/cc (agreement range - 9.4 to 11.4; P > 0.05, no significant difference). Regression analysis between PB-QCT and PL-QCT indicated a good correlation (R-square is 0.9723). Short-term repeatability and reproducibility of proximal humerus BMDs measured by PB-QCT (CV: 5.10% and 3.41%) were slightly better than those of PL-QCT (CV: 6.17% and 5.64%).

CONCLUSIONS

We evaluated the bone quality of the proximal humeral using chest CT through the semi-automatic PL-QCT system for the first time. Comparison between it and PB-QCT indicated that it could be a reliable shoulder BMD assessment tool with acceptable accuracy and precision. This study developed and verify a semi-automatic PL-QCT for assessment of proximal humeral bone density based on CT to assist in the assessment of proximal humeral osteoporosis and development of individualized treatment plans for shoulders.

Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial

BACKGROUND

The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures.

METHODS

95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up.

RESULTS

The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences.

CONCLUSION

The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis.

TRIAL REGISTRATION

The study protocol was registered in the US National Institutes of Health's database ( http://www.

CLINICALTRIALS

gov ) registry under NCT05952622.

Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

METHODS

A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

RESULTS

A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

CONCLUSIONS

This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Quantification of bone quality and distribution of the proximal humerus with dual-energy computed tomography

Background

The proximal humerus is a common site of osteoporotic fractures, and bone quality is a predictor of surgical reduction quality. Dual-energy computed tomography (DECT) is assuming an increasingly important role in the quantification of bone mineral density (BMD) due it is ability to perform three-material decomposition. We aimed to analyze the bone quality and distribution of the proximal humerus with DECT quantitatively.

Methods

Sixty-five consecutive patients (average age 49.5±15.2 years; male: female ratio 32:33) without proximal humerus fractures who had undergone DECT were retrospectively selected. The humeral head was divided into 4 regions on a cross section in the medial plane between the greater tuberosity and the surgical neck. The quantitative parameters, including virtual noncalcium (VNCa) value, computed tomography value of calcium (CaCT), computed tomography value of mixed-energy images (regular CT value) (rCT), and relative calcium density (rCaD), were measured. The correlations between the quantitative parameters and age and body mass index (BMI) were analyzed, and the correlations of age, sex, BMI, region of the humeral head, and VNCa value on CaCT were evaluated.

Results

The differences in CaCT, rCT, and rCaD between the 4 regions of proximal humerus were statistically significant (P<0.001), while the difference in VNCa values was not (P=0.688). The calcium concentration (CaCT and rCaD) was the densest in the posteromedial zone. The differences of CaCT, rCT, and rCaD between males and females in the 4 regions of proximal humerus were statistically significant (P<0.05), while those of the posterolateral zone were not (rCT; P>0.05). The differences in VNCa values between males and females were also not significant (P>0.05). Multivariable linear regression analysis indicated that sex, age, BMI, regions, and VNCa were significant (P<0.05) predictors of the CaCT value.

Conclusions

The concentration of calcium was the densest in the posteromedial region of proximal humerus, and the VNCa value of DECT may be used for quantifying the BMD of the proximal humerus.

Hounsfield units predicts the occurrence but not the patterns of proximal humerus fracture in the elderly patients

BACKGROUND

Increased incidence of fragility fractures of the proximal humerus has been reported. Proximal humerus Hounsfield unit (HU) measurements based on computed tomography (CT) scans of the shoulder can be used to evaluate bone mineral density (BMD). It is unknown whether HU values can predict the risk of proximal humerus osteoporotic fracture and /or fracture patterns. Therefore, the objectives of this study were to identify whether the HU value is associated with proximal humeral osteoporotic fracture risk, and whether or not it has an impact on the complexity of the fracture.

METHODS

We identified 60 + years old patients' CT scans between 2019 and 2021 according to the inclusion and exclusion criteria. All patients were divided into two groups based on the presence or lack of a fracture in the proximal humerus, meanwhile, patients with fractures were stratified into simple and comminuted fractures based on the Neer classification. HU values were calculated within the proximal humerus and compared between groups using the Student t-test, and receiver operating characteristic (ROC) curve analysis was used to determine the ability of HU values to predict fracture.

RESULTS

A total of 138 patients with proximal humerus fracture (PHF) including 62 simple PHFs and 76 complex PHFs and 138 non-fracture patients were enrolled in the study. The HU values decreased as age increased among all patients. Both male and female patients with PHF had significantly lower HU values compared with non-fracture patients, the area under the curve (AUC) of the ROC curve for males and females was 0.8 and 0.723 respectively. Nevertheless, no significant differences were found between simple and complex fractures of the proximal humerus in the HU values.

CONCLUSION

Decreasing HU values on CT may be an early warning sign of fracture potential, however, it was not a predictive factor for comminuted fracture of the proximal humerus.

Simple preoperative radiographic and computed tomography measurements predict adequate bone quality for stemless total shoulder arthroplasty

INTRODUCTION

Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA.

METHODS

This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA.

RESULTS

A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%.

CONCLUSIONS

Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data.