title: Computed tomography-based prediction of the straight antegrade humeral nail's entry point and exposure of "critical types": truth or fiction?
abstract: BACKGROUND
  Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus.
  
  
  METHODS
  Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types.
  
  
  RESULTS
  Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found.
  
  
  CONCLUSIONS
  Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff.
authors.affiliation: Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria; The Steadman Clinic, Vail, CO, USA; Steadman Philippon Research Institute, Vail, CO, USA. Electronic address: simon.euler@tirol-kliniken.at.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Euler
authors.affiliation: Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Clemens
authors.initials: C
authors.lastname: Hengg
authors.affiliation: Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Matthias
authors.initials: M
authors.lastname: Boos
authors.affiliation: Steadman Philippon Research Institute, Vail, CO, USA.
authors.forename: Grant J
authors.initials: GJ
authors.lastname: Dornan
authors.affiliation: Steadman Philippon Research Institute, Vail, CO, USA.
authors.forename: Travis Lee
authors.initials: TL
authors.lastname: Turnbull
authors.affiliation: Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Markus
authors.initials: M
authors.lastname: Wambacher
authors.affiliation: Department of Trauma Surgery, Wilhelminenspital, Vienna, Austria.
authors.forename: Franz S
authors.initials: FS
authors.lastname: Kralinger
authors.affiliation: The Steadman Clinic, Vail, CO, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Millett
authors.affiliation: The Steadman Clinic, Vail, CO, USA; Steadman Philippon Research Institute, Vail, CO, USA; Department of Trauma Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Petri
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D005260:Female; D005594:Fracture Fixation, Intramedullary; D006801:Humans; D058430:Humeral Head / Q000000981:diagnostic imaging*; D008297:Male; D015203:Reproducibility of Results; D012784:Shoulder Fractures / Q000000981:diagnostic imaging* / Q000601:surgery*; D014057:Tomography, X-Ray Computed
keywords: Proximal humerus fracture; entry point; fifth anchoring point; osteoporotic fracture; proximal anchoring point; straight antegrade humeral nailing