Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus
Background: Neurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail dep...
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| Format: | Article |
| Language: | English |
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Elsevier
2020-12-01
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| Series: | JSES International |
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S2666638320300864 |
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| author | Peter S. Johnston, MD Armodios M. Hatzidakis, MD Yahia M. Tagouri, MD Douglas Curran-Everett, PhD Benjamin W. Sears, MD |
| author_facet | Peter S. Johnston, MD Armodios M. Hatzidakis, MD Yahia M. Tagouri, MD Douglas Curran-Everett, PhD Benjamin W. Sears, MD |
| author_sort | Peter S. Johnston, MD |
| collection | DOAJ |
| description | Background: Neurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail depth, tuberosity screw position, and protecting the axillary nerve and rotator cuff insertion. Our hypothesis was that a more medialized starting point would protect soft tissue structures and improve locking screw positioning. Methods: Ten fresh-frozen cadavers underwent antegrade IMN with Grashey and modified lateral “precipice” view imaging. A guidewire was positioned medial to the coracoacromial ligament (CAL) in 5 cadavers and lateral to the CAL in 5. Distances from the nail entry point to anatomic landmarks were measured. Anatomic and histologic evaluations were performed, characterizing the nail perforation zone. Radiographs were compared between groups. Results: The medial CAL group had a greater distance of screw fixation to the axillary nerve, a shorter distance of greater tuberosity (GT) screw fixation at the rotator cuff insertion on the infraspinatus and teres minor tubercles, and greater screw spread with improved lesser tuberosity capture. Two laterally placed implants violated the rotator cuff tendon. Imaging demonstrated that the ideal starting pin position was medial to the articular margin at a distance equal to the width of the rotator cuff insertion footprint. Conclusions: Medial placement optimized fixation of the GT, avoided violation of the rotator cuff tendon and footprint, and was associated with an increased distance of proximal locking screw to the axillary nerve. |
| first_indexed | 2024-12-13T14:43:13Z |
| format | Article |
| id | doaj.art-a98d047638474f1797503182b405741f |
| institution | Directory Open Access Journal |
| issn | 2666-6383 |
| language | English |
| last_indexed | 2024-12-13T14:43:13Z |
| publishDate | 2020-12-01 |
| publisher | Elsevier |
| record_format | Article |
| series | JSES International |
| spelling | doaj.art-a98d047638474f1797503182b405741f2022-12-21T23:41:33ZengElsevierJSES International2666-63832020-12-0144745752Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerusPeter S. Johnston, MD0Armodios M. Hatzidakis, MD1Yahia M. Tagouri, MD2Douglas Curran-Everett, PhD3Benjamin W. Sears, MD4Centers for Advanced Orthopaedics, Leonardtown, MD, USA; Corresponding author: Peter S. Johnston, MD, 23000 Moakley Street, Suite 102, Leonardtown, MD 20650, USA.Western Orthopaedics, Denver, CO, USAMedstar St. Marys Hospital, Leonardtown, MD, USADivision of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO, USAWestern Orthopaedics, Denver, CO, USABackground: Neurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail depth, tuberosity screw position, and protecting the axillary nerve and rotator cuff insertion. Our hypothesis was that a more medialized starting point would protect soft tissue structures and improve locking screw positioning. Methods: Ten fresh-frozen cadavers underwent antegrade IMN with Grashey and modified lateral “precipice” view imaging. A guidewire was positioned medial to the coracoacromial ligament (CAL) in 5 cadavers and lateral to the CAL in 5. Distances from the nail entry point to anatomic landmarks were measured. Anatomic and histologic evaluations were performed, characterizing the nail perforation zone. Radiographs were compared between groups. Results: The medial CAL group had a greater distance of screw fixation to the axillary nerve, a shorter distance of greater tuberosity (GT) screw fixation at the rotator cuff insertion on the infraspinatus and teres minor tubercles, and greater screw spread with improved lesser tuberosity capture. Two laterally placed implants violated the rotator cuff tendon. Imaging demonstrated that the ideal starting pin position was medial to the articular margin at a distance equal to the width of the rotator cuff insertion footprint. Conclusions: Medial placement optimized fixation of the GT, avoided violation of the rotator cuff tendon and footprint, and was associated with an increased distance of proximal locking screw to the axillary nerve.http://www.sciencedirect.com/science/article/pii/S2666638320300864Proximal humerus fractureintramedullary nail fixationantegrade humeral nailtuberosity fixationstraight intramedullary nailfragility fracture |
| spellingShingle | Peter S. Johnston, MD Armodios M. Hatzidakis, MD Yahia M. Tagouri, MD Douglas Curran-Everett, PhD Benjamin W. Sears, MD Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus JSES International Proximal humerus fracture intramedullary nail fixation antegrade humeral nail tuberosity fixation straight intramedullary nail fragility fracture |
| title | Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| title_full | Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| title_fullStr | Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| title_full_unstemmed | Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| title_short | Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| title_sort | anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus |
| topic | Proximal humerus fracture intramedullary nail fixation antegrade humeral nail tuberosity fixation straight intramedullary nail fragility fracture |
| url | http://www.sciencedirect.com/science/article/pii/S2666638320300864 |
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