DIPHOS® nail for proximal humeral fractures: our experience with more than 190 procedures and surgical tips

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Fabrizio Quattrini
Corrado Ciatti https://orcid.org/0000-0002-7094-4344
Serena Gattoni
Valeria Burgio
Calogero Puma Pagliarello
Fabrizio Rivera
Pietro Maniscalco


Humeral nail, Nailing, Proximal Humerus fractures, Entry Point, Nailing Tips, Deltoid Tuberosity Index


Aim: evaluate the outcome of proximal  humeral nailing over 5 years follow-up, focusing  on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure.

Materials and Methods: the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject.

Results: mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded “very good” / “good” results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails).  Second surgery was performed in 8.2% (16/194) of cases.

Conclusion: intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support. 


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Launonen AP, Lepola V, Saranko A, Flinkkilä T, Laitinen M, Mattila VM. Epidemiology of proximal humerus fractures. Arch Osteoporos. 2015;10:209. doi: 10.1007/s11657-015-0209-4. Epub 2015 Feb 13.
Passaretti D, Candela V, Sessa P, Gumina S. Epidemiology of proximal humeral fractures: detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg. 2017 Dec;26(12):2117-24. doi: 10.1016/j.jse.2017.05.029. Epub 2017 Jul 20.
Egol, Kenneth A. (2015). Handbook of fractures. Koval, Kenneth J., Zuckerman, Joseph D. (Joseph David), 1952-, Ovid Technologies, Inc. (5th ed.). Philadelphia: Wolters Kluwer Health. ISBN 9781496301031. OCLC 960851324.
Hwansub Hyun, Jonghyun Ahn, Sang-Jin Shin.Conservative Treatment of Proximal Humeral Fracture . J Korean Fract Soc. 2018 Jan;31(1):29-35. Korean.Published online Jan 22, 2018. https://doi.org/10.12671/jkfs.2018.31.1.29
Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J.2017; 99-B(3):383–92. doi:10.1302/0301-620X.99B3.BJJ-2016-1028.
Calvo E, Morcillo D, Foruria AM, Redondo-Santamaría E, Osorio-Picorne F, Caeiro JR, GEIOS-SECOT Outpatient Osteoporotic Fracture Study Group. Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception. J Shoulder Elbow Surg. 2011 Jul; 20(5):795-801.
Carofino BC, Leopold SS. Classifications in brief: the Neer classification for proximal humerus fractures. Clin Orthop. 2013;471(1):39–43. doi:10.1007/s11999-012-2454-9.
Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, Jost B. Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures. Clin Orthop Relat Res. 2015 Sep;473(9):3038-45. doi: 10.1007/s11999-015-4322-x. Epub 2015 Apr 25.
Tingart MJ, Lehtinen J, Zurakowski D, Warner JJ, Apreleva M. Proximal humeral fractures: regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):620-4. Epub 2006 Aug 7.
Mather J, MacDermid JC, Faber KJ, Athwal GS. Proximalhumerus cortical bone thickness correlates with bone mineraldensity and can clinically rule out osteoporosis. J ShoulderElbowSurg. 2013;22:732–8
Tingart MJ, Apreleva M, von Stechow D, Zurakowski D, Warner JJ. The cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus.J Bone Joint Surg Br. 2003 May;85(4):611-7.
Agudelo J, Schürmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007 Nov-Dec;21(10):676-81.
Sjur Oppebøen, Annette K. B. Wikerøy, Hendrik F. S. Fuglesang, Filip C. Dolatowski, Per- Henrik Randsborg. Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years. Journal of Orthopaedic Surgery and Research 2018 Aug 9;13(1):197. doi: 10.1186/s13018-018-0906-y. PMID: 30092807; PMCID: PMC6085712.
Christ A.B., Gausden E.B., Warner S.J., Nellestein A.M., Thacher R.R., Lorich D.G., Rotator Cuff-Sparing Approach for Antegrade Humeral Nailing With Biceps Tenodesis: A Technical Trick With Clinical Implications. J Orthop Trauma. 2017 Feb; 31(2)
Dilisio MF, Nowinski RJ, Hatzidakis AM, Fehringer EV. Intramedullary nailing of the proximal humerus: evolution, technique, and results. J Shoulder Elb Surg. 2016;25:e130–8. doi: 10.1016/j.jse.2015.11.016.
Toon Dong Hao, Andy Wee Teck Huat. Surgical technique and early outcomes of intramedullary nailing of displaced proximal humeral fractures in an Asian population using a contemporary straight nail designJournal of Orthopaedic Surgery. 2017 May-Aug; 25(2) 1–9. doi.org/10.1177/2309499017713934
Jung SW, Shim SB, Kim HM, Lee JH, Lim HS. Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery. J Orthop Trauma. 2015 Jun;29(6):276-82.
Katthagen JC Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H. Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech (Bristol, Avon). 2014 Aug;29(7):735-41. doi:10.1016/j.clinbiomech.2014.06.008. Epub 2014 Jun 19
Russo R, Visconti V, Lombardi LV, Ciccarelli M, Giudice G. The block-bridge system: a new concept and surgical technique to reconstruct articular surfaces and tuberosities in complex proximal humeral fractures. J Shoulder Elbow Surg. 2008 Jan-Feb;17(1):29-36.
Xiaowei Huang, Baoqing Yu, Yong Gu, Zexiang Li. Biomechanical comparison of dynamic hip screw and Gamma nail for the treatment of unstable trochanteric fractures: a nite element study. Int J Clin Exp Med. 2017;10(5):7867-74. www.ijcem.com/ISSN:1940-5901/IJCEM0047129
Gadeaa F, Favarda L, Boileaub P, Cunyc C, d’Ollone T, Saragaglia D, Sirveauxe F. Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthopaedics & Traumatology: Surgery & Research. Vol 102, 8, Dec 2016, p.963-70. https://doi.org/10.1016/j.otsr.2016.09.015
Plath JE, Kerschbaum C, Seebauer T, Holz R, Henderson DJH, Förch S, Mayr E. Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial. BMC Musculoskelet Disord. 2019 Jan 10;20(1):20. doi: 10.1186/s12891-019-2399-1. PMID: 30630465; PMCID: PMC6329164.
Katthagen Jan Christoph, Meret Huber, Svenja Grabowski,Alexander Ellwein, Gunnar Jensen, and Helmut Lill. Failure and revision rates of proximal humeral fracture treatment with the use of a standardized treatment algorithm at a level-1 trauma center. J Orthop Traumatol. 2017 Sep; 18(3): 265–74. Published online 2017 Apr 18. doi: 10.1007/s10195-017-0457-8
Sosef N, van Leerdam R, Ott P, Meylaerts S, Rhemrev S. Minimal invasive fixation of proximal humeral fractures with an intramedullary nail: good results in elderly patients. Arch Orthop Trauma Surg. 2009;130:605–11. doi: 10.1007/s00402-009-1027-1.
Pastor MF., Kieckbusch M., Kaufmann M., Ettinger M., Wellman M., Smith T. Reverse shoulder arthroplasty for fracture sequelae: Clinical outcome and prognostic factors Journal of Orthopaedic Science March 2019 Vol 24, 2, p 237-42. doi.org/10.1016/j.jos.2018.09.016

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