J Shoulder Elbow Surg (2017) 26, 1931–1937

www.elsevier.com/locate/ymse

Defining optimal calcar screw positioning in

proximal humerus fracture fixation
Eric M. Padegimas, MDa, Benjamin Zmistowski, MDa, Cassandra Lawrence, MDb,
Aaron Palmquist, BAc, Thema A. Nicholson, MSd, Surena Namdari, MD, MScd,*

a
Department of Orthopaedic Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
b
Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
c
Drexel University College of Medicine, Philadelphia, PA, USA
d
The Rothman Institute of Orthopaedics, Thomas Jefferson University Hospitals, Philadelphia, PA, USA

Background: Anatomic reduction and placement of an inferior calcar screw are strategies to prevent fix-
ation failure in proximal humerus factures. Optimal position of the calcar screw remains unknown.
Methods: There were 168 shoulders (68.5% female; average age, 63.6 ± 11.5 years) that underwent open
reduction and internal fixation of a displaced proximal humerus fracture involving the surgical or ana-
tomic neck. Univariate and multivariate analyses were performed on preoperative clinical, preoperative
radiographic, and postoperative radiographic variables to determine association with fixation failure. A
receiver operating characteristic curve was performed to determine a maximum distance from the inferi-
or screw to the calcar (“calcar distance”) as well as a maximum ratio of this distance and the head diameter
(“calcar ratio”).
Results: There were 26 of 168 (15.5%) patients with radiographic failures (19 related to fixation failure).
Univariate analysis and multivariate analyses found quality of reduction (P < .001), calcar distance (P < .001),
and calcar ratio (P < .001) to be significantly associated with radiographic success. In all patients, receiv-
er operating characteristic analysis found quantifiable thresholds of 12 mm or within the bottom 25% of
the humeral head as measures to prevent fixation failure.
Conclusions: Quality of reduction, calcar distance, and calcar ratio independently correlated with fixa-
tion failure. This study provides optimal distances and ratios for calcar screw placement that can be used
clinically.
Level of evidence: Level III; Retrospective Cohort Design; Treatment Study
© 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Proximal humerus fracture; proximal humerus open reduction; internal fixation; calcar screw;
nonunion; malunion; varus collapse

Proximal humerus fractures account for approximately 10%

Institutional Review Board approval: 45 CFR 46.110; Control #16D.533.
*Reprint requests: Surena Namdari, MD, MSc, Shoulder & Elbow
Surgery, Rothman Institute—Thomas Jefferson University, 925 Chestnut St,
5th Floor, Philadelphia, PA 19107, USA.
E-mail address: surena.namdari@rothmaninstitute.com (S. Namdari).
of fractures in patients older than 65 years.2,9,10 Whereas
nonoperative management is the most common manage-
ment option, open reduction–internal fixation (ORIF) is the
most common surgical intervention.6 The incidence of prox-
imal humerus fracture fixation is increasing in the United
States.3 As the incidence of surgical treatment of proximal

1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2017.05.003
1932
humerus fractures increases, the burden of complications, in-
cluding fixation failure, will become increasingly significant.
A recent analysis of proximal humerus fracture ORIF found
an 18.4% rate of fixation failure and a reoperation rate of
27.6%.13 Interestingly, the quality of reduction at the time of
surgery was predictive of both radiographic and clinical out-
comes. Earlier analyses found age, local cortical density, quality
of reduction, and restoration of the medial cortical support
to be predictive of radiographic failure.8 Retrospective anal-
ysis of patients undergoing proximal humerus ORIF found
that placement of a medial support (calcar) screw was asso-
ciated with a decreased risk of loss of reduction.12,13
The inter-relatedness of fracture reduction quality and the
position of the medial support (calcar) screw has not been
quantified. The purpose of this study was to identify radio-
graphic variables that were independently associated with
failure of proximal humerus fracture ORIF and to generate
thresholds for optimal calcar screw placement based on the
quality of the reduction.
Methods
Study population
All operatively treated proximal humerus fractures were identified
by querying an institutional database by International Classifica-
tion of Diseases, Ninth Revision and Tenth Revision, Clinical
Modification and Current Procedural Terminology codes. This da-
tabase included patients from January 2008 through March 2016.
The codes used were 79.31 (open reduction of fracture with inter-
nal fixation, humerus), S42.2__ (all codes for fracture of upper end
of humerus), and 23615 (open reduction with internal fixation
of proximal humerus). Exclusion criteria were revision surgery,
associated diaphyseal fracture, fixation with an intramedullary
device, no anatomic or surgical neck component of the fracture
(eg, isolated greater tuberosity fractures were excluded), inadequate
preoperative or postoperative films, incomplete clinical variables,
previous shoulder fracture or nonunion, and <12-week postoperative
Figure 1 (A) Representative anterior-posterior radiograph of a Neer 2-part11 proximal humerus fracture in varus (neck-shaft angle of <120°).
(B) Representative anterior-posterior radiograph of a Neer 4-part11 proximal humerus fracture in valgus (neck-shaft angle of >150°).
E.M. Padegimas et al.
films. Direct chart review of all patients and radiographs was per-
formed to determine if they had in fact sustained a proximal humerus
fracture that underwent ORIF, if the fixation was with a locking plate
and screws construct, and if the patient did not meet any exclusion
criteria.
Independent variables
Preoperative clinical variables were identified for all patients.
These variables included age, gender, race, individual medical
comorbidities, and age-adjusted Charlson Comorbidity Index.4,14
Preoperative radiographic variables were identified for all patients
on true anterior-posterior and Y-view radiographs. These variables
were cortical density measurement,15 Neer classification,11 medial
hinge displacement,7 medial comminution,7 and presence of varus
or valgus angulation (Fig. 1). A neck-shaft angle of <120° was con-
sidered varus (Fig. 1, A), whereas a neck-shaft angle >150° was
considered valgus (Fig. 1, B).13
Early postoperative radiographs (true anterior-posterior and
Y-view radiographs) taken at 2 weeks postoperatively were re-
viewed for a number of variables. All preoperative and postoperative
radiographs are standardized at our institution. Based on the pa-
rameters for reduction quality described by Schnetzke et al, medial
head-shaft displacement of <5 mm, greater tuberosity cranialization
of <5 mm, and varus or valgus angulation of 120°-150° were
considered.13 If all 3 criteria were met, the fracture was considered
adequately reduced. If 2 of the 3 criteria were met, the fracture was
considered partially reduced. If only 1 or 0 of the 3 criteria was met,
the fracture was considered malreduced. In addition to the reduc-
tion quality, the integrity of the calcar, distance of inferior screw
to the calcar (referred to as calcar distance), ratio of calcar dis-
tance and the head diameter (referred to as calcar ratio), distance
of the inferior screw to the humeral head articular surface (re-
ferred to as tip distance), number of diaphyseal screws, number of
proximal screws, and number of proximal screws in the inferior half
of the head were also considered.1,17 The calcar distance was mea-
sured as the perpendicular from the threads of the calcar screw to
the apex of the arch of the calcar. A well-reduced and well-fixed
proximal humerus fracture that went on to successful radiographic
healing is shown in Figure 2 (all measurements shown).
Proximal humerus fixation
Figure 2 Representative anterior-posterior radiograph of an ad-
equately reduced right proximal humerus open reduction and internal
fixation with neck-shaft angle of 127.3°, calcar distance of 4.1 mm,
and distance from the tip of the calcar screw to the humeral head
of 1.6 mm.
Outcomes
Radiographic failure was evaluated retrospectively on routine, se-
quential postoperative radiographs at 2 weeks, 6 weeks, 12 weeks,
and 24 weeks after surgery. These were evaluated for malunion, non-
union, or varus collapse with screw cut-out. All radiographs were
compiled by 2 authors (T.A.N. and A.P.), and all were analyzed for
preoperative and postoperative variables by 2 authors (E.M.P. and
S.N.). Any discrepancy between the 2 reviewing authors was re-
solved with concurrent review of the radiographs by both authors.
Radiographic failures were considered either failures of the con-
struct (nonunion, varus or valgus malunion after initial appropriate
coronal reduction without screw penetration, varus or valgus
malunion after initial appropriate coronal reduction with screw pen-
etration), where the neck component failed to heal appropriately,
or failures unrelated to the construct (post-traumatic arthritis and
late avascular necrosis), where the neck component healed appro-
priately. In addition to radiographic failure, reoperations were
identified.
Statistical analysis
First, descriptive statistics were calculated for all of the aforemen-
tioned independent variables between those who went on to
radiographic failure of the construct and those who did not. To assess
differences, a Student t-test was used for continuous variables and
χ2 analysis for categorical variables. To confirm normality of con-
tinuous variables, it was confirmed that all variables had a skewness
1933
(measure of symmetry of the variable’s frequency-distribution curve)
<2 and kurtosis (measure of the sharpness of the curve) <12.16 After
identification of the variables that were associated with fixation failure
(P < .1), a multivariate logistic regression including these vari-
ables was performed. Because of the limited sample size and obvious
confounding between overall reduction quality and its subset (greater
tuberosity cranialization, alignment, and head-shaft displace-
ment), it was necessary to run multiple models. Similarly, the
correlation between the calcar distance and calcar ratio (the calcar
ratio is a direct function of the calcar distance) was so significant
that it precluded meaningful results from including both in multi-
variate analysis. Therefore, 3 separate models were performed. The
first included the 3 parameters of the reduction quality, the calcar
distance, and the calcar ratio. The second and third models tested
the calcar ratio and calcar distance independently with the 3 reduc-
tion quality parameters. In addition, the relationship between reduction
quality and Neer classification was performed by using a single-
factor analysis of variance comparing the reduction quality (based
on the number of the 3 reduction parameters achieved) for 2-, 3-,
and 4-part fractures.11,13 Last, because a lower calcar ratio and calcar
distance were independently associated with radiographic healing,
a receiver operating characteristic curve was generated for both to
identify a threshold predictive of successful union. The area under
the curve (AUC) was calculated to assess the predictive value of
these variables. Thresholds optimizing accuracy (Youden J statis-
tic) were calculated and reported. These thresholds and AUC were
calculated for all fractures, then stratified by reduction quality (all
reduction parameters met, 1 reduction parameter failed, and 2 or
more failed reduction parameters). Microsoft Excel (2013; Redmond,
WA, USA) and R (R Development Core Team; R: a language and
environment for statistical computing. Vienna, Austria: R Founda-
tion for Statistical Computing; 2008) were used for all statistical
calculations.
Results
The original search identified 292 shoulders that underwent
ORIF of a proximal humerus fracture by database search. After
application of inclusion and exclusion criteria, there were 193
that met full inclusion criteria. Of these 193 qualifying shoul-
ders, 168 shoulders (87.0%) had at least 12 weeks of
radiographic follow-up. On analysis of these 168 shoulders,
68.5% were female, and the average age was 63.6 ± 11.5 years.
Of the 168 proximal humerus fractures, 26 (15.5%) went on
to radiographic failure at a mean of 35.3 weeks (range, 6.1-
126.1 weeks) postoperatively. In those that healed successfully,
final radiographs were evaluated at a mean of 42.3 weeks
(range, 12.1-331.1 weeks) postoperatively. Of the 26 radio-
graphic failures, 19 were considered fixation failures. The
failures that were not considered construct failures included
2 patients with intra-articular screw placement, 1 patient who
fell and sustained a humeral shaft fracture, 2 patients who
developed late post-traumatic arthritis, and 2 who devel-
oped late avascular necrosis. These cases were not included
in the analysis of predictive variables for fixation failure. For
the construct failures, the modes of failure were nonunion
(47.4%; 9/19), varus malunion after initial appropriate coronal
correction without screw penetration (31.6%; 6/19), and varus
1934 E.M. Padegimas et al.

Table I Descriptive statistics of both the nonunion and successful groups

Fixation failure (n = 19) Healed (n = 142) P value
Age 65.9 (60.1-71.6) 62.8 (61.0-64.7) .27
Male 8 (42.1%) 42 (29.6%) .40
BMI 29.0 (24.5-33.5) 28.0 (27.1-28.2) .45
Cortical density 5.1 (4.6-5.5) 5.1 (4.9-5.3) .94
Head length (mm) 50.4 (47.5-53.3) 50.9 (50.1-51.7) .67
Fracture characteristics
Medial comminution 8 (42.1%) 36 (25.3%) .21
Medial hinge displacement 10 (52.6%) 55 (38.7%) .36
Calcar integrity 11 (57.9%) 104 (73.2%) .27
Alignment
Neutral 3 (15.8%) 33 (23.2%) .21
Varus 12 (63.2%) 59 (41.5%)
Valgus 4 (21.1%) 50 (35.2%)
Neer classification
2 12 (63.2%) 61 (43.0%) .09
3 1 (5.3%) 38 (26.8%)
4 6 (31.6%) 43 (30.3%)
Reduction and fixation parameters
No. of distal screws 2.9 (2.6-3.2) 3.0 (2.9-3.1) .72
No. of proximal screws 6.2 (5.5-6.9) 5.8 (5.6-6.1) .28
No. of screws in inferior half of head 2.4 (1.8-3.0) 2.9 (2.7-3.1) .13
Calcar screw
Distance to inferior calcar 18.0 (15.2-20.7) 10.1 (9.1-11.1) <.01
Ratio of calcar to head length 35.5% (31.2-39.8) 19.6% (17.8-21.5) <.01
Distance from screw to surface 12.6 (9.5-15.8) 10.9 (9.9-11.8) .21
Overall reduction quality 1.8 (1.4-2.3) 2.5 (2.4-2.6) <.01
Achieved greater tuberosity cranialization 17 (89.5%) 139 (97.9%) .20
No head-shaft displacement 8 (42.1%) 101 (71.1%) .02
No angulation 10 (52.6%) 118 (83.1%) .01
Anatomic 10 (52.6%) 118 (83.1%) <.01
Varus 8 (42.1%) 17 (12.0%)
Valgus 1 (5.3%) 7 (4.9%)
BMI, body mass index.
Continuous variables are reported with 95% confidence intervals and categorical variables with proportions.

collapse with screw penetration (21.1%; 4/19). These failures
were identified at a mean of 24.9 weeks (range, 12.0-46.6
weeks). None of the preoperative patient or fracture charac-
teristics considered were statistically significant predictors of
failure on univariate analysis (Table I). The quality of
reduction13 was predictive of failure (1.8 average of achieved
parameters in those that failed vs. 2.5 of 3 in those that did
not; P < .01). Individually, reduction of angulation (achieved
in only 52.6% of failures compared with 83.1% in success-
ful outcomes; P = .01) and correction of head-shaft
displacement (achieved in 42.1% of failures and 71.1% of
success cases; P = .02) were statistically significant predic-
tors of failure.
From the perspective of fixation, the fixation failures were
similar to the healed group with respect to the number of distal
screws (mean, 2.9 distal screws vs. 3.0; P = .72), the number
of proximal fragment screws (mean, 6.2 proximal screws vs.
5.8; P = .28), the number of screws in the inferior half of the
humeral head (mean, 2.4 screws in the inferior half of the
humeral head vs. 2.9; P = .13), or the distance between the
tip of the screw and the articular surface (12.6 mm vs.
10.9 mm; P = .21). With regard to the medial support screw,
both the shorter distance from the calcar to the screw (calcar
distance; P < .01) and the ratio of this distance to the humeral
head diameter (calcar ratio; P < .01) were strongly predic-
tive of failure. Isolating adequately reduced fractures (3/3
reduction parameters achieved), the average distance from the
screw to the calcar was 19.2 mm in failures and 9.5 mm in
successes (P < .01; Table II), with a calcar ratio of 38.4% vs.
18.6% (P < .01), respectively. Isolating partially reduced frac-
tures (2/3 reduction parameters achieved), the average calcar
distance was 18.8 mm in failures and 10.3 mm in successes
(P = .06; Table II), with a calcar ratio of 34.9% vs. 19.5%
(P = .02), respectively. Isolating malreduced fractures (0 or
1/3 reduction parameters achieved), the average calcar dis-
tance was 16.2 mm in failures and 13.3 mm in successes
(P = .10; Table II), with a calcar ratio of 33.5% vs. 25.8%
(P = .05), respectively.
Proximal humerus fixation 1935

Table II Results of receiver operating characteristic analysis

Variable Average radiographic finding Receiver operating characteristic
Fixation failure Union P value AUC Threshold Sensitivity Specificity Accuracy
All comers
Distance to calcar from inferior screw 18.0 mm 10.1 mm <.01 0.84 12.05 mm 100% 66.2% 70.2%
Ratio of distance to head length 35.5% 19.6% <.01 0.86 24.8% 94.7% 71.1% 73.9%
Two or 3 failed reduction parameters
Distance to calcar from inferior screw 16.2 mm 13.3 mm .10 0.69 11.4 mm 100% 47.1% 62.5%
Ratio of distance to head length 33.5% 25.8% .05 0.72 23.4% 100% 47.1% 62.5%
One failed reduction parameter
Distance to calcar from inferior screw 18.8 mm 10.3 mm .06 0.86 12.05 mm 100% 72.7% 76.9%
Ratio of distance to head length 34.9% 19.5% .02 0.87 21.0% 100% 70.0% 74.4%
No failed reduction parameters
Distance to calcar from inferior screw 19.2 mm 9.5 mm <.01 0.89 13.1 mm 100% 72.8% 74.5%
Ratio of distance to head length 38.4% 18.6% <.01 0.91 26.1% 100% 76.1% 77.6%
AUC, area under the curve.
For both parameters of calcar screw position, the predictive value of the parameter was calculated for all patients and then stratified by reduction quality.

Table III Three models of multivariate analysis of predictors of fixation failure after proximal humerus surgical neck fixation
Univariate correlation Model 1 Model 2 Model 3
coefficient OR P value OR P value OR P value
Neer classification (compared to 2-part)
3-part −0.16 0.13 .09 0.14 .09 0.11 .08
4-part 0.009 0.65 .52 0.69 .56 0.68 .56
Reduction quality −0.27 N/A 0.42 .01 0.42 .01
Head-shaft displacement −0.20 0.38 .16 N/A N/A
Angulation −0.24 0.42 .20
Calcar ratio 0.43 1.14 <.01 N/A 1.14 <.01
Distance to inferior calcar 0.40 N/A 1.20 <.01 N/A
OR, odds ratio; N/A, not applicable.

In multivariate analysis, the quality of reduction was an
independent predictor of success (Table III). On isolation of
the distance to the calcar from the inferior screw or the ratio
of this distance to the humeral head diameter, both param-
eters were predictors of failure independent of reduction quality
(odds ratio, 1.2 and 1.1, respectively). In addition, single-factor
analysis of variance was used to assess any potential corre-
lation between Neer classification and the quality of reduction.
There was no significant difference in the quality of reduc-
tion based on Neer classification, with 2-part fractures having
an average of 2.43 ± 0.72 reduction components achieved,
3-part fractures 2.50 ± 0.86, and 4-part fractures 2.38 ± 0.88
(F = 0.25; P = .78).11,13
Analysis of ideal medial support screw placement with re-
ceiver operating characteristic curve confirmed the predictive
value of the calcar distance and the calcar ratio (Table II).
The AUC was 0.84 and 0.86 for calcar distance and calcar
ratio, respectively. The optimal threshold for all patients to
minimize radiographic failures was a calcar distance of 12 mm
or less and a calcar ratio of 25% or less (Table II). On strati-
fying patients by reduction quality, the identified threshold
for both the calcar distance and calcar ratio became less strict
as the reduction quality improved. For adequately reduced
fractures, the optimal threshold was a calcar distance of
13.1 mm or less and a calcar ratio of 26.1% or less. For par-
tially reduced fractures, the optimal threshold was a calcar
distance of 12.1 mm or less and a calcar ratio of 21.0% or
less. Finally, for malreduced fractures, the optimal thresh-
old was a calcar distance of 11.4 mm or less and a calcar ratio
of 23.4% or less.
Ten of the 26 (38.5%) shoulders that went on to radio-
graphic failure underwent 12 future operations at a mean of
47.3 weeks (range, 2.1-166.3 weeks) after the index proce-
dure. These were 4 hardware removals, 1 hematoma washout,
1 rotator cuff repair, 2 arthroscopic débridements (1 with
concurrent removal of hardware), 3 revision ORIF, and 1 an-
atomic total shoulder arthroplasty. In comparison, 16 of
the 142 (11.3%) shoulders that healed radiographically
underwent 16 future operations at a mean of 48.6 weeks
(range, 14.0-153.9 weeks) after the index procedure (P < .01).
Thirteen reoperations were hardware removal (5 of which
underwent an arthroscopic débridement), 2 were arthro-
scopic débridements, and 1 was a reverse total shoulder
arthroplasty for rotator cuff insufficiency.
1936
Discussion
Recent study has demonstrated that anatomic fracture reduc-
tion with a locked plate significantly improved functional
outcomes and lowered the complication rate of unstable and
displaced proximal humeral fractures involving the anatom-
ic neck.13 In addition, the placement of an oblique locking
screw within the inferomedial quadrant of the proximal
humeral head fragment (calcar screw) has been previously
shown to be important for prevention of fixation failure.5,12,13
The optimal position of this calcar screw has not been defined.
In this study, we report quantifiable measurements that can
be used intraoperatively to guide acceptable calcar screw
position.
The primary finding of this current analysis is the asso-
ciation between the calcar distance and calcar ratio and
fixation failure. Prior studies show that placement of a medial
support screw decreases the likelihood of fixation failure.5,12,13
The importance of the medial support screw is validated by
biomechanical studies that show increased axial, shear, and
torsional stiffness with placement of a medial support screw.1,17
However, these studies do not analyze the importance of
the location of medial support screw placement in reference
to the calcar. Two possible reasons for failure to position
the calcar screw in an optimal position include a surgeon’s
decision to leave certain holes in a plate empty and superior
placement of a fixed-angle locking plate that in turn places
the calcar screw in a position that is farther from the
calcar.
After determining the importance of calcar distance and
calcar ratio to the success of fracture fixation, we attempted
to identify optimal threshold values for both variables. Whereas
we recommend that surgeons critically evaluate their intra-
operative fluoroscopy images for reduction quality, whether
fractures are anatomically reduced or malreduced, calcar
screws should be positioned <12 mm from the apex of the
arch of the calcar or within the bottom 25% of the humeral
head. In some cases, this may involve repositioning the plate
to a lower position. Alternatively, an advantage of polyaxial
locking technology in proximal humerus fracture fixation may
allow greater freedom for positioning of the calcar screw in
an optimal position irrespective of plate position.
We also analyzed reoperation rate in the context of radio-
graphic failure. Unsurprisingly, those patients who had
radiographic failure also had a significantly higher reoperation
rate (41.7%) than those who had well-healed radiographs
(11.1%; P < .01). This difference in reoperation rate demon-
strates the importance of achieving radiographic healing both
clinically and economically. Placement of a well-placed medial
support screw based on reduction quality appears to opti-
mize healing potential and avoids the cost and morbidity of
secondary procedures. Whereas our data indicate that an in-
feriorly placed calcar screw can minimize fixation failure in
partially reduced and malreduced fractures, we did not eval-
uate functional outcomes. Given that Schnetzke et al reported
worse functional outcomes in malreduced fractures, anatomic
E.M. Padegimas et al.
reduction remains a primary goal of proximal humerus frac-
ture fixation.13
The results of this study must be considered in the context
of the limitations. First, these were all proximal humerus frac-
tures treated in 1 hospital system during an 8-year period.
There were a wide range of experience levels of surgeons and
surgical implants used, different techniques for reattach-
ment of the tuberosities with rotator cuff sutures, and variable
use of bone graft. Therefore, surgical technique was unable
to be standardized and may have a confounding effect on the
results. However, the parameters evaluated on the radio-
graphs were standardized across all patients, and therefore
it would be expected that parameters that affect 1 surgeon’s
proximal humerus fixation would similarly affect that of others.
Second, as noted previously, no patient-reported outcomes
were obtained. Despite this, we would expect that function-
al outcomes scores would be worse in patients who sustained
fixation failure as described by previous studies.8,12,13 In ad-
dition, not all reoperations may be captured in this analysis.
If a patient underwent a second operation at a different in-
stitution, it would not be captured in our electronic records.
Therefore, the reported reoperation rate may be under-
stated. The range of follow-up was also highly variable.
Because of this, although early radiographic failures could
be reported accurately in this study, we are likely underes-
timating the occurrence of late failures, such as avascular
necrosis, symptomatic hardware, and arthrofibrosis. Despite
these limitations, this analysis is the first to quantify ideal fix-
ation construct parameters for proximal humerus fracture based
on reduction quality.
Conclusion
The results of this study demonstrate the importance of
fracture reduction quality and optimal calcar screw posi-
tion in proximal humerus fracture fixation. We find that
precise calcar screw positioning (smaller calcar screw dis-
tances and smaller calcar ratios) are necessary to avoid
fixation failure. Patients with calcar screws placed in po-
sitions outside of the thresholds identified were at increased
risk for fixation failure and subsequent reoperation.
Disclaimer
Surena Namdari reports that he receives research funding
from DePuy, Zimmer, Tornier, Integra Life Sciences, and
Arthrex; he is a consultant for DonJoy Orthopedics, Depuy-
Synthes, and Miami Device Solutions and receives product
design royalties from DonJoy Orthopedics, Miami Device
Solutions, and Elsevier. All the other authors, their im-
mediate families, and any research foundations with which
they are affiliated have not received any financial pay-
ments or other benefits from any commercial entity related
to the subject of this article.
Proximal humerus fixation
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