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BACKGROUND
Osteoporosis may complicate surgical fixation and healing of proximal humerus fractures and should be assessed preoperatively. Peripheral quantitative CT (pQCT) and the Tingart measurement are helpful methods, but both have limitations in clinical use because of limited availability (pQCT) or fracture lines crossing the area of interest (Tingart measurement). The aim of our study was to introduce and validate a simple cortical index to assess the quality of bone in proximal humerus fractures using AP radiographs.

QUESTIONS/PURPOSES
We asked: (1) How do the deltoid tuberosity index and Tingart measurement correlate with each other, with patient age, and local bone mineral density (BMD) of the humeral head, measured by pQCT? (2) Which threshold values for the deltoid tuberosity index and Tingart measurement optimally discriminate poor local bone quality of the proximal humerus? (3) Are the deltoid tuberosity index and Tingart measurement clinically applicable and reproducible in patients with proximal humerus fractures?

METHODS
The deltoid tuberosity index was measured immediately above the upper end of the deltoid tuberosity. At this position, where the outer cortical borders become parallel, the deltoid tuberosity index equals the ratio between the outer cortical and inner endosteal diameter. In the first part of our study, we retrospectively measured the deltoid tuberosity index on 31 patients (16 women, 15 men; mean age, 65 years; range, 22-83 years) who were scheduled for elective surgery other than fracture repair. Inclusion criteria were available native pQCT scans, AP shoulder radiographs taken in internal rotation, and no previous shoulder surgery. The deltoid tuberosity index and the Tingart measurement were measured on the preoperative internal rotation AP radiograph. The second part of our study was performed by reviewing 40 radiographs of patients with proximal humerus fractures (31 women, nine men; median age, 65 years; range, 22-88 years). Interrater (two surgeons) and intrarater (two readings) reliabilities, applicability, and diagnostic accuracy were assessed.

RESULTS
The correlations between radiograph measurements and local BMD (pQCT) were strong for the deltoid tuberosity index (r = 0.80; 95% CI, 0.63-0.90; p < 0.001) and moderate for the Tingart measurement (r = 0.67; 95% CI, 0.42-0.83; p < 0.001). There was moderate correlation between patient age and the deltoid tuberosity index (r = 0.65; p < 0.001), patient age and the Tingart measurement (r = 0.69; p < 0.001), and patient age and pQCT (r = 0.73; p < 0.001). The correlation between the deltoid tuberosity index and the Tingart measurement was strong (r = 0.84; p < 0.001). We determined the cutoff value for the deltoid tuberosity index to be 1.44, with the area under the curve = 0.87 (95% CI, 0.74-0.99). This provided a sensitivity of 0.88 and specificity of 0.80. For the Tingart measurement, we determined the cutoff value to be 5.3 mm, with the area under the curve = 0.83 (95% CI, 0.67-0.98), which resulted in a sensitivity of 0.81 and specificity of 0.85. The intraobserver reliability was high and not different between the Tingart measurement (intraclass correlation coefficients [ICC] = 0.75 and 0.88) and deltoid tuberosity index (ICC = 0.88 and 0.82). However, interobserver reliability was higher for the deltoid tuberosity index (ICC = 0.96; 95% CI, 0.93-0.98) than for the Tingart measurement (ICC = 0.85; 95% CI, 0.69-0.93).The clinical applicability on AP radiographs of fractures was better for the deltoid tuberosity index (p = 0.025) because it was measureable on more of the radiographs (77/80; 96%) than the Tingart measurement (69/80; 86%).

CONCLUSIONS
The deltoid tuberosity index correlated strongly with local BMD measured on pQCT and our study evidence shows that it is a reliable, simple, and applicable tool to assess local bone quality in the proximal humerus. We found that deltoid tuberosity index values consistently lower than 1.4 indicated low local BMD of the proximal humerus. Furthermore, the use of the deltoid tuberosity index has important advantages over the Tingart measurement regarding clinical applicability in patients with proximal humerus fractures, when fracture lines obscure the Tingart measurement landmarks. However, further studies are needed to assess the effect of the deltoid tuberosity index measurement and osteoporosis on treatment and outcome in patients with proximal humerus fractures.

LEVEL OF EVIDENCE
Level IV, diagnostic study.