There is no consensus on which glenoid plane should be used in total shoulder arthroplasty. Nevertheless, anatomical reconstruction of this plane is imperative for the success of a total shoulder arthroplasty. Three-dimensional reconstruction CT-scans were performed on 152 healthy shoulders. Four different glenoid planes, each determined by three surgical accessible bony reference points, are determined. The first two are triangular planes, defined by the most anterior and posterior point of the glenoid and respectively the most inferior point for the Saller's Inferior plane and the most superior point for the Saller's Superior plane. The third plane is formed by the best fitting circle of the superior tubercle and the most anterior and posterior point at the distal third of the glenoid (Circular Max). The fourth plane is formed by the best fitting circle of three points at the rim of the inferior quadrants of the glenoid (Circular Inferior). We hypothesized that the plane with normally distributed parameters, narrowest variability and best reproducibility would be the most suitable surgical glenoid plane.Background
Methods
During shoulder arthroplasty the native functionality of the diseased shoulder joint is restored, this functionality is strongly dependent upon the native anatomy of the pre-diseased shoulder joint. Therefore, surgeons often use the healthy contralateral scapula to plan the surgery, however in bilateral diseases such as osteoarthritis this is not always feasible. Virtual reconstructions are then used to reconstruct the pre-diseased anatomy and plan surgery or subject-specific implants. In this project, we develop and validate a statistical shape modeling method to reconstruct the pre-diseased anatomy of eroded scapulae with the aim to investigate the existence of predisposing anatomy for certain shoulder conditions. The training dataset for the statistical shape model consisted of 110 CT images from patients without observable scapulae pathologies as judged by an experienced shoulder surgeon. 3D scapulae models were constructed from the segmented images. An open-source non-rigid B-spline-based registration algorithm was used to obtain point-to-point correspondences between the models. The statistical shape model was then constructed from the dataset using principle component analysis. The cross-validation was performed similarly to the procedure described by Plessers et al. Virtual defects were created on each of the training set models, which closely resemble the morphology of glenoid defects according to the Wallace classification method. The statistical shape model was reconstructed using the leave-one-out method, so the corresponding training set model is no longer incorporated in the shape model. Scapula reconstruction was performed using a Monte Carlo Markov chain algorithm, random walk proposals included both shape and pose parameters, the closest fitting proposal was selected for the virtual reconstruction. Automatic 3D measurements were performed on both the training and reconstructed 3D models, including glenoid version, critical shoulder angle, glenoid offset and
Pre-operative 3D glenoid planning improves component placement in terms of version, inclination, offset and orientation. Version and inclination measurements require the position of the inferior angle. As a consequence, current planning tools require a 3D model of the full scapula to accurately determine the glenoid parameters. Statistical shape models (SSMs) can be used to reconstruct the missing anatomy of bones. Therefore, the objective of this study is to develop and validate an SSM for the reconstruction of the inferior scapula, hereby reducing the irradiation exposure for patients. The training dataset for the statistical shape consisted of 110 CT images from patients without observable scapulae pathologies as judged by an experienced shoulder surgeon. 3D scapulae models were constructed from the segmented images. An open-source non-rigid B-spline-based registration algorithm was used to obtain point-to-point correspondences between the models. A statistical shape model was then constructed from the dataset using principal component analysis. Leave-one-out cross-validation was performed to evaluate the accuracy of the predicted glenoid parameters from virtual partial scans. Five types of virtual partial scans were created on each of the training set models, where an increasing amount of scapular body was removed to mimic a partial CT scan. The statistical shape model was reconstructed using the leave-one-out method, so the corresponding training set model is no longer incorporated in the shape model. Reconstruction was performed using a Monte Carlo Markov chain algorithm, random walk proposals included both shape and pose parameters, the closest fitting proposal was selected for the virtual reconstruction. Automatic 3D measurements were performed on both the training and reconstructed 3D models, including glenoid version, inclination,
Lateralization of the reverse arthroplasty may be desirable to more effectively tension the remaining rotator cuff, decrease scapular notching, improve the cosmetic appearance of the shoulder, and improve stability as well as the arc of motion prior to impingement. There are two primary options to lateralise a reverse shoulder arthroplasty: bone graft with a long post (BIO-RSA) vs. using metal. The two metal options generally include a thicker glenosphere or a thicker glenoid baseplate. Potential benefits of a BIO-RSA include lateralization of the
Background:. Currently, there are a variety of different reverse shoulder implant designs but few anatomic studies to support the optimal selection of prosthetic size. This study analyzed the glenohumeral relationships of patients who underwent reverse shoulder arthroplasty (RSA). Methods:. Ninety-two shoulders of patients undergoing primary RSA for a massive rotator cuff tear without bony deformity or deficiency and 10 shoulders of healthy volunteers (controls) were evaluated using three-dimensional CT reconstructions and computer aided design (CAD) software. Anatomic landmarks were used to define scapular and humeral planes in addition to articular centers. After aligning the humeral center of rotation with the
Accurate and reproducible measurement of three-dimensional shoulder kinematics would contribute to better understanding shoulder mechanics, and therefore to better diagnosing and treating shoulder pathologies. Current techniques of 3D kinematics analysis use external markers (acromial cluster or scapula locator) or medical imaging (MRI or CT-Scan). However those methods present some drawbacks such as skin movements for external markers or cost and irradiation for imaging techniques. The EOS low dose biplanar X-Rays system can be used to track the scapula, humerus and thorax for different arm elevation positions. The aim of this study is to propose a novel method to study scapulo-thoracic kinematics from biplanar X-rays and to assess its reliability during abduction in the scapular plane. This study is based on the EOS™ system (EOS Imaging, Paris, France), which allows acquisition of 2 calibrated, low dose, orthogonal radiographs with the subject standing at 30 to 40° angle of coronal rotation to the plane of one of the X-ray beams, in order to limit superimposition with the ribcage and spine. Seven abduction positions in the scapular plane were maintained by the subjects for 10 seconds, during X-ray acquisition. Between two positions, the subjects returned at rest position. Arm elevations were approximately 0, 10, 20, 30, 60, 90 and 150° (position 1 to 7). Six subjects were enrolled to perform a reproducibility study based on the 3D reconstructions of 2 experienced observers three times each. For each subject, a personalised 3D reconstruction of the scapula was created. The observer digitises clearly visible anatomical landmarks on both stereoradiographs for each arm position. These landmarks are used to make a first adjustment of a parameterised 3D model of the scapula. This provides a pre-personalised model of the subject's scapula which is then rigidly registered on each pair of X-rays until its retroprojection fits best on the contours that are visible on the X-rays. The thorax coordinate system (CS) was built following the ISB (International Society of Biomechanics) recommendations. The CS associated to the scapula was a
Purpose: Glenoid replacement remains challenging due to the difficult visualization of anatomical reference landmarks and highly variable version angles. Improper positioning of the glenoid component leads to loosening, early wear, and instability. The objective of this study was to develop and evaluate a tracking system for glenoid implantation. We hypothesized that Computer Assisted Glenoid Implantation (CAGI) would achieve a more accurate and reliable placement of the glenoid component compared to traditional methods. Methods: 3D CT models of sixteen paired cadaveric shoulder specimens were reconstructed and angles were measured using 3D modeling softwares. Jigs were developed to track instruments and to correct for scapular motion. A standardized protocol for determining in real-time via electromagnetic tracking the
The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different. A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six shoulder surgeons independently planned a rTSA in each model using prototype development software with the ability to adjust for scapulothoracic orientation, the starting position of the humerus, as well as kinematic planes in a global reference system simulating previously described posture types A, B, and C. ROM with and without posture adjustment was calculated and compared in all movement planes.Aims
Methods
Reverse total shoulder arthroplasty (RTSA) has had rapidly increasingly utilization since its approval for U.S. use in 2004. RTSA accounted for 11% of extremity market procedure growth in 201. Although RTSA is widely used, there remain significant challenges in determining the location and configuration of implants to achieve optimal clinical and functional results. The goal of this study was to measure the 3D position of the shoulder joint center, relative to the center of the native glenoid face, in 16 subjects with RTSA of three different implant designs, and in 12 healthy young shoulders. CT scans of 12 healthy and 16 pre-operative shoulders were segmented to create 3D models of the scapula and humerus. A standardized bone coordinate system was defined for each bone (Figure 1). For healthy shoulders, the location of the humeral head center was measured relative to the
Introduction:. The complex 3D geometry of the scapula and the variability among individuals makes it difficult to precisely quantify its morphometric features. Recently, the scapular neck has been recognized as an important morphometric parameter particularly due to the role it plays in scapular notching, which occurs when the humeral component of a reverse shoulder arthroplasty (RSA) prosthesis engages the posterior column of the scapula causing mechanical impingement and osseous wear. Prosthetic design and positioning of the glenoid component have been accepted as two major factors associated with the onset of notching in the RSA patient population. The present image-based study aimed to develop an objective 3D approach of measuring scapular neck, which when measured pre-operatively, may identify individuals at risk for notching. Materials and Methods:. A group of 81 subjects (41 M, 69.7 ± 8.9 yrs.; 40 F, 70.9 ± 8.1 yrs.) treated with RSA were evaluated in this study. The 3D point-cloud of the scapular geometry was obtained from pre-operative computed tomography (CT) scans and rendered in Mimics. Subsequently, a subject-specific glenoid coordinate system was established, using the extracted glenoid surface of each scapula as a coordinate reference. The principal component analysis approach was used to establish three orthogonal coordinate axes in the geometric center of the glenoid. Utilization of glenoid-specific reference planes (glenoid, major axis, and minor axis plane) were selected in order to remove subjectivity in assessing “true” anterior/posterior and profile views of the scapula. The scapular neck length was defined as the orthogonal distance between the glenoid surface and the point on the posterior column with the significant change of curvature (Fig. 1). In addition, the angle between the glenoid plane, area center of the glenoid, and the point of significant change of the curvature were assessed (Fig. 2). This new parameter was developed to serve as a predictive critical value for the occurrence of notching. The incidence of notching increases as the value of the notching angle decreases. In order to evaluate relationships between glenoid and scapular neck, the glenoid width and height was also measured at the glenoid plane. Results:. Glenoid neck length and notching angle within the population were normally distributed with mean values of 7.8 ± 2.3 mm and 19.6 ± 4.8°, respectively (Fig. 3). No gender difference was found (p = 0.676). In one subject, a glenoid neck length of less than 1 mm was measured with the notching angle less than 2.5°. No association between glenoid neck length and glenoid size were identified (vs. glen. height r. 2. = 0.001, and vs. glen. width r. 2. = 0.05). Conclusion:. The present study reported on the scapular neck length and notching angle as measureable morphometric parameters that follow a normal distribution throughout the population and that are not correlated to the subject's glenoid size. Pre-operative acquisition of these novel and unique CT-based measurements may promote more appropriate RSA prosthesis selection to account for subject-specific anatomy in an effort to avoid scapular notching. Inferior placement of a baseplate or lateralization of
Lateralizing the center of rotation in reverse shoulder arthroplasty has been the subject of renewed interest due to complications associated with medialized center of rotation implants. Benefits of lateralization include: increased joint stability, decreased incidence of scapular notching, increased range of motion, and cosmetic appeal. However, lateralization may be associated with increased risk of glenoid loosening, which may result from the increased shear forces and the bending stresses that manifest at the bone-implant interface. To address glenoid loosening in reverse implants with lateralized joint centers, recent studies have focused on testing and improving implant fixation. However, these studies use loads derived from literature specific to subjects with normal anatomy. The aim of this study is to characterize how joint center lateralization affects the loading in reverse shoulder arthroplasty. Using an established computational shoulder model that describes the geometry of a commercial reverse prosthesis (DELTA® III, DePuy), motion in abduction, scapular plane elevation, and forward flexion was simulated. The simulations were run for five progressively lateralized centers of rotation: −5, 0, +5, +10, and +15 mm (Figure 1). The model was modified to simulate a full thickness rotator cuff tear, where all cuff musculature except Teres Minor were excluded, to reflect the clinical indication for reverse shoulder arthroplasty on cuff tear arthropathy patients. To analyze the joint contact forces, the resultant glenohumeral force was decomposed into compression, anterior-posterior shear, and superior-inferior shear on the
