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Nolte AK, Jäger S, Seifert MM, Bülhoff M, Schiltenwolf M, Schonhoff M, Raiss P, Renkawitz T, Kretzer JP, Panzram B. Capsule elongation occurs after first time shoulder dislocation A biomechanical in-vitro investigation on human cadaveric specimen. J Orthop 2024; 51:130-136. [PMID: 38384727 PMCID: PMC10878837 DOI: 10.1016/j.jor.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024] Open
Abstract
Purpose As capsule elongation is assumed to weaken the static stability of the shoulder joint, the purpose of this biomechanical study was to demonstrate that capsule elongation occurs immediately after a first-time shoulder dislocation and not just after recurrent dislocation events. We hypothesize an increment in joint clearance due to joint capsule elongation after a first-time dislocation. Methods An experimental in-vitro study was conducted on 6 paired fresh frozen human shoulders (4 females; 2 males; 12 specimen) with a mean age of 80 (Range 67-89) years. The shoulder joint with the articular capsule was exposed and an inferior static tension force of 2.5 N was applied to the humerus prior to dislocation. Next, the humeral head was dislocated and was then immediately reduced back into the start position. The joint gap as well as joint capsule deformation was assessed using optical techniques. Results The radiographic joint gap increased from 13.7 ± 6.9 mm (prior to dislocation) to 18.1 ± 6.5 mm (post dislocation) (p < .001). The increase in joint clearance was 4.4 mm. The joint capsule elongated from 5.9 ± 0.005 % (prior to dislocation) to 9.4 ± 0.007 % (post dislocation) (p < .001). The mean increase in joint capsule elongation was 3.5 %. Conclusions Capsule elongation was observed immediately after a simulated first-time shoulder dislocation in an in-vitro model of elderly human cadavers. It might therefore not only be a phenomenon of recurrent dislocation events.
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Affiliation(s)
- Anna-Katharina Nolte
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Sebastian Jäger
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Maxime Marie Seifert
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Matthias Bülhoff
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Marcus Schiltenwolf
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Mareike Schonhoff
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Patric Raiss
- OCM (Orthopadische Chirurgie Munchen), Steinerstraße 6, 81369, Munich, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - J. Philippe Kretzer
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Benjamin Panzram
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
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Effect of intraarticular pressure on glenohumeral kinematics during a simulated abduction motion: a cadaveric study. BMC Musculoskelet Disord 2023; 24:105. [PMID: 36750786 PMCID: PMC9906871 DOI: 10.1186/s12891-023-06127-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The current understanding of glenohumeral joint stability is defined by active restrictions and passive stabilizers including naturally-occurring negative intraarticular pressure. Cadaveric specimens have been used to evaluate the role of intraarticular pressure on joint stability, although, while the shoulder's negative intraarticular pressure is universally acknowledged, it has been inconsistently accounted for. HYPOTHESIS During continuous, passive humeral abduction, releasing the native intraarticular pressure increases joint translation, and restoring this pressure decreases joint translations. STUDY DESIGN Descriptive Laboratory Study. METHODS A validated shoulder testing system was used to passively abduct the humerus in the scapular plane and measure joint translations for seven (n = 7) cadaveric specimens. The pressure within the glenohumeral joint was measured via a 25-gauge needle during passive abduction of the arm, which was released and subsequently restored. During motion, the rotator cuff muscles were loaded using stepper motors in a force feedback loop and electromagnetic sensors were used to continuously measure the position of the humerus and scapula. Joint translation was defined according to the instant center of rotation of the glenohumeral head according to the recommendations by the International Society of Biomechanics. RESULTS Area under the translation versus abduction angle curve suggests that releasing the pressure within the capsule results in significantly less posterior translation of the glenohumeral head as compared to intact (85-90˚, p < 0.05). Posterior and superior translations were reduced after 70˚ of abduction when the pressure within the joint was restored. CONCLUSION With our testing system employing a smooth continuous passive motion, we were able to show that releasing intraarticular pressure does not have a major effect on the path of humeral head motion during glenohumeral abduction. However, both violating the capsule and restoring intraarticular pressure after releasing alter glenohumeral translations. Future studies should study the effect of simultaneous external rotation and abduction on the relationship between joint motion and IAP, especially in higher degrees of abduction. CLINICAL RELEVANCE Thoroughly simulating the glenohumeral joint environment in the cadaveric setting may strengthen the conclusions that can be translated from this setting to the clinic.
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Yoshida M, Takenaga T, Chan CK, Musahl V, Debski RE, Lin A. Location and magnitude of capsular injuries varies following multiple anterior dislocations of the shoulder: Implications for surgical repair. J Orthop Res 2021; 39:648-656. [PMID: 32940940 DOI: 10.1002/jor.24860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
Capsular injuries can occur during multiple shoulder dislocations. The purpose of this study is to evaluate the location and magnitude of glenohumeral capsular injury following multiple dislocations. We hypothesized that the magnitude of capsular injury would increase and the location of peak injury would vary depending on the number of dislocations. Seven fresh-frozen cadaveric shoulders were used. A 7 × 11 grid of strain markers was affixed to the anteroinferior capsule. Each joint was then mounted to a six degree-freedom robotic testing system. Marker tracking was performed following 1, 2, 3, 4, 5, and 10 dislocations to determine the nonrecoverable strain as capsular injury. Following each dislocation, the magnitude of the maximum principal strain representing the nonrecoverable strain in the inferior glenohumeral capsule was quantified by comparing the strain marker positions following each dislocation. The peak value of nonrecoverable strain statistically increased with the number of dislocations in five of seven specimens (p = .0007). The capsular location that had the peak value of nonrecoverable strain varied according to the number of dislocations, and from specimen to specimen. The nonrecoverable strain was identified in the posterior capsule and anterior axillary pouch, which increased with the number of dislocations compared to the other regions of the capsule (p = .001-.012) by up to 16%. Clinical significance: While plication of the anterior axillary pouch is important following multiple dislocations, a more extensive anterior capsular shift may be necessary with an increased number of dislocations in addition to a posterior capsular shift when appropriate.
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Affiliation(s)
- Masahito Yoshida
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tetsuya Takenaga
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Calvin K Chan
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard E Debski
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Albert Lin
- Orthopedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Arenas-Miquelez A, Karargyris O, Zumstein M. All-Arthroscopic, 270° Reconstruction of the Inferior Glenohumeral Ligament With Palmaris Longus Autograft. Arthrosc Tech 2019; 8:e1145-e1151. [PMID: 31921588 PMCID: PMC6948136 DOI: 10.1016/j.eats.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/08/2019] [Indexed: 02/03/2023] Open
Abstract
Numerous factors play a role in anterior shoulder stability. The inferior glenohumeral ligament, especially the anterior band, is the main passive anterior stabilizer in the end range of motion. Surgical treatment of this pathology continues to be a challenge in patients with capsular deficiency, in whom the recurrence rate of soft-tissue arthroscopic repair increases significantly. There is not yet a fair solution for these patients without glenoid bone loss, in whom the poor tissue quality determines recurrent instability. We present an all-arthroscopic technique for reconstruction of the inferior glenohumeral ligament by means of palmaris longus autograft as an alternative to nonanatomic bone block procedures.
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Affiliation(s)
| | | | - Matthias Zumstein
- Address correspondence to Matthias Zumstein, M.D., Shoulder and Elbow Division, Orthopaedics Department, Inselspital, Universitätsspital Bern, Freiburgstrasse, Bern CH-3010, Switzerland.
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Williamson P, Mohamadi A, Ramappa AJ, DeAngelis JP, Nazarian A. Shoulder biomechanics of RC repair and Instability: A systematic review of cadaveric methodology. J Biomech 2019; 82:280-290. [DOI: 10.1016/j.jbiomech.2018.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/19/2018] [Accepted: 11/01/2018] [Indexed: 01/11/2023]
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Rainis CA, Browe DP, McMahon PJ, Debski RE. Capsule function following anterior dislocation: implications for diagnosis of shoulder instability. J Orthop Res 2013; 31:962-8. [PMID: 23335098 DOI: 10.1002/jor.22300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/30/2012] [Indexed: 02/04/2023]
Abstract
During shoulder dislocation, the glenohumeral capsule undergoes non-recoverable strain, leading to joint instability. Clinicians use physical exams to diagnose injury and direct repair procedures; however, they are subjective and do not provide quantitative information. Our objectives were to: (1) determine the relationship between capsule function following anterior dislocation and non-recoverable strain; and (2) identify joint positions at which physical exams can be used to detect non-recoverable strain in specific capsule regions. Physical exams were simulated at three joint positions including external rotation (ER) using robotic technology before and after anterior dislocation. The resulting joint kinematics, strain distribution in the capsule, and non-recoverable strain were determined. Following dislocation, anterior translation increased by as much as 48% (0° ER: p = 0.03; 30° ER: p = 0.03; 60° ER: p < 0.01). Capsule sub-regions with less non-recoverable strain required more ER to detect differences in the strain ratios between the intact and injured joint. Strain ratio changes on the humeral side of the posterior axillary pouch (0.31 ± 0.32) were significant at all joint positions (0° ER: p = 0.03; 30° ER: p = 0.048; 60° ER: p = 0.04), whereas strain ratio differences on the humeral side of the anterior axillary pouch (0.18 ± 0.21) were significant only at 60° of ER (p = 0.03). Therefore, standardizing physical exams for joint position could help surgeons identify specific locations of non-recoverable strain that may have been ignored.
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Affiliation(s)
- Carrie A Rainis
- Department of Bioengineering, Swanson School of Engineering, Musculoskeletal Research Center, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, Pennsylvania 15219, USA
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Browe DP, Rainis CA, McMahon PJ, Debski RE. Injury to the anteroinferior glenohumeral capsule during anterior dislocation. Clin Biomech (Bristol, Avon) 2013; 28:140-5. [PMID: 23332942 DOI: 10.1016/j.clinbiomech.2012.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Glenohumeral dislocation commonly results in permanent deformation of the glenohumeral capsule. Knowing the location and extent of tissue damage may aid in improving diagnostic and repair procedures for shoulder dislocations. Therefore, the objectives of this study were to determine: (1) the strain in the anteroinferior capsule at dislocation and (2) the location and extent of injury to the anteroinferior capsule due to dislocation by quantifying the resulting non-recoverable strain. METHODS A robotic/universal force-moment sensor testing system was used to anteriorly dislocate six cadaveric shoulders. The magnitude of the maximum principle strain at dislocation and the resulting non-recoverable strain due to dislocation in the anteroinferior capsule were measured by tracking the change in the location of a grid of strain markers from a reference position. FINDINGS The glenoid side of the capsule experienced higher strains at dislocation than the humeral side. The greatest strains at dislocation were found on the glenoid side of the anterior band (strain ratio of 0.60), but the greatest non-recoverable strains were found in the posterior axillary pouch (strain ratio of 0.34 on the glenoid side and 0.31 on the humeral side). INTERPRETATION These findings suggest that even though the glenoid side of the anterior band undergoes more deformation during anterior dislocation, the most permanent deformation occurs in the posterior axillary pouch, and surgeons should consider also plicating the posterior axillary pouch when performing repair procedures following anterior dislocation. In the future, the mechanical properties of the normal and injured glenohumeral capsules will be compared.
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Affiliation(s)
- Daniel P Browe
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA 15219, USA
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Effects of simulated injury on the anteroinferior glenohumeral capsule. Med Biol Eng Comput 2012; 50:1299-307. [PMID: 23054378 DOI: 10.1007/s11517-012-0961-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 09/25/2012] [Indexed: 10/27/2022]
Abstract
Glenohumeral dislocation results in permanent deformation (nonrecoverable strain) of the glenohumeral capsule which leads to increased range of motion and recurrent instability. Minimal research has examined the effects of injury on the biomechanical properties of the capsule which may contribute to poor patient outcome following repair procedures. The objective of this study was to determine the effect of simulated injury on the stiffness and material properties of the AB-IGHL during tensile deformation. Using a combined experimental and computational methodology, the stiffness and material properties of six AB-IGHL samples during tensile elongation were determined before and after simulated injury. The AB-IGHL was subjected to 12.7 ± 3.2 % maximum principal strain which resulted in 2.5 ± 0.9 % nonrecoverable strain. The linear region stiffness and modulus of stress-stretch curves between the normal (52.4 ± 30.0 N/mm, 39.1 ± 26.6 MPa) and injured (64.7 ± 21.3 N/mm, 73.5 ± 53.8 MPa) AB-IGHL increased significantly (p = 0.03, p = 0.04). These increases suggest that changes in the tissue microstructure exist following simulated injury. The injured tissue could contain more aligned collagen fibers and may not be able to support a normal range of joint motion. Collagen fiber kinematics during simulated injury will be examined in the future.
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Sahoo S, Greeson CB, McCarron JA, Milks RA, Aurora A, Walker E, Iannotti JP, Derwin KA. Effect of pretension and suture needle type on mechanical properties of acellular human dermis patches for rotator cuff repair. J Shoulder Elbow Surg 2012; 21:1413-21. [PMID: 22265765 DOI: 10.1016/j.jse.2011.10.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 09/12/2011] [Accepted: 10/23/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dermal grafts are used for rotator cuff repair and augmentation. Although the in vitro biomechanical properties of dermal grafts have been reported previously, clinical questions related to their biomechanical performance as a surgical construct and the effect of surgical variables that could potentially improve repair outcomes have not been studied. METHODS This study evaluated the failure and fatigue biomechanics of acellular dermis constructs tested in a clinically relevant size (4 × 4 cm patches) and manner (loaded via sutures) for rotator cuff repair. Also investigated were the effect of 2 surgical variables: (1) the fixation of grafts under varying magnitudes of pretension (0, 10, 20N), and (2) the use of reverse-cutting vs tapered needles for suturing grafts. RESULTS Dermis constructs stretched ∼25% before bearing significant loads in the high stiffness region. Although 91% of the patches withstood 2500 cycles of loading to 150 N, the constructs stretched 13 to 19 mm after fatigue loading. This elongation could be reduced by 20% to 32% when reverse-cutting needles were used to prepare constructs or by applying 20 N of in situ circumferential pretension to the constructs before loading. CONCLUSIONS Although dermis patches demonstrated robustness for use in rotator cuff repair, the patches underwent significant, substantial, and presumably nonrecoverable elongation, even at low physiologic loads. This study indicates that use of reverse-cutting needles for suture passage, preconditioning (cyclically stretching several times), and/or surgical fixation under at least 20 N of circumferential pretension could be developed as strategies to reduce compliance of dermis for its use for rotator cuff repair.
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Affiliation(s)
- Sambit Sahoo
- Department of Biomedical Engineering and Orthopedic and Rheumatologic Research Center, Cleveland Clinic, Cleveland, OH, USA
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