Relevance of arm position and muscle activity on three-dimensional glenohumeral translation in patients with traumatic and atraumatic shoulder instability

Imaging modalities for atraumatic shoulder hypermobility: a scoping review

BACKGROUND

Objective measures from imaging studies have the potential to assist in timely diagnosis of atraumatic shoulder hypermobility to better guide management. The aim of this scoping review is to examine imaging modalities and techniques used to characterize atraumatic shoulder hypermobility.

METHODS

MEDLINE, EMBASE, SPORTDiscus, Cochrane Library, and Web of Science were searched up to May 2024 for any primary study investigating imaging findings seen in atraumatic shoulder hypermobility. Patients with unilateral instability were excluded given its frequent association with traumatic origin.

RESULTS

Eighteen observational studies met inclusion criteria. Results were divided into outcomes relating to capsular redundancy, glenohumeral anatomy, and muscle activation. Five studies using magnetic resonance arthrography (MRA) demonstrated statistically significant increases in capsular cross-sectional area (CSA), while a significant superior capsular elongation was reported by two studies in patients with multidirectional instability (MDI). Labrocapsular distance, glenocapsular ratio, and the presence of a combined sail and triangle sign on MRA were highly sensitive and specific parameters for identifying MDI. There were inconsistent findings for alterations of glenohumeral anatomy. Ultrasound assessments of acromiohumeral distance (AHD) were significantly increased in patients with MDI, but not in shoulders with hypermobility alone. Similarly, muscle activity measured by electromyography or glenohumeral translations differed significantly in patients with MDI, but not in those with hypermobility alone.

CONCLUSION

Radiographic markers of capsular redundancy (e.g., CSA, labrocapsular distance, glenocapsular ratio), AHD, and muscular activity are useful in the diagnosis of MDI. However, there are no definitive imaging markers for diagnosing atraumatic shoulder hypermobility without MDI.

Glenohumeral joint kinematics during apprehension-relocation test in patients with anterior shoulder instability and glenoid bone loss

Aims

This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient's contralateral healthy shoulder.

Methods

A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient's shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid.

Results

During the apprehension test, the centre of the humeral head was 1.0 mm (95% CI 0.0 to 2.0) more inferior on the glenoid for the ASI shoulder compared with the healthy shoulder. Furthermore, the contact point of the ASI shoulder was 1.4 mm (95% CI 0.3 to 2.5) more anterior and 2.0 mm (95% CI 0.8 to 3.1) more inferior on the glenoid compared with the healthy shoulder. The contact point of the ASI shoulder was 1.2 mm (95% CI 0.2 to 2.6) more anterior during the apprehension test compared to the relocation test.

Conclusion

The humeral head centre was located more inferior, and the GHJ contact point was located both more anterior and inferior during the apprehension test for the ASI shoulders than the healthy shoulders. Furthermore, the contact point displacement between the apprehension and relocation test revealed increased joint laxity for the ASI shoulder than the healthy shoulders. These results contribute to existing knowledge that ASI shoulders with glenoid bone loss may also suffer from inferior shoulder instability.

Minimal but potentially clinically relevant anteroinferior position of the humeral head following traumatic anterior shoulder dislocations: A 3D-CT analysis

In unstable shoulders, excessive anteroinferior position of the humeral head relative to the glenoid can lead to a dislocation. Measuring humeral head position could therefore be valuable in quantifying shoulder laxity. The aim of this study was to measure (1) position of the humeral head relative to the glenoid and (2) joint space thickness during passive motion in unstable shoulders caused by traumatic anterior dislocations and in contralateral uninjured shoulders. A prospective cross-sectional CT-study was performed in patients with unilateral anterior shoulder instability. Patients underwent CT scanning of both injured and uninjured side in supine position (0° abduction and 0° external rotation) and in 60°, 90°, and 120° of abduction with 90° of external rotation without an external load. Subsequently, 3D virtual models were created of the humerus and the scapula to create a glenoid coordinate system to identify poster-anterior, inferior-superior, and lateral-medial position of the humeral head relative to the glenoid. Joint space thickness was defined as the average distance between the subchondral bone surfaces of the humeral head and glenoid. Fifteen consecutive patients were included. In supine position, the humeral head was positioned more anteriorly (p = 0.004), inferiorly (p = 0.019), and laterally (p = 0.021) in the injured compared to the uninjured shoulder. No differences were observed in any of the other positions. A joint-space thickness map, showing the bone-to-bone distances, identified the Hill-Sachs lesion footprint on the glenoid surface in external rotation and abduction, but no differences on average joint space thickness were observed in any position.

Three-dimensional measurements of scapular kinematics: Interrater reliability and validation of a skin marker-based model against an intracortical pin model

A skin marker-based motion capture model providing measures of scapular rotations was recently developed. The aim of this study was to investigate the concurrent validity and the interrater reliability of the model. Shoulder range of motion (RoM) and activities of daily living (ADL) were tested in healthy volunteers with reflective markers on the scapula and thorax. To investigate the validity, the model was compared to simultaneous data collection from markers on a scapular intracortical pin. The interrater reliability was tested by comparing the skin marker-based protocol performed by two investigators. The mean root mean square error (RMSE) and the intraclass correlation coefficient (ICC(2,1)) were calculated to determine the validity and the interrater reliability, respectively. Eight subjects were included in the validity test: female/male = 2/6, mean (SD) age 35.0 (3.0) and BMI 23.4 (3.3). The mean RMSE of all scapular rotations ranged 2.3-6.7° during shoulder RoM and 2.4-7.6° during ADL. The highest errors were seen during sagittal and scapular plane flexions, hair combing and eating. The reliability test included twenty subjects: female/male = 8/12, mean (SD) age 31.4 (4.9) and BMI 22.9 (1.7). The ICC(2,1) for measuring protraction ranged 0.07-0.60 during RoM and 0.27-0.69 for ADL, for upward rotation the corresponding ICC(2,1) ranged 0.01-0.64 and 0.38-0.60, and anterior tilt 0.25-0.83 and 0.25-0.62. The validity and interrater reliability of the model are task dependent, and interpretation should be made with caution. The model provides quantitative measurements for objective assessment of scapular movements and can potentially supplement the clinical examination in certain motion tasks.

Stabilizing Mechanisms in Patients Treated Using Hill-Sachs Remplissage With Bankart Repair in Abduction-External Rotation Position

BACKGROUND

Hill-Sachs lesion (HSL) remplissage with Bankart repair (RMBR) provides a minimally invasive solution for treating HSLs and glenoid bone defects of <25%. The infraspinatus tendon is inserted into the HSL during the remplissage process, causing the infraspinatus to shift medially, leading to an unknown effect on glenohumeral alignment during the resting abduction-external rotation (ABER) and muscle-active states.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the possible check-rein effect and muscle-active control in stabilizing the glenohumeral joint after RMBR in vivo. We hypothesized that the check-rein effect and active control would stabilize the glenohumeral joint in the ABER position in patients after RMBR.

STUDY DESIGN

Controlled laboratory study.

METHODS

We included 42 participants-22 patients in group A who met the inclusion criteria after RMBR and 20 healthy participants in group B without shoulder laxity. Three-dimensional magnetic resonance imaging was performed to analyze the alignment relationship of the glenohumeral joint with and without muscular activity. Ultrasonic shear wave elastography was used to evaluate the elastic properties of the anterior capsule covered with the anterior bands of the inferior glenohumeral ligament.

RESULTS

Patients who underwent RMBR demonstrated more posterior (-1.81 ± 1.19 mm vs -0.76 ± 1.25 mm; P = .008) and inferior (-1.05 ± 0.62 mm vs -0.45 ± 0.48 mm; P = .001) shifts of the humeral head rotation center and less anterior capsular elasticity (70.07 ± 22.60 kPa vs 84.01 ± 14.08 kPa; P = .023) than healthy participants in the resting ABER state. More posterior (-3.17 ± 0.84 mm vs -1.81 ± 1.19 mm; P < .001) and less-inferior (-0.34 ± 0.56 mm vs -1.05 ± 0.62 mm; P < .001) shifts of the humeral head rotation center and less anterior capsular elasticity (36.57 ± 13.89 kPa vs 70.07 ± 22.60 kPa; P < .001) were observed in the operative shoulder during muscle-active ABER than in resting ABER states.

CONCLUSION

The check-rein effect and muscle-active control act as stabilizing mechanisms in RMBR during the ABER position.

CLINICAL RELEVANCE

Stabilizing mechanisms in RMBR during the ABER position include the check-rein effect and muscle-active control.

The arthroscopic double-button Latarjet does not modify the static posterior translation of the humeral head

INTRODUCTION

The Latarjet procedure treats anterior instability of the shoulder and is based on a triple anterior lock, where the conjoint tendon straps the lower third of the subscapularis muscle. Excessive posterior translation of the humeral head is a known risk factor for shoulder osteoarthritis. No in vivo study has investigated the effect of the bone block on the posterior static translation of the humeral epiphysis. The purpose of this study was to evaluate the effect of the bone block on the static posterior translation of the humeral head. The hypothesis was that this procedure increased this translation.

MATERIALS AND METHODS

This retrospective study included patients treated arthroscopically for anterior shoulder instability by a double-button Latarjet. An independent examiner analyzed the CT scans preoperatively, at 15 days, and at least 6 months postoperatively according to a standardized protocol. The analysis focused on the position of the bone block in the axial and coronal planes relative to the glenoid. The posterior translation was automatically calculated using the Blueprint© planning software.

RESULTS

Thirty-five patients were included with a mean age of 25 years (16-43), according to a 4M/1F sex ratio. The graft was perfectly flush to the subchondral bone in 63% (n=22) of cases and subequatorial in 91% (n=32). Preoperative posterior humeral translation was 52%. The mean immediate postoperative posterior humeral translation was 56%, and 57% at more than 6 months. The change in mean posterior humeral translation between preoperative/6 months was +0.94% [-20%; +12%] (p=0.29) and immediate postoperative/6 months +0.34% [-18%; +15%] (p=0.84). Gender, hypermobility and the axial position of the bone block did not influence the change in posterior humeral translation. The equatorial position of the bone block appeared to increase posterior humeral translation by +10%±5.2% [-0.427; 20.823] (p=0.07).

CONCLUSION

This work refutes our initial hypothesis. The change in static posterior humeral translation after arthroscopic Latarjet bone block remains stable at more than 6 months of follow-up. This procedure does not alter the anatomical position of the humeral head in relation to the glenoid. On the other hand, a more cranial positioning of the bone block could have an influence.

LEVEL OF EVIDENCE

IV.

Anterior-posterior glenohumeral translation in shoulders with traumatic anterior instability: a systematic review of the literature

Background

Reports of glenohumeral translation in shoulders with traumatic anterior instability have been presented. The aim of this systematic review was to investigate anterior-posterior translation in shoulders with traumatic anterior instability.

Methods

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies including patients aged ≥15 years with previous traumatic anterior shoulder dislocation or subluxation were included. The outcome was anterior-posterior glenohumeral translation. A search of PubMed, Embase, and Cochrane library was performed on July 17, 2022. Two reviewers individually screened titles and abstracts, reviewed full text, extracted data, and performed quality assessment.

Results

Twenty studies (582 unstable shoulders in total) of varying quality were included. There was a lack of standardization and unity across studies. Radiography, ultrasound, computed tomography, magnetic resonance imaging, motion tracking, instrumentation, and manual testing were used to assess the glenohumeral translation. The glenohumeral translation in unstable shoulders ranged from 0.0 ± 0.8 mm to 11.6 ± 3.7 mm, as measured during various motion tasks, arm positions, and application of external force. The glenohumeral translation was larger or more anteriorly directed in unstable shoulders than in stable when contralateral healthy shoulders or a healthy control group were included in the studies. Several studies found that the humeral head was more anteriorly located on the glenoid in the unstable shoulders.

Conclusion

This systematic review provides an overview of the current literature on glenohumeral translation in traumatic anterior shoulder instability. It was not able to identify a threshold for abnormal translation in unstable shoulders, due to the heterogeneity of data. The review supports that not only the range of translation but also the direction hereof as well as the location of the humeral head on the glenoid seem to be part of the pathophysiology. Technical development and increased attention to research methodology in recent years may provide more knowledge and clarity on this topic in the future.

Ultrasonographic Assessment of Glenohumeral Joint Stability Immediately After Arthroscopic Bankart-Bristow Procedure

Background:

The changes in glenohumeral joint stability after surgery in a clinical setting are yet unknown.

Purpose/Hypothesis:

This study aimed to compare the anterior humeral head translation between pre- and postsurgical conditions using ultrasonography. It was hypothesized that ultrasonographic assessment would reveal decreased anterior translation.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 27 patients (24 male, 3 female; mean age, 24.1 ± 9.7 years) with anterior shoulder instability were studied prospectively. All the patients underwent the arthroscopic Bankart-Bristow procedure under general anesthesia, and ultrasonographic evaluation was performed before and immediately after surgery. The forearm was fixed with an arm positioner in the beach-chair position, and the ultrasonographic transducer was located at the posterior part of the shoulder to visualize the humeral head and glenoid rim at the level of interval between the infraspinatus tendon and teres minor tendon. The upper arm was drawn anteriorly with a 40-N force at 0°, 45°, and 90° of shoulder abduction with neutral rotation. The distance from the posterior edge of the glenoid to that of the humeral head was measured using ultrasonography with and without anterior force. Anterior translation was defined by subtracting the distance with anterior force from the distance without anterior force.

Results:

The humeral head position was translated posteriorly immediately after surgery in all patients. Anterior translation decreased significantly after surgery at 45° (7.7 ± 4.3 vs 5.8 ± 2.0 mm; P = .031) and 90° (8.9 ± 3.4 vs 6.1 ± 2.2 mm; P < .001) of abduction, whereas there was no difference between pre- and postsurgical translation at 0° of abduction (4.9 ± 2.3 vs 4.0 ± 2.1 mm, P = .089).

Conclusion:

Ultrasonographic assessment immediately after a Bankart-Bristow procedure showed the humeral head was translated posteriorly relative to the glenoid at 0°, 45°, and 90° of abduction. The surgery also decreased anterior translation in response to an anteriorly directed force at 45° and 90° of abduction.

Four-dimensional computed tomography evaluation of shoulder joint motion in collegiate baseball pitchers

The purpose of this study is to evaluate the glenohumeral contact area, center of glenohumeral contact area, and center of humeral head during simulated pitching motion in collegiate baseball pitchers using four-dimensional computed tomography (4D CT). We obtained 4D CT data from the dominant and non-dominant shoulders of eight collegiate baseball pitchers during the cocking motion. CT image data of each joint were reconstructed using a 3D reconstruction software package. The glenohumeral contact area, center of glenohumeral contact area, center of humeral head, and oblateness of humeral head were calculated from 3D bone models using customized software. The center of glenohumeral contact area translated from anterior to posterior during maximum external rotation to maximum internal rotation (0.58 ± 0.63 mm on the dominant side and 0.99 ± 0.82 mm on the non-dominant side). The center of humeral head translated from posterior to anterior during maximum external rotation to maximum internal rotation (0.76 ± 0.75 mm on the dominant side and 1.21 ± 0.78 mm on the non-dominant side). The increase in anterior translation of the center of glenohumeral contact area was associated with the increase in posterior translation of the center of humeral head. Also, the increase in translation of the center of humeral head and glenohumeral contact area were associated with the increase in oblateness of the humeral head. 4D CT analyses demonstrated that the center of humeral head translated in the opposite direction to that of the center of glenohumeral contact area during external rotation to internal rotation in abduction in the dominant and non-dominant shoulders. The oblateness of the humeral head may cause this diametric translation. 4D CT scanning and the software for bone surface modeling of the glenohumeral joint enabled quantitative assessment of glenohumeral micromotion and be used for kinematic evaluation of throwing athletes.

Kinematics and biomechanical validity of shoulder joint laxity tests as diagnostic criteria in multidirectional instability

BACKGROUND

Clinical laxity tests are commonly used together to identify individuals with multidirectional instability (MDI). However, their biomechanical validity in distinguishing distinct biomechanical characteristics consistent with MDI has not been demonstrated.

OBJECTIVE

To determine if differences in glenohumeral (GH) joint laxity exist between individuals diagnosed with multidirectional instability (MDI) and asymptomatic matched controls without MDI.

METHODS

Eighteen participants (9 swimmers with MDI, 9 non-swimming asymptomatic matched controls without MDI) participated in this observational study. Participants were classified as having MDI with a composite laxity score from three laxity tests (anterior/posterior drawer and sulcus tests). Single plane dynamic fluoroscopy captured joint motion with 2D-3D joint registration to derive 3D joint kinematics. Average GH translations occurring during the laxity tests were compared between groups using an independent sample's t-test. The relationship of composite laxity scores to overall translations was examined with a simple linear regression. Differences of each laxity test translation between groups were analyzed with a two-way repeated measures ANOVA.

RESULTS

Mean composite translations for swimmers were 1.7 mm greater (p = 0.04, 95% Confidence Interval (CI): 0.1, 3.3 mm) compared to controls. A moderate association occurred (r² = 0.40, p = 0.005) between composite laxity scores and composite translation. Greater translations for the posterior drawer (-2.4 mm, p = 0.04, 95% CI: -0.1, -4.6) and sulcus tests (-2.7 mm, p = 0.03, 95% CI: -0.3, -5.0) existed in swimmers compared to controls.

CONCLUSION

Significant differences in composite translation existed between symptomatic swimmers with MDI and asymptomatic control participants without MDI during GH joint laxity tests. The results provide initial biomechanically based construct validity for the clinical criteria used to identify individuals with MDI.

The glenohumeral micromotion and influence of the glenohumeral ligaments during axial rotation in varying abduction angle

BACKGROUND

The patients with shoulder instability or disorders in overhead athletes have been considered to have an abnormal micromotion at the glenohumeral joint. However, the normal range of the micromotion has not been available during axial rotation with various abduction angles, especially above 90° abduction. This study aimed to investigate the glenohumeral translation and influence of the glenohumeral ligaments during axial rotation with up to maximum abduction.

METHODS

Fourteen healthy volunteers performed active axial rotations at 0°, 90°, 135°, and maximal abduction angles. The positions of the humeral head center relative to the glenoid at maximally external, neutral, and maximally internal rotations (ER, NR, IR, respectively) for each abduction angle were evaluated using two- (2D) and three-dimensional (3D) shape matching registration techniques. The shortest pathway and its length between the origin and insertion of the superior, middle, and inferior glenohumeral ligaments (SGHL, MGHL, and IGHL, respectively) were calculated for each position.

RESULTS

The glenohumeral joint showed 3.1 mm of superoinferior translation during axial rotation at 0° abduction (P < 0.0001), and 2.6 mm and 4.5 mm anteroposterior translation at 135° and maximal abduction (P < 0.0001), respectively. The SGHL and MGHL reached a maximum length at ER with 0° abduction, and the anterior and posterior bands of the IGHL reached a maximum at ER with 90° abduction and IR with 0° abduction.

CONCLUSIONS

These findings indicated that the SGHL played a role as an inferior suppressor at 0° abduction, while the anterior band of IGHL played a role as an anterior stabilizer at 90° abduction. Every glenohumeral ligament did not get taut and the anteroposterior translation became greater with increasing abduction angle, above 90°. These results could be used as a reference when comparing with the pathological shoulders in the future study.

Glenohumeral translation during active external rotation with the shoulder abducted in cases with glenohumeral instability: a 4-dimensional computed tomography analysis

BACKGROUND

Although glenohumeral instability is common, the mechanism of instability remains unclear. The purpose of this study was to quantitatively evaluate humeral head translation during active external rotation with abduction in patients with glenohumeral instability by use of 4-dimensional computed tomography scans.

METHODS

Ten patients with unilateral glenohumeral instability with a positive fulcrum test were prospectively included in this study. Sequential computed tomography of bilateral shoulders during active external rotation at 90° of shoulder abduction was performed for 6 seconds at 5 frames per second. The 3-dimensional positions of the humeral head center in the anteroposterior, superoinferior, and mediolateral directions were calculated at 0°, 20°, 40°, 60°, and maximum shoulder abduction-external rotation from the starting position. Translation of the humeral head center from the starting position was evaluated using Dunnett multiple-comparison tests, and the differences between the affected and intact shoulders were assessed using Wilcoxon signed rank tests.

RESULTS

The humeral head center translated posteriorly, inferiorly, and medially during glenohumeral external rotation with the shoulder in the abducted position on the intact side. However, the affected humeral head showed significantly less posterior translation (P = .028), greater inferior translation (P = .047), and less medial translation (P = .037) than the contralateral side.

CONCLUSIONS

This study indicated that dysfunction of the anterior band of the inferior glenohumeral ligament causes decreased posterior, increased inferior, and decreased medial translation of the humeral head during active shoulder abduction-external rotation.

The Effects of Filgrastim on Complications of Patients with Cerebral Hemorrhage Due To Head Trauma

BACKGROUND

Filgrastim, a neopogen brand, is a blood-forming agent and a natural protein in the body that plays a role in stimulating the growth of white blood cells and protecting them against infectious agents. To the best of knowledge, human and animal specimens have shown the effect of Filgrastim on treating brain injuries regarding bone marrow transfusion into the blood, neuroprotection, stimulation of neurons for forming new neural networks and reducing the risk of bacterial infections.

AIM

This study aimed to investigate the effect of Filgrastim on the prognosis of a cerebral haemorrhage in patients with traumatic brain injury.

METHODS

This study was conducted as a clinical trial, in which the initial diagnosis of patients with cerebral haemorrhage due to head trauma was performed with a clinical examination and CT scan. After the patient arrives at the emergency room, the patient's initial examination is performed, and blood tests are taken from the patient. Moreover, CBC values (Hb, Platelet, Hematocrit) were checked and recorded in the checklist. The intervention group received 150 mcg/day Filgrastim injected subcutaneously for 4 days. Furthermore, patients in the control group received the same amount of sterile water. At the end of the treatment period, blood tests were performed again in all patients, and their results were then recorded. All data were analysed by SPSS v.21 software package.

RESULTS

Our findings revealed that the mean volume of bleeding in the intervention group based on CT scan was significantly reduced after four days as compared to the control group. Moreover, the mean score of consciousness and muscular strength of patients in the intervention group was significantly higher than the control group. Also, WBCs in the intervention group exhibited a significant increase after four days of intervention, while platelet and hematocrit levels in the intervention group decreased significantly compared to the control group.

CONCLUSION

Regarding the results, the therapeutic application of filtration is considered to be effective. Given the lack of serious complications of the proposed dosages, the use of this drug can be suggested.

Dynamic kinematics of the glenohumeral joint in shoulders with rotator cuff tears

Background

No clear trend has emerged from the literature regarding three-dimensional (3D) translations of the humerus relative to the scapula in shoulders with rotator cuff tears (RCTs). The purpose of this study was to evaluate the kinematics of RCT shoulders using 3D-to-two-dimensional (2D) model-to-image registration techniques.

Methods

Dynamic glenohumeral kinematics during scapular plane abduction and axial rotation were analyzed in 11 RCT patients and 10 healthy control subjects. We measured the 3D kinematic parameters of glenohumeral joints using X-ray images and CT-derived digitally reconstructed radiographs.

Results

For scapular plane abduction, the humeral head center was positioned significantly more medially in shoulders with RCTs than in controls at 135° of humeral abduction (p = 0.02; RCTs versus controls: − 0.9 ± 1.6 versus 0.3 ± 1.3 mm). There was no significant difference in the superior/inferior translation of the humeral head center (p = 0.99). For axial rotation in adducted position, the humeral head center was positioned significantly more anteriorly in shoulders with RCTs than in controls at − 30° of glenohumeral external rotation (p < 0.0001; RCTs versus controls: 3.0 ± 1.7 versus 0.3 ± 1.5 mm).

Conclusions

This study revealed the kinematics of shoulders with large to massive full-thickness RCTs: the humeral head center showed a medial shift at the late phase of scapular plane full abduction, and an anterior shift at the internal rotation position during full axial rotation. The kinematic data in this study, which describe the patterns of movement of shoulders with large to massive full-thickness RCTs, provide valuable information for future studies investigating glenohumeral translations in other pathological conditions of the shoulder. For clinical relevance, quantitative assessment of the dynamic kinematics of shoulders with RCTs might be a therapeutic indicator for achieving functional restoration.

In vivo kinematic analysis of the glenohumeral joint during dynamic full axial rotation and scapular plane full abduction in healthy shoulders

PURPOSE

The purpose of this study was to evaluate the kinematics of healthy shoulders during dynamic full axial rotation and scapular plane full abduction using three-dimensional (3D)-to-two-dimensional (2D) model-to-image registration techniques.

METHODS

Dynamic glenohumeral kinematics during axial rotation and scapular plane abduction were analysed in 10 healthy participants. Continuous radiographic images of axial rotation and scapular plane abduction were taken using a flat panel radiographic detector. The participants received a computed tomography scan to generate virtual digitally reconstructed radiographs. The density-based digitally reconstructed radiographs were then compared with the serial radiographic images acquired using image correlations. These 3D-to-2D model-to-image registration techniques determined the 3D positions and orientations of the humerus and scapula during dynamic full axial rotation and scapular plane full abduction.

RESULTS

The humeral head centre translated an average of 2.5 ± 3.1 mm posteriorly, and 1.4 ± 1.0 mm superiorly in the early phase, then an average of 2.0 ± 0.8 mm inferiorly in the late phase during external rotation motion. The glenohumeral external rotation angle had a significant effect on the anterior/posterior (A/P) and superior/inferior (S/I) translation of the humeral head centre (both p < 0.05). 33.6 ± 15.6° of glenohumeral external rotation occurred during scapular plane abduction. The humeral head centre translated an average of 0.6 ± 0.9 mm superiorly in the early phase, then 1.7 ± 2.6 mm inferiorly in the late phase, and translated an average of 0.4 ± 0.5 mm medially in the early phase, then 1.6 ± 1.0 mm laterally in the late phase during scapular plane abduction. The humeral abduction angle had a significant effect on the S/I and lateral/medial (L/M) translation of the humeral head centre (both p < 0.05).

CONCLUSION

This study investigated 3D translations of the humerus relative to the scapula: during scapular plane full abduction, the humerus rotated 33.6° externally relative to the scapula, and during external rotation motion in the adducted position, the humeral head centre translated an average of 2.5 mm posteriorly. Kinematic data will provide important insights into evaluating the kinematics of pathological shoulders. For clinical relevance, quantitative assessment of dynamic healthy shoulder kinematics might be a physiological indicator for the assessment of pathological shoulders.

Shoulder proprioception - lessons we learned from idiopathic frozen shoulder

Background

Of all the most frequent soft tissue disorders of the shoulder, idiopathic frozen shoulder (IFS) offers the greatest potential for studying proprioception. Studies concerning the presence of proprioception dysfunctions have failed to determine the potential for spontaneous healing of passive shoulder stabilizers (anterior and posterior capsule, middle and inferior gleno-humeral ligaments), its relationship with passive (PJPS) and active (AJPS) shoulder proprioception for internal and external rotation (IR, ER), as well as the isokinetic muscle performance of the internal and external rotators. This study investigates these dependencies in the case of arthroscopic release of IFS.

Methods

The study group comprised 23 patients (average aged 54.2) who underwent arthroscopic release due to IFS and 20 healthy volunteers. The average follow-up time was 29.2 months. The Biodex system was used for proprioception measurement in a modified neutral arm position and isokinetic evaluation. The results were analysed using the T-test, Wilcoxon and interclass correlation coefficient. P-values lower than 0.05 were considered significant.

Results

Statistically significant differences were found between involved (I) and uninvolved (U) shoulders only in the cases of PJPS and AJPS, peak torque, time to peak torque and acceleration time for ER (p < 0.05). No statistically significant difference was noted between PJPS IR and PJPS ER or between AJPS IR and AJPS ER (p > 0.05) for the U shoulders.

Conclusions

The anatomical structure of anterior (capsule, middle and anterior band of inferior gleno-humeral ligament) and posterior (capsule and posterior band of inferior gleno-humeral ligament) passive shoulder restraints has no impact on the difference in PJPS values between ER and IR in a modified neutral shoulder position. The potential for spontaneous healing of the anterior and posterior passive shoulder restraints influences PJPS recovery after arthroscopic release of IFS. ER peak torque deficits negatively affect AJPS values. PJPS and AJPS of ER and IR can be measured with a high level of reproducibility using an isokinetic dynamometer with the arm in a modified neutral shoulder position. Differences greater than 15 % for PJPS and >24 % for AJPS for ER and IR can be helpful for future studies as baseline data for identification of particular passive and active shoulder stabilizers at risk.

Glenohumeral translation in ABER position during muscle activity in patients treated with Latarjet procedure: an in vivo MRI study

PURPOSE

The Latarjet procedure is frequently performed when treating traumatic anteroinferior shoulder instability. This procedure is supposed to have a triple effect: osseous, muscular and ligamentous. The main stabilizing mechanism in cadaver studies on fresh-frozen shoulders seems to be the sling effect produced by the subscapularis and the conjoint tendon. It has been hypothesized that muscle contraction in ABER position (abduction-external rotation) is able to translate the humeral head posteriorly and superiorly due to the sling effect. The aim of this study was to analyse the humeral head translation relative to the glenoid with the arm in ABER position with and without muscle contraction.

METHODS

Twenty-one subjects divided into two groups (Group A: after Latarjet; Group B: healthy subjects) were examined with an open MRI system with the shoulder in abduction-external rotation (ABER) position to analyse humeral head translation during muscle activity.

RESULTS

In normal shoulders, there was no significant difference in anteroposterior or superoinferior translation between the rest position and the muscle-activated state. In subjects after the Latarjet procedure, the difference was significant and was also significant between both groups of subjects for posterior translation, but not for superior translation.

CONCLUSION

In patients treated with Latarjet procedure, there are significant changes in glenohumeral translation during muscular activity when in ABER position, with the humeral head going more posteriorly, in comparison with normal shoulders. This study confirms the stabilizing sling effect of the transposed conjoint tendon in the ABER position.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

Effect of Arthroscopic Stabilization on In Vivo Glenohumeral Joint Motion and Clinical Outcomes in Patients With Anterior Instability

BACKGROUND

Glenohumeral joint (GHJ) dislocations are common, and the resulting shoulder instability is often treated with arthroscopic stabilization. These procedures result in favorable clinical outcomes, but abnormal GHJ motion may persist, which may place patients at risk for developing osteoarthritis. However, the effects of shoulder instability and arthroscopic stabilization on GHJ motion are not well understood.

HYPOTHESIS

GHJ motion is significantly influenced by anterior instability and arthroscopic stabilization, but postsurgical measures of GHJ motion are not different from those of control subjects.

STUDY DESIGN

Controlled laboratory study.

METHODS

In vivo GHJ motion was measured by applying a computed tomographic model-based tracking technique to biplane radiographic images acquired during an apprehension test in healthy control subjects (n = 11) and anterior instability patients (n = 11). Patients were tested before surgery and at 6 months after surgery. Control subjects were tested once. Shoulder strength, active range of motion (ROM), and the Western Ontario Shoulder Instability (WOSI) index were also measured.

RESULTS

Before surgery, the humerus of the instability patients during the apprehension test was located significantly more anteriorly on the glenoid (7.9% of glenoid width; 2.1 mm) compared with that of the controls (P = .03), but arthroscopic stabilization moved this joint contact location posteriorly on the glenoid (4.7% of glenoid width; 1.1 mm; P = .03). After surgery, GHJ excursion during the apprehension test was significantly lower (14.7% of glenoid width; 3.6 mm) compared with presurgical values (19.4% of glenoid width; 4.7 mm; P = .01) and with that of the controls (22.4% of glenoid width; 5.7 mm; P = .01). The external and internal rotation strength of patients was significantly lower than that of the controls before surgery (P < .05), but differences in strength did not persist after surgery (P > .17). External rotation ROM in patients was significantly lower than that in control subjects both before and after arthroscopic stabilization (P < .01). The WOSI score improved significantly, from 48.3 ± 13.1 presurgery to 86.3 ± 16.5 after surgery (P = .0002).

CONCLUSION

In patients with anterior instability, arthroscopic stabilization significantly improves measures of strength, ROM, and clinical outcome. However, GHJ excursion is not fully restored to levels seen in the control subjects.

CLINICAL RELEVANCE

Although arthroscopic stabilization satisfactorily restores most clinical outcome measures, GHJ excursion and external rotation ROM remain compromised compared with healthy control subjects and may contribute to the development of osteoarthritis in patients with anterior instability.

Glenohumeral translations during range-of-motion movements, activities of daily living, and sports activities in healthy participants

BACKGROUND

Glenohumeral translations have been mainly investigated during static poses while shoulder rehabilitation exercises, activities of daily living, and sports activities are dynamic. Our objective was to assess glenohumeral translations during shoulder rehabilitation exercises, activities of daily living, and sports activities to provide a preliminary analysis of glenohumeral arthrokinematics in a broad range of dynamic tasks.

METHODS

Glenohumeral translations were computed from trajectories of markers fitted to intracortical pins inserted into the scapula and the humerus. Two participants (P1 and P2) performed full range-of-motion movements including maximum arm elevations and internal-external rotations rehabilitation exercises, six activities of daily living, and five sports activities.

FINDINGS

During range-of-motion movements, maximum upward translation was 7.5mm (P1) and 4.7mm (P2). Upward translation during elevations was smaller with the arm internally (3.6mm (P1) and 2.9mm (P2)) than neutrally (4.2mm (P1) and 3.7mm (P2)) and externally rotated (4.3mm (P1) and 4.3mm (P2)). For activities of daily living and sports activities, only anterior translation during reach axilla for P1 and upward translation during ball throwing for P2 were larger than the translation measured during range-of-motion movements (108% and 114%, respectively).

INTERPRETATION

While previous electromyography-based studies recommended external rotation during arm elevation to minimize upward translation, measures of glenohumeral translations suggest that internal rotation may be better. Similar amplitude of translation during ROM movement and sports activities suggests that large excursions of the humeral head may be caused not only by fast movements, but also by large amplitude movements.

Coupling between 3D displacements and rotations at the glenohumeral joint during dynamic tasks in healthy participants

BACKGROUND

Glenohumeral displacements assessment would help to design shoulder prostheses with physiological arthrokinematics and to establish more biofidelic musculoskeletal models. Though displacements were documented during static tasks, there is little information on their 3D coupling with glenohumeral angle during dynamic tasks. Our objective was to characterize the 3D glenohumeral displacement-rotation couplings during dynamic arm elevations and rotations.

METHODS

Glenohumeral displacements were measured from trajectories of reflective markers fitted on intracortical pins inserted into the scapula and humerus. Bone geometry was recorded using CT-scan. Only four participants were recruited to the experiment due to its invasiveness. Participants performed dynamic arm abduction, flexion and axial rotations. Linear regressions were performed between glenohumeral displacements and rotations. The pin of the scapula of one participant moved, his data were removed from analysis, and results are based on three participants.

FINDINGS

The measurement error of glenohumeral kinematics was less than 0.15mm and 0.2°. Maximum glenohumeral displacements were measured along the longitudinal direction and reached up to +12.4mm for one participant. Significant couplings were reported especially between longitudinal displacement and rotation in abduction (adjusted R(2) up to 0.94).

INTERPRETATION

The proposed method provides the potential to investigate glenohumeral kinematics during all kinds of movements. A linear increase of upward displacement during dynamic arm elevation was measured, which contrasts with results based on a series of static poses. The systematic investigation of glenohumeral displacements under dynamic condition may help to provide relevant recommendation for the design of shoulder prosthetic components and musculoskeletal models.

Nonoperative and postoperative rehabilitation for glenohumeral instability

The glenohumeral joint is an inherently unstable joint that relies on the interaction of the dynamic and static stabilizers to maintain stability. Disruption of this interplay or poor development of any of these factors may result in instability, pain, and a loss of function. Rehabilitation will vary based on the type of instability present and the key principles described. Whether a course of nonoperative rehabilitation is followed or the patient presents postoperatively, a comprehensive program designed to establish full ROM and balance capsular mobility, in addition to maximizing muscular strength, endurance, proprioception, dynamic stability, and neuromuscular control is essential. A functional approach to rehabilitation using movement patterns and sport-specific positions along with an interval sport program will allow a gradual return to athletics. The focus of the program should minimize the risk of recurrence and ensure that the patient can safely return to functional activities.

Effects of surgical repair on active shoulder position sense and 3-dimensional reaching accuracy in a patient with anterior shoulder instability

The purpose of this report was to investigate whether a subject with anterior shoulder instability exhibited better active shoulder position sense and 3-dimensional (3-D) reaching accuracy after a surgical repair. The 19-year-old male subject underwent an open Bankart repair procedure for his left shoulder followed by a standardized post-operative rehabilitation program. Shoulder position sense was examined with traditional passive matching and active positioning protocols. Reaching accuracy in space with the unrestricted arm motion was also examined. The subject was tested 5 months prior to the surgery and re-tested 6 months after the surgery. With the traditional passive matching protocol, shoulder position sense improved <2° after surgery. However, shoulder position sense improved greatly after surgery with active shoulder abduction (up to 4.25°) and active shoulder rotation (up to 5.87°) testing protocols. In addition, reaching accuracy also greatly improved after surgery (up to 10.97 cm) with the most significant improvement when reaching to targets located in the frontal plane. Data suggest that anterior shoulder repair with rehabilitation can improve both active shoulder position sense and reaching accuracy, especially in shoulder positions involving abduction with external rotation.

Shoulder position sense during passive matching and active positioning tasks in individuals with anterior shoulder instability

BACKGROUND

Altered neuromuscular control due to compromised joint position sense may contribute to recurrent shoulder instability.

OBJECTIVE

The purpose of the present study was to examine whether individuals with anterior shoulder instability exhibit larger shoulder position sense errors than those with healthy shoulders in both passive matching and active positioning.

DESIGN

This was a between-groups study with repeated measures.

METHODS

Ten people with anterior shoulder instability and 15 people with healthy shoulders participated in the study. Shoulder position sense was examined with 3 different protocols (passive motion to remembered shoulder rotation angles and active shoulder abduction and rotation to verbally specified positions) in positions of both mid-range and end-range of motion.

RESULTS

Participants with unstable shoulders exhibited significantly larger errors (by 1.8° on average) in perception of shoulder position compared with those with healthy shoulders during passive matching. During active positioning, participants with unstable shoulders were able to voluntarily move the shoulder to verbally specified angles as accurately as those with healthy shoulders in both abduction (0.85° difference) and rotation (0.99° difference) tasks.

CONCLUSIONS

Results of this study indicate that people with unstable shoulders can perceive shoulder angles as accurately as people with healthy shoulders in activities with voluntary arm movements. Compared with passive matching, better information from muscle spindles and other sources during voluntary arm movements may compensate for the potential joint position sense deficits after the injury. Therefore, individuals with an unstable shoulder may have adequate neuromuscular control to engage proper protective mechanisms to stabilize the shoulder joint during functional activities.

The accuracy and repeatability of an automatic 2D-3D fluoroscopic image-model registration technique for determining shoulder joint kinematics

Fluoroscopic imaging, using single plane or dual plane images, has grown in popularity to measure dynamic in vivo human shoulder joint kinematics. However, no study has quantified the difference in spatial positional accuracy between single and dual plane image-model registration applied to the shoulder joint. In this paper, an automatic 2D-3D image-model registration technique was validated for accuracy and repeatability with single and dual plane fluoroscopic images. Accuracy was assessed in a cadaver model, kinematics found using the automatic registration technique were compared to those found using radiostereometric analysis. The in vivo repeatability of the automatic registration technique was assessed during the dynamic abduction motion of four human subjects. The in vitro data indicated that the error in spatial positional accuracy of the humerus and the scapula was less than 0.30mm in translation and less than 0.58° in rotation using dual plane images. Single plane accuracy was satisfactory for in-plane motion variables, but out-of-plane motion variables on average were approximately 8 times less accurate. The in vivo test indicated that the repeatability of the automatic 2D-3D image-model registration was 0.50mm in translation and 1.04° in rotation using dual images. For a single plane technique, the repeatability was 3.31mm in translation and 2.46° in rotation for measuring shoulder joint kinematics. The data demonstrate that accurate and repeatable shoulder joint kinematics can be obtained using dual plane fluoroscopic images with an automatic 2D-3D image-model registration technique; and that out-of-plane motion variables are less accurate than in-plane motion variables using a single plane technique.

Effect of shoulder stabilization on career length in national football league athletes

BACKGROUND

Shoulder instability and surgical stabilization are common in college football athletes. The effect of shoulder stabilization during college on the length of an athlete's career in the National Football League (NFL) has not been well examined.

HYPOTHESIS

Athletes with a history of shoulder stabilization before the NFL combine have a shorter career than do matched controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A database containing the injury history and career NFL statistics of athletes from 1987 to 2000 was used to match athletes with a history of shoulder stabilization and no other surgery or significant injury to controls without a history of any previous surgery or significant injury. Athletes were matched by position, year drafted, round drafted, and additional minor injury history.

RESULTS

Forty-two athletes with a history of shoulder stabilization were identified and matched with controls. A history of shoulder stabilization significantly reduced the length of career in terms of years (5.2 ± 3.9 vs 6.9 ± 3.6 years; P = .01) and games played (56 ± 53 vs 77 ± 50, P = .03) as compared with controls. By position, linemen and linebackers (20 athletes) with a history of shoulder stabilization had a significantly shorter career in years (4.7 ± 3.8 vs 6.7 ± 3.4 years; P = .049) and games played (51 ± 58 vs 81 ± 48; P = .046) than did controls. Among the other positions (22 athletes), the difference was not statistically significant in this small cohort.

CONCLUSION

A history of shoulder stabilization shortens the expected career of a professional football player, particularly for linemen and linebackers. Further research is warranted to better understand how these injuries and surgeries affect an athlete's career and what can be done to improve the long-term outcome after treatment.

Subacromial morphometric assessment of the clavicle hook plate

BACKGROUND

Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications.

MATERIALS AND METHODS

Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures.

RESULTS

Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens.

CONCLUSIONS

The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Simultaneous 3D assessment of glenohumeral shape, humeral head centering, and scapular positioning in atraumatic shoulder instability: a magnetic resonance-based in vivo analysis

BACKGROUND

Success rates in the treatment of atraumatic shoulder instability differ, and in vivo identification of the individual insufficient stabilizers is difficult.

HYPOTHESIS

Atraumatic shoulder instability is an inhomogeneous entity with varying alterations of the active and passive stabilizers. This might be a reason for inferior treatment results.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Shoulders of 28 healthy volunteers and both shoulders of 14 patients with atraumatic instability and multidirectional laxity were examined in different arm positions using open magnetic resonance imaging. Three-dimensional postprocessing techniques were applied to determine 3D glenoid size and retroversion, radius of the humeral head, and curvature of the glenoid. The results of static stabilizers were compared with those of glenohumeral and scapular positioning in the same patients for identification of the individual insufficient stabilizers.

RESULTS

The atraumatic unstable shoulders showed an increased mean retroversion on both sides, the difference being significant on the affected side (9.4 degrees +/- 4.8 degrees vs healthy 3.9 degrees +/- 1.3 degrees ; P < .05) with a range of 2.6 degrees to 16.6 degrees . The curvature analysis demonstrated a pronounced flatness of the glenoid with a significantly increased mean radius (103.8 mm vs healthy 41.7 mm). The extent of these changes varied widely among patients. Comparison of the static stabilizers with glenohumeral and scapular positioning revealed that isolated changes of the active stabilizers exist in some patients, whereas no isolated changes of passive stabilizers were found.

CONCLUSION

All active and passive stabilizers need to be analyzed in patients with atraumatic instability because the magnitude of alteration varied widely among individuals. Different combinations of alterations of the stabilizers were found. The presented technique allows for in vivo identification of the specific alterations. This is necessary for a better understanding of individual pathomechanics and for initiating a specific causal treatment.

Complex shoulder disorders: evaluation and treatment

Evaluation of patients with shoulder disorders often presents challenges. Among the most troublesome are revision surgery in patients with massive rotator cuff tear, atraumatic shoulder instability, revision arthroscopic stabilization surgery, adhesive capsulitis, and bicipital and subscapularis injuries. Determining functional status is critical before considering surgical options in the patient with massive rotator cuff tear. When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice. Arthroscopic revision of failed arthroscopic shoulder stabilization procedures may be undertaken when bone and tissue quality are good. Arthroscopic release is indicated when idiopathic adhesive capsulitis does not respond to nonsurgical treatment; however, results of both nonsurgical and surgical treatment of posttraumatic and postoperative adhesive capsulitis are often disappointing. Patients not motivated to perform the necessary postoperative therapy following subscapularis repair are best treated with arthroscopic débridement and biceps tenotomy.

Scapular positioning in athlete's shoulder : particularities, clinical measurements and implications

Despite the essential role played by the scapula in shoulder function, current concepts in shoulder training and treatment regularly neglect its contribution. The 'scapular dyskinesis' is an alteration of the normal scapular kinematics as part of scapulohumeral rhythm, which has been shown to be a nonspecific response to a host of proximal and distal shoulder injuries. The dyskinesis can react in many ways with shoulder motion and function to increase the dysfunction. Thoracic kyphosis, acromio-clavicular joint disorders, subacromial or internal impingement, instability or labral pathology can alter scapular kinematics. Indeed, alteration of scapular stabilizing muscle activation, inflexibility of the muscles and capsule-ligamentous complex around the shoulder may affect the resting position and motion of the scapula. Given the interest in the scapular positioning and patterns of motion, this article aims to give a detailed overview of the literature focusing on the role of the scapula within the shoulder complex through the sports context. Such an examination of the role of the scapula requires the description of the normal pattern of scapula motion during shoulder movement; this also implies the study of possible scapular adaptations with sports practice and scapular dyskinesis concomitant to fatigue, impingement and instability. Different methods of scapular positioning evaluation are gathered from the literature in order to offer to the therapist the possibility of detecting scapular asymmetries through clinical examinations. Furthermore, current concepts of rehabilitation dealing with relieving symptoms associated with inflexibility, weakness or activation imbalance of the muscles are described. Repeating clinical assessments throughout the rehabilitation process highlights improvements and allows the therapist to actualize rationally his or her intervention. The return to the field must be accompanied by a transitory phase, which is conducive to integrating new instructions during sports gestures. On the basis of the possible scapular disturbance entailed in sports practice, a preventive approach that could be incorporated into training management is encouraged.

Functional malcentering of the humeral head and asymmetric long-term stress on the glenoid: potential reasons for glenoid loosening in total shoulder arthroplasty

We tested the hypothesis that functional malcentering of the humeral head during arm elevation exists in patients with glenohumeral osteoarthritis and influences long-term glenoid loading. Twenty-eight healthy volunteers and 10 patients with primary osteoarthritis, 10 with cuff-arthropathy, and 1 with dysplastic glenoid were examined. Open magnetic resonance imaging and 3-dimensional (3D) digital postprocessing techniques were applied in various arm positions. Osteoabsorptiometry was used to determine 3D subchondral mineralization patterns of the glenoid as an indicator of integral long-term stress distribution. At 30 degrees of abduction, 5 patients demonstrated malcentering of the humeral head posteriorly; all patients with cuff arthropathy had malcentering superiorly. At 90 degrees, most patients displayed significant (P < .001) malcentering in the superior and posterior direction. The shoulders showed maximal subchondral mineralization patterns in the direction of malcentering. Most patients with glenohumeral osteoarthritis displayed functional malcentering, which might be responsible for postoperative glenoid loosening in shoulder arthroplasty if not corrected intraoperatively.

In vivo glenohumeral analysis using 3D MRI models and a flexible software tool: feasibility and precision

PURPOSE

To implement a PC-based morphometric analysis platform and to evaluate the feasibility and precision of MRI measurements of glenohumeral translation.

MATERIALS AND METHODS

Using a vertically open 0.5T MRI scanner, the shoulders of 10 healthy subjects were scanned in apprehension (AP) and in neutral position (NP), respectively. Surface models of the humeral head (HH) and the glenoid cavity (GC) were created from segmented MR images by three readers. Glenohumeral translation was determined by the projection point of the manually fitted HH center on the GC plane defined by the two main principal axes of the GC model.

RESULTS

Positional precision, given as mean (extreme value at 95% confidence level), was 0.9 (1.8) mm for the HH center and 0.7 (1.6) mm for the GC centroid; angular GC precision was 1.3 degrees (2.3 degrees ) for the normal and about 4 degrees (7 degrees ) for the anterior and superior coordinate axes. The two-dimensional (2D) precision of the HH projection point was 1.1 (2.2) mm. A significant HH translation between AP and NP was found.

CONCLUSION

Despite a limited quality of the underlying model data, our PC-based analysis platform allows a precise morphometric analysis of the glenohumeral joint. The software is easily extendable and may potentially be used for an objective evaluation of therapeutical measures.

Qualitative and quantitative descriptions of glenohumeral motion

Joint modelling plays an important role in qualitative and quantitative descriptions of both normal and abnormal joints, as well as predicting outcomes of alterations to joints in orthopaedic practice and research. Contemporary efforts in modelling have focussed upon the major articulations of the lower limb. Well-constrained arthrokinematics can form the basis of manageable kinetic and dynamic mathematical predictions. In order to contain computation of shoulder complex modelling, glenohumeral joint representations in both limited and complete shoulder girdle models have undergone a generic simplification. As such, glenohumeral joint models are often based upon kinematic descriptions of inadequate degrees of freedom (DOF) for clinical purposes and applications. Qualitative descriptions of glenohumeral motion range from the parody of a hinge joint to the complex realism of a spatial joint. In developing a model, a clear idea of intention is required in order to achieve a required application. Clinical applicability of a model requires both descriptive and predictive output potentials, and as such, a high level of validation is required. Without sufficient appreciation of the clinical intention of the arthrokinematic foundation to a model, error is all too easily introduced. Mathematical description of joint motion serves to quantify all relevant clinical parameters. Commonly, both the Euler angle and helical (screw) axis methods have been applied to the glenohumeral joint, although concordance between these methods and classical anatomical appreciation of joint motion is limited, resulting in miscommunication between clinician and engineer. Compounding these inconsistencies in motion quantification is gimbal lock and sequence dependency.

Measuring dynamic in-vivo glenohumeral joint kinematics: technique and preliminary results

Rotator cuff tears are a common injury that affect a significant percentage of the population over age 60. Although it is widely believed that the rotator cuff's primary function is to stabilize the humerus against the glenoid during shoulder motion, accurately measuring the three-dimensional (3D) motion of the shoulder's glenohumeral joint under in-vivo conditions has been a challenging endeavor. In particular, conventional motion measurement techniques have frequently been limited to static or two-dimensional (2D) analyses, and have suffered from limited or unknown in-vivo accuracy. We have recently developed and validated a new model-based tracking technique that is capable of accurately measuring the 3D position and orientation of the scapula and humerus from biplane X-ray images. Herein we demonstrate the in-vivo application of this technique for accurately measuring glenohumeral joint translations during shoulder motion in the repaired and contralateral shoulders of patients following rotator cuff repair. Five male subjects were tested at 3-4 months following arthroscopic rotator cuff repair. Superior-inferior humeral translation was measured during elevation, and anterior-posterior humeral translation was measured during external rotation in both the repaired and contralateral shoulders. The data failed to detect statistically significant differences between the repaired and contralateral shoulders in superior-inferior translation (p=0.74) or anterior-posterior translation (p=0.77). The measurement technique overcomes the limitations of conventional motion measurement techniques by providing accurate, 3D, in-vivo measures of glenohumeral joint motion during dynamic activities. On-going research is using this technique to assess the effects of conservative and surgical treatment of rotator cuff tears.

Glenohumeral motion: review of measurement techniques

Measurement of upper limb motion is problematic, not least because of the large range of path dependent description of motion of the joints, and the multiple non-cyclical unstandardised motion tasks measured. Furthermore, appreciation of shoulder motion specifically is obscured by overlying soft tissue. In order to satisfy the complexity of a clinically useful model of the movement of the joint, input data must be acquired from a set of pre-determined movements using a non-invasive technique with a high level of accuracy. Descriptive and predictive modeling of the glenohumeral joint requires input of high-fidelity data into a 6 degree of freedom representation, without which, the application of the tool is of limited clinical significance to the advancement of both operative and non-operative management of shoulder pathology. Electromagnetic, linkage and radiographic techniques have previously been used, however, an optimal solution is yet to be described.

Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls

BACKGROUND

Evidence that persons with multidirectional instability (MDI) of the shoulder have abnormal shoulder kinematics is limited. A kinematic description of scapulothoracic and glenohumeral motion can assist both conservative and surgical rehabilitative programs.

HYPOTHESIS

Persons with MDI of the shoulder demonstrate increased anterior and inferior glenohumeral translation and decreased scapular upward rotation and increased scapular internal rotation compared with age-matched and gender-matched asymptomatic controls.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixty-two subjects were recruited from an outpatient orthopaedic clinic. Subjects with MDI were matched according to age, gender, and hand dominance to asymptomatic controls. An electromagnetic motion capture system evaluated the 3-dimensional position of the trunk, scapula, and humerus during frontal and scapular plane elevation. A repeated measures analysis of variance evaluated joint positions and glenohumeral translations during 4 phases of elevation (0 degrees-30 degrees, 31 degrees-60 degrees, 61 degrees-90 degrees, and 91 degrees-120 degrees).

RESULTS

When averaged across the 4 phases of elevation, persons with MDI demonstrated a significant decrease in scapular upward rotation in scapular plane abduction (8 degrees, P = .006) and abduction (5.8 degrees, P = .016) and increased internal rotation during scapular plane abduction (12.2 degrees, P = .03). Alterations in glenohumeral translations in the MDI group did not reach statistical significance (P = .54-.71).

CONCLUSION

Abnormal scapular kinematics are seen in the MDI shoulder, highlighting the importance of incorporating scapular positioning and stability exercises during rehabilitation. Additional study is warranted concerning the efficacy of various rehabilitation programs, and also both surgical and nonsurgical interventions in this population.

The three-dimensional motions of glenohumeral joint under semi-loaded condition during arm abduction using vertically open MRI

BACKGROUND

Magnetic resonance imaging is an accurate non-invasive tool for visualizing muscles, tendons, and bones. It also provides 3D coordinate values. The purpose of the present study was to visualize and quantify the 3D positions of the glenohumeral joint during isometric abduction of the arm using vertically open magnetic resonance imaging.

METHODS

We examined 14 shoulders of seven healthy volunteers. Magnetic resonance images were obtained in a seated position and in seven static positions of the arm from 0 degrees to maximum abduction using vertically open magnetic resonance imaging. 3D surface models were created and 3D movements of each bone in the glenohumeral joint were calculated using a computer algorithm. We analyzed the translation and contact pattern of the glenohumeral joint.

FINDINGS

In supero-inferior direction, the humeral head translated slight inferiorly from +1.9 (SD 1.0) mm at 0 degrees to +0.8 (SD 1.8) mm at the maximum abduction. In antero-posterior direction, the humeral head translated anteriorly from 0 degrees to 90 degrees (mean +2.4, SD 2.6 mm) and posteriorly from 90 degrees to 150 degrees of abduction (mean -1.4, SD 2.7 mm). Furthermore, the humeral head had a unique contact patterns with the glenoid; the contact part of the humeral head with the glenoid changed from the central part to the posterior in the midrange of abduction.

INTERPRETATION

The humeral head showed a small translation in the antero-posterior direction between 90 degrees and 150 degrees of abduction. In addition, the posterior part of the humeral head contacted the glenoid in this range of abduction. These findings of motion patterns in asymptomatic subjects will be necessary when comparing the kinematics with pathologic condition such as the glenohumeral instability and rotator cuff tear.

Validation of a new model-based tracking technique for measuring three-dimensional, in vivo glenohumeral joint kinematics

Shoulder motion is complex and significant research efforts have focused on measuring glenohumeral joint motion. Unfortunately, conventional motion measurement techniques are unable to measure glenohumeral joint kinematics during dynamic shoulder motion to clinically significant levels of accuracy. The purpose of this study was to validate the accuracy of a new model-based tracking technique for measuring three-dimensional, in vivo glenohumeral joint kinematics. We have developed a model-based tracking technique for accurately measuring in vivo joint motion from biplane radiographic images that tracks the position of bones based on their three-dimensional shape and texture. To validate this technique, we implanted tantalum beads into the humerus and scapula of both shoulders from three cadaver specimens and then recorded biplane radiographic images of the shoulder while manually moving each specimen's arm. The position of the humerus and scapula were measured using the model-based tracking system and with a previously validated dynamic radiostereometric analysis (RSA) technique. Accuracy was reported in terms of measurement bias, measurement precision, and overall dynamic accuracy by comparing the model-based tracking results to the dynamic RSA results. The model-based tracking technique produced results that were in excellent agreement with the RSA technique. Measurement bias ranged from -0.126 to 0.199 mm for the scapula and ranged from -0.022 to 0.079 mm for the humerus. Dynamic measurement precision was better than 0.130 mm for the scapula and 0.095 mm for the humerus. Overall dynamic accuracy indicated that rms errors in any one direction were less than 0.385 mm for the scapula and less than 0.374 mm for the humerus. These errors correspond to rotational inaccuracies of approximately 0.25 deg for the scapula and 0.47 deg for the humerus. This new model-based tracking approach represents a non-invasive technique for accurately measuring dynamic glenohumeral joint motion under in vivo conditions. The model-based technique achieves accuracy levels that far surpass all previously reported non-invasive techniques for measuring in vivo glenohumeral joint motion. This technique is supported by a rigorous validation study that provides a realistic simulation of in vivo conditions and we fully expect to achieve these levels of accuracy with in vivo human testing. Future research will use this technique to analyze shoulder motion under a variety of testing conditions and to investigate the effects of conservative and surgical treatment of rotator cuff tears on dynamic joint stability.

Effect of abducting and adducting muscle acitivity on glenohumeral translation, scapular kinematics and subacromial space width in vivo

It is currently unknown in which ways activity of the ab- and adductor shoulder muscles affects shoulder biomechanics (scapular kinematics and glenohumeral translation), and whether these changes are relevant for alterations of the subacromial space width. The objective of this experimental in vivo study was thus to test the hypotheses that potential changes of the subacromial space width (during antagonistic muscle activity) are caused by alterations of scapular kinematics and/or glenohumeral translation. The shoulders of 12 healthy subjects were investigated with an open MRI-system at 30 degrees, 60 degrees, 90 degrees, 120 degrees and 150 degrees of arm elevation. A force of 15N was applied to the distal humerus, once causing isometric contraction of the abductors and once contraction of the adductors. The scapulo-humeral rhythm, scapular tilting and glenohumeral translation were calculated from the MR image data for both abducting and adducting muscle activity. Adducting muscle activity led to significant increase of the subacromial space width in all arm positions. The scapulo-humeral rhythm (2.2-2.5) and scapular tilting (2-4 degrees) remained relatively constant during elevation, no significant difference was found between abducting and adducting muscle activity. The position of the humerus relative to the glenoid was, however, significantly (p < 0.05) different (inferior and anterior) for adducting versus abducting muscle activity in midrange elevation (60-120 degrees). These data show that the subacromial space can be effectively widened by adducting muscle activity, by affecting the position of the humerus relative to the glenoid. This effect may be employed for conservative treatment of the impingement syndrome.