-
BMC Musculoskeletal Disorders Jun 2022Atraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in... (Review)
Review
BACKGROUND
Atraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in these patients with a reported success rate near 85% within 12 weeks of treatment. The critical shoulder angle (CSA) is a radiographic metric that relates the glenoid inclination with the lateral extension of the acromion in the coronal plane. A larger CSA has been associated with higher incidence of AFTRCT and a higher re-tear rate after surgical treatment. However, no study has yet described an association between a larger CSA and failure of conservatory treatment in ARCT. The main objective of this study is to determine whether there is an association between CSA and failure of physical therapy in patients with AFTRCT.
METHODS
We reviewed the imaging and clinical records of 48 patients (53 shoulders), 60% female, with a mean age of 63.2 years (95% CI ± 10.4 years); treated for AFTRCT who also underwent a true anteroposterior radiograph of the shoulder within a year of diagnosis of the tear. We recorded demographic (age, sex, type of work), clinical (comorbidities), and imaging data (CSA, size and location of the tear). We divided the patients into two groups according to success or failure of conservative treatment (indication for surgery), so 21 shoulders (39.6%) required surgery and were classified as failure of conservative treatment. Univariate and multivariate analysis was performed to detect predictors of failure of conservative treatment.
RESULTS
The median CSA was 35.5º with no differences between those with failure (median 35.5º, range 29º to 48.2º) and success of conservative treatment (median 35.45º, range 30.2º to 40.3º), p = 0.978. The multivariate analysis showed a younger age in patients with failure of conservative treatment (56.14 ± 9.2 vs 67.8 ± 8.4, p < 0.001) and that male gender was also associated with failure of conservative treatment (57% of men required surgery vs 28% of women, p = 0.035).
CONCLUSIONS
It is still unclear if CSA does predict failure of conservative treatment. A lower age and male gender both could predicted failure of conservative treatment in AFTRCT. Further research is needed to better address this subject.
Topics: Acromion; Conservative Treatment; Female; Humans; Male; Middle Aged; Rotator Cuff Injuries; Rupture; Scapula; Shoulder; Shoulder Joint
PubMed: 35689223
DOI: 10.1186/s12891-022-05519-y -
Revista Brasileira de Ortopedia 2014To correlate the acromial curvature, using the angles proposed, with the subacromial space and types of acromion.
OBJECTIVE
To correlate the acromial curvature, using the angles proposed, with the subacromial space and types of acromion.
METHODS
Ninety scapulas were studied. The acromia were classified as types I, II or III. The acromial curvature was analyzed by means of the alpha, beta and theta angles. We also measured the distance between the anteroinferior extremity of the acromion and the supraglenoid tubercle (DA). The scapulas were grouped in relation to sex and age. The angles proposed were analyzed in relation to each type of acromion and also in relation to the measurements of the distance DA.
RESULTS
Out of the total number of acromia, 39 (43.3%) were type I, 43 (47.7%) type II and eight (9%) type III. The mean ages for each type of acromion (I-III) were 45.6, 55.2 and 51.1 years, respectively. The proportions of the different types of acromion varied in relation to sex and age. The evaluations on the mean beta angle (p = 0.008) and theta angle (p = 0.028), with comparisons in relation to each type of acromion and measurements of the distance DA (p = 0.037), were shown to be statistically significant.
CONCLUSION
The angles proposed in our study can be used for morphometric analysis on the acromion, especially regarding its curvature, and can contribute towards studies on diseases of the shoulder and aid in surgical planning and analysis of the acromial slope, by means of radiography or magnetic resonance.
PubMed: 26229874
DOI: 10.1016/j.rboe.2013.10.005 -
The American Journal of Sports Medicine May 2021Acromioclavicular joint (ACJ) injuries are common. Despite this, it remains unclear how best to assess, classify, and manage these cases. A simple, reliable, valid, and...
BACKGROUND
Acromioclavicular joint (ACJ) injuries are common. Despite this, it remains unclear how best to assess, classify, and manage these cases. A simple, reliable, valid, and accurate radiographic parameter to measure ACJ displacement would allow improved consistency of diagnosis and subsequent treatment pathways.
PURPOSE
To evaluate "the circles measurement" and associated "ABC classification" as a tool for assessing ACJ displacement and injury classification.
STUDY DESIGN
Descriptive laboratory study.
METHODS
The circles measurement is taken from a lateral Alexander radiograph of the shoulder. The measurement is the center-to-center distance between 2 circles drawn to define the lateral extent of the clavicle and the anteromedial extent of the acromion; it is independent of the displacement plane, judging total ACJ displacement in any direction rather than trying to quantify vertical and/or horizontal displacement. When utilized clinically, the circles measurement is a single measurement calculated as the difference between values recorded for the injured and uninjured sides. Validation of the circles measurement was performed using lateral Alexander radiographs (including ±20° projection error in all planes) and computed tomography of standardized ACJ injury simulations. We assessed inter- and intrarater reliability, convergent validity, and discriminant validity of the circles measurement and subsequently generated a classification of ACJ injury based on displacement.
RESULTS
Reliability and validity of the circles measurement was excellent throughout. Interrater reliability (ICC [intraclass correlation coefficient] [2,1], 95% CI; n = 78; 4 observers) was 0.976 (0.964-0.985). Intrarater reliability (ICC [2,1]; 95% CI; n = 78; 2 measures) was 0.998 (0.996-0.998). Convergent validity (Pearson correlation coefficient, ) was 0.970 for ideal radiographs and 0.889 with ±20° projection error in all planes. Discriminant validity, with 1-way analysis of variance, showed a value of <.0001 and effect size () of 0.960, with the ability to distinguish between the previously defined stable (Rockwood IIIA) and unstable (Rockwood IIIB) injuries. The results permitted objective, statistically sound parameters for the proposed ABC classification system.
CONCLUSION
The circles measurement is a simple, reliable, valid, accurate, and resilient parameter for assessing ACJ displacement and can be used in conjunction with the proposed ABC classification to define ACJ injuries more accurately and objectively than previously described.
CLINICAL RELEVANCE
This novel parameter has the potential to standardize the initial assessment and possibly the subsequent clinical management of ACJ injuries, in addition to providing a standardized measure for future research.
Topics: Acromioclavicular Joint; Acromion; Clavicle; Humans; Joint Diseases; Joint Dislocations; Reproducibility of Results
PubMed: 33856933
DOI: 10.1177/03635465211003300 -
JSES International Mar 2021There is evidence that specific variants of scapular morphology are associated with dynamic and static posterior shoulder instability. To this date, observations...
BACKGROUND
There is evidence that specific variants of scapular morphology are associated with dynamic and static posterior shoulder instability. To this date, observations regarding glenoid and/or acromial variants were analyzed independently, with two-dimensional imaging or without comparison with a healthy control group. Therefore, the purpose of this study was to analyze and describe the three-dimensional (3D) shape of the scapula in healthy and in shoulders with static or dynamic posterior instability using 3D surface models and 3D measurement methods.
METHODS
In this study, 30 patients with unidirectional posterior instability and 20 patients with static posterior humeral head subluxation (static posterior instability, Walch B1) were analyzed. Both cohorts were compared with a control group of 40 patients with stable, centered shoulders and without any clinical symptoms. 3D surface models were obtained through segmentation of computed tomography images and 3D measurements were performed for glenoid (version and inclination) and acromion (tilt, coverage, height).
RESULTS
Overall, the scapulae of patients with dynamic and static instability differed only marginally among themselves. Compared with the control group, the glenoid was 2.5° ( = .032), respectively, 5.7° ( = .001) more retroverted and 2.9° ( = .025), respectively, 3.7° ( = .014) more downward tilted in dynamic, respectively, static instability. The acromial roof of dynamic instability was significantly higher and on average 6.2° ( = .007) less posterior covering with an increased posterior acromial height of +4.8mm ( = .001). The acromial roof of static instability was on average 4.8° ( = .041) more externally rotated (axial tilt), 7.3° ( = .004) flatter (sagittal tilt), 8.3° ( = .001) less posterior covered with an increased posterior acromial height of +5.8 mm (0.001).
CONCLUSION
The scapula of shoulders with dynamic and static posterior instability is characterized by an increased glenoid retroversion and an acromion that is shorter posterolaterally, higher, and more horizontal in the sagittal plane. All these deviations from the normal scapula values were more pronounced in static posterior instability.
PubMed: 33681835
DOI: 10.1016/j.jseint.2020.11.003 -
Orthopaedics & Traumatology, Surgery &... Apr 2022Shoulder impingement syndrome is evaluated radiologically with two-dimensional measurement parameters. None of these measurement parameters accurately reflect the...
INTRODUCTION
Shoulder impingement syndrome is evaluated radiologically with two-dimensional measurement parameters. None of these measurement parameters accurately reflect the three-dimensional geometry. The purpose of this study was to evaluate the volumetric status of the subacromial space in patients with shoulder impingement syndrome and to investigate its relationship with two-dimensional parameters.
HYPOTHESIS
The primary hypothesis of this study is that subacromial volume is reduced in patients with impingement syndrome. The second hypothesis is that the sagittal plane morphology of the acromion reflects the subacromial volume better than the coronal plane morphology.
PATIENTS AND METHODS
This retrospective study consisted of a total of 52 participants: 26 patients with impingement syndrome and 26 controls. Volumetric measurements were performed with using magnetic resonance imaging. The relationship between humerus and acromion was evaluated by acromiohumeral distance. The sagittal plane morphology of the acromion was evaluated with an objective acromial angle, while the coronal plane morphology was evaluated with a lateral acromial angle. The radiological parameters between groups were compared.
RESULTS
The mean subacromial volume was significantly smaller in the impingement group compared to the control group (p=0.01). The subacromial volume had a negative correlation with the objective acromial angle (R=-0.46; p=0.01) The mean tendon volume was significantly higher in the impingement group (p<0.001). The mean acromiohumeral distance in the impingement group (6.8mm±1.0mm), was calculated to be significantly lower than the control group (10.1mm±1.5mm) (p<0.001). There was a positive moderate correlation between subacromial volume and acromiohumeral distance (R=0.61; p=0.01).
DISCUSSION
This is the first study to demonstrate a reduction in subacromial volume in patients with impingement syndrome. The sagittal plane morphology of the acromion, rather than the coronal plane, appears to be more closely related to the subacromial volume.
LEVEL OF EVIDENCE
III; case-control study.
Topics: Acromion; Case-Control Studies; Humans; Retrospective Studies; Rotator Cuff Injuries; Shoulder Impingement Syndrome
PubMed: 34649000
DOI: 10.1016/j.otsr.2021.103110 -
Revista Brasileira de Ortopedia 2011To establish anatomical parameters for the axillary nerve by measuring the distances to the acromion and the deltopectoral access, and to ascertain whether there are any...
OBJECTIVE
To establish anatomical parameters for the axillary nerve by measuring the distances to the acromion and the deltopectoral access, and to ascertain whether there are any differences in comparative measurements between the left and right sides.
METHOD
An anatomical study on the path of the axillary nerve was conducted by dissecting 30 shoulders of 20 fresh adult cadavers. For comparative study, bilateral dissection was performed on 10 cadavers. Digital caliper gauges, accurate to the nearest 0.05 cm, were used to measure the distances between the lateral extremity of the acromion and the anterior and posterior branches of the axillary nerve, and between the deltopectoral space and the anterior branch of the axillary nerve.
RESULTS
The shortest distance between the acromion and the axillary nerve was 5.47 cm, and the greatest distance was 7.06 cm. The shortest distance between the deltopectoral groove and the axillary nerve was 3.94 cm. A statistically significant difference was found using Wilcoxon's test in comparative measurements between the left and right sides for the distances between the posterior branch of the axillary nerve and the midpoint of the lateral border of the acromion (A-E), and between the anterior branch of the axillary nerve and the anterior extremity of the acromion (B-C), both of which were larger on the right side.
CONCLUSIONS
The axillary nerve was situated between 5.47 and 7.06 cm distally to the acromion, and 3.94 cm laterally to the deltopectoral space. There was a statistically significant difference in the comparison between the left and right sides, and both measurements were larger on the right side.
PubMed: 27047824
DOI: 10.1016/S2255-4971(15)30201-9 -
BMC Musculoskeletal Disorders Nov 2021The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the...
INTRODUCTION
The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate pin entry point and angle, and simulate surgery.
METHODS
11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for pin placement.
RESULTS
Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral pining, the distance of the inferior border of the acromion from the axillary nerve (5.90 ± 0.43) cm, range (5.3-6.9) cm, was selected for pining along the medial axis of the humeral head, close to the medial cervical cortex, and the pining angle was measured in the coronal plane (42.84 ± 2.45)°, range (37.02° ~ 46.31°), and in the sagittal plane (28.24 ± 2.25)°, range (19.22° ~ 28.51°). The pin was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral pin, and the pin angle was measured in the coronal plane (36.14 ± 1.75)°, range (30.32° ~ 39.61°), and in the sagittal plane (28.64 ± 1.37)°, range (22.82° ~ 32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26 ± 1.98) to the coronal surface of the humeral stem, range (155.79° ~ 165.08°), and the sagittal angle (161.76 ± 2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus.
CONCLUSION
Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the pin on the 3D model for pin placement, which is simple and practical to meet the relevant individual parameters.
Topics: Aged; External Fixators; Female; Fracture Fixation; Humans; Humeral Fractures; Humeral Head; Humerus; Male; Shoulder; Shoulder Fractures
PubMed: 34836534
DOI: 10.1186/s12891-021-04826-0 -
JSES International Sep 2021Bigliani types of acromion and critical shoulder angle (CSA) have been implicated as indicators of rotator cuff disease. A sharpened inferolateral edge of acromion...
BACKGROUND
Bigliani types of acromion and critical shoulder angle (CSA) have been implicated as indicators of rotator cuff disease. A sharpened inferolateral edge of acromion (termed as Sharpened Lateral Acromion Morphology or SLAM sign) is frequently observed in anteroposterior radiographs of the glenohumeral joint in patients with rotator cuff tears (RCT). We aimed to evaluate the association of the SLAM sign with RCT in comparison to high CSA (≥35°) and Bigliani type 3 (hooked) acromion.
METHODS
A cohort of 100 consecutive patients undergoing non-arthroplasty surgery for RCT and 106 patients with primary frozen shoulder were matched manually in 1:1 ratio based on age and gender to yield study population with 50 patients in each group. The 2 groups were compared for the presence of the SLAM sign, high CSA, and type 3 acromion on the radiographs.
RESULTS
All the 3 parameters were found more prevalent in the RCT group than the frozen shoulder group (SLAM, 46% vs. 0; high CSA, 60% vs. 40%; type 3 acromion, 18% vs. 4%) ( < .05). The SLAM sign showed stronger correlation with RCT than high CSA and type 3 acromion ( = 0.562 vs. 0.220 vs. 0.224 respectively).
CONCLUSION
The SLAM sign is a simple and easily identifiable radiological predictor of rotator cuff disease.
PubMed: 34505095
DOI: 10.1016/j.jseint.2021.05.013 -
Orthopaedics & Traumatology, Surgery &... Oct 2020Critical shoulder angle (CSA) is the angle between glenoid inclination and the lateral edge of the acromion. CSA>35° has been shown to be a risk factor for primary and... (Observational Study)
Observational Study
INTRODUCTION
Critical shoulder angle (CSA) is the angle between glenoid inclination and the lateral edge of the acromion. CSA>35° has been shown to be a risk factor for primary and iterative rotator cuff tendon tear. The present study aimed to assess change in CSA after anterior acromioplasty. The study hypothesis was that CSA is significantly reduced.
METHOD
A single-center retrospective descriptive observational study included patients undergoing open or arthroscopic anterior acromioplasty, with strict AP pre- and post-operative radiographs. Patients with radiographs not meeting Moor's criteria were excluded.
RESULTS
One hundred and forty-eight patients were included: arthroscopy, 112; open surgery, 36. Mean age was 57.8 years (range, 29-80 years). Mean preoperative CSA was 36.1±4.25° (range, 25-48.4°) and postoperative CSA 33.5±3.9° (23.8-45.2°), for a significant reduction of -2.6±2.5° (p=0.001). Surgical technique did not affect change in CSA: open surgery, -2.3±1.9° (-6.3° to -1°); arthroscopy, -2.7±2.7° (-10.5° to -5°) (p=0.06). In pathologic CSA (>35°), the mean reduction was -3.2±2.6° (-10.5°to -5°). CSA normalized below the 35° threshold in 48% of patients.
DISCUSSION
Despite reduction in CSA, the 35° threshold for iterative tear is not always reached after anterior acromioplasty. Complementary strictly lateral resection is theoretically required. However, change in CSA is difficult to predict intraoperatively.
CONCLUSION
Anterior acromioplasty significantly reduced CSA, independently of technique and preoperative value.
LEVEL OF EVIDENCE
IV, retrospective descriptive study.
Topics: Acromion; Adult; Aged; Aged, 80 and over; Arthroscopy; Humans; Middle Aged; Retrospective Studies; Rotator Cuff Injuries; Shoulder; Shoulder Joint
PubMed: 32703718
DOI: 10.1016/j.otsr.2020.04.013 -
JSES Reviews, Reports, and Techniques Aug 2022Several bone morphological parameters, including the anterior acromion morphology, the lateral acromial angle, the coracohumeral interval, the glenoid inclination, the...
BACKGROUND
Several bone morphological parameters, including the anterior acromion morphology, the lateral acromial angle, the coracohumeral interval, the glenoid inclination, the acromion index (AI), and the shoulder critical angle (CSA), have been proposed to impact the development of rotator cuff tears and glenohumeral osteoarthritis. This study aimed to develop a deep learning tool to automate the measurement of CSA and AI on anteroposterior shoulder radiographs.
METHODS
We used MURA Dataset v1.1, which is a large publicly available musculoskeletal radiograph dataset from the Stanford University School of Medicine. All normal shoulder anteroposterior radiographs were extracted and annotated by an experienced orthopedic surgeon. The annotated images were divided into train (1004), validation (174), and test (93) sets. We use for U-Net implementation and framework for training the model. The test set was used for final evaluation of the model.
RESULTS
The mean absolute error for CSA and AI between human-performed and machine-performed measurements on the test set with 93 images was 1.68° (95% CI 1.406°-1.979°) and 0.03 (95% CI 0.02 - 0.03), respectively.
CONCLUSIONS
A deep learning model can precisely and accurately measure CSA and AI in shoulder anteroposterior radiographs. A tool of this nature makes large-scale research projects feasible and holds promise as a clinical application if integrated with a radiology software program.
PubMed: 37588867
DOI: 10.1016/j.xrrt.2022.03.002