Objectives

Cadaveric models of the shoulder evaluate discrete motion segments using the glenohumeral joint in isolation over a defined trajectory. The aim of this study was to design, manufacture and validate a robotic system to accurately create three-dimensional movement of the upper body and capture it using high-speed motion cameras.

Analyzing shoulder kinematics is challenging as the shoulder is comprised of a complex group of multiple highly mobile joints. Unlike at the elbow or knee which has a primary flexion/extension axis, both primary shoulder joints (glenohumeral and scapulothoracic) have a large range of motion (ROM) in all three directions. As such, there are six degrees of freedom (DoF) in the shoulder joints (three translations and three rotations), and all these parameters need to be defined to fully describe shoulder motion. Despite the importance of glenohumeral and scapulothoracic coordination, it's the glenohumeral joint that is most studied in the shoulder. Additionally, the limited research on the scapulothoracic primarily focuses on planar motion such as abduction or flexion. However, more complex motions, such as internally rotating to the back, are rarely studied despite the importance for activities of daily living. A technique for analyzing shoulder kinematics which uses 4DCT has been developed and validated and will be used to conduct analysis. The objective of this study is to characterize glenohumeral and scapulothoracic motion during active internal rotation to the back, in a healthy young population, using a novel 4DCT approach. Eight male participants over 18 with a healthy shoulder ROM were recruited. For the dynamic scan, participants performed internal rotation to the back. For this motion, the hand starts on the abdomen and is moved around the torso up the back as far as possible, unconstrained to examine variability in motion pathway. Bone models were made from the dynamic scans and registered to neutral models, from a static scan, to calculate six DoF kinematics. The resultant kinematic pathways measured over the entire motion were used to calculate the ROM for each DoF. Results indicate that anterior tilting is the most important DoF of the scapula, the participants all followed similar paths with low variation. Conversely, it appears that protraction/retraction of the scapula is not as important for internally rotating to the back; not only was the ROM the lowest, but the pathways had the highest variation between participants. Regarding glenohumeral motion, internal rotation was by far the DoF with the highest ROM, but there was also high variation in the pathways. Summation of ROM values revealed an average glenohumeral to scapulothoracic ratio of 1.8:1, closely matching the common 2:1 ratio other studies have measured during abduction. Due to the unconstrained nature of the motion, the complex relationship between the glenohumeral and scapulothoracic joints leads to high variation in kinematic pathways. The shoulder has redundant degrees of freedom, the same end position can result from different joint angles and positions. Therefore, some individuals might rely more on scapular motion while others might utilize primarily humeral motion to achieve a specific movement. More analysis needs to be done to identify if any direct correlations can be drawn between scapulothoracic and glenohumeral DoF. Analyzing the kinematics of the glenohumeral and scapulothoracic joint throughout motion will further improve understanding of shoulder mechanics and future work plans to examine differences with age

Introduction. Treatment strategies for irreparable Massive Rotator Cuff Tears (MRCTs) are debatable, especially for younger, active patients. Superior Capsular Reconstruction (SCR) acts as a static stabilizer, while Lower Trapezius Transfer (LTT) serves as a dynamic stabilizer. This study compares the biomechanical effectiveness of SCR and LTT, hypothesizing that their combination will enhance shoulder kinematics. Methods. Eight human shoulders from donors aged 55-75 (mean = 63.75 years), balanced for gender, averaging 219.5 lbs, were used. Rotator cuff and deltoid tendons were connected to force sensors through a pulley system, with the deltoid linked to a servohydraulic motor for dynamic force measurement. Results. From intact to MRCT, deltoid force was reduced by 28% (p = 0.023). LTT increased deltoid force by 27.25 (p = 0.166). SCR decreased deltoid force by 34% (p = 0.208). Combining LTT with SCR increased deltoid force by 32.57% compared to SCR (p = 0.023) and decreased it by 13.6% compared to LTT alone (p = 0.017). Combined LTT and SCR reduced deltoid force by 20.9% from the control (p = 0.001). Subacromial contact pressure rose by 15% in MRCT over intact, but LTT decreased it by 7.6%, achieving nearly 50% correction. SCR increased subacromial space volume, raising pressure by 6.5%. The humeral head translation (HHT) increases with MRCT, reaching 3.33 mm (SD = 0.95) at 0 degrees, compared to 2.24 mm (SD = 0.78) in the intact. LTT and the combined LTT + SCR significantly reduce HHT, with combined LTT + SCR achieving HHT of 2.24 mm (SD = 0.63) at 0 degrees, comparable to the control. Conclusion. Notable changes in deltoid force were observed. LTT outperformed the combined SCR and LTT in reducing deltoid force and subacromial peak pressure. Both SCR and LTT corrected HTT, with LTT being more effective. However, combining SCR and LTT optimally corrected HHT

Background:. It is not well known how different external loads influence shoulder kinematics and muscle activity in patients with shoulder prostheses. Study objective: define shoulder kinematics and determine the scapulothoracic contribution to total shoulder motion, in combination with shoulder muscle activity and the degree of co-contraction, of patients with total (TSA) and reverse shoulder arthroplasties (RSA) and healthy individuals during rehabilitation exercises using different loading conditions. Methods:. Shoulder motions (anteflexion and elevation in the scapular plane) of 17 patients (20 shoulders) with a TSA, 8 patients (9 shoulders) with a RSA and 15 healthy subjects were measured using anelectromagnetic tracking device. A force transducer recorded force signals during loaded conditions (without external load, 1 kg and elastic resistance). Electromyographic (EMG) activity of the deltoid (anterior, middle, posterior parts), latissimus dorsi, pectoralis major (clavicular and sternal parts), teres major and serratus anterior was recorded and the degree of co-contraction calculated. Results:. The scapula contributed more to movement of the arm in subjects with prostheses compared to healthy subjects and during loaded versus unloaded tasks. Glenohumeral elevation angles during anteflexion were significantly higher in the TSA than in the RSA group. Higher activity of the middle and posterior deltoid was found in the TSA group compared to healthy subjects and for the pectoralis major (sternal part) in the RSA group compared to TSA and healthy subjects. For all muscles, except the serratus anterior, activity was lower for unloaded tasks compared to 1 kg dumbbell and elastic band resistance. No main effect of group or load for degree of co-contraction was detected in both exercises. Conclusions:. Differences in contribution of the scapula to total shoulder motion between patients with different types of arthroplasties were not significant, but differed both compared to healthy subjects. Scapular kinematics of patients with shoulder arthroplasties were influenced by implementation of external loads, however, not by the type of load. There were no differences in muscle activity and degree of co-contraction between patient groups

Measurements of shoulder kinematics during activities of daily living (ADL) can be used to evaluate patient function before and after treatment and help define device testing conditions. However, due to the difficulties of making 3D motion measurements outside of laboratory conditions, there are few reports of measured shoulder 3D kinematics during ADL. The purpose of this study was to demonstrate the feasibility of using wearable inertial measurement units (IMUs) to track shoulder joint angles. A nonrandom sample of 5 subjects with normal shoulders was selected based on occupation. The occupations were: dental hygienist, primary school teacher, mechanical project engineer, administrative assistant, and retail associate. Subjects wore two OPAL IMUs (APDM, Portland OR) as shown in Figure 1 on the sternum and on the upper arm for approximately 4 hours while at their workplace performing their normal work place activities and then up to 4 hours while off-work. Orientation angles from IMUs have traditionally been estimated by integrating gyroscope data and calculating inclination angles relative to gravity with accelerometers. A significant problem is that inaccuracies inherent in the measurements can degrade accuracy. In this study, we used an Unscented Kalman Filter (UKF) with IMU output to track shoulder angles. The UKF mitigates the effect of random drift by incorporating domain knowledge about the shoulder normal range of motion, and the gyroscope and accelerometer characteristics into the state-space models. Initially, in the horizontal plane, without gravity measurements from the accelerometer to aid the gyroscope data, there were unacceptable errors in transverse rotation. To mitigate this error, additional constraints were applied to model gyroscope drift and a zero velocity update strategy was included. These additions decreased tracker errors in heading by 63%. The resulting accuracy with the modified tracker in all motion planes was about 2° (Figure 2). Subjects commented that the IMUs were well tolerated and did not interfere with their ability to perform tasks in a normal manner. The overall averaged 95th percentile angles (Figure 3) were: flexion 128.8°, adduction 128.4°, and external rotation 69.5°. These peaks angles are similar to other investigator's reports using laboratory simulations of ADL tasks measured with optical and electromagnetic technologies, though this study's observations did show 17% greater extension and 40% greater adduction. Additionally, in these observations, occurrences of maximal internal rotation were rare compared to maximal external rotation and when maximum external rotation did occur, it was in combination with an average flexion angle of 103°. Finally, by performing a Fourier transform of the arm angles and using the 50th percentile frequency the number of arm cycles in a 10 year period was calculated at over 600,000 cycles. Application of the UKF with the additional drift correction made substantial improvements in shoulder tracking performance and this feasibility data suggests that IMUs with the UKF are suitable for extended use outside of laboratory settings. The motion data collected provides a novel description of arm motion during ADLs including estimating the cycle count of the upper arm at more than 600,000 cycles over 10 years

Treatment of massive rotator cuff tears can be challenging. Previous studies with irreparable rotator cuff tears showed good clinical results of tendon healing with the arthroscopic insertion of a protective biodegradable spacer balloon filled with saline solution between the repaired tendon and the acromion [1,2], but so far no scientific evidence has showed how the device alters pressures over the repaired tendon. This biomechanical study investigated the effects of a spacer inserted in the subacromial space on pressures over the repaired rotator cuff tendon in passive motion cycles typical for post-operative rehabilitation routines. Six human cadaveric shoulders were prepared with the humerus cut 15cm below the joint and embedded in a pot, while the scapula fixed at three points on a plate. A rotator cuff tear was simulated and repaired using a suture anchor and a Mason-Allen suture. The specimens were then mounted on a custom-made pneumatic testing rig to induce passive motion cycles of adduction-abduction (90–0°) and flexion-extension (0–40°) with constant glenohumeral and superior loads and tension is exerted on the supraspinatus tendon with weights. A pressure sensor was placed between the supraspinatus tendon and the acromion. After pressure measurements for 15 cycles of each motion type, the InSpace balloon (OrthoSpace, Inc, Israel) was inserted and the specimens tested and pressure measured again for 15 cycles. Statistically significant changes in peak pressures were then measured before and after balloon. Peak pressures were measured near 90 degrees abduction. No statistical differences were observed for internal-external rotation before and after balloon-shaped subacromial spacer was inserted. Mean pressures in abduction-adduction were significantly reduced from 121.7 ± 9.5 MPa to 51.5 ± 1.2 MPa. Peak pressures after repair were 1171.3 ± 99.5 MPa and 1749.6 ± 80.7 MPa in flexion-extension and abduction-adduction motion, respectively, and significantly decreased to 468.7 ± 16.0 MPa and 535.1 ± 27.6 MPa after spacer insertion (p<0.0001). The use of the spacer above the repaired tendon reduced peak pressures and distributed them more widely over the sensor during both abduction-adduction and flexion-extension motions and therefore can reduce the stress on the rotator cuff repair. The InSpace system may reduce the pressure on the repaired tendon, thus potentially protecting the repair. Further studies to investigate this phenomenon are warranted, in particular relating these changes to shoulder kinematics following tear repair and spacer insertion

Accurate and reproducible measurement of three-dimensional shoulder kinematics would contribute to better understanding shoulder mechanics, and therefore to better diagnosing and treating shoulder pathologies. Current techniques of 3D kinematics analysis use external markers (acromial cluster or scapula locator) or medical imaging (MRI or CT-Scan). However those methods present some drawbacks such as skin movements for external markers or cost and irradiation for imaging techniques. The EOS low dose biplanar X-Rays system can be used to track the scapula, humerus and thorax for different arm elevation positions. The aim of this study is to propose a novel method to study scapulo-thoracic kinematics from biplanar X-rays and to assess its reliability during abduction in the scapular plane. This study is based on the EOS™ system (EOS Imaging, Paris, France), which allows acquisition of 2 calibrated, low dose, orthogonal radiographs with the subject standing at 30 to 40° angle of coronal rotation to the plane of one of the X-ray beams, in order to limit superimposition with the ribcage and spine. Seven abduction positions in the scapular plane were maintained by the subjects for 10 seconds, during X-ray acquisition. Between two positions, the subjects returned at rest position. Arm elevations were approximately 0, 10, 20, 30, 60, 90 and 150° (position 1 to 7). Six subjects were enrolled to perform a reproducibility study based on the 3D reconstructions of 2 experienced observers three times each. For each subject, a personalised 3D reconstruction of the scapula was created. The observer digitises clearly visible anatomical landmarks on both stereoradiographs for each arm position. These landmarks are used to make a first adjustment of a parameterised 3D model of the scapula. This provides a pre-personalised model of the subject's scapula which is then rigidly registered on each pair of X-rays until its retroprojection fits best on the contours that are visible on the X-rays. The thorax coordinate system (CS) was built following the ISB (International Society of Biomechanics) recommendations. The CS associated to the scapula was a glenoid centred CS based on the ellipse which fit on the glenoid rim on the 3D model of scapula. Scapular CS orientation and translation in the thorax CS was calculated following a Y,X,Z angle sequence for each position. Each 3D reconstruction of the scapula was performed in approximately 30 minutes. The most reproducible rotation was upward/downward rotation (along X axis) with a 95% confidence interval (95% CI) from 2.71° to 3.61°. Internal/external rotation and anterior/posterior tilting were comprised respectively between 5.18° to 8.01° and 5.50° to 7.23° (CI 95%). The most reproducible translation was superior-inferior translation (along Y axis) with a 95% CI from 1.22mm to 2.46mm. Translation along X axis (antero-posterior) and Z axis (medio-lateral) were comprised respectively between 2.49mm to 4.26mm and 2.47mm to 3.30mm (CI 95%). We presented a new technique for 3D functional quantitative analysis of the scapulo-thoracic joint. This technique can be used with confidence; uncertainty of the measures seems acceptable compared to the literature. Main advantages of this technique are the very low dose irradiation compared to the CT-Scan and the possibility to study arm elevation above 120°

Rotator cuff tears are a common cause of shoulder pain and dysfunction. Therefore, the purpose of this in-vitro biomechanical study was conducted to determine the effects of simulated tears and subsequent repairs of the rotator cuff tendons on joint kinematics. Eight paired fresh-frozen cadaveric shoulder specimens (mean age: 66.0 ± 8.7 years) were tested using a custom loading apparatus designed to simulate unconstrained motion of the humerus. Cables were sutured to the rotator cuff tendons and the deltoid. Loads were applied to the cables based on variable ratios of electromyographic (EMG) data and average physiological cross-sectional area (pCSA) of the muscles. An electromagnetic tracking device (Flock of Birds, Ascension Technologies, VT) was used to provide real-time feedback of abduction angle, to which the loading ratio was varied correspondingly. 2 and 4cm tears were made starting at the rotator cuff interval and extending posteriorly. Specimens were randomised to receive either single or double suture anchor repair. In order to quantify repeatability, five successive tests on each of the intact, torn, and repaired cases were performed. Statistical significance was established using One- and Two-way Repeated Measured ANOVAs (p< 0.05). Rotator cuff tears caused alteration in glenohumeral kinematics. A 2cm tear caused the humerus to consistently move posterior through the arc of abduction; however, as the tear increased to 4cm the humerus moved anteriorly, returning towards the intact state. Double row suture anchor repairs more accurately reproduced the kinematics of the intact specimen compared to single row suture anchor repair. The initial posterior displacement in the plane of elevation with the sectioning of the supraspinatus is related to the diminished anterior moment on the glenohumeral joint. As the tear proceeds into the infraspinatus, the anterior and posterior forces become more balanced and a return to near normal intact kinematics was observed. This study demonstrates that double row suture anchor repair more accurately reproduces active shoulder kinematics of the intact shoulder specimens

INTRODUCTION. Total shoulder arthroplasty (TSA) implants are used to restore function to individuals whose shoulder motions are impaired by osteoarthritis. To improve TSA implant designs, it is crucial to understand the kinematics of healthy, osteoarthritic (OA), and post-TSA shoulders. Hence, this study will determine in vivo kinematic trends of the glenohumeral joints of healthy, OA, and post-TSA shoulders. Methods. In vivo shoulder kinematics were determined pre and post-operatively for five unilateral TSA subjects with one healthy and a contralateral OA glenohumeral joint. Fluoroscopic examinations were performed for all three shoulder categories (healthy, OA, and post-TSA) for each subject shoulder abduction and external rotation. Then, three-dimensional (3D) models of the left and right scapula and humerus were constructed using CT scans. For post-operative shoulders, 3D computer-aided design models of the implants were obtained. Next, the 3D glenohumeral joint kinematics were determined using a previously published 3D to 2D registration technique. After determining kinematics, relative Euler rotation angles between the humerus and scapula were calculated in MATLAB® to determine range of motion (ROM) and kinematic profiles for all three shoulder categories. The ROMs for each category were compared using paired t-tests for each exercise. Also, the location of the contact point of the humerus on the glenoid was found. This allowed the vertical translation from the most superior to most inferior contact point (SI contact range) to be calculated as well as the horizontal translation from the most anterior to most posterior contact point (AP contact range). The SI and AP contact ranges for all shoulder categories were compared using paired t-tests for each exercise. Results. Abduction. According to preliminary results, the averages range of abduction for healthy, OA, and post-TSA shoulders was 51.5 °, 19.4°, and 56.7°, respectively. The average SI contact range of abduction for healthy, OA, and post-TSA shoulders was 14.1 mm, 16.4 mm, and 14.1 mm, respectively while the AP contact range was 10.0, 14., and 14.3, respectively. The ranges of abduction between healthy and OA and between OA and post-TSA shoulders, and the AP contact range for healthy and OA shoulders displayed statistically significant differences at the α=0.05 level. External Rotation. The averages range of External Rotation for healthy, OA, and post-TSA shoulders was 63.6°, 31.1°, and 44.5°, respectively. The averages SI contact range of External Rotation for healthy, OA, and post-TSA shoulders was 20.7, 12.7, and 15.9 mm, respectively while the averages AP contact range was 8.5,12.9 mm, and 13.8 mm, respectively. The ranges of abduction for healthy and OA as well as AP contact range for healthy and OA shoulders were statistically different at the α=0.05 level. Conclusions. This study's preliminary results indicate that healthy, OA, and post-TSA shoulders show statistically significant difference in kinematic trends including ROM and contact point translation. These differences may result from the varying geometries of each condition or from subjects altering kinematic trends to reduce pain in OA shoulders. In addition, this study may provide a reference for future studies analyzing the kinematics of post TSA shoulders

The numbers of anatomic total shoulder joint replacements (ATSR) is increasing during the past years with encouraging clinical results. However, the survivorship of ATSR is lower as compared to total knee and hip replacements. Although the reasons for revision surgery are multifactorial, wear-associated problems like loosening are well-known causes for long-term failure of ATSR. Furthermore there is lack of valid experimental wear tests for ATSR. Therefore the purpose of this study was to define experimental wear testing parameters for ATSR and to perform a wear study comparing ceramic and metallic humeral heads. Kinetic and kinematic data were adopted from in-vivo loading measurements of the shoulder joint (. orthoload.com. ) and from several clinical studies on shoulder joint kinematics. As activity an ab/adduction motion of 0 to 90° in combination with an ante/retroversion while lifting a load of 2 kg has been chosen. Also a superior-inferior translation of the humeral head has been considered. The wear assessment was performed using a force controlled AMTI joint simulator for 3×10. 6. cycles (Fig. 1) and polyethylene wear has been assed gravimetrically. The studied ATSR (Turon. TM. , DJO Surgical, USA) resulted in a polyethylene wear rate of 62.75 ± 1.60 mg/10. 6. cycles in combination with metallic heads. The ceramic heads significantly reduced the wear rate by 26.7 % to 45.99 ± 1.31 mg/10. 6. (p<0.01). The wear scars dimensions were in good agreement to clinical retrievals. This study is the first that experimentally studied the wear behavior of ATSR based on clinical and biomechanical data under load controlled conditions. In term of wear the analyzed ATSR could clearly benefit from ceramic humeral heads. However, in comparison to experimental wear studies of total knee and hip replacements the wear rate of the studied ATSR was relatively high. Therefore further research may focus on optimized wear conditions of ATSR and the hereby described method may serve as a tool to evaluate a wear optimization process

Purpose: Subacromial impingement syndrome is a painful condition which occurs during overhead activities as the rotator cuff is compressed between the greater tuberosity and the acromion. Unrecognized secondary causes of impingement syndrome may lead to treatment failure. Posterior capsular tightness, believed to alter shoulder joint kinematics, is often cited as a secondary cause but scientific evidence is lacking. The objective of this study was to evaluate the effect of posterior capsular tightness on pressure in the subacromial space. Method: Ten fresh-frozen cadaver shoulder specimens were mounted on a custom testing apparatus. With the scapula fixed, the deltoid and cuff muscles were loaded statically with a constant ratio to elevate the humerus in the scapular plane under physiologic loading conditions. For each treatment (intact capsule, 1cm and 2cm plication), pressure in the subacromial space and glenohumeral kinematics were recorded during elevation. The treatment order was randomly assigned to each specimen. Peak pressure and translation of the humeral head center were compared using a repeated measures ANOVA. Results: Peak subacromial pressures (mean±sd) were similar between treatment groups: 345±152 kPa, 410±213 kPa and 330±164 kPa for the intact, 1cm and 2cm plication respectively (p> 0.05). No significant differences were found for superior or antero-posterior translations of the humeral head at the peak pressure position (p> 0.05). Conclusion: Posterior capsular tightness, as a sole variable, did not contribute significantly to increased pressure in the subacromial space or to increased anterior or superior humeral head translation during abduction. Clinically, posterior capsular tightness may occur in association with impingement syndrome but may not play a significant role in causation