While reverse shoulder arthroplasty (RSA) is a reliable treatment option for patients with rotator cuff deficiency, loss of glenoid baseplate fixation often occurs due to screw loosening. We questioned whether an analysis of the trabecular bone density distribution in the scapula would indicate more optimal sites for screw placement. As such, the purpose of this study was to determine the anatomic distribution of trabecular bone density in regions of the scapula available for screw placement in RSA.

Seven cadaveric shoulders were computed tomography (CT) scanned, and then voxels of the scapulae were isolated from the CT volume (Mimics 15.0 Materialise, Leuven, Belgium). Analyses were conducted in a common, 3D coordinate system. Volumetric regions of interest (ROI) within the scapula were identified based on potential baseplate screw sites. ROIs included areas at the base of the coracoid process lateral and inferior to the suprascapular notch, in the posterior and anterior lateral spine and in the anterosuperior and posteroinferior lateral border. Hounsfield Units (HU) were extracted from voxels corresponding to trabecular bone within each ROI. Overall bone density was summarised as the frequency of HU values above 80% of the ROI's maximum density value. Paired, two-tailed t-tests assuming unequal variance were used for pairwise comparisons (P≤0.05). Intra-region analyses compared two ROIs within the same broad anatomical structure; inter-region analyses compared ROIs between anatomical structures.

Areas of the spine and lateral border of the scapula appeared to be denser than the coracoid process. Intra-region comparisons indicated no significant differences within ROI: coracoid P=0.43, spine P=0.95, lateral border P=0.41. ROI inferior to the suprascapular notch were on average 3.78% (P=0.08) and 6% (P=0.04) less dense than the anterosuperior and posteroinferior lateral border and 7.59% (P=0.006) and 7.72% (P=0.01) less dense than the anterior and posterior lateral spine. ROI lateral to the suprascapular notch were 6% (P=0.05) and 8.21% (P=0.02) less dense than the anterosuperior and posteroinferior lateral border and 9.8% (P=0.006) and 9.94% (P=0.008) less dense than the anterior and posterior lateral spine. There was no significant difference between the anterior spine and anterosuperior and posteroinferior lateral border (P=0.12, P=0.58), nor between the posterior spine and anterosuperior and posteroinferior lateral border (P=0.14, P=0.57).

Results from this study indicate that the spine and lateral border of the scapula contain denser trabecular bone relative to regions in the coracoid. The higher quality bone of the spine and lateral border should be favoured over the coracoid process when fixing the glenoid baseplate in RSA. Further research may support the redesign of the glenoid baseplate geometry to better integrate the anatomy of the scapula and improve implant survival.

Osteophytes are bony spurs on normal bone that develop as an adaptive reparative process due to excessive stress at/near a joint. As osteophytes develop from normal bone, they are not always well depicted in common imaging techniques (e.g. CT, MRI). This creates a challenge for preoperative planning and image-guided surgical methods that are commonly incorporated in the clinical routine of orthopaedic surgery.

The study examined the accuracy of osteophyte detection in clinical CT and MRI scans of varying types of joints.

The investigation was performed on fresh-frozen ex-vivo human resected joints identified as having a high potential for presentation of osteophytes. The specimens underwent varying imaging protocols for CT scanning and clinical protocols for MRI. After dissection of the joint, the specimens were subjected to structured 3D light scanning to establish a reference model of the anatomy. Scans from the imaging protocols were segmented and their 3D models were co-registered to the light scanner models. The quality of the osteophyte images were evaluated by determining the Root Mean Square (RMS) error between the segmented osteophyte models and the light scan model.

The mean RMS errors for CT and MRI scanning were 1.169mm and 1.419mm, respectively. Comparing the different CT parameters, significance was achieved with scanning at 120kVp and 1.25mm slice thickness to depict osteophytes; significance was also apparent at a lower voltage (100kVp).

Preliminary results demonstrate that osteophyte detection may be dependent on the degree of calcification of the osteophyte. They also illustrate that while some imaging parameters were more favourable than others, a more accurate osteophyte depiction may result from the combination of both MRI and CT scanning.

Reverse shoulder arthroplasty has a high complication rate related to glenoid implant instability and screw loosening. Better radiographic post-operative evaluation may help in understanding complications causes. Medical radiographic imaging is the conventional technique for post-operative component placement analysis. Studies suggest that volumetric CT is better than use of CT slices or conventional radiographs. Currently, post-operative CT use is limited by metal-artifacts in images. This study evaluated inter-observer reliability of pre-operative and post-operative CT images registration to conventional approaches using radiographs and CT slices in measuring reverse shoulder arthroplasty glenoid implant and screw percentage in bone.

Pre-operative and post-operative CT scans, and post-operative radiographs were obtained from six patients that had reverse shoulder arthroplasty. CT scans images were imported into a medical imaging processing software and each scapula, glenoid implant and inferior screw were reconstructed as 3D models. Post-operative 3D models were imported into the pre-operative reference frame and matched to the pre-operative scapula model using a paired-point and a surface registration. Measurements on registered CT models were done in reference to the pre-operative scapula model coordinate frame defined by a computer-assisted designed triad positioned in respect to the center of the glenoid fossa and trigonum scapulae (medial-lateral, z axis) and superior and inferior glenoid tubercle (superior-inferior, y axis). The orthogonal triad third axis defined the anterior-posterior axis (x axis). A duplicate triad was positioned along the central axis of the glenoid implant model. Using a virtual protractor, the glenoid implant inclination was measured from its central axis and the scapula transverse plane (x - z axes) and version from the coronal plane (y - z axes). Inferior screw percentage in bone was measured from a Boolean intersection operation between the pre-operative scapula model and the inferior screw model.

For CT slices and radiographic measurements, a first 90-degree Cobb angle, from medical records software, was positioned from the trigonum scapulae to the centre of the central peg. Using the 90-degree line as reference, a second Cobb angle was drawn from the most superior to the most inferior point of the glenoid implant for inclination and from of the most anterior to the most posterior point for version. Version can only be measured using CT slices. Screw percentage in bone was calculated from screw length measures collected with a distance-measuring tool from the software.

For testing the inter-observer reliability of the three methods, measures taken by three qualified observers were analysed using an intra-class correlation coefficient (ICC) method.

The 3D registration method showed excellent reliability (ICC > 0.75) in glenoid implant inclination (0.97), version (0.98) and screw volume in bone (0.99). Conventional methods showed poor reliability (ICC < 0.4); CT-slice inclination (0.02), version (0.07), percentage of screw in bone (0.02) and for radiographic inclination (0.05) and percentage screw in bone (0.05).

This CT registration of post-operative to pre-operative novel method for quantitatively assessing reverse shoulder arthroplasty glenoid implant positioning and screw percentage in bone, showed excellent inter-observer reliability compared to conventional 2D approaches. It overcomes metal-artifact limitations of post-operative CT evaluation.