A Morphometric Evaluation of the Humerus in relation to Shoulder Arthroplasty

 

Safa Abdul Nasser Fadhil, Hayder Jawad Mubarak

Department of Human Anatomy, College of Medicine-Al-Nahrain University, Iraq.

*Corresponding Author E-mail: Alkasapsafa@gmail.com

 

ABSTRACT:

Background: The shoulder prosthesis design resulted in significant reductions in loss of work force and mortality if industries manufacturing prostheses design and manufacture prostheses according to the morphometric data of the population of their own country. Objectives: This morphometric evaluation was proposed to find a correspondence of the anthropometric parameters measured at the proximal and distal humeral parts of humerus. Materials and methods: The claims of this study were appraised on radiographs of dry bones. In this study, (20) dry bones available in the anatomy museum of the department of human anatomy/College of medicine/ Al-Nahrain University were used. The parameters measured on the X-ray of dry bones at the proximal and the distal parts of humerus were statistically compared and evaluated. Results: Significant and high significant correlations found for the parameters provide regression equations for them; these equations allow extraction of missing limit from an available one. Accordingly, statistical regression equations has been concluded for the parameters of the proximal part of the x-ray of dry bone from the values obtained from comparable parameter of the distal part of the x-ray of dry bone. Conclusions: The statistical evaluation upraised the theory of "recapitulation" and introducing a scheme for mathematic reprocessing of approximate estimation for the proper choice of humeral head arthroplasty depending on plain X-imaging to the proximal and distal part of the humerus.

 

KEYWORDS: Humerus, radiograph, morphometry, prosthesis, shoulder.

 

 

INTRODUCTION:

Arthroplasty is an orthopedic surgical procedure where the articular surface of musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. However, the application of arthroplasty has faced different complications that lead to various improvements; arthroplasty presents varied and continuous challenges to the engineer and operating surgeon1.

 

There are 3 main categories of shoulder reconstruction surgery: Hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (rTSA)2.

 

It was reported that industries manufacturing prostheses design and manufacture prostheses according to the morphometric data of the population of their own country3. Patient satisfaction of prosthesis industry is resolved if appropriate morphometric features of countries with different ethnic characteristics were considered4.

 

Desai et al.5 reported that anthropometric and anatomical data are fundamental requirements for optimum postoperative consequences after the shoulder implants, these authors stated that more sufficient data on parameters related to anatomical structure of humeral arthroplasty are needed6.

 

The geometry of humerus had been a topic for statistical evaluation in researches done previously7. The better design of artificial replacements providing the physiological response and strength is the most important goal of shoulder prosthetics research. The prosthesis trying to replace the limb physiologically, much effort had been offered in research field of upper- limb prosthesis was directed to create prostheses as true limb replacements, however, limitations were faced because of the complicated physiological role of the upper limb and the multifunctional mechanisms that must be considered9.

 

In practice, a visual estimate had been used previously for the humeral retroversion at operation, and recent design of humeral head prosthesis needs to have more accurately parameters in order to reduce the influence of non-systematic (random) errors in the measuring procedure depending on the biological variation. The successful shoulder arthroplasty was suggested to be a consequence of anatomic reconstruction of the glenohumeral joint10.

 

It was reported that the shoulder joint has a great range of motion of the human, and in order to have proper functions, it is vital that all articular and periarticular structures are in anatomical position11,12. This study aims to promote and provide orthopedic surgeons with a more efficient and affordable methods of surgical preparation by judgments of the possibility of using the anthropometric parameters measured at the proximal and distal humeral parts of humerus evaluated on radiographs of dry bones.

 

MATERIAL AND METHODS:

In this study, (20) dry bones available in the anatomy museum of the department of human anatomy/College of medicine/Al-Nahrain University were used. The parameters measured on the X-ray of dry bones at the proximal and the distal parts of humerus were statistically compared and evaluated.

The linear parameter measured on X-ray of the proximal part of the dry humerus bone includes:

1    The Proximal Head-Greater Tubercle Distance (PHGD)2,13.‏

2    The Proximal Head-Neck Distance (PHND)2.

3    The Breadth of Proximal End (BPE)4.

4    The Head Diameter (FBD)2,14.‏

5    The Head Height (HH)15,16.

6    The Endosteal Diameter at surgical neck (ED)17,18. ‏

7    The Endosteal Diameter 3cm below surgical neck (ED3)18.

8    The Endosteal Diameter 6cm below surgical neck (ED6)18.

 

The linear parameter measured on the X-ray of distal part of dry humerus bone includes:

1    The Breadth of Distal End (BDE)19.

2    The Inter-Condyler Line (ICL)20.

3    The Intercondylar-Breadth Distance (IBD):

 

It is the distance between the intercondylar line (ICL) and the breadth of distal end (BDE).

The angular parameters measured on proximal part of the X-ray of dry humerus bone include:

1    The Anatomical Neck-Proximal Shaft (ANS), Angle (I)18.

2    The Head – Endosteal Axis (HEA), Angle (II):

This angle is measured by intersection of:

a.   The line perpendicular to the head diameter (anatomical neck).

b. The line of the humeral endosteal axis passing throughout the midpoints of the endosteal diameters ED and ED6.

3    The Head –Shaft Axis (HSA), Angle (III)18.

4    The Head-Anatomical Neck Angle (HAN), angle (IV) 18.

5    The Endosteal Diameter Axis-Shaft Axis (EDA-SA), angle (V):

It was measured on the antero-posterior projection and was formed by the intersection of:

a    The line of the humeral endosteal axis passing throughout the midpoints of the endosteal diameters ED and ED6.

b    The line of the humeral shaft axis below the deltoid tuberosity, passing throughout the midpoints of the outer diameter of the shaft.

6    The (PSA –EDA), Angle (VI):

It was measured on the antero-posterior projection and was formed by the intersection of:

a    The axis of proximal humerus which is the line extending from the mid-point of the outer surgical neck diameter to the mid-point of the head diameter (anatomical neck).

b    The line of the humeral endosteal axis.

7    The (PSA-SA), Angle (VII):

It was measured on the antero-posterior projection and was formed by the intersection of:

a    The axis of proximal humerus.

b    The line of the humeral shaft axis.

 

The angular parameters measured on the X-ray of distal parts of the dry humerus bone include:

1    Trochlea-Capitilum Angle:

The angle measured between:

a    The line connecting the distal surface of trochlea to the incision between lateral epicondyle and capitulum.

b    Humeral shaft – axis.

2    Distal Articular Surface Inclination Angle (DASI):

The angle measured between:

a    Line connecting incision of lateral epicondyle with capitulum and medial epicondyle with trochlea.

b    Line connecting the distal surfaces of trochlea and incision between capitulum and lateral epicondyle.

3    Distal end –Shaft Axis Angle (DESA):

The angle measured between:

a    Humeral shaft axis.

b    Line connecting incision of lateral epicondyle with capitulum and medial epicondyle with trochlea.

4    Capitulum- Inclination Angle (CIA):

The angle measured between:

a    Line connecting incision of lateral epicondyle and capitulum-trochlea incision.

b    Humeral shaft axis.

5    Trochlear Inclination Angle (TIA):

The angle measured between:

a    Incision between medial epicondyle and trochlea and incision of capitulum and trochlea.

b    Humeral shaft axis.

 

All these parameters (linear and angular) listed above whether in X-ray of dry bone or in the X-ray of healthy individuals was made by using the (Radiant Dicom Viewer program).

 

And the statistical evaluation done by statistical program called Statistical Package for the Social Sciences (SPSS) which is could be a package of programs for manipulating, analyzing, and presenting data; the package is wide employed in the social and activity sciences and will manufacture basic descriptive statistics, like averages and frequencies, still as advanced tests like time series analysis and statistical procedure, the program is also capable of manufacturing high quality graphs and tables 21, 22.

 

RESULTS:

The statistical evaluation of linear parameters from distal and proximal dry hummers bone X-ray was evaluated using the Pearson correlation and regression analysis for the comparison of these parameters. The significant and high significant correlations found for these parameters provide regression equations for them; these equations allow extraction of missing limit from an available one. Accordingly, statistical regression equations has been concluded for the linear parameters of the proximal part of the x-ray of dry bone from the values obtained from comparable linear parameter of the distal part of the x-ray of dry bone (table 1).

 

Also the statistical evaluation of angular parameters from distal and proximal dry hummers bone X-ray was evaluated with the Pearson correlation and regression analysis for comparison of them. The significant and high significant correlations found for these parameters provide regression equations for them; these equations allow extraction of missing limit from an available one. Accordingly, statistical regression equations has been concluded for the angular parameters of the proximal part of the x-ray of dry bone from the values obtained from comparable angular parameter of the distal part of the x-ray of dry bone (table 2).

 

Table (1): Pearson correlation and regression analysis between linear parameters of X-ray of dry bone (proximal and distal measurements) with Regression equations between them.

Dry bone parameters

Proximal Linear measurements

Distal Linear measurements

Correlation significantly

p-value

sig. (2-tailed)

Regression equation

PHGD

BDE

NS*

Nil

Nil

ICL

NS*

Nil

Nil

IBD

 NS*

Nil

Nil

PHND

 

BDE

0.604**

0.005

Y= 16.68+1.1*X

ICL

0.733**

0.000

Y= 7.86+0.93*X

IBD

0.522*

0.018

Y= -1.11+0.29*X

BPE

BDE

0.887**

0.000

Y= -1.24+1.24*X

ICL

0.862**

0.000

Y= 4.86+0.78*X

IBD

0.661**

0.001

Y= -2.91+0.26*X

FBD

BDE

0.797**

0.000

Y= 2.93+1.24*X

ICL

0.786**

0.000

Y= 7.44+0.78*X

IBD

0.547*

0.013

Y= -1.02+0.24*X

HH

BDE

0.601**

0.005

Y= 21.17+1.93*X

ICL

0.576**

0.008

Y= 19.53+1.18*X

IBD

0.519*

0.019

Y= 0.85+0.47*X

ED

BDE

0.538*

0.014

Y= 32.81+1.77*X

ICL

0.720**

0.000

Y= 20.76+1.56*X

IBD

 0.473*

0.035

Y= 3.37+0.45*X

ED3

BDE

NS*

Nil

Nil

ICL

0.453*

0.045

Y=26.74+1.17*X

IBD

NS*

Nil

Nil

ED6

BDE

NS*

Nil

Nil

ICL

NS*

Nil

Nil

IBD

NS*

Nil

Nil

NOTE:

* Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

* NS is no significant correlation.

 

Table (2): Pearson correlation and regression analysis between angular parameters of the X-ray of dry bone (proximal and distal measurements) with Regression equations between them.

Proximal Angle measurement

Distal angle measurements

Correlation significantly

p-value sig.

(2 tailed)

Regression equation

ANS Angle I

 

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

HEA Angle II

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

HSA Angle III

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

-0.500*

0.025

Y=1.24E2-1.05*X

HNA Angle IV

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

EDA-SA

Angle V

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

PSA-EDA

Angle VI

TCA

NS*

Nil

Nil

DASI

0.650**

0.002

Y=10.35+0.65*X

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

PSA-SA

Angle VII

TCA

NS*

Nil

Nil

DASI

NS*

Nil

Nil

DESA

NS*

Nil

Nil

CIA

NS*

Nil

Nil

TIA

NS*

Nil

Nil

NOTE:

NS*= No significant correlation.

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

 

DISCUSSION:

The issue of morphometric evaluation of humeral head in relation to shoulder arthroplasty was recently considered for morphometric analyses as it represents an important knowledge to preserve anthropological data of bones of the human body during surgical repair or replacement6. The dry bone used in this study had been obtained from foreign population as these bones were imported to the college of medicine – Al-Nahrian University since establishment about 1987. Therefore, the statistical evaluation of parameters represents a comparable data between foreign populations.

 

This study may be regarded as an evaluation that is directed toward creating comparative values for the implant design by performing morphometric measurements of plain X-ray images of the proximal and distal parts of the humerus. The use of dry bones in this study for assessments considering construction of prosthesis and to help the surgeons in determining the dimensions of bones that makes better understanding of the factors related to suitable prostheses design was in congruence with the methodology used in the field of preoperative planning23.

 

Biomechanics is defined as a term indicating two elements, namely; applied mathematics (mechanics) and biology. The principle of biomechanics is fairly truthful if it implicates logical models24. Force and moments are kinetic variables. The force in biomechanics is applied either by muscles acting on the joints, or by heavy external objects acting on the human body. Kinetics is classified into two sets: linear and angular. Linear kinetics usually indicates those associated with overall forces exerted upon the joint (as ground reply forces during jumping, or muscle force) and angular kinetics are those associated with the turning forces at specific joints24. Because the shoulder is not a weight-bearing joint, it was thought that biomechanical principals are irrelevant and unimportant in consideration to arthroplasty. The load-bearing function of this joint and its adherence to principles of muscle length-tension interactions proclaim much consequence ensuring the endurance of maximal function and patient satisfaction25.

 

The shoulder hemiarthroplasty was progressed by Neer in 1950s, and since then, total and hemiarthroplasty of the shoulder had been performed26. The total shoulder was the procedure indicated for primary osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, and instability arthropathy. This procedure showed an excellent long-term outcome with persistent pain relief, function, and range of function27.

 

Since years ago, pioneers of shoulder arthroplasty concluded that successful procedure must consider the soft tissue adjustment. Recently, the understanding of sophisticated shoulder biomechanics reinforces this impression. The shoulder joint has the least intrinsic stability and it depends primarily on accurate physiologically correction of soft tissue tensions for stability, motion, and function28. This proposal does not disputed the results obtained from data collected in this study as estimation of the prosthesis with parameters closely resembling the person-specific anthropometry is a logic concept supported by the scientific judgments29.

Authors suggesting that abnormal shoulder biomechanics may be attributed to underlying disease process leading to arhtroplasty and could not restored after total shoulder arthroplasty30.

 

It was postulated that the postnatal skeletal development of the proximal humerus follows unique sequential patterns of maturation with variable chronology of the secondary ossification centers31. Authors stated that the inherent osseous articular congruity of the humerus was sacrificed for soft tissue stability to achieve more mobility at the glenohumeral joint32. Accordingly, the postulation concluded in this study that industries manufacturing prostheses should design and manufacture prostheses according to the morphometric data of the population in the country may be related to the functional mannerisms associated with the socio-economic desires.

 

The humerus undergone morphologic alterations during its evolution, its head moved proximally from the horizontal plane to a more vertical resting orientation. This evolutionary change of humeral head had been associated with migration of deltoid insertion distally to improve the lever arm of the deltoid muscle33,34. The antero-posterior dimension of the thoracic cage was described to undergo evolutionary decreased over time, and the scapula and glenoid fossa assumed a more dorsal position in the thoracic cage resulting in a laterally directed glenoid fossa associated with external rotation of the humeral head and an internal rotation of the shaft occurred35.

 

The distal humeral shaft experienced an evolutionary episode of twisting relative to its proximal end, thereby making the humeral head internally rotated relative to the epicondyles35. The exclusive correlation found in this study between the head-shaft angle (HSA angle III) measured on the proximal dry humerus bone with trochlear – inclination angle (TIA) that measured on the distal part of dry humerus bone and the PSA-EDA (VI) angle measured on the dry humerus bone with Distal articular surface inclination angle (DASI) that measured on the distal part of dry humerus bone may reflect an evolutionary attribute of this correlation.

 

The results of this study may formulate hypothetical explanation for the Pearson correlation and regression analysis between parameters considered, these finding may be related to static twisting of the distal humerus relative to its proximal end in the same manner considering the evolutional aspects of this bone. This hypothesis is supported by the principles of the theory of recapitulation, or called the embryological parallelism expressing that "ontogeny recapitulates phylogeny″36.

 

The term (embryonic attachment unit) was used to indicate the tip of a tendon and the bone eminence into which it is inserted. Muscle loads are important for tissue to mature and mineralize37.

 

The embryological development of the humerus is initiated when a subset of mesenchymal cells derived from the lateral plate mesoderm is specified as chondroprogenitors. Thenafter, the differentiation of chondroprogenitors is completed and cartilaginous templates of future bone are formed. The bony eminences developed shortly after this primary template has been established38. Accordingly, the embryological development of the humerus modulated by the prenatal and postnatal muscle load may be the potential regulative traits of the humeral anthropometric variability between the different populations.

 

Recently, it was reported that shoulder arthroplasties are generally effective in improving patients’ comfort and function; however, the results of arthroplasty were variable for reasons that are not well explained34. The conclusions and finding obtained in this morphometric study represent a step forward hoping to add new data that may improve the expectation of the shoulder arthroplasty. Definitely, further considerations should be elaborated in correspondence with practical awareness of local manufacturing of prosthesis models. The results of this study agree with parameters specified by38. that factors are associated with better outcomes after shoulder arthroplasty could involve a sensitive specific positive and negative predictive values of a multivariate predictive model for better outcome after controlling for potentially relevant mysterious variables.

 

The conclusive parameters obtained in this study may predict the expected results for each patient as a prognostic baseline for the patient and shoulder characteristics aiming for better clinical outcomes by attempting to complete part of the reports about the cessation in knowledge.

 

ACKNOWLEDGEMENT:

The author is grateful to the Deanship of Medicine college, Al-Nahrain University, and regard be presented to the staff members department of human anatomy for their assistance and cooperation and provide all facilities for the success of this work

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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Received on 09.08.2019           Modified on 24.09.2019

Accepted on 08.11.2019         © RJPT All right reserved

Research J. Pharm. and Tech. 2020; 13(10):4817-4822.

DOI: 10.5958/0974-360X.2020.00847.1