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The Influence of Three-Dimensional Computed Tomography Images of the Shoulder in Preoperative Planning for Total Shoulder Arthroplasty
Jason J. Scalise, MD1; Michael J. Codsi, MD2; Jason Bryan, MS3; John J. Brems, MD3; Joseph P. Iannotti, MD, PhD3
1 The CORE Institute, 3010 West Agua Fria Freeway, Suite 100, Phoenix, AZ 85027. E-mail address: jason.scalise@thecoreinstitute.com
2 The Everett Clinic, 3927 Rucker Avenue, Everett, WA 98201. E-mail address: mcodsi@yahoo.com
3 Departments of Biomedical Engineering (J.B.) and Orthopaedic Surgery (J.J.B. and J.P.I), The Cleveland Clinic, 9500 Euclid Avenue, ND-20 (J.B.), EU10 (J.J.B.), and A-41 (J.P.I.), Cleveland, OH 44195. E-mail address for J. Bryan: bryanj2@ccf.org. E-mail address for J.J. Brems: bremsj@ccf.org. E-mail address for J.P. Iannotti: iannotj@ccf.org
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (DePuy Johnson and Johnson and Tornier) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Investigation performed at The Cleveland Clinic, Cleveland, Ohio

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Nov 01;90(11):2438-2445. doi: 10.2106/JBJS.G.01341
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Background: Arthritic changes to glenoid morphology can be difficult to fully characterize on both plain radiographs and conventional two-dimensional computer tomography images. We tested the hypothesis that three-dimensional imaging of the shoulder would increase inter-rater agreement for assessing the extent and location of glenoid bone loss and also would improve surgical planning for total shoulder arthroplasty.

Methods: Four shoulder surgeons independently and retrospectively reviewed the preoperative computed tomography scans of twenty-four arthritic shoulders. The blinded images were evaluated with conventional two-dimensional imaging software and then later with novel three-dimensional imaging software. Measurements and preoperative judgments were made for each shoulder with use of each imaging modality and then were compared. The glenoid measurements were glenoid version and bone loss. The judgments were the zone of maximum glenoid bone loss, glenoid implant fit within the glenoid vault, and how to surgically address abnormal glenoid version and bone loss. Agreement between observers was evaluated with use of intraclass correlation coefficients and the weighted kappa coefficient (?), and we determined if surgical decisions changed with use of the three-dimensional data.

Results: The average glenoid version (and standard deviation) measured -17° ± 2.2° on the two-dimensional images and -19° ± 2.4° on the three-dimensional images (p < 0.05). The average posterior glenoid bone loss measured 9 ± 2.3 mm on the two-dimensional images and 7 ± 2 mm on the three-dimensional images (p < 0.05). The average anterior bone loss measured 1 mm on both the two-dimensional and the three-dimensional images. However, the intraclass correlation coefficients for anterior bone loss increased significantly with use of the three-dimensional data (from 0.36 to 0.70; p < 0.05). Observers were more likely to locate mid-anterior glenoid bone loss on the basis of the three-dimensional data (p < 0.05). The use of three-dimensional data provided greater agreement among observers with regard to the zone of glenoid bone loss, glenoid prosthetic fit, and surgical decision-making. Also, when the judgment of implant fit changed, observers more often determined that it would violate the vault walls on the basis of the three-dimensional data (p < 0.05).

Conclusions: The use of three-dimensional imaging can increase inter-rater agreement for the analysis of glenoid morphology and preoperative planning. Important considerations such as the extent and location of glenoid bone loss and the likelihood of implant fit were influenced by the three-dimensional data.

Clinical Relevance: We believe that these data support the concept that three-dimensional imaging techniques applied to the shoulder provide further information that may be useful to the surgeon during the planning of total shoulder arthroplasty.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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