Three-dimensional morphometric analysis of glenoid in the Indonesian population and its clinical significance

Holong Mangasah; Iman Widya Aminata

doi:10.1016/j.jor.2023.02.002

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doi:

10.1016/j.jor.2023.02.002

Three-dimensional morphometric analysis of glenoid in the Indonesian population and its clinical significance

Holong Mangasah , Iman Widya Aminata

Department of Orthopaedics and Traumatology, Fatmawati General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

∗Corresponding author: Holong Mangasah. hmangasah@gmail.com

Received: 2022-10-13, Accepted: 2023-2-8, Published: 2023-2-9

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Understanding glenoid morphometry is important in shoulder prosthetic replacement surgery. In total and reverse shoulder arthroplasty, the size of the implants has to be determined according to the morphometry of the shoulder. However, there has been no known data on glenoid morphometry in the Indonesian population.

Seventy-four computed tomography scans of asymptomatic shoulders were obtained from the medical databases of a third referral hospital in Jakarta. Mimics Research 21.0 was used to reconstruct 3D models of the scapula from the DICOM files. The morphometry parameters included were glenoid fossa height (GFH), maximum glenoid fossa width (MGW), glenoid width at center of the glenoid fossa (CGW), vertical distance between maximum width and center (VDMC), glenoid version angle (GVA), glenoid inclination (GI), glenopolar angle (GPA), glenoid vault depth (GVD), coracoid length (CL), coracoid midpoint length (CML), coracoid tip height (CTH) and width (CTW), and coracoid midpoint height (CMH) and width (CMW).

Our study found the average Indonesian GFH was 30.24 mm, the MGW was 24.03 mm, the CGW was 22.46 mm, the VDMC was 3.67 mm, the GPA was 42.76°, the GVD 18.8 mm, the GVA was 2.39° retroverted, the GI was 3.15° superiorly inclined, the CL was 37.76 mm, the CML was 18.89 mm, the CTW was 13.31 mm, the CTH was 8.52 mm, the CMW was 14.21 mm, and the CMH was 10.46 mm. All parameters except VDMC, GVA, and GI showed significant differences between male and female subjects Meanwhile, there was no significant difference in dimension and orientation of the glenoid and coracoid between the right and left shoulder.

Our study showed a lower value of MGW, GFH, and GVD compared to other Asian ethnicities. These results may be helpful in designing smaller prostheses suitable for Indonesian glenoids.

1 Introduction

The success of shoulder surgery depends on the understanding of the morphometry of the patient's shoulder.¹ Surgeons' knowledge of common shoulder morphometry may differ from actual shoulder morphometry in their population. Adjustments corresponding to the shoulder morphometry have to be considered during surgery to achieve the best result. For example, in shoulder arthroplasty, the size and orientation of the shoulder hold an important role in determining the best prosthesis size and design to avoid implant loosening and surgical failure.² The shoulder replacement prostheses are designed according to the native bony anatomy to restore normal joint kinematics.³

Several studies of shoulder morphometry in the Asian population had been conducted but there has been no study measuring shoulder size and orientation in the Indonesian population. Among studies of the Asian population, there were also differences in some shoulder morphological measurements.⁴

This study aimed to define the morphometry of the glenoid and coracoid processes using a 3D reconstructed CT scan. Many studies involving measurement from 3D images had been conducted and the result was deemed accurate. We chose to perform measurements in 3D images rather than using cadavers or plain CT scan images because reconstructed 3D images and models enable precise and easier measurement of the geometry and morphology of the scapula.⁵

2 Materials and method

The Institutional Review Board approval was obtained from Fatmawati General Hospital (01.01/VIII.2/5007/2020) prior to the study. We reviewed seventy-four CT scan thorax images from adult patients with asymptomatic shoulders by consecutive sampling. The images were collected from medical records in the hospital. The thorax CT scans were performed prior to this study. Therefore, there were no patients who underwent radiological exposure solely for this study. The exclusion criteria for this study were patients who have undergone shoulder surgery, history of fractures around the shoulder, congenital shoulder deformity, and cancer.

2.1

2.1 Image acquisition and 3D modelling of the scapula

The CT scan imaging was performed from 2018 to 2022 in Fatmawati General Hospital using a GE Revolution CT Scanner with slice thickness of 1 mm. The CT images were retrieved from the picture archiving and communication system (PACS) and then segmented with a semi-automated method using MIMICS (Mimics Research 21.0, Materialise, Leuven, Belgium). Bone segmentation with a single threshold was performed to rule out the soft tissue.⁶

2.2

2.2 Geometry extraction and glenoid parameter measurements

The measurements were conducted on a random side of the shoulder for each subject. The parameters included in this study were glenoid fossa height (GFH), maximum glenoid fossa width (MGW), glenoid width at center of the glenoid fossa (CGW), vertical distance between maximum width and center (VDMC), glenoid version angle (GVA), glenoid inclination (GI), gleno-polar angle (GPA), glenoid vault depth (GVD), coracoid length (CL), coracoid midpoint length (CML), coracoid tip height (CTH) and width (CTW), and coracoid midpoint height (CMH) and width (CMW).

The GFH was measured from a line which was drawn from the superior pole of the glenoid to the most inferior part of the glenoid (line (a) in Fig. 1).⁷ The CGW was measured from a line which was drawn perpendicular to the GFH connecting the anterior glenoid rim and posterior glenoid rim through the midpoint of the GFH (line (b) in Fig. 1).⁷ Adjacent to this line, the MGW was measured as the longest possible line connecting the anterior and posterior glenoid rim (line (c) in Fig. 1).⁷ The vertical distance between line (a) and line (b) is the VDMC (line (c) in Fig. 1).

The morphometry measurements of the glenoid fossa. (a) GFH, (b) CGW, (c) MGW, (d) VDMC.

GVD was defined as the length of the line drawn perpendicular to the glenoid surface from the centre of the glenoid to the vault until it intersects with the endosteal bone.⁸ Sugaya et al. measured GVD by drawing a line parallel to the X-axis from the glenoid face (YZ-plane).⁷

The GFH was parallel with the Y axis and the MGW was parallel to the Z axis.⁷ In this study, we projected the glenoid surface plane that was comprised of line (a) and line (b). The normal line of this glenoid surface plane was pointing to the X-axis. A line was drawn from the central point of the glenoid fossa parallel to the normal line of the glenoid surface plane until it intersected with the endosteal bone (Fig. 2).⁷^,⁸ The length of this line was the GVD.

Coronal cut of the 3D reconstructed glenoid at the centre. GVD was the length of the red line. The surrounding yellow shade was the cortical bone.

The GVA was measured using Ganapathi-Iannotti 3D measurement method.⁹ GVA was defined as the angle between the plane of the glenoid fossa and the plane of the scapula.¹⁰ The plane of the glenoid fossa was constructed from 3 points in the glenoid fossa rim, which are the superior pole of the glenoid, the anterior part of the lower third of the glenoid rim, and the posterior part of the lower third of the glenoid rim (Fig. 3a & b).⁹ The plane of the scapula was projected from the center of the glenoid fossa, the medial end of the scapular spine, and the inferior angle of the scapula (Fig. 3c).⁹ The CT transverse slice at the center of the glenoid projecting both planes were used to measure the angle between the glenoid plane and the normal of the scapular plane (Fig. 3d).⁹

(a). Referenced points for the plane of the glenoid fossa. (b). The projection of the plane of the glenoid fossa. (c). Projection of the scapular plane consists of three points of reference, which are the center of the glenoid fossa, the medial end of the scapular spine, and the inferior angle of the scapula. (d). The CT transverse view of the glenoid at the level of the center of the glenoid. The green line is the normal line of the scapular line. The GVA is the angle between the green line and the adjacent white line connecting the anterior and posterior glenoid rim.

The method of measuring the GI was described by Maurer et al.¹¹ The GI was best defined as the angle between the glenoid fossa line and the floor of the supraspinous fossa. The glenoid fossa line was drawn as the line connecting the uppermost point and the lowermost point of the glenoid. Another line was drawn along the cortical margin of the supraspinous fossa (Fig. 4). The angle between them was the GI.¹¹ GPA was described by Bestard et al.¹² as the angle between the line connecting the superior poles and inferior poles of the glenoid and the line connecting the superior poles of the glenoid with the inferior angle of the scapula (Fig. 5).

Coronal view of the posterior scapula with the dissected acromion. (a). Projection of the glenoid fossa line. (b). The black line represents the floor of the supraspinous fossa.

The GPA measurement. The coracoid was cut to allow better view.

2.3

2.3 Coracoid measurements

The CL was measured from the base to the tip.⁴ The coracoid midpoint was a point halfway between the base and the tip.⁴ The width and height of the coracoid at the tip and the midpoint were then recorded (Fig. 6).

Measurement of Coracoid. CL (green line), CML (brown line), coracoid tip (purple) and midpoint (cyan) with D1 as the width and D2 as the height.4

2.4

2.4 Statistical analysis

Statistical analyses were performed using SPSS Statistic version 25.0 (IBM, Armonk, NY, USA). Descriptive statistics were described in Microsoft Excel. Kolmogorov-Smirnov tests were used to examine the normality of data distribution. Normally distributed data were presented as mean and standard deviation and were analyzed using Independent T-Test. Meanwhile, data with abnormal distribution were presented as median and range and were analyzed using Mann Whitney U Test. The statistical significance was determined from a two-tailed test. The p-value of <0.05 was considered to be significant.

3 Results

This study included a total of 74 subjects consisting of 28 male (37.8%) and 46 female (62.2%) subjects. The mean age was 51.3 ± 12.92 years and the male to female ratio was (14:23). The mean age in the male group was 49.8 years while in the female group was 52.2 years. Most subjects were female (62.2%) and from the age of 50–59 (32.4%). The characteristics of the subjects were summarized in Table 1.

Table 1 Patient characteristics.

Demographic data	N (%)
Gender
Male	28 (37.8)
Female	46 (62.2)
Age Group (years)
18–29	6 (8.1)
30–39	8 (10.8)
40–49	15 (20.2)
50–59	24 (32.4)
60–69	16 (21.6)
70–79	5 (6.8)
Sides
Right shoulder	35 (47.3)
Left shoulder	39 (52.7)

The average measurements of GFH and MGW were 30.57 mm and 24.04 mm respectively. All of the glenoid were retroverted and superiorly inclined. The average GPA and the GVD were 42.54° and 18.88 mm respectively. The mean total length of the coracoid was 38.14 mm. The average dimension of the coracoid at the tip was 8.69 mm in height and 13.58 mm in width. The average midpoint of the glenoid height and width was 10.65 mm and 14.28 mm respectively (Table 2).

Table 2 The glenoid morphometry parameters.

Parameter	Measurements
GFH^a (mm)	30.57 ± 2.85
CGW^b (mm)	22.47 (18.52–29.72)
MGW^b(mm)	24.04 (19.99–31.24)
VDMC^b(mm)	3.87 (0.84–5.93)
GPA^a (°)	42.54 ± 4.17
GVA^a (°)	−1.71 ± 5.12
GI^a (°)	2.86 ± 5.57
GVD^a(mm)	18.88 (14.50–26.50)
CL^a(mm)	38.14 ± 3.99
CML^a(mm)	19.07 ± 2.00
CTH^a(mm)	8.69 ± 1.41
CTW^a(mm)	13.58 ± 1.80
CMH^a(mm)	10.65 ± 1.71
CMW^a(mm)	14.28 ± 1.84

a Normal distribution, presented as mean and standard deviation.

b Abnormal distribution, presented as median and range.

There was a significant difference in all glenoid parameters (except VDMC, GVA, and GI) between the male and female gender (Table 3). The male group had a larger glenoid dimension with a mean GFH of 33.05 mm and a mean MGW of 26.94 mm while in the female group, the mean GFH was 29.07 mm, and the mean MGW was 23.08 mm. The median GVD in the male group was 20.0 mm while in the female group was 18.00 mm. The lowest GVD in the male group was 16.0 mm while in the female group was 15.0 mm. All of the coracoid parameters showed significant differences. The male group had a coracoid length roughly 5 mm larger than the female group. The height and width at the tip for the male were 9.68 mm and 14.76 mm while for females were 8.08 mm and 12.87 mm. Meanwhile, for the coracoid midpoint, the height and width of the male group were 11.87 mm and 15.51 mm while in the female group were 9.90 and 13.53 mm.

Table 3 Gender differences in glenoid morphology parameters.

Parameter	Male	Female	p-value
GFH^a (mm)	33.05 ± 2.65	29.07 ± 1.70	< 0.001
CGW^a (mm)	25.65 ± 2.17	21.55 ± 1.62	< 0.001
MGW^a (mm)	26.94 ± 2.12	23.08 ± 1.75	< 0.001
VDMC^a (mm)	4.04 (0.84–5.76)	3.67 (1.60–5.93)	0.111
GPA^b (°)	41.45 (32.42–47.89)	44.87 (35.06–52.74)	0.002
GVA^b (°)	−2.60 ± 4.75	−1.18 ± 5.32	0.250
GI^a (°)	1.60 ± 6.41	3.64 ± 4.91	0.128
GVD^b (mm)	20.00 (16.00–26.50)	18.00 (15.00–23.50)	0.003
CL^a(mm)	41.29 ± 3.03	36.23 ± 3.23	< 0.001
CML^a(mm)	20.65 ± 1.51	18.12 ± 1.62	< 0.001
CTH^a(mm)	9.68 ± 1.55	8.08 ± 0.88	< 0.001
CTW^a (°)	14.76 ± 1.73	12.87 ± 1.45	< 0.001
CMH^a (°)	11.87 ± 1.64	9.90 ± 1.23	< 0.001
CMW^b (°)	15.51 ± 1.52	13.53 ± 1.60	< 0.001

a Normal distribution, presented as mean and standard deviation.

b Abnormal distribution, presented as median and range.

Comparing right and left shoulders, there were no significant differences found on any parameters. The dimension of the glenoid and the coracoid showed similar results (Table 4). We also compare the measurements in our study with other study conducted in other Asia region, assuming the similar profile of the morphometry. We found that Indonesian glenoid had similar dimension with glenoid from Indian population but considerably smaller than other Asian populations (see Table 5).

Table 4 Comparison of glenoid morphology parameters between the right and left shoulder.

Parameter	Right Shoulder	Left Shoulder	p value
GFH^a (mm)	30.37 ± 2.61	30.81 ± 3.12	0.509
CGW^b (mm)	21.76 (19.11–28.71)	23.40 (18.52–29.72)	0.148
MGW^a (mm)	24.22 ± 2.48	24.89 ± 2.86	0.284
VDMC^b (mm)	3.75 (1.34–5.93)	4.02 (0.84–5.76)	0.465
GPA^a (°)	42.41 ± 4.05	42.69 ± 4.34	0.771
GVA^a (°)	−2.44 ± 5.37	−0.91 ± 4.78	0.200
GI^b (°)	3.19 (−9.73–18.27)	2.82 (−12.77–12.18)	0.485
GVD^a (mm)	18.87 ± 2.25	19.43 ± 2.95	0.352
CL^a (mm)	37.96 ± 3.61	38.34 ± 4.42	0.686
CML^a (mm)	18.98 ± 1.80	19.17 ± 2.21	0.686
CTH^b (mm)	8.65 (6.63–11.23)	8.35 (6.12–14.03)	0.468
CTW^a (mm)	13.56 ± 2.02	13.61 ± 1.56	0.922
CMH^b (mm)	10.83 (7.28–14.27)	10.10 (7.87–16.89)	0.705
CMW^a (mm)	14.03 ± 1.71	14.56 ± 1.96	0.222

a Normal distribution, presented as mean and standard deviation.

b Abnormal distribution, presented as median and range.

Table 5 Comparison of glenoid morphometry with other Asian studies.

	Indonesian	Malaysian²³	Myanmarese²⁴	Japanese⁷ (male/female)	Chinese⁴	Indian⁴^,¹⁴	Korean¹⁹
GFH (mm)	30.57	–	–	38.6/33.1	–	31.3	37.67
MGW (mm)	22.47	–	–	29.4/24.4	27.86	24.0	27.52
CGW (mm)	24.04	–	–	–	–	–	26.89
VDMC (mm)	3.87	–	–	–	–	–	–
GPA (°)	42.54	–	–	–	–	–	–
GVD (mm)	18.88		–	26.1/23.6	–	–	–
GVA (°)	−1.71	–	–	−2.2/-3.2	–	1.8	–
GI (°)	2.86	–	–	3.2/2.6	–	−11.3	–
CL (mm)	38.14	37.94	39.19	–	41.6	43.32	–
CMP (mm)	19.07	–	–	–	20.8	–	–
CTH (mm)	8.69	9.24	8.58	–	9.05	11.47	–
CTW (mm)	13.58	11.63	13.02	–	13.09	13.63	–
CMH (mm)	10.65	–	–	–	11.12	8.54	–
CMW (mm)	14.28	13.84	–	–	14.59	14.16	–

4 Discussion

Bone morphometry is varied among multiple ethnicities and always becomes a major consideration for surgeons to obtain the best surgical outcome.¹ This study is the first glenoid morphometry study in the Indonesian population. Specifically, this study focused on the population in Jakarta. Jakarta is the capital city of Indonesia and it has the densest population in Indonesia.¹³ It is currently the sixth most populous region in Indonesia with 10.56 million residents.¹³

Asian people generally have a smaller figure in comparison to European or African people.⁷ The average GFH in the European population was 36.6 mm ± 3.6 mm and the MGW was 27.8 ± 3.1 mm.¹ While in the Asian population, Sahu et al.¹⁴ found that the mean GFH in the Indian population was 31.4 mm and the MGW was 24.0 mm. Another study on the Indian population by Bodanki et al. also showed a lower glenoid dimension than Europeans and Americans. They found the mean GFH was 32.9 mm, the MGW was 23.4, GVA 0.07° retroverted, and GI 6.68° superiorly inclined.¹⁵

Our study showed significant differences between male and female glenoid fossa morphometry. Other studies also reported similar results. Sugaya et al. showed that GFH and MGW in the Japanese population significantly differed between male and female groups. In their study, the mean GFH was 38.6 mm in male and 33.1 mm in female group while the mean MGW was 29.4 mm in male and 24.4 mm in female group.⁷ Shi et al. reported that mean GFH in the Chinese population was 36.8 mm in male and 32.6 mm in female group while the MGW was 28.5 mm in male and 24.8 mm in female group.¹⁶ Compared to studies of the Japanese, Indian, and Chinese populations, we found smaller glenoid fossa dimensions in both male and female group of the Indonesian population. This finding could increase the concern of unsuitable shoulder prosthetic implant sizes that were designed and developed in other countries.

The GPA from this study is consistent with other studies. A study by Tucek et al. showed an average GPA of 43°.¹⁷ In this study, the GPA was 42.54° but with significant differences between males and females. We found no other study that reported significant differences in the GPA value of males and females. This may be a coincidence due to the low number of male subjects in our study. GPA was first proposed by Bestard et al. with a normal value of 30–45° and it is used to evaluate outcomes of shoulder dislocation.¹² Currently, GPA is used as one of the indicators for the displacement of a scapular neck fracture.¹⁸ GPA ≤22° is considered as the displacement threshold and surgery is indicated.¹⁷ The final GPA after surgery also serves as a major predictor of the clinical outcome.¹⁹

In this study, the mean of GVA was 1.71° in retroversion and the GI was 2.86° superior in inclination. Our study also showed that gender and shoulder side did not affect the value of GVA and GI. This finding was similar to other studies. A study by Kwon et al. showed the GVA in the European and American populations was 2.65° in retroversion while the African population had a 0.20° in retroversion.²⁰ A study by Ozel et al. with a large sample also showed retroverted GVA with the value of 11° and the GI was 8°.²¹ A study by Rispoli et al. showed even more retroverted GVA with 12.2° in retroversion.²² In patients with osteoarthritic shoulder, Boileau et al. reported GVA of 9.75° in retroversion with GI of 7.28° superiorly inclined.¹⁰ Preoperative glenoid version is used as a major predictor of outcome of reverse shoulder arthroplasty. Excess retroversion of the glenoid version is related to early loosening of the prosthesis.²¹

The GVD from our study was 18.88 mm. Male glenoid had significantly larger GVD (20.0 mm in males, 18.0 mm in females). Previous studies also showed larger GVD in males than females but the GVD found in our study was lower than in many other studies. A study by Mallon et al. on the American population showed a mean GVD of 31.5 mm ± 2.9 mm.²³ Another study in the Japanese population analyzed the optimum location for measuring GVD and gained the highest mean value of 26.1 mm in males and 23.6 mm in females.⁷ Another study from Chile measured an average GVD of 26.5 mm.⁸ As a general rule, GVD needs to be at least 15 mm to accommodate the majority of cemented glenoid components in total shoulder arthroplasty.²² In reverse shoulder arthroplasty, the smallest circular baseplate has a 15 mm long center post.⁷ This center post is planted in the glenoid vault and therefore the GVD needs to be at least 15 mm.⁷ Although this study showed a low value of the glenoid vault, only one patient in this study had a glenoid vault less than 15 mm.

The CL from our study was most similar to the study from Malaysia which had a mean length of 37.94 mm.⁴ A study comparing the CL of Chinese, Indian, and Myanmarese populations showed significant differences in all ethnicities.⁴ The highest coracoid length in Asia was in the Indian population with a mean of 43.32 mm, followed by the Chinese at 42.47 mm, then the Myanmarese population at 39.19 mm.⁴

The coracoid morphometry is also described by the height and width of the tip and midpoint.⁴ In our study, the CTH, CTW, CMH, and CMW were 8.69 mm, 13.58 mm, 10.65 mm, and 14.28 mm respectively. Compared to studies from Malaysian, Myanmarese, Indian and Chinese populations, our study showed similar value. The CTH in our study was larger than the Myanmarese population but smaller than the Malaysian, Indian, and Chinese populations. The CTW was larger than Myanmarese, Malaysian, and Chinese populations, but smaller than the Indian population. The CMH and CMW both showed larger values than the Indian population but smaller than the Chinese population.⁴^,²⁴^,²⁵ Similar to this study, other studies also reported significant differences in coracoid morphometry between male and female subjects.⁴

In Latarjet surgery, the coracoid is used as a bone block which is fixed to the glenoid. The minimum safe margin for coracoid osteotomy was found to be 26.4 mm.²⁶ On average, the mean length of bone graft in Latarjet surgery ranged from 25 to 30 mm.²⁷ All subjects in our study had a larger coracoid length than the safe margin except in 2 subjects.

The comparison of right and left shoulder morphometry in this study did not differ significantly. Sari et al. found no significant difference in GFH, MGW, and GVA of the right and left shoulder.²⁸ However, they found that the GVA was significantly more retroverted in the dominant hand.²⁸ Plessis et al. also did not find a significant difference in coracoid height and width between the right and the left sides.²⁹ Meanwhile, Welsch et al.⁵ showed significantly larger scapula height (superior to inferior angle) and width (length of the scapular spine from medial to lateral) in the dominant hand. However, the GVA between the sides had no significant difference.⁵ In our study, the hand dominance of the subjects was not considered because such information was not provided in the medical record.

One of the limitations of this study is the scope of the study. Indonesia consists of many ethnicities and some people are also from mixed races. The subjects of this study were patients at Fatmawati General Hospital in Jakarta. Although Fatmawati General Hospital is a third referred hospital, the patients are mostly people from Jakarta, which is dominated by the Javanese and Sumatran populations.³⁰ The sample populations were not diverse enough to represent the whole Indonesian population. Indonesia also has many other populous cities and other cities may be dominated by different ethnicities. Therefore, different bone morphometry may be found in other regions in Indonesia. Another weakness of the study is that the measurements in this study were done by an observer. Ideally, the measurements should be done by a minimum of two independent observers. Therefore, this study is vulnerable to observer bias.

Disclaimer

No patient or author details are included in the figures.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The research protocol was approved by the Fatmawati Hospital research ethics committee.

Consent for publication

Non available.

Authors contribution

Holong Mangasah: Methodology, Software, Validation, Formal analysis, Writing-Original Draft. Iman Widya Aminata: Conceptualization, Methodology, Resources, Verification, Writing – Review & Editing, Supervision.

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