STUDY OF CORRELATION BETWEEN BIGLIANI’S ACROMION
RESEARCH ARTICLEDOI: 10.5958/2395-1362.2015.00008.0STUDY OF CORRELATION BETWEEN BIGLIANI’S ACROMIONTYPES AND SHOULDER PROBLEMSManish Dwivedi1,*, Atul Varshney21AssistantProfessor, Department of Orthopaedics, P.C.M.S. & R.C., Bhopal, M.P.Department of Orthopaedics, P.C.M.S. & R.C., Bhopal, M.P.2Professor,*Corresponding Author:E-mail: ortho.md12@gmail.comABSTRACTPurpose of the study: Acromion Morphology have been implied to have a major role in shoulder pathology especially caused byaffecting subacromial space. Among Acromion Morphology studied includes – Acromion Index, Acromion Types, and AcromionSlope etc. Acromion Types as classified according to Bigliani is a faster way to differentiate Acromion on a plain X-ray. Purposeof the study was to assess the effect of Acromion type on shoulder problems.Material and Methods: 100 Patients of above age 40 coming to orthopaedic OPD for shoulder problems (Impingement or rotatorcuff pathology) were examined. Their Acromion type were assessed on the basis of x-ray of shoulder (supraspinatus outlet view).Acromion type was then classified according to Bigliani classification.Results: There were 100 patients in the study – 58 males and 42 females. There were 44 type I, 55 Type II and 01 Type III Acromiontypes accordingly to Bigliani‘s Classification. Mean age of study group was 56.67 6.57.However in Impingement group patientswere younger (55.4 6.53) as compared to rotator cuff group patients (58.84 6.06).There were more females in Type I Acromiongroup and subsequently number of males outnumbered females in Acromion Type II and Type III. There were 63 patients inImpingement group and 37 in rotator cuff group. Right sided shoulders were affected in 68 patients and 32 patients had their leftshoulders affected. 73 affected shoulders were of dominant sides.Conclusion: As Acromion Type changes from Type I to Type III, then symptoms of impingement and rotator cuff pathology startto appear at a younger age. This warrants aggressive approach of management of these shoulder pathology in Acromion type IIand type III.Keyword: Acromion Types, Bigliani, Impingement,INTRODUCTIONThe shoulder joint is a complex jointconsisting of four joints, two spaces, numerousstabilizing ligaments and more than 30 muscles andtheir respective tendons. The shoulder joint requiressynchronized movements to function properly. One ofthe most important structure around shoulder joint isAcromion process and subacromial space.This space is filled by rotator cuff tendons –supraspinatous, infraspinatous tendon and teres minortendon. Subacromial impingement and rotator cuffpathology are common problems of shoulder andunderlying causes for these two are still poorlyunderstood. Either intrinsic degenerative changes inthe tendons or extrinsic mechanical compression bythe acromion had been matter of debate foraetiological reasons for many decades.In 1949, Armstrong suggested thatcompression of the bursa and rotator cuff tendonsunder the acromion causes the supraspinatus syndrome1, 2. Later on, Neer (1983) stated that 95% of cuff tearsare caused by mechanical impingement2,3.Acromioplasty is still the standard operative procedurefor impingement lesions, and there has been asubstantial increase in its incidence 2,3. Althoughthe indication for acromioplasty is based on clinicalevaluation of the patient. This clinical diagnosis isgenerally supported by typical changes in acromialmorphology on standard radiographs2,4,5,6,7,8,9,10,11.Acromial type was classified according to Bigliani etal. (1986) – Type I is a flat undersurface, Type II is acurved undersurface, and Type III is a hookedundersurface of the acromion on ionmorphology, subacromial impingement and rotatorcuff pathology is well documented2, 12. In somestudies, a type-III acromion has been found to beassociated with a higher prevalence of rotator cufftears27, 12, 13 whereas not all authors have found this2, 14.Despite the numerous studies that have been carriedout in an attempt to support or refute Neer’s originaltheory of extrinsic mechanical impingement as theprimary aetiology of rotator cuff disease, the role ofthe acromion is still unclear. 2MATERIAL AND METHODSPatients: We took data of 100 patients who were ofabove age 40 and attended orthopaedic OPD forshoulder pain consistent for rotator cuff pathology andimpingement which were confirmed by tests for same– Impingement tests according to Neer and Hawkins,and Rotator cuff tests (Jobe test, internal and externalrotation, belly-press test, and lift off test). Patient wereIndian Journal of Orthopaedics Surgery, April – June 2015;2(2);111-115111
Study of Correlation Between Bigliani’s Acromion Types and Shoulder ProblemsDwivedi et al.advised X-ray of affected shoulder includingSupraspinatus Outlet view. Acromion Type wasassessed on this view and Classified according toBigliani’s Classification7.was kept at p 0.05(Confidence Interval - 95%).Acromion type was correlated to age, sex, affected anddominant side, and diagnosis using Spearman nonparametric correlation test. The Mean and Standarddeviation were calculated for age.Acromial type: Acromial type was classifiedaccording to Bigliani et al. (1986) – Type I is a flatundersurface, Type II is a curved undersurface, andType III is a hooked undersurface of the acromion onoutlet-view radiographs7. Acromion Type were thenanalysed with patients diagnosis, age, dominant hand,affected side.RESULTSAfter analysing the data of 100 patients –there were two groups. One with patients whopredominantly tested for positive impingement test(Impingement Group) and another was with patientswho predominantly tested for positive test for rotatorcuff pathology (Rotator Cuff Group). Thus furtheranalysis was done with data along two groupsImpingement Group and Rotator Cuff Group. (Table –1, 2, 3, 4)STATISTICAL ANALYSISThe study was statistically analysed withSPSS software (version - 22). Level of significanceTable: 1BiglianiType IBiglianiType IIBiglianiType 00(0%)(0%)3330(33%) (30%)Total32(32%)31(31%)0(0%)63(63%)Rotator al44(44%)55(55%)1(1%)100(100%)Table: 2Bigliani typeIIIIIISexM14 (14 %)43 (43 %)1(1 %)F30(30 %)12(12 %)0(0 %)AgeImpingement groupRotator Cuff Group60.9 6.5366.45 4.0349.7 6.5555.75 3.00049 0Table: 3AgeSexAffectedSideDominantSideAffectedImpingement Group55.40 6.53M – 33F – 30MFTotalR231942L101121M – 25 (25%)F – 20 (20%)Total - 45(45%)Rotator Cuff Group58.84 6.06M – 25F – 12MFTotalR18826L7411M – 20(20%)F – 8(8%)Total - 28(28%)Indian Journal of Orthopaedics Surgery, April – June 2015;2(2);111-115Total56.67 6.57M – 58F – 42MFR41 27L17 15M – 45 (45%)F – 28 (28%)Total - 73(73%)Total68(68%)32(32%)112
Study of Correlation Between Bigliani’s Acromion Types and Shoulder ProblemsDwivedi et al.Table: 4CorrelationsSpearman's rhoAgeSexTypeDominantSideAffectedSideDiagnosisType -1CorrelationCoefficientSig. (2-tailed)CorrelationCoefficientSig. *.014.001.8881.000.229*.314**.001.796*-.472***Sig. 00CoefficientSig. **CoefficientSig. 0.014CoefficientSig. (2-tailed).021.140.058.888**. Correlation is significant at the 0.01 level (2-tailed).*. Correlation is significant at the 0.05 level (2-tailed).Type -2ImpingementGroupType -3.022.229*1.000.022Rotator CuffGroupFigure 1: Boxplot showing significant findings.Patient Demographics:A. SEX – In this study there were 58(58%) malesand 42 (42 %) females. In Impingement Groupthere were 33 (33%) males and 30 (30 %)females and in rotator cuff group there were25(25%) males and 12(12%) females. ( Table – 2)B. AGE – Mean Age of All 100 patients was 56.67 6.57 In Impingement Group the mean agewas55.40 6.53 and in rotator cuff group themean age was58.84 6.06. ( Table – 3 )C. SIDE AFFECTED – There were 68 (68%)patient with right side affected and 32(32%)patient with left side affected. ( Table – 3 )D. DOMINANT SIDE AFFECTED – There werein total 73 (73%) patients haver dominant sideaffected. There were 45(45%) patient withDominant Side Affected In ImpingementGroup and patient with 28(28%) Dominant SideAffected in rotator cuff group. ( Table – 3)E. ACROMION TYPES - There were 44 (44%)patient with Bigliani Type I, 55 (55%) patientwith Bigliani Type II and 1 (1%) patient withBigliani Type III. With respect to ImpingementGroup, there were 32 (32%) patient withBigliani Type I, 31 (31%) patient with BiglianiType II and 0 (0%) patient with Bigliani TypeIII and in Rotator cuff group there were 12(12%) patient with Bigliani Type I, 24 (24%)patient with Bigliani Type II and 1 (1%) patientwith Bigliani Type III. ( Table – 1 )Indian Journal of Orthopaedics Surgery, April – June 2015;2(2);111-115113
Dwivedi et al.F.Study of Correlation Between Bigliani’s Acromion Types and Shoulder ProblemsCORRELATION – Spearman Correlation (NonParametric) test was applied and correlationbetween patient demographics, acromion type,dominant and affected side and diagnosis wasanalysed. Significant correlation was foundbetween age, type and diagnosis(Table -4)DISCUSSIONIn our study highest number of acromion wasof type II followed by Type I and least number was ofType III. The result of our study is similar to study ofYazici et al15, Getz et al16 and Shah et al17, Nigar etal18, Paraskevas et al19 and Balke et al2. But it differsfrom study of Bigliani et al7 and Natsis et al 20(II III I). However our study has limitation of havingonly 1 patient with type III.In our study patients were of younger age ineither group with type II or III acromion as comparedto Type I. There was only single type III acromion inour study and that too in rotator cuff pathology groupand patient was comparative younger. It helps us toform an opinion that as type of acromion goes higherthere is small subacromial space making patientsymptomatic at younger age. However this assumptionneeds further well designed large cohort study.We did not find any significant correlationbetween acromion type and age similar to asmentioned by Banas et al8, Getz et al16, Vahakari etal21 and Balke et al.2However male to female ratio changed (M Type III and F Type I) as type of acromion changedtowards Type III as already mentioned by Getz et al16and Paraskevas et al19.In the present study, the patients withsubacromial impingement were younger compared torotator cuff pathology group. This finding was to beexpected as the incidence of rotator cuff tears increaseswith age as reported by Banas et al8, Yamaguchi et al22,Balke et al2.There were limitations in our study as thepatient designated to each group were classifiedaccording to clinical examination and not on the basisof MRI. So this has its limitation in stricter terms butthis is also the strong point of this study. As in oursociety patient has to bear the cost of MRI which is acostly investigation. Thus only by basis of clinical andradiographical examination we can decide whichpatient to aggressively investigate with MRI.Another limitation was that only one aspectof Acromion Morphology i.e. type was taken intoconsideration. So the results were somehow bound tobe changed albeit slightly when more number ofacromion morphology characters were applied on thestudy like – Acromion Slope, Acromion Index etc.upon as the decision maker regarding shoulderpathology but it serves as a valuable guide in decidingwhich patient to be treated aggressively. As acromiontype goes from Type I to Type III i.e. towards higherside the incidence of impingement and rotator cuffpathology appears to appear at younger age in bothgroups so that they can be aggressively evaluated andtheir progression towards rotator cuff pathology can bedelayed by suitable and timely intervention.AUTHOR’S CONTRIBUTIONThe study was designed by MD, AV. Patientsscreening, data collection, documentation, and reviewwas done by MD, AV. Radiographic assessment doneby MD.MD, AV wrote the manuscript.ACKNOWLEDMENTDr. Ashish Dwivedi’s help is acknowledgedfor his help in statistical analysis.CONFLICT OF ONCLUSIONWe can summarize our study that thoughacromion type is not the only indicator to be lookedIndian Journal of Orthopaedics Surgery, April – June 2015;2(2);111-115Armstrong J R. Excision of the acromion in treatment ofthe supraspinatus syndrome; report of 95 excisions. JBone Joint Surg (Br) 1949; 31 (3): 436-42.Maurice Balke, Carolin Schmidt, Nicolas Dedy, MarcBanerjee, Bertil Bouillon, and Dennis Liem. Correlationof acromial morphology with impingement syndromeand rotator cuff tears.Acta Orthopaedica 2013; 84 (2):178–183Neer C S, 2nd. Impingement lesions. Clin Orthop 1983;(173): 70-7.Vitale M A, Arons R R, Hurwitz S, Ahmad C S,Levine W N. The rising incidence of acromioplasty. JBone Joint Surg (Am) 2010; 92 (9): 1842-50.Neer C S, 2nd. Anterior acromioplasty for the chronicimpingement syndrome in the shoulder: a preliminaryreport. J Bone Joint Surg (Am) 1972; 54 (1): 41-5Aoki M, Ishii S, Usui M. The slope of the acromion androtator cuff impingement. Orthop Trans 1986; 10: 228.Bigliani L U, Morrison D S, April E W. Themorphology of the acromion and its relationship torotator cuff tears. Orthop Trans 1986; 10: 228Banas M P, Miller R J, Totterman S. Relationshipbetween the lateral acromion angle and rotator cuffdisease. J Shoulder Elbow Surg 1995; 4 (6): 454-61.Zuckerman J D, Kummer F J, Cuomo F, Simon J,Rosenblum S, Katz N. The influence of coracoacromialarch anatomy on rotator cuff tears. J Shoulder ElbowSurg 1992; 1 (1): 4-14.Toivonen D A, Tuite M J, Orwin J F. Acromial structureand tears of the rotator cuff. J Shoulder Elbow Surg1995; 4 (5): 376-83.Tetreault P, Krueger A, Zurakowski D, Gerber C.Glenoid version and rotator cuff tears. J Orthop Res2004; 22 (1): 202-7.Bigliani L U, Ticker J B, Flatow E L, Soslowsky L J,Mow V C. The relationship of acromial architecture torotator cuff disease. Clin Sports Med 1991; 10 (4): 82338.114
Dwivedi et al.13.14.15.16.17.18.19.20.21.22.Study of Correlation Between Bigliani’s Acromion Types and Shoulder ProblemsMacGillivray J D, Fealy S, Potter H G, O’Brien S J.Multiplanar analysis of acromion morphology. Am JSports Med 1998; 26 (6): 836-40.Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K, TamaiS. Tears of the rotator cuff of the shoulder associatedwith pathological changes in the acromion . A study incadavera. J Bone Joint Surg (Am) 1988; 70 (8): 122430.Getz JD, Recht MP, Piraino DW, Schils JP, LatimerBM, Jellema LM, Obuchowski NA Acromialmorphology: relation to sex, age, symmetry, 3):737-42.Getz JD, Recht MP, Piraino DW, Schils JP, LatimerBM, Jellema LM, Obuchowski NA Acromialmorphology: relation to sex, age, symmetry, 3):737-42.Nigar C, Kamil K,Can C, Bahadir D, Muzaffer S.Anatomical basics and variation of the scapula inTurkish Adults. J Should Elbow Surg 2006,27(9):132025.Paraskevas G, Tzaveas A, Papaziogas B, Kitsoulis P,Natsis K, Spanidou S. Morphological parameters of theacromion Folia Morphol (Warsz).2008 Nov;67(4):25560.Paraskevas G, Tzaveas A, Papaziogas B, Kitsoulis P,Natsis K, Spanidou S. Morphological parameters of theacromion Folia Morphol (Warsz).2008 Nov;67(4):25560.Natsis K, Tsikaras P, Totlis T, Gigis I, Skandlakis P,Appell H.J, Koebke J. Correlation between the fourtypes of acromion and the existence of enthesophytes: Astudy of 423 dried scapulas. Clin Anat 2007,20:267-72.Vahakari M, Leppilahti J, Hyvonen P, Ristiniemi J,Paivansalo M, Jalovaara P. Acromial shape inasymptomatic subjects: a study of 305 shoulders indifferent age groups. Acta Radiol 2010; 51 (2): 202-6.Yamaguchi K, Ditsios K, Middleton W D, Hildebolt CF, Galatz L M, Teefey S A. The demographic andmorphological features of rotator cuff disease. Acomparison of asymptomatic and symptomaticshoulders. J Bone Joint Surg (Am) 2006; 88 (8): 1699704.Indian Journal of Orthopaedics Surgery, April – June 2015;2(2);111-115115
Dwivedi et al. Study of Correlation Between Bigliani’s Acromion Types and Shoulder Problems Indian Journal of Orthopaedics Surgery, April – June 2015;2(2)
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