Annals of 3D Printed Medicine 11 (2023) 100114

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Research paper

Biometrics and three-dimensional alignment of the acromioclavicular

joint. A biomechanical proof of concept study using the “reversed cadaver
model”(RCM)
€rn Kirchera
Marius Junkera,b,*, Milad Farkhondeh Falc, Jo
a
Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Germany
b
Department of Orthopedic Surgery, Krankenhaus Tabea Hamburg, Germany
c
Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Germany

A R T I C L E I N F O

Article History:
Received 6 April 2023
Accepted 12 May 2023
Available online 14 May 2023

Introduction measured exactly on radiographs [16]. We showed that some degenera-

Degeneration of the acromioclavicular joint (ACJ) represents a com-
mon justification for orthopaedic consultation. These degenerative
changes can already be detected in early adulthood while other joints do
not yet show degeneracy [1−4]. Causes for degeneration of the ACJ range
from traumatic events to repetitive overhead activities and other athletic
activity [5−9]. Another frequent reason can be all forms of inflammatory
processes affecting the ACJ that lead to cartilage degeneration and ulti-
mately to destruction of the articulating partners [10]. Yet the majority
of the patients presenting with pain and functional impairment do not
report inflammatory or traumatic events but show definite signs of joint
degeneration which goes along with a rising incidence of surgical inter-
vention [23]. A great number of patients with early stages of ACJ degen-
eration do not present with symptoms, some of them stay asymptomatic
despite showing advanced destruction of the joint [11,4]. Surprisingly lit-
tle is known about the normal three-dimensional anatomy, the biometry
and alignment of the ACJ. In a radiographic study Petersson et al. ana-
lysed the joint space of 151 ACJs on antero-posterior radiographs using a
ruler [12]. Here the authors noticed that the joint space decreased with
growing age. The correlation of degenerative changes of the ACJ and age
is confirmed by Nicholson et al. in their analysis of 420 scapulas [13].
Zanca et al. reported that the normal width of the ACJ ranges from 1 to
3 mm [14]. Petersson et al. also assessed the ACJ in the frontal plane on
anterior-posterior radiographs and observed a joint space width of 2,0 −
4,8 mm [12]. The AC-joint tends to show a complex three-dimensional
orientation with individual variations in which radiographs might pro-
duce an overlapping of these structures [15]. In this context it has been
shown that smaller degenerative changes can neither be depicted nor
* Corresponding author at: Department of Shoulder and Elbow Surgery, ATOS Klinik
Fleetinsel Hamburg, Germany.
E-mail address: marius.junker@web.de (M. Junker).
tively affected ACJs tend to open up the anterior joint space which leads
to an increased AC-angle anteriorly. This could be mistaken for a normal
joint space on anterior-posterior radiographs [17]. Edelson already
described a typical course which takes place in degenerative ACJs leading
to elongation of the posterior aspect of the acromial facet [18]. In a study
by us we could show that the posterior contact of the distal clavicle with
the acromial joint facet is typical for patients showing degeneration of
the ACJ [19]. This could be explained by formation of osteophytes and
changes of the bony surfaces in the posterior part.
The goal of this study was to compare the biometric findings of 3D
printed specimens and measurements performed on tomographic
imaging of the patients and simultaneously proof that the RCM can
lead to reproducible results.
Methods
Patients
In this study 23 patients without relevant pathology of the ACJ
with complete dataset of MRI and CT scans were included. All CT
scans were anonymized and added into processing of the 3D recon-
struction for printing. Due to varying quality of the data 18 patients
had to be excluded (Fig. 1). Five of them were further processed to 3D
models. Three patients were male and two female while the age
ranged from 29 to 62 in the processed group and from 17 to 83 in the
excluded group. The study was approved by Ethics Committee and
written consent was obtained from all patients.
3D reconstruction and printing
The processing of the CT datasets was performed with Mimics
inPrintÓ (Materialise) and Autodeskࣨ Fusion 360. This was

https://doi.org/10.1016/j.stlm.2023.100114
2666-9641/© 2023 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
M. Junker, M. Farkhondeh Fal and J. Kircher
Fig. 1. Computed 3D model after automatic 3D recognition a Good result with acurate depiction of bony surfaces b Poor depiction of anatomy due to CT quality.
performed by a trained individual who carried out the analysation
and processing of the CT scans. The processing of the CT dataset is
depicted in Fig. 2 while the data processing and 3D-printing was per-
formed with the help of the Airbus ProtoSpace Network and the
Fraunhofer Institution for Additive Manufacturing Technologies IAPT.
Measurements
The measurements of the printed models were performed on 5
printed models with a digital measuring stick (Hogetexࣨ) and digital
protractor (Hogetexࣨ) (Fig. 3). The measurements contained joint
spaces in the anterior, central and posterior part of the ACJ. The AC
angle was measured in the coronal and transverse plane. The meas-
urements were performed on the printed models as well as magnetic
Fig. 2. Formation process of a model showing step by step preparation of the dataset
until the final product.
2
Annals of 3D Printed Medicine 11 (2023) 100114
resonance tomographies (MRT) and computed tomography (CT)
scans. All measurements were performed by two observers (MJ, JK).
Statistical analysis
Statistical data analysis was performed using SPSS version 29 (IBM
Corporation, New York). The Intraclass Correlation Coefficient (ICC)
for the different measurement modalities was determined based on a
mean-rating absolute-agreement, two-way mixed-effects model.
Results
Biometrical measurements
The analysis of the biometry and anatomical findings of the ACJs is
shown in Table 1 for the 3D measurements, CT-measurements and
MRT measurements respectively. In this all observers identified
curved anatomy of the ACJ as well as greatest joint spaces in the ante-
rior part independent of measurement modality. The anterior joint
space showed higher values for the 3D and CT measurements in
which CT analysis revealed broadest mean anterior joint space. The
central and posterior joint space measurements demonstarted lower
values compared to the anterior joint space. 3D survey showed
higher mean length of the assessed specimen compared to tomo-
graphic analysis. Both angles that were analysed showed lower mean
values for 3D assessment compared to CT and MRT technique.
Survey of the 3D printed models revealed continous decreas of the
joint space from the anterior aspect over the central part to the poste-
rior section of the joint for models 1, 2 and 3 for both observers.
Model 4 showed the same shaping for one observer as a joint space
increase fromthe central part to posterior aspect was detected by the
other observer. The decrease of the joint space from anterior to cen-
tral was confirmed for model 5 by both observers. However a broader
posterior joint space compared to the central part was detected by
both observers in which the posterior joint space did not reach the
scale of the anterior joint space (Table 2).
To investigate the inter-rater reliability of the measurement
modlities the ICC was determined. The overall ICC for the performed
measurements was 0.881 (0.749 − 0.944), 0.833 (0.649 − 0.920) and
0.951 (0.887 − 0.979) for 3D, CT and MRT measurements respec-
tively. Separate analysis revealed highest inter-rater reliability for
distances using 3D measurements (0.991). For the evaluation of
angles the MRT measurements showed the highest inter-rater reli-
ability (0.898).
Discussion
It has already been shown that 3D printing produces reliable
results in comparison to sectional imaging. The 3D assessment has
also been used to analyse variables of the shoulder joint and to mea-
sure planning outcomes in shoulder arthroplasty. Yet no analysis of
the biometrics of the ACJ has been performed. 3D printing is used by
M. Junker, M. Farkhondeh Fal and J. Kircher Annals of 3D Printed Medicine 11 (2023) 100114

Fig. 3. Exemplatory depiction of measurements: a Measurement of the anterior joint space of the ACJ with the digital measuring stick b Evaluation of the transverse angle of the ACJ
with the digital protractor.

Table 1
Means of ACJ variables in all modalities (range).

Variable 3D CT MRT

Joint shape Curved Curved Curved

Joint space anterior (mm)
Joint space central (mm)
Joint space posterior (mm)
Joint length (mm)
ACJ angle coronal (°)
ACJ angle transverse (°)
4.14 (3.04 − 6.24) 4.24 (2.7 − 5.9) 3.94 (2.5 − 6.9)
2.36 (1.03 − 2.84) 2.16 (0.7 − 3.41) 2.12 (1.1 − 3.9)
2.14 (1.4 − 3.3) 2.22 (0.4 − 3.61) 2.07 (1.3 − 4.0)
17.31 (13.72 − 21.67) 13.9 (8.9 − 17.9) 14.60 (11.5 − 18.6)
10.32 ( 0.5 − 16.7) 15.8 (5.9 − 39.6) 20.54 (8.7 − 40.7)
6.41 (1 − 14.2) 14.9 (2.7 − 28.3) 10.68 (4 − 18.4)

different medical specialties in which orthopedics have the largest individual digital models that are derived from CT scans. The quality
percentage. The analysis of the shoulder is performed in 2% only [20]. can already be evaluated in the automatic recognition phase of the
As orthopaedic surgeons derive many therapeutical consequences 3D processing and is highly correlated with the resolution of the CT
from imaging in correspondence with the clinical manifestations, an scan. In case of bad resolution the automatic 3D recognition already
exact depiction of the factual anatomy is crucial. The exact knowl- showed uneven bony surfaces with gaps and artifacts whereby
edge of the three-dimensional ACJ anatomy is mandatory for indicat- extensive manual corrections as smoothing may have lead to a print-
ing ACJ resection or ACJ stabilization procedures. It has been shown able but most likely not anatomical model. Therefore 18 of the 23 CT
that relevant discrepancies exist in glenoid inclination and version scans (78%) could not be considered for anatomical and biometrical
between measurements with software technique and 3D computed analysis. Four (80%) of the processed scans showed excellent depic-
tomography printed scapula as controls [21]. Our assessment also tion of the bony structures after automatic recognition and fast proc-
revealed discrepant values regarding angle measurements but essing. One (20%) scan showed good depiction without gaps and
showed even values for evaluation of distances for all modalities. It could be processed after minor manual work over. The results impli-
could be stated that this is due to impaired technical reproducibility cate that the RCM is a reliable model to test anatomy and biometrics
as the digital protractor is more difficult to place on the landmarks of musculoskeletal structures, especially distances. However, a higher
than the measurement stick. Based on the findings of our collective it number would be necessary to confirm these findings and make a
has to be considered that a high quality of CT scans is required to pro- statement about the “normal” anatomy whereby our results suggest
duce reliable models which can be used for anatomical studies. a higher variability of the joint space width than previously reported
Researchers and clinicians should be very critical which CT scan is in the literature. A reason for this could be the inadequate depiction
considered for 3D printing either for preoperative planning or ana- of the biometry of the ACJ in plain radiographs which was used for
tomical studies. Our study shows the discrepancy (Fig 1) between the the assessment by Zanca and Petersson [12,14]. In this we found that
the mean 3D-measured joint space lies between 3.04 mm and
6.24 mm anteriorly, 1.03 mm and 1.84 mm centrally, 1.4 mm and
3.3 mm posteriorly. Our data show the tendency of the ACJ to open
Table 2
3D Joint Space (mm) Evaluation (Observer 1, Observer 2).
up anteriorly, which goes along with the findings of our prior studies
[17,19].
Variable anterior central posterior This study promotes the possibility of anatomical and biometrical
Model 1 4,09 3,35 2,62 2,28 1,40 1,91 analysis of “reversed cadavers”. Researchers could make use of this
Model 2 3,04 3,12 2,24 2,77 2,20 2,50 method to study the bony anatomy both in symptomatic and asymp-
Model 3 6,24 4,58 2,43 2,28 1,65 2,02 tomatic patients without the disadvantages of the traditional method
Model 4 5,73 4,85 2,34 2,74 1,80 2,88
of cadaveric studies. These are at first the costs associated with pres-
Model 5 3,38 3,05 1,03 2,84 1,73 3,30
ervation of human cadavers. Additionally the donor programs are
3
M. Junker, M. Farkhondeh Fal and J. Kircher
confronted with a high effort to face the ethical and legal issues.
Nowadays the use of cadaverous materials tend to become more dif-
ficult due to ensuring safety of students and labour force. Finally plas-
tination is not only a time-consuming process but also cadavers do
not always represent the exactness of the anatomical structures
which is mandatory for meaningful research [22]. The most impor-
tant advantage of the “reversed cadaver” method is the fact, that the
specimens can represent all age groups, especially younger patients
and it would be relatively easy to establish a control group with unaf-
fected subjects, as long as a CT data set is available. This is in contrast
to traditional cadaver studies, where most of the specimen are
derived from older deceased people with inevitable degenerative
changes and additional artefacts created by any necessary preserva-
tive measures, such as cooling, formaldehyde or such.
Because of the high drop-out rate due to lacking CT quality we can
not make a valid statement about the normal biometry of the ACJ
which can be seen as the main limitation of the study. Nonetheless
the primary goal of the study was to introduce a new method for ana-
tomical evaluation of bony structures and proof reproducibility in
principle. Our results show good to excellent inter-rater reliability for
the RCM method. The overall inter-rater reliability was higher for 3D
measurements compared to CT measurements. After separate analy-
sis of the ICC for the evaluation of distances and angles it showed
that the RCM leads to best inter-rater reliability for measuring joint
spaces and distances. That the MRT technique performed best regard-
ing angle measurements could be biased as JK and MJ performed a
high amount of ACJ angle measurements as part of prior publications.
In total our results depict the potential of the method and by generat-
ing and analysing larger cohorts even the definition of normal anat-
omy of the ACJ as well as the shoulder could be achieved.
The RCM is a method that provides accurate anatomical results and
can be used for evaluation of biometric analyses in the ACJ. It has to be
noted, that the quality of the CT data set is imparative. We can con-
clude that the RCM provides reproducible results. To determine nor-
mal biometry of the shoulder a larger population would be needed.
Researchers who want to confirm or refute certain anatomical findings
by 3D printing have to be aware of the required quality of the CT scans
based on which the printing is performed. Furthermore, the infrastruc-
ture as a high-quality 3D printer and personal which is trained in 3D
rendering and preparation of the datasets. In case these circumstances
are factual the method can provide exact results and could serve as a
modality to evaluate bony anatomy without the disadvantages of the
traditional method such as plastination artefacts.
Research ethics
The study was approved by the Institutional Ethics Committee of
€ sseldorf [number 3429].
the University of Du
Funding
€ger Stiftung [Grant No.
This work was supported by the Alwin Ja
P2019001].
Declaration of Competing Interest
The authors declare no conflict of interest. The funders had no role
in the design of the study, in the collection, analyses, or interpretation
Annals of 3D Printed Medicine 11 (2023) 100114
of data, in the writing of the manuscript, or in the decision to publish
the results.
Acknowledgements
The Airbus ProtoSpace Network performed the analysis and proc-
essing of the CT datasets. The Fraunhofer Institution for Additive
Manufacturing Technologies IAPT produced the 3D models.
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