Gravity center estimation for evaluation of standing whole body compensation using virtual barycentremetry based on biplanar slot-scanning stereoradiography - validation by simultaneous force plate measurement.

BACKGROUND: Whole body standing alignment (WBSA) in terms of biomechanics can be evaluated accurately only by referring the gravity line (GL) which lies on the gravity center (GC). Here, we introduce a method for estimating GL and simultaneous WBSA measurement using the EOS® imaging system and report on the reproducibility and reliability of the method. METHODS: A 3-dimensional (3D) avatar to estimate GC was created following three steps: 3D reconstruction of the bone based on EOS images; deformation into a generic morphotype (MakeHuman statistical model) before density integration with 3D rasterization of the full body into 1-mm3 voxels (the content of each voxel is considered homogeneous); computation of the density of all the voxels provides the center of mass, which can be projected onto the floor as the GC of the full body, providing the GL in relation to the WBSA. The repeatability, reproducibility, and accuracy of the estimated GC and body weight of the avatar were compared with clinical estimation using a force plate in healthy volunteers and patients with degenerative and deformative diseases. RESULTS: Statistical analyses of the data revealed that the repeatability and reproducibility of the estimation was high with intra-rater and inter-rater intraclass correlation coefficient. ≥0.999. The coordinate values of the GC and body weight estimation did not differ significantly between the avatar and force plate measurements, demonstrating the high accuracy of the method. CONCLUSION: This new method of estimating GC and WBSA is reliable and accurate. Application of this method could allow clinicians to quickly and qualitatively evaluate WBSA with GL with various spinal malalignment pathologies.

Spino-femoral muscles affect sagittal alignment and compensatory recruitment: a new look into soft tissues in adult spinal deformity.

OBJECTIVE: To quantify muscle characteristics (volumes and fat infiltration) and identify their relationship to sagittal malalignment and compensatory mechanism recruitment. METHODS: Female adult spinal deformity patients underwent T1-weighted MRI with a 2-point Dixon protocol from the proximal tibia up to the T12 vertebra. 3D reconstructions of 17 muscles, including extensors and flexors of spine, hip and knee, were obtained. Muscle volume standardized by bone volume and percentage of fat infiltration (Pfat) were calculated. Correlations and regressions were performed. RESULTS: A total of 22 patients were included. Significant correlations were observed between sagittal alignment and muscle parameters. Fat infiltration of the hip and knee flexors and extensors correlated with larger C7-S1 SVA. Smaller spinal flexor/extensor volumes correlated with greater PI-LL mismatch (r = - 0.45 and - 0.51). Linear regression identified volume of biceps femoris as only predictor for PT (R2 = 0.34, p = 0.005) and Pfat of gluteus minimus as only predictor for SVA (R2 = 0.45, p = 0.001). Sagittally malaligned patients with larger PT (26.8° vs. 17.2°) had significantly smaller volume and larger Pfat of gluteus medius, gluteus minimus and biceps femoris, but similar values for gluteus maximus, the hip extensor. CONCLUSION: This study is the first to quantify the relationship between degeneration of spino-femoral muscles and sagittal malalignment. This pathoanatomical study identifies the close relationship between gluteal, hamstring muscles and PT, SVA, which deepens our understanding of the underlying etiology that contributes to adult spinal deformity.

Invariance of head-pelvis alignment and compensatory mechanisms for asymptomatic adults older than 49 years.

PURPOSE: The aim was to quantify the postural alignment of asymptomatic elderly, in comparison to a reference population, searching for possible invariants and compensatory mechanisms. METHODS: 41 volunteers (49-76 years old) underwent bi-planar X-rays with 3D reconstructions of the spine and pelvis. Alignment parameters were compared with those of a reference group of asymptomatic subjects younger than 40 years old, with a particular focus on center of acoustic meati (CAM) and odontoid (OD) with regard to hip axis (HA). Possible markers of compensation were also investigated. RESULTS: No significant difference among groups appeared for CAM-HA and OD-HA parameters. Twenty four percent of elders had an abnormally high SVA value and twenty seven percent had an abnormal global spine inclination. Increased pelvic tilt and cervical lordosis allowed maintaining the head above the pelvis. CONCLUSIONS: CAM-HA and OD-HA appeared quasi-invariant even in asymptomatic elderly. Some subjects exhibited alteration of spine alignment, compensated at the pelvis and cervical regions.

Estimation of spinopelvic muscles' volumes in young asymptomatic subjects: a quantitative analysis.

PURPOSE: Muscles have been proved to be a major component in postural regulation during pathological evolution or aging. Particularly, spinopelvic muscles are recruited for compensatory mechanisms such as pelvic retroversion, or knee flexion. Change in muscles' volume could, therefore, be a marker of greater postural degradation. Yet, it is difficult to interpret spinopelvic muscular degradation as there are few reported values for young asymptomatic adults to compare to. The objective was to provide such reference values on spinopelvic muscles. A model predicting the muscular volume from reduced set of MRI segmented images was investigated. METHODS: A total of 23 asymptomatic subjects younger than 24 years old underwent an MRI acquisition from T12 to the knee. Spinopelvic muscles were segmented to obtain an accurate 3D reconstruction, allowing precise computation of muscle's volume. A model computing the volume of muscular groups from less than six MRI segmented slices was investigated. RESULTS: Baseline values have been reported in tables. For all muscles, invariance was found for the shape factor [ratio of volume over (area times length): SD < 0.04] and volume ratio over total volume (SD < 1.2 %). A model computing the muscular volume from a combination of two to five slices has been evaluated. The five-slices model prediction error (in  % of the real volume from 3D reconstruction) ranged from 6 % (knee flexors and extensors and spine flexors) to 11 % (spine extensors). CONCLUSION: Spinopelvic muscles' values for a reference population have been reported. A new model predicting the muscles' volumes from a reduced set of MRI slices is proposed. While this model still needs to be validated on other populations, the current study appears promising for clinical use to determine, quantitatively, the muscular degradation.

A new quasi-invariant parameter characterizing the postural alignment of young asymptomatic adults.

PURPOSE: Our study aims to describe the postural alignment of young asymptomatic subjects from head to feet from bi-planar standing full-body X-rays, providing database to compare to aging adults. Novelty resides in the inclusion of the head and lower limbs in the erected posture's analysis. METHODS: For 69 young asymptomatic subjects (18-40 years old) 3D reconstructions of the head, spine, pelvis and lower limbs segments were performed from bi-planar full-body X-rays. Usual studied spinal, pelvic and lower limbs' parameters were computed in 3D, sagittal and frontal planes of the patient. Relationships between these parameters were investigated. Inclinations of different lines were studied to characterize the erected posture. RESULTS: Values found for spinal curvatures, pelvic parameters and lower limbs geometrical parameters agreed with the literature: thoracic kyphosis, lumbar lordosis, pelvic incidence, pelvic tilt and sagittal vertical axis were respectively in average of 26.9° (SD 7.2°), 30.5° (SD 7.5°), 51.0° (SD 9.4°), 11.1° (SD 5.6°) and -8.9 mm (SD 21.6 mm). The angle between the vertical and the line joining the most superior point of dentiform apophyse of C2 (OD) and the center of the bi-coxofemoral axis (HA) was the less variable one (SD 1.6°). CONCLUSIONS: This study on 3D postural alignment reports the geometry of the spine, pelvis and lower limbs, of the young asymptomatic adult. The less variable angle is the one of the line OD-HA with the vertical, highlighting the vertical alignment of the head above the pelvis. This study provides a basis for future comparisons when investigating aging populations.

Virtual Scoliosis Surgery Using a 3D-Printed Model Based on Biplanar Radiographs.

The aim of this paper is to describe a protocol that simulates the spinal surgery undergone by adolescents with idiopathic scoliosis (AIS) by using a 3D-printed spine model. Patients with AIS underwent pre- and postoperative bi-planar low-dose X-rays from which a numerical 3D model of their spine was generated. The preoperative numerical spine model was subsequently 3D printed to virtually reproduce the spine surgery. Special consideration was given to the printing materials for the 3D-printed elements in order to reflect the radiopaque and mechanical properties of typical bones most accurately. Two patients with AIS were recruited and operated. During the virtual surgery, both pre- and postoperative images of the 3D-printed spine model were acquired. The proposed 3D-printing workflow used to create a realistic 3D-printed spine suitable for virtual surgery appears to be feasible and reliable. This method could be used for virtual-reality scoliosis surgery training incorporating 3D-printed models, and to test surgical instruments and implants.

The centre of rotation of the shoulder complex and the effect of normalisation.

Shoulder motions consist of a composite movement of three joints and one pseudo-joint, which together dictate the humerothoracic motion. The purpose of this work was to quantify the location of the centre of rotation (CoR) of the shoulder complex as a whole. Dynamic motion of 12 participants was recorded using optical motion tracking during coronal, scapular and sagittal plane elevation. The instantaneous CoR was found for each angle of elevation using helical axes projected onto the three planes of motion. The location of an average CoR for each plane was evaluated using digitised and anthropometric measures for normalisation. When conducting motion in the coronal, scapular, and sagittal planes, respectively, the coefficients for locating the CoRs of the shoulder complex are -61%, -61%, and -65% of the anterior-posterior dimension - the vector between the midpoint of the incisura jugularis and the xiphoid process and the midpoint of the seventh cervical vertebra and the eighth thoracic vertebra; 0%, -1%, and -2% of the superior-inferior dimension - the vector between the midpoint of the acromioclavicular joints and the midpoint of the anterior superior iliac spines; and 57%, 57%, and 78% of the medial-lateral dimension -0.129 times the height of the participant. Knowing the location of the CoR of the shoulder complex as a whole enables improved participant positioning for evaluation and rehabilitation activities that involve movement of the hand with a fixed radius, such as those that employ isokinetic dynamometers.

Determination of a new uniform thorax density representative of the living population from 3D external body shape modeling.

Body segment parameters (BSP) for each body׳s segment are needed for biomechanical analysis. To provide population-specific BSP, precise estimation of body׳s segments volume and density are needed. Widely used uniform densities, provided by cadavers׳ studies, did not consider the air present in the lungs when determining the thorax density. The purpose of this study was to propose a new uniform thorax density representative of the living population from 3D external body shape modeling. Bi-planar X-ray radiographies were acquired on 58 participants allowing 3D reconstructions of the spine, rib cage and human body shape. Three methods of computing the thorax mass were compared for 48 subjects: (1) the Dempster Uniform Density Method, currently in use for BSPs calculation, using Dempster density data, (2) the Personalized Method using full-description of the thorax based on 3D reconstruction of the rib cage and spine and (3) the Improved Uniform Density Method using a uniform thorax density resulting from the Personalized Method. For 10 participants, comparison was made between the body mass obtained from a force-plate and the body mass computed with each of the three methods. The Dempster Uniform Density Method presented a mean error of 4.8% in the total body mass compared to the force-plate vs 0.2% for the Personalized Method and 0.4% for the Improved Uniform Density Method. The adjusted thorax density found from the 3D reconstruction was 0.74g/cm(3) for men and 0.73g/cm(3) for women instead of the one provided by Dempster (0.92g/cm(3)), leading to a better estimate of the thorax mass and body mass.

A 3D reconstruction method of the body envelope from biplanar X-rays: Evaluation of its accuracy and reliability.

The aim of this study was to propose a novel method for reconstructing the external body envelope from the low dose biplanar X-rays of a person. The 3D body envelope was obtained by deforming a template to match the surface profiles in two X-rays images in three successive steps: global morphing to adopt the position of a person and scale the template׳s body segments, followed by a gross deformation and a fine deformation using two sets of pre-defined control points. To evaluate the method, a biplanar X-ray acquisition was obtained from head to foot for 12 volunteers in a standing posture. Up to 172 radio-opaque skin markers were attached to the body surface and used as reference positions. Each envelope was reconstructed three times by three operators. Results showed a bias lower than 7mm and a confidence interval (95%) of reproducibility lower than 6mm for all body parts, comparable to other existing methods matching a template onto stereographic photographs. The proposed method offers the possibility of reconstructing body shape in addition to the skeleton using a low dose biplanar X-rays system.