Glenoid Deformity Research Articles

Minimum two-year follow-up of a reverse total shoulder arthroplasty using a wedged baseplate.

Avoiding inclination of the glenoid baseplate in reverse shoulder arthroplasty often requires considerable glenoid reaming. It is proposed that the use of a metal wedged baseplate in all patients can achieve neutral inclination with reduced glenoid reaming. A prospective clinical single-centre study with minimum two-year follow-up was carried out. Glenoid deformity was classified on CT and surgery planned using BluePrintTM. The Tornier Perform® Reversed Wedged Augmented Glenoid was used in all cases. Clinical outcome scores and radiographs were assessed. Seventy-three patients, mean age 76.6 years. Twenty-eight demonstrated no glenoid deformity and 19 demonstrated marked retroversion. Seventy completed two-year follow-up. Mean pain scores fell from 6 to 0.7. All Patient Reported Outcome Meaures (PROMS) were significantly improved. Active elevation increased by 62° and external rotation by 28.7° (p < 0.001). In patients with no glenoid wear (E0/A1), correction of inferior inclination was achievable with a 15° full-wedge baseplate in all cases, reducing the reaming depth by 4.4 mm (p < 0.001). In patients with severe glenoid wear, a 35° half wedge baseplate was often necessary to correct the deformity. The most common complications were stress reactions/fractures. A metal wedged baseplate can achieve neutral inclination in all patients, minimising bone reaming and preserving lateralisation with good two-year outcomes. IV (case series with no comparison group).

Outcomes following humeral head autograft glenoid reconstruction in primary reverse total shoulder arthroplasty

Patients with severe glenoid bone loss are at increased risk for poor implant fixation, scapular notching, dislocation, joint kinematic disturbances, and prosthetic failure following reverse total shoulder arthroplasty (rTSA). Glenoid bone grafting has proven useful when performing rTSA in patients with inadequate glenoid bone stock, although the current literature is limited. The purpose of this study is to evaluate clinical outcomes in patients with significant glenoid deformity undergoing primary rTSA with one-stage glenoid reconstruction using a humeral head autograft. A database of prospectively enrolled patients was reviewed to identify patients who underwent primary rTSA with humeral head autograft (n=40) between 2008 and 2020 by 6 high-volume shoulder arthroplasty surgeons with a minimum 2-year follow-up. Variables studied included demographics, medical comorbidities, range of motion, Constant score, American Shoulder and Elbow Surgeons score, pain score, patient satisfaction, glenoid deformity, revisions, and complications. Preoperative glenoid deformity was characterized using glenoid version and beta-angles, measured on computed tomography. Improvement at final follow-up was compared to a matched control group of 120 standard primary rTSA patients. Following the post hoc Bonferroni correction, an adjusted alpha value of 0.004 was used to define statistical significance. Forty patients were included with a mean follow-up of 5.3 (range, 2.0-13.2) years. Patients exhibited a mean preoperative glenoid retroversion and beta-angle of 29° and 80°, respectively. At final follow-up, patients who received a graft exhibited lower mean scores for active external rotation (25° vs. 39°; P=.001) in comparison to those who did not receive a graft. No differences were observed in active abduction (P=.029), active forward elevation (P=.009), active internal rotation (P=.147), passive external rotation (P=.082), Global Shoulder Function score (P=.157), Constant score (P=.036), American Shoulder and Elbow Surgeons score (P=.009), or pain score (P=.186) between groups. Seven patients (17.5%) exhibited complications of which the most common being aseptic glenoid loosening (15%). This study demonstrates that patients undergoing primary rTSA with autogenous humeral head autograft for severe glenoid deficiency experience postoperative improvements in range of motion and functional outcome scores that exceeded the minimal clinically important difference and substantial clinical benefit but inferior to matched controls. This suggests that glenoid reconstruction using a resected humeral head autograft is an effective strategy when conducting primary rTSA in patients with significant glenoid deformity.

Comparison of 3D computer-assisted planning with and without patient-specific instrumentation for severe bone defects in reverse total shoulder arthroplasty

BackgroundPreoperative planning is an integral aspect of managing complex deformity in reverse shoulder arthroplasty (RSA). The purpose of this study was to compare the success of patient specific instrumentation (PSI) and 3D computer-assisted planning with standard instrumentation (Non-PSI) in achieving planned corrections of the glenoid among patients undergoing RSA with severe bony deformity requiring glenoid bone grafts. MethodsA retrospective case-control study was performed, including all patients that underwent RSA with combined bone grafting procedures (BIO-RSA or structural bone grafting) for severe glenoid deformity by a single between June 2016 and July 2023. Patients were required to have preoperative and postoperative CT scans as well as preoperative 3D planning performed for inclusion. Patients were divided into two groups based on the use of 3D computer-assisted planning with or without PSI (PSI vs. Non-PSI). The corrected inclination and version were measured by two separate reviewers on preoperative and postoperative 2D CT scans and compared to their corresponding preoperative planning goals utilizing bivariate analyses. ResultsWe identified 45 patients that met our inclusion criteria (22 PSI and 23 Non-PSI). Preoperative inclination (mean ± SD) (PSI 10.12° ± 15.86°, Non-PSI 9.43° ± 10.64°; P = 0.864) and version (PSI -18.78° ± 18.3°, Non-PSI -17.82° ± 11.49°; P = 0.835) measurements were similar between groups. No significant differences in the mean deviation (error) between the postoperative and planned inclination (PSI 5.49° ± 3.72; Non-PSI 6.91° ± 5.05; P = 0.437) and version (PSI 8.37° ± 5.7; Non-PSI 5.37° ± 4.43; P = 0.054) were found between groups. No difference in the rate of outliers (>10° error) was noted in inclination (P = 0.135) or version (P = 0.445) between groups. Greater planned version correction was correlated with greater error when PSI was utilized (PSI r = 0.519, P = 0.013; Non-PSI r = 0.362, P = 0.089). ConclusionBoth PSI and 3D computer-assisted planning without PSI (Non-PSI) appear to be useful techniques to achieve version and inclination correction among patients undergoing RSA with severe glenoid deformity required glenoid bone grafting with no clear superiority of one method over the other. Surgeons should be aware that when utilizing PSI, slightly greater error in achieving version goals may occur as version correction is increased.

Prognostic value of the Favard classification for patients before and after reverse shoulder arthroplasty performed for rotator cuff tear arthropathy

BackgroundAlthough the Favard classification is commonly utilized by surgeons to describe the supero-inferior morphology of the glenoid when treating rotator cuff arthropathy (RCA), its utility in prognosticating patients’ clinical state before and after reverse shoulder arthroplasty (RSA) remains unproven. We assessed the prognostic value of the Favard glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in RSA. MethodsA prospectively collected, multicenter database for a single-platform shoulder arthroplasty system was queried for patients with RCA who underwent RSA with a minimum 2-year clinical follow-up. Differences in patient reported outcome scores (PROMs) (Simple Shoulder Test, American Shoulder and Elbow Surgeons, Shoulder Pain and Disability Index, visual analog scale pain, Shoulder Function score), combined patient-reported and clinical-input scores (Constant, University of California Los Angeles, Shoulder Arthroplasty Smart), active range of motion values (forward elevation, abduction, external rotation [ER], internal rotation [IR]), radiographic outcomes (humeral radiolucency line rates, scapular notching rate), and the incidence of postoperative complications and revision surgery were compared by glenoid deformity type per the Favard classification. Comparisons were performed to assess the ability of the Favard classification to prognosticate the preoperative, postoperative, and improved state after RSA. Results400 RSAs performed for RCA were included. Comparison of outcomes between Favard glenoid types resulted in 6 pairwise comparisons of 12 clinical outcome metrics, yielding 72 total Favard glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 216 possible pairwise Favard glenoid type/metric comparisons, statistical significance was only reached for 3% of the combinations (7/216). Among E0, E1, and E2 glenoids, the only statistically significant pairwise comparison identified among all three clinical states was a more favorable preoperative American Shoulder and Elbow Surgeons score for E0 vs. E2 glenoids. Preoperatively, E3 glenoids had poorer ER, IR, and Shoulder Arthroplasty Smart scores compared to E0 glenoids and poorer ER compared to E2 glenoids. Postoperatively, E3 glenoids had a poorer IR score compared to E0 glenoids and poorer ER compared to E1 glenoids. No pairwise differences in preoperative to postoperative improvement were found. There were no statistically significant pairwise differences in humeral lucency rate, scapular notching rate, complication rates, or revision rates between Favard glenoid types. ConclusionAlthough useful for describing degenerative changes to the glenohumeral joint, the Favard classification offers little prognostic information regarding patient outcomes before and after RSA aside from poorer preoperative and postoperative axial rotation in E3 glenoids. Alternative glenoid classification systems or predictive models should be considered for more precise prognoses of patients undergoing RSA for RCA.

Early to short-term radiographic follow-up of metal-augmented baseplates in reverse shoulder arthroplasty for treatment of glenoid deformity in glenohumeral arthritis and rotator cuff arthropathy

Hypothesis and backgroundAs reverse total shoulder arthroplasty (rTSA) has evolved, the use of augmented glenoid baseplates has increased. While there are benefits of metal augmentation, literature concerning the mid- to long-term follow-up of these implants is emerging. The purpose of this study is to report early to short-term radiographic follow-up of patients with glenoid deformity treated with a metal-augmented glenoid baseplate. Our hypothesis is that we will see a low incidence of osteolysis, loosening, complications, and revision of these implants regardless of diagnosis, augment type, or patient demographics. MethodsWe performed a single-center retrospective review of all patients undergoing primary reverse shoulder arthroplasty with an augmented metallic baseplate for rotator cuff arthropathy and glenohumeral arthritis. Patients undergoing revision procedures or reverse arthroplasty for fractures were excluded. All patients had a minimum of 1-year radiographic follow-up. Preoperative imaging was reviewed to confirm the diagnosis and glenoid deformity classification. Postoperative radiographs were reviewed for evidence of complications, revisions, osteolysis, baseplate loosening, and failure. Clinical data were reviewed for complications. ResultsPrimary rTSA with a metal-augmented baseplate (38 full wedge and 22 half wedge augments) was performed on 60 patients who met inclusion criteria (mean age 74 ± 7). The average radiographic follow-up of all patients was 17 months. In our cohort, there was one patient with aseptic loosening of a full wedge implant that was not revised. There were no other complications, revision surgeries, baseplate failures, or acromial stress fractures. Six patients developed scapular notching, and five patients were found to have asymptomatic glenoid osteolysis. Two patients with full wedge implants developed aseptic humeral loosening. Pearson chi-square post hoc analysis found no correlation between augment type, gender, or glenoid deformity classification and radiographic changes such as glenoid or humeral osteolysis, loosening, or scapular notching. We did find a statistically significant correlation (P = .018) between patients with body mass index > 35 and glenoid osteolysis. Discussion and conclusionPrimary rTSA for patients with rotator cuff arthropathy or glenohumeral arthritis with glenoid deformity corrected with metal-augmented glenoid baseplates results in a low complication rate and an acceptable outcome at a minimum 1-year follow-up. Compared to other similar cohorts, our patients did not experience any acromial stress fractures, and only one patient had loosening of the glenoid component that was not ultimately revised. Further studies with longer follow-up will be needed, but early outcomes are promising and support the increase in the use of these implants.

Utility of superior augments in reverse shoulder arthroplasty (Exactech, Equinoxe GPS) without significant glenoid deformity

IntroductionSuperior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal is to compare superior augments versus no augment baseplates in RSA for patients with rotator cuff dysfunction and no significant superior glenoid erosion. MethodsA multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Exactech, Equinoxe GPS) and three-year follow-up (mean 32-month follow-up, range 20 to 61 months) who had preoperative superior inclination less than 10 degrees and retroversion less than 15 degrees. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to three years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. Chi-square test used to compare categorical variables and student t-test used to compare augment and no augment cohorts. ResultsThe study population consisted of 54 superior augment patients and 91 no augment patients. The augment cohort had lower BMI (27.2 vs. 29.4, p-0.023), higher native superior inclination (5.9 vs. 1.4 degrees, p<0.001). No difference between the augment and no augment cohorts was found regarding age (p=0.643), gender (p=0.314), medical comorbidities (p>0.05), surgical indication (p=0.082), and native glenoid version (p=0.564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, p=0.023), all remaining ROM and PROs preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative SAS score was significantly higher (78.0 vs. 73.6, p=0.042), and ASES score trended towards higher (83.6 vs. 77.5, p=0.063) in the augment cohort. The augment cohort had significantly lower proportion of patients planned to have superior baseplate tilt (1.9% vs. 14.3%, p=0.012), and had greater mean inclination correction (6.3 vs. 1.3 degrees, p<0.001), compared to no augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no augment cohorts (5.6% vs. 3.3%, p=0.509). DiscussionSuperior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared to non-augmented baseplates at 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity.

Three-dimensional analysis of biplanar glenoid deformities: what are they and can they be virtually reconstructed with anatomic total shoulder arthroplasty implants?

Descriptions of glenoid deformities in glenohumeral osteoarthritis (GHOA) have focused on the axial plane. Less is known regarding arthritic glenoids with higher amounts of superior inclination and little evidence exists to guide management of inclination or combined version-inclination deformity when performing anatomic total shoulder arthroplasty (aTSA). We hypothesized that biplanar deformities (BD) would be present in a higher proportion of GHOA patients than previously appreciated, and these deformities would be difficult to adequately reconstruct with contemporary aTSA implants. A retrospective query was performed of GHOA patients indicated for TSA 2012-2017 with a computed tomography (CT) scan within three months of surgery. Images were uploaded to three-dimensional (3D) software for automated measurements. Glenoids with superior inclination ≥10°, and retroversion ≥20° were considered to have BD. Walch classification was determined, and C-type glenoids were excluded. Rotator-cuff muscle cross-sectional area (CSA) was measured and fatty infiltration was graded. Glenoids withBD were virtually planned for aTSA with correction to neutral inclination and version, then with 5° superior inclination and 10° retroversion. Two-hundred and sixty-eight shoulders in 250 patients were included; average age was 65years, 67% male. There were no differences in inclination between Walch types (P=.25). Twenty-nine shoulders with BD were identified (11%). These deformities were not associated with age (P=.47) or gender (P=.50) but were skewed towards Walch B-type, specifically B2 (P=.03). Acromial index and posterior humeral head subluxation were higher in BD patients (P=.04, P<.001, respectively). Biplanar deformities had similar cuff CSA compared to those without but were less frequently associated with fatty infiltration of the subscapularis (P=.05). When correcting to neutral version and inclination, 41% BD could not be reconstructed. Of those that could, 94% required augmented implants. When correcting to 5° superior inclination and 10° retroversion, 10% could not be reconstructed. Of those that could, 58% required augmented implants. With partial correction, augment use was predicted by retroversion >26° (P=.009). Inclination did not predict augment use (P=.90). Final implant position commonly involved unseating in the posterosuperior quadrant and cancellous exposure in the anteroinferior quadrant. This retrospective computed tomography (CT)-based study of 268 shoulders with GHOA found an 11% prevalence of BD. These deformities were commonly associated with Walch B2 wear patterns. Virtual aTSA planning showed a high failure rate (41%) when correcting to neutral version and inclination. Posteriorly augmented implants were frequently required, and often still involved unseating in the posterosuperior quadrant, increased cancellous exposure in the anteroinferior quadrant, and vault perforation.

External Rotation Strength After TSA in Osteoarthritic Shoulders with Eccentric Deformity Is Not Impacted by Posterior Rotator Cuff Deficiency.

Patients with persistent glenohumeral osteoarthritis symptoms despite nonoperative management may pursue anatomic total shoulder arthroplasty (TSA). TSA revision rates are higher in patients with preoperative eccentric (asymmetric posterior erosion) compared with concentric (symmetric) glenoid deformity. If posterior rotator cuff deficiency demonstrated preoperatively in patients with eccentric deformity persists after TSA, it may manifest as relative weakness in external compared with internal rotation secondary to deficient activity of the shoulder external rotator muscles. Persistent posterior rotator cuff deficiency is hypothesized to contribute to TSA failures. However, it remains unknown whether rotational strength is impaired after TSA in patients with eccentric deformity. Our goal was to determine if patients with eccentric deformity exhibit relative external rotation weakness that may be explained by posterior rotator cuff deficiency after TSA. Patients who were >1 year after TSA for primary glenohumeral osteoarthritis and had had preoperative eccentric or concentric deformity were prospectively recruited. Torque was measured and electromyography was performed during maximal isometric contractions in 26 three-dimensional direction combinations. Relative strength in opposing directions (strength balance) and muscle activity of 6 shoulder rotators were compared between groups. The internal (+) and external (-) rotation component of strength balance did not differ in patients with eccentric (mean internal-external rotation component of strength balance: -7.6% ± 7.4%) compared with concentric deformity (-10.3% ± 6.8%) (mean difference: 2.7% [95% confidence interval (CI), -1.3% to 6.7%]; p = 0.59), suggesting no relative external rotation weakness. Infraspinatus activity was reduced in patients with eccentric (43.9% ± 10.4% of maximum voluntary contraction [MVC]) compared with concentric (51.3% ± 10.4% of MVC) deformity (mean difference: -7.4% [95% CI, -13.4% to -1.4%] of MVC; p = 0.04). A relative external rotation strength deficit following TSA was not found, despite evidence of reduced infraspinatus activity, in the eccentric-deformity group. Reduced infraspinatus activity suggests that posterior rotator cuff deficiencies may persist following TSA in patients with eccentric deformities. Longitudinal study is necessary to evaluate muscle imbalance as a contributor to higher TSA failure rates. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcome of wedged glenoid reconstruction in anatomic total shoulder arthroplasty for osteoarthritic retroverted glenoid: a minimum 2-year follow-up

BackgroundGlenoid retroversion and humeral head subluxation is a progressive disorder due to abnormal force coupling and increased contact force. In situ placement of anatomic total shoulder arthroplasty (TSA) components in this scenario results in edge loading, progressive subluxation and early failure. Wedged glenoid components have been demonstrated to improve glenohumeral alignment, but have not been correlated with mid-term clinical outcomes. MethodsPatients undergoing TSA utilizing a wedged all polyethylene glenoid component for retroverted glenoid deformity were identified from a prospectively maintained database. Preoperative planning CT was routinely performed and compared to postoperative correction on radiographic evaluation. Evidence of loosening was correlated to prospectively collected clinical outcome using patient reported outcome measures. A matched group of neutrally aligned glenohumeral joints undergoing anatomic total shoulder arthroplasty was utilized to compare improvement in clinical outcomes. ResultsOver a 5-year period, 17 patients with mean age 60 (range 43-81, SD 10.5) were identified with a mean preoperative neoglenoid retroversion of 16.7° (SD 4.5). At a mean follow-up of 43.8 months (range 27-60). No revision surgeries were undertaken. Improvement in the Oxford shoulder score was 18 points (p<0.0001). The mean improvement was compared to a matched control group demonstrating a comparable magnitude of improvement of 20.4 points. ConclusionsWedged polyethylene components for Walch B2-type glenoids in TSA yields acceptable correction of the joint line, excellent clinical outcomes and survivorship is maintained in the short-term. The clinical and radiological outcome demonstrated similar improvement to that seen in A type deformities.

The functional and radiographic outcomes of nonaugmented anatomic total shoulder arthroplasty in patients with Walch B3 glenoid deformities

BackgroundAchieving a durable result with anatomic total shoulder arthroplasty (aTSA) in shoulders with glenoid retroversion deformities, specifically Walch B3 glenoid deformities, can be a challenge. In this retrospective series, we report the mid-term clinical and radiographic follow-up of aTSA in patients with B3 glenoids with nonaugmented polyethylene implants. MethodsPatients who had undergone aTSA at a single institution by fellowship-trained surgeons between January 2013 and August 2017 with a preoperative computed tomography scan demonstrating a B3 glenoid were identified. All patients underwent aTSA with a lesser tuberosity osteotomy and a nonaugmented all-polyethylene glenoid. Eccentric reaming was performed to achieve near complete seating of the glenoid component with less emphasis on retroversion. Patients were contacted to complete patient-reported outcome scores and radiographic review. Immediate postoperative radiographs were assessed for posterior humeral subluxation measured relative to the axis of the glenoid component and implant seating. Final radiographs were reviewed for glenoid loosening using Lazarus rating and change in posterior humeral subluxation. ResultsTwenty-five subjects met inclusion criteria and were available for follow-up. The cohort had a mean age of 65.1 (range: 55-81) years and consisted of 6 females (24%; 6/25). These patients had a mean follow-up of 6.2 years (range: 3.9-8.4). American Shoulder and Elbow Surgeons improved from 38.2 ± 13.2 to 90.0 ± 16.9 (P < .001). Eighty percent (20/25) of these patients were available for radiographic review and had an average Lazarus grade of 1.9 (range: 0-5). There was no change in mean posterior glenohumeral subluxation (4.6% vs. 2.3%; P = .15) relative to their immediate postoperative films. The 12 patients with a Lazarus grade less than 2 had a greater Western Ontario Osteoarthritis of the Shoulder Index (96.9 ± 1.3 vs. 67.4 ± 12.8; P < .001), American Shoulder and Elbow Surgeons (94.0 ± 5 vs. 76.3 ± 16; P = .03), Single Assessment Numeric Evaluation (88.2 ± 8.7% vs. 66.7 ± 15%; P = .02), and satisfaction (98.5 ± 0.7% vs. 79.9 ± 13.2%; P = .002) compared to the 8 patients with a Lazarus grade more than or equal to 2. These 8 patients were more likely to have had severe preoperative biplanar deformity (retroversion >25° and inclination >10°) than the 12 without early glenoid radiolucency (63% [5/8] vs. 17%; P = .04). ConclusionAt mid-term follow-up, aTSA with standard implants for B3 glenoid deformity provides a reliable treatment option for restoration of function and improvement in pain. Mid-term radiographic review demonstrated development of early glenoid component lucencies in shoulders with severe biplanar deformities with associated deterioration in their clinical function. Long-term follow-up is needed to understand the clinical and radiographic outcome durability after aTSA in the setting of a B3 glenoid.

Influence of backside seating parameters and augmented baseplate components in virtual planning for reverse shoulder arthroplasty

BackgroundThe primary goal of this investigation was to examine the influence of a backside seating percentage variable on volume of reamed bone and contact area in virtual planning for glenoid baseplate placement for reverse shoulder arthroplasty (RTSA). The secondary goal was to assess how the option of augmented glenoid baseplate components affected reamed volume and cortical contact area of virtually positioned baseplates. MethodsNine surgeons virtually planned 30 RTSA cases using a commercially available software system. The 30 cases were chosen to span a spectrum of glenoid deformity. The study consisted of three phases. In Phase 1, cases were planned with the backside seating percentage blinded and without the option of augmented baseplate components. In Phase 2, the backside seating parameter was unblinded. In Phase 3, augmented baseplate components were added as an option. Implant version and inclination were recorded. Using CAD models, total volume of bone reamed as well as reamed cortical volume and cancellous volume were calculated. Total, cortical and cancellous baseplate contact area were also calculated. Finally, total glenoid lateralization was calculated for each phase and compared. ResultsThe mean implant version was clinically similar across phases, but statistically lower in Phase 3 (p = 0.006 compared to Phase 1, p = 0.001 compared to Phase 2). Mean implant inclination was clinically similar across phases, but statistically lower in Phase 3 (p < 0.001). Phase 3 had statistically significantly lower cancellous and total reamed bone volumes compared to Phase 1 and Phase 2 (p < 0.001 for all comparisons). Phase 3 had statistically significantly larger cortical contact area, lower cancellous contact area, and larger total contact area compared to Phase 1 and Phase 2 (p < 0.001 for all comparisons). Phase 3 had significantly greater glenoid lateralization (mean 10.5 mm) compared to Phase 1 (mean 7.8, p < 0.001) and Phase 2 (mean 7.9, p < 0.001). ConclusionsAcross a wide range of glenoid pathology during virtual surgical planning, experienced shoulder arthroplasty surgeons chose augmented baseplates frequently, and the option of a full wedge augmented baseplate resulted in statistically significant greater correction of glenoid deformity, improved total and cortical baseplate contact area, less cancellous reamed bone, and greater glenoid lateralization. Backside seating information does not have a significant impact on how glenoid baseplates are virtually positioned for RTSA, nor does it impact the baseplate contact area or volume of reamed bone.

Anatomic vs. reverse total shoulder arthroplasty with glenoid retroversion of at least 15 degrees in rotator cuff intact patients: a comparison of short-term results

BackgroundSevere glenoid deformity has been associated with inferior outcomes and higher complication rates in shoulder arthroplasty. In patients with intact rotator cuffs, there is no clear consensus as to whether anatomic total shoulder arthroplasty (aTSA) or reverse (rTSA) shoulder arthroplasty is the optimal implant in patients with glenoid deformities. The purpose of this study was to compare outcomes of aTSA vs. rTSA in glenoid deformities with greater than 15° retroversion. MethodsA retrospective review of a large multicenter database was conducted. All patients who underwent either aTSA or rTSA with an intact rotator cuff and glenoid retroversion 15° or greater with minimum 2-year follow-up were included. Range of motion (ROM), revisions, and patient reported outcomes (PROs) including Constant score, Simple Shoulder test, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, Shoulder Pain and Disability Index), Shoulder Arthroplasty Smart score were collected for all patients pre and postsurgery. ResultsOverall, 336 patients were included with 187 receiving an aTSA and 149 rTSA. Reverse patients overall had more comorbidities (75.0% vs. 65.1%; P = .05) and were older (70.9 ± 7.0 vs. 66.3 ± 7.7 years; P < .001). Average follow-up for the aTSA group was 62.0 ± 37.8 months vs. 40.6 ± 22.9 months for rTSA (P < .001). Preoperative retroversion in the anatomic group averaged 20.7 ± 5.5 degrees vs. 24.2 ± 7.7 in reverse patients (P < .001). Both groups demonstrated significant improvements in all PROs and ROM from pre to postsurgery. At latest follow-up aTSA patients had significantly better internal rotation scores (4.9 ± 1.6 vs. 4 ± 1.8; P < .001), external rotation (50 ± 19 vs. 38 ± 18; P < .001) and Shoulder Arthroplasty Smart scores (80.2 ± 13.5 vs. 76.6 ± 11.3; P = .017) but worse pain VAS (1.5 ± 2.3 vs. 0.9 ± 1.9; P = .016). There was no significant difference in abduction or forward elevation or PRO’s (Shoulder function, Simple Shoulder test, Constant, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, or Shoulder Pain and Disability Index). Overall revision rate (7% vs. 1%; P = .002) was higher in aTSA. ConclusionATSA and rTSA results in significant improvements in patients with glenoid retroversion equal or greater than 15°. Anatomic TSA patients have better postoperative internal rotation score, external rotation, and SAS score but demonstrated no other significant improvement in ROM or PRO. However, there was significantly higher rate of complications and revisions with short-term follow-up following aTSA.

BIO-RSA vs metal augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that i) metal augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to BIO-RSA; ii) bone graft viability and healing in BIO-RSA patients become compromised over time. Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal augmented baseplate (MIO-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (β angle) and retroversion were also measured. Delta scores of active anterior elevation were higher in the MIO-RSA group (p= 0.027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in Type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (p = 0.022), while the values of β angle and postoperative retroversion were similar in the two groups. BIO-RSA group showed radiolucent lines < 2mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rate of humerus condensation lines in MIO-RSA patients (p= 0.01) and higher rate of cortical thinning and tuberosity resorption in the BIO-RSA group (p= 0.027 and p = 0.004, respectively). Metal augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patient raise concern about the risk of baseplate loosening and requires further long term studies.

Prognostic value of the Walch classification for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff

The Walch classification is commonly utilized by surgeons when determining the treatment of osteoarthritis (OA). However, its utility in prognosticating patient clinical state before and after TSA remains unproven. We assessed the prognostic value of the modified Walch glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in total shoulder arthroplasty (TSA). A prospectively-collected, multi-center database for a single-platform TSA system was queried for patients with rotator cuff-intact OA and minimum 2 year follow-up after anatomic and reverse TSA (aTSA, rTSA). Differences in patient-reported outcome scores (PROMS) [SST, ASES, SPADI, VAS Pain, Shoulder Function score], combined patient-reported and clinical-input scores (Constant, UCLA, SAS), active range of motion (ROM) values (forward elevation [FE], abduction, external rotation [ER], internal rotation [IR], and radiographic outcomes (humeral and glenoid radiolucency line rates, scapula notching rate) were stratified and compared by glenoid deformity type per the Walch classification for aTSA and rTSA cohorts. Comparisons were performed to assess the ability of the Walch classification to predict the preop, postop, and improved state after TSA. 1,008 TSAs were analyzed including 576 aTSA and 432 rTSA. Comparison of outcomes between Walch glenoid types resulted in 15 pairwise comparisons of 12 clinical outcome metrics, yielding 180 total Walch glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 180 possible pairwise Walch glenoid type / metric comparisons studied for aTSA and rTSA cohorts, <6% and < 2% significantly differed in aTSA and rTSA cohorts, respectively. Significant differences based on Walch type were seen after adjustment for multiple pairwise comparisons in the aTSA cohort for FE and ER preoperatively, the Constant score postoperatively, and for abduction, FE, ER, Constant score, and SAS score for pre- to postoperative improvement. In the rTSA cohort, significant differences were only seen in abduction and Constant score both postoperatively and for pre- to postoperative improvement. There were no statistically significant differences in humeral lucency rate, glenoid lucency rate (aTSA), scapular notching rate (rTSA), complication rates, or revision rates between Walch glenoid types after TSA. Although useful for describing degenerative changes to the glenohumeral joint, we demonstrate a weak association between preoperative glenoid morphology according to the Walch classification and clinical state when evaluating patients undergoing TSA for rotator cuff-intact OA. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses for patients undergoing TSA for rotator cuff-intact OA.

Rotator cuff preserving reverse shoulder arthroplasty vs. eccentrically reamed anatomic total shoulder arthroplasty for glenohumeral osteoarthritis and an intact rotator cuff with B2 glenoid deformity

BackgroundAnatomic total shoulder arthroplasty (TSA) is a common treatment choice for patients with advanced glenohumeral osteoarthritis and an intact rotator cuff. In the setting of B2 glenoid deformity, eccentric glenoid reaming with a TSA is a viable option; however, an increasing trend is to perform a reverse shoulder arthroplasty (RSA). The ideal implant choice for these patients is still uncertain. MethodsA retrospective review of an eccentrically reamed TSA (ER-TSA) cohort vs. a rotator cuff–preserving RSA (RCP-RSA) cohort performed from 2013 to 2021 was completed. Any patient with evidence of a B2 glenoid verified by preoperative computed tomography or magnetic resonance imaging was considered for inclusion. A retrospective review of patients’ last clinical follow-up was performed and radiographic review of postoperative complications. All patients were then contacted by phone to determine if they underwent any revision surgery and to obtain American Shoulder and Elbow Surgeons (ASES) scores. ResultsIn the ER-TSA cohort, 18 patients were identified and contacted for follow-up ASES questionnaire. The average age was 72. The average follow-up was 4.7 years, with an average clinic follow-up period of 15 months. The delta range of motion (ROM) for forward flexion was +35° improvement, for abduction was +17°, and for external rotation was +23°. The average ASES score was 87. For the RCP-RSA cohort, 17 patients were identified and contacted for ASES questionnaire with 19 total shoulders. The average age was 75. The average follow-up was 2.5 years, with an average clinic follow-up period of 18 months. The delta ROM for forward flexion was +53° improvement, for abduction was +61°, and for external rotation was +23°. The average ASES score was 93. ConclusionIn the present cohorts of ER-TSA vs. RCP-RSA for glenohumeral osteoarthritis with an intact rotator cuff and B2 glenoid deformity in patients 65+ years old, there were no revisions, and overall patients reported an ASES score of 87 for ER-TSA and 93 for RCP-RSA. This study demonstrates that both ER-TSA and RCP-RSA remain a viable option, however it also shows that RCP-RSA has better early to midterm patient-reported outcome measures, the ability to account for worse posterior glenoid deformity, and has greater overall improvement in ROM in such a commonly encountered patient population.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA. Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (-rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained. Twenty-four patients underwent+rcRSA, 69 underwent -rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the -rcRSA (37.7%, P=.001) and TSA (37.6%, P=.001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P=.021) but similar to that of -rcRSA (72.4, P=.237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with -rcRSA (10.5°, P=.011) but was similar to TSA (14.7°; P=.244). Postoperatively, there were no differences in VAS or ASES between+rcRSA vs. -rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with -rcRSA (91.8, P=.021), but was similar to TSA (90.5, P=.073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between+rcRSA and -rcRSA, but TSA had greater external rotation (44° vs. 38°, P=.041) and internal rotation (6.5° vs. 5.0°, P=.001) compared with+rcRSA. There were no differences in complication rates. At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.

Total Shoulder Arthroplasty in Patients with a B2 Glenoid Addressed with Corrective Reaming: Mean 8-year Follow-up.

The management of Walch B2 glenoid deformities in primary glenohumeral osteoarthritis is frequently debated. Previous literature has shown that the treatment of B2 glenoids with high-side reaming and anatomic total shoulder arthroplasty (TSA) perform well in the short-term, but is associated with an increased glenoid component failure rate in severe deformities. Therefore, many have explored alternative options, including augmented anatomic glenoid components and reverse shoulder arthroplasty. Our goal in this study is to provide mid-term radiographic and clinical outcomes after high-side reaming and anatomic TSA for B2 glenoids. Patients were followed both clinically and radiographically. Preoperative CT scans were used for retrospective analysis of deformity. Both preoperative and postoperative VAS pain, ASES score, and SST scores were collected. Radiographs were analyzed preoperatively and postoperatively for humeral head decentering relative to the glenoid vault, immediate glenoid seating, and final glenoid peg radiolucency. Of the original cohort of 59 patients (6 now deceased) reported at a mean radiographic follow-up of 3.4 years, 34 shoulders in 33 patients with B2 glenoids (mean retroversion 18.9°, range 4°-32°) were available for follow-up at a mean of 8.6 years (range 5.5-11.2) after high-side glenoid reaming with anatomic TSA. Three (5.1%) of the original 59 shoulder were revised. At final follow-up, 3 of 30 (10.0%) shoulders had radiographic glenoid component failure, but were unrevised. Glenoid component failure was associated with worse initial glenoid component seating (mean Lazarus score 1.2 vs. 2.0, p=0.002). Glenoid failure was also associated with increased posterior humeral head subluxation at 2-4 year follow-up (mean 5.6% vs 12.6%, p=0.045) and at final follow-up (mean 7.0% vs. 21%, p=0.002). There was no association between glenoid component failure and preoperative retroversion, inclination, or humeral head subluxation (all p>0.05). Glenoid component failure was associated with worse ASES (88 vs. 73) and VAS pain (0.8 vs. 2.1) scores (both p=0.03). At a mean of 8.6 years, 88% of shoulders available for follow-up had well-fixed glenoid components. Glenoid component failure was associated with poor initial glenoid component seating, with failed components having an average of 25% of the glenoid component not seated. Preoperative deformity such as glenoid retroversion, inclination, or humeral head subluxation did not predict glenoid component failure. This study supports that initial glenoid component seating and recurrence of posterior humeral head subluxation may be the most important factors for mid-term glenoid component survival in anatomic TSA in patients with B2 glenoids.

Management of Glenoid Bone Loss in Primary Reverse Total Shoulder Arthroplasty.

Glenoid bone loss presents distinct challenges in reverse total shoulder arthroplasty (rTSA) which, if unaddressed, can cause complications including poor outcomes and early implant failure. The purpose of this review is to discuss the etiology, evaluation, and management strategies of glenoid bone loss in primary rTSA. Three-dimensional computed tomography (3D CT) imaging and preoperative planning software have revolutionized the understanding of complex glenoid deformity and wear patterns from bone loss. With this knowledge, a detailed preoperative plan can be created and implemented for a more optimal management strategy. When appropriately indicated, deformity correction techniques with biologic or metal augmentation are successful in addressing the glenoid bone deficiency, creating optimal implant position, and thus providing stable baseplate fixation and improving outcomes. Thorough evaluation and characterization of the degree of glenoid deformity with 3D CT imaging is necessary prior to treatment with rTSA. Eccentric reaming, bone grafting, and augmented glenoid components have shown promising results in correcting glenoid deformity due to bone loss, but long-term outcomes are currently unknown.

Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n=246), 10° superior glenoid augments (n=97), or combined 10° superior/8° posterior glenoid augments (n=177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P<.05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P=.006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P<.001), nearly 33% less intraoperative blood loss volume (P<.001), approximately 3-fold less scapular notching (P<.01), and approximately 15-fold less adverse events requiring revision (P<.01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P=.003 and P=.013). The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.