Glenoid Reaming 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).

B2 and B3 glenoid osteoarthirtis: outcomes of corrective and concentric (C2) reaming of the glenoid combined with pyrocarbon hemiarthroplasty

Posterior humeral subluxation (PHS) in B2/B3 glenoid is a cause of asymmetric long-term stress on the glenoid and the potential reason for glenoid loosening in anatomic total shoulder arthroplasty (ATSA) and painful glenoid erosion in hemiarthroplasty with metallic heads (HA-Metal). We hypothesized that corrective and concentric reaming (CCR) of the glenoid associated with pyrocarbon hemiarthroplasty (HA-PYC) could improve the centering of the humeral head and decrease the risk of persistent painful glenoid erosion in young/active patients with B2/B3 glenoid. Between 2014 and 2020, 41shoulders (in 35 patients, mean age of 57.9 years) underwent HA-PYC combined with CCR reaming for B2 (n=30) or B3 (n=11) osteoarthritis. Patients were prospectively followed with computed tomography (CT) scans performed preoperatively, immediate postoperatively and at last follow-up (> 2 years). The primary outcomes were 3D-corrected CT-scan measurements of glenoid version, PHS, progression of glenoid erosion. Secondary outcomes included functional outcome scores, return to activities, and revision rate and complications. At a mean follow-up of 4.5 years (2 to 9.5 years), the prosthesis survival was 95% (39/41). No patient has been reoperated for painful glenoid erosion. The mean glenoid retroversion decreased from 17.1° ± 7.5 preoperatively to 8.3° ± 8.2 at last follow-up (p=0.001), and the mean PHS from 74% to 56.5% (p=0.001) based on the scapular plane and from 59.9% to 50.3% based on the glenoid plane. The humeral head was recentered in 97% according to the glenoid surface and 71% according to the scapular plane. Correction of PHS in the scapular plane was highly correlated to correction of glenoid retroversion (p<0.001). CT-scan measurements showed that the average total medialization was 3.7 ± 3.2 mm (2.0 ± 1.8 mm due to reaming and only 1.7 ± 2.4 mm due to erosion). The Adjusted Constant score increased from 43% ± 13 to 97% ± 16 and the Subjective Shoulder Value from 38% ± 14 to 84 % ± 12 (p<0.001). Overall, 84% of active patients returned to work and all patients returned to sports. In B2/B3 glenoid arthritis, corrective, concentric glenoid reaming combined with HA-PYC improves centering of the humeral head and shows a low risk of painful glenoid erosion at mid-term follow-up. The combined procedure results in excellent functional outcomes and high prosthesis survivorship at mid-term follow-up. HA-PYC and CCR is offering an alternative shoulder arthroplasty for young/active patients with B2/B3 glenoid osteoarthritis who want to return to work or sports practice.

Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at minimum 5-year follow-up

In patients with glenohumeral osteoarthritis and posteriorly eccentric wear patterns, the early to mid-term results of TSA using conservative glenoid reaming with no attempt at version correction have been favorable at early follow-up. The purpose of this study is to compare the clinical and radiographic outcomes of TSA using this technique for patients with and without eccentric wear patterns at a minimum 5-year follow-up. Patients who underwent TSA with minimum 5-year follow-up were identified from an institutional registry. Preoperative and postoperative radiographs were used to determine humeroglenoid alignment (HGA-AP), humeroscapular alignment (HSA-AP), version, Walch classification and glenoid component seating. The outcome measures were the Simple Shoulder Test, glenoid component radiolucencies, and the occurrence of complications or revisions. Two hundred and ten patients were included in the study, of which 98 (47%) had posteriorly decentered humeral heads and 108 (51%) had centered humeral heads. There were 77 shoulders with Walch type A glenoids and 122 with Walch type B glenoids. At a mean 8-year follow-up, the final SST, change in SST and percentage of maximal improvement was not correlated with pre- and postoperative humeral head centering, Walch classification or glenoid version. There were no preoperative predictors of a low final SST. Two patients (1%) underwent open re-operations during the study period. In patients with Walch B1 and B2 glenoids (n=110), there were no differences in outcome measures between patients with postoperative retroversion of more and less than 15o. While 15 of 51 patients (29%) with minimum 5-year radiographs had glenoid radioluciences, these radiographic findings were not associated with inferior clinical outcomes. On multivariable analysis glenoid component radiolucencies were most strongly associated with incomplete component seating (OR 3.3, p = 0.082). The results of TSA with conservative glenoid reaming without attempt at version correction are favorable at minimum 5 year, mean 8-year follow-up. There were no differences in clinical and radiographic outcomes between patients with eccentric and concentric wear patterns. Incomplete glenoid component seating was the greatest predictor of glenoid component radiolucency, but these radiolucencies were not associated with inferior clinical outcomes.

The effect of eccentric glenoid reaming in reverse shoulder artrhoplasty for glenohumeral osteoarthritis

BackgroundThe objective of this study was to evaluate the abilitiy of eccentric reaming in reverse total shoulder arthroplasty (RSA), in patients with glenohumeral osteoarthritis (GHOA), to correct preoperative glenoid retroversion and to compare with cuff tear arthopaty (CTA) cases. MethodsFifty-nine patients who underwent RSA with GHOA or CTA diagnosis between 2013 and 2022 and who had pre- and postoperative computed tomography scans were included in the study. Preoperative glenoid version and postoperative glenoid component versions of 17 patients with GHOA and 40 patients with CTA were measured by Friedman method. ResultsThe median preoperative glenoid versions in GHOA and CTA groups were measured as 16° and 4° retroverted respectively (p < 0.01). The median postoperative glenoid component versions in GHOA and CTA groups were 5° and 3° retroverted respectively (p = 0.09). The version change differences between the two groups varied significantly (p < 0.01). ConclusionsGHOA is related with higher preoperative glenoid retroversion compared to CTA. However; with eccentric glenoid reaming, adequate version correction and similar postoperative glenoid version can be achieved in GHOA compared to CTA when performing a RSA. Level of evidenceLevel III. Retrospective study. Treatment study.

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.

Pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up

The success of traditional shoulder hemiarthroplasty with cobalt-chromium (CoCr) heads is limited by a painful glenoid erosion with problematic bone loss. Hemiprostheses with pyrolytic carbon (PyC) heads have shown reduced glenoid erosion in experimental laboratory studies. Few in vivo data are available. Single-center consecutive cohort study of 31 of 34 patients (91%) who underwent PyC hemiarthroplasty between 09.2013 and 06.2018. For eleven of these concentric glenoid reaming was additionally performed. The mean follow-up was 5.5 (range 3.5 - 7) years. Standardized x-rays were taken and clinical function (Constant score) and pain on the visual analogue scale (VAS) were recorded. AP x-rays were analyzed according to an established method by 2 independent observers: A line parallel to the superior and inferior glenoid rim was translated to the most medial point of the glenoid surface. A further parallel line was placed on the spinoglenoid notch (SGN) and the distance between the two lines was measured. Measurements were scaled using the known diameter of the implanted humeral head component. To assess eccentric erosion AP and axial images were classified according to Favard and Walch respectively. The mean medial glenoid erosion was 1.4 mm over 5.5 years. In the first year there was 0.8 mm of erosion, significantly more than the average erosion per year of 0.3 mm (p < 0.001). Mean erosion per year of patients with glenoid reaming was 0.4 mm, without reaming 0.2 mm (p = 0.09). An evolution of glenoid morphology was observed in 6 patients, of which 4 had a progression of the erosion grade. Prosthesis survival rate was 100%. The Constant score improved from 45.0 preoperatively to 78.0 2-3 years postoperatively and 78.8 at latest follow-up 5.5 years postoperatively (p < 0.001). Pain decreased from VAS 6.7 (3 - 9) preoperatively to 2.2 (0 - 8) at latest follow-up (p < 0.001). There was a weak correlation (r = 0.37) between erosion and pain improvement (p = 0.039) and no correlation between erosion and delta Constant score (r = 0.06). PyC HA caused little glenoid erosion and a sustained improvement in clinical function in our cohort at mid-term follow-up. PyC demonstrates a biphasic development of glenoid erosion, with a reduced rate after the first year. PyC hemiarthroplasty should therefore be considered as an alternative to total shoulder arthroplasty or CoCr hemiarthroplasty for patients with a high risk of glenoid component complications.

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.

Serial 3D CT analysis of humeral head alignment in relation to glenoid correction and outcomes after total shoulder arthroplasty

Posterior humeral head (HH) subluxation after anatomic total shoulder arthroplasty (aTSA) is associated with worse outcomes, but it is unclear how corrective glenoid reaming correlates with HH alignment and whether HH alignment changes over time. Therefore, it was aimed to analyze the relationship between HH alignment and the scapula following aTSA to identify anatomic andsurgical factors that contribute to realignment of the HH, glenoid loosening, and clinical outcomes. Three-dimensional scapulohumeral alignment was assessed on three-dimensionally reconstructed computed tomography scans of 23 patients: preoperative (T0), 2 years post-aTSA (T1), and ≥5 years post-aTSA (T2). Anterior-posterior (AP), superior-inferior (SI), and medial-lateral offset measures of the HH center to the scapula were referenced to the HH diameter (scapulohumeral subluxation index). Glenoid version and inclination were measured at T0 and T1. Central peg osteolysis, rotator cuff fatty infiltration, and vault perforation were assessed on two-dimensional computed tomography. Relative Constant Score at T2 measured clinical outcome. Glenoid correction correlated strongly with AP and SI position of the HH (r=0.733 and r=0.797, respectively). Each degree of retroversion correction resulted in 0.9% AP scapulohumeral subluxation index offset change toward anterior. Each degree of inclination correction to superior resulted in a 1.0% offset change toward superior. A gradual postoperative proximal (mean difference [MD],-3%; P=.019), anterior (MD, 2%; P=.025), and medial (MD, 3 mm; P<.001) HH migration was observed. Asymmetric progressive rotator cuff fatty infiltration was associated with the direction of change in AP alignment over time (odds ratio, 2.04; P=.046), with progressive subscapularis fatty infiltration as the primary factor associated with gradual anterior HH translation (odds ratio, 15.61; P=.028). Gradual HH medialization was an indicator of glenoid components at risk for loosening (difference between medians, 4 mm; P=.003). Osteolysis around the central glenoid peg was influenced by overcorrection of glenoid version (MD, 7°; P=.038). Preoperative glenoid inclination was the sole anatomical or surgical factor predicting clinical outcome, as larger inferior inclination at T0 was associated with worse relative Constant Score at T2 (P=.016). Corrective glenoid reaming was an effective surgical technique to correct HH alignment in the AP and SI direction. Gradual anterior HH translation after aTSA was associated with progressive subscapularis fatty infiltration, and substantial HH medialization was an important indicator for potential glenoid loosening. While postoperative glenoid version and AP HH alignment were important for radiographic outcome, preoperative glenoid inclination predicted clinical outcome, as larger preoperative inferior inclination resulted in worse clinical scores.

"Can You Feel It": An Early Experience with Simulated Vibration to Recreate Glenoid Reaming.

We validated a novel custom simulator constructed using a vibration transducer transmitting simulated reaming vibrations to a powered nonwearing reamer tip through a 3D-printed glenoid. Validation and system fidelity were evaluated by 9 fellowship-trained shoulder surgeon experts performing a series of simulated reamings. We then completed the validation process through a questionnaire focused on experts' experience with the simulator. Experts correctly identified 52% ± 8% of surface profiles and 69% ± 21% of cartilage layers. Experts identified the vibration interface between simulated cartilage and subchondral bone (77% ± 23% of the time), indicating high fidelity for the system. An interclass correlation coefficient for experts' reaming to the subchondral plate was 0.682 (confidence interval 0.262-0.908). On a general questionnaire, the perceived utility of the simulator as a teaching tool was highly ranked (4/5), and experts scored "ease of instrument manipulation" (4.19/5) and "realism of the simulator" (4.11/5) the highest. The mean global evaluation score was 6.8/10 (range 5-10). We examined a simulated glenoid reamer and feasibility of haptic vibrational feedback for training. Experts validated simulated vibration feedback for glenoid simulation reaming, and the results suggested that this may be a useful additional training adjuvant. Level II, prospective study.

Implications of navigation system use for glenoid component placement in reverse shoulder arthroplasty

Recently, three-dimensional (3D) planning, patient-specific instruments, and navigation system have been developed to improve the accuracy of baseplate placement in reverse shoulder arthroplasty (RSA). The purpose of this study was to evaluate baseplate placement using the navigation system. Sixty-four shoulders in 63 patients who underwent RSA for rotator cuff tear arthropathy or irreparable rotator cuff tears were enrolled. Conventional RSA was performed in 31 shoulders and navigated RSA using pre-operative planning software was performed in 33 shoulders. The use of augmented baseplates, the version and inclination of the baseplate, and screw length were compared between conventional RSA and navigated RSA. Augmented baseplates were used more frequently in navigated RSA than in conventional RSA (20 vs 9 shoulders, p = 0.014). Baseplate alignment was 1.0° (SD 5.1) of retroversion and 2.4° (SD 6.8) of superior inclination in conventional RSA and 0.2° (SD 1.9) of anteversion and 0.3° (SD 1.7) of superior inclination in navigated RSA. Compared with conventional RSA, precision of baseplate version and inclination were higher in navigated RSA (both p < 0.001). Superior, inferior, and posteroinferior screws were significantly longer in navigated RSA than in conventional RSA (p = 0.021, 0.001 and < 0.001, respectively). Precision of superior and inferior screw lengths was significantly higher in navigated RSA than in conventional RSA (both p = 0.001). Our results suggest that adoption of pre-operative planning software increased augmented baseplate use to minimize the glenoid reaming. The navigation system allows placement of the baseplate accurately, according to the pre-operative plan. Furthermore, the navigation system enables monitoring of screw length and direction in real time.

Early outcome of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for treatment of advanced glenohumeral osteoarthritis.

Long-term outcomes of anatomic total shoulder arthroplasty (aTSA) can be compromised by glenoid loosening and failure. The purpose of this study was to evaluate the short- and midterm outcomes of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for the treatment of advanced glenohumeral osteoarthritis, and to identify associations between preoperative factors and outcomes. Forty-nine shoulders (mean age 60±7 years) with minimum 2-year follow-up (mean 4.6±1.7) were evaluated. Forty-three (87.8%) were male. Thirteen (26.5%) had previous nonarthroplasty shoulder surgery. There were 19 (38.8%) Walch type A and 30 (61.2%) type B glenoids. Pre- and postoperative shoulder motion, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) were assessed. Pre- and postoperative plain radiographs were evaluated. Mixed effects models were used to investigate factors associated with outcomes. Active forward elevation and active external rotation improved from 111.7°±23.8° to 139.2°±21.1° and 13.3°±20.7° to 38.7°±14.7°, respectively (P<.001). The mean American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) shoulder pain scores at the most recent follow-up were 86.6±19.9, 10.1±14.1, 10.5±2.2, and 1.5±2.3, respectively. The mean changes of PROMs were significant and exceeded the minimal clinically important difference for aTSA. The percentage maximal possible improvement for ASES, DASH, and SST were greater than 75%. Male sex (P<.008) and not having prior shoulder surgery (P<.04) were significantly associated with better absolute and greater change in PROMs. Age, preoperative shoulder motion, and Walch glenoid classification were not associated with PROMs. Five (10.2%, 95% confidence interval [CI]1.8%-18.6%) patients underwent revision for pain. Three additional patients were dissatisfied at final follow-up without undergoing revision, resulting in 16.7% (95% CI6.1%-27.2%) of patients being dissatisfied with their outcome after their initial RnR. Mean Short Form-6 Dimensions scores improved from 0.66±0.12 to 0.77±0.13 and mean EuroQol-5 Dimensions scores improved from 0.68±0.20 to 0.85±0.17 (P<.001). Improvement in HRQoL was significantly associated with nondominant arm treatment, increased age, and greater preoperative SST score. Annual medialization of the humeral head center of rotation was 0.56±1.6 mm/yr. No radiographic measure was associated with long-term PROMs. Ream and Run can provide significant and clinically important improvement in PROMs and HRQoL for a high percentage of patients at short- and midterm follow-up. This procedure is an appropriate alternative to aTSA in select patients.

Outcomes of hemiarthroplasty and concentric glenoid reaming: a systematic review and meta-analysis of the ream and run technique

BackgroundAnatomic total shoulder arthroplasty is the gold standard surgical treatment for glenohumeral arthritis. Concerns for this procedure are glenoid bone loss and glenoid component wear, particularly in young and active individuals. The ream and run procedure using hemiarthroplasty and concentric glenoid reaming without placing a glenoid component has been proposed as an alternative. Only a few studies have assessed its outcomes and complications. This systematic review and meta-analysis aims to better quantify the ream and run’s outcomes and revision rates. MethodsA systematic review on the outcomes of the ream and run procedure was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Descriptive statistics and pooled values were synthesized from the included studies to determine patient demographics, range of motion, patient-reported outcome measures, and revision rates. Values were compared with the minimum clinically important difference. ResultsFrom 82 initial search results, 5 studies (3 level III and 2 level IV) met our selection criteria. These included 470 shoulders from 468 patients with an average age of 56.7 years (range: 22-81 years) and average follow-up of 4.7 years (range: 0.7 – 16.0 years). Improvement in the Simple Shoulder Test (2 studies), Visual Analog Scale (2 studies), and American Shoulder and Elbow Surgeons score (4 studies) were 5.4, 4.5, and 43, respectively. This was greater than the minimum clinically important difference for each of these measures (2.4, 1.4, and 20.9, respectively). The mean postoperative forward elevation achieved was 143.5°, and external rotation was 44.0°. At the mean follow-up of 4.7 years, the revision rate was 7.6%, including 4.0% that underwent conversion to total shoulder arthroplasty. DiscussionThe ream and run technique to surgically treat glenohumeral arthritis leads to improvement of functional outcomes above the thresholds that predict patient satisfaction. These midterm results are similar to those achieved by anatomic total shoulder arthroplasty over the same follow-up period, but not enough long-term data exist to compare long-term survivorship. Outcomes across the same time frame are also very similar to those of traditional hemiarthroplasty. The ream and run remains an option for functional improvement and pain control in the short-term to midterm follow-up period.

Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming.

HypothesisBoth clinical outcomes and early rates of failure will not be associated with glenoid retroversion.MethodsAll patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported.ResultsOne hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, −3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, −11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively (P < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs.ConclusionAnatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.

Clinical and radiographic results of eccentric glenoid reaming in reverse total shoulder arthroplasty

BackgroundOne option for treating glenoid bone loss in reverse shoulder arthroplasty (RSA) is eccentric reaming of the glenoid, but the effect on clinical results is unclear. The aim of this study was to investigate the association between medialization of the bone-baseplate interface (herein, ‘medialization’) caused by eccentric reaming of the glenoid and scapular notching, baseplate loosening, and clinical outcomes after RSA. MethodsWe retrospectively reviewed data for 91 patients who underwent primary RSA between January 2014 and December 2016 with a lateralized implant and a minimum 2-year follow-up. The amount of medialization was estimated using a 3-dimensional computed tomography scan-based computer planning software. The average amount of medialization estimated by the 3-dimensional planning software was 3.4 mm (range, 0.5-10 mm). Outcomes included range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, visual analog scale (VAS) for pain, and the rates of scapular notching and baseplate loosening. The association between the estimated medialization and the outcomes of interest was evaluated using multivariate models. ResultsAfter controlling for age, sex, diagnosis, subscapularis repair, glenosphere size, and baseline ROM, medialization was not associated with the postoperative abduction (P = .35), external rotation (ER) at 90° (P = .16), internal rotation at 90° (P = .08), and internal rotation at the back (P = .06). However, we found a significant association between medialization and postoperative ER at the side (P = .02). According to the multivariate model, for a 1-mm increase in medialization during surgery, a decrease of 1.6° in postoperative ER would be expected. We found no association between medialization and the postoperative ASES score (P = .48), SST score (P = .59), or VAS score (P = .27). At a minimum of 2 years of follow-up, we found no baseplate loosening or radiographic signs of baseplate loosening in any patient. Scapular notching of grades 1 to 2 was observed in 22 patients (24%). We were not able to detect a difference in scapular notching when medialization was > 1 mm ver when medialization ≤ 1 mm (odds ratio, 2.5; 95% confidence interval: 0.28-23). ConclusionsIncreasing medialization due to eccentric reaming after RSA with a lateralized implant was associated with a decrease in postoperative ER at the side. However, increasing medialization was not associated with worse patient-reported outcome scores or increased baseplate loosening at short-term follow-up.

Short-term outcomes and survival of pyrocarbon hemiarthroplasty in the young arthritic shoulder.

The purpose was to report the short-term outcomes and survival of hemiarthroplasty with a pyrocarbon head (HA-PYC) for the treatment of shoulder osteoarthritis in patients aged ≤ 60 years. We hypothesized that HA-PYC could be an alternative to hemi-metal (avoiding the risk of rapid glenoid erosion) and total shoulder arthroplasty (TSA) (avoiding the risk of rapid glenoid loosening) in an active patient population. Sixty-four consecutive patients (mean age, 53 years) who underwent HA-PYC for glenohumeral osteoarthritis were included. The primary outcome was revision to TSA or reverse shoulder arthroplasty. Secondary outcome measures included functional outcome scores; return to work and sports; and radiographic evaluation of humeral reconstruction quality using the "circle method" of Mears, as well as glenoid erosion severity and progression using the Sperling classification. Patients were reviewed and underwent radiography at an average follow-up of 33 months (range, 24-60 months). At last follow-up, the rate of survival of the HA-PYC prosthesis was 92%. Revision was performed in 5 patients, with a mean delay of 24 months (range, 15-37 months): 1 conversion to TSA and 4 conversions to reverse shoulder arthroplasty. The Constant score and Subjective Shoulder Value increased from 36 points (range, 26-50 points) to 75 points (range, 69-81 points) and from 35% (range, 20%-50%) to 80% (range, 75%-90%), respectively (P < .001). Postoperatively, 91% of the patients (42 of 46) returned to work and 88% (15 of 17) returned to sport. The severity of preoperative and postoperative glenoid wear (Sperling grade 3 or 4) had no influence on the functional results. Patients who underwent associated concentric glenoid reaming (n = 23) had similar Constant scores and Subjective Shoulder Values (P = .95) to other patients and did not show more progression of glenoid wear. Nonanatomic reconstruction of the proximal humerus (center of rotation of the prosthesis > 3 mm from the anatomic center) occurred in 29% (18 of 62 patients) and was associated with significantly lower functional and subjective results, more complications (subscapularis insufficiency and/or symptomatic glenoid erosion), and a higher risk of revision. The additional 1.5-mm thickness of the metal disc under the pyrocarbon head was found to be the main reason for oversizing of the prosthetic head. HA-PYC is a reliable procedure to treat shoulder osteoarthritis and allows return to work and sports in a young (≤60 years) and active patient population. The severity of glenoid bone erosion or the association with glenoid reaming does not affect functional outcomes and failure risk. By contrast, nonanatomic reconstruction of the proximal humerus after HA-PYC (because of humeral head oversizing) occurred in one-third of the cases and is associated with lower functional outcomes, as well as higher risks of complications and revision.

Clinical and radiographic predictors of difficult primary shoulder arthroplasty

BackgroundAnecdotally there is a spectrum of complexity in performing shoulder arthroplasty, however, there is limited information to predict easy versus difficult cases. The purpose of this study was to identify clinical and radiographic factors that are associated with difficult primary shoulder arthroplasty. MethodsAll consecutive primary shoulder arthroplasties performed by one-of-five high-volume shoulder and elbow fellowship-trained surgeons from 4/2018-8/2018 were included. Mean (range) surgeon years in practice was 19.4 (6-29). Surgeons completed a preoperative questionnaire estimating the level of complexity in performing the operation from very easy, easy, average, difficult, and very difficult. The same questionnaire was completed immediately postoperatively regarding level of complexity. Difficult group was defined if the surgeon rated as difficult or very difficult on the postoperative questionnaire. If the procedure was difficult, the postoperative questionnaire assessed what aspect of the procedure made it difficult. Demographics, clinical and radiographic factors, and procedure time were collected. ResultsDuring the study period, 224 primary shoulder arthroplasties were performed (53% reverse, 44% anatomic, 3% hemiarthroplasty with concentric glenoid reaming). Difficult group consisted of 95 shoulder arthroplasties (42.4%). Difficult group procedure time was a mean 21.8 minutes longer (120.7 ± 3.1 min vs. 98.9 ± 2.4 min; P <.001). Glenoid reaming and implantation (48.4%) were the most common reason for difficult cases, followed by glenoid exposure (33.7%). The surgeon correctly predicted level of complexity in 77% of cases (i.e., predicted difficult preoperatively and assigned difficulty postoperatively). There were 39 cases that were incorrectly predicted easy preoperatively and assigned as difficult postoperatively. Of all the cases predicted to be easy, those cases that were rated as difficult postoperatively were associated with younger age (67.1 ± 1.4 vs. 71.2 ± 0.7; P =.006), males (61.5% vs. 34.3%; P = .003), higher BMI (31.7 ± 0.9 vs. 29.6 ± 0.5; P = .045), history of instability (30.8% vs. 10.5%; P = .003), decreased passive external rotation (17.5 ± 3.1 vs. 25.1 ± 1.4, P = .031), larger inferior humeral head osteophyte (14.1mm vs. 7.8mm, P = .001) and B2 or B3 glenoids (39.3% vs. 17.2%; P =.026). Discussion and conclusionFor experienced high-volume shoulder and elbow surgeons performing primary shoulder arthroplasty, cases that were unexpectedly difficult were associated with younger age, males, stiffness, history of instability, large inferior humeral head osteophyte, and posterior glenoid bone loss. Difficulty with glenoid reaming and glenoid component implantation were the most frequent reason for difficult cases. This information may allow surgeons to anticipate difficult cases, appropriately schedule their operative day, and identify potentially difficult cases that warrant referral to high-volume shoulder arthroplasty surgeon. Level of evidenceLevel III; Prospective Case-Control Study

Clinical and radiographic results of eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and PSI

BackgroundTreatment of deformed type B glenoids with anatomical total shoulder arthroplasty (TSA) can be challenging when using standard imaging and instrumentation. 3D planning and PSI-guided (patient-specific instrumentation) eccentric reaming may substantially aid in both the glenoid correction and implantation of anatomical components in difficult cases. We hypothesized that the implementation of preoperative planning and a PSI-guided anatomical component protocol would result in accurate correction of the glenoid deformity and precise glenoid implant positioning. MethodsTwenty-two consecutive patients with primary glenohumeral osteoarthritis, intact rotator cuff and modified-Walch type B glenoids were treated with anatomical total shoulder arthroplasty. Preoperative 3D planning and PSI were used to guide eccentric reaming and correct glenoid deformity. Postoperative clinical and radiographic outcomes were assessed in all patients with a minimum follow-up of 2 years (mean of 26 months). Postoperative corrections of glenoid version and inclination were measured and the variation between preoperative planning and postoperative implant position was evaluated on CT 3D reconstructions. Similarly, both humeral subluxation in the axial scapular plane and glenoid joint line medialization were compared between preoperative and postoperative computed tomographic imaging. ResultsThe mean age was 57 years (range, 54-68). Significant improvements in pain and functional outcome measurements were seen in all 22 subjects. Mean native glenoid version and inclination were −15° ± 5° and 3° ± 5°, respectively. Postoperatively, version was corrected to −7° ± 6° and inclination to 1° ± 2°. Cortical central peg perforation was noted in 1 case and cement perforation in 3 cases. The mean deviation from the preoperative plan was 3° ± 3° for version and 2° ± 2° for inclination. Humeral head subluxation improved from 68% ± 6% to 37% ± 6% and re-centering on the glenoid implant was achieved in all cases. The mean executed medialization of the glenoid joint line was 6 ± 3 mm and proved accurate to within 1 ± 1 mm of the planned medialization. A strong linear correlation was found between the degree of correction of retroversion and the amount of medialization (R = 0.82; P< .001). Conclusion3D preoperative planning and PSI guided correction of deformed modified-type B glenoids resulted in accurate postoperative correction of the glenoid deformity, correct glenoid component implantation with low deviation from the planned position and excellent short-term functional and radiographic results. Level of Evidence: Level IV; Case Series; Treatment Study.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff: A Concise 5-Year Follow-up of a Previous Report.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Glenoid and acetabular reaming force varies in simulation between fellowship trained surgeons

BackgroundThe acquisition of surgical skills required to correctly perform orthopedic procedures varies among different institutions due to the diversity of training curriculums. With its technologic advances, surgical simulation can provide trainees with an accurate, safe, and standardized mean to practice procedures throughout their time in residency. The force utilized by a surgeon while reaming relies on prior experience and muscle memory developed throughout their career. The aim of the present study was to evaluate and compare the average force applied during reaming of an acetabulum vs. a glenoid by fellowship trained orthopedic surgeons in order to provide trainees a standard to use during simulation and in practice and to provide an understanding of the force differentials. MethodsA reaming simulator was created by installing a force transducer onto a reamer which allowed the testing of fellowship trained hip and shoulder orthopedic surgeons from the surrounding communities. Each surgeon was given 6 trials to determine the mean clinical force and their max effort force. Demographic information was surveyed for each participating surgeon to determine their level of experience and personal characteristics. Statistical analysis was performed using a Welch t test for scale variables and a Levene's F test to compare variances between groups via SPSS Statistics 24 software. ResultsA 61% greater mean clinical force was applied while simulating reaming of the acetabulum (90.12 N ± 30.12) than of the glenoid (55.91 N ± 25.65), t (184) = 8.0, P< .001. When shoulder (297.62 N ± 82.25) and hip surgeons (318.11 N ± 112.06) were asked to push the reamer at a maximal effort, there was no significant difference between the max effort force generated by the 2 groups (P = .16). For glenoid reaming, shoulder surgeons applied 19% of their max effort force while for acetabular reaming, hip surgeons applied 28% of their max force. ConclusionThe mean clinical force utilized to ream an acetabulum is greater than that of a glenoid by nearly twofold. Application of this knowledge can be translated into surgical simulation training for residents to help them develop the proper muscle memory for reaming in the 2 different clinical scenarios throughout residency. Reamers with an incorporated force transducer could provide surgeons, in real time, feedback on the force they apply to bone. With the advances in simulations, these tools can be optimized to give trainees tactile feedback when learning crucial steps of surgery. Level of evidenceClinical Science Study; Biomechanics

Comparison of mid-term outcomes of total shoulder arthroplasty for B2 and A glenoids treated with trabecular metal glenoid components

BackgroundTreatment of B2 glenoids in total shoulder arthroplasty (TSA) has been associated with worse clinical outcomes and increased rates of glenoid loosening. The purpose of this study was to describe and compare the mid-term outcomes of TSA using a trabecular metal-backed glenoid in patients with B2 and A glenoids. MethodsPatients who underwent anatomic TSA with a trabecular metal-backed glenoid component (second generation trabecular metal glenoid) for primary osteoarthritis and had minimum 5-year follow-up were reviewed. All patients underwent eccentric glenoid reaming to treat biconcavity, if present. Preoperative imaging was reviewed and patients were divided into 2 groups: Type A and Type B2. Mid-term outcome measures including patient-rated outcome scores (Patient Reported Outcome Measurement Information System and American Shoulder and Elbow Surgeons [ASES]) and shoulder range of motion were determined. ASES score was compared between groups. Radiographs were graded for radiolucent lines and posterior humeral head migration and evaluated for glenoid loosening. ResultsTwenty-two patients had Type A glenoids and 22 patients had B2 glenoids. Sixteen patients in the A group and 18 patients in the B2 group had full radiographic and physical exam follow-up. Both groups had similar follow-up (6.7 ± 1.1 years A, 6.6 ± 0.9 years B2, P = .88). Groups were similar in terms of age at surgery, gender distribution, body mass index, severity of medical comorbidities, and hand dominance distribution. The B2 patients had a mean preoperative glenoid retroversion of 17.5° ± 6.7° and posterior subluxation of 8.5% ± 5.3%. No patients in either group had evidence of glenoid loosening at follow-up. No patients required revision surgery. Nine of 16 in the A group had evidence of mild radiolucent lines (8 grade 1, 1 grade 2). Eight of 18 patients in the B2 group had mild radiolucencies (all grade 1). Two of 16 Type A and 6 of 18 B2 patients had evidence of posterior humeral migration, but all cases were graded as mild. Both groups had similar follow-up mean ASES scores (95.5 A, 89.0 B2, P = .25). ConclusionAt minimum 5-year follow-up, patients who underwent TSA with a trabecular metal-backed glenoid component demonstrated excellent clinical and patient-reported outcomes regardless of preoperative glenoid morphology (A or B2). No patients in either group had evidence of glenoid loosening or required revision surgery. These favorable mid-term outcomes of trabecular metal-backed glenoids in B2 deformities need to be followed longitudinally to determine long-term durability. Level of EvidenceLevel III; Retrospective Comparative Study