Severe Glenoid Bone Loss Research Articles

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.

Structural bone grafting with reverse shoulder arthroplasty for osteoarthritis with severe glenoid bone loss: outcomes using a long post

Severe posterior glenoid bone loss with glenohumeral osteoarthritis with an intact rotator cuff can be managed with reverse shoulder arthroplasty but requires lateralization and version correction to avoid potential complications, such as instability, notching and implant failure. Angled bone grafting with humeral head autograft can provide durable glenoid bone stock, but results have been mixed. The purpose of this study was to evaluate patient-reported and objective outcomes as well as complication and failure rates for patients who underwent angled humeral head autografting for severe retroversion. All patients who underwent a primary reverse shoulder arthroplasty with angled humeral head autograft and Stryker Tornier long central postbaseplate for severe glenoid bone loss in the setting of glenohumeral osteoarthritis with an intact rotator cuff at our institution between November 2018 and February of 2022 were identified. Individuals with a primary diagnosis of osteoarthritis and preoperative glenoid retroversion of ≥30° were included. Patients undergoing revision procedures, planned 2-stage arthroplasty were excluded. Differences in pre- and postoperative range of motion, as well as patient-reported outcomes were assessed. Intraoperative complications, postoperative complications, and re-operation rates were analyzed. A total of 24 shoulders in 23 patients (61% male), with a mean age of 65.6years were included. Average preoperative retroversion was 37.4° (range: 30°-51°). Mean follow-up was 2.9years (range: 2-4.3years). Significant improvements were found in flexion, abduction, and external rotation. Patient-reported subjective outcomes were excellent, with average American Shoulder and Elbow Surgeons score of 93.6 and average Subjective Shoulder Value score of 93.8%. Sixteen (67%) shoulders received postoperative computed tomography scans and all were found to have incorporated. Complications included one shoulder hematoma requiring incision and drainage without revision, and a post-traumatic fracture of the inferior glenoid screw at 11months, requiring revision reverse shoulder arthroplasty with bone grafting. No atraumatic catastrophic failures occurred due to component loosening. This study suggests that using angled humeral head bone grafting is a good solution for version correction in extreme posterior glenoid bone loss. Significant improvements are reported in range of motion, pain, and subjective functional scores, with excellent graft incorporation rates and a low complication profile at early follow-up. Further work should focus on gathering higher levels of evidence, detailed radiographic analyses, and exploring humeral head bone grafting for other indications.

The Use of a Distal Radius Allograft for Severe Glenoid Bone Loss in the Setting of Revision Shoulder Arthroplasty: A Case Report.

A 71-year-old female patient presented with severe glenoid bone loss and deformity after 2 subsequent failed arthroplasty procedures because of baseplate failures. The patients then underwent a conversion from reverse shoulder arthroplasty to hemiarthroplasty, while using a distal radius allograft to augment the deformed glenoid. At the 2-year follow-up, the patient reported minimal pain and satisfactory outcomes. This case presents the distal radius as a potentially useful allograft option for augmenting severe glenoid bone loss in the setting of revision shoulder arthroplasty.

A scapular statistical shape model can reliably predict premorbid glenoid morphology in conditions of severe glenoid bone loss

Knowledge of premorbid glenoid parameters at the time of shoulder arthroplasty, such as inclination, version, joint line position, height, and width, can assist with implant selection, implant positioning, metal augment sizing, and/or bone graft dimensions. The objective of this study was to validate a scapular statistical shape model (SSM) in predicting patient-specific glenoid morphology in scapulae with clinically relevant glenoid erosion patterns. Computed tomography scans of 30 healthy scapulae were obtained and used as the control group. Each scapula was then virtually eroded to create 7 erosion patterns (Walch A1, A2, B2, B3, D, Favard E2, and E3). This resulted in 210 uniquely eroded glenoid models, forming the eroded glenoid group. A scapular SSM, created from a different database of 85 healthy scapulae, was then applied to each eroded scapula to predict the premorbid glenoid morphology. The premorbid glenoid inclination, version, height, width, radius of best-fit sphere, and glenoid joint line position were automatically calculated for each of the 210 eroded glenoids. The mean values for all outcome variables were compared across all erosion types between the healthy, eroded, and SSM-predicted groups using a 2-way repeated measures analysis of variance. The SSM was able to predict the mean premorbid glenoid parameters of the eroded glenoids with a mean absolute difference of 3°±2° for inclination, 3°±2° for version, 2 ± 1 mm for glenoid height, 2 ± 1 mm for glenoid width, 5 ± 4 mm for radius of best-fit sphere, and 1 ± 1 mm for glenoid joint line. The mean SSM-predicted values for inclination, version, height, width, and radius were not significantly different than the control group (P>.05). An SSM has been developed that can reliably predict premorbid glenoid morphology and glenoid indices in patients with common glenoid erosion patterns. This technology can serve as a useful template to visually represent the premorbid healthy glenoid in patients with severe glenoid bony erosions. Knowledge of the premorbid glenoid preoperatively can assist with implant selection, positioning, and sizing.

Prediction of premorbid three-dimensional anatomy of the glenoid based on statistical shape modeling

BackgroundRestoration of an anatomic joint line after anatomic total shoulder arthroplasty and of the optimal lateral offset after reverse total shoulder arthroplasty may be relatively straightforward when the glenoid does not present with severe erosion. However, in cases of severe glenoid bone loss, the surgeon is left with no preoperative landmark to restore these parameters. The objective of this study was to use statistical shape modeling, to predict the premorbid morphology of the glenoid. We hypothesized that this would allow us to accurately determine premorbid glenoid version and inclination, in addition to accurately quantifying bone loss and medialization. MethodsFifty-six bilateral computed tomography scans of the shoulders of patients scheduled for shoulder arthroplasty and determined to have unilateral osteoarthritis (primary osteoarthritis or cuff tear arthropathy with a healthy contralateral side) were obtained. A statistical shape model was automatically applied on the pathologic arthritic side to predict its premorbid anatomy. Glenoid version, inclination, height, width, and glenoid and scapula lateral offset were measured automatically. These measurements were obtained on the pathological arthritic cases, on the contralateral control healthy cases, and on the premorbid predictions of the pathological arthritic cases and were compared pair by pair. ResultsThe mean difference between the pathological arthritic side and the contralateral healthy side was 9.1° ± 7.3° for version, 4.8° ± 4.8° for inclination, 4.9 ± 4.5 mm for height, 4.7 ± 5.3 mm for width, 2.4 ± 1.9 mm for scapula lateral offset, and the glenoid lateral offset was 1.5 ± 1.5 mm. The mean difference between the premorbid prediction of the pathological side and the contralateral healthy side was reduced to 3.3° ± 2.4° for version, 3.4° ± 2.6° for inclination, 3.0 ± 1.9 mm for height, 2.3 ± 1.4 mm for width, 2.2 ± 1.7 mm for scapula lateral offset, and the glenoid lateral offset was 0.9 ± 0.8 mm. ConclusionThis study shows that statistical shape modeling can allow accurate prediction of the premorbid morphology of the glenoid. This could help optimize implant selection and positioning after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty to restore optimal soft-tissue tension.

Patient-specific implants in reverse shoulder arthroplasty.

Reverse total shoulder arthroplasty (RTSA) is widely popular among shoulder surgeons and patients, and its prevalence has increased dramatically in recent years. With this increased use, the indicated pathologies associated with RTSA are more likely to be encountered, and challenging patient presentations are more likely to be seen. One prominent challenging presentation is RTSA patients with severe glenoid bone loss. Several techniques with varying degrees of invasiveness, including excessive reaming, alternate centerline, bone grafting, and patient-specific implants (PSIs), have been developed to treat patients with this presentation. PSI treatment uses a three-dimensional reconstruction of a computed tomography scan to design a prosthetic implant or component customized to the patient's glenoid morphology, allowing compensation for any significant bone loss. The novelty of this technology implies a paucity of available literature, and although many studies show that PSIs have good potential for solving challenging shoulder problems, some studies have reported questionable and equivocal outcomes. Additional research is needed to explore the indications, outcomes, techniques, and cost-efficiency of this technology to help establish its role in current treatment guidelines and strategies.

Distal clavicle autograft for large glenoid defects during revision reverse total shoulder arthroplasty

IntroductionRevision reverse total shoulder arthroplasty (rTSA) can be complicated by significant glenoid bone loss and require augmented baseplates or structural bone grafts to fill the defect while optimizing glenosphere lateralization. Distal clavicle autografting is a newly described type of structural graft that has shown promising outcomes in revision reverse rTSA to address severe glenoid bone loss. Additionally, distal clavicle autografts are an option that is proposed to be more cost effective and have low morbidity in addressing glenoid bone defects. The technique for distal clavicle autografting during revision rTSA and the outcomes of a series of cases are contained within this report. Materials and MethodsA retrospective chart review was conducted for 9 patients who underwent revision rTSA with a distal clavicle autograft for glenoid bone loss between January 2013 to January 2022. The primary outcome was component survivorship at two years postoperatively. Patient charts were reviewed for clinical and radiographic information, and any complications were recorded. Postoperative radiographs were assessed for evidence of component loosening or failure. Distal clavicle and glenoid defect dimensions were measured using preoperative CT scans and compared. Results9 patients were identified who underwent revision rTSA with distal clavicle autograft to address glenoid bone loss. All patients had clinical and radiographic data available two years postoperatively. There was significant improvement in active forward flexion and abduction, and no-significant change in external rotation compared to preoperative measurements. Patient-reported QuickDASH score improved significantly with non-significant improvements in VAS function, SANE, and ASES scores. 8 of 9 (88.9%) of patients had stable prostheses with no evidence of loosening or failure at two years. One patient experienced component failure and graft osteolysis requiring conversion to hemiarthroplasty. No other complications were noted. Dimensions of the distal clavicle are similar to the dimensions of contained glenoid vault defects and glenoid defects with minimal loss of containment. ConclusionUsing a distal clavicle autograft during revision rTSA is an effective technique that can address severe glenoid bone loss. This technique has excellent radiographic outcomes at short-term follow-up and is a fortuitous autograft option in revision rTSA due to its location, dimensions, and low cost.

Reconsidering "Critical" Bone Loss in Shoulder Instability: 17-Year Follow-Up Study following Arthroscopic Bankart Repair.

Glenoid bone loss is a risk factor leading to the failure of arthroscopic Bankart repair. While 20-25% glenoid bone loss has long been considered the level to necessitate bony augmentation, recent studies indicate that 13.5% has a "subcritical" glenoid bone loss level, which is associated with decreased short- and medium-term functional scores. Few researchers worked on the long-term effect of "subcritical" or even less severe degrees of glenoid bone loss on redislocation rates and functional outcomes after arthroscopic Bankart repair. This study aimed to evaluate the effect of subcritical or less severe glenoid bone loss on redislocation rates and function after arthroscopic Bankart repair. A patient cohort who had undergone computed tomography (CT) of glenoid bone loss and arthroscopic Bankart repair over 15 years ago was reviewed. Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, redislocation after operation, mechanism of recurrence, and revision details were reviewed. Seventy-five patients were reassessed 17.6 ± 1.9 years following initial surgery. The age at enrolment was 26.8 ± 8.3 years. Twenty-two (29%) patients of the 75 patients had a redislocation on long-term follow-up, though this was not related to glenoid bone loss severity. The impaired functional score was found in patients with initial glenoid bone loss of 7% or more on long-term follow-up: WOSI (physical symptoms): 0.98 ± 2.00 vs 2.25 ± 4.01, p=0.04 and WOSI (total): 0.79 ± 1.43 vs 1.88 ± 3.56, p=0.04. At a mean of 17.5 years following arthroscopic Bankart repair, redislocation occurs in over a quarter of 75 patients, and they are not related to initial glenoid bone loss severity. Impaired functional outcome is apparent in patients with initial glenoid bone loss of >7%, though this impairment does not seem sufficiently severe to warrant an alternative treatment approach.

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.

Clinical and radiologic outcomes of Lima ProMade custom 3D-printed glenoid components in primary and revision reverse total shoulder arthroplasty with severe glenoid bone loss: a minimum 2-year follow-up.

The purpose of this study is to report the clinical and radiologic outcomes of patients undergoing primary or revision reverse total shoulder arthroplasty using custom 3D-printed components to manage severe glenoid bone loss with a minimum of 2-year follow-up. Following ethical approval, patients were identified and invited to participate. Inclusion criteria were (1) severe glenoid bone loss necessitating the need for custom implants and (2) patients with definitive glenoid and humeral components implanted more than 2 years prior. Included patients underwent clinical assessment using the Oxford Shoulder Score (OSS), Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). Radiographic assessment included anteroposterior and axial projections. Patients were invited to attend a computed tomography (CT) scan to confirm osseointegration. Statistical analysis used descriptive statistics (mean and standard deviation [SD]) and paired t test for parametric data. Eleven patients declined to participate. Five patients were deceased prior to study commencement, leaving 42 remaining patients in this analysis. Three patients had revision surgery before the 2-year follow-up; of these, 2 retained their custom glenoid components. Mean follow-up was 31.6 months from surgery (range 24-52 months). All 4 scores improved: OSS from a mean 15 (SD8.4) to 36 (SD12) (P<.001), Constant-Murley score from a mean 15 (SD11.2) to 52 (SD20.1) (P<.001), QuickDASH from a mean 70 (SD21) to 31 (SD24.8) (P=.004), and the ASES score from a mean 22 (SD17.8) to 71 (SD23.3) (P=.007). Radiologic evaluation demonstrated good osseointegration in all but 1 included patient. The utility of custom 3D-printed components for managing severe glenoid bone loss in primary and revision reverse total shoulder arthroplasty yields significant clinical improvements in this complex cohort. Large complex glenoid bone defects can be managed successfully with custom 3D-printed glenoid components.

Cadaveric Biomechanical Study of Partial Glenoid Arthroplasty Versus the Latarjet Procedure for Anterior Glenoid Bone Loss

Background: For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common. Purpose/Hypothesis: The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation. Study Design: Controlled laboratory study. Methods: A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement. Results: The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger (P = .006) with less articular stepoff (P = .030). PGA better approximated the intact state’s external (P = .006) and total (P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state (P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness (P = .031) and loading (P = .002) at 2-mm construct displacement were demonstrated in the PGA group. Conclusion: In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure. Clinical Relevance: A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

Survivorship analysis of CAD-CAM total shoulder replacement.

Glenoid bone loss represents a challenge in shoulder arthroplasty and often precludes standard implants. The CAD-CAM total shoulder replacement (TSR) is an option in these cases. This study aimed to assess survivorship and long-term patient outcomes of the CAD-CAM TSR. Fifty-eight patients that underwent a CAD-CAM TSR by three surgeons at a single tertiary referral centre between 2009 and 2017 were reviewed. The mean follow-up was 70 months (28-130). Data was collected on survivorship, range of movement, Oxford shoulder score (OSS, 0-48), subjective shoulder value (SSV, 0-100%), pain score (0-10), and overall patient satisfaction. CAD-CAM TSR was undertaken as a primary procedure in 28% (n = 16) for end-stage arthritis with severe glenoid bone loss, and as a revision procedure in 72% (n = 42). Of the total, 17% (n = 10) required component revision at a mean of 24 months (4x prosthesis loosening, 3x infection, 3x periprosthetic fracture). Forward elevation improved from 45° ± 27° to 59° ± 29° (P = 0.0056), abduction from 43° ± 29° to 55° ± 26° (P = 0.034) and external rotation from 8° ± 11° to 16° ± 14° (P = 0.031). OSS improved from 15 ± 8 to 29 ± 9 (P = 0.0009), SSV from 18 ± 16 to 62 ± 23 (P < 0.0001), and pain score from 8 ± 2 to 2 ± 2 (P < 0.0001). 88% of patients would undergo the procedure again. CAD-CAM TSR is reserved for complex cases involving severe glenoid bone loss, offering significant improvements in pain and function with overall positive patient satisfaction.

CLINICAL AND RADIOLOGICAL OUTCOMES OF CUSTOM 3D-PRINTED GLENOID COMPONENTS IN PRIMARY AND REVISION REVERSE POLARITY TOTAL SHOULDER ARTHROPLASTY WITH SEVERE GLENOID BONE LOSS: A MINIMUM TWO-YEAR FOLLOW-UP

The purpose of this study is to report the clinical and radiological outcomes of patients undergoing primary or revision reverse total shoulder arthroplasty using custom 3D printed components to manage severe glenoid bone loss with a minimum of 2-year follow-up.After ethical approval (reference: 17/YH/0318), patients were identified and invited to participate in this observational study. Inclusion criteria included: 1) severe glenoid bone loss necessitating the need for custom implants; 2) patients with definitive glenoid and humeral components implanted more than 2 years prior; 3) ability to comply with patient reported outcome questionnaires. After seeking consent, included patients underwent clinical assessment utilising the Oxford Shoulder Score (OSS), Constant-Murley score, American Shoulder and Elbow Society Score (ASES), and quick Disabilities of the Arm, Shoulder, and Hand Score (quickDASH). Radiographic assessment included AP and axial projections. Patients were invited to attend a CT scan to confirm osseointegration. Statistical analysis utilised included descriptive statistics (mean and standard deviation) and paired t test for parametric data.3 patients had revision surgery prior to the 2-year follow-up. Of these, 2/3 retained their custom glenoid components. 4 patients declined to participate. 5 patients were deceased at the time of commencement of the study. 21 patients were included in this analysis. The mean follow-up was 36.1 months from surgery (range 22–60.2 months). OSS improved from a mean 16 (SD 9.1) to 36 (SD 11.5) (p &lt; 0.001). Constant-Murley score improved from mean 9 (SD 9.2) to 50 (SD 16.4) (p &lt; 0.001). QuickDASH improved from mean 67 (SD 24) to 26 (SD 27.2) (p = 0.004). ASES improved from mean 28 (SD 24.8) to 70 (SD 23.9) (p = 0.007). Radiographic evaluation demonstrated good osseointegration in all 21 included patients.The utility of custom 3D-printed components for managing severe glenoid bone loss in primary and revision reverse total shoulder arthroplasty yields significant clinical improvements in this complex patient cohort.

Shoulder arthroplasty in patients with glenohumeral osteoarthritis, glenoid bone loss and an intact rotator cuff: an algorithmic approach and review of the literature.

In patients with severe glenohumeral osteoarthritis (OA) and preserved rotator cuff function who have failed nonoperative treatment, anatomic total shoulder arthroplasty (TSA) has historically been the preferred surgical treatment. Shoulder arthroplasty in the setting of glenoid bone loss setting is technically demanding. Many techniques have been described to deal with glenoid bone loss including eccentric reaming, bone grafting, augmented glenoid baseplates, and patient-specific implants. Still, the decision to perform anatomic TSA or reverse total shoulder arthroplasty (RTSA) is often unclear, especially as the use of RTSA increases and evolves, making historical studies less useful when considering modern implant designs. RTSA has been advocated as a solution for patients with severe glenoid bone loss with intact rotator cuff function. Moreover, in appropriately selected patients, good outcomes can be achieved without the use of bone grafting or augmented baseplates. In cases of severe glenoid bone loss, RTSA can be performed with reaming the glenoid flat such that the baseplate rests on native glenoid bone. We have previously reported excellent prosthetic survival with this technique at 5-year follow-up. The purpose of this article is to highlight our suggested treatment algorithm for glenohumeral OA with glenoid bone loss and intact rotator cuff. Specifically, we focus on situations where RTSA may be preferred as opposed to anatomic TSA, and our suggested approach to managing bone loss intraoperatively in this complex patient population.

RTSA With Humeral Head Autograft Glenoid Reconstruction

Background: Untreated chronic massive rotator cuff tears and primary osteoarthritis can lead to conditions of significant retroversion, posterior bone loss, and humeral head subluxation. Indications: Reverse total shoulder arthroplasty with humeral head autograft glenoid reconstruction may be indicated in patients with advanced glenohumeral osteoarthritis and/or severe glenoid retroversion/bone loss due to rotator cuff arthropathy, trauma, primary, or inflammatory osteoarthritis. Technique: Besides routine radiography and preoperative computed tomography (CT) scans, 3-dimensional (3D) planning software is often performed as a routine part of preoperative planning. A 3D printed model of the glenoid can also be helpful in cases of significant bone deformity. Patients are placed in a 45° modified beach chair position. Using a standard deltopectoral approach, the glenoid is exposed. An anatomic humeral head resection is made. The contour of the articular margin of the humeral head should match the glenoid bone deficiency anatomically as it has been chronically resting within the glenoid defect. Three dimensional preoperative planning and the 3D printed model are used to make an asymmetric humeral head autograft which should match the deficiency perfectly. The articular cartilage is removed with a burr. The graft and baseplate are coupled together (metaphyseal bone facing the baseplate and prepared articular side of the graft facing native bone) and measurements are performed with the preoperative planning software to fashion a graft with the appropriate dimension and with the desired amount of lateralization. The bone graft is then compressed with the baseplate to the native glenoid and fixed with screws. Results: In select patients with careful preoperative planning, excellent outcomes can be achieved with careful gradual resumption of range of motion and strength with physical therapy. Sequential radiographic imaging is performed up to 6 months and beyond to confirm solid union of graft to native glenoid bone and incorporation into the baseplate. Discussion/Conclusion: Reverse total shoulder arthroplasty (rTSA) with humeral head autograft glenoid reconstruction is an excellent option to address severe glenoid bone loss and restore the native joint line for both primary osteoarthritis and rotator cuff arthropathy. Using 3D CT scans, 3D preoperative planning software and 3D printing of the glenoid can help achieve a good outcome. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Total shoulder arthroplasty using an inlay glenoid component for glenoid deficiency: mid-to long-term follow-up of a previously published cohort.

The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients. We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores. Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P<.001]; external rotation, 18.8° [P<.001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P<.001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively. Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Hemi-reverse revision arthroplasty in the setting of severe glenoid bone loss.

Glenoid bone loss is one of the main challenges in revision of failed shoulder arthroplasties. The concept of a hemi-reverse procedure is to implant a glenoid baseplate and glenosphere to protect the glenoid reconstruction to allow it to heal and to preserve the joint space for a potential second-stage humeral component implantation. The purpose of this study was to report the results of hemi-reverse procedures. Revision to a hemi-reverse procedure was performed in 15 patients: 8 with a failed anatomic total shoulder arthroplasty, 3 with a failed reverse shoulder arthroplasty, 3 with a failed humeral hemiarthroplasty, and 1 with placement of a cement spacer owing to sepsis after a total shoulder arthroplasty. After complete removal of the initial prosthesis, all patients underwent glenoid reconstruction with bone grafting and implantation of a reverse arthroplasty baseplate and glenosphere. A humeral implant was not placed in any case. The patients were prospectively followed up and underwent complete clinical and radiologic studies preoperatively and postoperatively at a minimum of 2 years after the surgical procedure. Thirteen hemi-reverse implants and glenoid bone grafts healed (86%) and remained radiographically stable. One hemi-reverse construct migrated and became mechanically loose, which was attributed to absent fixation of the central post in the native glenoid bone. In 1 patient, an implant-related infection developed; irrigation and debridement were performed, in addition to revision to a resection arthroplasty. After documented radiographic healing of the hemi-reverse glenoid reconstruction, 5 patients underwent a second-stage revision to a reverse procedure with insertion of a humeral component at a median of 6 months (interquartile range [IQR], 6-8 months). In this group, the median follow-up period was 73 months (IQR, 45-153 months), the median Constant score was 48 (IQR, 41-56), median active forward elevation was 135° (IQR, 100°-150°), and the median Subjective Shoulder Value was 50% (IQR, 50%-60%). In the group of 9 patients with remaining hemi-reverse implants, the median follow-up period was 38 months (IQR, 29-60 months), the median Constant score was 41 (IQR, 38-46), median active forward elevation was 100° (IQR, 80°-100°), and the median Subjective Shoulder Value was 50% (IQR, 40%-60%). The hemi-reverse procedure is an effective revision procedure to reconstruct a severely deficient glenoid. The hemi-reverse procedure may function as the definitive procedure, with satisfactory outcomes. Additionally, in patients who undergo the hemi-reverse procedure, second-stage revision to a total reverse procedure can be performed once imaging confirms bone graft and construct stability.

Identifying areas of screw fixation in glenoids with severe bone loss in shoulder arthroplasty.

Severe glenoid bone loss (SGBL) poses significant technical challenges. Adequate fixation of glenoid implants may require the use of alternative screw placement. Although bone volumes for the spine and lateral pillars have previously been defined, insufficient evidence exists regarding the distribution of screw placement for fixation in such regions for cases with SGBL. The purpose of this study is to evaluate the variability of screw placement. We hypothesize that determining this variability and establishing common patterns of glenoid bone loss will allow for recommendations for preoperative planning, and implant design and selection. An internal registry of 2 high-volume shoulder and elbow surgeons was queried, and 65 three-dimensional scapulae models exhibiting SGBL were identified. A fellowship-trained shoulder and elbow surgeon simulated the placement of two 3.5 mm × 30 mm screws, one in the scapular spine (CS) bone volume and one in the inferior column (IS) bone volume. Three orthogonal reference planes were created using anatomic reference points: the scapula trigonum, estimated glenoid center, and inferior pole. Screw positions were mapped, and deviations from the reference planes were calculated. Mutual positions of the IS to CS were also computed. Intraobserver reliability was assessed using 10 randomly selected samples. Median and 25th and 75th percentiles were reported for screw orientation distributions. Means and standard deviations were reported for screw head positions. We demonstrated excellent intraobserver reliability (intraclass correlation coefficients, 0.90-0.98). Fifty percent of CS were oriented 10°±5° of retroversion from the scapula plane, with 5° ± 5° of inclination. For IS, 50% were positioned 0° ± 4° from the scapula plane, with -33° ± 7° of inclination. The relationship of the IS with the CS was medial and posterior in 49% of cases, lateral and posterior in 45%, and lateral and anterior in 6% of cases. On average, the distance between the CS and IS heads was 25 mm ± 4 mm. For SGBL, adequate fixation of glenoid implants can be achieved by placing screws in the spine and lateral columns, with excellent reproducibility. Future implant designs should accommodate CS positioned -16° to -5° from the scapula plane, with 0° to 12° of inclination, and IS positioned -6° to 4° from the scapula plane, with -40° to -25° of inclination. Moreover, mutual screw positions suggested bone loss distributions anteriorly and inferiorly. Future implant designs should consider the potential benefits of augmentation to accommodate interscrew distances of 21-29 mm and anatomic locations of the IS relative to the CS.

Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty.

Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss. We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value(SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version. Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up. Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

Arthroscopic Biceps Transfer to the Glenoid With Bankart Repair Grants Satisfactory 2-Year Results for Recurrent Anteroinferior Glenohumeral Instability in Subcritical Bone Loss

To evaluate the short-term outcomes of the arthroscopic dynamic anterior stabilization (DAS), which is a transfer of the intra-articular portion of the long head biceps through the subscapularis split and fixation on the anterior glenoid, combined with a Bankart repair. A retrospective evaluation was performed of DAS and a minimum of 2-year follow-up. Inclusion criteria were the presence of anteroinferior instability, a positive apprehension test at 90° of abduction and external rotation, and subcritical glenoid bone loss (less than 20%). Exclusion criteria were severe (≥20%) glenoid bone loss, presence of biceps lesions or rupture (spontaneous or biceps tenotomy), pre-existing glenohumeral osteoarthritis, multidirectional or voluntary instability, previous arthroscopic stabilization procedure, and epilepsy. Outcomes included the Rowe score, range of motion (ROM), and recurrence. Twenty-three patients were treated with DAS and arthroscopic Bankart repair during the study period. One person was lost to follow-up, leaving 22 patients available at last follow-up. Those 22 patients had an average age of 31.9 ± 12.3 years (range, 18-68) and were evaluated at an average follow-up of 3.2 ± 0.7 years (range, 1.2-4.2). The Rowe score increased from 36.1 ± 16.2 (range, 10-70) preoperatively to 89.8 ± 20.1 (range, 30-100) postoperatively (P < .001) with almost all patients (90.9%) improving their score beyond the minimal clinically important difference of 9.7 points. Postoperatively, ROM was maintained. Three patients (13.6%) analyzed at final follow-up demonstrated recurrence, one was successfully treated conservatively, but two revised with a Latarjet. No postoperative Popeye deformity, biceps cramping, or other complication were reported. The DAS procedure may be an option for augmentation of a Bankart repair in patients with anterior shoulder instability and subcritical bone loss. ROM is maintained without evidence of postoperative Popeye deformity or biceps cramping. Level IV, retrospective study.