Severe Glenoid Bone Loss Research Articles

Patient-Specific Implants in Severe Glenoid Bone Loss.

Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be encountered in the primary setting (degenerative, congenital, post-traumatic), severe glenoid bone loss is encountered in most revision total shoulder arthroplasties. Severe glenoid bone loss is treated with various techniques including hemiarthroplasty, eccentric reaming, and glenoid reconstruction with bone autografts and allografts. Despite encouraging short- to mid-term results reported with these reconstruction techniques, the clinical and radiographic outcomes remain inconsistent and the high number of complications is a concern. To overcome this problem, more recently augmented components and patient specific implants were introduced. Using the computer-aided design and computer-aided manufacturing technology patient-specific implants have been created to reconstruct the glenoid vault in cases of severe glenoid bone loss. In this article we describe a patient specific glenoid implant, its indication, technical aspects and surgical technique, based on the author's experience as well as a review of the current literature on custom glenoid implants.

Management of glenoid bone defects with reverse shoulder arthroplasty—surgical technique and clinical outcomes

Management of significant glenoid bone loss in patients undergoing a reverse shoulder arthroplasty (RSA) poses a significant treatment challenge. The long-term outcome of single-stage RSA with glenoid bone grafting is unknown. This study assesses the indications, technique, and outcome of RSA with glenoid bone grafting. Between 2001 and 2010, there were 1074 RSAs performed at our institution; 94 patients had significant glenoid bone loss. Each glenoid defect was subclassified as centric or eccentric and graded 1-4. The patients underwent a single-stage or 2-stage RSA with glenoid bone grafting. A retrospective analysis of the preoperative and postoperative clinical and radiologic outcome was carried out. The mean follow-up was 2.4 years (0.52-10.7 years). Of these patients, 17% had a centric defect and 83% had an eccentric glenoid defect. Composite glenoid grafts were required in 12 patients, 9 of whom required a glenoid baseplate with a long central peg; 92.5% (87/94) of the patients could be managed with a single-stage procedure. Improvement in the Constant score of 61 points (17.9 to 78.9; P < .01) and the mean Simple Shoulder Test score of 5.8 points (1.6 to 7.5; P < .001) was noted. No correlation was found between the clinical outcome and indication for surgery, age, location of defect, and size of defect. Severe glenoid bone loss can usually be managed by a single-stage bone graft and RSA. A 2-stage procedure is recommended when primary baseplate stability is not attainable.

Management of Glenoid Bone Loss in Reverse Shoulder Arthroplasty

Clinical Results and Treatment algorithm for management of severe glenoid bone loss with reverse shoulder arthroplasty with a min 2.4 year followup. Management of significant glenoid bone loss in patients undergoing a Reverse Shoulder Arthroplasty (RSA) poses a significant treatment challenge. The long-term outcome of single stage RSA with glenoid bone grafting is unknown. This study assesses the indications, technique and outcome of RSA with glenoid bone grafting. Between 2001 and 2010, 1074 RSA were performed at our institution. Out of this cohort 94 patients had significant glenoid bone loss. These patients underwent a single or two-stage RSA with glenoid bone grafting. Intra operatively each patient was subcategorized on the basis of the size of the glenoid defect and managed in accordance with a standardized treatment protocol. The defects were sub classified as centric or eccentric and graded from 1-4 based upon their size. A retrospective analysis of the pre and post-operative clinical and radiological outcome was carried out. The mean follow up was 2.4 years, (0.52 years – 10.7 years). Indication for RSA were as follows: 1) 29.3% Cuff tear arthropathy, 2) 27.2% failed prior arthroplasty, 3) 21% chronic dislocation, 4) 17.4% post traumatic cases. During the operation 17 % had a centric defect and 83 % of patients had an eccentric glenoid defect; the bone loss being anterior in the majority (51.1%). Composite glenoid grafts were required in 10 patients and 9 patients required a revision specific glenoid base plate. 92.5% (87/94) of the patients could be managed as a single stage procedure. There was a significant improvement in the Constant score (p value <0.01) and the subjective shoulder test score (SST) (p value <0.05) in all the patients. No correlation was found between the clinical outcome and indication for surgery, age, location of defect and size of defect. 7 patients had complications. There was 1 case of early implant failure (graft & glenoid component), Complex glenoid defects are encountered in less than 10 % of all cases undergoing a RSA (94/ 1074) and the requirement of complex grafts and revision specific base plates is even rarer (0.8% in our cohort). There by the surgeon must possess an easy intraoperative decision making tool to guide them in an often complex surgical procedure. Pre operative assessment of extent and amount of bone defect with 3D-CT-reconstruction is critical for successful operative technique. However in a revision setting often the bone loss exceeds the surgeons expectations. To combat this problem we have classified glenoid defects based upon the intraoperative finding. A treatment protocol is than followed based upon the size and location of each defect. Sufficient primary fixation of the glenoid base plate is a prerequisite for a single stage procedure and is attainable in 92.3% of patients as per our study. The goal of restoration of the glenoid joint line in a coronal plane is imperative to attain a stable prosthesis with impingement free arc of motion. The vast majority of patients could be managed by autografts however in 9.5% (9/94) of patients revision specific glenoid base plate with a longer peg was required. Improved preoperative planning and better prosthesis subtraction CT algorithms will enable an early identification of this patient cohort and avoid intraoperative surprises.

Bone Graft Augmentation for Severe Glenoid Bone Loss in Primary Reverse Total Shoulder Arthroplasty: Outcomes and Evaluation of Host Bone Contact by 2D-3D Image Registration.

Background:The treatment of patients with severe glenoid bone loss using reverse total shoulder arthroplasty (RSA) is challenging because of the difficulty in obtaining glenoid fixation. The outcomes following primary RSA with structural bone-grafting for severe glenoid bone loss and the amount of native bone support necessary to achieve clinical improvement are unclear.Methods:We reviewed functional outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test [SST], visual analog scale [VAS] for pain and function, patient satisfaction, and range of motion) for 57 patients who were treated with a primary RSA and glenoid bone-grafting for severe glenoid bone loss. Three glenoids were classified as type A2; 2, as type B2; and 2, as type C, according to the Walch classification; 16 glenoids, as grade E1; and 19, as grade E3, according to the Sirveaux classification; 9 glenoids, as grade 3, according to the Levigne classification; and 6 were unable to be classified. For the 44 patients with adequate preoperative computed tomographic (CT) data and postoperative radiographs, we evaluated native bone contact under the glenoid baseplate by matching the projected shape of the implant and scapula from the postoperative radiographs with a generated 3-dimensional (3D) model of the preoperative scapula. We then analyzed functional outcomes in relation to native bone support of the baseplate.Results:At a mean of 46 months (minimum, 24 months), the patients demonstrated significant improvements in function, motion, and pain (change in the ASES total score = 38.6, change in SST = 5.4, change in forward elevation = 72.4°, change in abduction = 67.7°, change in external rotation = 24.3°, and change in VAS pain score = −4.6; p < 0.001 for all). On the basis of the generated 3D model, the baseplate contact to host bone was a mean (and standard deviation) of 17% ± 12% (range, 0% to 50%). There was no significant correlation between host bone coverage and change in the ASES score (p = 0.51) for the 44 patients included in this analysis. There were 4 major complications (7%) in the study group but no glenoid baseplate failures.Conclusions:Glenoid bone-grafting in a primary RSA in a shoulder with severe bone loss produces good functional outcomes that do not correlate with the degree of native bone contact under the baseplate. We had observed no glenoid component failures at the time of writing.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bipolar Bone Loss of the Shoulder Joint due to Recurrent Instability: Use of Fresh Osteochondral Distal Tibia and Humeral Head Allografts

With increasing shoulder instability events, the likelihood of a bony lesion of the glenoid and/or humeral head rises. Although bone loss of either the glenoid or humeral head may result in recurrent instability, bipolar lesions have been shown, in particular, to result in a negative and additive effect on glenohumeral stability. In the case of a bipolar lesion comprising severe glenoid bone loss and an engaging, “off-track” Hill-Sachs lesion, the bony foundation of the glenohumeral joint is compromised and bony augmentation is necessary. We present our preferred technique, made up of the application of a distal tibia allograft to address the glenoid bone loss and humeral head allograft to address the Hill-Sachs lesion, for the treatment of a severe bipolar lesion in the setting of recurrent anterior shoulder instability after a failed Latarjet procedure.

Paper #28 - Bone graft augmentation for severe glenoid bone loss in primary reverse total shoulder arthroplasty: outcomes and evaluation of host bone contact by 2D/3D image registration

Paper #28 - Bone graft augmentation for severe glenoid bone loss in primary reverse total shoulder arthroplasty: outcomes and evaluation of host bone contact by 2D/3D image registration

Glenoid bone grafting in primary reverse total shoulder arthroplasty

Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and may necessitate glenoid bone grafting. The purpose of this study was to determine results, complications, and rates of failure of glenoid bone grafting in primary reverse shoulder arthroplasty. Forty-one shoulders that underwent primary reverse arthroplasty between 2006 and 2013 with a minimum follow-up of 2 years (mean, 2.8 years; range, 2-6 years) were reviewed. Thirty-four (83%) received corticocancellous grafts and 7 (17%) structural grafts. Active range of motion and pain levels were significantly improved (P < .001), with mean American Shoulder and Elbow Surgeons score of 77, Simple Shoulder Test score of 9, and patient satisfaction of 93% at the most recent follow-up. Preoperative severe glenoid erosion and increasing body mass index were significantly associated with worse American Shoulder and Elbow Surgeons scores (P = .04). On radiographic evaluation, 7 patients (18%) had grade 1 or grade 2 glenoid lucency. Glenoid bone graft incorporation was observed in 31 patients (78%). Twelve patients (30%) suffered from grade 1 or grade 2 scapular notching. All of the patients with structural grafts showed graft incorporation and no signs of glenoid lucency. Although glenoid lucency, glenoid graft resorption, and scapular notching were present at short-term to midterm follow-up, none of the patients needed revision surgery. Primary reverse shoulder arthroplasty with glenoid reconstruction using bone graft relieved pain and restored shoulder function and stability.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff.

Treating shoulders with osteoarthritis, an intact rotator cuff, and substantial glenoid bone loss is challenging. One option is reaming the glenoid flat and inserting a reverse prosthesis. This study reports the subjective, objective, and radiographic results of reverse total shoulder arthroplasty (RTSA) in this population. We retrospectively reviewed 42 consecutive patients (23 women; mean age, 71 years [range, 53 to 89 years]) with primary glenohumeral osteoarthritis, intact rotator cuffs, and Walch type-A2 (n = 19), B2 (n = 5), or C glenoids (n = 18) who had undergone a total of 42 RTSAs with glenoid reaming without bone-grafting between 2008 and 2013 (mean follow-up, 36 months [range, 24 to 66 months]). All patients were evaluated before and after surgery subjectively (using a visual analog scale for pain and 5 shoulder-specific outcome instruments), objectively (with goniometric examination of shoulder range of motion), and radiographically (to assess baseplate loosening and degree of scapular notching). One baseplate (2%) failed, requiring revision surgery. There were no other signs of baseplate loosening in any patient at the last follow-up. Preoperatively to postoperatively, pain improved significantly (p < 0.001), as did all patient-reported outcome measures and the following range-of-motion parameters (p ≤ 0.001): active abduction, active flexion, and active external rotation with the arm elevated 90°. Eight (19%) of the patients had notching. RTSA without bone-grafting and with medialization of the baseplate in patients with osteoarthritis and severe glenoid bone loss resulted in significant improvement in pain and function with reliable short-term implant survivorship and may be a good alternative to anatomical TSA. Longer follow-up is needed to determine the relative advantages and disadvantages. This was an "off-label" indication for this device. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Bankart Repair Versus Open Bristow-Latarjet for Shoulder Instability

Background: The arthroscopic Bankart repair and open Bristow-Latarjet procedure are the 2 most commonly used techniques to treat recurrent shoulder instability. Purpose: To compare in a case control–matched manner the 2 techniques, with particular emphasis on return to sport after surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A study was conducted in 2 hospitals matching 60 patients with posttraumatic recurrent anterior shoulder instability with a minimum follow-up of 2 years (30 patients treated with arthroscopic Bankart procedure and 30 treated with open Bristow-Latarjet procedure). Patients with severe glenoid bone loss and revision surgeries were excluded. In one hospital, patients were treated with arthroscopic Bankart repair using anchors; in the other, patients underwent the Bristow-Latarjet procedure. Patients were matched according to age at surgery, type and level of sport practiced before shoulder instability (Degree of Shoulder Involvement in Sports [DOSIS] scale), and number of dislocations. The primary outcomes were return to sport (Subjective Patient Outcome for Return to Sports [SPORTS] score), rate of recurrent instability, Oxford Shoulder Instability Score (OSIS), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability Index (WOSI), and range of motion (ROM). Results: After a mean follow-up of 5.3 years (range, 2-9 years), patients who underwent arthroscopic Bankart repair obtained better results in terms of return to sport (SPORTS score: 8 vs 6; P = .02) and ROM in the throwing position (86° vs 79°; P = .01), and they reported better subjective perception of the shoulder (SSV: 86% vs 75%; P = .02). No differences were detectable using the OSIS or WOSI. The rate of recurrent instability was not statistically different between the 2 groups (Bankart repair 10% vs Bristow-Latarjet 0%; P = .25), although the study may have been underpowered to detect a clinically important difference in this parameter. The multiple regression analysis showed that the independent variables associated with return to sport were preoperative DOSIS scale, type of surgery, and recurrent dislocations after surgery. Patients who played sports with high upper extremity involvement (eg, swimming, rugby, martial arts) at a competitive level (DOSIS scale 9 or 10) had a lower level of return to sport with both repair techniques. Conclusion: Arthroscopic stabilization using anchors provided better return to sport and subjective perception of the shoulder compared with the open Bristow-Latarjet procedure in the population studied. Recurrence may be higher in the arthroscopic Bankart group; further study is needed on this point.

Primary shoulder arthroplasty using a custom-made hip-inspired implant for the treatment of advanced glenohumeral arthritis in the presence of severe glenoid bone loss

Total shoulder arthroplasty for end-stage glenohumeral arthritis with severe glenoid bone loss poses a unique challenge for shoulder surgeons. Current surgical solutions are limited and associated with high complication rates. We hypothesized that a custom-made computer-aided design-computer-aided manufacturing (CAD-CAM) total shoulder replacement (TSR; Stanmore Implants Worldwide, Elstree, UK) resembling a total hip prosthesis could offer a reliable alternative for this challenging subset of patients. Thirty-seven patients with rotator cuff-deficient end-stage glenohumeral arthritis and severe glenoid bone loss (assessed as not amenable to treatment with standard anatomic or reverse total shoulder implants) were treated with the CAD-CAM TSR between 2006 and 2013. Clinical data were collected prospectively and analyzed at a mean follow-up of 5 years. Postoperatively, the pain level with activity decreased from 9.2 ± 1.7 to 2.4 ± 2.9 (P < .001). The Oxford Shoulder Score improved from 11 ± 8 points to 27 ± 11 points (P < .001), and the Subjective Shoulder Value (on a 0%-100% scale) improved from 23% ± 14% to 60% ± 24% (P < .001). Active forward elevation improved from 39° ± 23° to 63° ± 38° (P < .001), and external rotation improved from 6° ± 16° to 15° ± 17° (P = .001). Component revision was required in 6 of 37 patients (16%) (glenoid loosening in 1, humeral stem loosening in 3, periprosthetic fracture in 1, and prosthesis dislocation in 1). The CAD-CAM TSR offers a reliable alternative for the treatment of end-stage glenohumeral arthritis with severe glenoid deficiency not amenable to standard anatomic or reverse total shoulder implants, with maintenance of significant pain relief and clinical-functional improvement at 5-year postoperative follow-up.

Shoulder arthroplasty in the presence of posterior glenoid bone loss.

➤ Chronic osteoarthritis of the glenohumeral joint, traumatic injury, post-reconstruction arthropathy, and developmental conditions such as glenoid dysplasia can result in posterior glenoid bone loss and excessive retroversion of the glenoid. Shoulder replacement in this setting is technically challenging and characterized by higher rates of complications and revisions.➤ Current options that should be considered for managing glenoid bone loss that results in >15° of retroversion include bone-grafting, augmented glenoid components, and reverse total shoulder replacement.➤ Asymmetric reaming is commonly used to improve version but should be limited to correction of 10° to 15° of retroversion in order to preserve subchondral bone.➤ Bone-grafting of glenoid defects has had mixed results and has been associated with graft-related complications, periprosthetic radiolucencies, and glenoid component failure; however, it provides a biologic option for patients with severe bone loss.➤ Implantation of an augmented polyethylene glenoid component offers the potential to improve version while preserving subchondral bone, but the procedure is technically demanding and without clinical follow-up data at this point.➤ Reverse total shoulder arthroplasty offers improved fixation and stability compared with an anatomic prosthesis for elderly patients with severe glenoid bone loss but is associated with a high complication rate.➤ Glenoid dysplasia is defined as a deformity that results in >25° of glenoid retroversion. Advanced imaging needs to be obtained in order to ensure enough glenoid bone stock is present to allow anatomic glenoid component placement.

Step-Cut Bone-Graft Technique for Osteoarthritis with Severe Glenoid Bone Loss.

We describe a bone-graft technique, for shoulder arthroplasty in patients with severe glenoid bone loss, that utilizes a "step cut," a trapezoidal bone wedge from the resected humeral head, and graft fixation with screws placed from posterior to anterior through the graft. Carry out preoperative planning for the step-cut procedure. Expose the glenoid for bone graft insertion, taking care to avoid excessive reaming. Cut the appropriately sized glenoid bone graft from the resected humeral head. Position the bone graft in the glenoid defect and stabilize it with screws. Create an even concave surface between the anterior aspect of the glenoid and the posterior aspect of the graft. Position the glenoid component following step-cut graft implantation. Postoperative rehabilitation is mostly the same as that for standard total shoulder replacement without bone-grafting. The range of motion improved significantly in our study of twelve patients (p < 0.001).IndicationsContraindicationsPitfalls & Challenges.

Arthroscopic Bristow-Latarjet combined with bankart repair restores shoulder stability in patients with glenoid bone loss.

BackgroundArthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure.Questions/purposesWe determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout.MethodsBetween July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed.ResultsAt latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion.ConclusionsThe arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Use of a Custom Glenoid Component for the Treatment of Severe Glenoid Bone Loss in Reverse Total Shoulder Arthroplasty

The Use of a Custom Glenoid Component for the Treatment of Severe Glenoid Bone Loss in Reverse Total Shoulder Arthroplasty

Hip-inspired implant for revision of failed reverse shoulder arthroplasty with severe glenoid bone loss

Background and purpose — Glenoid reconstruction and inverted glenoid re-implantation is strongly advocated in revisions of failed reverse shoulder arthroplasty (RSA). Nevertheless, severe glenoid deficiency may preclude glenoid reconstruction and may dictate less favorable solutions, such as conversion to hemiarthropasty or resection arthropasty. The CAD/CAM shoulder (Stanmore Implants, Elstree, UK), a hip arthroplasty-inspired implant, may facilitate glenoid component fixation in these challenging revisions where glenoid reconstruction is not feasible. We questioned (1) whether revision arthroplasty with the CAD/CAM shoulder would alleviate pain and improve shoulder function in patients with failed RSA, not amenable to glenoid reconstruction, (2) whether the CAD/CAM hip-inspired glenoid shell would enable secure and durable glenoid component fixation in these challenging revisions.Patients and methods — 11 patients with failed RSAs and unreconstructable glenoids underwent revision with the CAD/CAM shoulder and were followed-up for mean 35 (28–42) months. Clinical outcomes included the Oxford shoulder score, subjective shoulder value, pain rating, physical examination, and shoulder radiographs.Results — The average Oxford shoulder score and subjective shoulder value improved statistically significantly after the revision from 50 to 33 points and from 17% to 48% respectively. Pain rating at rest and during activity improved significantly from 5.3 to 2.3 and from 8.1 to 3.8 respectively. Active forward flexion increased from 25 to 54 degrees and external rotation increased from 9 to 21 degrees. 4 patients required reoperation for postoperative complications. No cases of glenoid loosening occurred.Interpretation — The CAD/CAM shoulder offers an alternative solution for the treatment of failed RSA that is not amenable to glenoid reconstruction.

Clinical and Radiographic Outcomes of Total Shoulder Arthroplasty with Bone Graft for Osteoarthritis with Severe Glenoid Bone Loss

Glenohumeral osteoarthritis may be associated with severe posterior glenoid bone loss and glenoid retroversion. Treatment with total shoulder arthroplasty and autologous bone graft obtained from the humeral head has been infrequently reported in the peer-reviewed literature. The clinical and radiographic results of primary total shoulder replacement with an all-polyethylene glenoid component and autologous humeral head graft augmentation performed by a single surgeon in thirteen consecutive patients were evaluated. Twelve of the thirteen patients were followed for a minimum of two years (average, fifty-three months; range, twenty-six to 110 months). The average glenoid retroversion on preoperative computed tomography (CT) scans was 44° (range, 20° to 65°). Based on the Walch classification of pathologic glenoid morphology, nine glenoids were B2 and three were type C. All patients had an intact cuff at the time of surgery. At the time of the last follow up, ten of the twelve patients had graft incorporation without any resorbtion and two had minor bone graft resorption. Broken screws occurred in two of these ten cases. Two patients, both of whom required revision surgery, had failure of fixation and of graft incorporation; one of these failures was due to early postoperative trauma and the other, to Propionibacterium acnes infection. The early and midterm results of total shoulder arthroplasty with autogenous bone graft demonstrated substantial clinical and radiographic improvement in most cases.

Prediction of coracoid thickness using a glenoid width–based model: implications for bone reconstruction procedures in chronic anterior shoulder instability

Chronic anterior shoulder instability with glenoid bone loss can be a very challenging clinical problem. Significant bone loss is commonly managed with the Latarjet procedure. However, in some cases with severe glenoid bone loss, iliac crest bone grafting is required to obtain a graft of adequate size. Iliac crest bone graft is associated with high rates of donor-site complications. Whereas glenoid dimensions can be determined by use of 3-dimensional computed tomography reconstructions, the thickness of the coracoid cannot be easily measured. This study aims to define a ratio between glenoid width and coracoid thickness that can be used in preoperative planning to determine whether coracoid transfer will yield adequate bone graft to restore glenoid contour or whether iliac crest bone graft must be taken. We studied 100 paired cadaveric scapulae (50 male and 50 female scapulae). The bony dimensions of the coracoid and glenoid were measured for each specimen. Coracoid and glenoid dimensions are provided. The mean thickness of the male coracoid was 35.4% of the width of the glenoid. The mean female coracoid thickness was 34.4% of the glenoid width. A new biomorphologic model is presented to predict coracoid thickness and the ability of the Latarjet procedure to restore stability to a given bone-deficient glenoid. This model may aid the shoulder surgeon in preoperative planning and help promote successful outcomes in glenoid reconstruction surgery by determining whether a Latarjet procedure or iliac crest bone graft is the most appropriate procedure given the predicted amount of coracoid bone graft available.

Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency

Treatment of patients with shoulder arthritis and severe glenoid bone loss is controversial. Medial and posterior bone loss limits the size of the glenoid vault, which is the structural support of all current glenoid designs. This study presents short-term outcomes of a treatment using inset glenoid implants during shoulder replacement surgery in deficient glenoid bone. This study presents short-term outcomes of total shoulder replacement surgery using custom inset glenoid implants in deficient glenoid bone. Seven consecutive patients (3 men, 4 women; mean age 70 years) treated with inset glenoid implants for severe bone deficiency were retrospectively evaluated at a minimum 3-year follow-up. Severely deficient bone was defined by a neutral glenoid vault depth of less than 15 mm. No bone grafts were used. All patients were evaluated before and after surgery with physical examination, radiographic studies, and outcome measures. All patients had a diagnosis of osteoarthritis. No patients had rotator cuff tears or a history of instability. No surgical complications occurred. At an average of 4.3 years, the mean American Shoulder and Elbow Surgeon score improved 68 points. There were statistically significant improvements in range of motion (forward flexion 33°, external rotation 34°, internal rotation 6 spinal levels) and in pain (6.9 to 0.1). Independent radiographic analysis determined all implants were classified as "low risk" for glenoid loosening. The treatment of shoulder arthritis with severe glenoid bone loss is controversial and the results are mixed. Current treatments consist of hemiarthroplasty with or without glenoid reaming, total shoulder replacement without version correction, and total shoulder replacement with bulk bone grafting and version correction. The surgical technique and clinical results described in this case series demonstrate a novel approach of inset glenoid fixation for severely deficient bone. This study documents for the first time the possibility of safely and effectively using inset glenoid implants to reconstruct deficient bone for which standard implants are contraindicated.

Glenoid Tricortical Iliac Crest Structural Bone Graft Enhanced With Resorbable Cement for the Treatment ofAseptic Glenoid Loosening

Aseptic glenoid loosening is the most frequent cause of revision and can be associated with severe cavitary, segmental, or combined glenoid bone defects. In this study, we describe a glenoid reconstruction technique using tricortical iliac crest graft supplemented with resorbable bone cement. We report on the results of this technique in 6 patients with an average follow-up of 15 months. The average Constant score improved from 36.8 to 59.8 points after revision. Subjectively, 5 of the 6 patients were satisfied with their results and 1 patient was disappointed. We observed satisfactory healing of the graft and maintained homogenous density of the graft in 5 of 6 cases. There was severe erosion of the graft in the case with poor healing and graft resorption, possibly due to a low-grade infection, although this was not proven. There was a partial erosion of the graft observed in 2 additional cases, whereas the remaining 3 cases had no, or only minimal, erosion. Although long-term follow-up is necessary, we have been pleased with the early results of this technique for glenoid reconstruction in the presence of severe glenoid bone loss, an extremely difficult and challenging surgical problem. Level of Evidence: Case series IV.

Reverse Total Shoulder Replacement in Patients with Severe Glenoid Bone Loss

A commonly cited contraindication to reverse total shoulder arthroplasty is deficient glenoid bone stock. Deficient glenoid bone stock can lead to inadequate glenoid baseplate fixation and, eventually, glenoid component loosening and prosthesis failure . However, with improved prosthetic designs and increased surgeon experience, indications for use of reverse total shoulder arthroplasty continue to expand to include shoulders that would have previously seemed doomed to failure if treated with a reverse prosthesis. In this article, 3 cases are presented, 1 of cuff tear arthropathy and 2 of chronic anterior dislocations, in whom primary reverse total shoulder arthroplasty was performed despite the presence of severe glenoid bone deficiency. Corticocancellous bone grafting was used at the time of the reverse arthroplasty to augment the deficient glenoid and allow for simultaneous and adequate glenoid component fixation. All 3 cases showed excellent results in short-term follow-up, providing surgeons with an option for how to treat these difficult shoulders.