Severe Glenoid Bone Loss Research Articles

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.

Open Reconstruction of Large Bony Glenoid Erosion with Allogeneic Bone Graft for Recurrent Anterior Shoulder Dislocation

Background Severe glenoid bone loss in recurrent anterior glenohumeral instability is rare and difficult to treat. Purpose The authors present a surgical technique using allogeneic bone grafting for open anatomic glenoid reconstruction in addition to the capsular shift procedure. Study Design Case series; Level of evidence, 4. Methods Nine consecutive patients with a history of recurrent anterior shoulder instability underwent reconstruction of large bony glenoid erosion with a femoral head allograft combined with an anteroinferior capsular shift procedure. Preoperative computed tomographic and arthroscopic evaluation was performed to confirm a ≥120° osseous defect of the anteroinferior quadrant of the glenoid cavity, which had an “inverted-pear” appearance. Patients were followed for at least 4.5 years (range, 4.5-14). Serial postoperative radiographs were evaluated. Functional outcomes were assessed using Rowe scores. Results All grafts showed bony union within 6 months after surgery. The mean Rowe score improved to 84 from a preoperative score of 24. The mean loss of external rotation was 7° compared with the normal shoulder. One subluxation and 1 dislocation occurred after grand mal seizures during follow-up. These 2 patients regained shoulder stability after closed reduction. The remaining patients did not report recurrent instability. All patients resumed daily activities without restricted motion. Conclusion This technique for open reconstruction is viable for the treatment of recurrent anterior glenohumeral instability with large bony glenoid erosion.

(i) Shoulder arthroplasty for osteoarthritis and rheumatoid arthritis

Replacement arthroplasty represents the treatment of choice for most patients with end-stage glenohumeral osteoarthritis or rheumatoid arthritis. Multiple studies have documented reliable improvements in pain, range of motion, function and quality of life after this procedure. Total shoulder arthroplasty seems to be associated with more reliable pain relief and improvements in elevation when compared to hemiarthroplasty. The main surgical principles of shoulder arthroplasty apply equally to patients with osteoarthritis and rheumatoid arthritis; however, the different underlying pathology associated with these two conditions needs to be understood in order to modify the surgical technique accordingly. Most patients with osteoarthritis have an intact rotator cuff and enough glenoid bone stock to allow implantation of a glenoid component. Asymmetric posterior glenoid erosion often needs to be corrected and capsular releases are needed to restore elevation and external rotation. In rheumatoid arthritis, implantation of a glenoid component may not be possible in the presence of severe glenoid bone loss or a massive irreparable cuff tear; in addition, rheumatoid involvement of other joints needs to be taken into consideration. Infection, instability, periprosthetic fractures, and glenoid loosening or erosion are the main failure mechanisms of shoulder arthroplasty. Careful surgical technique and a well-executed physical therapy program translate into successful outcomes in most patients with osteoarthritis and rheumatoid arthritis. Replacement arthroplasty represents the treatment of choice for most patients with end-stage glenohumeral osteoarthritis or rheumatoid arthritis. Multiple studies have documented reliable improvements in pain, range of motion, function and quality of life after this procedure. Total shoulder arthroplasty seems to be associated with more reliable pain relief and improvements in elevation when compared to hemiarthroplasty. The main surgical principles of shoulder arthroplasty apply equally to patients with osteoarthritis and rheumatoid arthritis; however, the different underlying pathology associated with these two conditions needs to be understood in order to modify the surgical technique accordingly. Most patients with osteoarthritis have an intact rotator cuff and enough glenoid bone stock to allow implantation of a glenoid component. Asymmetric posterior glenoid erosion often needs to be corrected and capsular releases are needed to restore elevation and external rotation. In rheumatoid arthritis, implantation of a glenoid component may not be possible in the presence of severe glenoid bone loss or a massive irreparable cuff tear; in addition, rheumatoid involvement of other joints needs to be taken into consideration. Infection, instability, periprosthetic fractures, and glenoid loosening or erosion are the main failure mechanisms of shoulder arthroplasty. Careful surgical technique and a well-executed physical therapy program translate into successful outcomes in most patients with osteoarthritis and rheumatoid arthritis.

Locations for screw fixation beyond the glenoid vault for fixation of glenoid implants into the scapula: An anatomic study

Screw fixation is often required for glenoid implants and glenoid bone grafting, yet no study has evaluated the complex and irregular anatomy of the scapula to determine the best positions for the screws. Current implants rely solely on the bone in the glenoid vault for screw fixation, but in cases with glenoid bone loss, screw fixation may not confer adequate stability. The purpose of this study was to find the best positions for screws that are secured in bone beyond the glenoid vault. Twenty-seven scapulae from the Hamann-Todd osteologic collection underwent a computed tomography scan, and the images were transferred to a custom computer program that allowed 3-dimensional manipulation of the scapular images. Virtual screws were inserted into the scapula through the glenoid fossa, and the starting points and screw lengths were recorded. The coordinates of the starting points were scaled to allow comparisons among the different sizes of scapula. Once the ideal screw position was found, the angle of insertion was altered by 15 degrees in 4 directions, and the resulting screw length was recorded to show the effects of screw insertion error. Three screws could be inserted through the glenoid fossa into bone beyond the glenoid vault. The superior screw had a median length of 29 mm and exited at the junction of the coracoid and the suprascapular notch. The middle screw had a median length of 60 mm and exited at the junction of the spine and the scapular body. The inferior screw had a median length of 75 mm and exited posterior to the tip of the scapula. When the starting positions were constrained by a symmetric implant, the median superior screw length was 19 mm, the median inferior screw length was 61 mm, and the median middle screw length was 55 mm. Screw fixation in bone beyond the glenoid vault can be used for fixation of glenoid implants or glenoid bone grafting. Future studies are required to test the biomechanical stability of this new screw configuration, as well as methods and tools for precise implantation of the screws into the described locations. Once these studies are completed revision total shoulder arthroplasty with severe glenoid bone loss may be treated in 1 stage with screw fixation of a glenoid implant over bulk allograft.

Anatomical Glenoid Reconstruction for Recurrent Anterior Glenohumeral Instability with Glenoid Deficiency Using an Autogenous Tricortical Iliac Crest Bone Graft

Background Anterior shoulder instability associated with severe glenoid bone loss is rare, and little has been reported on this problem. Recent biomechanical and anatomical studies have suggested guidelines for bony reconstruction of the glenoid. Hypothesis Anatomical glenoid reconstruction will restore stability in shoulders with recurrent anterior instability owing to glenoid bone loss. Study Design Case series; Level of evidence, 4. Methods Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. Results At mean follow-up of 33 months, the mean American Shoulder and Elbow Surgeons score was 94, compared with a preoperative score of 65. The University of California, Los Angeles score improved to 33 from 18. The Rowe score improved to 94 from a preoperative score of 28. The mean motion loss compared with the contralateral, normal shoulder was 7° of flexion, 14° of external rotation in abduction, and one spinous process level for internal rotation. All patients returned to preinjury levels of sport, and only 2 complained of mild pain with overhead sports activities. No patients reported any recurrent instability (dislocation or subluxation). The CT scans with 3-dimensional reconstructions obtained 4 to 6 months postoperatively demonstrated union of the bone graft with incorporation along the anterior glenoid rim and preservation of joint space. Conclusion Anatomical reconstruction of the glenoid with autogenous iliac crest bone graft for recurrent glenohumeral instability in the setting of bone deficiency is an effective form of treatment for this problem.

Anterior shoulder dislocation: quantification of glenoid bone loss with CT.

In recurrent anterior shoulder dislocation, glenoid bone loss may predispose the patient to further dislocation and failure of a Bankart repair. This study investigates the quantification of glenoid bone loss in anterior shoulder dislocation using CT. CT examinations were performed on 40 patients (average age, 31 years; range, 13-82 years), comprising 46 shoulders with anterior dislocation and 34 contralateral normal shoulders. Twenty shoulders in 10 healthy subjects were also examined. Both shoulders were examined simultaneously. Image reconstruction included oblique sagittal reformatted images en face to the glenoid fossa. Seven aspects of glenoid fossa shape and size were measured, including the cross-sectional area, maximum width, maximum height, and flattening of the anterior glenoid curvature. Variable flattening of the anterior glenoid curvature was a feature in 42 (91%) of 46 dislocated shoulders although it was seen in only two (4%) of 54 normal shoulders. Anterior glenoid flattening increased exponentially with an increasing number of dislocations. Anterior glenoid flattening, decreased maximum glenoid width, and decreased maximum width-to-length ratio were the most useful measures of bone loss. Maximum glenoid width was smaller than on the contralateral side in 79% of patients with unilateral dislocation by an average of 3.0 mm (range, 0.1-10 mm) or 10.8% (range, 0.4-32%). Glenoid cross-sectional area was a less useful measure of glenoid bone loss. Flattening of the anterior glenoid curvature is shown in most patients with anterior dislocation. In unilateral dislocation, a comparison of maximum glenoid width with that on the contralateral side was the best discriminator of moderate to severe glenoid bone loss.