Glenoid revision surgery after total shoulder arthroplasty

Revision shoulder arthroplasty: a systematic review and comparison of North American vs. European outcomes and complications

BACKGROUND

Joint registries provide invaluable data on primary arthroplasties with revision as the endpoint; however, the revision outcomes are often excluded. Therefore, a PROSPERO registered review (CRD42015032531) of all revision studies in North America and Europe was conducted to evaluate demographics, etiologies and indications, implant manufacturer, and complications by geographic region.

METHODS

The MEDLINE, EMBASE, and CENTRAL databases were searched for revision arthroplasty clinical studies with a minimum mean 24-month follow-up. There were no language exclusions. Articles published in German, French, and Italian were reviewed by research personnel proficient in each language.

RESULTS

The mean age at revision was 66 ± 5 years (male = 759, female = 1123). The male-female ratio in North American and Europeans studies was 43:57 and 34:66, respectively. The most common etiology for primary surgery in both regions was osteoarthritis or glenoid arthrosis (38%). The most common revision indication overall was rotator cuff tear, deficiency, or arthropathy (26%). The most common implant type used in revisions was a reverse shoulder arthroplasty (54%). The complication rate for all revisions was 17%. There were a total of 465 complications, and of those, 74% lead to a reoperation.

CONCLUSION

Generally, shoulder arthroplasties are designed to last 10-15 years; however, revisions are being performed at a mean 3.9 years from the primary procedure, based on the published studies included in this systematic review. Additionally, of the complications, a large number (74%) went on to a reoperation. Further insight into the reasons for early revisions and standardized reporting metrics and data collection on revisions is needed.

Bone grafting in primary and revision reverse total shoulder arthroplasty for the management of glenoid bone loss: A systematic review

Purpose

We performed a systematic review of the studies including clinical/functional outcomes and complications of bone grafting for glenoid defects in reverse total shoulder arthroplasty (RTSA).

Methods

The PubMed and Cochrane databases were searched for relevant papers.

Results

Thirteen articles were included. The mean clinical/functional subjective scores significantly improved postoperatively. The implant revision rate for primary and revision RTSA was 3.1% and 21.1% respectively. The reoperation rate was 3.5% and 24.4% respectively.

Conclusions

There was moderate evidence that bone grafting is effective for glenoid defects in primary RTSA. Further high-quality research is required about revision RTSA for moderate-to-severe glenoid defects.

Conversion of Failed Reverse Total Shoulder Arthroplasty to Hemiarthroplasty: Three Cases of Instability and Three Cases of Glenoid Loosening

Background

Glenoid loosening and postoperative instability are common causes of failed reverse total shoulder arthroplasty (RTSA). When soft-tissue problems or large glenoid bone defect interferes with reimplantation in revision RTSA, conversion to hemiarthroplasty can be considered. We present a case series of patients who underwent conversion to hemiarthroplasty due to glenoid loosening and early instability after RTSAs, along with clinical results.

Methods

A total of 72 primary RTSAs using the Aequalis prosthesis were performed at our institution from May 2009 to December 2016. Of these, five patients, including one with humeral neck fracture and absent rotator cuff and four with cuff tear arthropathy, underwent conversion to hemiarthroplasty. Another patient who had RTSA at a local clinic underwent hemiarthroplasty at our institution for unresolved postoperative anterior dislocation. The mean age of the six patients was 71.7 years (range, 62 to 76 years), and the mean follow-up period was 24.4 months (range, 18 to 30 months). Clinical assessments were conducted by using the visual analog scale (VAS), American Shoulder and Elbow Surgery (ASES) score, and University of California at Los Angeles (UCLA) shoulder score at the last follow-up.

Results

The conversion to hemiarthroplasty in the six patients dramatically improved the mean VAS score (preoperative, 8.1; postoperative, 2.5), ASES score (preoperative, 22.1; postoperative, 56.5), and UCLA score (preoperative, 12; postoperative, 18.1). However, the range of motion was almost unchanged after surgery.

Conclusions

Conversion to hemiarthroplasty can be a good alternative to revision RTSA in patients with serious complications (such as unresolved instability and glenoid loosening) difficult to treat with revision RTSA.

Accuracy of patient-specific instrumentation in shoulder arthroplasty: a systematic review and meta-analysis

Background

There has been significant recent emphasis on the use of patient-specific instrumentation (PSI) in shoulder arthroplasty. However, clinical data are lacking to support the increased time and expense associated with PSI. Our purposes were to determine whether PSI significantly improves implantation accuracy during total shoulder arthroplasty (TSA) and to analyze available techniques and correlation with clinical outcomes. We hypothesized that PSI may improve glenoid component position radiographically but without correlation with clinical outcomes.

Methods

The MEDLINE, Scopus, Embase, and Cochrane Library databases were queried. Included articles reported use of any preoperative or intraoperative PSI techniques, models, or guides to assist with TSA prosthesis implantation. The primary outcomes were mean deviation from the preoperative plan in version (in degrees), inclination (in degrees), and entry-point offset on the glenoid (in millimeters).

Results

Among the included articles, 518 TSA procedures (352 anatomic and 166 reverse) were performed. The mean postoperative errors in both version and inclination angles were 5° or less in 20 articles (90.9%) using PSI. Meta-analysis revealed no statistically significant differences in version error (P > .999, I ² = 64.6%), inclination error (P = .702, I ² = 82.2%), or positional offset (P = .777, I ² = 85.7%) between PSI and standard instrumentation. No data regarding patient-reported outcome measures, range of motion, strength, or glenoid component loosening and longevity were reported.

Conclusions

Meta-analysis revealed no significant differences in accuracy between PSI and standard instrumentation. Although PSI may possess the potential to improve TSA techniques, further investigations regarding long-term clinical outcomes, impact on operating room time, and cost-effectiveness are warranted before PSI can be routinely recommended over conventional instrumentation.

[Shoulder prosthesis replacement options : New implants, treatment algorithms and clinical results]

BACKGROUND

Bony defect situations are a common problem in revision arthroplasty of the shoulder and are the cause of the complexity of the procedure. Aseptic and septic loosening as well as difficult implant removal can result in humeral and/or glenoid bone loss.

PLANNING

A careful preoperative imaging is needed to estimate the extent of the bony defect and to enable precise planning of the bone reconstruction and the required implants. However, the size of the defect needs to be re-evaluated intraoperatively after removal of the implant components and any larger defects have to be addressed appropriately.

PROSTHESIS DESIGN

While in the glenoid autologous bone grafts and, to a lesser extent, allogenic bone grafts are preferred, metallic augmented implants have recently become available to fill the glenoid bone defect. However, humeral defects are normally addressed with longer revision stems, possibly with allograft augmentation. The soft tissue loss in proximal humeral defects can be addressed with fixation techniques to improve function and reduce the risk of dislocation. Modern modular prosthesis designs allow prosthesis conversion while leaving bony, tightly integrated component parts on the glenoid or shaft. This review describes the preoperative diagnostic steps as well as techniques for revision surgery of the shoulder in the case of bone loss.

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under

BACKGROUND

Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy.

METHODS

A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined.

RESULTS

A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA.

CONCLUSION

In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.

Treatment of severe glenoid deficiencies in reverse shoulder arthroplasty: the Glenius Glenoid Reconstruction System experience

BACKGROUND

The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant.

METHODS

We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans.

RESULTS

At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm³ (range, 1-14 cm³). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively.

CONCLUSION

Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Revision of failed hemiarthroplasty and anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty

BACKGROUND

The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Revision of failed anatomic arthroplasty to reverse total shoulder arthroplasty has shown promise alongside concerning complication rates.

METHODS

Patients who underwent revision shoulder arthroplasty during a 7-year period at a tertiary care health system were identified. Presurgical and operative data were analyzed for 110 patients who met inclusion and exclusion criteria. Patients were contacted at a mean follow-up of 57 ± 26 months (range, 23-113 months) from revision surgery for functional outcomes scores, reoperations, and implant survival.

RESULTS

Implant survival was 92% at 2 years and 74% at 5 years. Mean American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, and visual analog scale pain scores were 63 ± 24 (range, 5-97), 60 ± 25 (range, 0-100), and 2.9 ± 2.9 (range, 0-10), respectively. Seventy percent of patients were "very satisfied" or "satisfied with their outcome. Complications occurred in 18 patients (20%), and 10 patients (11%) underwent reoperation.

CONCLUSIONS

Modest patient results and satisfaction can be achieved with revision of a failed anatomic arthroplasty to a reverse total shoulder arthroplasty. As is typical of revision surgery, complications are common and can compromise results. Further study is needed to identify factors that may contribute to successful outcomes.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.

Management of the Failed Arthroplasty for Proximal Humerus Fracture

A variety of reasons exist for failure of arthroplasty performed for management of proximal humerus fracture. Revision surgery for these failures is complex and has a high likelihood of inferior outcomes compared with primary arthroplasty. Successful management requires consideration of various modes of failure including tuberosity malunion or resorption, rotator cuff deficiency, glenoid arthritis, bone loss, component loosening, stiffness, or infection. Although revision to a reverse shoulder arthroplasty is an appealing option to address instability, rotator cuff dysfunction, and glenoid arthritis, there are concerns with higher complication rates and inferior results compared with primary reverse replacement. Any treatment plan should appropriately address the cause for failure to optimize outcomes.

Comparison of radiographic and clinical outcomes of revision reverse total shoulder arthroplasty with structural versus nonstructural bone graft

BACKGROUND

Revision shoulder arthroplasty in the setting of glenoid bone loss poses substantial surgical challenges. This study's purpose was to compare radiographic and clinical results of patients requiring structural iliac crest bone autograft (ICBA) for severe bone loss versus patients with less severe bone loss treated with nonstructural bone allograft (NSBA) in the setting of revision reverse total shoulder arthroplasty (RSA).

METHODS

A retrospective cohort of 30 patients (70% of the 43 patients who met the inclusion criteria) undergoing revision RSA with ICBA (n = 15) or NSBA (n = 15) between 2007 and 2015 were analyzed at a minimum 2-year follow-up. Radiographic assessment included bone graft integration, bone graft resorption, glenosphere tilt, glenosphere version, and the presence of scapular notching. Clinical assessment included active range of motion, Penn Shoulder Score, Veterans RAND 12-item health survey, and need for revision surgery.

RESULTS

No radiographic difference was found between the ICBA and NSBA groups with regard to implant position, graft integration, scapular notching, implant shift, or failure of fixation (P > .05). Of 15 patients with ICBA, 14 (93%) had at least partial integration of the bone graft. Some degree of resorption of the bone graft was noted in 6 of 15 patients (40%). There was no significant difference in postoperative active range of motion, Penn Shoulder Score, or Veterans RAND 12-item health survey score (P > .05 for all comparisons). One patient in the ICBA group underwent revision surgery for glenoid baseplate failure.

CONCLUSION

Revision RSA with glenoid bone grafting resulted in good clinical and radiographic outcomes at short-term follow-up. Patients requiring structural ICBA were not at increased risk of component failure, radiographic or clinical complications, or inferior clinical outcomes.

Revision of Failed Resurfacing Hemiarthroplasty: Midterm Results, Survival, and Group Comparison

Shoulder arthroplasty is a valuable option for treating glenohumeral osteoarthritis. Revision surgery for a failed shoulder arthroplasty is associated with difficult procedures, complications, and worse outcomes. Compared with a total joint arthroplasty, a resurfacing prosthesis has the supposed advantages of limited perioperative complications and little bone loss during revision. The aim of this study was to describe patient-reported outcome measures of revision surgery from failed uncemented Global CAP (DePuy, Warsaw, Indiana) resurfacing hemiarthroplasty to total shoulder or reverse shoulder arthroplasty. Eleven patients from 2 collaborating institutes had a failed resurfacing prosthesis. Revision surgery was performed to total shoulder prosthesis in 7 patients and to reverse shoulder prosthesis in 3 patients. Data were missing for 1 patient. Outcomes were monitored using the Constant-Murley score, Dutch Simple Shoulder Test, Short Form-12, visual analog scale for pain, and physical examination. Mean time to revision was 54 months (SD, 15.6 months). No perioperative complications occurred. At 42 months of follow-up (SD, 15.9 months), clinical and patient-reported outcomes were excellent. The Constant-Murley score improved a significant 29 points (P<.01). The visual analog scale pain score decreased from 55 to 5 points (P<.01), and the Dutch Simple Shoulder Test and Short Form-12 scores improved significantly (P≤.02). Five-year survival was 82.6% (95% confidence interval, 71.6%-93.6%). At 3.5-year follow-up, clinical and patient-reported outcome measures had satisfying results. [Orthopedics. 2019; 42(1):e111-e117.].

Can a reverse shoulder arthroplasty be used to revise a failed primary reverse shoulder arthroplasty?: Revision reverse shoulder arthroplasty for failed reverse prosthesis

AIMS

Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA.

PATIENTS AND METHODS

We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10).

RESULTS

Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01).

CONCLUSION

Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493-98.

The Effect of Obesity in Shoulder Arthroplasty Outcomes and Complications

The effect of obesity in shoulder arthroplasty has been recently reported in the literature with different and conflicting results. This review analyzes the role of obesity on outcomes and complications in shoulder arthroplasty. Morbid obesity (body mass index >40 kg/m²), more than standard obesity, is associated with a longer operative time, higher complication rate, reoperation rate and superficial infection. Obesity does not have a detrimental effect on functional outcomes. The magnitude of functional improvement in obese patients, however, can be inferior to that in nonobese patients. Obesity and morbid obesity do not increase hospital charges.

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

BACKGROUND

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.

MATERIALS AND METHODS

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).

RESULTS

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.

CONCLUSION

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.

Structural glenoid grafting during primary reverse total shoulder arthroplasty using humeral head autograft

BACKGROUND

Large glenoid bone defects in the setting of glenohumeral arthritis can present a challenge to the shoulder arthroplasty surgeon. The results of large structural autografting at the time of reverse total shoulder arthroplasty (RTSA) are relatively unknown.

METHODS

This retrospective case series describes the clinical and radiographic results of large structural autografting from the humeral head to the glenoid during primary RTSA.

RESULTS

Of 17 patients who met inclusion criteria, 14 (82% follow-up) were evaluated postoperatively at a mean of 2.6 years (range, 2.0-5.4 years). Mean inclination correction was 19° ± 12° (range, 3°-35°). Complications occurred in 3 patients, including 1 transient brachial plexus palsy, 1 loose baseplate, and 1 dislocation treated with closed reduction. Radiographic images showed 100% of grafts incorporated. Active forward elevation improved from 80° ± 40° to 130° ± 49° (P = .028). The visual analog scale score for pain improved from 8.1 ± 1.3 to 2.5 ± 3.1 (P = .005). The Simple Shoulder Test improved from 1.8 ± 1.1 to 6.5 ± 4 (P = .012). The American Shoulder and Elbow Surgeons score improved from 22 ± 10 to 66 ± 25 (P = .012). All patients (100%) were satisfied, and all patients (93%) but 1 stated that they would undergo the procedure again if given the chance.

CONCLUSIONS

RTSA incorporating structural grafting of the glenoid with humeral head autograft results in significant improvements in active forward elevation, pain, and function, with a low complication rate. This technique can reliably be used to achieve correction of large (up to 35°) glenoid defects with a 93% chance of baseplate survival and a 100% chance of graft incorporation in the short-term.

Revision of failed shoulder hemiarthroplasty to reverse total arthroplasty: analysis of 157 revision implants

BACKGROUND

There remains a paucity of studies examining the conversion of failed hemiarthroplasty (HA) to reverse total shoulder arthroplasty (RTSA). Therefore, the purpose of this study was to examine a large series of revision HA to RTSA.

METHODS

A population of 157 patients who underwent conversion of a failed HA to a revision RTSA from 2006 through 2014 were included. The mean follow-up was 49 months (range, 24-121 months). The indications for revision surgery included instability with rotator cuff insufficiency (n = 127) and glenoid wear (n = 30); instability and glenoid wear were associated in 38 cases. Eight patients with infection underwent 2-stage reimplantation.

RESULTS

Patients experienced significant improvements in their preoperative to postoperative pain and shoulder range of motion (P < .0001), with median American Shoulder and Elbow Surgeons and Simple Shoulder Test scores of 60 and 6 points, respectively. There were 11 (7%) repeated revision surgeries, secondary to glenoid component loosening (n = 3), instability (n = 3), humeral component disassembly (n = 2), humeral stem loosening (n = 1), and infection (n = 2). Implant survivorship was 95.5% at 2 years and 93.3% at 5 years. There were 4 reoperations including axillary nerve neurolysis (n = 2), heterotopic ossification removal (n = 1), and hardware removal for rupture of the metal cerclage for an acromial fracture (n = 1). At final follow-up, there were 5 "at-risk" glenoid components.

CONCLUSION

Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. There was a relatively low revision rate, with glenoid loosening and instability being the most common causes.

Bone grafting in oblique versus prepared rectangular uncontained glenoid defects in reversed shoulder arthroplasty. A biomechanical comparison

BACKGROUND

How the shape of the glenoid defect being reconstructed influences stability in reversed shoulder arthroplasty has never been evaluated. The purpose of this study was to compare the reconstruction of two different shaped defects in reversed shoulder arthroplasty.

METHODS

Two groups (ten Sawbone scapulae each) of oblique- and rectangular-shaped glenoid defects were tested biomechanically. On the anterior half of the glenoid, bony defects (rectangular and oblique shaped) were prepared and reconstructed subsequently with a graft and reversed shoulder arthroplasty. As a control group, Sawbones without glenoid deficiency were used. In addition, these tests were reproduced in cadavers.

FINDINGS

In Sawbones, no significant difference in initial stability was found between the two groups (p>0.05). Additionally, in the cadaver tests no significant difference was found between the groups with different defects (p>0.05). During the preparation, macroscopic loosening of the oblique bone grafts was found in three cases after the performance of the reversed shoulder arthroplasty due to the lack of medial support. The localization of the highest micromotion were measured primarily between the scapula bone and the graft compared to the measured micromotions between glenoid implant and the graft.

INTERPRETATION

If the oblique-shaped bone graft was secured under the baseplate, the rectangular defect preparation did not show a significantly higher primary stability. However, the advantage of medial support in rectangular defects leads to more stability while placing the bone graft and baseplate during the surgical technique and should therefore be considered a preferable option.

Biomechanical analysis of anterior bone graft augmentation with reversed shoulder arthroplasty in large combined glenoid defects compared with total bony joint line reconstruction (modified bony-increased-offset reversed shoulder arthroplasty)

BACKGROUND

The aim of this biomechanical study was to compare 2 surgical techniques for the reconstruction of large, combined, uncontained glenoid defects with reversed shoulder arthroplasty (RSA).

METHODS

Three groups of scapulae with RSA were tested by the application of a physiological combination of compressive/shear loads in Sawbones (Pacific Research Laboratories, Inc., Vashon Island, WA, USA) and cadavers. Two of the groups (both Sawbones and cadaveric specimens) consisted of anterior combined defects (14 mm in depth), and the third group served as a control group (only Sawbones specimens). The first group with an anterior combined defect was reconstructed with anterior bone grafts to contain the defect and cancellous bone to fill the central defect before RSA with partial bony joint line reconstruction (p-BJR). In the second group with an anterior combined defect, the dorsal rim was reamed and the joint line was reconstructed with a bone disc fully covering the peg. This total BJR (t-BJR) corresponds to the technique of bony-increased-offset-RSA (BIO-RSA).

RESULTS

At 150 µm of displacement, the loadings in the inferior-superior (IS) direction were significantly more stable than those in the anterior-to-posterior (AP) direction within both reconstructed defect groups (P ≤ .002). In contrast, no significant differences were found between the partial BJR and t-BJR group in either direction (Sawbones: AP: P = .29; IS: P = .44; cadavers: AP: P = .67; IS: P = .99). The control group revealed significantly higher values in all loadings of the IS direction and significantly higher loadings at 40 µm and 150 µm in the AP direction.

CONCLUSION

Both techniques could be applied for such complex defects provided that there is sufficient medial bone stock for a t-BJR. Significantly greater stability was found in the IS direction than in the AP direction within each group, which could be explained by the longer screw anchoring within the superior and inferior columns. Both defect groups were less stable than the group of intact glenoids.

Three-Dimensional Templating and Use of Standard Instrumentation in Primary Anatomic Total Shoulder Arthroplasty

Introduction

Three-dimensional (3D) templating of the glenoid in anatomic shoulder arthroplasty allows for more accurate planning and more optimal positioning of the glenoid component than 2-dimensional computed tomography (2D CT) scans through an improved understanding of both the pathologic and the premorbid glenoid joint line, version, and inclination in reference to an idealized calculated glenoid position.

Indications & Contraindications

Step 1 Obtain a CT Scan with 3D Reconstruction and Define Glenoid Version and Inclination

Obtain a CT scan of the entire scapula and proximal part of the humerus with slices of ≤1 mm and a 3D reconstruction with subtraction of the humeral head, and identify the scapular and glenoid planes to define the pathologic version and inclination, which can be done in any commercially available software program while following these basic principles (Video 1).

Step 2 Define Premorbid Glenoid Morphology

Carefully evaluate for the presence of the native glenoid, noting its version and inclination, and be careful to distinguish the true native glenoid from osteophytes (Video 2).

Step 3 Place the Virtual Implant

Place the virtual glenoid component to restore the premorbid glenoid anatomy (Video 3).

Step 4 Evaluate the Need for an Augmented Glenoid Component Bone Graft or Eccentric Reaming

In the presence of bone loss from posterior glenoid wear, assess the need for an augmented glenoid component, bone graft, or eccentric reaming to achieve adequate backside seating (Video 4).

Step 5 Note the Center Pin Position and Trajectory

Once the glenoid component has been templated, note the starting location and trajectory of the center pin used for cannulated glenoid reaming and bone preparation (Video 5).

Step 6 Remove Remaining Cartilage and Soft Tissue from the Glenoid Surface

Intraoperatively, remove remaining labrum and any remaining cartilage or soft tissue, and expose the glenoid periphery to clearly define the osseous anatomy, including the base of the coracoid, such that it mirrors what the 3D CT scan and preoperative plan display (Video 6).

Step 7 Place the Center Pin According to the Preoperative Plan

Place the center pin for glenoid preparation in the previously templated location and trajectory to emulate the surgical plan defined in the software (Video 7).

Results

We performed a prospective, randomized controlled trial of positioning of the glenoid component in anatomic TSA using preoperative planning with 3D CT scans and standard instrumentation compared with using 3D CT preoperative planning with patient-specific instrumentation²⁹.

Pitfalls & Challenges

Midterm outcomes of bone grafting in glenoid defects treated with reverse shoulder arthroplasty

BACKGROUND

Large glenoid defects are a difficult reconstructive problem for shoulder surgeons. The purpose of this study was to determine the complications, rate of healing, and functional results of glenoid bone grafting in primary or revision surgery with reverse shoulder arthroplasty.

METHODS

We retrospectively reviewed 23 patients with glenoid bone loss who underwent primary or revision surgery using a glenoid bone graft with a minimum follow-up of 2 years. Range of motion and the Constant, American Shoulder and Elbow Surgeons, and visual analog scale scores were obtained from preoperative assessment and the latest follow-up visit. Radiographic evaluation included analysis of plain radiographs as well as preoperative and follow-up computed tomography.

RESULTS

Three patients were excluded from the study. Allografts were used in 13 cases and autografts in 7 cases. The mean Constant score improved from 30.7 ± 9.4 to 51.3 ± 13.4 (P < .001). At a mean follow-up of 26 months, computed tomography imaging revealed that the glenoid bone graft was fully incorporated in 95% of cases. No statistically significant differences were found on analysis of the clinical and radiographic outcomes related to the graft source. There was a 20% postoperative complication rate: 1 case of aseptic glenoid component loosening, 1 surgical wound hematoma, 1 acromial fracture, and a symptomatic grade 3 scapular notching.

CONCLUSIONS

The use of bone grafts in glenoid defects is a useful technique by which, in the majority of cases, single-stage reconstruction surgery may be performed, even in the presence of severe bone loss. Incorporation rates are high, with satisfactory clinical outcome.

Outcome and revision rate of uncemented glenohumeral resurfacing (C.A.P.) after 5-8 years

BACKGROUND

Resurfacing of the glenohumeral joint for patients with glenohumeral arthritis has gained popularity since the first introduction. We report the mid-term results of the Global C.A.P. uncemented resurfacing shoulder prosthesis (DePuy Synthes).

METHODS

From January 2007 to December 2009, 48 humeral cementless resurfacing prostheses in 46 patients were performed. All patients were diagnosed with primary glenohumeral osteoarthritis. Patients were contacted for review; the Constant Score, visual analog pain scale, Dutch Simple Shoulder Test, SF-12 scores and physical examination were assessed both preoperatively and yearly postoperatively. Complications and revision surgery were documented. Radiographs were evaluated for component size, offset, inclination, height, loosening and subluxation.

RESULTS

Forty-six patients (12 males) with a mean age of 72 years old (range 59-89) were included. At a mean 6.4-year follow-up (range 5-8), the Constant Score, visual analog pain scale and the Dutch Simple Shoulder Test scores improved significantly (p < 0.05) from baseline. Three patients were lost to follow-up. One patient died and two patients were not able to attend the follow-up appointments, due to other health-related issues. Eleven patients (23%) had a revision operation.

CONCLUSIONS

The most important findings of this study of the Global C.A.P. shoulder resurfacing arthroplasty were an increase of range of motion, a reduction of pain complaints, but a concerning high rate of revision after mid-term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Revisions for aseptic glenoid component loosening after anatomic shoulder arthroplasty

BACKGROUND

Glenoid component loosening is a common indication for revision shoulder arthroplasty. The objective of this study is to assess the longer-term outcomes of patients undergoing revision specifically for aseptic loosening.

MATERIALS AND METHODS

Between 1985 and 2005, 34 revision shoulder arthroplasties were performed for aseptic glenoid loosening. Three patients were lost to follow-up. Treatment included component reimplantation in 20 shoulders (group I) or component removal with bone grafting in 11 shoulders (group II). We identified 9 cases of instability with or without rotator cuff tearing prior to revision. The mean follow-up period was 8.3 years.

RESULTS

The rate of survival free of reoperation at 10 years was 78.9% in group I and 83.9% in group II (P = .5). Pain relief occurred in 26 of 31 shoulders, with no difference between groups (P > .99). Active elevation and external rotation improved in both groups (P = .8). Five shoulders in group I had radiographically loose glenoids, with two requiring reoperation. Nine shoulders in group II had medial glenoid erosion, with two requiring reoperation for pain. There was a trend toward reoperation in those with preoperative instability (5 of 8 re-revisions).

DISCUSSION AND CONCLUSION

Glenoid revision surgery in the absence of infection provides satisfactory results, especially when instability is not coexisting. When glenoid bone stock permits, reimplantation of a new glenoid component in an active patient with an intact rotator cuff and no instability is reasonable. When the remaining glenoid bone will not support a new component, conversion to a hemiarthroplasty is also reasonable.

Reverse arthroplasty for patients with chronic locked dislocation of the shoulder (type 2 fracture sequela)

BACKGROUND

The aim of this multicenter study was to analyze the clinical and radiographic outcome and to report on the types of complications in patients with chronic locked shoulder dislocation treated with reverse shoulder arthroplasty.

METHODS

Twenty-two patients with a mean age of 71 years were included. The mean duration of follow-up was 3.5 years. Preoperatively, computed tomography or magnetic resonance imaging scans were performed and analyzed for bone defects and the status of the rotator cuff. Radiographs in 2 planes were obtained before arthroplasty and at final follow-up (mean, 3.5 years; range, 2-9 years). The Constant-Murley score was documented, together with active shoulder flexion, external rotation, and internal rotation.

RESULTS

There was a significant increase in mean Constant-Murley score from 13.6 points preoperatively to 47.4 points postoperatively (P < .001). Mean shoulder flexion was 37.7° before arthroplasty and 103° thereafter (P < .001). External rotation increased from -0.5° to 14.7° (P < .003). There were 7 complications (32%), leading to revision surgery in 6 cases (27%). The most common reason for revision surgery was failure of the glenoid component due to bone defects on the glenoid side. Eight patients rated their subjective result as very good, 5 as good, 5 as satisfactory, and 4 as unsatisfactory.

CONCLUSION

Reverse shoulder arthroplasty may be a viable treatment option for chronic locked shoulder dislocations with concomitant rotator cuff lesions and an intact glenoid. However, improvement in function is only fair and in this series, there was a high percentage of complications requiring re-operation.

Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with End-stage Shoulder Arthritis

BACKGROUND

Young patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment.

QUESTIONS/PURPOSES

We asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society?

METHODS

The incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with "satisfactory" or "excellent" outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States.

RESULTS

During the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient).

CONCLUSIONS

Treatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old.

LEVEL OF EVIDENCE

Level II, economic and decision analysis study.

Conversion to hemiarthroplasty as a salvage procedure for failed reverse shoulder arthroplasty

BACKGROUND

Optimal treatment of a failed reverse shoulder arthroplasty (RSA) is unclear. In the case of poor glenoid bone stock, retaining a RSA may be infeasible. We report our experience with conversions to hemiarthroplasty.

METHODS

Within 7 years, 16 patients underwent conversion to hemiarthroplasty after failed RSA. All patients had insufficient bone stock for reimplantation of another RSA. Standard radiographs and Constant, Shoulder Pain and Disability Index, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand scores were assessed preoperatively and up to a minimum of 24 months after surgery. Postoperative superior migration and complications were also documented.

RESULTS

Glenoid loosening was the primary reason for RSA failure in 11 patients. Three required revision surgery because of infection. Postoperative functional outcome was generally poor at the latest follow-up, with mean Constant, Shoulder Pain and Disability Index, and 11-item version of the Disabilities of the Arm, Shoulder and Hand scores of 25, 37, and 63 points, respectively. Baseline pain also did not improve. Medialization progressed beyond the coracoid in 6 patients, and complete anterosuperior escape was reported in 3 patients. Three postoperative complications were recorded by the final follow-up, including 2 periprosthetic humeral fractures treated conservatively and 1 patient with painful humeral component medialization leading to resection arthroplasty.

CONCLUSION

With excessive bone stock loss, hemiarthroplasty remains an option, despite the associated risks of uncertain pain relief and poor functional outcome. This technique offers a lower likelihood of undertaking further surgical interventions within the short-term to midterm postoperative period. Nevertheless, resection arthroplasty may still be considered another valuable solution.

Glenoid bone loss in primary and revision shoulder arthroplasty

The management of glenoid bone loss is a major challenge in both complex primary and revision arthroplasty surgery. To deal with this problem, a number of techniques have been advocated, although there has been no previous systematic review of the literature. In the present review, we have attempted to identify a coherent strategy for addressing this problem, taking into account the degree of bone loss, the advantages and limits of standard implants, bone reconstruction techniques and the use of customized prostheses.

Challenges in Reverse Shoulder Arthroplasty: Addressing Glenoid Bone Loss

Reverse shoulder arthroplasty (RSA) was designed for the treatment of elderly patients with cuff tear arthropathy. Because of its success, the indications for RSA have expanded beyond cuff tear arthropathy to include acute fractures, fracture sequelae, massive rotator cuff tears, inflammatory arthritis, and revision shoulder arthroplasty. Consequently, the number of RSAs performed has increased steadily. Glenoid bone loss is not uncommon in patients undergoing primary or revision RSA. Failure to appreciate and address glenoid bone loss during RSA can lead to improper baseplate positioning and early failure or complications such as dislocation or scapular notching. The authors present a review of the current literature as well as recommended strategies for characterization of glenoid bone loss and preferred surgical techniques for addressing bone loss during RSA.

Reverse total shoulder arthroplasty with structural bone grafting of large glenoid defects

BACKGROUND

Large glenoid defects pose difficulties in shoulder arthroplasty. Structural grafts consisting of a humeral head autograft, iliac crest, and allograft have been described. Few series describe grafts used with reverse total shoulder arthroplasty (RTSA).

METHODS

We retrospectively reviewed patients who had undergone primary or revision RTSA. We identified 44 patients (20 men and 24 women; mean age, 69 years) as having a bulk structural graft to the glenoid behind the baseplate. The grafts consisted of a humeral head autograft in 29, iliac crest autograft in 1, or femoral head allograft in 14. Range of motion data, American Shoulder and Elbow Surgeons score, simple shoulder test, shoulder pain and disability index, and Constant scores were obtained from preoperative and the latest follow-up visits. Radiographs were reviewed from the initial postoperative visit and the latest follow-up. The grafting cohort was compared with an age- and sex-matched cohort of RTSA patients without glenoid grafting.

RESULTS

Improvements were seen in the functional outcome scores at the latest follow-up. No significant differences were found in the preoperative or postoperative data between allografts and autografts. Postoperative scores for the bone graft cohort were significantly lower than those in the cohort without grafting. Complete or partial incorporation was shown radiographically in 81% of grafts. Six baseplates were considered loose. Complications included 2 infections, 1 dislocation, 1 humeral loosening, and 2 instances of clinical aseptic baseplate loosening. Six patients showed mild scapular notching.

CONCLUSIONS

The use of bulk structural grafts is a promising treatment option. Allografts may yield equally acceptable results compared with autografts.

Accuracy of patient-specific instrumentation in anatomic and reverse total shoulder arthroplasty

PURPOSE

Glenoid component malposition is associated with poor function and early failure of both anatomic and reverse total shoulder arthroplasty. Glenoid positioning is challenging particularly in the setting of bone loss or deformity. Recently, the use of computer assistance has been shown to reduce implantation error. The aim of this study is to evaluate the accuracy of patient-specific instrumentation in cases of anatomic and reverse shoulder replacement in vivo.

METHODS

Twenty patients underwent total shoulder arthroplasty using a computed tomography (CT)-based patient-specific instrumentation (PSI) system, ten anatomic and ten reverse. Preoperative three-dimensional digital templating of glenoid component position was undertaken and surgery then performed using a custom-made guide. Postoperative CT scans were used to compare final implanted component position to the preoperatively planned position in the same patient.

RESULTS

Final component position and orientation closely reflected the preoperatively templated position. Mean deviation in the glenoid version from planned was 1.8° ±1.9° (range, 0.1°-7.3°). Mean deviation in inclination was 1.3° ±1.0° (range, 0.2°-4.5°). Mean deviation in position on the glenoid face was 0.5 ± 0.3 mm (range, 0.0-1.3 mm) in the anteroposterior plane and 0.8 ± 0.5 mm (range, 0.0-1.9 mm) in the superoinferior plane. Actual achieved version was within 7° of neutral in all cases except for one where it was deliberately planned to be outside of this range.

CONCLUSION

PSI in both anatomic and reverse shoulder arthroplasty is highly accurate in guiding glenoid component implantation in vivo. The system can reliably correct bony deformity.

A patient-specific guide for optimizing custom-made glenoid implantation in cases of severe glenoid defects: an in vitro study

BACKGROUND

Glenoid component and screw malpositioning in cases of severe glenoid defects might result in complications. We examined the efficacy of a surgical method to treat severe glenoid defects, including a custom-made glenoid component and accurate screw positioning, using a patient-specific positioning guide.

METHODS

Glenoid defects were created in 10 cadaveric shoulders. Computed tomography images were used to plan reversed shoulder arthroplasty and design patient-specific glenoid components. A patient-specific positioning guide was designed for 5 specimens. The remaining 5 specimens were implanted without the guide. Computed tomography images were used to determine the postoperative glenoid component and screw positions. Differences from the preoperatively planned implant and screw positions were calculated.

RESULTS

The patient-specific positioning guide significantly reduced the angular deviations from the planned glenoid implant positioning (P < .05) and also significantly improved the positioning of the screws (P < .001). In the group without the guide, the average total intraosseous screw length was 52% of the ideal preoperatively planned length compared with 89% for the group with the guide. A strong correlation (r = -0.85) was found between the orientation of the implant and the postoperative total intraosseous screw length.

CONCLUSIONS

A patient-specific positioning guide significantly improves the position and fixation of a custom-made glenoid component in cases of severe glenoid defects.

A new classification of glenoid bone loss to help plan the implantation of a glenoid component before revision arthroplasty of the shoulder

Aims

Glenoid bone loss can be a challenging problem when revising a shoulder arthroplasty. Precise pre-operative planning based on plain radiographs or CT scans is essential. We have investigated a new radiological classification system to describe the degree of medialisation of the bony glenoid and that will indicate the amount of bone potentially available for supporting a glenoid component. It depends on the relationship between the most medial part of the articular surface of the glenoid with the base of the coracoid process and the spinoglenoid notch: it classifies the degree of bone loss into three types. It also attempts to predict the type of glenoid reconstruction that may be possible (impaction bone grafting, structural grafting or simple non-augmented arthroplasty) and gives guidance about whether a pre-operative CT scan is indicated.

Patients and Methods

Inter-method reliability between plain radiographs and CT scans was assessed retrospectively by three independent observers using data from 39 randomly selected patients. Inter-observer reliability and test-retest reliability was tested on the same cohort using Cohen's kappa statistics. Correlation of the type of glenoid with the Constant score and its pain component was analysed using the Kruskal-Wallis method on data from 128 patients. Anatomical studies of the scapula were reviewed to explain the findings.

Results

Excellent inter-method reliability, inter-observer and test-retest reliability were seen. The system did not correlate with the Constant score, but correlated well with its pain component. Take home message: Our system of classification is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. Cite this article: Bone Joint J 2016;98-B:374–80.

Early revision within 1 year after shoulder arthroplasty: patient factors and etiology

BACKGROUND

The objective of this study is to investigate the patient factors associated with early revision within 1 year after shoulder arthroplasty, including total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse TSA, and the cause of failure leading to early revision.

METHODS

Patients who underwent shoulder arthroplasty from 2005 to 2012 were identified using International Classification of Diseases, Ninth Revision procedure codes. Those who underwent revision shoulder arthroplasty were then divided into early (<1 year) and late (>1 year) groups. Patients in each of the cohorts were queried for demographic data and etiologic factors for revision arthroplasty.

RESULTS

A total of 221,381 patients who underwent shoulder arthroplasty were identified, including 115,956 TSAs, 75,208 hemiarthroplasties, and 30,217 reverse TSAs. The patient factors significantly associated with early revision after shoulder arthroplasty regardless of type were age younger than 65 years, smoking, obesity, and morbid obesity. Dislocation was the most common reason for early revision after all types of arthroplasties. Loosening was a more common reason for early revision after TSA compared with both hemiarthroplasty and reverse TSA.

CONCLUSIONS

Several patient factors appear to be associated with early revision after shoulder arthroplasty, including younger age, smoking, obesity, and male sex. The cause of failure leading to early revision varies between late and early revision cases. These findings are important to identify patients preoperatively who may be at risk of early revision after shoulder arthroplasty to allow appropriate patient counseling and risk stratification.

The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty

BACKGROUND

Revision shoulder arthroplasty can be complicated by osseous and soft tissue deficiencies. Proximal humeral bone loss can result in diminished implant stability and reduced functional outcomes, and some studies have advocated the use of humeral allograft in this setting. This study compares the outcomes of revision reverse total shoulder arthroplasty (RTSA) in patients both with and without proximal humeral bone loss.

METHODS

During a 6-year period, 32 patients were revised to RTSA for failed shoulder hemiarthroplasty. Proximal humeral bone loss was found in 16 patients, with an average loss of 36.3 mm (range, 17.2-66 mm). Patients were followed up an average of 51.2 months with the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, visual analog scale score for pain, subjective outcome ratings, and radiographs.

RESULTS

Significant improvement was found for average American Shoulder and Elbow Surgeons score (30.7 to 66.8), Simple Shoulder Test score (1.6 to 5.3), visual analog scale score (6.0 to 2.6), and forward flexion (51° to 100°) but not for external rotation (15° to 19.1°). No difference was demonstrated for functional or subjective outcomes compared with patients with intact humeral bone, except for active motion. On radiographic examination, 3 patients demonstrated humeral-sided loosening. Five complications were noted in patients with humeral bone loss.

CONCLUSION

Revision RTSA can provide successful outcomes in the presence of proximal humeral bone loss without the use of allograft. Implant stability may be improved by the use of a cemented long-stem monoblock humeral prosthesis in revision settings.

Assessment of painful total shoulder arthroplasty using computed tomography arthrography

BACKGROUND

This study assessed the accuracy of computed tomography (CT) arthrography when evaluating glenoid component stability in the setting of postarthroplasty shoulder pain.

METHODS

We retrospectively reviewed all patients presenting to the clinic during a 5.5-year period to identify those with a painful shoulder arthroplasty more than 1 year after the index procedure. We excluded reverse and hemiarthroplasty procedures, patients with a clearly identifiable cause for pain, such as rotator cuff insufficiency or gross component loosening as seen on plain radiographs, and those with culture-positive aspiration. There were 14 patients with suspected glenoid component loosening but inconclusive plain radiographs. Each of the 14 patients underwent a CT arthrogram that was evaluated by the senior author (J.J.P.W.) for the presence or absence of contrast material underneath the polyethylene component. Operative reports and surgical videos from subsequent arthroscopy were reviewed to assess glenoid component stability as determined by direct arthroscopic visualization.

RESULTS

CT arthrography suggested glenoid component loosening in 8 of 14 patients (57.1%), and arthroscopic inspection identified loosening in 10 of 14 patients (71.4%). In 3 of 10 patients (30%), CTA suggested a well-fixed glenoid component, but gross loosening was identified during arthroscopy. In this study, CTA yielded a sensitivity of 70%, a specificity of 75%, a positive predictive value of 87.5%, and a negative predictive value of 50.0%.

CONCLUSION

CTA had a low negative predictive value (50%), and therefore, the prediction of component stability based on the absence of contrast between the glenoid component and the bone-cement interface does not always reflect true stability.

Difference in clinical outcome between total shoulder arthroplasty and reverse shoulder arthroplasty used in hemiarthroplasty revision surgery

Introduction:

The increase of shoulder replacements will lead to a higher revision rate of shoulder arthroplasties. The aim of this study is to evaluate the clinical results of revision surgery performed in our hospital, distinguish the differences in clinical outcome according to revision indication and differences between total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) in hemiarthroplasty (HA) revision surgery.

Materials and Methods:

All patients with an indication for revision of HA were retrospectively included. Clinical evaluation consisted of pre- and post-operative constant scores, disability of arm-shoulder-hand-score (DASH), Dutch translation of the simple shoulder test ((D)SST), Oxford shoulder score test (OSS), short form (SF-36) and the complication rate.

Results:

From July 1994 to July 2008, 39 patients (40 shoulders) underwent revision arthroplasty. Of 19 patients (19 shoulders) we obtained a complete follow-up. The mean age at revision surgery 69 ± 10 years (range: 46-83) and the mean follow-up 41 ± 31 months (range: 10-113). In 7 cases TSA was used for revision when the cuff was intact, 12 times RSA was performed. The indications for the revision were glenoid erosion (n = 4), humeral component malposition (n = 2), cuff-pathology (n = 12) and infection (n = 1). Postoperative constant score 51.7 ± 11.4 for TSA and 31.1 ± 18.7 for RSA (P = 0.008). The DASH was 48.3 ± 25.1 and 68.7 ± 17.5, respectively (P = 0.09). DSST showed 6 ± 4 and 4 ± 4 (P = 0.414). OSS 41.3 ± 10.1 and 28.1 ± 10.3 (P = 0.017). SF-36 43.3 ± 22.1 and 24.5 ± 12.8 (P = 0.072). Four shoulders (21%) presented four complications.

Conclusions:

In this study, revision surgery showed poor to reasonable postoperative results and better clinical outcome for TSA. When a revision after HA was needed, and the soft-tissue component of the shoulder was intact, a TSA proved to be a preferable solution.

Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad?

BACKGROUND

The arthritic triad of glenoid biconcavity, glenoid retroversion, and posterior displacement of the humeral head on the glenoid is associated with an increased risk of failure of total shoulder joint replacement. Although a number of glenohumeral arthroplasty techniques are being used to manage this complex pathology, problems with glenoid component failure remain. In that the ream and run procedure manages arthritic pathoanatomy without a glenoid component, we sought evidence that this procedure can be effective in improving the centering of the humeral head contact on the glenoid and in improving the comfort and function of shoulders with the arthritic triad without the risk of glenoid component failure.

QUESTIONS/PURPOSES

We asked, for shoulders with the arthritic triad, whether the ream and run procedure could improve glenohumeral relationships as measured on standardized axillary radiographs and patient-reported shoulder comfort and function as recorded by the Simple Shoulder Test.

METHODS

Between January 1, 2006 and December 14, 2011, we performed 531 primary anatomic glenohumeral arthroplasties for arthritis, of which 221 (42%) were ream and run procedures. Of these, 30 shoulders in 30 patients had the ream and run procedure for the arthritic triad and had two years of clinical and radiographic follow-up. These 30 shoulders formed the basis for this case series. The average age of the patients was 56 ± 8 years; all but one were male. Two of the 30 patients requested revision to total shoulder arthroplasty within the first year after their ream and run procedure because of their dissatisfaction with their rehabilitation progress. For the 28 shoulders not having had a revision, we determined on the standardized axillary views before and after surgery the glenoid type, glenoid version (90° minus the angle between the plane of the glenoid face and the plane of the body of the scapula), and location of the humeral contact point with respect to the anteroposterio dimension of the glenoid (the ratio of the distance from the anterior glenoid lip to the contact point divided by the distance between the anterior and posterior glenoid lips). We also recorded the patient's self-assessed shoulder comfort and function before and after surgery using the 12 questions of the Simple Shoulder Test.

RESULTS

For the 28 unrevised shoulders the mean followup was 3.0 years (range, 2-9.2 years). In these patients, the ream and run procedure resulted in improved centering of the humeral head on the face of the glenoid (preoperative: 75% ± 7% posterior; postoperative: 59% ± 10% posterior; mean difference 16% [95% CI, 13%-19%]; p < 0.001), notably this improved centering was achieved without a significant change in the glenoid version. Patient-reported function was improved (preoperative Simple Shoulder Test: 5 ± 3, postoperative Simple Shoulder Test: 10 ± 4, mean difference 5 [95% CI, 4-6], p < 0.001).

CONCLUSIONS

For shoulders with the arthritic triad, the ream and run procedure can provide improvement in humeral centering on the glenoid and in patient-reported shoulder comfort and function without the risk of glenoid component failure. In that ream and run is a new procedure, substantial additional clinical research with long-term follow-up is needed to define specifically the shoulder characteristics, the patient characteristics and the technical details that are most likely to lead to durable improvements in the comfort and function of shoulders with the challenging pathology known as the arthritic triad.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Three-dimensional imaging and templating improve glenoid implant positioning

BACKGROUND

Preoperative quantitative assessment of glenoid bone loss, selection of the glenoid component, and definition of its desired location can be challenging. Placement of the glenoid component in the desired location at the time of surgery is difficult, especially with severe glenoid pathological conditions.

METHODS

Forty-six patients were randomly assigned to three-dimensional computed tomographic preoperative templating with either standard instrumentation or with patient-specific instrumentation and were compared with a nonrandomized group of seventeen patients with two-dimensional imaging and standard instrumentation used as historical controls. All patients had postoperative three-dimensional computed tomographic metal artifact reduction imaging to measure and to compare implant position with the preoperative plan.

RESULTS

Using three-dimensional imaging and templating with or without patient-specific instrumentation, there was a significant improvement achieving the desired implant position within 5° of inclination or 10° of version when compared with two-dimensional imaging and standard instrumentation.

CONCLUSION

Three-dimensional assessment of glenoid anatomy and implant templating and the use of these images at the time of surgery improve the surgeon's ability to place the glenoid implant in the desired location.

Management of complications after revision shoulder arthroplasty

Complications after revision shoulder arthroplasty are similar to those in the primary setting which include instability, fracture, bone loss, infection, nerve injury, and loosening. Unlike in the primary setting, however, the rate of complications for revisions is significantly greater and the management is more complex because of overlapping complications and limited treatment options. Furthermore, there is a paucity of evidence-based literature to direct the management options in these patients. The purposes of this review are to broadly outline the major complications that are seen in revision shoulder arthroplasty and to provide general principles on how to recognize and approach these complex cases.

Reverse shoulder arthroplasty due to glenoid bone defects

OBJECTIVE

Reverse shoulder arthroplasty is becoming a useful tool for many diseases of the shoulder. Any severe glenoid bone defect may affect the fixing of the glenoid component. The aim of this paper is to evaluate the medium-term outcomes of reverse shoulder arthroplasty associated with a glenoplasty.

MATERIALS AND METHODS

A retrospective study was conducted on 5 patients from our hospital, selected due to glenoid defects of different etiology. All of them where treated with reverse shoulder arthroplasty associated with glenoplasty with bone graft.

RESULTS

The minimum follow-up was one year (mean 30.4 months). All grafts were radiologically integrated, with no signs of resorption or necrosis being observed. At 12 months, the Constant score was 66.75 and the mean EVA score was 1.

DISCUSSION

Glenoplasty surgery is technically demanding for restoring original bone size in patients with glenoid structural defects, enabling a reverse shoulder arthroplasty to be implanted. Thus improving both the function and clinical outcomes in selected patients with glenohumeral pathology and providing them with a solution.