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Cheng SSM, Yung CSY, Wong SDH, Yip CCH, Khoo IJR, Wong TWK, Fang C. Computer modeling and validation testing for glenoid component rotation and optimal glenoid screw angles for reverse shoulder arthroplasty in an Asian population. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06340-z. [PMID: 39347986 DOI: 10.1007/s00264-024-06340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024]
Abstract
PURPOSE Good initial fixation of glenoid component for reverse total shoulder arthroplasty (RTSA) relies on component placement and screw purchase in the scapula bone. This is especially difficult in an Asian population with small glenoid geometry. Optimal glenoid component roll angle and screw angulation to achieve the longest screws for best fixation has not been defined in the current literature. METHODS Computer 3D modelling of 133 scapulas with RTSA performed were analyzed to determine patient specific optimal glenoid roll angle (GRA) for the longest bi-cortical screws attainable. The cranial-caudal angle (CCA), anterior-posterior angle (APA) and lengths for the superior and inferior screws were measured. Validation testing using calculated average (CA) angles and rounded average (RA) angles to the nearest 5 degree were recomputed for each case to determine the bi-cortical screw lengths achievable. The CA and RA screw lengths were compared against patient specific modelling using paired-sample t-tests. RESULTS Average GRA was - 1.6°, almost perpendicular to the long axis of the glenoid and achieves an average bi-cortical screw length of 51.3 mm and 45.5 mm for the superior and inferior screws respectively. The CCA and APA were 9.1° cranial and 6.5° posterior for the superior screw and screw angulation of 11.2° caudal and 0.7° anterior for the inferior screw. Validation testing shows statistically shorter screw lengths in the CA and RA models compared to patient specific modelling (p < 0.01). CONCLUSION Validation testing with average angles for GRA, CCA and APA demonstrates strong patient heterogeneity and anatomical variation. Despite this, screw lengths attainable in the RA group were > 38 mm with good safety profile. Surgeons may consider the additional use of navigation-assisted, or 3D printed patient specific instrumentation to optimize baseplate and screw configuration for RTSA.
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Affiliation(s)
| | - Colin Shing-Yat Yung
- Department of Orthopaedics of Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Samuel De Hoi Wong
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Issac Jun Ren Khoo
- Department of Orthopaedics of Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Tsoi Wan Karen Wong
- Department of Orthopaedics of Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong.
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Narang A, Dupley L, Davies R, Phillips N, Peach C. Suprascapular nerve irritation as an important cause of pain following reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:e291-e295. [PMID: 38461937 DOI: 10.1016/j.jse.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Ashish Narang
- Shoulder and Elbow Unit, Manchester University Hospitals, Manchester, UK.
| | - Leanne Dupley
- Shoulder and Elbow Unit, Manchester University Hospitals, Manchester, UK
| | - Ronnie Davies
- Shoulder and Elbow Unit, Manchester University Hospitals, Manchester, UK
| | - Nicholas Phillips
- Shoulder and Elbow Unit, Manchester University Hospitals, Manchester, UK
| | - Christopher Peach
- Shoulder and Elbow Unit, Manchester University Hospitals, Manchester, UK
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Spek RW, Hoogervorst LA, Brink RC, Schoones JW, van Deurzen DF, van den Bekerom MP. Ten technical aspects of baseplate fixation in reverse total shoulder arthroplasty for patients without glenoid bone loss: a systematic review. Clin Shoulder Elb 2024; 27:88-107. [PMID: 38147872 PMCID: PMC10938023 DOI: 10.5397/cise.2023.00493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 12/28/2023] Open
Abstract
The aim of this systematic review was to collect evidence on the following 10 technical aspects of glenoid baseplate fixation in reverse total shoulder arthroplasty (rTSA): screw insertion angles; screw orientation; screw quantity; screw length; screw type; baseplate tilt; baseplate position; baseplate version and rotation; baseplate design; and anatomical safe zones. Five literature libraries were searched for eligible clinical, cadaver, biomechanical, virtual planning, and finite element analysis studies. Studies including patients >16 years old in which at least one of the ten abovementioned technical aspects was assessed were suitable for analysis. We excluded studies of patients with: glenoid bone loss; bony increased offset-reversed shoulder arthroplasty; rTSA with bone grafts; and augmented baseplates. Quality assessment was performed for each included study. Sixty-two studies were included, of which 41 were experimental studies (13 cadaver, 10 virtual planning, 11 biomechanical, and 7 finite element studies) and 21 were clinical studies (12 retrospective cohorts and 9 case-control studies). Overall, the quality of included studies was moderate or high. The majority of studies agreed upon the use of a divergent screw fixation pattern, fixation with four screws (to reduce micromotions), and inferior positioning in neutral or anteversion. A general consensus was not reached on the other technical aspects. Most surgical aspects of baseplate fixation can be decided without affecting fixation strength. There is not a single strategy that provides the best outcome. Therefore, guidelines should cover multiple surgical options that can achieve adequate baseplate fixation.
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Affiliation(s)
- Reinier W.A. Spek
- Department of Orthopaedic Surgery, Flinders University and Flinders Medical Center, Adelaide, Australia
- Department of Orthopaedic Surgery, OLVG Amsterdam, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lotje A. Hoogervorst
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences and Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob C. Brink
- Department of Orthopaedic Surgery, OLVG Amsterdam, Amsterdam, the Netherlands
| | - Jan W. Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Michel P.J. van den Bekerom
- Department of Orthopaedic Surgery, OLVG Amsterdam, Amsterdam, the Netherlands
- Shoulder and Elbow Expertise Center, Amsterdam, the Netherlands
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Diaz MA, Hutchinson AJ, Ricchetti ET, Hsu JE, Garrigues GE, Gutiérrez S, Frankle MA. How to avoid baseplate failure: the effect of compression and reverse shoulder arthroplasty baseplate design on implant stability. J Shoulder Elbow Surg 2024; 33:389-398. [PMID: 37689101 DOI: 10.1016/j.jse.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Failure to achieve fixation of the glenoid baseplate will lead to clinical failure. The fixation of the baseplate to the scapula must be able to withstand sufficient shear forces to allow bony ingrowth. The importance of compression to neutralize the forces at the baseplate-bone interface has been assumed to be critical in limiting excessive micromotion. The purpose of this study is to determine the effect of compression on implant stability with different baseplate designs. METHODS Various baseplate designs (1-piece monolithic central screw [1P], 2-piece locking central screw [2PL], and 2-piece nonlocking center screw [2PNL]) were investigated at 3 different compressive forces (high [810 N], medium [640 N], and low [530 N]). Synthetic bone cylinders were instrumented, and peripheral screws were used in all models. The combination of 1 locking and 3 nonlocking peripheral screw fixation was selected as worst-case scenario. Dynamic testing protocol followed the ASTM F2028-17 standard. The baseplate micromotion at high compression was compared to low compression. Additionally, the baseplate micromotion for each design was compared at baseline (first 50 cycles) and at 10,000 cycles for the 3 different compressive forces where motion above 150 μm was defined as failure. RESULTS Baseplate micromotion was found to negatively correlate with compression (rpb = -0.83, P < .0001). At baseline, all baseplate designs were considered stable, regardless of compression. With high compression, average micromotion at the glenoid baseplate-bone interface remained below the 150-μm threshold for all baseplate designs at 10,000 cycles (1P: 50 ± 10 μm; 2PL: 78 ± 32 μm; 2PNL: 79 ± 8 μm; P = .060). With medium compression, average micromotion at 10,000 cycles for all 3 designs remained below the 150-μm threshold (1P: 88 ± 22 μm; 2PL: 132 ± 26 μm; 2PNL: 107 ± 39 μm). The 2PL design had the highest amount of micromotion (P = .013). With low compression, both 2-piece designs had an average micromotion above the 150-μm threshold whereas the 1-piece design did not (1P: 133 ± 35 μm; 2PL: 183 ± 21 μm; 2PNL: 166 ± 39 μm). The 2PL design had significantly higher micromotion when compared to 1P design (P = .041). DISCUSSION The stability of a central screw baseplate correlates with the amount of compression obtained and is affected by implant design. For the same amount of compression, more micromotion is observed in a 2-piece design than a 1-piece design.
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Affiliation(s)
- Miguel A Diaz
- Foundation for Orthopaedic Research & Education, Tampa, FL, USA
| | | | - Eric T Ricchetti
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | | | - Mark A Frankle
- Department of Orthopaedics & Sports Medicine, University of South Florida, Tampa, FL, USA; Florida Orthopaedic Institute, Tampa, FL, USA.
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Chen J, Chen C, Nour M, Liu D, Zhu Y, Zhang W, Polat K, Deng X. Morphology properties of scapular spine relative to reverse shoulder arthroplasty: A biomechanical study. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2023.104827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Surgeon-designed patient-specific instrumentation improves glenoid component screw placement for reverse total shoulder arthroplasty in a population with small glenoid dimensions. INTERNATIONAL ORTHOPAEDICS 2023; 47:1267-1275. [PMID: 36763126 PMCID: PMC10079732 DOI: 10.1007/s00264-023-05706-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/16/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE Glenoid component loosening is a potential complication of reverse total shoulder arthroplasty (rTSA), occurring in part due to lack of adequate screw purchase in quality scapular bone stock. This study was to determine the efficacy of a surgeon-designed, 3D-printed patient-specific instrumentation (PSI) compared to conventional instrumentation (CI) in achieving longer superior and inferior screw lengths for glenoid component fixation. METHODS A multi-centre retrospective analysis of patients who underwent rTSA between 2015 and 2020. Lengths of the superior and inferior locking screws inserted for fixation of the glenoid baseplate component were recorded and compared according to whether patients received PSI or CI. Secondary outcomes included operative duration and incidence of complications requiring revision surgery. RESULTS Seventy-three patients (31 PSI vs. 42 CI) were analysed. Average glenoid diameter was 24.5 mm (SD: 3.1) and 81% of patients had smaller glenoid dimensions compared to the baseplate itself. PSI produced significantly longer superior (44.7 vs. 30.7 mm; P < 0.001) and inferior (43.0 vs. 31 mm; P < 0.001) mean screw lengths, as compared to CI. A greater proportion of maximal screw lengths for the given rTSA construct (48 mm) were observed in the PSI group (71.9% vs. 11.9% superior, 59.4% vs. 11.9% inferior). Operative duration was not statistically significantly different between the PSI and CI groups (150 min vs. 169 min, respectively; P = 0.229). No patients had radiographic loosening of the glenoid component with an average of 2-year follow-up. CONCLUSION PSI facilitates longer superior and inferior screw placement in the fixation of the glenoid component for rTSA. With sufficient training, PSI can be designed and implemented by surgeons themselves.
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Velasquez Garcia A, Abdo G. Does computer-assisted navigation improve baseplate screw configuration in reverse shoulder arthroplasty? A systematic review and meta-analysis of comparative studies. J Orthop 2023; 36:29-35. [PMID: 36582549 PMCID: PMC9793209 DOI: 10.1016/j.jor.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/18/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Navigation technologies have improved accuracy and precision in positioning glenoid components during shoulder arthroplasty. The influence of navigation on baseplate screw placement has not been independently investigated. This study aimed to evaluate and synthesize the best scientific evidence on the influence of intraoperative navigation on the length and number of screws for primary baseplate fixation in reverse total shoulder arthroplasty procedures. Methods In August 2022, PubMed, Scopus, and Embase databases were accessed. We analyzed the screw purchase length, the number of screws required for the fixation of the baseplate, and the proportion of cases fixed with two screws in all clinical trials, comparing navigation to standard instrumentation for reverse shoulder arthroplasty. Following an evaluation of the heterogeneity of the studies, DerSimonian-Laird random-effects models were utilized to merge data from separate studies. Results The systematic search revealed a total of 2034 articles. After excluding duplicates and irrelevant studies, 633 shoulder arthroplasties from 6 trials were included in the analysis. The pooled mean difference in screw purchase length was 5.839 mm (95 %CI 4.496 to 7. 182) in favor of navigation (P < .001). In addition, significant differences were also found in the number of screws per case (- 0.547, 95 %CI -0.890 to -0.203, P = .002) and in the proportion of cases fixed with two screws (Odds Ratio 3.182 95 %CI 1.057 to 9.579, P = .040) in favor of the navigation group. Conclusions Intraoperative navigation improves the baseplate screw placement, allowing for a greater screw purchase length and fewer screws to achieve primary fixation of the glenoid component during reverse shoulder arthroplasty. It is unclear whether these improvements will increase the longevity of the prosthesis or the clinical outcomes of the patients.
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Affiliation(s)
- Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Clinica Universidad de Los Andes, Santiago, Chile
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Glen Abdo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- St Mary's General Hospital, Department of Graduate Medical Education, Internal Medicine Residence Program, Passaic, NJ, USA
- Department of Basic Sciences, Touro College of Osteopathic Medicine, New York, NY, USA
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Features of reverse arthroplasty of the shoulder joint in orthopedic pathology of the glenoid (literature review). ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.5-2.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The reverse shoulder arthroplasty in the conditions of the modified anatomy of the glenoid is complex and often excludes the possibility of using the standard tactics of installing the glenoid component. There are no identical glenoids, each articular cavity of the scapula differs in height, width, angle of inclination, density of bone tissue, absence or presence of various defects of bone tissue. Given the variety of options for changing the structure and quality of the glenoid bone tissue in injuries and diseases of the shoulder joint, each case of endoprosthetics should be considered individually. In order to perform an adequate metaglen installation, these parameters must be normalized or standardized. The purpose of this work is to review the domestic and foreign literature devoted to the features of reversible shoulder joint replacement during deformation of the articular cavity of the scapula. Based on the analysis of literature data, the percentage of complications associated with unsatisfactory treatment results due to the instability of the glenosphere is quite large, which indicates the lack of elaboration of this topic and its relevance for practical traumatology and orthopedics. The paper considers eccentric non-standard methods of rimming the articular cavity of the scapula, methods of its bone grafting, the use of metaglens made taking into account the deformation of the glenoid, as well as indications for the use of technology for the individual manufacture of scapular components. The study and analysis of indications for the use of various types of techniques for solution glenoid deformities made it possible to systematize and differentially approach the issue of preoperative planning and choosing the correct, right treatment tactics in complex cases of reversible shoulder joint replacement.
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Torkan L, Bryant JT, Bicknell RT, Ploeg HL. Accuracy of an Apparatus for Measuring Glenoid Baseplate Micromotion in Reverse Shoulder Arthroplasty. J Med Device 2022. [DOI: 10.1115/1.4055063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Reverse shoulder arthroplasty (RSA) is used to treat patients with cuff tear arthropathy. Loosening remains one of the principal modes of implant failure and the main complication leading to revision. Excess micromotion contributes to glenoid loosening. This study assessed the predictive accuracy of an experimental system designed to assess factors contributing to RSA glenoid baseplate micromotion. A half-fractional factorial experiment was designed to assess 4 factors: central element type (screw vs. peg), central element length (13.5 vs. 23.5 mm), anterior posterior peripheral screw type (locking vs. nonlocking) and cancellous bone density (10 vs. 25 pounds per cubic foot [pcf]). Four linear variable differential transducers (LVDTs) recorded micromotion from a stainless-steel disc surrounding a modified glenosphere. The displacements were used to interpolate micromotion at each of the respective peripheral screw positions. The mean absolute percentage error (MAPE) was used to determine the predictive accuracy and error range of the system. The MAPE for each condition ranged from 6.8% to 12.9% for an overall MAPE of (9.5&#177;0.9)%. The system had an error range of 2.7 &#181;m to 20.1 &#181;m, which was lower than those reported by prior studies using optical systems. One of the eight conditions had micromotion that exceeded 150 &#181;m. These findings support the use of displacement transducers, specifically LVDTs, as an accurate system for determining RSA baseplate micromotion in rigid polyurethane foam bone surrogates.
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Affiliation(s)
- Lawrence Torkan
- Human Mobility Research Centre, Queen's University, Kingston, ON, Canada; Department of Mechanical and Materials Engineering , Queen's University, Kingston, ON, Canada
| | - John T Bryant
- Human Mobility Research Centre, Queen's University, Kingston, ON, Canada; Department of Mechanical and Materials Engineering , Queen's University, Kingston, ON, Canada
| | - Ryan T Bicknell
- Human Mobility Research Centre, Queen's University, Kingston, ON, Canada; Department of Surgery, Queen's University , Kingston, ON, Canada
| | - Heidi-Lynn Ploeg
- Human Mobility Research Centre, Queen's University, Kingston, ON, Canada; Department of Mechanical and Materials Engineering , Queen's University, Kingston, ON, Canada
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Central fixation element type and length affect glenoid baseplate micromotion in reverse shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:1385-1392. [PMID: 35172207 DOI: 10.1016/j.jse.2022.01.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) is commonly used to treat patients with rotator cuff tear arthropathy. Loosening of the glenoid component remains one of the principal modes of failure and represents a significant complication that requires revision surgery. This study assessed the effects of various factors on glenoid baseplate micromotion for primary fixation of RSA. MATERIALS AND METHODS A half-fractional factorial design of experiment was used to assess 4 factors: central element type (central peg or screw), central cortical engagement according to length (13.5 or 23.5 mm), anterior-posterior peripheral screw type (nonlocking or locking), and cancellous bone surrogate density (160 or 400 kg/m3, 10 or 25 PCF). Glenoid baseplates were implanted into high- or low-density Sawbones rigid polyurethane foam blocks and cyclically loaded at 60° for 1000 cycles (500-N compressive force range) using a custom-designed loading apparatus. Micromotion at the 4 peripheral screw positions was recorded using linear variable differential transformers. RESULTS Central peg fixation generated 358% greater micromotion at all peripheral screw positions compared with central screw fixation (P < .001). Baseplates with short central elements that lacked cortical bone engagement generated 328% greater micromotion than those with long central elements (P = .001). No significant effects were observed when varying anterior-posterior peripheral screw type or bone surrogate density. There were significant interactions between central element type and length (P < .001). DISCUSSION A central screw and a long central element that engaged cortical bone reduced RSA baseplate micromotion. These findings serve to inform surgical decision making regarding baseplate fixation elements to minimize the risk of glenoid loosening and, thus, the need for revision surgery.
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Martin EJ, Duquin TR, Ehrensberger MT. Reverse total shoulder arthroplasty baseplate stability with locking vs. non-locking peripheral screws. Clin Biomech (Bristol, Avon) 2022; 96:105665. [PMID: 35636305 DOI: 10.1016/j.clinbiomech.2022.105665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are many options for glenosphere baseplate fixation commercially available, yet there is little biomechanical evidence supporting one type of fixation over another. In this study, we compared the biomechanical fixation of a reverse total shoulder glenoid baseplate secured with locking or non-locking peripheral screws. METHODS Both a non-augmented mini baseplate with full backing support and an augmented baseplate were testing after implantation in solid rigid polyurethane foam. Each baseplate was implanted with a 30 mm central compression screw and four peripheral screws, either locking or non-locking (15 mm anterior/posterior and 30 mm superior/inferior). A 1 Hz cyclic force of 0-750 N was applied at a 60o angle for 5000 cycles. Throughout the test, the displacement of the baseplate was measured using a 3D Digital Image Correlation System. FINDINGS The amount of migration measured in the both the non-augmented and augment cases shows no significant differences between locking and non-locking cases at the final cycle count (non-augment: 5.66 +/- 2.29 μm vs. 3.71 +/- 1.23 μm; p = 0.095, augment: 15.43 +/- 8.49 μm vs. 12.46 +/- 3.24 μm; p = 0.314). Additionally, the amount of micromotion measured for both sample types shows the same lack of significant difference (non-augment: 10.79 +/- 5.22 μm vs. 10.16 +/- 7.61 μm; p = 0.388, augment: 55.03 +/- 10.13 μm vs. 54.84 +/- 10.65 μm; p = 0.968). INTERPRETATION The presence of locking versus non-locking peripheral screws does not make a significant difference on the overall stability of a glenoid baseplate, in both a no defect case with a non-augmented baseplate and a bone defect case with an augmented baseplate.
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Affiliation(s)
- Elise J Martin
- Department of Biomedical Engineering, State University of New York at Buffalo, Buffalo, NY, USA; Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Thomas R Duquin
- Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mark T Ehrensberger
- Department of Biomedical Engineering, State University of New York at Buffalo, Buffalo, NY, USA; Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, NY, USA.
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Eyberg BA, Wilder LB, Simon P, Gutierrez S, Ayala G, Iannotti JP, Mighell MA, Frankle MA. Identifying areas of screw fixation in glenoids with severe bone loss in shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:S136-S142. [PMID: 35182767 DOI: 10.1016/j.jse.2022.01.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe glenoid bone loss (SGBL) poses significant technical challenges. Adequate fixation of glenoid implants may require the use of alternative screw placement. Although bone volumes for the spine and lateral pillars have previously been defined, insufficient evidence exists regarding the distribution of screw placement for fixation in such regions for cases with SGBL. The purpose of this study is to evaluate the variability of screw placement. We hypothesize that determining this variability and establishing common patterns of glenoid bone loss will allow for recommendations for preoperative planning, and implant design and selection. METHODS An internal registry of 2 high-volume shoulder and elbow surgeons was queried, and 65 three-dimensional scapulae models exhibiting SGBL were identified. A fellowship-trained shoulder and elbow surgeon simulated the placement of two 3.5 mm × 30 mm screws, one in the scapular spine (CS) bone volume and one in the inferior column (IS) bone volume. Three orthogonal reference planes were created using anatomic reference points: the scapula trigonum, estimated glenoid center, and inferior pole. Screw positions were mapped, and deviations from the reference planes were calculated. Mutual positions of the IS to CS were also computed. Intraobserver reliability was assessed using 10 randomly selected samples. Median and 25th and 75th percentiles were reported for screw orientation distributions. Means and standard deviations were reported for screw head positions. RESULTS We demonstrated excellent intraobserver reliability (intraclass correlation coefficients, 0.90-0.98). Fifty percent of CS were oriented 10° ± 5° of retroversion from the scapula plane, with 5° ± 5° of inclination. For IS, 50% were positioned 0° ± 4° from the scapula plane, with -33° ± 7° of inclination. The relationship of the IS with the CS was medial and posterior in 49% of cases, lateral and posterior in 45%, and lateral and anterior in 6% of cases. On average, the distance between the CS and IS heads was 25 mm ± 4 mm. DISCUSSION For SGBL, adequate fixation of glenoid implants can be achieved by placing screws in the spine and lateral columns, with excellent reproducibility. Future implant designs should accommodate CS positioned -16° to -5° from the scapula plane, with 0° to 12° of inclination, and IS positioned -6° to 4° from the scapula plane, with -40° to -25° of inclination. Moreover, mutual screw positions suggested bone loss distributions anteriorly and inferiorly. Future implant designs should consider the potential benefits of augmentation to accommodate interscrew distances of 21-29 mm and anatomic locations of the IS relative to the CS.
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Affiliation(s)
- Blake A Eyberg
- Shoulder Service, Florida Orthopaedic Institute, Tampa, FL, USA
| | - Lauren B Wilder
- Department of Translational Research, Foundation for Orthopaedic Research and Education, Tampa, FL, USA
| | - Peter Simon
- Department of Translational Research, Foundation for Orthopaedic Research and Education, Tampa, FL, USA; Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - Sergio Gutierrez
- Department of Translational Research, Foundation for Orthopaedic Research and Education, Tampa, FL, USA; Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - Giovanni Ayala
- Department of Translational Research, Foundation for Orthopaedic Research and Education, Tampa, FL, USA
| | - Joseph P Iannotti
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark A Mighell
- Shoulder Service, Florida Orthopaedic Institute, Tampa, FL, USA
| | - Mark A Frankle
- Shoulder Service, Florida Orthopaedic Institute, Tampa, FL, USA.
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Telfer S, Kleweno CP, Hughes B, Mellor S, Brunnquell CL, Linnau KF, Hebert-Davies J. Changes in scapular bone density vary by region and are associated with age and sex. J Shoulder Elbow Surg 2021; 30:2839-2844. [PMID: 34118420 DOI: 10.1016/j.jse.2021.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Decreases in bone density of the scapula due to age and disease can make orthopedic procedures such as arthroplasty and fracture fixation challenging. There is limited information in the literature regarding the effect of age and sex on the patterns of these density changes across the bone. Characterizing these changes could assist the surgeon in planning optimal instrumentation placement. METHODS Ninety-seven 3-dimensional models of the scapula were segmented from routine clinical computed tomography scans, and an opportunistic quantitative computed tomography approach was used to obtain detailed calibrated bone density measurements for each bone model. The effects of age and sex on cortical and trabecular bone density were assessed for the entire scapula. Specific regions (eg, scapular spine) where these factors had a significant effect were identified. Three-dimensional models were generated to allow clear visualization of the changes in density patterns. RESULTS Cortical bone loss averaged 1.0 mg/cm3 and 0.3 mg/cm3 per year for female and male subjects, respectively, and trabecular bone loss averaged 1.6 mg/cm3 and 1.2 mg/cm3, respectively. However, several regions had loss rates several times greater. Areas that were significantly affected by age included the acromion, scapular spine, base of the coracoid, inferior glenoid neck, and glenoid vault. Areas that were significantly affected by sex were the scapular spine and body. CONCLUSIONS These findings provide evidence that the bone density distribution across the scapula changes non-uniformly because of factors including sex and age. Despite overall trends of bone loss, there remains significant variability between individuals, and subject-specific tools for planning surgical procedures in which scapular fixation is required may be beneficial.
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Affiliation(s)
- Scott Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.
| | - Conor P Kleweno
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | | | - Sam Mellor
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Ken F Linnau
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Jonah Hebert-Davies
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
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14
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Nabergoj M, Denard PJ, Collin P, Trebše R, Lädermann A. Mechanical complications and fractures after reverse shoulder arthroplasty related to different design types and their rates: part I. EFORT Open Rev 2021; 6:1097-1108. [PMID: 34909228 PMCID: PMC8631242 DOI: 10.1302/2058-5241.6.210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.Zumstein et al defined a 'complication' following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient's final outcome.High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture. Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039.
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Affiliation(s)
- Marko Nabergoj
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Patrick J. Denard
- Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint-Grégoire, France
| | - Rihard Trebše
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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15
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Serrano N, Kissling M, Krafft H, Link K, Ullrich O, Buck FM, Mathews S, Serowy S, Gascho D, Grüninger P, Fornaciari P, Bouaicha S, Müller-Gerbl M, Rühli FJ, Eppler E. CT-based and morphological comparison of glenoid inclination and version angles and mineralisation distribution in human body donors. BMC Musculoskelet Disord 2021; 22:849. [PMID: 34610804 PMCID: PMC8493698 DOI: 10.1186/s12891-021-04660-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/25/2021] [Indexed: 11/11/2022] Open
Abstract
Background For optimal prosthetic anchoring in omarthritis surgery, a differentiated knowledge on the mineralisation distribution of the glenoid is important. However, database on the mineralisation of diseased joints and potential relations with glenoid angles is limited. Methods Shoulder specimens from ten female and nine male body donors with an average age of 81.5 years were investigated. Using 3D-CT-multiplanar reconstruction, glenoid inclination and retroversion angles were measured, and osteoarthritis signs graded. Computed Tomography-Osteoabsorptiometry (CT-OAM) is an established method to determine the subchondral bone plate mineralisation, which has been demonstrated to serve as marker for the long-term loading history of joints. Based on mineralisation distribution mappings of healthy shoulder specimens, physiological and different CT-OAM patterns were compared with glenoid angles. Results Osteoarthritis grades were 0-I in 52.6% of the 3D-CT-scans, grades II-III in 34.3%, and grade IV in 13.2%, with in females twice as frequently (45%) higher grades (III, IV) than in males (22%, III). The average inclination angle was 8.4°. In glenoids with inclination ≤10°, mineralisation was predominantly centrally distributed and tended to shift more cranially when the inclination raised to > 10°. The average retroversion angle was − 5.2°. A dorsally enhanced mineralisation distribution was found in glenoids with versions from − 15.9° to + 1.7°. A predominantly centrally distributed mineralisation was accompanied by a narrower range of retroversion angles between − 10° to − 0.4°. Conclusions This study is one of the first to combine CT-based analyses of glenoid angles and mineralisation distribution in an elderly population. The data set is limited to 19 individuals, however, indicates that superior inclination between 0° and 10°-15°, and dorsal version ranging between − 9° to − 3° may be predominantly associated with anterior and central mineralisation patterns previously classified as physiological for the shoulder joint. The current basic research findings may serve as basic data set for future studies addressing the glenoid geometry for treatment planning in omarthritis. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04660-4.
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Affiliation(s)
- Nabil Serrano
- Institute of Evolutionary Medicine (IEM), University of Zurich, Zurich, Switzerland
| | - Marc Kissling
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | - Hannah Krafft
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Karl Link
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland.,Anatomy, University of Fribourg, Fribourg, Switzerland
| | - Oliver Ullrich
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Florian M Buck
- Medical Radiology Institute, Schulthess Clinic, Zurich, Switzerland
| | - Sandra Mathews
- Institute of Evolutionary Medicine (IEM), University of Zurich, Zurich, Switzerland
| | - Steffen Serowy
- Clinic of Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Dominic Gascho
- Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | | | - Paolo Fornaciari
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland.,Department of Orthopaedic Surgery and Traumatology, University Hospital Fribourg, Fribourg, Switzerland
| | - Samy Bouaicha
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Magdalena Müller-Gerbl
- Musculoskeletal Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Frank-Jakobus Rühli
- Institute of Evolutionary Medicine (IEM), University of Zurich, Zurich, Switzerland.
| | - Elisabeth Eppler
- Musculoskeletal Research, Department of Biomedicine, University of Basel, Basel, Switzerland. .,Clinic of Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany. .,Institute of Anatomy, University of Bern, Bern, Switzerland.
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16
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Ehrlich JH, Vendries V, Bryant TJ, Rainbow MJ, Ploeg HL, Bicknell RT. Trabecular bone density distribution in the scapula of patients undergoing reverse shoulder arthroplasty. JSES Int 2021; 6:32-39. [PMID: 35141673 PMCID: PMC8811382 DOI: 10.1016/j.jseint.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background To improve implant survival after reverse shoulder arthroplasty (RSA), surgeons need to maximize screw fixation. However, bone density variation and distribution within the scapula are not well understood as they relate to RSA. The three columns of bone in the scapula surrounding the glenoid fossa are the lateral border, the base of the coracoid process, and the spine of the scapula. In our previous study by Daalder et al on cadaveric specimens, the coracoid column was significantly less dense than the lateral border and spine. This study’s objective was to verify whether these results are consistent with computer tomography (CT) scan information from patients undergoing RSA. Methods Two-dimensional axial CT images from twelve patients were segmented, and a three-dimensional digital model of the scapula was subsequently created using Mimics 17.0 Materialise Software (Leuven, Belgium). Hounsfield unit (HU) values representing cortical bone were filtered out to determine the distributions of trabecular bone density. An analysis of variance with post hoc Bonferroni tests determined the differences in bone density between the columns of bone in the scapula. Results The coracoid superolateral (270 ± 45.6 HU) to the suprascapular notch was significantly less dense than the inferior (356 ± 63.6 HU, P = .03, ds = 1.54) and anterosuperior portion of the lateral border (353 ± 68.9 HU, P = .04, ds = 1.42) and the posterior (368 ± 70 HU, P = .007, ds = 1.65) and anterior spine (370 ± 78.9 HU, P = .006, ds = 1.54). Discussion/Conclusion The higher-density bone in the spine and lateral border compared with the coracoid region may provide better bone purchase for screws when fixing the glenoid baseplate in RSA. This is in agreement with our previous study and indicates that the previous cadaveric results are applicable to clinical CT scan data. When these studies are taken together, they provide robust evidence for clinical applications, including having surgeons aim screws for higher-density regions to increase screw fixation, which may decrease micromotion and improve implant longevity.
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17
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Hones KM, King JJ, Schoch BS, Struk AM, Farmer KW, Wright TW. The in vivo impact of computer navigation on screw number and length in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:e629-e635. [PMID: 33647443 DOI: 10.1016/j.jse.2021.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/21/2020] [Accepted: 01/10/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little information exists regarding the benefit of computer navigation in shoulder arthroplasty in the clinical setting. This study aimed to quantify how computer navigation affects the number and length of screws used during in vivo reverse total shoulder arthroplasty (RSA) placement. METHODS We performed a retrospective review of a research database to identify patients who underwent primary RSA before and after the use of computer navigation between January 1, 2015, and December 31, 2019. One hundred consecutive RSAs were selected from the computer navigation implantation date; then, 100 consecutive sex-matched RSAs were chosen prior to navigation implantation in reverse chronologic order. Baseplate augmentations were chosen based on surgeon discretion, with the goal of restoring version to within 10° of neutral and inclination to neutral or slightly inferior with removal of the smallest amount of subchondral bone possible. Screws were placed with the goal of ≥3 screws with good purchase and were added as needed, with up to 5 screws used. We compared demographic factors, comorbidities, preoperative diagnosis, number of screws, screw length, number of wasted screws, and number of cases with bone graft used behind the baseplate between the 2 groups. We used the χ2 test for bivariate analysis and the Student t test for continuous variables. RESULTS A total of 200 RSAs were included, with 100 primary RSAs (mean age, 69.3 years) performed prior to computer navigation compared with 100 primary RSAs (mean age, 69.7 years) performed using computer navigation. The total number of screws used in RSAs without computer navigation was 414; the total used in the computer navigation cases was 344. RSAs placed with computer navigation used significantly fewer screws per case (3.4 screws vs. 4.1 screws, P < .001) and had a significantly greater average screw length (35.0 mm vs. 32.6 mm, P < .001). Three screws were implanted in 61% of computer navigation cases vs. 1% of cases without computer navigation (P < .001). Screws ≥ 30 mm in length were more commonly used in patients undergoing RSA using computer navigation (84.6% vs. 73.7%, P < .001). CONCLUSION This study shows that computer navigation in RSA leads to longer and fewer glenoid baseplate screws being implanted. Computer navigation appears to assist with better screw placement, which may have similar clinical benefits of better glenoid fixation. Additionally, using fewer screws can save glenoid bone stock, avoid added glenoid stress risers, and decrease operative time.
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Affiliation(s)
- Keegan M Hones
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
| | - Bradley S Schoch
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Aimee M Struk
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Kevin W Farmer
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
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18
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Eroğlu ON, Hüsemoğlu B, Başçı O, Özkan M, Havıtçıoğlu H, Hapa O. Scapular spine base fracture with long outside-in superior or posterior screws with reverse shoulder arthroplasty. Clin Shoulder Elb 2021; 24:141-146. [PMID: 34488294 PMCID: PMC8423534 DOI: 10.5397/cise.2021.00213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background The purpose of the present study was to determine how long superior screws alone or in combination with posterior placement of metaglene screws protruding and penetrating into the scapular spine in reverse total shoulder arthroplasty affect the strength of the scapular spine in a fresh cadaveric scapular model. Methods Seven fresh cadaver scapulas were allocated to the control group (short posterior and superior screws) and seven scapulars to the study group (spine base fixation with a four long screws, three with both long superior and long posterior screws). Results The failure load was lower in the spine fixation group (long screw, 869 N vs. short screw, 1,123 N); however, this difference did not reach statistical significance (p>0.05). All outside-in long superior or superior plus posterior screws failed due to scapular spine base fracture; failures in the short screw group were due to acromion fracture. An additional posterior outside-in screw failed to significantly decrease the failure load of the acromion spine. Conclusions The present study highlights the significance of preventing a cortical breach or an outside-in configuration when a superior or posterior screw is inserted into the scapular spine base.
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Affiliation(s)
- Osman Nuri Eroğlu
- Department of Orthopedics and Traumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey.,Department of Biomechanics, Graduate School of Sciences, Dokuz Eylül University, İzmir, Turkey
| | - Buğra Hüsemoğlu
- Department of Biomechanics, Graduate School of Sciences, Dokuz Eylül University, İzmir, Turkey
| | - Onur Başçı
- Department of Orthopedics and Traumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Mustafa Özkan
- Department of Orthopedics and Traumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Hasan Havıtçıoğlu
- Department of Orthopedics and Traumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey.,Department of Biomechanics, Graduate School of Sciences, Dokuz Eylül University, İzmir, Turkey
| | - Onur Hapa
- Department of Orthopedics and Traumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
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19
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Lau SC, Large R. Acromial fracture after reverse total shoulder arthroplasty: a systematic review. Shoulder Elbow 2020; 12:375-389. [PMID: 33281942 PMCID: PMC7689606 DOI: 10.1177/1758573219876486] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/27/2019] [Accepted: 07/27/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND The reverse total shoulder arthroplasty has become the most common method of arthroplasty of the shoulder. The complication of acromial or scapular stress fracture deserves consideration to describe incidence and determine whether prosthetic design or patient factors act as risk factors. METHODS A systematic review of the literature was performed including the EMBASE, Medline and the Cochrane Library in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS The search returned 565 articles. After exclusion, 25 papers remained. In total, 208 fractures were reported in the literature, with an overall incidence of 5% and stress fractures were more common than post-traumatic ones; 24 fractures underwent osteosynthesis and there were nine revision arthroplasty surgeries. Outcomes worsened after fracture - whether treated with surgery or not. In patients with scapular base fractures, there was an improvement in functional outcome scores after surgery. Heterogeneous reporting of the risk factors prior to fractures, treatment methods and outcomes made recommendations weak. DISCUSSION Acromial stress fracture after reverse total shoulder arthroplasty occurs relatively commonly but is poorly reported in the literature. It is unclear whether immobilisation, fixation or revision arthroplasty is the best treatment, although fixation may offer a better outcome. In future, reports should aim for greater consistency to allow a better understanding of this condition.
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Affiliation(s)
- Simon C Lau
- Simon C Lau, Peninsula Health, Frankston Hospital, 2 Hastings Road, Frankston, Victoria 3199, Australia.
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20
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Moreschini F, Colasanti GB, Cataldi C, Mannelli L, Mondanelli N, Giannotti S. Pre-Operative CT-Based Planning Integrated With Intra-Operative Navigation in Reverse Shoulder Arthroplasty: Data Acquisition and Analysis Protocol, and Preliminary Results of Navigated Versus Conventional Surgery. Dose Response 2020; 18:1559325820970832. [PMID: 35185413 PMCID: PMC8851139 DOI: 10.1177/1559325820970832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
Reverse total shoulder arthroplasty (RSA) successfully restores shoulder function in different conditions. Glenoid baseplate fixation and positioning seem to be the most important factors influencing RSA survival. When scapular anatomy is distorted (eccentric osteoarthrirtis, rotator cuff arthropathy), optimal baseplate positioning and secure screw purchase can be challenging. The aim of this study was to evaluate whether CT-based pre-operative planning, integrated with intra-operative navigation could improve glenoid baseplate fixation and positioning by increasing screw length, reducing number of screws required to obtain fixation and increasing the use of augmented baseplate to gain the desired positioning. Twenty patients who underwent navigated RSA were compared retrospectively with 20 patients operated on with a conventional technique. All the procedures were performed by the same surgeon, using the same implant. Mean screw length was significantly longer in the navigation group (35.5 ± 4.4 mm vs 29.9 ± 3.6 mm; p = .001). Significant higher rate of optimal fixation using 2 screws only (17 vs 3 cases, p = .019) and higher rate of augmented baseplate usage (13 vs 4 cases, p = .009) was also present in the navigation group. Pre-operative CT-based planning integrated with intra-operative navigation can improve glenoid component positioning and fixation, possibly leading to an improvement of RSA survival.
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Affiliation(s)
- Fabio Moreschini
- Section of Orthopaedics, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Giovanni Battista Colasanti
- Section of Orthopaedics, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Carlo Cataldi
- Section of Orthopaedics, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Lorenzo Mannelli
- IRCCS SDN Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy
| | - Nicola Mondanelli
- Section of Orthopaedics, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Stefano Giannotti
- Section of Orthopaedics, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
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21
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Li J, Zhou J, Wang D, Li D, Zhang W. Applied anatomical study on suprascapular nerve protection in reverse total shoulder arthroplasty. J Orthop Surg Res 2020; 15:524. [PMID: 33176828 PMCID: PMC7661197 DOI: 10.1186/s13018-020-02061-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to investigate the three-dimensional (3D) anatomical relationship between the suprascapular nerve and scapula, and the method of protecting the suprascapular nerve in reverse total shoulder arthroplasty (RTSA) METHODS: In the present study, 12 fresh adult cadaver shoulder specimens were dissected. X-ray and computed tomography (CT) were used to investigate the 3D scapular and suprascapular nerve images. RESULTS The results revealed that the best fitting baseplate diameter was 24.73 ± 1.56 mm. Furthermore, the baseplate diameter correlated with the glenoid cavity width. After the osteotomy, a simulated screw placement on the baseplate was performed. The dangerous area for the posterior screw placement was at the angle between the upper edge and transverse axis exceeding 38° and between the lower edge and transverse axis exceeding 76°. The distance between the nearest point of the nerve and osteotomy plane was 15.38 ± 2.02 mm, and the angle between the projection point of the nearest point and transverse axis was 27.33 ± 7.96°, which was the dangerous area for retractor placement. The suitable angle between the superior screw and longitudinal axis was 21.67 ± 13.27°, and the suitable superior screw length was 34.66 ± 2.41 mm. CONCLUSION In RTSA, the baseplate size correlates with the glenoid cavity width. The relationship between the screw and suprascapular nerve and retractor placement position should be carefully considered to avoid damaging the suprascapular nerve.
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Affiliation(s)
- Jianfeng Li
- Department of Orthopaedics, Beijing Chaoyang Hospital of Capital Medical University, No. 8 of Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, PR China
| | - Junlin Zhou
- Department of Orthopaedics, Beijing Chaoyang Hospital of Capital Medical University, No. 8 of Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, PR China.
| | - Dong Wang
- Department of Orthopaedics, Beijing Chaoyang Hospital of Capital Medical University, No. 8 of Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, PR China
| | - Dacun Li
- Department of Upper Limb Surgery, Beijing Shunyi District Hospital, No. 3 of Guangming Nanjie, Shunyi District, Beijing, 101300, PR China
| | - Wentong Zhang
- Department of Upper Limb Surgery, Beijing Shunyi District Hospital, No. 3 of Guangming Nanjie, Shunyi District, Beijing, 101300, PR China
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22
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Jacxsens M, Elhabian SY, Brady SE, Chalmers PN, Mueller AM, Tashjian RZ, Henninger HB. Thinking outside the glenohumeral box: Hierarchical shape variation of the periarticular anatomy of the scapula using statistical shape modeling. J Orthop Res 2020; 38:2272-2279. [PMID: 31965594 PMCID: PMC7375008 DOI: 10.1002/jor.24589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 01/13/2020] [Indexed: 02/04/2023]
Abstract
Variation in the shape of the glenoid and periarticular anatomy of the scapula has been associated with shoulder pathology. The goal of this study was to identify the modes of shape variation of periarticular scapular anatomy in relation to the glenoid in nonpathologic shoulders. Computed tomography scans of 31 cadaveric scapulae, verified to be free of pathology, were three-dimensionally reconstructed. Statistical shape modeling and principal component analysis identified the modes of shape variation across the population. Corresponding linear and angular measurements quantified the morphometric variance identified by the modes. Linear measures were normalized to the radius of the inferior glenoid to account for differences in the scaling of the bones. Five modes captured 89.7% of total shape variation of the glenoid and periarticular anatomy. Apart from size differences (mode 1: 33.0%), acromial anatomy accounted for the largest variation (mode 2: 32.0%). Further modes described variation in glenoid inclination (mode 3: 11.8%), coracoid orientation and size (mode 4: 9.0%), and variation in coracoacromial (CA) morphology (mode 5: 3.1%). The average scapula had a mean acromial tilt of 49 ± 7°, scapular spine angle of 61 ± 6°, the glenoid inclination of 84 ± 4°, coracoid deviation angle of 26 ± 4°, coracoid length of 3.7 ± 0.3 glenoid radii, and a CA base length of 5.6 ± 0.5 radii. In this study, the identified shape modes explain almost all of the variance in scapular anatomy. The acromion exhibited the highest variance of all periarticular anatomic structures of the scapula in relation to the glenoid, which may play a role in many shoulder pathologies.
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Affiliation(s)
- Matthijs Jacxsens
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA,Department of Orthopaedics and Traumatology, University Hospital of Basel, Basel, Switzerland,Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Shireen Y. Elhabian
- Scientific Computing and Imaging Institute, School of Computing, University of Utah, Salt Lake City, UT, USA
| | - Sarah E. Brady
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Peter N. Chalmers
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Andreas M. Mueller
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Basel, Switzerland
| | | | - Heath B. Henninger
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA,Scientific Computing and Imaging Institute, School of Computing, University of Utah, Salt Lake City, UT, USA,Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
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Pitocchi J, Wirix-Speetjens R, van Lenthe GH, Pérez MÁ. Integration of cortical thickness data in a statistical shape model of the scapula. Comput Methods Biomech Biomed Engin 2020; 23:642-648. [DOI: 10.1080/10255842.2020.1757082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jonathan Pitocchi
- Materialise NV, Heverlee, Belgium
- Multiscale in Mechanical and Biological Engineering (M2BE), University of Zaragoza, Zaragoza, Spain
- Biomechanics Section, KU Leuven (University of Leuven), Leuven, Belgium
| | | | | | - María Ángeles Pérez
- Multiscale in Mechanical and Biological Engineering (M2BE), University of Zaragoza, Zaragoza, Spain
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24
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Diaz MA, Hsu JE, Ricchetti ET, Garrigues GE, Gutierrez S, Frankle MA. Influence of reverse total shoulder arthroplasty baseplate design on torque and compression relationship. JSES Int 2020; 4:388-396. [PMID: 32490432 PMCID: PMC7256898 DOI: 10.1016/j.jseint.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background A linear relationship between baseplate insertion torque and compression force in reverse shoulder arthroplasty (RSA) baseplates with central screw design has been recently established. In this study, we evaluated 3 different baseplate designs and their influence on the torque-compression relationship. Methods Three different RSA baseplate designs were evaluated through biomechanical testing using a glenoid vault, bone surrogate model. A digital torque gauge was used to measure insertion torque applied to the baseplate, whereas compression data were collected continuously from a load cell. Additionally, 2 predictive models were developed to predict the compression forces of each baseplate design at varying levels of torque. Results A linear relationship was found between baseplate compression and insertion torque for all 3 baseplate designs. Both the monoblock and 2-piece locking designs achieved the goal torque of 6.8 Nm, whereas the 2-piece nonlocking design did not due to material strip-out. No significant difference in maximum compression was found between the monoblock and 2-piece locking designs. However, the 2-piece nonlocking design achieved significantly higher compression. Both predictive models were shown to adequately predict compressive forces at different torque inputs for the monoblock and 2-piece locking designs but not the 2-piece nonlocking design. Conclusion The torque-compression relationship of a central screw baseplate is significantly affected by baseplate design. A 2-piece nonlocking baseplate reaches higher compression levels and risks material strip-out at lower insertional torques compared with a monoblock and 2-piece locking design. This has implications both on component design and on surgeon tactile feedback during surgery.
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Affiliation(s)
- Miguel A Diaz
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Eric T Ricchetti
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Sergio Gutierrez
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA
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25
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The precision of patient-specific instrumentation guides for the positioning of the glenoid component in total reverse shoulder arthroplasty: an in vivo scanographic study. INTERNATIONAL ORTHOPAEDICS 2020; 44:1761-1766. [DOI: 10.1007/s00264-020-04524-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
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Whitham RDJ, Clifford ZJ, Tasker AJB, Woods DA. Rib fracture as a complication of erroneous baseplate and inferior screw placement in reverse total shoulder replacement: a case report. J Shoulder Elbow Surg 2020; 29:e87-e92. [PMID: 32067713 DOI: 10.1016/j.jse.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/07/2019] [Accepted: 11/16/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Robert D J Whitham
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK.
| | - Zoë J Clifford
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
| | - Andrew J B Tasker
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
| | - David A Woods
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
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Nashikkar PS, Scholes CJ, Haber MD. Role of intraoperative navigation in the fixation of the glenoid component in reverse total shoulder arthroplasty: a clinical case-control study. J Shoulder Elbow Surg 2019; 28:1685-1691. [PMID: 31262637 DOI: 10.1016/j.jse.2019.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fixation of the glenoid baseplate in reverse total shoulder arthroplasty (rTSA) is an important factor in the success of the procedure. There is limited information available regarding the effect of navigation on fixation characteristics. Therefore, the aims of this study were to determine whether computed tomography-based computer navigation improved the glenoid base plate fixation by (1) increasing the length of screw purchase, (2) altering screw angulation, and (3) decreasing central cage perforation in patients undergoing rTSA. METHODS Patients undergoing rTSAs using navigation (NAV, N = 27) and manual technique (MAN, N = 23) from January 2014 to July 2017 were analyzed in a case-control design. Screw purchase length and central cage perforation were assessed using multiplanar computed tomography. RESULTS Median screw purchase length was significantly longer in the NAV group for both anterior (20 mm vs. 15 mm, P < .01) and posterior screws (20 mm vs. 13 mm, P < .01). In addition, the NAV group displayed significantly lower incidences of inadequate screw purchase (<22 mm) for the anterior (64.7% vs. 95.2%, P = .03) and posterior (70.6% vs. 100%, P = .01) screws. Significant differences in axial and coronal screw angulation were observed between groups. Similarly, the NAV group displayed significantly reduced incidence of central cage perforation (17.7% vs. 52.4%, P = .04). CONCLUSION The use of computer-assisted navigated rTSA contributes to significant alterations in screw purchase length, screw angulation, and central cage perforation of the glenoid baseplate compared with non-navigated methods.
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Affiliation(s)
| | | | - Mark D Haber
- Southern Orthopaedics, Wollongong, NSW, Australia.
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28
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Central screw use delays implant dislodgement in osteopenic bone but not synthetic surrogates: A comparison of reverse total shoulder models. J Biomech 2019; 93:11-17. [DOI: 10.1016/j.jbiomech.2019.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/21/2019] [Accepted: 06/03/2019] [Indexed: 11/18/2022]
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29
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Jeong YS, Yum JK, Lee JS. Another Glenoid Measurements for Shoulder Surgery. Clin Shoulder Elb 2018; 21:179-185. [PMID: 33330174 PMCID: PMC7726404 DOI: 10.5397/cise.2018.21.4.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022] Open
Abstract
Background We analyzed the angle between the glenoid anterior surface and glenoid axis, the range of the glenoid apex and the location of the glenoid apex for assistance during shoulder surgery. Methods Sixty-two patients underwent a computed tomography of the shoulder with a proximal humerus fracture. In the range of the glenoid apex, the ratios of the distribution of triangles with a Constant anterior and posterior area of the glenoid were measured. The location of glenoid apex was confirmed as the percentage of the position with respect to the upper part of the glenoid with the center of the part, analyzed the angle between the glenoid anterior surface and glenoid axis was measured. Results The angle between the glenoid anterior surface and glenoid axis was 19.80° ± 3.88°. The location of the glenoid apex is 60.36% ± 9.31%, with the upper end of the glenoid as the reference. The range of the glenoid apex was 21.16% ± 4.98%. When the height of the glenoid becomes smaller, the range of the glenoid apex tends to become larger (p=0.001) and the range of the glenoid apex becomes wider (p=0.001) as the glenoid width narrows. Conclusions We believe the anatomical measurements of the glenoid will be helpful for a more accurate insertion in glenoid component. It is thought that more accurate insertion is possible if we can set other anatomical measurements using computed tomography imaging of the glenoid which can develop into the study of other anatomical measurements.
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Affiliation(s)
- Yeon-Seok Jeong
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Jae-Kwang Yum
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University School of Medicine, Seoul, Korea
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Trabecular bone density distribution in the scapula relevant to reverse shoulder arthroplasty. JSES OPEN ACCESS 2018; 2:174-181. [PMID: 30675591 PMCID: PMC6334872 DOI: 10.1016/j.jses.2018.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background How trabecular bone density varies within the scapula and how this may lead to more optimal reverse shoulder arthroplasty (RSA) screw placement has not been addressed in the scientific literature. The 3 columns of trabecular bone within the scapula adjacent to the glenoid fossa, one extending through the lateral border, a second into the base of the coracoid process, and a third extending into the spine of the scapula, were hypothesized to be of relatively similar density. Methods Two-dimensional axial computed tomography (CT) images of 19 fresh frozen cadaver specimens were obtained. Digital Imaging and Communications in Medicine (DICOM; National Electrical Manufacturers Association, Rosslyn, VA, USA) image files of the CT scanned scapulae were imported into Mimics 17.0 Materialise Software (Leuven, Belgium) for segmentation and 3-dimensional digital model generation. To determine the distribution of trabecular bone density, Hounsfield unit (HU) values in the scapulae gray value files obtained from Mimics were filtered to remove any cortical bone. HU values of 650 define the corticocancellous interface in CT image data and were considered to be cortical bone. Analyses of variance with post hoc Bonferroni tests were used to determine statistical differences between the intra- and inter-regions of bone density comparisons. Results The base of the coracoid process was statistically significantly less dense than the spine and the lateral border of the scapulae examined (P < .05). Discussion/Conclusion The higher-quality bone in the spine and lateral border, compared with the coracoid regions, may provide better bone purchase for screws when fixing the glenoid baseplate in RSA.
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Glenoid morphology and the safe zone for protecting the suprascapular nerve during baseplate fixation in reverse shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2017; 42:587-593. [PMID: 28956117 DOI: 10.1007/s00264-017-3646-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to investigate glenoid morphology and define the safe zone for protecting the suprascapular nerve baseplate screw during baseplate fixation in reverse shoulder arthroplasty (RSA) in a Chinese population. METHODS Shoulder computed tomography (CT) scans from 56 subjects were retrospectively reviewed. Three-dimensional (3D) reconstruction was performed using Mimics software, and corresponding bony references were used to evaluate glenoid morphology. To standardize evaluation, the coronal scapular plane was defined. Safe fixation distances and screw placements were investigated by constructing a simulated cutting plane of the baseplate during RSA. RESULTS Mean glenoid height was 35.83 ± 2.95 mm, and width was 27.32 ± 2.78 mm, with significant sexual dimorphism (p < 0.01). According to the cutting plane morphology, the average baseplate radius was 13.84 ± 1.34 mm. The distances from the suprascapular notch and from two bony reference points at the base of the scapular spine to the cutting plane were 30.27 ± 2.77 mm, 18.39 ± 1.67 mm and 16.52 ± 1.52 mm, respectively, with a gender-related difference. Based on the clock face indication system, the danger zone caused by the suprascapular nerve projection was oriented between the two o'clock and eight o'clock positions in reference to the right shoulder. CONCLUSIONS Glenoid size and the safe zone for screw fixation during RSA were characterized in a Chinese population. Careful consideration of baseplate fixation and avoidance of suprascapular nerve injury are important for improved clinical outcome.
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32
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Mathews S, Burkhard M, Serrano N, Link K, Häusler M, Frater N, Franke I, Bischofberger H, Buck FM, Gascho D, Thali M, Serowy S, Müller-Gerbl M, Harper G, Qureshi F, Böni T, Bloch HR, Ullrich O, Rühli FJ, Eppler E. Glenoid morphology in light of anatomical and reverse total shoulder arthroplasty: a dissection- and 3D-CT-based study in male and female body donors. BMC Musculoskelet Disord 2017; 18:9. [PMID: 28068966 PMCID: PMC5223371 DOI: 10.1186/s12891-016-1373-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/19/2016] [Indexed: 11/19/2022] Open
Abstract
Background Placement of the glenoid baseplate is of paramount importance for the outcome of anatomical and reverse total shoulder arthroplasty. However, the database around glenoid size is poor, particularly regarding small scapulae, for example, in women and smaller individuals, and is derived from different methodological approaches. In this multimodality cadaver study, we systematically examined the glenoid using morphological and 3D-CT measurements. Methods Measurements of the glenoid and drill hole tunnel length for superior baseplate screw placement were recorded to define size of the glenoid and the distance to the scapular notch on cadaveric specimens. Glenoid angles were determined on both, 3D-CT-scans of the thoraxes using the Friedman method and on subsequently isolated scapulae from 18 male and female donors (average 84 years, range 60–98 years). Results Mean glenoid height was 36.6 mm ± 3.6, and width 27.8 mm ± 3.1 with a significant sex dimorphism (p ≤ 0.001): in males, glenoid height 39.5 mm ± 3.5, and width 30.3 mm ± 3.3, and in females, glenoid height 34.8 mm ± 2.2, and width 26.2 mm ± 1.6. The average distance from the superior screw entry to its exit in the scapular notch measured by calliper was 27.2 mm ± 6.0 with a sex difference: in males, 29.4 mm ± 5.7, and in females, 25.8 mm ± 5.9 mm with a minimum recorded distance of 15 mm. Measured by CT, the mean inclination angle for male and female donors combined was 13.0° ± 7.0, and the ante-/retroversion angle −1.0° ± 4.0°. Conclusion This study is one of the first to combine dissection, including drill holes, with anatomical measurements and radiological data. In some women and smaller individuals, smaller baseplates should be selected. The published safe zone of 20 mm is generally feasible for superior screw placement, however, in small patients this distance may be substantially shorter than expected and start as of 13 and 15 mm, respectively. No correlation between glenoid height or width with the length of our drilling canal towards the scapular notch was found. Preoperative CT-based treatment planning to determine version and inclination angles is recommended.
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Affiliation(s)
- Sandra Mathews
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.
| | - Marco Burkhard
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Nabil Serrano
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.,Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Karl Link
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.,Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Martin Häusler
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.,Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Nakita Frater
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland
| | - Ingeborg Franke
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Helena Bischofberger
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Florian M Buck
- Medical Radiology Institute, Schulthess Clinic, Zurich, Switzerland.,Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Dominic Gascho
- Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Michael Thali
- Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Steffen Serowy
- Institute of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Magdalena Müller-Gerbl
- Musculoskeletal Research Unit, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Gareth Harper
- Shoulder Unit, Queen Alexandra Hospital, Portsmouth, UK
| | - Ford Qureshi
- Shoulder Unit, Doncaster Royal Infirmary, Doncaster, UK
| | - Thomas Böni
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.,Technical Orthopedics Unit, University Hospital Balgrist, Zurich, Switzerland
| | | | - Oliver Ullrich
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland
| | - Frank-Jakobus Rühli
- Institute of Evolutionary Medicine (IEM), University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland
| | - Elisabeth Eppler
- Division of Gross Anatomy, Institute of Anatomy, University of Zurich, Zurich, Switzerland.,Institute of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany.,Musculoskeletal Research Unit, Department of Biomedicine, University of Basel, Basel, Switzerland
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Obert L, Peyron C, Boyer E, Menu G, Loisel F, Aubry S. CT scan evaluation of glenoid bone and pectoralis major tendon: interest in shoulder prosthesis. SICOT J 2016; 2:33. [PMID: 27716461 PMCID: PMC5054739 DOI: 10.1051/sicotj/2016021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 07/11/2016] [Indexed: 01/08/2023] Open
Abstract
Introduction: The shoulder arthroplasty brings satisfaction to patients in terms of quality of life and indolence. However whether anatomic implant or reverse, it does not escape from the loosening of the glenoid component. Moreover, optimal implantation is required to ensure the functional outcome without shortening of the arm. The purpose of this study is obtain CT scan evaluation of the glenoid bone stock in order to optimize glenoid component implantation and obtain a reference to determine optimal humeral component placement in case of humeral proximal fracture. Materials and methods: Between 2010 and 2011 we have analyzed 200 intact shoulder’s CT. We measured maximal and minimal width in the transverse plane of the glenoid, the distance from the pectoralis major (PM) tendon to the humeral head, the greater tubercle, change of curvature and the anatomical neck. Results: Mean maximum width was 27.4 ± 3.4 mm and mean minimum width was 15.5 ± 2.8 mm. Distances between upper edge of PM tendon to: humeral head, greater tubercle, change of curvature and anatomical neck were respectively: 67.6 ± 9.98 mm, 57.8 ± 10.3 mm, 28.7 ± 9 mm, and 34.2 ± 9.7 mm. Conclusion: Our study has produced an assessment of glenoid bone stock for optimal positioning of the glenoid implant but also to obtain a reference to determine the ideal location of the humeral component in the case of proximal humerus fracture.
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Affiliation(s)
- Laurent Obert
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besançon, 25000 Besançon, France - Intervention, Innovation, Imagery, Engineering in Health (EA 4268), Medical and Pharmacology Section, IFR 133, University of Franche-Comté, 25000 Besançon, France
| | - Christelle Peyron
- Intervention, Innovation, Imagery, Engineering in Health (EA 4268), Medical and Pharmacology Section, IFR 133, University of Franche-Comté, 25000 Besançon, France - Radiology unit, Research Unit: EA 4268 I4S - IFR 133 INSERM University Hospital of Besançon, 25000 Besançon, France
| | - Etienne Boyer
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besançon, 25000 Besançon, France
| | - Gauthier Menu
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besançon, 25000 Besançon, France
| | - François Loisel
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besançon, 25000 Besançon, France - Intervention, Innovation, Imagery, Engineering in Health (EA 4268), Medical and Pharmacology Section, IFR 133, University of Franche-Comté, 25000 Besançon, France
| | - Sébastien Aubry
- Intervention, Innovation, Imagery, Engineering in Health (EA 4268), Medical and Pharmacology Section, IFR 133, University of Franche-Comté, 25000 Besançon, France - Radiology unit, Research Unit: EA 4268 I4S - IFR 133 INSERM University Hospital of Besançon, 25000 Besançon, France
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Mayne IP, Bell SN, Wright W, Coghlan JA. Acromial and scapular spine fractures after reverse total shoulder arthroplasty. Shoulder Elbow 2016; 8:90-100. [PMID: 27583005 PMCID: PMC4950466 DOI: 10.1177/1758573216628783] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/04/2016] [Indexed: 11/16/2022]
Abstract
Acromial and scapular spine fractures after reverse total shoulder arthroplasty occur predominantly as a result of bony insufficiency secondary to patient and intra-operative technical factors. The spectrum of the pathology can range from a stress reaction to an undisplaced or displaced fracture. Prompt diagnosis of these fractures requires a high suspicion in the postoperative patient with a clinical presentation of acute onset of pain along the acromion or scapular spine and/or deterioration of shoulder function. Conventional shoulder radiographs are frequently unreliable in identifying these fractures, especially if they are undisplaced. Computed tomography (CT) and/or single photon emission computed tomography/CT scans are useful imaging modalities for obtaining a definitive diagnosis. Early diagnosis and non-operative treatment of a stress reaction or undisplaced fracture is essential for preventing further displacement and potential disability. The management of displaced fractures is challenging for the orthopaedic surgeon as a result of high rates of mal-union or non-union, decreased functional outcomes, and variable results after open reduction and internal fixation. Strategies for preventing these fractures include optimizing the patient's bone health, correct glenoid baseplate screw length and position, and avoiding excessive deltoid tension. Further research is required to identify the specific patient and fracture characteristics that will benefit from conservative versus operative management.
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Affiliation(s)
- Ian P Mayne
- Department of Surgery, Melbourne Shoulder and Elbow Centre, Monash University, Melbourne, Australia,Ian Mayne, Melbourne Shoulder & Elbow Centre, 31 Normanby Street, Brighton, VIC 3186, Australia. Tel: +61 4 1018 2635.
| | - Simon N Bell
- Department of Surgery, Melbourne Shoulder and Elbow Centre, Monash University, Melbourne, Australia
| | | | - Jennifer A Coghlan
- Department of Surgery, Melbourne Shoulder and Elbow Centre, Monash University, Melbourne, Australia
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35
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Lee JM, Kim IB, Jung DW. Clinical and Radiological Results of Reverse Total Shoulder Arthroplasty Using a 25-mm Glenoid Baseplate. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.4.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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36
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Wang HJ, Giambini H, Hou DB, Huan SW, Liu N, Yang J, Chen C, Gao YP, Shang RG, Li YK, Zha ZG. Classification and Morphological Parameters of the Scapular Spine: Implications for Surgery. Medicine (Baltimore) 2015; 94:e1986. [PMID: 26559282 PMCID: PMC4912276 DOI: 10.1097/md.0000000000001986] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Incidence of scapular spine (SS) fractures as a result of complications of reverse total shoulder arthroplasty is relatively high leading to inferior clinical outcomes and an increased risk of revision and dislocation. Fractures of SS because of trauma, including the acromion, constitute 6% to 23% of scapula fractures. The purpose of this study was to classify the SS and present specific geometrical parameters according to osteologic features. A total of 319 intact dry scapulae were collected and classified based on morphological characteristics and shape of the SS. Nine bony landmarks were also chosen and described for their relevance to regions of interest for scapular fixation. Five specific types of SS were noted and the most prevalent groups were Type 1 (Fusiform shape) (47.17%) and Type 5 (Horizontal S-shape) (19.18%). Overall, Types 3, 4, and 1 showed thicker landmark values compared to Type 5, with Type 2 having smaller values. Our classification into 5 distinct types allowed appreciation of the anatomical variance of SSs. The contours of Types 5 and 1 presented a more complex morphology and may lead to a worse surgical approach due to a fracture. As Types 2 and 5 were much thinner than the other types, these may be more susceptible to fractures.
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Affiliation(s)
- Hua-Jun Wang
- From the First Clinical College, Jinan University and Department of Orthopedics, The First Affiliated Hospital, Jinan University, Guangzhou, China (HJW, DBH, SWH, NL, JY, ZGZ); Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA (HG); Department of Orthopedics, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou (CC, YKL); Department of Orthopedics, Shenzhen Pingle Orthopedic Hospital, Shenzhen (YPG); and Department of Orthopedics, Guangzhou Orthopedic Hospital, Guangzhou, China (RGS)
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Stephens BF, Hebert CT, Azar FM, Mihalko WM, Throckmorton TW. Optimal baseplate rotational alignment for locking-screw fixation in reverse total shoulder arthroplasty: a three-dimensional computer-aided design study. J Shoulder Elbow Surg 2015; 24:1367-71. [PMID: 25819730 DOI: 10.1016/j.jse.2015.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/19/2015] [Accepted: 01/21/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Baseplate loosening in reverse total shoulder arthroplasty (RTSA) remains a concern. Placing peripheral screws into the 3 pillars of the densest scapular bone is believed to optimize baseplate fixation. Using a 3-dimensional computer-aided design (3D CAD) program, we investigated the optimal rotational baseplate alignment to maximize peripheral locking-screw purchase. METHODS Seventy-three arthritic scapulae were reconstructed from computed tomography images and imported into a 3D CAD software program along with representations of an RTSA baseplate that uses 4 fixed-angle peripheral locking screws. The baseplate position was standardized, and the baseplate was rotated to maximize individual and combined peripheral locking-screw purchase in each of the 3 scapular pillars. RESULTS The mean ± standard error of the mean positions for optimal individual peripheral locking-screw placement (referenced in internal rotation) were 6° ± 2° for the coracoid pillar, 198° ± 2° for the inferior pillar, and 295° ± 3° for the scapular spine pillar. Of note, 78% (57 of 73) of the screws attempting to obtain purchase in the scapular spine pillar could not be placed without an in-out-in configuration. In contrast, 100% of coracoid and 99% of inferior pillar screws achieved full purchase. The position of combined maximal fixation was 11° ± 1°. CONCLUSIONS These results suggest that approximately 11° of internal rotation is the ideal baseplate position for maximal peripheral locking-screw fixation in RTSA. In addition, these results highlight the difficulty in obtaining optimal purchase in the scapular spine.
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Affiliation(s)
- Byron F Stephens
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Casey T Hebert
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Frederick M Azar
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - William M Mihalko
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Thomas W Throckmorton
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA.
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Chae SW, Kim SY, Lee H, Yon JR, Lee J, Han SH. Effect of baseplate size on primary glenoid stability and impingement-free range of motion in reverse shoulder arthroplasty. BMC Musculoskelet Disord 2014; 15:417. [PMID: 25488492 PMCID: PMC4295354 DOI: 10.1186/1471-2474-15-417] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 12/05/2014] [Indexed: 11/30/2022] Open
Abstract
Background Use of a baseplate with a smaller diameter in reverse shoulder arthroplasty is increasing, especially in patients with a small glenoid or glenoid wear. However, the effect of a smaller baseplate on stability of the glenoid component has not been evaluated. Thus, the purpose of this study was to determine whether a smaller baseplate (25 mm) is beneficial to the initial stability of the glenoid component compared to that with a baseplate of a commonly used size (29 mm). Methods Micromotion of glenoid components attached to 14 scapulae of fresh-frozen cadavers was measured and compared between 25- and 29-mm baseplates in biomechanical testing. Impingement-free range of motion in abduction, adduction, internal rotation, and external rotation was evaluated by using a simulated computer model constructed based on the same fresh-frozen cadavers used in biomechanical testing. Results Micromotion at the inferior third of the glenoid-glenosphere interface was higher in the 29-mm baseplate group than in the 25-mm baseplate group during both 0.7- and 1-body weight cyclic loading in biomechanical testing. Adduction deficit was smaller, and total impingement-free range of motion from abduction to adduction and rotation were greater in the 25-mm baseplate group than in the 29-mm baseplate group in the simulated computer model. Conclusions Use of a baseplate with a smaller diameter (25 mm) in reverse shoulder arthroplasty is suitable for improving the primary stability of the glenoid component. With a smaller baseplate, impingement-free range of motion is optimized in a smaller glenoid. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-417) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Soung-Yon Kim
- Department of Orthopaedic Surgery, Hallym University, Kangnam Sacred Heart Hospital, Seoul, South Korea.
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Improving glenoid-side load sharing in a virtual reverse shoulder arthroplasty model. J Shoulder Elbow Surg 2013; 22:954-62. [PMID: 23313366 DOI: 10.1016/j.jse.2012.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND The goal of glenoid fixation in reverse shoulder arthroplasty (RSA) is to provide a stable environment to allow bony ingrowth into the baseplate. When this does not occur, eventual baseplate failure is likely. This study aims to determine the additional implant-bone contact achieved when the glenosphere undersurface is in contact with the glenoid and if this increase in implant-bone contact improves stability through load sharing with respect to baseplate fixation. We hypothesize that substantial increases in contact area are possible and that this increased contact area will improve baseplate stability through load sharing. METHODS A computer-assisted design program was used to create 3-dimensional models of 7 currently available RSA devices. Total implant-bone contact area was compared in 2 conditions: (1) baseplate flush with bone and no additional glenosphere contact, or (2) baseplate and glenosphere undersurface in contact with bone. Next, finite element models were created from a commercially available system. Micromotion and stress were computed for each size of implant in the 2 conditions. RESULTS All devices tested can achieve increased total contact area when the glenosphere is in contact with bone. Stress and micromotion were reduced when comparing condition 2 with condition 1 in all sizes of one commercially available system. The average micromotion decreased 37%, from 98.04 to 61.97 μm. Larger glenospheres experienced a greater reduction in micromotion. Likewise, average von Mises stress decreased 26%, from 3.29 to 2.42 MPa. CONCLUSION Increasing glenosphere size and allowing glenosphere undersurface contact increased overall implant-bone contact area and baseplate stability.
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Bateman E, Donald SM. Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. J Shoulder Elbow Surg 2012; 21:925-34. [PMID: 22036536 DOI: 10.1016/j.jse.2011.07.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 07/05/2011] [Accepted: 07/10/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND This report documents our experiences with a new technique for reconstructing massive uncontained defects of the glenoid with reverse total shoulder arthroplasty. MATERIALS AND METHODS We use a modified deltopectoral approach to perform the combined allograft-autograft construct glenoid reconstruction. We make use of a peripherally seated cortical allograft acting as a sleeve bushing to provide a stable ring under compression in which to house impacted cancellous autograft centrally for early incorporation and in-growth with the long-peg Aequalis (Tornier, Saint-Ismier Cedex, France) reverse total shoulder arthroplasty baseplate. RESULTS Our case series now comprises 10 patients with postoperative follow-up of up to 36 months. We report the first 5 patients here, all of whom have more than 12 months of follow-up. Computed tomography scanning demonstrates incorporation of the graft as early as 6 months. None of these patients have had loosening, implant failures, dislocations, periprosthetic fractures, or infections. One patient sustained an acromial stress fracture that was successfully treated nonoperatively, and 1 patient has nonprogressive grade I notching. CONCLUSION The hybrid graft glenoid reconstruction is a useful and versatile technique in the setting of massive uncontained defects of the glenoid and permits the implantation of a reverse total shoulder arthroplasty. We believe this technique is reproducible and uses materials that are both readily available and familiar.
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Affiliation(s)
- Edward Bateman
- Newcastle Shoulder & Elbow Centre, Newcastle, NSW, Australia
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Chung SW, Kim JY, Oh JH. Reverse Total Shoulder Arthroplasty - Techniques and Pitfalls -. Clin Shoulder Elb 2011. [DOI: 10.5397/cise.2011.14.1.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cho CH, Jung GH, Sin HK, Lee YK, Park JH. Coracoclavicular Ligament Augmentation Using Endobutton for Unstable Distal Clavicle Fractures - Preliminary Report -. Clin Shoulder Elb 2011. [DOI: 10.5397/cise.2011.14.1.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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