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

[Current concepts and treatment options for complex glenoid bone defects : Patient-specific instrumentation and custom-made implants]

Glenoid bone defects are frequent and the etiology is multifactorial. To prevent increased loosening rates of the glenoid component in total shoulder arthroplasty (TSA), various techniques are available to address the loss of glenoid bone. When corrective reaming and bone grafting techniques are no longer sufficient, patient-specific instrumentation (PSI) and custom-made implants have become core strategies for managing these defects. Following precise planning based on computed tomography (CT) imaging and three-dimensional reconstruction of the bony surface, an individualized guide can be used to accurately position the implant. When the limits of bone reconstruction have been reached, specially prepared (custom-made) implants can be used to compensate for the bony defect. Patients often require minimal postoperative immobilization of the shoulder joint. The currently limited literature describes favorable clinical outcomes, although these findings are almost exclusively limited to reverse shoulder arthroplasty.

Current trends in shoulder arthroplasty - Are the trends backed by evidence?

Shoulder arthroplasty is the third most common joint replacement performed worldwide and remains a rapidly innovative area for improvement in patient care. This article explores the evidence surrounding current trends aiming to improve patient outcome in all forms of shoulder arthroplasty.

Accuracy of placement of the glenoid component in reverse shoulder arthroplasty using a custom baseplate for severe glenoid deficiency

Background

Glenoid bone deficiency can lead to early component loosening and implant failure during reverse total shoulder arthroplasty (rTSA). Recently, the glenoid Vault Reconstruction System (Zimmer-Biomet, Warsaw, IN, USA), a computer-aided design ot computer-assisted manufacturing system, was developed, with good clinical outcomes, including no radiographic loosening. This study examined the postoperative accuracy of glenoid component placement using this system at three different facilities.

Methods

Nine patients undergoing rTSA with vault reconstruction system performed by three board-certified, fellowship-trained shoulder surgeons at three different institutions between August 2020 and January 2023 were included. Preoperative and postoperative computed tomography was performed, and glenoid inclination and version were measured using a postoperative three-dimensional evaluation system. Surgical time and intraoperative blood loss were also measured.

Results

The range of errors of glenoid inclination and version were 3.5 ± 2.5° (0.4-8.3) and 3.2 ± 2.2° (0.4-6.7), respectively. In primary cases, the error ranges of both glenoid inclination and version were within 5° in six of seven cases (85.7%). In revision cases, both glenoid inclination and version were within 10°. The mean operative time was 131.4 ± 48.9 (80-206) min and the mean intraoperative blood loss was 161.1 ± 94.2 (30-300) ml; there were no intraoperative complications.

Conclusion

In the present study, the placement position was good in primary and revision cases, making the placement of the glenoid component of the rTSA using vault reconstruction system in cases of glenoid bone deficiency highly reproducible.

Early results of reverse total shoulder arthroplasty using a patient-specific baseplate to address severe glenoid deficiency

Background

The purpose of this study was to describe outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) using a patient-specific, custom glenoid component to address severe glenoid deficiency.

Methods

Retrospective chart review identified patients at a single institution undergoing rTSA using the glenoid vault reconstruction system (VRS) between 2017 and 2022. Radiographic evaluation, range of motion and patient-reported outcome (PRO) measures, complications, and re-operations were assessed.

Results

Fourteen shoulders were included. There was 100% implant survivorship of the glenoid baseplate at mean follow-up of 26.6 months. Mean range of motion improved in forward elevation (62-106 degrees), abduction (41-100 degrees), and external rotation (11-36 degrees). In 7 of 13 patients available for PRO collection, the mean final Visual Analog Pain Scale (VAS) score was 1.29, Single Assessment Numeric Evaluation (SANE) score was 72.14, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score was 77.14, and Penn Shoulder score was 72.26.

Conclusions

Use of this custom glenoid resulted in encouraging clinical and radiographic outcomes, with no failures in implant survivorship seen at early follow-up. Larger prospective studies with longer-term follow-up should be undertaken in order to better determine the efficacy and longevity of this implant.

Study Design

Retrospective case series; Level of evidence, 4.

Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up

INTRODUCTION

Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment.

HYPOTHESIS

Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results.

METHODS

This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported.

RESULTS

The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83).

DISCUSSION

Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up.

LEVEL OF EVIDENCE

IV; retrospective study.

Primary and revision reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid bone deficiency

BACKGROUND

Severe glenoid bone loss in the setting of both primary and revision reverse total shoulder arthroplasty (rTSA) continues to remain a significant challenge. The purpose of this study was to report on radiographic and clinical outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed metal glenoid implant to address severe glenoid bone deficiency. This is a follow-up study to previously reported preliminary results.

METHODS

A retrospective review was performed on 62 patients with severe glenoid bone deficiency who underwent either primary or revision rTSA using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain scores as well as active range of motion (ROM) were collected and compared using the Wilcoxon signed rank test with the level of statistical significance set at P < .05. The percentage of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also calculated.

RESULTS

Fifty-five of 62 shoulders (88.7%) were able to be contacted at a minimum of 2 years postoperatively, with 47 of 62 (75.8%) having complete clinical and radiographic follow-up with a mean age of 67.5 years (range, 48-85 years) and follow-up of 39.2 months (range, 25-56 months). There were 19 primary and 28 revision rTSAs. Significant improvements were seen in mean active forward flexion (63.1° ± 30.3° to 116.8° ± 35°), abduction (48.1° ± 16.1 to 76.2° ± 13.4°) (P < .001), external rotation (16° ± 23.7° to 32.1° ± 24.5°) (P < .005), DASH (59.9 ± 17.7 to 35.7 ± 24.3), Constant (23.4 ± 13.1 to 53.1 ± 17.4), ASES (27.8 ± 16.2 to 69.1 ± 25.2), SST (3.3 ± 2.5 to 7.6 ± 3.5), SANE (28.9 ± 18.3 to 66.7 ± 21.2), and VAS pain (7.1 ± 2.4 to 1.8 ± 2.6) scores (P < .001). MCID and SCB was achieved in a majority of patients postoperatively. The overall complication rate was 29.1%, with only 1 baseplate failure.

CONCLUSION

This study demonstrates promising evidence that the VRS implant can be used as a viable option to achieve clinically important improvement in a majority of patients treated for severe glenoid bone deficiency with rTSA in both the primary and revision setting.

Patient-specific implants in reverse shoulder arthroplasty

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

Femoral head allograft for glenoid bone loss in primary reverse shoulder arthroplasty: functional and radiologic outcomes

BACKGROUND

Several techniques have been adopted during primary reverse shoulder arthroplasty (RSA) to manage glenoid bone defect. Among bone grafts, humeral head autograft is currently the mainstream option. However, autologous humeral heads may be unavailable or inadequate, and allografts may be a viable alternative. The aim of the present study was to evaluate the functional and radiologic outcomes of femoral head allografts for glenoid bone defects in primary RSA.

METHODS

We conducted a retrospective study with prospective data collection enrolling 20 consecutive patients who underwent RSA with femoral head allografts for glenoid bone defects. Indications for surgery were eccentric cuff tear arthropathy in 10 cases (50%), concentric osteoarthritis in 9 cases (45%), and fracture sequelae in 1 case (5%). Each patient was evaluated preoperatively and at follow-up by radiologic and computed tomography (CT) and by assessing the range of motion (ROM) and the Constant-Murley score (CMS). A CT-based software, a patient-specific 3D model of the scapula, and patient-specific instrumentation were used to shape the graft and to assess the position of K-wire for the central peg. Postoperatively, CT scans were used to identify graft incorporation and resorption.

RESULTS

After a median follow-up of 26.5 months (24-38), ROM and CMS showed a statistically significant improvement (all P = .001). The median measures of the graft were as follows: 28 mm (28-29) for diameter, 22° (10°-31°) for angle, 4 mm (2-8 mm) for minimum thickness, and 15 mm (11-21 mm) for maximum thickness. Before the surgery, the median glenoid version was 21.8° (16.5°-33.5°) for the retroverted glenoids and -13.5° (-23° to -12°) for the anteverted glenoids. At the follow-up, the median postoperative baseplate retroversion was 5.7° (2.2°-1.5°) (P = .001), and this value was close to the 4° retroversion planned on the preoperative CT-based software. Postoperative major complications were noted in 4 patients: 2 dislocations, 1 baseplate failure following a high-energy trauma, and 1 septic baseplate failure. Partial graft resorption without glenoid component failure was observed in 3 cases that did not require revision surgery.

CONCLUSION

The femoral head allograft for glenoid bone loss in primary RSA restores shoulder function, with CMS values comparable to those of sex- and age-matched healthy individuals. A high rate of incorporation of the graft and satisfactory correction of the glenoid version can be expected after surgery. The management of glenoid bone defects remains a challenging procedure, and a 15% risk of major complication must be considered.

Custom-made Glenoid Baseplate and Intra-Operative Navigation in Complex Revision Reverse Shoulder Arthroplasty: A Case Report

Prosthetic instability is one of the most challenging complications to manage when considering reverse shoulder arthroplasty (RSA). Additional tools are available to improve accuracy in planning and execution of arthroplasties, such as 3-dimensional (3D) virtual planning based on computer tomography (CT) scan and intra-operative navigation. We report a case of an 84-year-old male treated for RSA prosthetic instability combined with severe glenoid deformity and bone loss, and subclinical periprosthetic joint infection (PJI). The definitive surgery consisted in implanting a customized metaglene component realized on the basis of the bone defect detected in the 3D-CT scan and implanted with the aid of computer-assisted intra-operative navigation. The patient was periodically followed-up for a year with clinical and radiological evaluations with the absence of further prosthetic dislocations nor PJI, a good overall satisfaction, a satisfying range of motion, and acceptable functional scores (American Shoulder and Elbow Surgeons Score 62, Constant-Murley Score 36). This is the first description, to our knowledge, of a customized glenoid baseplate implanted with the aid of intraoperative navigation. The combined use of 3D-CT planning and intra-operative computer-assisted navigation allows to manage complex cases of prosthetic revision surgery even where extensive bone defects are present.

Use of custom glenoid components for reverse total shoulder arthroplasty

BACKGROUND

Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications.

METHODS

This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported.

RESULTS

Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both).

CONCLUSIONS

Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.

Strategies for the planning of complex shoulder arthroplasty: Use of a custom-made glenoid component in reverse shoulder arthroplasty for a neglected posterior fracture dislocation of the shoulder with malunited scapula fractures and severe eccentric glenoid bone loss

Glenoid bone loss associated with abnormal glenoid morphology can be encountered in complex primary and revision reverse shoulder arthroplasty. Strategies to deal with this include allografts, augments and custom-made prostheses. We describe a unique case of a long-standing neglected posterior fracture dislocation of the shoulder with severe glenoid bone loss and retroversion. The patient also had malunited acromial and scapula fractures and an associated rotator cuff tear. The primary challenges were access to the shoulder joint due to the malunited fractures, reconstruction of the dysplastic glenoid and providing joint stability. A reverse shoulder replacement was planned using a custom-made glenoid component and patient-specific instrumentation (PSI). The custom base plate was manufactured based on the pre-operative computerised tomography (CT) scan and conformed to the native glenoid. A post-operative CT scan confirmed adequate positioning of the implants. 30 months following surgery, there was a significant improvement in pain and range of motion with an Oxford Shoulder Score (OSS) of 39/48, compared to a pre-operative score of 12/48. Plain radiographs did not show any evidence of loosening or osteolysis. This case report highlights the approach for planning a complex reverse shoulder arthroplasty and the use of custom-made prostheses and PSI in such scenarios.

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

BACKGROUND

The purpose of this study is to report the clinical and radiologic outcomes of patients undergoing primary or revision reverse total shoulder arthroplasty using custom 3D-printed components to manage severe glenoid bone loss with a minimum of 2-year follow-up.

METHODS

Following ethical approval, patients were identified and invited to participate. Inclusion criteria were (1) severe glenoid bone loss necessitating the need for custom implants and (2) patients with definitive glenoid and humeral components implanted more than 2 years prior. Included patients underwent clinical assessment using the Oxford Shoulder Score (OSS), Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). Radiographic assessment included anteroposterior and axial projections. Patients were invited to attend a computed tomography (CT) scan to confirm osseointegration. Statistical analysis used descriptive statistics (mean and standard deviation [SD]) and paired t test for parametric data.

RESULTS

Eleven patients declined to participate. Five patients were deceased prior to study commencement, leaving 42 remaining patients in this analysis. Three patients had revision surgery before the 2-year follow-up; of these, 2 retained their custom glenoid components. Mean follow-up was 31.6 months from surgery (range 24-52 months). All 4 scores improved: OSS from a mean 15 (SD 8.4) to 36 (SD 12) (P < .001), Constant-Murley score from a mean 15 (SD 11.2) to 52 (SD 20.1) (P < .001), QuickDASH from a mean 70 (SD 21) to 31 (SD 24.8) (P = .004), and the ASES score from a mean 22 (SD 17.8) to 71 (SD 23.3) (P = .007). Radiologic evaluation demonstrated good osseointegration in all but 1 included patient.

CONCLUSION

The utility of custom 3D-printed components for managing severe glenoid bone loss in primary and revision reverse total shoulder arthroplasty yields significant clinical improvements in this complex cohort. Large complex glenoid bone defects can be managed successfully with custom 3D-printed glenoid components.

Comparison of glenoid bone grafting vs. augmented glenoid baseplates in reverse shoulder arthroplasty: a systematic review

BACKGROUND

Management of bone loss and glenoid deformity can present a significant challenge to surgeons. The purpose of this review was to compare outcomes of reverse shoulder arthroplasty (RSA) using either bone graft or augmented baseplates for the management of glenoid bone loss and deformity.

METHODS

A comprehensive search of MEDLINE, Embase, and Cochrane indices was performed for studies reporting clinical outcomes following primary RSA with bone grafting or use of augmented baseplates. Pooled and frequency-weighted means, standard deviations, and ranges were calculated and reported for comparison.

RESULTS

Overall, 19 studies and 652 patients with bone grafting (n = 401) and augmented baseplates (n = 251) were included in the study. Mean patient age and gender were 70.3 ± 3.1 years and 47% female in the bone grafting group and 72.9 ± 3.7 years and 59.0% female in the augmented baseplate group. Mean follow-up for the augmented baseplate group was 23.1 ± 8.2 months and 29.5 ± 10.1 months for the bone grafting group. Overall complication and revision rates were 11.7% and 4.5% for the bone grafting group and 11.8% and 3.7% for the augmented baseplate group. Range of motion as well as patient-reported and functional outcome scores were similar between both techniques. Infections, component loosening, and notching were 1.9%, 3.6%, and 24.6% in the bone grafting group and 0.7%, 1.6%, and 4.7% in the augmented baseplate group.

CONCLUSIONS

Glenoid bone grafting and augmented baseplates are effective treatment options for the management of bone loss and glenoid deformity. Both treatments improve overall clinical outcomes with relatively low complication rates and revision rates.

A review of custom implants for glenoid bone deficiency in reverse shoulder arthroplasty

Reverse Total Shoulder Arthroplasty is being increasingly performed, with indications in both elective and trauma settings. Accordingly, there are an increasing number of revision cases where glenoid bone loss is a concern. There are well recognised surgical techniques for dealing with mild to moderate glenoid wear, including eccentric reaming and impaction grafting. In cases of severe wear or uncontained glenoid defects these may not be suitable, and the surgeon may look to a customised implant to deal with such bone loss. There are several implant manufacturers who currently market and produce patient specific instrumentation and customised glenoid baseplates to achieve the best possible fixation in cases of severe bone loss. This article outlines some examples of custom implants currently available to surgeons, and the process by which they may be procured and used. Implant and surgical considerations, and key aspects of surgical technique are also covered. Literature on outcomes and complications following custom shoulder arthroplasty shows promising results, but at present is limited to relatively small case series with no long-term outcome data.

[Metal glenoid augmentation in revision arthroplasty]

Glenoid implantation in revision arthroplasty of the shoulder remains a technical challenge in the case of severe bone loss. Metal glenoid augmentation and patient-specific glenoid implants represent new treatment options with great potential. Virtual planning techniques allow a differentiated evaluation of the extent of the bone loss and the planning of different augmentation options. Although not clearly defined so far, a patient-specific implant can be indicated if adequate fixation of the base plate in the native bone appears questionable. The planning is carried out with the support of the prostheses manufacturer and the stability is simulated using finite element analysis. A high level of primary stability is achieved by an optimized fitting of the implant into the bony defect. The short-term results are promising. However, in the absence of long-term results and limited options in case of revision, the use of a custom-made glenoid warrants a strict indication.

Clinical and Radiological Outcomes after Total Shoulder Arthroplasty Using Custom-Made Glenoid Components: A Systematic Review

Reverse total shoulder arthroplasty presents itself sometimes as challenging when it comes to addressing massive bone loss, either in primary or revision settings. Custom components recently have made their way into shoulder prosthetics and are meant to help in the case of extensive glenoid bone destruction. Because of strict indication and the fairly recent introduction of these implants, the usage of custom-made glenoid implants is not very common yet. However, the early results are promising. The purpose of this review was to summarize and analyze the available literature. Therefore, a systematic review was performed according to PRISMA guidelines. A comprehensive search of the databases PubMed, Cochrane, and Livivo was performed to screen for studies reporting on clinical and radiological outcomes of custom glenoid implants. Four studies with a total of 46 shoulders were included in this review. The mean patient age was 68.8 years and the mean time of follow-up was 24.3 months. The weighted means showed an increase in CMS (32.7 points), in ASES (39.8 points), in anteversion (67.4 degrees), and in abduction (51.9 degrees) and a decrease in VAS (5.4 points). Custom-made glenoid implants are therefore a viable option in cases of large combined glenoid bone loss, both in primary and revision shoulder arthroplasty.

Management of glenoid bone loss in primary reverse shoulder arthroplasty

Aims

Rates of reverse total shoulder arthroplasty (rTSA) continue to grow. Glenoid bone loss and deformity remains a technical challenge to the surgeon and may reduce improvements in patients’ outcomes. However, there is no consensus as to the optimal surgical technique to best reconstruct these patients’ anatomy. This review aims to compare the outcomes of glenoid bone grafting versus augmented glenoid prostheses in the management of glenoid bone loss in primary reverse total shoulder arthroplasty.

Methods

This systematic review and meta-analysis evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We performed searches of Medline (Ovid), Embase (Ovid), and PubMed from their dates of inception to January 2022. From included studies, we analyzed data for preoperative and postoperative range of motion (ROM), patient-reported functional outcomes, and complication rates.

Results

A total of 13 studies (919 shoulders) were included in the analysis. The mean age of patients at initial evaluation was 72.2 years (42 to 87), with a mean follow-up time of 40.7 months (24 to 120). Nine studies with 292 rTSAs evaluated the use of bone graft and five studies with 627 rTSAs evaluated the use of augmented glenoid baseplates. One study was analyzed in both groups. Both techniques demonstrated improvement in patient-reported outcome measures and ROM assessment, with augmented prostheses outperforming bone grafting on improvements in the American Shoulder and Elbow Surgeons Score. There was a higher complication rate (8.9% vs 3.5%; p < 0.001) and revision rate among the bone grafting group compared with the patients who were treated with augmented prostheses (2.4% vs 0.6%; p = 0.022).

Conclusion

This review provides strong evidence that both bone graft and augmented glenoid baseplate techniques to address glenoid bone loss give excellent ROM and functional outcomes in primary rTSA. The use of augmented base plates may confer fewer complications and revisions. Cite this article: Bone Joint J 2022;104-B(12):1334–1342.

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

BACKGROUND

Glenoid bone loss is one of the main challenges in revision of failed shoulder arthroplasties. The concept of a hemi-reverse procedure is to implant a glenoid baseplate and glenosphere to protect the glenoid reconstruction to allow it to heal and to preserve the joint space for a potential second-stage humeral component implantation. The purpose of this study was to report the results of hemi-reverse procedures.

METHODS

Revision to a hemi-reverse procedure was performed in 15 patients: 8 with a failed anatomic total shoulder arthroplasty, 3 with a failed reverse shoulder arthroplasty, 3 with a failed humeral hemiarthroplasty, and 1 with placement of a cement spacer owing to sepsis after a total shoulder arthroplasty. After complete removal of the initial prosthesis, all patients underwent glenoid reconstruction with bone grafting and implantation of a reverse arthroplasty baseplate and glenosphere. A humeral implant was not placed in any case. The patients were prospectively followed up and underwent complete clinical and radiologic studies preoperatively and postoperatively at a minimum of 2 years after the surgical procedure.

RESULTS

Thirteen hemi-reverse implants and glenoid bone grafts healed (86%) and remained radiographically stable. One hemi-reverse construct migrated and became mechanically loose, which was attributed to absent fixation of the central post in the native glenoid bone. In 1 patient, an implant-related infection developed; irrigation and debridement were performed, in addition to revision to a resection arthroplasty. After documented radiographic healing of the hemi-reverse glenoid reconstruction, 5 patients underwent a second-stage revision to a reverse procedure with insertion of a humeral component at a median of 6 months (interquartile range [IQR], 6-8 months). In this group, the median follow-up period was 73 months (IQR, 45-153 months), the median Constant score was 48 (IQR, 41-56), median active forward elevation was 135° (IQR, 100°-150°), and the median Subjective Shoulder Value was 50% (IQR, 50%-60%). In the group of 9 patients with remaining hemi-reverse implants, the median follow-up period was 38 months (IQR, 29-60 months), the median Constant score was 41 (IQR, 38-46), median active forward elevation was 100° (IQR, 80°-100°), and the median Subjective Shoulder Value was 50% (IQR, 40%-60%).

CONCLUSION

The hemi-reverse procedure is an effective revision procedure to reconstruct a severely deficient glenoid. The hemi-reverse procedure may function as the definitive procedure, with satisfactory outcomes. Additionally, in patients who undergo the hemi-reverse procedure, second-stage revision to a total reverse procedure can be performed once imaging confirms bone graft and construct stability.

[3D printing in the field of shoulder surgery]

The 3D printing technology is a relatively new procedure with a high potential, especially in the field of shoulder surgery. The 3D printing procedures are increasingly being developed and also gaining new users. Principally, 3D printing procedures can be applied preoperatively in planning the surgical procedure, patient clarification and in teaching; however, the technology is increasing being used intraoperatively. In addition to intraoperative visualization of the models, 3D printing permits the use of individual and specific instruments and implants. This allows the precise transfer of the preoperative planning to the surgical procedure. Inaccuracies are mainly caused by soft tissues. The 3D printing can be beneficial in the fields of arthroplasty, shoulder instability as well as orthopedic trauma. The literature shows promising results in relation to duration of surgery, blood loss and clinical results of the procedure. On the other hand, it is still unclear which indications warrant the use of 3D printing. Other aspects that raise questions are the time of planning, the production time and the additional cost that the use of 3D printing entails. Nonetheless, 3D printing represents a meaningful enhancement of the portfolio of surgeons, which becomes highly beneficial and useful in complex situations. Furthermore, this procedure enables a certain amount of flexibility when reacting to certain circumstances.

Glenoid version: the role of genetic and environmental factors on its variability. An MRI study on asymptomatic elderly twins

BACKGROUND

Glenoid version is the most variable parameter of the shoulder joint. No authors investigated if intrinsic genetic factors or influences from extrinsic sources are responsible for its variability.

AIM

We compared glenoid version between elderly monozygotic and dizygotic twins intending to separate the contributions of genetics from shared and unique environments.

METHODS

Glenoid version of the dominant shoulder was assessed by MRI using Friedman's method in 30 pairs of elderly twins (16 monozygotic-14 dizygotic; mean age ± SD: 63.72 ± 3.37, 53-72). Heritability was estimated as twice the difference between the intraclass correlation coefficients for monozygotic and dizygotic pairs. The influence of shared environment was calculated as the difference between monozygotic correlation coefficient and the heritability index. According to job category, one way analysis of variance was used to estimate the differences between groups in the total sample and within zygosity groups.

RESULTS

Glenoid version angle in monozygotic and dizygotic twins was -2° (SD: 2°) and -3° (SD: 3°), respectively (p = 0.334). Heritability index was 0.98, while the contributions of shared and unique environment were 0 and 0.02, respectively. According to working classes, no significant differences were found between the groups (p = 0.732, F = 0.31).

CONCLUSIONS

Glenoid version is mainly genetically determined and only marginally influenced by environments.Level of evidence: III.

Functional and Radiological Outcomes after Treatment with Custom-Made Glenoid Components in Revision Reverse Shoulder Arthroplasty

Glenoid implant position and fixation are challenging in severe glenoid defects in reverse total shoulder arthroplasty (rTSA). Custom-made glenoid implants are metal augmented implants that are specially produced for a certain defect. They provide the restoration of the joint line and proper fixation. This retrospective data analysis investigated the clinical and radiological outcomes after revision using custom-made glenoid implants. Between 2018 and 2020, nine patients (10 shoulders) with severe glenoid defects underwent revision rTSA using a custom-made glenoid implant (Materialise Glenius or Lima ProMade). The pre- and postoperative Constant Murley Score (CMS), UCLA Score and Subjective Shoulder Value (SSV) were assessed. Postoperative CT scans and X-rays in two planes were available. The minimum follow-up was 12 months, with a mean follow-up of 23.1 months. The mean preoperative CMS, UCLA Score and SSV were 10.9, 4.1 and 11.0, respectively. The mean postoperative CMS, UCLA Score and SSV showed significant increases of 51.7 (<0.001), 22.9 (<0.001) and 52.0 (<0.001), respectively. There were no signs of loosening implants or scapular notching, and no revision was necessary. This trial showed promising clinical and radiological short-term outcomes for custom-made glenoid components in revision rTSA.

Custom-made reverse shoulder arthroplasty for severe glenoid bone loss: review of the literature and our preliminary results

The treatment of severe glenoid bone loss in shoulder arthroplasty represents a challenge, and the results of current prosthetic designs with only glenoid fixation still remain unsatisfactory. In the past decade, customized glenoid prostheses have been developed to address severe glenoid arthritis and in the revision setting. In this review, we analyzed the current surgical options, the classification limits, past literature evidence, and our preliminary results of 6 patients (3 male, 3 female) treated with a reverse implant and custom-made glenoid implant (ProMade; LimaCorporate, Italy). Computer analysis of the residual shape and the amount of glenoid bone stock in association with new classifications could help the surgeon to obtain good clinical and radiological outcomes. The development of navigation systems could improve the adequacy of the implant and, thus, the reliability and longevity of the implant itself.

Early results of reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid bone deficiency

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) in the presence of significant glenoid bone loss remains a challenge. This study presents preliminary clinical and radiographic outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed custom metal glenoid implant to address severe glenoid bone deficiency.

METHODS

Between September 2017 and November 2018, 19 patients with severe glenoid bone deficiency underwent primary (n = 9) or revision rTSA (n = 10) using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet, Warsaw, IN, USA) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand score, Constant score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numeric Evaluation score, and visual analog scale pain score and active range of motion were compared using the Wilcoxon signed rank test with the level of statistical significance set at P < .05.

RESULTS

Complications occurred in 4 patients (21%), including a nondisplaced greater tuberosity fracture treated conservatively in 1, intraoperative cortical perforation during humeral cement removal treated with an allograft strut in 1, and recurrent instability and hematoma formation treated with humeral component revision in 1. One patient with an early periprosthetic infection was treated with component removal and antibiotic spacer placement at an outside facility and was subsequently lost to follow-up. Eighteen patients with 1-year minimum clinical and radiographic follow-up were evaluated (mean, 18.2 months; range, 12-27 months). Significant improvements were noted in the mean Disabilities of the Arm, Shoulder and Hand score (57.4 ± 16.5 vs. 29.4 ± 19.5, P < .001), mean Constant score (24.6 ± 10.2 vs. 60.4 ± 14.5, P < .001), mean American Shoulder and Elbow Surgeons score (32 ± 18.2 vs. 79 ± 15.6, P < .001), mean Simple Shoulder Test score (4.5 ± 2.6 vs. 9.3 ± 1.8, P < .001), mean Single Assessment Numeric Evaluation score (25.4 ± 13.7 vs. 72.2 ± 17.8, P < .001), mean visual analog scale pain score (6.2 ± 2.9 vs. 0.7 ± 1.3, P < .001), mean active forward flexion (53° ± 27° vs. 124° ± 23°, P < .001), and mean active abduction (42° ± 17° to 77° ± 15°, P < .001). Mean external rotation changed from 17° ± 19° to 32° ± 24° (P = .06). No radiographic evidence of component loosening, scapular notching, or hardware failure was observed at last follow-up in any patient.

CONCLUSION

The preliminary results of rTSA using the VRS to manage severe glenoid bone deficiency are promising, but longer follow-up is necessary to determine the longevity of this implant.

Reverse Shoulder Arthroplasty for B2 Glenoid Deformity

In shoulder osteoarthritis, the B2 glenoid presents challenges in treatment because of the excessive retroversion and posterior deficiency of the glenoid. Correction of retroversion and maintenance of a stable joint line with well-fixed implants are essential for the successful treatment of this deformity with arthroplasty. Reverse shoulder arthroplasty offers several key advantages in achieving this goal, including favorable biomechanics, a well-fixed baseplate, and proven success in other applications. Techniques such as eccentric reaming, bone grafting, and baseplate augmentation allow surgeons to tailor treatment to the patient’s altered anatomy. Eccentric reaming is favored for correction of small defects or mild version anomalies. Current trends favor bone grafting for larger corrections, though augmented components have shown early promise with the potential for expanded use. With overall promising results reported in the literature, reverse shoulder arthroplasty is a useful tool for treating older patients with B2 glenoid deformities.

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

Purpose

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

Methods

The PubMed and Cochrane databases were searched for relevant papers.

Results

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

Conclusions

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