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Seidl AJ, Daniels SD. Instability and the Anatomic Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2024:00124635-990000000-01089. [PMID: 39254950 DOI: 10.5435/jaaos-d-23-01072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 07/24/2024] [Indexed: 09/11/2024] Open
Abstract
Instability of the anatomic total shoulder arthroplasty is a challenging problem. With an incidence of 1% to 5% reported in the literature, it is critical for shoulder surgeons to understand and be capable of addressing this complication. Etiology is multifactorial and related to soft-tissue imbalance, osseous pathology, implant malposition, or more commonly, a combination of these various causes. Historically, high rates of failure have been reported after revision procedures, prompting a movement toward the more inherently stable reverse shoulder arthroplasty as a reliable form of management. However, this may not be the ideal solution for all patients, particularly the young and active population. Consequently, the purpose of this article was to provide a review of the literature on the management of postoperative instability and intraoperative strategies to prevent this complication during the index procedure.
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Affiliation(s)
- Adam J Seidl
- From the Department of Orthopedic Surgery, University of Colorado
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Hill JR, Olson JJ, Aleem AW, Keener JD, Zmistowski BM. Three-dimensional analysis of biplanar glenoid deformities: what are they and can they be virtually reconstructed with anatomic total shoulder arthroplasty implants? J Shoulder Elbow Surg 2024; 33:2048-2056. [PMID: 38423250 DOI: 10.1016/j.jse.2024.01.026] [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: 09/18/2023] [Revised: 12/26/2023] [Accepted: 01/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Descriptions of glenoid deformities in glenohumeral osteoarthritis (GHOA) have focused on the axial plane. Less is known regarding arthritic glenoids with higher amounts of superior inclination and little evidence exists to guide management of inclination or combined version-inclination deformity when performing anatomic total shoulder arthroplasty (aTSA). We hypothesized that biplanar deformities (BD) would be present in a higher proportion of GHOA patients than previously appreciated, and these deformities would be difficult to adequately reconstruct with contemporary aTSA implants. METHODS A retrospective query was performed of GHOA patients indicated for TSA 2012-2017 with a computed tomography (CT) scan within three months of surgery. Images were uploaded to three-dimensional (3D) software for automated measurements. Glenoids with superior inclination ≥10°, and retroversion ≥20° were considered to have BD. Walch classification was determined, and C-type glenoids were excluded. Rotator-cuff muscle cross-sectional area (CSA) was measured and fatty infiltration was graded. Glenoids with BD were virtually planned for aTSA with correction to neutral inclination and version, then with 5° superior inclination and 10° retroversion. RESULTS Two-hundred and sixty-eight shoulders in 250 patients were included; average age was 65 years, 67% male. There were no differences in inclination between Walch types (P = .25). Twenty-nine shoulders with BD were identified (11%). These deformities were not associated with age (P = .47) or gender (P = .50) but were skewed towards Walch B-type, specifically B2 (P = .03). Acromial index and posterior humeral head subluxation were higher in BD patients (P = .04, P < .001, respectively). Biplanar deformities had similar cuff CSA compared to those without but were less frequently associated with fatty infiltration of the subscapularis (P = .05). When correcting to neutral version and inclination, 41% BD could not be reconstructed. Of those that could, 94% required augmented implants. When correcting to 5° superior inclination and 10° retroversion, 10% could not be reconstructed. Of those that could, 58% required augmented implants. With partial correction, augment use was predicted by retroversion >26° (P = .009). Inclination did not predict augment use (P = .90). Final implant position commonly involved unseating in the posterosuperior quadrant and cancellous exposure in the anteroinferior quadrant. CONCLUSIONS This retrospective computed tomography (CT)-based study of 268 shoulders with GHOA found an 11% prevalence of BD. These deformities were commonly associated with Walch B2 wear patterns. Virtual aTSA planning showed a high failure rate (41%) when correcting to neutral version and inclination. Posteriorly augmented implants were frequently required, and often still involved unseating in the posterosuperior quadrant, increased cancellous exposure in the anteroinferior quadrant, and vault perforation.
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Affiliation(s)
- J Ryan Hill
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA; Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Jeffrey J Olson
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Alexander W Aleem
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Jay D Keener
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Benjamin M Zmistowski
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
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Shields DW, A’Court J, Rashid MS, Monga P. Clinical outcome of wedged glenoid reconstruction in anatomic total shoulder arthroplasty for osteoarthritic retroverted glenoid: a minimum 2-year follow-up. JSES Int 2024; 8:343-348. [PMID: 38464446 PMCID: PMC10920140 DOI: 10.1016/j.jseint.2023.11.019] [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] [Indexed: 03/12/2024] Open
Abstract
Background Glenoid retroversion and humeral head subluxation is a progressive disorder due to abnormal force coupling and increased contact force. In situ placement of anatomic total shoulder arthroplasty (TSA) components in this scenario results in edge loading, progressive subluxation, and early failure. Wedged glenoid components have been demonstrated to improve glenohumeral alignment, but have not been correlated with mid-term clinical outcomes. Methods Patients undergoing TSA using a wedged all-polyethylene glenoid component for retroverted glenoid deformity were identified from a prospectively maintained database. Preoperative planning computed tomography was routinely performed and compared to postoperative correction on radiographic evaluation. Evidence of loosening was correlated to prospectively collect clinical outcome using patient-reported outcome measures. A matched group of neutrally aligned glenohumeral joints undergoing anatomic TSA was used to compare improvement in clinical outcomes. Results Over a 5-year period, 17 patients with mean age 60 (range 43-81, standard deviation 10.5) were identified with a mean preoperative neoglenoid retroversion of 16.7° (standard deviation 4.5). At a mean follow-up of 43.8 months (range 27-60), no revision surgeries were undertaken. Improvement in the Oxford Shoulder Score was 18 points (P < .0001). The mean improvement was compared to a matched control group demonstrating a comparable magnitude of improvement of 20.4 points. Conclusion Wedged polyethylene components for Walch B2-type glenoids in TSA yield acceptable correction of the joint line, excellent clinical outcomes, and survivorship is maintained in the short term. The clinical and radiological outcome demonstrated similar improvement to that seen in A type deformities.
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Affiliation(s)
| | - Jamie A’Court
- Wrightington Upper Limb Unit, Wrightington Hospital, Wigan, Lancashire, UK
| | - Mustafa S. Rashid
- University of Calgary, Alberta Health Services, Calgary, Alberta, Canada
| | - Puneet Monga
- Wrightington Upper Limb Unit, Wrightington Hospital, Wigan, Lancashire, UK
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Sheth U, Lee JYJ, Nam D, Henry P. Early outcomes of augmented glenoid components in anatomic total shoulder arthroplasty: a systematic review. Shoulder Elbow 2022; 14:238-248. [PMID: 35599710 PMCID: PMC9121292 DOI: 10.1177/17585732211032922] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective was to evaluate the short-term clinical and radiological outcomes following augmented anatomic total shoulder arthroplasty in patients with posterior glenoid deficiency. METHODS An electronic search of EMBASE, MEDLINE, and PubMed identified studies reporting clinical and radiographic outcomes following augmented anatomic total shoulder arthroplasty among patients with posterior glenoid deficiency. RESULTS Nine studies including 312 shoulders underwent anatomic total shoulder arthroplasty using an augmented glenoid implant between 2015 and 2020. A statistically significant improvement in range of motion (ROM), visual analog scale (VAS), American Shoulder & Elbow Surgeons (ASES), Constant, University of California - Los Angeles and Simple Shoulder Test (SST) scores was demonstrated at mean follow-up of 37.1 months. Glenoid retroversion improved from 21.8° to 9.5°. At final follow-up, radiolucency was reported in 35.1% of shoulders. The 16° full-wedge augment led to higher and more severe radiographic lucency, while high peg perforation rates (44%) were observed among 5-mm augment stepped implants. The overall rate of complication was 2.6%. Rate of revision surgery was 1.9%. CONCLUSIONS Overall, early- to mid-term outcomes following augmented anatomic total shoulder arthroplasty for posterior glenoid deficiency demonstrate good to excellent overall clinical results. More radiographic and clinical failures were reported in larger full wedge (16°) augments and stepped augments (5 mm). Prospective studies examining mid- and long-term outcomes will help further elucidate safety and efficacy of these relatively new implants.
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Affiliation(s)
- Ujash Sheth
- Ujash Sheth, Sunnybrook Orthopaedic Upper Limb,
Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, University of Toronto,
2075 Bayview Avenue, MG352, Toronto, ON M4N 3M5, Canada.
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Lo L, Koenig S, Leong NL, Shiu BB, Hasan SA, Gilotra MN, Wang KC. Glenoid bony morphology of osteoarthritis prior to shoulder arthroplasty: what the surgeon wants to know and why. Skeletal Radiol 2021; 50:881-894. [PMID: 33095290 DOI: 10.1007/s00256-020-03647-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 02/08/2023]
Abstract
Shoulder arthroplasty is performed with increasing frequency, and osteoarthritis is the most common indication for this procedure. However, the glenoid side of the joint is widely recognized as a limiting factor in the long-term durability of shoulder replacement, and osteoarthritis leads to characteristic bony changes at the glenoid which can exacerbate this challenge by reducing the already limited glenoid bone stock, by altering biomechanics, and by interfering with operative exposure. This article reviews the Walch classification system for glenoid morphology. Several typical findings of osteoarthritis at the glenoid are discussed including central bone loss, posterior bone loss, retroversion, biconcavity, inclination, osteophyte formation, subchondral bone quality, and bone density. The three primary types of shoulder arthroplasty are reviewed, along with several techniques for addressing glenoid deformity, including eccentric reaming, bone grafting, and the use of augmented glenoid components. Ultimately, a primary objective at shoulder arthroplasty is to correct glenoid deformity while preserving bone stock, which depends critically on characterizing the glenoid at pre-operative imaging. Understanding the surgical techniques and the implications of glenoid morphology on surgical decision-making enables the radiologist to provide the morphologic information needed by the surgeon.
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Affiliation(s)
- Lawrence Lo
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA
| | - Scott Koenig
- Department of Orthopaedics, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA
| | - Natalie L Leong
- Department of Orthopaedics, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA.,Department of Orthopaedics, University of Maryland, School of Medicine, 110 S. Paca Street, 6th Floor, Baltimore, MD, 21201, USA
| | - Brian B Shiu
- Department of Orthopaedics, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA.,Department of Orthopaedics, University of Maryland, School of Medicine, 2200 Kernan Drive, Suite 1154, Baltimore, MD, 21207, USA
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA.,Department of Orthopaedics, University of Maryland, School of Medicine, 100 Penn Street, Room 540D, Baltimore, MD, 21201, USA
| | - Kenneth C Wang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA. .,Imaging Service, Baltimore VA Medical Center, 10 N. Greene St, Rm. C1-24, Baltimore, MD, 21201, USA.
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Sandow MJ, Tu CG. Porous metal wedge augments to address glenoid retroversion in anatomic shoulder arthroplasty: midterm update. J Shoulder Elbow Surg 2020; 29:1821-1830. [PMID: 32305149 DOI: 10.1016/j.jse.2020.01.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wedge-shaped porous metal augments were used to address bone deficiency in shoulder arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate bone cement, and porous metal implant. This article presents an ongoing review of the use of the generically designed augments in the shoulder to address glenoid retroversion as part of anatomic total shoulder arthroplasty (aTSA). MATERIALS Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42-85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients underwent preoperative 3-dimensional (3D) templating; based on that planning, patients received either a 15° or 30° PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Intraoperative glenoid alignment was assessed using a reusable guide that referenced the anterior scapular neck. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores, and forward elevation [FE]) preoperatively; at 3, 6, and 12 months postoperation; and yearly thereafter, with similar radiologic surveillance. RESULTS Of the total consecutive series, 49 shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24-87 months). For this cohort, median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90° to 140°) from preoperative outcomes to the most recent review, respectively. Four patients died, but no others were lost to follow-up. Apart from 1 infection at 18 months postoperatively and 1 minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency, or posterior resubluxations. Radiographs showed good incorporation of the wedge augment, with correction of glenoid retroversion from median 22° (13° to 46°) to 4° (17° to anteversion 16°). All but 4 glenoids were corrected to within the target range (less than 10° retroversion), and only 2 glenoid components were implanted outside 15° of neutral glenoid version. CONCLUSIONS The porous metal wedge-shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure.
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Affiliation(s)
- Michael J Sandow
- Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia; Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia.
| | - Chen G Tu
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
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