Posterior deltoid-sparing approach for displaced inferior or posterior glenoid fossa fractures: technical note and case series.

Scapular surgery has usually been performed through the posterior Judet approach. This approach allows access to the entire posterior scapular body, but causes significant soft tissue damage and detaches the deltoid muscle. To date, there has been no clinical study of a deltoid-preserving approach to access the joint for displaced postero-inferior glenoid fractures (Ideberg type II or Ib). We describe an easy and less invasive approach to the postero-inferior glenoid fossa.

Mini-augmented glenoid baseplate and mini-humeral tray reverse total shoulder arthroplasty implant comparisons: two-year clinical outcomes.

BACKGROUND: Augmented glenoid baseplate and offset humeral tray reverse total shoulder arthroplasty (RTSA) implants may decrease the mechanical impingement that creates scapular notching and improve shoulder function. This study evaluated the clinical efficacy of three different RTSA glenoid baseplate and offset humeral tray combinations for patient-reported shoulder function, pain and instability, radiographic imaging evidence of glenoid baseplate or humeral stem subsidence and migration, bony changes associated with implant loosening, and scapular notching over the initial 2 years post-RTSA. Primary outcomes included active shoulder mobility, perceived function, pain, instability, scapular notching, and implant survival. METHODS: Sixty-seven patients from 6 research sites received one of three different glenoid baseplate and humeral tray combinations. Group 1 (n = 21) received a mini-augmented glenoid baseplate with a standard humeral tray; Group 2 (n = 23) received a standard glenoid baseplate and a mini-humeral tray with 3 trunnion offset options; Group 3 (n = 23) received both a mini-augmented glenoid baseplate and a mini-humeral tray with 3 trunnion offset options. Subjects underwent radiologic evaluation, completed the ASES scale, the EQ-5D-5L quality of life scale, VAS shoulder pain and instability questions, and active shoulder mobility measurements pre-operatively, and 6-weeks, 6-months, 1-2 years post-RTSA. RESULTS: Improved active shoulder mobility, quality of life, perceived function, decreased shoulder pain and instability, excellent implant survival and minimal scapular notching were observed for all groups. Group 3 had better overall active shoulder mobility than the other groups and better perceived function than Group 1. CONCLUSION: The group that received the mini-augmented glenoid baseplate and mini-humeral tray combination had better overall active shoulder flexion, external rotation at 90° abduction, and internal rotation. This group also had better perceived shoulder function compared to the group that received a mini-augmented glenoid baseplate with a standard humeral tray.

Yoke procedure as a salvage treatment option for failed reverse total shoulder arthroplasty with irreconstructible glenoid.

BACKGROUND: Glenoid bone loss is a known challenge in primary and revision reverse total shoulder arthroplasty. In severe deficiency, even placing the baseplate in alternative centerline or using an augmented baseplate may be insufficient. This study reports on the use of a soft tissue resurfacing technique using Achilles tendon allograft, coined Yoke procedure, for salvage treatment of glenoid deficient shoulder requiring reconstruction. MATERIALS AND METHODS: All patients who underwent the Yoke procedure between 2014 and 2020 by a single surgeon at a single academic center were identified and had their charts retrospectively reviewed. Demographics and surgical information were recorded. Preoperative X-rays and 3D-computed tomography scans were reviewed to classify patient glenoid types, evaluate glenoid medialization, and measure shoulder angles. Preoperative and postoperative range of motions and patient-reported outcome scores were evaluated, including anterior elevation, external rotation, internal rotation, visual analog scale, subjective shoulder value score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons (ASES) scores. Postoperative radiographs and follow-up notes were reviewed to evaluate postoperative complication profiles at 1 year. RESULTS: Seven patients with a median age of 69 years (range, 54-77 years) underwent Yoke procedure and had a median 12-month follow-up (range, 9-56 months). All patients were female and had a median of 2 prior shoulder surgeries (range, 0-13). Of all the patients, the most common comorbidity was osteoporosis (6) followed by rheumatoid arthritis (3). Of the 5 patients who had previous arthroplasty, the most common indications were baseplate failure (4), followed by instability (3) and infection (3). The median visual analog scale score improved from 8 (range, 3-9) to 2 (range, 1-4). The median Simple Shoulder Test improved from 8% (range, 0%-42%) to 33% (range, 17%-83%). The median ASES score improved from 15 (range, 5-38) to 52 (range, 40-78). The median anterior elevation and external rotation improved from 20° (range, 0°-75°) to 100° (range, 40°-145°) and 10° (range, 0°-20°) to 20° (range, 0°-55°), respectively. There was no change in median internal rotation. As of the last follow-up, one patient reported postoperative complications of anterior-superior implant escape, heterotopic ossification, and scapular notching. CONCLUSION: The Yoke procedure is a promising salvage treatment that can offer patients consistent pain reduction and moderate functional improvements at short-term follow-up. In the setting of poor bone quality and severe glenoid deficiency, glenoid baseplate implantation may not be absolutely necessary for a pain-relieving, functionally acceptable outcome.

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.

3-dimensionally printed patient-specific glenoid drill guides vs. standard nonspecific instrumentation: a randomized controlled trial comparing the accuracy of glenoid component placement in anatomic total shoulder arthroplasty.

BACKGROUND: Traditional, commercially sourced patient-specific instrumentation (PSI) systems for shoulder arthroplasty improve glenoid component placement but can involve considerable cost and outsourcing delays. The purpose of this randomized controlled trial was to compare the accuracy of glenoid component positioning in anatomic total shoulder arthroplasty (aTSA) using an in-house, point-of-care, 3-dimensionally (3D) printed patient-specific glenoid drill guide vs. standard nonspecific instrumentation. METHODS: This single-center randomized controlled trial included 36 adult patients undergoing primary aTSA. Patients were blinded and randomized 1:1 to either the PSI or the standard aTSA guide groups. The primary endpoint was the accuracy of glenoid component placement (version and inclination), which was determined using a metal-suppression computed tomography scan taken between 6 weeks and 1 year postoperatively. Deviation from the preoperative 3D templating plan was calculated for each patient. Blinded postoperative computed tomography measurements were performed by a fellowship-trained shoulder surgeon and a musculoskeletal radiologist. RESULTS: Nineteen patients were randomized to the patient-specific glenoid drill guide group, and 17 patients were allocated to the standard instrumentation control group. There were no significant differences between the 2 groups for native version (P = .527) or inclination (P = .415). The version correction was similar between the 2 groups (P = .551), and the PSI group was significantly more accurate when correcting version than the control group (P = .042). The PSI group required a significantly greater inclination correction than the control group (P = .002); however, the 2 groups still had similar accuracy when correcting inclination (P = .851). For the PSI group, there was no correlation between the accuracy of component placement and native version, native inclination, or the Walch classification of glenoid wear (P > .05). For the control group, accuracy when correcting version was inversely correlated with native version (P = .033), but accuracy was not correlated with native inclination or the Walch classification of glenoid wear (P > .05). The intraclass correlation coefficient was 0.703 and 0.848 when measuring version and inclination accuracy, respectively. CONCLUSION: When compared with standard instrumentation, the use of in-house, 3D printed, patient-specific glenoid drill guides during aTSA led to more accurate glenoid component version correction and similarly accurate inclination correction. Additional research should examine the influence of proper component position and use of PSI on clinical outcomes.

Pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up.

BACKGROUND: The success of traditional shoulder hemiarthroplasty (HA) with cobalt-chromium heads is limited by painful glenoid erosion with problematic bone loss. Hemiprostheses with pyrolytic carbon (PyC) heads have shown reduced glenoid erosion in experimental laboratory studies. Few in vivo data are available. METHODS: We performed a single-center consecutive cohort study of 31 of 34 patients (91%) who underwent PyC HA between September 2013 and June 2018. In 11 of these patients, concentric glenoid reaming was additionally performed. The mean follow-up period was 5.5 years (range, 3.5-7 years). Standardized radiographs were taken, and clinical function (Constant score) and pain (visual analog scale score) were recorded. Anteroposterior radiographs were analyzed according to an established method by 2 independent observers: A line parallel to the superior and inferior glenoid rim was translated to the most medial point of the glenoid surface. A further parallel line was placed on the spinoglenoid notch. The distance between these 2 lines was measured. Measurements were scaled using the known diameter of the implanted humeral head component. To assess eccentric erosion, anteroposterior and axial images were classified according to Favard and Walch, respectively. RESULTS: Mean medial glenoid erosion measured 1.4 mm at an average of 5.5 years of follow-up. In the first year, 0.8 mm of erosion was observed, significantly more than the average erosion per year of 0.3 mm (P < .001). Mean erosion per year was 0.4 mm in patients with glenoid reaming vs. 0.2 mm in those without reaming (P = .09). An evolution of glenoid morphology was observed in 6 patients, of whom 4 had a progression of the erosion grade. The prosthesis survival rate was 100%. The Constant score improved from 45.0 preoperatively to 78.0 at 2-3 years postoperatively and 78.8 at latest follow-up (5.5 years postoperatively) (P < .001). The pain score on a visual analog scale decreased from 6.7 (range, 3-9) preoperatively to 2.2 (range, 0-8) at latest follow-up (P < .001). There was a weak correlation (r = 0.37) between erosion and pain improvement (P = .039) and no correlation between erosion and change in Constant score (r = 0.06). CONCLUSION: PyC HA caused little glenoid erosion and a sustained improvement in clinical function in our cohort at mid-term follow-up. PyC demonstrates a biphasic development of glenoid erosion, with a reduced rate after the first year. PyC HA should therefore be considered as an alternative to cobalt-chromium HA and to anatomical total shoulder arthroplasty for patients with a high risk of glenoid component complications.

Treatment of Glenoid Wear with the Use of Augmented Glenoid Components in Total Shoulder Arthroplasty: A Scoping Review.

¼ Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.¼ Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.¼ Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.¼ The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).¼ Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

Bilateral Posterior Bone Graft Augmentation for Severe Glenoid Hypoplasia Without Instability: A Case Report.

CASE: A 40-year-old man with shoulder pain secondary to severe bilateral glenoid hypoplasia without posterior instability was treated successfully with bilateral posterior glenoid bone graft augmentation. CONCLUSION: While glenoid hypoplasia is associated with a variety of patient presentations, treatment of the stable and nonarthritic shoulder is rarely described. A posterior glenoid bone graft can be used to augment deficient posterior glenoids, increasing the articulating surface area, restoring function, and potentially facilitating future shoulder arthroplasty.

A prospective radiostereometric analysis of the stability of a metal-backed glenoid component/autograft composite in reverse shoulder arthroplasty.

Aims: Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA). Methods: A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion. Results: RSA analysis showed a small increase in all translation and rotational values up to six months postoperatively, consistent with settling of the implant. The mean values plateaued by 12 months, with no evidence of further migration. In four patients, there was significant variation outside the mean, which corresponded to postoperative complications. There was a significant improvement in the clinical and patient-reported outcomes from the preoperative values to those at two years postoperatively (p < 0.001). Conclusion: These findings show, using RSA, that a glenoid baseplate composite of a trabecular titanium peg with autograft stabilizes within the glenoid about 12 months after surgery, and reinforce findings from a previous study of this implant/graft with CT scans at two years postoperatively, indicating that this type of structural composite results in sound early fixation.

Comparison of long-term clinical and radiological outcomes for cemented keel, cemented peg, and hybrid cage glenoids with anatomical total shoulder arthroplasty using the same humeral component.

Aims: The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system. Methods: We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217). Results: Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%). Conclusion: These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids.

Glenoid component placement in reverse shoulder arthroplasty assisted with augmented reality through a head-mounted display leads to low deviation between planned and postoperative parameters.

BACKGROUND: Navigated augmented reality (AR) through a head-mounted display (HMD) may lead to accurate glenoid component placement in reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the deviation between planned, intra- and postoperative inclination, retroversion, entry point, depth, and rotation of the glenoid component placement assisted by a navigated AR through HMD during RSA. METHODS: Both shoulders of 6 fresh frozen human cadavers, free from fractures or other bony pathologies, were used. Preoperative computed tomography (CT) scans were used for the 3-dimensional (3D) planning. The glenoid component placement was assisted using a navigated AR system through an HMD in all specimens. Intraoperative inclination, retroversion, depth, and rotation were measured by the system. A postoperative CT scan was performed. The pre- and postoperative 3D CT scan reconstructions were superimposed to calculate the deviation between planned and postoperative inclination, retroversion, entry point, depth, and rotation of the glenoid component placement. Additionally, a comparison between intra- and postoperative values was calculated. Outliers were defined as >10° inclination, >10° retroversion, >3 mm entry point. RESULTS: The registration algorithm of the scapulae prior to the procedure was correctly completed for all cases. The deviations between planned and postoperative values were 1.0° ± 0.7° for inclination, 1.8° ± 1.3° for retroversion, 1.1 ± 0.4 mm for entry point, 0.7 ± 0.6 mm for depth, and 1.7° ± 1.6° for rotation. The deviation between intra- and postoperative values were 0.9° ± 0.8° for inclination, 1.2° ± 1.1° for retroversion, 0.6 ± 0.5 mm for depth, and 0.3° ± 0.2° for rotation. There were no outliers between planned and postoperative parameters. CONCLUSION: In this study, the use of a navigated AR system through an HMD for RSA led to low deviation between planned and postoperative values and between intra- and postoperative parameters.

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.

Editorial Commentary: High Variability Exists Among Different Techniques for Measuring Glenoid Bone Loss.

Glenoid bone loss is a predominant factor in determining proper surgical management for glenohumeral instability. Precise measurements of glenoid (and humeral) bone defects are fundamental, and millimeters matter. Three-dimensional computed tomography scans may provide the highest interobserver reliability for making these measurements. Yet, because imprecision in the range of millimeters is observed with even the most precise glenoid bone loss measurement techniques, it could be a mistake to over-rely, let alone solely rely, on glenoid bone loss measurement as the primary determinant for selecting one surgical procedure over another. Surgeons must measure glenoid bone loss but also thoughtfully consider patient age, associated soft-tissue injuries, and activity level, including throwing and participation in collision sports. When choosing the proper surgical procedure for a shoulder instability patient, we should not focus on only one variably measured parameter but, instead, on a comprehensive assessment of the patient.

Arthroscopic Bankart repair with inferior glenohumeral ligament tightening using the antegrade suture passer.

Arthroscopic repair is the gold standard for treating Bankart lesions, with commonly used portals including the posterior, anterosuperior, and anteroinferior portals. The two anterior portals are established through a safe triangle created by the superior margin of the subscapularis, the inferior margin of the biceps tendon, and the anterior superior edge of the glenoid cavity. However, the disadvantage of this conventional method is that it can lead to crowding of the instruments at the rotator interval, making it difficult to handle. The inferior glenohumeral ligament (IGHL) and its bands play a major role in the pathophysiology of glenohumeral instability. Restoration of the capsular tension by tightening the anterior band of the IGHL is an integral part of a successful Bankart repair, achieved by suturing the labrum at the 6 o'clock position to an anchor placed at the 5 o'clock position of the glenoid, creating a south-to-north capsulolabral shift. Traditionally, this is done using a curved suture passer (Lasso). However, taking a bite using the Lasso through the anteroinferior portal is difficult.

Glenoid component placement accuracy in total shoulder arthroplasty with preoperative planning and standard instrumentation is not influenced by supero-inferior glenoid erosion.

PURPOSE: Accurate glenoid component placement in total shoulder arthroplasty (TSA) remains challenging even with preoperative planning, especially for variable glenoid erosion patterns in the coronal plane. METHODS: We retrospectively reviewed 170 primary TSAs in which preoperative planning software was used. After registration of intraoperative bony landmarks, surgeons were blinded to the navigation screen and attempted to implement their plan by simulating placement of a central-axis guide pin: 230 screenshots of simulated guide pin placement were included (aTSA = 66, rTSA = 164). Displacement, error in version and inclination, and overall malposition from the preoperatively-planned target point were stratified by the Favard classification describing superior-inferior glenoid wear: E0 (n = 89); E1 (n = 81); E2 (n = 29); E3(n = 29); E4(n = 2). Malposition was considered > 10° for version/inclination errors or > 4 mm displacement from the starting point. RESULTS: Mean displacement error was 3.5 ± 2.7 mm (aTSA = 2.7 ± 2.3 mm, rTSA = 3.8 ± 2.9 mm), version error was 5.7 ± 4.7° (aTSA = 5.8 ± 4.4°, rTSA = 5.7 ± 4.8°), inclination error was 7.1 ± 5.6 (aTSA = 4.8 ± 4.8°, rTSA = 8.1 ± 5.7°), and malposition rate was 53% (aTSA = 38%, rTSA = 59%). When compared by Favard classification, there were no differences in any measure; when stratified by TSA type, version error differed for rTSAs (P = .038), with E1 having the greatest version error (6.9 ± 5.2°) and E3 the least (4.2 ± 3.4°). When comparing glenoids without wear (E0) and glenoids with superior wear (E2 and E3), the only difference was greater version error in glenoids without wear (6.0 ± 4.9° vs. 4.6 ± 3.7°, P = .041). CONCLUSIONS: Glenoid malposition did not differ based on coronal glenoid morphology. Although, malposition was relatively high, suggesting surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation in TSA. LEVEL OF EVIDENCE III: Retrospective Cohort Study.

Anatomic and reverse shoulder arthroplasty for management of type B2 and B3 glenoids: a matched-cohort analysis.

BACKGROUND: Severe glenohumeral osteoarthritis (GHOA) with posterior glenoid erosion remains challenging to address for shoulder surgeons. Whereas anatomic total shoulder arthroplasty (TSA) has historically been the treatment of choice, reverse shoulder arthroplasty (RSA) offers an alternative option. Limited evidence exists directly comparing these 2 treatments in a similar patient population. The purpose of this study was to compare the clinical outcomes of patients with GHOA and Walch type B2 and B3 glenoid morphologies treated with TSA vs. RSA. METHODS: We performed a multicenter retrospective cohort study of patients with GHOA who were treated with primary shoulder arthroplasty and had a minimum follow-up period of 2 years. Preoperative computed tomography was used to determine type B2 and B3 glenoid morphology as described by the modified Walch classification. Three-dimensional perioperative planning software was used to characterize glenoid retroversion and humeral subluxation. Patients were categorized based on type of arthroplasty (TSA or RSA) and were matched 1:1 by sex, Walch classification, and age. Patient-reported outcome measures, active range of motion, presence and severity of glenoid loosening, and complications were compared. The percentage of patients who reached previously established clinically significant thresholds of the minimal clinically important difference and substantial clinical benefit for the American Shoulder and Elbow Surgeons score was also comparatively assessed. RESULTS: In total, 202 patients (101 per group) with GHOA and type B2 or B3 glenoids were included in the 1:1 matched analysis. The mean length of follow-up (± standard deviation) was 39 ± 18.7 months. The cohorts were well matched, with no differences in sex, age, American Society of Anesthesiologists score, body mass index, preoperative glenoid morphology (Walch classification), glenoid retroversion, or posterior subluxation (P > .05). RSA was associated with a lower postoperative visual analog scale pain score (0.5 in RSA group vs. 1.2 in TSA group, P = .036); however, no other no other significant differences in patient-reported significant differences in patient-reported outcome measures were found. Most patients in both groups (95.0% in TSA group vs. 98.0% in RSA group, P = .436) reached the minimal clinically important difference, and 82% of TSA patients and 90% of RSA patients reached the substantial clinical benefit value (P = .292). No significant differences in the overall complication rate (P = .781) and active range of motion were found, with the exception of internal rotation (scored on a numeric scale) being worse in the RSA group (2.7 preoperatively and 5.2 postoperatively in RSA group vs. 3.9 and 6.5, respectively, in TSA group; P < .001). Baseplate loosening occurred in 2 RSA cases, and 29 TSA cases had glenoid radiolucencies (P < .001), with 3 grossly loose glenoid components. CONCLUSION: Primary RSA results in short-term outcomes largely comparable to those of TSA in patients with Walch type B2 or B3 glenoid morphology. Both TSA and RSA provide substantial clinical benefit to patients with significant posterior glenoid wear.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Aseptic glenoid baseplate loosening after reverse total shoulder arthroplasty with a single prosthesis.

BACKGROUND: Early reverse total shoulder arthroplasty (rTSA) designs had high failure rates, mainly from loosening of the glenoid baseplate. The purpose of this study was to determine the incidence of aseptic glenoid baseplate loosening after primary rTSA using a contemporary medialized glenoid-lateralized humerus system and identify significant risk factors associated with loosening. METHODS: A total of 7162 patients underwent primary rTSA with a single-platform rTSA system between April 2007 and August 2021; of these primary rTSA patients, 3127 with a minimum 2-year follow-up period were identified. Patients with aseptic glenoid baseplate loosening were compared with all other primary rTSA patients without loosening. Univariate and multivariate analyses were performed to compare these cohorts and identify the demographic characteristics, comorbidities, operative parameters, and implant characteristics associated aseptic glenoid loosening after rTSA. Odds ratios (ORs) were calculated for each significant risk factor and for multiple combinations of risk factors. RESULTS: Irrespective of minimum follow-up, 53 of 7162 primary rTSA shoulders (31 female and 22 male shoulders) experienced aseptic glenoid loosening, for an overall rate of 0.74%. At latest (2-year minimum) follow-up, 30 of 3127 patients experienced aseptic glenoid loosening and showed significantly lower clinical scores, function, and active range of motion and higher pain scores than patients without loosening. Univariate analysis identified rheumatoid arthritis (P = .029; OR, 2.74) and diabetes (P = .028; OR, 1.84) as significant risk factors for aseptic glenoid loosening after rTSA, and multivariate analysis identified Walch glenoid types B2 (P = .002; OR, 4.513) and B3 (P = .002; OR, 14.804), use of expanded lateralized glenospheres (P = .025; OR, 2.57), and use of augmented baseplates (P = .001; OR, 2.50) as significant risk factors. CONCLUSION: The incidence of aseptic glenoid baseplate loosening was 0.74% for the evaluated medialized glenoid-lateralized humerus rTSA system. Numerous risk factors for aseptic loosening were identified, including rheumatoid arthritis, diabetes, Walch type B2 and B3 glenoids, posteriorly-superiorly augmented baseplates, and expanded lateralized glenospheres. Finally, analysis of multiple combinations of risk factors identified patients and implant configurations with the greatest risk of aseptic glenoid loosening.

Surgeon-designed patient-specific instrumentation improves glenoid component screw placement for reverse total shoulder arthroplasty in a population with small glenoid dimensions.

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.

Outcomes of femoral head allograft for the management of glenoid bone defects in revision reverse shoulder arthroplasty: a case-controlled study.

BACKGROUND: Revision shoulder arthroplasty often requires management of glenoid bone defects. Options include using allograft, harvesting iliac crest autograft, or using augmented metal components. The purpose of this study is to report outcomes of revision shoulder arthroplasty requiring management of glenoid bone defects with femoral head allograft in a large cohort of patients using a single reverse shoulder implant system and compare them to a matched cohort based on the indication for surgery. Outcomes of patients who had successful glenoid reconstruction were compared to those that required a re-revision, and to a control group that was revised without the need for bone graft. METHODS: This was a retrospective review of data collected from 2009 to 2018. There were 36 patients in the bone graft group and 52 in the control group. All patients underwent revision to a reverse shoulder arthroplasty to manage a failed total shoulder arthroplasty (n = 29 and 11), hemiarthroplasty (n = 1 and 24), or reverse shoulder arthroplasty (n = 6 and 17). All patients had a minimum of 2 yr of clinical follow-up. The primary endpoint was survival of baseplate fixation. Secondary outcomes included range of motion and functional outcome scores. Patients that had recurrent baseplate failure and were re-revised were compared to patients with bone graft that did not require additional surgery, and to patients who were revised without the need for bone graft. Patients who required revisions for reasons other than recurrent baseplate failure were also recorded. RESULTS: Five of 36 (14%) patients had recurrent baseplate failure. Mean time to failure was 12 mo. Three of 5 had successful re-implantation of another baseplate. Two of 5 were revised to a hemi arthroplasty after failure of their revisions. Preoperative American Shoulder and Elbow Surgeons scores were 31 in the grafted patients that did not require re-revision, 39 in the grafted patients that required re-revision, and 33 in the control group. Final American Shoulder and Elbow Surgeons scores were 64, 36, and 56, respectively. One patient required revision surgery not related to baseplate failure. There were no baseplate failures in the control group. CONCLUSION: The use of femoral head allograft to manage glenoid bone defects in the revision setting produces predictable improvement in functional outcomes that is not inferior to those in patients revised without bone graft. However, there is a 14% rate of baseplate failure.