Wednesday, November 23, 2011

The ream and run in the face of severe posterior glenoid erosion

One of the biggest challenges we face in shoulder arthroplasty is the posteriorly eroded glenoid.
Here's a recent example. Note that the anteroposterior view doesn't look all that remarkable.
However a well done axillary shows the problem.
We know that in this circumstance, a plastic glenoid has an increased chance of failure because of rocking horse loosening.
On the other hand, doing a hemiarthroplasty alone does not address the glenoid biconcave deformity.
Our approach starts with a conservative capsular release, preserving the inferior glenohumeral ligament complex.

Next, we convert the glenoid biconcavity into a single concavity, without trying to change the glenoid version.
We then insert the humeral trial component to see if there is unwanted posterior translation - a positive 'drop back' sign when the arm is lifted forward,
If this occurs, in spite of using a large sized humeral head prosthesis, we use an eccentric humeral head with the eccentricity anterior to re-center the head in the glenoid.
If a positive drop back remains, we perform a rotator interval plication.
Here are some postoperative films showing the effectiveness of these methods in centering the head in the early postoperative period, using the case above as an example.

Additional support against posterior instability can be gained by external rotation strengthening exercises.

Managing this complex situation is difficult and requires careful attention to surgical technique and postoperative care.

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