Tuesday, December 17, 2013

Is a humeral resurfacing " CAP " a consideration in the face of a retroverted glenoid?

Recently we've been corresponding with an individual regarding the management of an arthritic shoulder. Readers may find the conversation of interest.

"I have been following your procedure for a few years after being diagnosed with arthritis of the shoulder several years ago. I am now 53 years old and still active in basketball and sports. One quick question I had was regarding the emergence of a CAP resurfacing procedure, which appears to preserve more of the humeral head bone. Is there a marked comparative advantage or disadvantage to either procedure? I'm looking to get one or the other procedure done sometime this year or early next. Thank you for your input and I enjoy reading your material."

We responded, "In the treatment of glenohumeral arthritis, there is no advantage in preserving the bone of the humeral head, in fact trying to preserve this bone compromises access to the glenoid making it more difficult to manage the glenoid perfectly."

The patient asks "I am still interested in the nearer future in having shoulder work done.  I’ve attached some xrays from last year for a quick review. Is shoulder resurfacing (CAP) still not a viable option? It may seem strange but the long-stem prosthesis is more intimidating to me than the resurfacing technique. " 

Even though the axillary is not our desired standardized film , our readers will easily see that the axillary shows retroversion, biconcavity and posterior subluxation of the humeral head on the glenoid = the bad arthritic triad (BAT) or B2 glenoid.

We responded "If you look at the image #31 that you sent (the lower one above), you’ll see that you have posterior glenoid erosion and posterior humeral head subluxation. If a CAP is used these key elements of your pathology cannot be addressed. In order to address the severe glenoid pathology, we need to proceed with humeral head resection. Please see:

The patient asks "Does the glenoid erosion mean that a “ream and run” procedure is ruled out? I’ve been concerned about glenoid prosthesis loosening. "

We informed the patient that the concern about glenoid prosthesis loosening is well-founded in cases with the BAT. This is why we often consider the ream and run in this situation.  But again, we've found it necessary to carefully resect the abnormal humeral head to gain sufficient access to the glenoid for reaming and then to replace the humeral head with a stemmed prosthesis. Examples of the use of the ream and run to manage the "B2" BAT glenoid can be found here.

Consultation for those who live a distance away from Seattle.

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