Friday, April 15, 2016

Reverse total shoulder and glenoid bone defects

Reverse total shoulder arthroplasty with structural bone grafting of large glenoid defects

These authors retrospectively reviewed 44 patients (20 men and 24 women; mean age, 69 years) who had undergone primary or revision reverse total shoulder arthroplasty (RTSA) using a bulk structural graft to augment the glenoid bone behind the baseplate.

The grafts consisted of a humeral head autograft in 29, iliac crest autograft in 1, or femoral head allograft in 14. The graft was shaped to fit the defect.  The graft was provisionally held with Kirschner wires inserted at an angle that did not impede placement of the baseplate. The new surface was reamed with the standard reamers to fit the back of the baseplate. The final fixation of the graft was achieved using screws through the baseplate, spanning the graft into the native glenoid.

Average follow-up was 40.6 ± 16 months. Improvements were seen in the functional outcome scores at the latest follow-up.

The grafting cohort was compared with an age- and sex-matched cohort of RTSA patients without glenoid grafting. Postoperative scores for the bone graft cohort were significantly lower than those in the cohort without grafting.

21 grafts (51.7%) fully incorporated, 12 (29.3%) partially incorporated, and 8 (19.5%) were not incorporated.

Six baseplates were considered loose. Complications included 2 infections, 1 dislocation, 1 humeral loosening, and 2 instances of clinical aseptic baseplate loosening. Six patients showed mild scapular notching.

Comment: These authors have taken on some difficult reconstructions. The loads applied to the baseplate fixation in a reverse total shoulder will challenge the healing of the graft as well as the security of the screw and peg fixation. 6 of the 41 baseplates were loose.

The authors point out that the results of reverses with grafts are not as good as those without grafts, but they do not address the important and difficult questions "when is the glenoid bone loss of sufficient severity to merit consideration of a bone graft?" and "when is the residual glenoid too compromised to support the fixation of a graft?"


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