Monday, May 7, 2018

Managing the B2 glenoid

Anatomic total shoulder arthroplasty with posterior capsular plication versus reverse shoulder arthroplasty in patients with biconcave glenoids: A matched cohort study

These authors sought tocompare the outcomes of total shoulder arthroplasty (TSA) with posterior capsule plication (PCP) and reverse shoulder arthroplasty (RSA) in patients with primary osteoarthritis, posterior subluxation, and bone loss (Walch B2).

15 shoulders undergoing anatomic TSA with PCP were retrospectively identified (group 1) and compared to 16 shoulders undergoing RSA (group 2) for Walch B2 osteoarthritis.

The mean Simple Shoulder Test score at followup was 10.6 in group 1 and 8.5 in group 2 (p . 0.01).  There were no reoperations in either group.

In Group 1, four shoulders were considered a radiographic failure: two had glenoid component loosening and three had radiographic failure of the posterior capsular plication.

Two additional shoulders in group 1 developed progressive late cuff insufficiency with superior migration of the humeral component.

Comment: It is not clear how the surgeons selected which procedure each patient should have. While the study "matched" patients from the two groups, what factors led the surgeons to perform anatomic arthroplasty in 15 and reverse in 16? 

While posterior capsular plication has been advocated to manage posterior humeral translation, we have found that a more robust reconstruction can be achieved in shoulders found to be posteriorly unstable at surgery by using an anteriorly eccentric humeral head component without or with a rotator interval plication.



Management of intraoperative posterior decentering in shoulder arthroplasty using anteriorly eccentric humeral head components

Background: Posterior humeral decentering presents a challenge in glenohumeral arthroplasty. Soft tissue releases and osteophyte resection can lead to intraoperative decentering not evident preoperatively. Inferior outcomes result if decentering is not addressed as a part of the arthroplasty. When there is >50% posterior subluxation of the humeral head on passive elevation of the arm at surgery, we have used an anteriorly eccentric humeral head component to improve centering of the humeral articular surface on the glenoid. 
Methods: We reviewed the 2-year outcomes for 33 shoulder arthroplasties in which anteriorly eccentric humeral heads were used to manage posterior decentering identified at surgery. Rotator interval plication was performed in 16 cases as an adjunctive stabilizing procedure. Shoulders were evaluated preoperatively and postoperatively with the Simple Shoulder Test (SST). Radiographic centering was characterized before surgery and at follow-up on standardized axillary radiographs with the arm held in a position of functional elevation. 
Results: With the anteriorly eccentric head component, preoperative radiographic humeral decentering was reduced from 10.4% ± 7.9% to 0.9% ± 2.3% postoperatively (P <.001). SST scores improved from 4.8 ± 2.3 to 10.0 ± 2.3 (P <.001). Preoperative posterior humeral head decentering did not correlate with preoperative glenoid version. Glenoid retroversion was 19.8° ± 8.9° preoperatively and 15.5° ± 7.5° postoperatively. 
Conclusions: Posterior decentering identified at surgery when standard trial components are in place can be addressed by replacing the anatomic humeral head with an anteriorly eccentric humeral head component.

See also

While glenoid retroversion and posterior humeral head decentering are common preoperative features of severely arthritic glenohumeral joints, the relationship of postoperative glenoid component retroversion to the clinical results of total shoulder arthroplasty (TSA) is unclear. Studies have indicated concern for inferior outcomes when glenoid components are inserted in 15° or more retroversion.

In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, we asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion.

Between August 24, 2010 and October 22, 2013, information for 201 TSAs performed using a standard all-polyethylene pegged glenoid component were entered in a longitudinally maintained database. Of these, 171 (85%) patients had SST scores preoperatively and between 18 and 36 months after surgery. Ninety-three of these patients had preoperative radiographs in the database and immediate postoperative radiographs and postoperative radiographs taken in a range of 18 to 30 months after surgery. Twenty-two patients had radiographs that were inadequate for measurement at the preoperative, immediate postoperative, or latest followup time so that they could not be included. These excluded patients did not have substantially different mean age, sex distribution, time of followup, distribution of diagnoses, American Society of Anesthesiologists class, alcohol use, smoking history, BMI, or history of prior surgery from those included in the analysis. Preoperative retroversion measurements were available for 11 (11 shoulders) of the 22 excluded patients. For these 11 shoulders, the mean (± SD) retroversion was 15.8° ± 14.6°, five had less than 15°, and six had more than 15° retroversion. We analyzed the remaining 71 TSAs, comparing the 21 in which the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°) with the 50 in which it was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°). At the 2-year followup (mean ± SD, 2.5 ± 0.6 years; range, 18–36 months), we determined the latest SST scores and preoperative to postoperative improvement in SST scores, the percentage of maximal possible improvement, glenoid component radiolucencies, posterior humeral head decentering, and percentages of shoulders having revision surgery. Radiographic measurements were performed by three orthopaedic surgeons who were not involved in the care of these patients. The primary study endpoint was the preoperative to postoperative improvement in the SST score.

With the numbers available, the mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The mean difference in improvement between the two groups was 0.9 (95% CI, − 2.5 to 0.7; p = 0.412). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%). The mean difference between the two groups was 3% (95% CI, − 18% to 12%; p = 0.857). The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, − 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. With the numbers available, the radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4–6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). With the numbers available, the percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

In this series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. This suggests that it may be possible to effectively manage arthritic glenohumeral joints without specific attempts to modify glenoid version. Larger, longer-term studies will be necessary to further explore the results of this approach.

Finally, the reader may be interested in these figures from a recent review:
Outcomes of Anatomic Total Shoulder Arthroplasty with B2 Glenoids

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