Salvaging the failed humeral arthroplasty with humeral bone loss.

Proximal humerus bone loss is commonly encountered in revision shoulder arthroplasty. Bone loss can occur from component loosening and ensuing osteolysis, infection, as well as preoperative and intraoperative fracture. Careful preoperative assessment of the humeral anatomy can inform planning for surgical revision. Of particular importance is the quantity and quality of bone along the humeral diaphysis and metaphysis and the condition of the important soft tissue attachments, including the rotator cuff, deltoid and pectoralis major.

Humeral bone deficiencies can contribute both to instability of the joint and to instability of fixation of the revision implant.



1. Joint instability

The stability of the reverse total shoulder depends on concavity compression: the compression of the glenosphere into the concavity of the humeral liner by the deltoid and other scapulohumeral muscles.

Post-revision glenohumeral instability of the reverse total shoulder can be caused by inadequate restoration of humeral length and/or soft tissue attachments to the proximal humerus. Loss of humeral length reduces the tension in the deltoid, and thereby decreases its ability to provide the compressive force that stabilizes the joint. Compromised insertions of subscapularis, coracobrachialis, latissimus dorsi / teres major and pectoralis major can also contribute to insufficient joint compression.

2. Implant instability.

Instability of the humeral component is often manifested by inadequate rotational stability of the implant in the humerus. The non-circular cross section of the metaphyseal canal provides the best opportunity for obtaining rotational stability.

Some of the steps that are helpful in optimizing (1) the stability of the joint and (2) the stability of the humeral component in revision reverse total shoulder include

1. Assessing the quantity, quality and pathoanatomy at each level of the humeral bone.

Humeral Bone Loss in Revision Total Shoulder Arthroplasty: the Proximal Humeral Arthroplasty Revision Osseous Insufficiency (PHAROS) Classification System characterized the bone loss in three regions (epiphysis (1), metadiaphysis above the deltoid insertion (2), and diaphysis below the deltoid insertion (3)) as well as the bone quality in terms of cortical thinning of greater (A) or less than 50% (B) of the expected thickness. Epiphyseal bone loss can isolated compromise of the medial calcar (C) or greater tuberosity (G).



Some examples are shown below. The authors recommend that grade 2B and 3 bone loss be treated with allograft-prosthetic composites (APC) or a humeral replacement mega-prosthesis.




2) Determining whether residual cement is securely attached to bone and of possible use of cement-within-cement fixation of a new humeral implant

The example below shows an intact cement mantle without radiographic signs of loosening at the bone-cement interface. The revision was performed with a cement-in-cement revision and resulted in stable fixation at 4 years after surgery.




The example below shows a cement mantle fracture and radiolucency at the bone-cement interface that raises concern about the applicability of a cement-in-cement revision



3) Evaluation of the risk of infection (serum WBC, ESR, CRP, frozen sections, joint fluid for cell count, frozen sections, as well as submission of tissue explant specimens for culture). Often a course of postoperative antibiotics is used until the results of the intraoperative cultures become available. 

4) Restoring humeral length to optimize soft tissue tension 

One approach to restoring humeral length is to utilize contralateral films as guide to the desired humeral length as shown below.

Another approach is to determine the added length necessary to restore soft tissue tension as detailed by the authors of Revision Arthroplasty with Use of a Reverse Shoulder Prosthesis-Allograft Composite

5) Achieving secure fixation of the implant to healthy host bone, such as purchase in a length of healthy diaphysis exceeding two cortical diameters (see Evaluation and treatment of postoperative periprosthetic humeral fragility fractures)

6) Assuring robust rotational control of implant, for example through plate fixation of APC to host bone.

7) Retaining or restoring critical soft tissue attachments, such as deltoid, pectoralis major, remaining rotator cuff and subscapularis 

Example below from Ben Sharareh, past UW Shoulder Fellow

8) Minimizing stress risers at distal end of APC, especially in osteoporotic bone (avoid ending plate and stem at same level, “protecting the whole bone”). Example below from Jonah Hebert-Davies, UW Shoulder Faculty.

9) Optimizing stability of glenohumeral articulation (selection of glenosphere diameter of curvature and lateral offset, tensioning using polyethylene liner of appropriate thickness, avoiding unwanted contact between humerus and scapula (neck, acromion).

The example below shows a glenosphere exchange to a larger diameter, inferior offset at a revision for humeral loosening with massive humeral bone loss. The new glenosphere optimizes soft tissue tension and compression.

Below are some of the relevant articles on revision reverse total shoulder arthroplasty in shoulders with loss of humeral bone.

2009 Revision Arthroplasty with Use of a Reverse Shoulder Prosthesis-Allograft Composite recommended allograft-prosthesis composites in cases with humeral defects ranging from 3.5 to 15.0 cm.

2013 Revision surgery of reverse shoulder arthroplasty points to the association of bone loss with humeral loosening, lack of rotational stability, and infection.

2014 The metaphyseal bone defect predicts outcome in reverse shoulder arthroplasty for proximal humerus fracture sequelae found that the clinical outcome was influenced by a metaphyseal bone defect of more than 3 centimeters and degenerative changes of the teres minor. 

2016 Long-term analysis of revision reverse shoulder arthroplasty using cemented long stems  emphasized the importance of sufficient quantity and quality of distal humeral bone in obtaining fixation with long stem cemented humeral components.

2017 Large diaphyseal-incorporating allograft prosthetic composites: when, how, and why : Treatment of advanced proximal humeral bone loss  found that well-fixed humeral stems could be treated with short metaphyseal allografts in most cases. Loose stems required longer diaphyseal-incorporating allografts. Noncemented stems required diaphyseal grafts in most cases, compared to cemented stems which required larger grafts in one-third of cases.

2018 Humeral Bone Loss in Revision Shoulder Arthroplasty indicated proximal humeral allograft for revisions of shoulders with 5 cm or more proximal humeral bone loss). 

2019 Clinical outcomes following reverse shoulder arthroplasty-allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up." 

2019 Humeral Bone Loss in Revision Total Shoulder Arthroplasty: the Proximal Humeral Arthroplasty Revision Osseous Insufficiency (PHAROS) Classification System  divided bone loss into three regions (epiphysis, metadiaphysis above the deltoid insertion, and diaphysis below the deltoid insertion) and bone quality by cortical thinning of greater or less than 50% of the expected thickness. Epiphyseal bone loss is subdivided into isolated compromise of the medial calcar or greater tuberosity. The authors provided radiographic examples of each degree of bone loss.

2023 Humeral bone defects in revision shoulder arthroplasty  divided bone loss based on the involvement of five segments of the humerus, as shown below This classification helps accounts for loss of bone in regions of stabilizing muscle attachments.

This post was prepared with the great help and direction from Mihir Sheth, M.D., UW shoulder fellow.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

32 year old athlete with B2 glenoid and posterior bone loss

A young athlete presented with the following history. "I am 31 years old. I’ve been having shoulder problems since I was around 16 years old. I had torn my posterior labrum pitching in baseball. At that time I was advised that surgery was not necessary since shoulder was not hurting. Over the next 10 years I did more strenuous shoulder activities: weight lifting, golfing, football, etc.

In 2015, I was already having a severe difficulty raising my arm, I got into a motorcycle accident which made things even worse. After the accident, I was advised to have arthroscopic posterior labrum slap tear surgery. Now in 2020, I have increased pain/pressure in my shoulder."

At presentation, he had a painful stiff right dominant shoulder and these radiographs showing advanced glenohumeral arthritis. The axillary "truth" view shows posterior decentering of the humeral head on a B2 glenoid with posterior bone loss.

Because of his young age and desire to return to sports, he elected the ream and run procedure. The procedure was performed under general anesthesia. On the first post operative day he had full assisted flexion and was taking only Tylenol for comfort.

He vigorously pursued the rehabilitation program (see this link). He sent frequent videos of his progression. Here are a few still shots of his function at six months after surgery.

 

At a year and a half after surgery he is back at many of his sports, including swimming and cycling and has started working on throwing. His should has full comfortable active motion. His shoulder is becoming progressively stronger.

His radiographs at 18 months after surgery are shown below, showing an impacted grafted standard stem. The anteriorly eccentric humeral head prosthesis is centered in the glenoid.  Not the absence of stress shielding and the regenerated radiographic joint space.

This patient earned his outcome with an exceptional rehabilitation effort. He provided this report on his keys to success:

1)    First and foremost sticking religiously to your stretching regimen since the first day of surgery was essential. Without that the recovery would have been extremely difficult. I think that because I was so amazed I could stretch again, I didn't see the stretches as a difficult/arduous task, but rather it was fun to push my shoulder through the stretches. I was looking forward to some stretches especially the pulley workouts - each stretch I did I tried to get to full extension or 180-degrees. I am actually still doing that now whenever I casually stretch (not with the pulleys – just natural arm raises and reaches).I don’t quite get to 180, but I am still trying!

 

2)    Swimming - I wish I had done this more because it would have been the single best rehabilitation exercise. The times that I did swim - my shoulder was really able to stretch and function nicely. At first, breaststroke and crawl/freestyle were painful and impossible - I could not swim. When that happened I went to the hot tub and performed breaststroke until it mildly hurt. I particularly like hot tubs and how my muscles feel there so it made perfect sense to take the swimming strokes to the hot tub. On top of that I didn’t feel like I had to stay there for an hour so it became 10-15 minutes of focused swimming stroke training in hot water. Perfect for me – comfortable and short work out. In the hot tub my intent was just to have my shoulder do the swimming motions and pull enough water to activate the stiffness/tenderness in my shoulder. If I swam and then did this daily, my recovery would have been much faster -  Unfortunately I just don’t like to swim – but I do like to bike. 

 

3)    What I believe helped me most was cycling. I cycle 7 miles a day commuting to work (round trip). On the surface, cycling as supposed to kill two birds with one stone - I was able to get blood flow through the joint by riding quickly, and I was able to train my shoulder stability by adjusting the pressure I put on the handlebars. Additionally, the ride was not too long nor stressful so it was just the right amount of time my shoulder needed under pressure. I constantly rode feeling out places where my shoulder was unstable/mildly hurting and made it a point to focus on those areas while I cycled. This was something I did in all modes of the rehab. When I stretched, reached for cups, or the remote, I would feel out the stiffness and take a few minutes to work it out and push through it gently. I became very familiar with my stiff points until they became unstiff. What I didn't realize about cycling was that I would be building shoulder strength when I was off the bicycle by simply walking the bike at my side. At first my shoulder was completely incapable of performing this task – if it leaned into me at any angle the bike would fall to my hip (painless for my hip, but painful for my shoulder) - my shoulder failed to support it. I then had to lean into the bike to raise it upright or use my other hand to assist it upright. This immediately became another short term goal of mine - supporting the bicycle as I walk it at my side with limited pain from my shoulder. Mentally, I couldn't be the weak link that couldn't support his own bicycle so this naturally was a short term goal. Another part of my work commute includes catching the train with my bicycle - so I again get to train my shoulder walking the bicycle at my side. Also, to access the train I have to take stairs/escalators. It would be easier to sit the bike on the escalator or elevator, stand and ride the machine up - but that takes too long and I like to be on the go and I am not patient enough to stand in one place when I could be moving. So I was forced mentally to train my shoulder in hoisting my bicycle on my right shoulder. (I could not use my left shoulder because the center gear would have made my clothes black with gear lubricant before arriving to work). I carried my bicycle up on my shoulder up the stairs - Twice Daily - 5 days a week. At first this too was impossible, I couldn't lift the bicycle so I had to use my left arm to assist in hoisting the bicycle on my right shoulder. The practice of then removing the bike from my shoulder was painful/sore as well, however it was key to slowly building the muscle/resistance needed to perform the task of eventually raising the bicycle to my shoulder. I could not be the weak link who couldn't lift his bike to his shoulder so this became another goal of mine. Cycling was not only good for bloodflow/stability training, but it forced my shoulder muscles to undertake tasks similar to what you had outlined in your program - it just was a bit more fun and challenging to do with the bicycle. I can compare the act of supporting of the bike at my side to the act of pushing out against the wall at my side - very similar exercises, except holding the bike at your side also trains your muscles to perform precise movements rather than just strength building. 

 

4)    Going to the gym every so often was godo but I wouldn't say it was extremely helpful for me early on. In fact I would try to limit the gym until late in the process – it can easily be replaced with swimming/cycling for me. When it comes to my shoulder, my body is a little different than most. The less force I put on my shoulder, the more naturally flexible it becomes. I had learned that from my first surgery, however I thought it would be different with the ream and run. Early on I was very worried about building strength in my shoulder so my goal was to 15-30 reps of using very light weights with the recommended workouts. However, I found that my shoulder became too tired and stiff consistently. So I thought let me just relax it, and stretch plenty more than I lift weights. I began to go to the gym once a week at maximum (I was already working it out cycling and walking my bicycle daily) – My arm began to take on natural movements quickly as a result. When I visited the gym consistently again, those natural movements became difficult so I knew working out fully was not in my body's playbook. That's when I let Physical Therapy sessions handle the strength training aspect of my recovery. The best thing I got from physical therapy was the massaging followed by the stretching they performed on me - and I believe this is what helped me the most with regaining strength. My recommendation for strength training (for my body) is to be very mild with resistance training until you have reached a point where you are extremely comfortable with your flexibility and find a way to have consistent massages and deep stretches. Younger patients will benefit from this most because it is much easier for them to regain strength. My body builds muscle quickly, however the goal early on was mobility. I knew that there was no purpose in having the strength if I didn’t have the flexibility, so my mind was centrally focused on having maximum flexibility first and foremost. The Gym was a distraction to that, but it would be something I needed later on.

 

5)    After Months 12-ish I started back in the gym with a little more consistency – still weak but able to the workouts and not be stiff. I began doing upright rows, curls, lawn mowers, lat pull downs – all with light weight and high reps. When I did certain workouts I noticed my shoulders were uneven and my right shoulder was cheating in the workouts so I made it a point to make the weight light enough so I could do the workouts while keeping my shoulders even throughout the workouts – this meant using extremely light weights because the work out was not about lifting, it was about pushing through the tightness of the shoulder and building out those small muscles that you used during routine motions. I did not want my shoulders to cheat workouts either – I always prefer to do the workout correctly with no weights than incorrectly with weights. Eventually I was able to do these workouts with a little bit of weight and still maintain square shoulders during the workouts – that is where I am now and slowly increasing the weight. I still cannot do a clean pushup, but I can do clean pull ups. I can run without pain in my shoulder and I can cycle without pain in my shoulder. Hoisting my bike on my shoulder is now painless as well. I believe a lot of the success I’ve had with this shoulder is from the mental side of things. I constantly challenged myself to maximize the stretch routines that you had given me, make sure my shoulders were square while resistance training, and work out any points of weakness/struggle when I found them. Additionally, because I had to bike to work I was blessed with an ideal mixture for a successful rehabilitation. I still find tightness/stiffness and I still work them out for a few minutes just to ensure no stone is left unturned.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Stemless total shoulder arthroplasty - what is its value?

Reliability of stemless shoulder arthroplasty in rheumatoid arthritis: observation of early lysis around the humeral component

These authors sought to evaluate whether stemless shoulder implants in rheumatoid arthritis (RA) patients provide comparable functional outcomes to patients with osteoarthritis or post-traumatic arthritis. In addition, the study assessed for differences in incidence of radiolucent lines or proximal humeral bone loss during radiographic follow-up.

Consecutive stemless shoulder arthroplasties performed in RA patients and a matched control group were retrospectively identified between February 2012 and 2018. Thirty-five patients were included in each group: 24 total shoulder arthroplasty (TSA) and 11 hemiarthroplasty (HA). Patients were evaluated annually using the Oxford Shoulder Score (OSS) and radiographically. The implant used in this study is shown below.

The mean OSS significantly improved in all groups until 24 months. The mean improvement for RA TSA and HA patients at 24 months was 19.86 (95% CI 10.66–29.05, p = 0.0004) and 19.71 (95% CI 7.33–32.31, p = 0.0084), respectively. The mean improvement in the control TSA and HA patients at 24 months was 20.86 (95% CI 17–24.71, p = 0.0001) and 17.86 (95% CI 1.36–34.35, p = 0.0381), respectively. During the study period, two patients in the RA TSA group (8%), one patient in the control TSA group (4%) and one patient in the control HA group (9%) required revision. The proportion of progressive proximal humeral bone loss after TSA was 33% in the RA group and 13% in the control group.

All six cases of progressive proximal humeral bone loss occurred in TSA cases, but no humeral shift or subsidence was observed in these patients during follow-up. There was no significant difference in the presence of progressive proximal humeral bone loss after TSA between the RA and control groups, p = 0.3575.

Examples of humeral bone loss are shown below.

 

Comment: This results suggest a >10%risk of progressive proximal humeral bone loss with this stemless prosthesis in partients with either osteoarthritis or rheumatoid arthritis.

We have not observed this type of bone loss when a standard impaction grafted humeral stem is used.

To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. JSES

Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. This article provides a useful approach for managing severe glenoid bone loss in the performance of a reverse total shoulder. They have taken the innovative step of using a ring of femoral neck allograft to help support the base plate and to contain autograft cancellous bone within. This method enables the surgeon to customize the graft to accommodate asymmetric glenoid defects.  In the five cases they reported, the grafts united.

In the application of this method, it seems important to (1) assure a solid contact between the graft and the residual glenoid bone and (2) to robustly compress the graft into the bone using secure screw placement in the patient's scapula.

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If you have suggestions for topics you'd like us to address in this blog, please send an email to
shoulderarthritis@uw.edu

Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.

Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management. JAAOS

Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management. This article, published recently in the JAAOS, nicely describes the various types of glenoid pathoanatomy encounted when we perform shoulder arthroplasty. Again, the authors point out that the #1 complication of total shoulder arthroplasty is glenoid component failure, and suggest that altered glenoid joint reaction forces, glenoid component malposition, and insufficient bone support are contributing factors to this complication. The use the Walch classification to describe glenoid anatomy.

In cases of glenoid retroversion (Walch C) or biconcavity (Walch B2) the conventional wisdom is to 'correct' the version in hopes of stabilizing the humeral head in the glenoid with a 'normalized' orientation. Various authors have used (1) reaming of the anterior glenoid (eccentric reaming), (2) posterior bone grafting, or (3) special glenoid components with a built up posterior segment to help manage these situations, which are commonly encountered in shoulders with osteoarthritis or capsulorrhaphy arthropathy. However, each of these approaches has a downside. Eccentric reaming removes precious glenoid bone. Posterior bone grafting is technically difficult and runs the risk of graft resorption, leaving the component unsupported. Glenoid components with thickened posterior aspects run the risk of cold flow as they attempt to support posteriorly directed humeral joint reaction forces. Furthermore, and perhaps most importantly, as pointed out in an article reviewed in our Sept 26 post, "Glenoid morphology rather than version predicts humeral subluxation: a different perspective on the glenoid in total shoulder arthroplasty".  As we pointed out then, the reason that retroversion is not necessarily associated with subluxation lies in the concavity compression mechanism of glenohumeral stability. As long as the ball is pressed into a suitable concavity, the shoulder is stable. With the biconcave glenoid, however, the humeral head is pressed into the posterior concavity and remains there unless the biconcavity is corrected. 

Apparently some authors have recently advocated using a Reverse Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis with Biconcave Glenoid, but, due to the limitations on physical activity after a reverse shoulder, this would not seem the preferred option for those individuals seeking active use of their shoulder after surgery.

In selected cases, we have taken a different approach. Rather than 'correcting' the retroversion, we have converted the biconcavity to a single concavity through reaming and have stabilized the humeral head prosthesis using soft tissue balancing and possibly eccentric humeral components. Our approach to the correction of posterior humeral subluxation and biconcavity with a ream and run is shown in this post. This technique minimizes the amount of bone removed by reaming and avoids the risks of glenoid bone grafting and glenoid component failure and avoids the activity limitations associated with a reverse total shoulder. 

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If you have suggestions for topics you'd like us to address in this blog, please send an email to

shoulderarthritis@uw.edu.

Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See the countries from which our readers come on this post.

Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency. JSES

Total shoulder arthroplasty

JSES published "Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency."

The authors present seven cases in which they used a small custom glenoid implant that was inset within the remaining bone of shoulders with erosion.  While the three-year results showed improvement without complications, there are several concerns about this approach. (1) The rationale for a custom component is that it avoids penetration of the keel used in some commercial components. However, when a standard pegged glenoid component is used there have been no problems associated with peg penetration. (2) The technique requires a custom component not generally available. (3) Because the component is inset rather than onset, it does not take advantage of all the bone available for support of the glenoid component in these cases where severe glenoid erosion has already taken place. (4) The short single glenoid peg would seem to offer less resistance to eccentric glenoid loading with perhaps increased risk of rocking horse loosening.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You might like to see the countries from where our visitors come.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, revision surgery for failed shoulder joint replacement, rotator cuff disease, and rotator cuff surgery.You may also be interested in our information about quadriceps sparing or 'mini' total knee replacement or about hip replacement arthroplasty.

Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear

JSES published a recent article on Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear.

This article points to the scarcity of data on the different factors potentially influencing the risk of glenoid component failure, one of the most important causes of unsatisfactory results from a total shoulder arthroplasty. They reviewed concepts in glenoid component design, metal glenoid components, polyethylene glenoid components, pegs vs keels, glenohumeral component mismatch, glenoid version and bone stock and observed the lack of high quality evidence supporting any particular approach to prosthetic glenoid resurfacing. They also pointed to the potentially serious problems of glenoid bone deficiency after glenoid component failure making revision difficult and less satisfactory than primary arthroplasty.

Hopefully the future will see higher quality studies that can inform better surgical techniques and component designs. 

It is of interest that the figure below showing to radiographs of the same shoulder only 6 months apart is reminiscent of the problem of secondary cuff dysfunction discussed in a previous post.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.