Failed shoulder arthroplasty with posterior instability.

Revision anatomic shoulder arthroplasty with posterior capsular plication for correction of posterior instability {Journal of Orthopaedic Surgery 26(3) 1–9 2018}.

These authors reported the clinical and radiographic outcomes, complications, and reoperations of posterior capsular plication (PCP) performed in 16 revision anatomic shoulders performed between 1975 and 2013.

Indications for revision arthroplasty included posterior instability in 15, glenoid loosening in 3, polyethylene wear in 2, and glenoid erosion in 1 shoulder. 

At the last follow-up, nine shoulders (56%) had absence of posterior radiographic subluxation. Five (31%) cases underwent reoperation due to persistent posterior instability. Complications were observed in seven (44%) cases. Complete pain relief was achieved in four (25%) shoulders. 

Results were excellent in two (13%), satisfactory in seven (44%), and unsatisfactory in seven (44%) shoulders.

The authors concluded that PCP to correct posterior instability during revision anatomic shoulder arthroplasty had an unacceptably high failure rate. 

Comment: What is especially interesting is that in these 16 cases, glenoid retroversion was felt to contribute to the posterior instability in only one, and that shoulder had 70 degrees of humeral retroversion combined with 30 degrees of glenoid retroversion.

We agree with the authors that posterior capsular plication is often not a robust technique for managing posterior instability. We prefer instead the use of an anteriorly eccentric humeral head component and rotator interval plication.

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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.

          

 

See 

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

Abstract:
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

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

Abstract
Background
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.

Questions/Purposes
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.

Methods
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.

Results
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).

Conclusion
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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Ream and run for posteriorly decentered humeral head on a biconcave glenoid

A bit over two years ago, we met a 53 year old author, radio and podcast host, fitness trainer, model, and international motivational speaker from California who presented with substantial pain and stiffness in his right shoulder. He could perform only 3 of the 12 functions of the Simple Shoulder Test. His preoperative x-rays are shown below.

 His axillary view shows a posteriorly decentered humeral head on a biconcave glenoid.

Because of his active lifestyle he elected the ream and run procedure. No CT scan, no polyethylene, no cement. We used a 56 18 humeral head, and 18 stem and performed a rotator interval plication to manage the shoulder's tendency for posterior  translation.

He sent us a video at 9 months after surgery (see this link) showing his ability to perform pull ups - something he'd been unable to do for 18 years before surgery.

At his two year followup, he reported the ability to perform all 12 of the Simple Shoulder Test questions, and "besides lifting weights again. I am back on a mountain bike with no pain. I compete in shotgun competitions (Trap). This means that in practice, I pull a trigger more than 600 times per week. That is 600 jolts to the "surgery shoulder" with no discomfort other than the normal shotgun related soreness. I can do 10+ pullups with no problem. I still do the flexibility exercises everyday and have continued to push the envelope there."

Yesterday he emailed, "Also, I'm planning a 100 mile kayak trip in Louisiana on the Bayou I grew up on, next spring. I'm attempting to do it non-stop. Thanks for completely changing my life. I was becoming fairly miserable to be around because of the constant pain. "

Once again, the patient's dedication to rehab makes the result!

Comment: The ream and run: not for every patient, every surgeon or every problem.

In a total shoulder arthroplasty, the humeral head prosthesis articulates with a polyethylene glenoid surface placed on the bone of the glenoid. Failure of the glenoid component is recognised as the principal cause of failure of total shoulder arthroplasty. By contrast, in the ream and run procedure, the humeral head prosthesis articulates directly with the glenoid, which has been conservatively reamed to provide a stabilising concavity and maximal glenohumeral contact area for load transfer. While no interpositional material is placed on the surface of the glenoid, animal studies have demonstrated that the reamed glenoid bone forms fibrocartilage, which is firmly fixed to the reamed bony surface. Glenohumeral motion is instituted on the day of surgery and continued daily after surgery to mold the regenerating glenoid fibrocartilage. When the healing process is complete - as indicated by a good and comfortable range of motion - exercises and activities are added progressively without concern for glenoid component failure.

The experience to date indicates that a technically well done ream and run procedure can restore high levels of comfort and function to carefully selected patients with osteoarthritis, capsulorrhaphy arthroplathy, and posttraumatic arthritis.

Patients considering the ream and run procedure should understand that this technique avoids the risks and limitations associated with a polyethylene glenoid component, but that it requires strong motivation to follow through on a rehabilitation course that may require many months. The outcome of this procedure depends on the body's regeneration of a new surface for the glenoid and requires rigorous adherence to a daily exercise program.
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Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

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Information about shoulder exercises can be found at this link.

Use the "Search" 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 as well as the 'ream and run essentials'See from which cities our patients come.

Ream and run for arthritis with severe posterior decentering

A 50 year old active man presented with pain, stiffness and posterior instability of his right shoulder. He could perform only 5 of the 12 functions of the Simple Shoulder Test.
His AP x-ray showed 'ordinary' arthritis.

 However his axillary 'truth' view showed essentially 100% posterior decentering of the the humeral head on a posteriorly eroded glenoid. This is another of those glenoids that doesn't fall neatly into a 'type' - the native glenoid was not retroverted, the head was decentered and there was a posterior pathologic concavity.

He elected to have ream and run. An anteriorly eccentric humeral head and a rotator interval plication were used to manage the severe posterior instability.  His postoperative films are shown below.

The morning after surgery he was off all narcotic medications and busy with his stretching exercises, having no feelings of posterior instability.

Here's his motion at one week post surgery.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" 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 as well as the 'ream and run essentials'See from which cities our patients come.

Standard total shoulder for severe B2 glenoid

A 76 year old man presented to us with severe right shoulder pain, stiffness and the x-rays shown below. While his AP view suggested straightforward osteoarthritis

his axillary, 'truth' view showed what is known as the 'severe arthritic triad': glenoid retroversion, glenoid biconcavity, and posterior decentering of the humeral head on the glenoid. No CT needed to define the pathoanatomy!

He elected to proceed with a total shoulder using a standard glenoid component. At surgery we reamed the glenoid to a single concavity without trying to change glenoid version. We used an anteriorly eccentric humeral component and a rotator interval plication to optimize posterior stability. Immediately after surgery he was started on the standard total shoulder rehabilitation program with continuous passive motion and assisted flexion. At six weeks he started the supine press and active flexion.

At four months he has a comfortable shoulder, no problems with instability, active flexion over 120 degrees, and is continuing his rehab.

His four month films are shown below.

While this is very short term followup, it does demonstrate that immediate postoperative glenohumeral stability can be achieved with this approach. To date we've not had problems with posterior instability using a standard glenoid component inserted in retroversion.

See also:

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?
That study analyzed the two year outcomes in 71 TSAs, comparing the 21 in a "retroverted" group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the "non-retroverted group" (the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). The results in the retroverted group were not inferior to those for the non-retroverted group. 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 percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  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. 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). 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 conclusion, glenoid retroversion is a relatively common finding in arthritic glenohumeral joints coming to shoulder arthroplasty. Shoulders with preoperative glenoid retroversion tend to have poorer preoperative shoulder comfort and function, posterior decentering, and glenoid biconcavity, all indicating a more severe form of the disease. There is currently great interest in methods for managing this glenoid retroversion commonly found in osteoarthritic glenohumeral joints using posterior glenoid bone grafts, reaming the anterior aspect of the glenoid, and posteriorly augmented glenoid components. The first study reviewed above reports the result of shoulders managed by altering the glenoid version with a posterior humeral head autograft. The second study reviewed above reports the two year results of a more conservative approach in which minimal glenoid bone is removed by reaming and specific attempts to alter glenoid version are not used.

Here is the two year radiographic followup on a 55 year old patient from our practice. Preoperative films show a type B2 genoid with retroversion, biconcavity and posterior humeral subluxation.

Here are the 2 year films of this shoulder after conservative shoulder arthroplasty using a standard glenoid component without attempts to modify glenoid version. The humeral head is centered in the prosthetic glenoid. At two years after surgery the patient was able to perform all 12 functions of the Simple Shoulder Test.

Note that sufficient bone stock remains to perform a revision total or a reverse total shoulder arthroplasty shoulder these procedures become necessary in the future of this young person.

Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" 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 as well as the 'ream and run essentials'See from which cities our patients come.

Managing arthritic posterior instability

Many approaches have been suggested for managing the posteriorly decentered humeral head that has come to rest in a pathological posterior concavity. These include posterior bone grafting (a technically difficult procedure with associated problems of hardware failure and graft resorption), reaming the anterior ‘high side” (a procedure that sacrifices bone stock without improving stability), posteriorly augmented plastic glenoid components (devices than increase the force and pressure on the posterior polyethylene with the associated risks of cold flow and increased ‘rocking horse’ lever arm) , and reverse total shoulder (with its associated risks and limitations).

Here are the preoperative x-rays on a heavy set, active patient.  The AP view suggests 'standard' osteoarthritis.

However the axillary 'truth' view shows severe posterior decentering into a pathologic glenoid concavity resulting from severe posterior erosion.

Our approach to this pathoanatomy is to convert the biconcavity into a single concavity by conservative reaming without attempting to change glenoid version, to insert a standard (non-augmented) all polyethylene glenoid, and then to manage any tendency for excessive posterior translation using an anteriorly eccentric humeral head and a rotator interval plication.

The postoperative AP view is shown below

Along with the axillary view that shows the anteriorly eccentric humeral head component to be centered in the glenoid component, which has been inserted in retroversion. Note the slight anterior penetration of the central peg.

At surgery the shoulder was stable to posteriorly directed forces applied to the humeral head. Postoperatively, the patient was able to participate fully in the standard post total shoulder rehabilitation program, including assisted flexion on the evening of surgery.

Of note in this approach is that the head is stabilized in large part by the posterior soft tissues (blue arrows in the figure below),

rather than by loading the posterior aspect of an augmented glenoid component.

Time will tell the best approach for managing this complex pathology. Stay tuned!
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Posterior instability and arthritis: ream and run

An active patient fell on his outstretched arm 17 years ago.
He had a SLAP surgery, but continued to have symptoms of his shoulder slipping when he raised it.
5 years ago at the age of 34 this x-rays looked like this.

He elected to continue trying to cope with his ongoing shoulder instability. Four months ago his symptoms of instability and pain and progressed to the point of needing an arthroplasty. At that time his radiographic posterior instability had also progressed as seen on the 'truth view' below.

Because of his young age (<40) and his desire to participate in high level activities, he elected to proceed with a ream and run surgery. This procedure required an anteriorly eccentric humeral head and a rotator interval plication.

Two months after surgery he had regained full assisted elevation of a comfortable shoulder without feelings of instability. His radiographs at that time are shown below.

Note the improved centering of the humeral head on the glenoid.

While it is still very early, this is a most encouraging demonstration of the effectiveness of the ram and run coupled with a rotator interval plication and an anteriorly eccentric humeral head prosthesis.

Other approaches that might have been considered include a fusion, posterior bone graft, total shoulder with a posteriorly augmented glenoid, or a reverse total shoulder.

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B2 glenoid: simple evaluation and management tools

A 50 year old patient presented with shoulder pain, stiffness, and a clunking sensation when the arm was raised.

We obtained our standard AP view

and the 'truth' axillary view, showing biconcavity and posterior decentering of the humeral head on the glenoid.

An outside CT scan came with the patient, but did not add information that was not apparent from the plain films.

A total shoulder was performed using an anteriorly eccentric humeral head and a rotator interval plication to manage intraoperative posterior decentering.

A postoperative 'truth' view shows the humeral head centered in the glenoid.

The patient was discharged with over 150 degrees of assisted elevation and no suggestion of posterior instability.

Comment: Preoperative CT scans were not necessary to understand the pathology and special glenoid components were not necessary to correct the posterior decentering.

See these related posts:

Shoulder joint replacement arthroplasty - x-ray evaluation
Managing posterior instability with an anteriorly eccentric humeral head component

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" 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 as well as the 'ream and run essentials'

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