These authors sought to compare the orientation and location of glenoid placement achieved at surgery with different types of instrumentation in comparison to a preoperative plan based on 3D CT scans in primary total shoulder shoulder arthroplasty.
173 patients with end-stage glenohumeral arthritis were enrolled in 3 prospective studies evaluating patient-specific instrumentation and 3D preoperative planning. All patients underwent preoperative 3D CT planning to determine optimal glenoid component and guide pin position based on surgeon preference.
Patients were placed into 1 of 5 instrument groups used for intraoperative guide pin placement:
(1) standard instrumentation,
(2) standard instrumentation combined with use of a 3D glenoid bone model containing the guide pin,
(3) use of the 3D glenoid bone model combined with single-use patient-specific instrumentation,
(4) use of the 3D glenoid bone model combined with reusable patient-specific instrumentation,
and (5) use of reusable patient-specific instrumentation with an adjustable, reusable base.
Postoperatively, all patients underwent 3D CT to compare actual versus planned glenoid component position. Deviation from the plan was compared across groups on the basis of absolute differences and outlier analysis.
In nearly all comparisons, there were no significant differences in the deviation from the plan for glenoid implant orientation or location across the 3 major treatment groups.
This study did not demonstrate that any type of patient-specific instrumentation resulted in consistent differences in accuracy of glenoid implant placement in primary TSA with 3D CT preoperative planning.
Comment: This article does not give the cost or time necessary for 3D CT preoperative planning or for the different types of patient-specific instrumentation. They do state that "the value of these technologies can also be compared on the basis of their current cost and time to delivery. The 3D CT preoperative software and templating were used in all groups in the study and this is therefore not a differentiating factor. Reusable instruments that do not add substantial cost to the provider were used in Groups 1, 2, 4, and 5. The additional cost and time to deliver the bone model are negative factors for Groups 2, 3, and 4. Use of a reusable base with reusable patient specific instrumentation (Group 5) may provide the lowest cost and shortest time to delivery," however the actual costs are not provided.
Questions remain regarding the use/value of preoperative 3D CT planning and patient specific instrumentation. (1) Are these technologies being recommended for all surgeons and hospitals performing shoulder arthroplasty? (2) Are these technologies being recommended for all shoulder arthroplasties or just for managing complex pathologies? It is noted that 76 of the cases in this series had the relatively straightforward type A glenoid pathoanatomy, for example. (3) In that these approaches appear to involve extra time, radiation exposure and cost, has it be determined for which cases these technologies lead to better patient-reported outcomes than those conventionally obtained for total shoulders performed without preoperative CT planning? In other words, for which cases is there evidence of clinical significance resulting from improvement in the accuracy of the match between the preoperative plan and the postoperative result?
Questions remain regarding the use/value of preoperative 3D CT planning and patient specific instrumentation. (1) Are these technologies being recommended for all surgeons and hospitals performing shoulder arthroplasty? (2) Are these technologies being recommended for all shoulder arthroplasties or just for managing complex pathologies? It is noted that 76 of the cases in this series had the relatively straightforward type A glenoid pathoanatomy, for example. (3) In that these approaches appear to involve extra time, radiation exposure and cost, has it be determined for which cases these technologies lead to better patient-reported outcomes than those conventionally obtained for total shoulders performed without preoperative CT planning? In other words, for which cases is there evidence of clinical significance resulting from improvement in the accuracy of the match between the preoperative plan and the postoperative result?
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