Managing the B2 glenoid in an active young man

A 46 yo man presented with a history of progressive left shoulder pain and stiffness. He grew up with an active lifestyle and played football and lacrosse. He injured his shoulder playing football but did not have prior shoulder surgery. He is reliant on his upper extremity function for his work that requires routinely lifting more than 25 lbs overhead. He had complaints of worsening shoulder pain and stiffness despite receiving 3 corticosteroid injections and 1 synvisc injection. He was told by his local orthopaedist that he was too young for a conventional total shoulder replacement.

His physical examination revealed very limited range of motion

His preoperative images are shown below.

Note the functional posterior decentering on his axillary "truth" view

In contrast to the relationship between the humeral head and the glenoid shown on the CT scan.

Because he had exhausted non-surgical treatment and his symptoms continued to impact his quality of life, surgical treatment was discussed, including ream-and-run arthroplasty and anatomic total shoulder arthroplasty. Because of his active lifestyle and activity demands at work, he decided to proceed with a ream-and-run arthroplasty. The long head of the biceps was tenodesed to the upper border of the pectoralis major and a lesser tuberosity osteotomy was performed to gain access to the shoulder joint. Correction of glenoid version was not attempted, and an anteriorly eccentric humeral head was used to improve centering of the articulation between the humeral head and glenoid. A short humeral stem was used to allow the use of an anteriorly eccentric humeral head. In this cases, impaction grafting was not needed to achieve adequate stability of the stem. 

His postoperative images are shown below.

Note the humeral head is nicely centered in a mono-concave glenoid.

At 6-months, he is doing great and is back at work without any activity limitations. He has done a terrific job of maintaining his motion and the focus is now on continuing to strengthen his rotator cuff, deltoid and periscapular musculature. 

This case was submitted by the patient's surgeon, Corey Schiffman.

Comment: Alternative management might have included continued non-operative management, an anatomic total shoulder without corrective reaming and a standard glenoid component, an anatomic total shoulder with an augmented glenoid component, or a reverse total shoulder. In this case a ream and run was selected - a procedure that preserved the maximum amount of glenoid and humeral bone stock, while avoiding the risks and limitations associated with anatomic or reverse total shoulder arthroplasty.

Contact: shoulderarthritis@uw.edu

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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).