The ream and run with pyrocarbon for B2 and B3 glenoids.

There is great current interest in the ream and run, the pyrocarbon humeral head and B type glenoids.

A recent publication, B2 and B3 glenoid osteoarthirtis: outcomes of corrective and concentric (C2) reaming of the glenoid combined with pyrocarbon hemiarthroplasty, reports a series of 41shoulders (in 35 patients, mean age of 57.9 years) that had a ream and run (glenoid reaming and humeral hemiarthroplasty without a prosthetic glenoid component) using a pyrocarbon humeral head. This procedure was offered to healthy young and/or active individuals (heavy workers or athletes) who had failed conservative management (cortisone injections, platelet-rich plasma, physical therapy) and who sought to avoid the activity restrictions and potential risks associated with anatomic or reverse total shoulder arthroplasty.

This study included patients with B2 (30 (73%)) or B3 (11 (27%)) glenoid pathoanatmy who had computed tomography (CT) performed with the arm at the side (1) before arthroplasty, (2) 6 months or less after surgery, and (3) at the last follow-up (>2 years).  

The humeral stem was implanted in anatomic retroversion and inclination. Considering the additional thickness (+2 mm) of the metallic tray under the pyrocarbon head, the surgeon downsized the prosthetic head (one size lower than the trial head) to avoid overstuffing of the glenohumeral joint. 

Glenoid reaming was performed to a "radius of curvature (ROC) close to that of the chosen prosthetic head (6-mm mismatch)" and "to correct 10 degrees of retroversion". This was carried out in two steps, first with a large radius of curvature to "partially (10 degrees) correct the excessive retroversion by reaming the high side (below top); a second reamer (with a small radius of curvature) was used to perform a concentric and congruent reaming" (below bottom).

This is in contrast to the standard ream and run technique in which the priority is preserving glenoid bone stock by minimizing the amount of bone removed and accepting the glenoid version (below).

The mean glenoid retroversion was changed by 9 degrees (from 17.1°preoperatively to 8.3°) at last follow-up.

Humeral centering on the glenoid was measured using Walch's mediatrice method where line "M" is the perpendicular bisector of the glenoid face and A divided by D is the percentage of the humeral head lying posterior to M. 

    

The centering of the humeral head on the glenoid concavity was improved from  59.9% to 50.3% (50% being a completely centered humeral head).

The authors point out that that decentering of the humeral head on the glenoid was measured on CT with the arm at side and not with the arm elevated. Prior studies have shown that functional decentering of the humeral head on the glenoid occurs during arm elevation.

The medialization of the glenoid face relative to the body of the scapula was measured on CT scans after multiplane reconstruction: 2 planes, orthogonal to the scapular plane, were selected: (a) the plane tangent to the center of the glenoid surface (G) and (b)  the plane tangent to the lateral cortex of the base of the coracoid (C). The distance between these 2 planes (C-G distance) was measured preoperatively and at each follow-up representing the amount of glenoid medialization. A positive value means that the glenoid surface is lateral to the base of the coracoid, whereas a negative value means that the glenoid surface is medial to the base of the coracoid .

The average total medialization was 3.7 ± 3.2 mm (2.0 ± 1.8 mm due to reaming and 1.7 ± 2.4 mm due to erosion occurring between 6 months or less after surgery and final followup. 

The adjusted Constant Score increased from 43% to 97%; the Subjective Shoulder Value from 38% to 84%. 84% of active patients returned to work, and all patients returned to sports.

In comparison to images obtained 6 or fewer months after surgery, 11 (28%) shoulders showed progression of glenoid erosion by 1 grade, whereas 28 shoulders (72%) showed no increased glenoid erosion at the last follow-up. Shoulders with increased glenoid erosion of 1 grade had 9 points lower Constant scores and 9 percent lower subjective shoulder value scores than those with no increased erosion; no correlations were found between increased glenoid erosion and shoulder pain.

At a mean follow-up of 4.5 years, the prosthesis survival was 95% (39 of 41). No patient has been reoperated for painful glenoid erosion. 

Comment: This is a very carefully done and clearly presented study. A major strength is that the authors used the same imaging method to assess the shoulder's geometry before and sequentially after surgery. 

This paper confirms the utility of the ream and run procedure for young and active patients with B2 and B3 type glenoids who wish to avoid the limitations associated with anatomic and reverse total shoulder arthroplasty. 

The authors point out that there is a risk of overstuffing the glenohumeral joint 

with the pyrocarbon implant because of the presence of a metallic tray under the pyrocarbon head that increases the global thickness of the humeral head as shown in an annotated figure from their paper shown below.

Their study found that the amount of medialization for the ream and run with pyrocarbon was 1.7 mm between 6 months or less and 4.5 years after arthroplasty.

Here are two studies using metallic heads:

Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less (average medialization of 1.1 mm between immediate postoperative and a mean of 44 months after arthroplasty).

Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis (average medialization of 2.4 mm between immediate postoperative and a mean of 28 months after arthroplasty; glenoid type was not associated with the amount of medialization; the amount of medialization was not associated with the clinical outcome realized by the patient).

Conclusion:

The ream and run procedure is a reliable option for active patients who wish to avoid the risks and limitations of an anatomic or reverse total shoulder. Well controlled studies are needed to determine the importance of preoperative pathoanatomy, version modification, component position and humeral head material composition on the quality and durability of the clinical outcome realized by the patient following this procedure.

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).

B3 glenoid in a 73 year old woman, 12 year followup

A 73 year old woman presented with pain and stiffness of the left shoulder. Her radiographs showed glenohumeral arthritis with a retroverted monoconcave (B3) glenoid. Her Simple Shoulder Test indicated that she could not sleep comfortably, reach the small of her back, lift eight pounds, toss, throw, wash back of her opposite shoulder or do her usual work. She had 120 degrees of active elevation with grade 5 strength.

       

After a discussion of the surgical options, she elected an anatomic total shoulder. This was performed without preoperative MRI, CT scan, 3D planning or brachial plexus block. The long head tendon of the biceps was preserved. Conservative glenoid reaming was performed with no attempt to alter glenoid version. A standard (non-augmented) glenoid component was used. A standard length smooth humeral stem was impaction-grafted into the humeral canal.

At 12 years after her arthroplasty at the age of 85, she reported being able to perform 8 of the 12 functions of the Simple Shoulder Test and was pleased with the outcome of her surgery.

Her x-rays at that time show secure fixation of the humeral and glenoid components with bony ingrowth between the fins of the central glenoid peg. Penetration of the anterior glenoid vault by the central peg is seen on the axillary view.

Comment: As pointed out by the authors of Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies, this standardized economical approach (minimal reaming, standard, non augmented, glenoid component) is effective across the range of glenoid types:

Humeral centering on the glenoid can be achieved

without change in glenoid version.

Comments welcome at shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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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). 

Three approaches to the B3 glenoid

As pointed out in Characterization of the Walch B3 glenoid in primary osteoarthritis, the type B3 arthritic pathoanatomy is characterized by a humeral head that is centered in a uniconcave retroverted glenoid (below right), but that lies posterior to the plane of the scapula (below center).

Using figures based on those from Early clinical and radiographic outcomes of anatomic total shoulder arthroplasty with a biconvex posterior augmented glenoid for patients with posterior glenoid erosion: minimum 2-year follow-up we can consider three different approaches to this type of arthritic pathoanatomy, each which has its proponents.

Corrective reaming to neutralize glenoid version and align the center of the humeral head with the plane of the scapula (see  How much does "corrective glenoid reaming" actually change version?) As shown below, this approach requires removal of a substantial amount of bone (red arrow) leaving less support for a glenoid component.

Using an augmented glenoid component to neutralize glenoid version and align the center of the humeral head with the plane of the scapula. (see Augmented glenoid components for B2 and B3 glenoids). As shown below, posteriorly directed loads are applied to thicker posterior polyethylene of the glenoid component. Theoretically, this might increase the risks of rocking horse loosening.

Conservative glenoid reaming - only as much reaming as is needed to achieve a glenoid concavity that conforms to the back of a standard glenoid component without an attempt to correct glenoid version or to align the humeral head with the scapular plane.  (See Arthritic glenoid retroversion: what to do about it.)

Comment: The optimal approach to the B3 glenoid is yet to be established and may depend on the characteristics of the individual patient and the experience of the surgeon. Yet as we go forward, it seems important to keep an eye on the evidence supporting the need for correcting glenoid version versus that favoring accepting the retroversion to which the soft tissues of the shoulder have become accustomed (see Glenoid version: acceptors and correctors).

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

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
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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).

Anatomic or reverse total shoulder arthroplasty for B2 and B3 glenoid pathoanatomy?

Severe glenohumeral osteoarthritis (GHOA) with posterior glenoid erosion remains challenging to address for shoulder surgeons, especially for glenoid types B2 and B3.

The authors of Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies evaluated 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version. The component was inserted using a standardized technique (see this link) that minimized glenoid bone removal and optimized cementing and seating.

 
The Simple Shoulder Test score improved from

3.2 preoperatively to 9.9 postoperatively at a mean followup of 2.8 years for type-B2 glenoids 

and from 

3.0 preoperatively to 9.4 postoperatively at a mean followup of 2.9 years for type-B3 glenoids.

These results were not inferior to those for shoulders with other glenoid types. 

Postoperative glenoid version was not significantly different (p > 0.05) from preoperative glenoid version. 

The mean humeral-head decentering on the glenoid face was reduced 

for type-B2 glenoids from -14% preoperatively to -1% postoperatively

and for type-B3 glenoids from -4% preoperatively to -1% postoperatively. 

The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for glenoid types without posterior bone deficiencies. 

None of the total shoulders performed on shoulders with type-B2 glenoids or type-B3 glenoids required revision surgery. 

In spite of this high success rate with this approach to anatomic total shoulder arthroplasty (aTSA), some surgeons prefer reverse total shoulder arthroplasty (RSA) for B2 and B3 glenoids. 

The authors of Anatomic and Reverse Shoulder Arthroplasty for Management of B2 and B3 Glenoids: A Matched Cohort Analysis compared the clinical outcomes of patients with glenohumeral arthritis and Walch B2 and B3 glenoid morphologies treated with aTSA and RSA.

Patients undergoing aTSA were treated with "a standard cemented all-polyethylene glenoid component", however the types of glenoid component and insertion technique were not specified. By contrast, for RSA, all patients had similar implants(AltiVate Reverse). The RSA system includes a glenosphere designed to have a center of rotation lateral to the glenoid (diameter range of 32-40 mm and lateralized center of rotation range of 2-10 mm) and a humeral stem with a 135-degree neck-shaft angle.

Patients were matched 1:1 by sex, Walch classification, and age. However the mean followup for the RSApatients was over a year shorter (mean 47 months for aTSA and 31 months for RSA).

They observed no statistically significant difference between aTSA and RSA for the preoperative change in VAS pain score, SANE score,  ASES score, forward flexion, external rotation or internal rotation.

At a mean of 47 months followup 3 of 101 shoulders with aTSA had gross glenoid loosening.

At a mean of 31 months followup 2 of 101 shoulders with RSA had gross glenoid loosening.

At a mean of 47 months followup complications had occurred in 3 of 101 TSA cases: subscapularis failure, transient postoperative neuropathy, and a revision for infected prosthesis.

At a mean of 31 months followup complications had occurred in 4 of 101 RSA cases : postoperative acromion fracture, transient postoperative neuropathy, transient cubital tunnel syndrome, and revision for glenoid component loosening. 

Comment: While in the report above, primary RSA appeared to yield in largely comparable short-term outcomes compared to TSA in patients with Walch B2 or B3 glenoid morphology, the patients were not matched for length of followup: the aTSA group was followed for over a year longer than the RSA group.

As demonstrated the figure below, complications and revisions continue to increase after shoulder arthroplasty, so in comparing two types of arthroplasty it is important that the periods of followup for the two implants are comparable.

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

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
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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).

Is the B3 glenoid anything different than a somewhat more retroverted A2? Does it require special treatment?

Mid-to-Long Term Outcomes of Augmented and Non-Augmented Anatomic Shoulder Arthroplasty in Walch B3 Glenoids

These authors sought to determine mid-to-long term (minimum 6 year) outcomes and reoperation rates for 35 patients receiving augmented (n=16) or non-augmented (n=19) aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity - that is a mono concave glenoid with increased retroversion.

Preoperative glenoid retroversion was 24˚+/-8.6˚ in the standard cohort and 29˚+/- 5.8˚  in those who received augmented glenoid components. At the time of glenoid preparation, there was anterior perforation of the central peg hole in 5 patients in the standard component cohort and 9 patients in the augmented component cohort.

 At final follow-up there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs 85.7), ASES pain score (47.2 vs  41.6), SANE score (87.8 vs 86.0), and percent patient satisfaction (95.6% vs 96.8%), forward  elevation (148˚ vs 149˚), or external rotation (36˚ vs 39˚). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients would want to undergo the same surgery again.

While the authors reported that shoulders receiving standard components had the version "partially corrected with asymmetric reaming", they did not report the postoperative version or the change in version for the augmented or standard glenoid components. 

Comment: These authors achieved excellent 6 year outcomes in managing B3 glenoids without a significant difference between those treated with augmented and standard glenoid components. They concluded that in their experience an anatomic shoulder arthroplasty was appropriate management for the B3 glenoid. 

As pointed out in Subluxation in the Arthritic Shoulder, humeral head is centered (not posteriorly decentered) in the B3 glenoid, just as it is in the A2 glenoid. The difference between the A2 and the B3 glenoid types is based on the latter being retroverted by an arbitrarily defined 15 degrees (see this link).

Perhaps, therefore, it is not surprising that a standard glenoid component is a reliable treatment for both A2 and B3 glenoids.

A recent publication,  Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies reported clinical and radiographic outcomes treating  B3 glenoids with TSA with a standard all polyethylene glenoid component without attempting to normalize glenoid version. In that series glenoid version averaged 26 degrees preoperatively and 23 degrees postoperatively. The humeral heads were well centered postoperatively. Simple shoulder test scores improved from 3/12 to 10/12.

The data for all glenoid types are shown below.

In a related article, Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty? standard glenoid components inserted in more than 15 degrees of retroversion did not have results inferior to those inserted in less than 15 degrees of retroversion. The humeral heads were well centered in both groups.

These articles suggest that postoperative centering of the humeral head on the glenoid may be more important to the outcome than the postoperative glenoid version.

A glenoid bone-preserving approach to total shoulder arthroplasty using a standard glenoid component is shown in this link..

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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).

Management if the B2 and B3 glenoid types with an augmented glenoid component

Stepped Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for B2 and B3 Glenoid Pathology A Study of Early Outcomes

These authors studied the use of a stepped augmented glenoid component for management of Walch B2 (n=29) and B3 (n=21) glenoids and compared the radiographic and clinical outcomes at short-term follow-up with those achieved with a non-augmented component of the same design in Walch A1 glenoids (n=42).

Sequential 3-dimensional (3D) computed tomography (CT) imaging was performed preoperatively, within 3 months postoperatively with metal artifact reduction (MAR) to define implant position, and at a minimum of 2 years postoperatively with MAR. 

Preoperatively, these images showed that the alignment of the humeral head to the glenoid (HGA - represented by the circles in the graph below) was independent of glenoid version. Type B3 (yellow symbols) showed centering of the humeral head on the glenoid that was comparable to type A1 (blue symbols). On the other hand, the alignment of the humeral head to the scapular body (HSA - represented by the triangles) was strongly related to glenoid version. 

Similarly at two years after surgery the humeroscapular alignment (but not the humeroglenoid alignment) was closely related to glenoid version.

The desired implant placement was achieved in all (100%) of the 42 A1 glenoids, 27 (93%) of the 29 B2 glenoids, and 15 (71%) of the 21 B3 glenoids.

Radiographic followup at two years showed:

A1 glenoids: Central peg osteolysis (CPO) was present in 5% of the A1 glenoids. 40% had glenoid component shift.

B2 glenoids: There was only a small difference in the frequency of CPO between B2 glenoids with the augmented component (10%) and A1 glenoids (5%) with the standard component. The short-term clinical and radiographic results were equivalent to those for patients without glenoid bone loss (Walch A1) treated with a non-augmented component. 55% had glenoid component shift.

B3 glenoids: Central peg osteolysis (CPO) with or without implant shift occurred in a higher percentage of B3 glenoids treated with the augmented glenoid component (29%) than A1 glenoids treated with a standard component (5%) B3 glenoids were associated with more component medialization relative to the premorbid joint line compared with A1 and B2 glenoids. 62% had glenoid component shift.

The two year clinical outcome scores were not different for the three glenoid types.

Comment: This authors have continued their careful and thoughtful analysis of arthritic glenohumeral anatomy. Their observations on glenoid component shift and central peg osteolysis obtained with metal subtraction imaging provide knowledge that informs our understanding and management of shoulder arthritis.

They point out both the severity and the shape of glenoid bone loss are important when considering the type of glenoid component to use and its location in aTSA. Use of the stepped augmented glenoid component requires more anterior glenoid reaming to correct pathologic glenoid retroversion in moderate-to-severe B3 glenoids, resulting in implant medialization. These B3 glenoids had a higher rate of central peg osteolysis and persistent postoperative joint-line medialization relative to the premorbid joint line. They do  not recommend use of the stepped augmented glenoid component for correction of severe B3 glenoid retroversion that requires excessive anterior glenoid reaming.

Recognizing that high degrees of retroversion, bone loss and humeral head decentering on the glenoid are indicators of worse pathoanatomy and that each of these - separately or in combination - can negatively affect the durability of the arthroplasty, several questions arise:

(1) How important is it to re-establish the premorbid joint line; how much medialization of the the joint line be compensated for by modification of the prosthetic head curvature and thickness?

(2) How important is it to re-establish the premorbid version in the B2 glenoid at the expense of removing sclerotic glenoid bone; how much abnormal glenoid retroversion be compensated for by using soft tissue balancing and anteriorly eccentric humeral components to center the humeral head?

(3) How important is it to re-establish the premorbid version in the B3 glenoid at the expense of removing sclerotic glenoid bone; since the humeral head is centered in the glenoid is it necessary to change the version?

(4) How important is it to avoid peg perforation; might perforation of the glenoid neck by the central peg actually enhance fixation as it appears to do with many designs of reverse total shoulder?

In sum, what is the best way to balance bone preservation vs "correction" of the pathoanatomy?

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).

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).