Preserving glenoid bone in total shoulder arthroplasty

Short-term radiographic results of a cemented polyethylene keeled glenoid component with varying backside radiuses of curvature

These authors analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature implanted in 118 shoulders.

A type A1 glenoid was found in 28 shoulders, an A2 in 51, a B1 in 24, a B2 in 18, and a B3 in 4. The surgical technique included measuring the curvature of the arthritic glenoid and selecting a backside curvature that closely matched it so that minimal glenoid reaming was required.

Mean follow-up was 38 months. The mean radiolucent line score after surgery was 0.54 points and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points) and 74% had no or only 1 radiolucent line. The radiolucent line score increased significantly over time. No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines.

Comment: These authors have advocated an approach to glenoid arthroplasty that minimizes glenoid reaming and maximizes preservation of the subchondral glenoid bone.

It is interesting, however, that they do not describe how they managed the important problem of glenoid retroversion and biconcavity for the type "B" glenoids included in this study.

In performing prosthetic glenoid arthroplasty, our goal (like that of theses authors) is to minimize the amount of glenoid bone removed, striving to preserve the subchondral bone. We do not attempt to "correct" glenoid retroversion by eccentric reaming

In the presence of retroversion and a biconcave glenoid, we adjust the angle of the reamer to preserve glenoid bone stock while still providing a good match of the reamed glenoid bone to the backside of the glenoid component.

See this link:  

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

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Bone-preserving total shoulder and reverse total shoulder arthroplasty - a simple approach

Today we had the pleasure of seeing a lady for routine followup of bilateral shoulder arthroplasties. On the right side a reverse total shoulder was performed because of the combination of cuff deficiency and arthritis. Here are her preoperative films,

 showing posterior decentering on the axillary 'truth' view

and her postoperative films showing secure, but bone-preserving fixation of the glenoid component and bone-preserving, cementless impaction autograft fixation of a non-ingrowth, thin-stemmed humeral component.

She had a standard total shoulder performed on the left because of arthritis with an intact cuff.

Her preoperative films are shown here

 showing posterior decentering on the axillary 'truth' view

and her postoperative films showing secure but bone-preserving fixation of the glenoid component and bone-preserving, cementless impaction autograft fixation of a non-ingrowth, thin-stemmed humeral component.

While several different approaches to bone preservation in shoulder arthroplasty have been proposed, the methods above appear to preserve at least as much bone as any of the alternatives, while still optimizing component orientation and fixation and avoiding stress-shielding.
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Healing through joint replacement

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'

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Total shoulder - a conservative, bone-preserving approach

Two years ago a woman in her late 50's presented with pain in the right shoulder, an SST score of 5 out of 12, and these x-rays: 

Note the hooking osteophyte and the lack of joint space on the AP view

And the glenoid retroversion, biconcavity and posterior decentering on the the axillary 'truth' view.

She returned for her two year followup with an SST score of 12 out of 12 and these x-rays:

Note the preservation of the humeral bone stock, the stable fixation of the long stem achieved with impaction autografting, and the absence of stress shielding/bone resorption.

Note also the absence of radiolucent lines around the glenoid component, the absence of cement on the back side of the glenoid component, and the bone ingrowth between the flanges of the central peg of the glenoid component (arrow).

On the postoperative 'truth' axillary view, note again the bone ingrowth, the absence of back side cement, and the absence of radiolucent lines as well as the centering of the humeral head in the glenoid and the preservation of glenoid bone stock.

This technique provides a dependable, adaptable and bone-preserving approach to total shoulder arthroplasty.

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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.

Short-stemmed humeral components - do they 'preserve more bone'?

Short-term clinical outcome of an anatomic short-stem humeral component in total shoulder arthroplasty

These authors evaluated the short-term clinical outcomes of an anatomic short-stem humeral

component in total shoulder arthroplasty. They hypothesized that the implant would lead to significant functional improvement with low rates of radiographic loosening at a minimum follow-up of 2 years. 

This is the implanted used.

After an anatomic head cut was made, the canal of the humerus was sequentially broached until optimal fit was achieved and rotational stability of the implant was obtained. All humeral implants were impacted with a press-fit technique without the use of cement.

Sixty-four patients with a mean age of 64.1 years were available for follow-up at a mean of 25 months postoperatively. There were significant improvements in the Visual Analog Scale (6 to 2; P < .001), Simple Shoulder Test (4 to 10; P < .001), Single Assessment Numeric Evaluation (32 to 84; P < .001), and American Shoulder and Elbow Surgeons (37 to 80; P < .001) scores. Forward flexion improved from 116° to 148° (P < .001), external rotation improved from 30° to 57° (P < .001), and internal rotation improved from an average spinal level of S1 to L2 (P < .001). On radiographic examination, 9% of stems were deemed "at risk" for loosening (defined as the presence of any stem subsidence, varus or valgus tilt, or radiolucent lines ≥2 mm in 3 or more radiographic zones), but there was no gross loosening in any patient. 

They reviewed one recent report (see this link) evaluating the clinical and radiographic outcomes of 73 TSAs performed with a collarless press-fit short stem which demonstrated a 71% rate of radiolucent lines. The overall revision rate at a mean of 33 months was 12%, and 8.7% of the remaining stems were considered at risk for loosening. They reviewed another recent report (see this link) that reported radiolucencies in 22% of 49 short-stem TSAs with a press-fit collared design.

Comment: Short stemmed humeral components are usually described as 'bone preserving". We agree that bone preservation is important, but find that this objective can be achieved with a standard humeral component inserted with impaction grafting - an approach that is at least as bone preserving as with the use of short stemmed implants. Because impaction grafting distributes interface forces over a broad area, a standard length stem without ingrowth surfaces minimizes problems with stress shielding and achieves additional stability through greater bone-prosthesis contact.

Compare the amount of bone preserved with this method (seen below) in comparison to that with the short stemmed component (shown above).

 

Additional thoughts on humeral components can be found here.

Humeral component what's in a stem?

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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.

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Reverse total shoulder - does a stemless design preserve more bone?

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study.

These authors report on 102 patients having a reverses total shoulder with a "short metaphyseal reverse total shoulder arthroplasty prosthesis without a diaphyseal stem" which they designed.

98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions.

Clinical outcomes were improved. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21%.

Comment: The authors goal in designing this prosthesis was to preserve humeral bone. It is unclear, however, that their approach is more bone-preserving than an impaction-grafted standard stem as shown below.

We prefer the standard humeral stem with the offset glenosphere shown above because it can manage a wide range of pathologies, some of which (such as that shown below) would be out of reach of a stemless prosthesis.

Our bone preserving reverse total shoulder technique is shown in this post.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

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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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What does a well-done total shoulder look like at two years after surgery

Our practice is follow routinely our patients after reconstructive surgery, with clinical and radiographic assessments at two years and well beyond. We're often asked, 'what should the x-rays of a total shoulder arthroplasty look like?' Below is an example of a typical two year set of films, showing the bone-preserving approach: minimal reaming on the glenoid side and fixation with impaction grafting on the humeral side. Note the quantity and quality of the remaining glenoid and humeral bone without the effects of stress shielding.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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.

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