Pre-operative planning for anatomic shoulder arthroplasty and ream and run hemiarthroplasty – what can be accomplished using plain x-rays?

Dwight D. Eisenhower, our 34^th President, said “the plan is nothing, planning is everything”, meaning that while specific plans may change, the act of planning itself is crucial because it prepares us to anticipate, adapt and respond effectively.

Thus, while there are important qualities of each patient’s arthritic shoulder that are only be revealed once the osteophytes have been removed and the contracted soft tissues are released, we can anticipate some elements of the surgery with consideration of the patient’s pre surgical anatomy as seen on plain radiographs and the preoperative physical examination. 

Michael Hachadorian, one of our current fellows, put together this blog post addressing this topic. He pointed to 4 major considerations that can help guide us in the planning of the shoulder arthroplasty

(1) Is the patient a better candidate for an anatomic total shoulder or for a ream and run procedure?

(2) Is the patient stiff (i.e. <100º of presurgical forward elevation and ≤0º of external rotation)?

(3) Does the patient exhibit posterior decentering on the preoperative axillary “truth” view?

(4) Is "overstuffing" only a humeral problem, or is it a potential issue with the global lateralization that can accompany the addition of a polyethylene glenoid component? (see Seven ways to overstuff an anatomic arthroplasty)

Here he presents five cases as illustrations of an approach to preoperative planning for shoulder arthroplasty that does not utilize CT scans or 3D planning software.

Case 1, The preoperatively centered, stiff arthritic shoulder

Here is a 44 year old male with severe OA who desired a ream and run. His preoperative examination reveals a stiff left shoulder with FE 80º, ER to 0º, ERA to 5º and IRA to 5º.

 

His plain radiographs showed many loose bodies and osteophytes. His axillary “truth” view shows a humeral head centered on an A2 type glenoid, suggesting that posterior instability is unlikely to be an issue with this shoulder.  

In this case the most important thing is to restore mobility to this shoulder, rather than trying to restore the "premorbid" anatomy. 

The PACS (Picture Archiving and Communication System) is available to most shoulder surgeon. It has tools for “trying” different prosthetic head sizes as shown below.

50 mm diameter of curvature.

54 mm diameter of curvature

The  54 diameter of curvature intersects the 3 points of the “perfect circle” and reveals the medialization resulting from arthritic humeral head bone loss. However, given the considerable presurgical stiffness that is likely to recur after surgery despite vigorous soft tissue relases, one can anticipate that the 50 mm diameter of curvature might be a better choice if confirmed by intraoperative testing.

Using angle tool at 135º relative to the humeral shaft, the PACS tools can then be used to explore the location of the head cut for this size head component, including its relation to the cuff insertion superiorly and to the osteophytes inferiorly. 

Based on this head cut, the thickness of the humeral head implant can be estimated measuring the distance from the medial aspect of the circle to the cut line. This example shows a 20 mm thickness head component.

However, given that this patient has considerable stiffness, what might it look like if we used the same head cut then downsized the head height to 50x18, deliberately “understuffing “? We can change the measurement tool to 18 by dragging the medial marker of this tool slightly lateral until the measurement reads “18.0 mm”. Then we can match the circle by dragging the entire circle laterally. Note that our perfect circle is no longer “perfect” in that it now extends slightly lateral to the GT.

Intraoperatively, both of these configurations were trialed and it was found that the range of motion was better with the 50 18 head and the stability was adequate. Here is the postoperative film with the  50 18 in place.

With the subscapularis closed his forward flexion was 165 degrees and his external rotation 30 degrees.

Case 2, The preoperatively decentered, stiff arthritic shoulder

This patient is an active 64 M who desired a ream and run procedure. His preoperative exam showed 90º forward elevation, external rotation at the side of 10º, external rotation in abduction to 30º, internal rotation in abduction to 0, and cross body adduction of 30 cm to contralateral acromioclavicular joint. 

His preoperative x-rays are shown below. His axillary “truth” view demonstrates essentially complete posterior decentering on a posteriorly eroded glenoid.

 

So here we have the challenging combination of stiffness and posterior instability. How can preoperative planning guide our efforts?

A 54 size head seems to fit well, but there was concern about posterior instability with an "anatomic" humeral reconstruction given his preoperative decentering. Note that while in the previous example, we elected to “undersize” the humeral head, we anticipate that the same strategy in this case could increase concern about postoperative instability.

On the “truth” view about 75% of the humeral head would lie posterior to the perpendicular bisector of the glenoid face.

 

We marked out the head height (18 mm) and the desired cut angle 135º. This head position would leave a 1 mm berm. We wanted to avoid a "too high" head because a head that is high with the arm at the side is posterior with the arm flexed forward at 90º

However, at surgery after osteophyte resection and anterior soft tissue releases,  the planned 54 18 concentric head component was (as anticipated) posteriorly unstable.

As a result, a 54 18  anteriorly eccentric humeral head was placed on a short stem (selected to assure implant stability in the humerus). 

The postoperative AP view shows the head in the planned position. 

The reconstruction did not substantially alter the global lateralization in comparison to the preoperative position.

The postoperative “truth” view shows the anteriorly eccentric humeral head centered on the glenoid that was reamed conservatively without glenoid version "correction". 

While some might argue that "correcting' glenoid version would have stabilized the shoulder against posterior instability, that approach seems less certain that what was performed here. While some are concerned about the effect of the anterior offset head on the subscapularis repair, the use of the 4 mm eccentric head has not been associated with tendon failure (see Total shoulder arthroplasty with an anterior-offset humeral head in patients with a B2 glenoid). As shown in this case, the amount of anterior prominence of the humeral head component is small.

This reconstruction provided a stable shoulder with postoperative flexion to 150º and external rotation to 30º.

Case 3 Total shoulder with overstuffing resulting from the addition of the glenoid polyethylene.

While focus on the reconstruction of the humeral head is reasonable for ream and run surgery, the effect of the addition of a 4 mm thick polyethylene glenoid component in total shoulder arthroplasty needs to be accounted for. In these cases, an anatomically reconstructed humeral head may lead to excessive global lateralization and resulting stiffness.

Here are the preoperative radiographs from a patient who had longstanding shoulder OA and was notably stiff on preoperative examination (FE 80, ER to 10, ERA 20 and IRA 10). 

The “truth” view indicated some posterior decentering. This patient had elected to undergo total shoulder arthroplasty.

In this case, 50 x 20 appeared to be like a reasonable option to re-create humeral anatomy. 

Post-operative radiographs demonstrated re-creation of humeral anatomy.   

However by drawing a “plum line” down from the lateral aspect of the acromion parallel to the glenoid face we see that the center of rotation of the humeral head is now lateral to the acromion whereas it was medial to the acromion preoperatively. Despite re-creation of humeral anatomy, the humerus now has more global lateralization. This patient had stiffness postoperatively which required a manipulation under anesthesia.

 Case 4. Total shoulder with undersizing of the humeral head to accommodate the stuffing effect of the glenoid component.

Here are preoperative radiographs from a patient who had longstanding shoulder OA and was notably stiff on preoperative examination (FE 90, ER to neutral, ERA 10 and IRA 10). The “truth” view did not indicate posterior instability. 

 

A head size of 54 would nicely reapproximate the patient’s humeral anatomy, 

 

however there was concern that the 4 mm glenoid component could lead to a stiff shoulder by increasing the global lateralization.

Downsizing to a size 50 x 18 head would avoid excessive global lateralization once the thickness of the glenoid component is factored in. 

 

The revised plan is shown below 

And here is the postoperative x-ray

While the humeral component may appear to be undersized, the reconstruction did not increase the global lateralizing, avoiding tightening of the shoulder. 

The humeral head remained concentric on the postoperative “truth” view despite under sizing the humeral head component.

Case 5: Total shoulder in a posteriorly decentered humeral head without stiffness. 

An anatomic head cut was templated using a 50 20 humeral head.

 

During surgery, it was determined that an anterior eccentric humeral head was needed given persistent posterior instability with all head sizes. After trialing the 50 20 anterior eccentric head offered the desired stability. 

The postoperative "truth" view showed the anteriorly eccentric humeral head centered on the glenoid. Note the minimal anterior prominence of the eccentric head.

Comment: First of all, thanks to Mike for the heavy lifting in putting this together. Second, thanks to all our past shoulder fellows and colleagues such as Armodios (Armand) Hatzidakis and Surena Namdari for their active role in continuing to shape our thoughts about shoulder arthroplasty.

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
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Using humeral head geometry to establish immediate postoperative mobility and stability in a B2 glenoid

A man in his 50s from another state presented with a grinding and aching pain in his left shoulder after prior arthroscopic surgery and cortisone injections. 

On his Simple Shoulder Test he reported the inability to tuck in his shirt behind his back, to place his hand behind his head with his elbow out to the side, to lift a gallon of milk, to toss under hand, to throw overhand, and had difficulty doing his work as a general contractor.  He was previously a competitive archer, however he was currently unable to hold his bow properly given the range of motion deficits and pain in his left shoulder.

His examination revealed 140 degrees of humerothoracic motion of which only 80 degrees was humeroscapular. External rotation was limited to 0 degrees at the side and 10 degrees with the arm in abduction. Internal rotation with the arm abducted was 10 degrees. Reach up the back was to the gluteal area. 

His preoperative x-rays are shown below. The axillary truth view showed severe posterior decentering of the humeral head on a biconcave glenoid. 

After discussion of the options of an anatomic and a reverse total shoulder, the patient elected a ream and run procedure. 

The surgical challenge was to manage the posterior instability while loosening this tight shoulder (avoiding overstuffing).  Without using a preoperative CT or 3D planning, it was anticipated that the posterior decentering would require the use of an anteriorly eccentric humeral head component with a short stem to provide secure fixation that would resist eccentric loading.

At surgery, the stiffness of the shoulder was confirmed on examination under general anesthesia, no nerve block was used. The shoulder was approached through a deltopectoral incision and a subscapularis peel. The long head of the biceps was preserved. 

The humeral head was deformed as anticipated.

Extensive subscapularis and anterior / inferior capsular releases were performed as shown in these diagrams from Steve Lippitt.

The glenoid was conservatively reamed to a single concavity without attempting to "correct" glenoid retroversion.

The sizing of the humeral head component was determined by trialing, paying attention to the 40, 50, 60 rules and assuring that easy flexion to at least 150 degrees could be achieved.

Implant manufacturers typically describe the size of their humeral head components in terms of diameter of curvature and height.

It is useful to recognize that the humeral head component is a spherical cap (shown in blue below) with a height of h and a radius of r (half the diameter of curvature).

The volume of the humeral head is an important factor in determining the degree of stuffing of the joint. The humeral head volume is determined by 

The effect of changing the diameter curvature and the height of the humeral component are show in diagrams below. As pointed out by Jason Hsu, increasing the height has a greater effect on humeral head volume than increasing the diameter of curvature.

This effect is quantitatively demonstrated in the table below showing the humeral head volume for a commonly used range of prosthetic humeral head diameters and radii. The different component geometries are arranged in order of decreasing head volume. Note that it is the head height that is the primary driver of joint volume.

In this case a 54 20 head provided the necessary stability and mobility as demonstrated by this photo taken after wound closure.

His immediate postoperative x-rays show the impaction grafted humeral stem with an anteriorly eccentric humeral head centered in the conservatively reamed glenoid. 

Four days after his surgery he reported that he was taking only Tylenol for his shoulder and sent this report:

 

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

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).