Arthritis in a young woman after Latarjet - challenges in management

 A woman in her mid thirties developed painful arthritis of the right shoulder after prior arthroscopic Bankart with remplissage and a subsequent Latarjet procedure for glenohumeral instability. On exam her shoulder was very stiff and felt unstable with "clunking" on movement.

X-rays at presentation showed glenhumeral arthritis, posterior decentering on a biconcave glenoid, and fixation of the coracoid on the anteroinferior glenoid by two large screws.

After discussion regarding the pros and cons of the alternatives, the patient elected an anatomic total shoulder arthroplasty.

No preoperative CT scan or 3D planning was used. The procedure was performed under general anesthesia without a brachial plexus block. 

The arthritic humeral head showed a large posterior Hill-Sachs defect.

The long head tendon of the biceps was preserved. 

After concentric reaming with a nubbed (non-cannulated) reamer, one of the pegs on the glenoid component could not be fully seated because of interference with one of the screws. A pine-cone bur was used to remove part of the screw to allow for full, secure seating of the glenoid component.   A posteriorly eccentric humeral head was used to control excess anterior translation. 

After careful mobilization of the subscapularis, a robust repair was achieved with 6 fiber wire sutures and two additional reinforcement sutures placed in the lateral rotator interval.

In the post anesthesia care unit, the patient demonstrated near full assisted flexion without the preoperative "clunking" and without feelings of instability.

Comment: In this case it was elected not to attempt removal of the screws to avoid the risk of damage to the musculocutaneous nerve, axillary nerve, and axillary artery that may be scarred in non-anatomical positions. 

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
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). 

Repost - anteriorly augmented polyethylene glenoid or posteriorly eccentric humeral head.

One of our regular readers pointed out that the prior post on this topic omitted the great post now added at the end showing the functional result after a posteriorly eccentric humeral head with a ream and run. So here it is again with the case added at the bottom - check it out.

Total shoulder arthroplasty with an augmented component for anterior glenoid bone deficiency.

These authors present 5 patients having total shoulder arthroplasty using an anteriorly augmented glenoid component. The preoperative diagnoses were anterior glenoid erosion in 2 patients, and 1 patient each with malunited glenoid fracture, nonunited glenoid fracture, and post-traumatic arthritis. The mean age at the time of surgery was 67.4 years (range, 53-75 years).

At an average of 33.2 months (range, 21.9-43.2 months) after surgery no patient had demonstrated radiographic or clinical signs of glenoid component loosening or instability. 

Comment: Anterior glenoid erosion predisposes the shoulder to anterior instability. As shown in this figure from the paper, it can usually be identified on a standardized axillary x-ray.

These authors have reported the use of an augmented glenoid component in the management of five such shoulders with durable results.

An alternative approach is to use a posteriorly eccentric humeral head component with a standard glenoid component accepting the glenoid anteversion as shown in the case below. This approach preserves the maximal amount of glenoid bone stock.

The posteriorly eccentric humeral head component has also improved useful in the management of failed arthroplasty with anterior glenoid bone deficiency, again accepting the anteversion of the glenoid.

The posteriorly eccentric humeral head can also manage post traumatic deformity in which the head is posteriorly malunited.

And one final case posted along with post surgical video showing the functional level achieved.