The power of the "truth" view in the detection of early shoulder arthritis

 A young man presented with pain and stiffness after prior procedures on his clavicle, biceps, and subscapularis.

His examination confirmed mild-moderate stiffness of his glenohumeral joint.

His Grashey view was not remarkable

However, his axillary "truth" view revealed decentering of the humeral head on the glenoid and moderate glenohumeral osteoarthritis.

Our thoughts on how to get the most information out of three simple plain films is shown in this link.

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).

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).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Ream and run - imaging the shoulder before and after surgery

Standardized imaging of the shoulder before and after the ream and run is important both for preoperative planning and for evaluating the arthroplasty. We use three views, as shown below: the AP in the plane of the scapula (Grashey view) on the left; the axillary "truth" view in the center, and the AP templating view on the right.

The AP templating view gives a good view of the humeral canal to anticipate any issues with placement of the stem as shown in the three examples below 

The AP in the plane of the scapula or Grashey is used for identifying medialization relative to the lateral acromial line, bone stock, glenoid inclination, foreign bodies and the size of the osteophytes.

This view is also used to evaluate proximal deformities that may require special placement of the humeral component.

And situations in which the humeral head cannot be dislocated safely so that an in situ osteotomy may be required.

The axillary "truth" view is used for evaluating the centering of the humeral head on the glenoid

Using this view, the centering can be compared before and after surgery

The axillary "truth" view is used to evaluate the glenoid bone stock and version relative to the plane of the scapula.

It can also be used to identify the glenoid type

However, we have found that the glenoid type is not an important consideration in the ream and run procedure, because in all cases the goal of reaming is to create a single glenoid concavity with maximal preservation of glenoid bone; changing glenoid version is not a priority and does not seem necessary for achieving stability or for a good functional result

Using these views we have not found that preoperative CT scans or 3D CT planning are needed.

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To see a YouTube video on how the ream and run is done, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

The arthritic shoulder: version, biconcavity and humeral head decentering

A good understanding of arthritic shoulder arthroplasty can be gained from standard plain x-ray views without the need for CT scans or 3D planning software.

Here is the anteroposterior view of the right shoulder of a former baseball pitcher in his early 30's several years after a posterior labral repair. The film shows loss of radiographic joint space and osteophytes.

His axillary "truth" view, taken with the arm in a functional position of elevation, shows the humeral head sitting in the posterior concavity of a biconcave glenoid

With a usual amount of glenoid retroversion

And substantial posterior decentering of the humeral head on the face of the glenoid

The amount of decentering can be measured in terms of the amount of posterior displacement of the center of the humeral head in reference to the perpendicular bisector of a line segment connecting the anterior and posterior edges of the glenoid.

This is all the information needed to plan his reconstructive surgery which will be a ream and run.

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To see a YouTube video on how the ream and run is done, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Does a preoperative CT scan improve patient outcomes?

Comparing the Use of Axillary Radiographs and Axial Computed Tomography Scans to Predict Concentric Glenoid Wear

These authors sought to compare the use of axillary radiographs and midglenoid axial CT scans to identify glenoid wear.

Five independent examiners with differing levels of experience characterized the glenoid morphology as either concentric or eccentric on preoperative axillary radiographs and mid-glenoid axial CT scans for 330 patients who underwent anatomic total shoulder arthroplasty.

Intraobserver consistency averaged 75% for radiographs and 73% for CT scans. There was significant interobserver consistency, as higher levels of training corresponded with greater consistency between imaging analyses (p < 0.001).


Comment: Especially in these times with huge strains on the nation's medical budget, we need to be thoughtful about how our health care dollars are spent.

As the authors state, "Although CT scans are associated with greater financial cost and exposure to radiation than radiographs, the literature has yet to describe the additional clinical value and/or potential cost-value benefit as a result of improved outcomes provided by the use of CT scans in patients undergoing total shoulder arthroplasty, even when integrated with virtual planning software and generation of patient specific instrumentation."

We agree that CT scans without or with 3D reconstructions can provide additional detail regarding glenohumeral pathoanatomy in comparison to plain radiographs, it remains to be seen whether this increment in information leads to significantly better clinical outcomes for the patient. Any benefit would need to be balanced against the increased costs and the 200 to 1,000 fold increase in radiation exposure of the CT scans (2.06 mSV)75 (10.83 mSV)76 in comparison to plain radiographs (0.01 mSV). In addition to the cost, physicians are increasingly concerned about the relationship between radiation dosage and the risk of the patient developing cancer.

Further research is needed to show that preoperative CT scans contribute to improved outcomes for the patient.

Meanwhile, standardized preoperative views can provide the information needed to evaluate and manage the arthritic shoulder (see article below).

Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function

These authors examined 544 patients within 6 weeks before shoulder joint replacement arthroplasty with the goals of characterizing the radiographic characteristics of the arthritic joint and the relationship of these pathologic changes to the patients' age, sex and diagnosis. They also studied the inter-relationships among glenoid type, glenoid version, and amount of decentering of the humeral head on the glenoid; as well as the relationships of the pathoanatomy to the patient’s self-assessed shoulder comfort and function.

Examples of the different types of glenoid pathoanatomy are shown below.

They found that male patients had a higher frequency of type B2 glenoids and a lower frequency of A2 glenoids.

The arthritic shoulders of men were more retroverted and had greater amounts of posterior decentering.

Patients with types A1 and C glenoids were younger than those with other glenoid types. 

Shoulders with osteoarthritis were more likely to be type B2 and to be retroverted. 

Types B2 and C had the greatest degree of retroversion, whereas types B1 and B2 had the greatest amounts of posterior decentering. 

Shoulders with glenoid types B1 and B2 and those with more decentering did not have worse preoperative self-assessed shoulder comfort and function.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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How you can support research in shoulder surgery Click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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 arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

What is the best way to image an arthritic shoulder?

Recently we met an active 70 year old man with shoulder arthritis. His Grashey view is shown here

and his axillary "truth" view (below) clearly shows posterior decentering of the humeral head on a retroverted biconcave glenoid.

Previously he had had an MRI

and a CT scan

neither of which showed the posterior decentering that was revealed by the simple "truth" view taken with the arm in a position of function, in contrast to the "advanced" imaging (MRI / CT) obtained with the arm at the side which did not reveal the functional decentering.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Why is so much money and time being spent on detailed measurements of glenoid version?

Comparative analysis of 2 glenoid version measurement methods in variable axial slices on 3-dimensionally reconstructed computed tomography scans

These authors analyzed the variation of the glenoid vault compared with the Friedman angle according to different CT slice heights and angulations in 60 shoulder CT scan reconstructions.

Seven axial slices of different heights and coronal angulations were selected, and measurements were carried out by 3 observers. 

Mid-glenoid mean version was −8.0° (±4.9°; range, −19.6° to +7.0°) and −2.1° (± 4.7°; range, −13.0° to +10.3°) using the vault method and Friedman angle, respectively. Increasing slice height or angulation significantly increased anteversion for the vault method (P < .001). Both interobserver reliability and intraobserver reliability were significantly higher using the Friedman angle. 

They concluded that "the vault method shows less reliability and more variability according to slice height or angulation. Yet, as it significantly differs from the Friedman angle, it should still be used in situations where maximum bone purchase is sought with glenoid implants. For any other situation, the Friedman angle remains the method of choice".


Comment: While this paper asserts that preoperative measurement of glenoid version "is crucial for proper surgical implant positioning", it shows that with CT reconstruction there is substantial variability depending on which CT slices are used in the measurement and on the method of angle measurement.

It has not been demonstrated that patients having expensive CT reconstructions preoperatively have better outcomes than those having a standardized axillary "truth" view (see this link) - which is less costly, less time consuming and gives the patient 1/26th the radiation.

Even in complex pathologies, the axillary "truth" view gives us all the information we need for discussing the situation with the patient and for planning the procedure.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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'

Addressing arthritic posterior decentering with the ream and run

Here are examples of the standardized AP and axillary x-rays we obtain prior to shoulder arthroplasty. The AP view shows joint space narrowing and osteophytes.

 while the axillary "truth" view shows posterior decentering when the arm is placed in the functional position of elevation in the plane of the scapula.

Whether the glenoid 'type' is a severe B1 or a mild B2 is not an important surgical consideration. It is of interest, however, that the humeral head is decentered posteriorly even though there is no glenoid retroversion. 

We find that we can obtain all the radiographic information we need for characterizing this shoulder and for preoperative planning without a CT scan and without patient specific instrumentation.

This shoulder was managed with a ream and run using an anteriorly eccentric humeral head component connected to a thin, smooth impaction grafted standard length humeral body.

 The postoperative axillary projection is essentially the same as the preoperative film shown above, enabling comparison. Note that the head is now centered in the reamed glenoid.

In comparing the preoperative and postoperative radiographs, note the conservative nature of the procedure with maximal preservation of the patient's native bone and without a glenoid component.

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The reader may also be interested in these posts:

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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