Glenoid in Total Shoulder Replacement
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The document provides a comprehensive overview of total shoulder and glenoid management, detailing anatomy, indications for surgery, and various surgical options such as hemiarthroplasty and total shoulder replacement. It discusses clinical studies comparing these methods, highlighting pain relief, range of motion, and revision rates associated with each approach. Additionally, the document covers glenoid anatomy, complications, and technical tips for surgical procedures, addressing common modes of shoulder replacement failure.
Glenoid in Total Shoulder Replacement
- 1. Comprehensive Total Shoulder & Glenoid Management Bijayendra SinghBijayendra Singh Consultant Trauma & Upper Limb SurgeonConsultant Trauma & Upper Limb Surgeon Medway Foundation NHS TrustMedway Foundation NHS Trust Honorary Senior Clinical Lecturer Canterbury Christ Church UniversityHonorary Senior Clinical Lecturer Canterbury Christ Church University
- 2. • Anatomy • Indications • Options • Humerus / Glenoid • Approach • Why important? • Literature • Management of Deficiencies • Tips & Tricks
- 3. Anatomy
- 7. Indications • Osteoarthritis • Trauma Sequelae • Chronic Locked Dislocations • Acute Fractures??
- 8. Options • Hemiarthroplasty without glenoid resurfacing • Hemiarthroplasty with concentric reaming • Anatomic Shoulder Replacement • Asymmetric Reaming • Bone Grafting • Specialised Implants • Reverse Shoulder Replacement
- 11. Hemi or Total
- 12. Total Shoulder Replacement compared with humeral head replacement for treatment of primary glenohumeral osteoarthritis: A systematic Review Radnay CS, et al: J Shoulder Elbow Surg. 2007 Jul-Aug;16(4):396-402 •Clinical studies published between 1966 and 2004 that reported on shoulder replacement for primary glenohumeral osteoarthritis •23 studies, with a total of 1952 patients and mean follow-up of 43.4 months (range, 30-116.4 months). •Compared to Hemi; TSR had greater •pain relief (P < .0001) •forward elevation (P < .0001) •gain in forward elevation (P < .0001) •gain in external rotation (P = .0002) •patient satisfaction (P < .0001) •6.5% vs 10.2% revision rate (TSR vs Hemi) •1.7% revision for polyethylene wear
- 13. Total shoulder arthroplasty versus hemiarthroplasty for glenohumeral arthritis: A systematic review of the literature at long-term follow-up Bekerom et al: Int J Shoulder Surg. 2013 Jul-Sep; 7(3): 110–115. • Hemi vs TSR since 1990, minimum 7 yrs follow up • 18 studies, 1958 patients, 2111 shoulders (all level 4) • 328 hemi, 1783 TSR • Revision rate 7% in TSR, 13% in Hemi (p< 0.001) • Any complication: 12% TSR, 8% Hemi (p = 0.065) • Greater increase in range of movements • Greater improvement in pain (5.5 vs 4.2)
- 14. Complications Bohsali KI, et al: Complications of total shoulder arthroplasty. J Bone Joint Surg Am 88:2279-2292, 2006 •33 studies minimum 2 yr follow up (mean 5.3 yrs) • Glenoid Loosening - 39% • Superior Instability - 19% • Periprosthetic Fracture - 11% • Rotator Cuff Tear - 7.7% • Humeral Loosening - 6.5% • Other Instability, Nerve Injury & Infection - 10%
- 15. •Long Term •Less Revision Rates with TSA • Early Results • Function & Pain Relief better with TSA
- 16. Approach •Beach Chair / Deck Chair • Reclined about 40 / 45 degrees • Shoulder pulled away from table • Make sure imaging can be performed before draping
- 18. Delto - Pectoral
- 19. Tips • Identify the cephalic vein •Retraction • Use soft retractors • Identify Pectoralis Major •Release • Partial release anterior Deltoid Insertion
- 20. Humeral Component • Adequte Exposure • Release upper 1/3 of the pectoralis • Release of capsule / anterior capsulectomy • Excision of Osteophytes • Gentle Adduction & Extension • Release of upper Lat Dorsi
- 24. Gentle Adduction & Extension Release of upper Lat Dorsi
- 29. 3 years post op
- 30. Why Do Shoulder Replacement Fail • Rotator Cuff Failure • Glenoid Failure • Others • Dislocation / Disassociation • Fractures • Infection • Miscell
- 31. Glenoid • Weak Link? • Most common mode of failure • Component fail to replicate the function of normal shoulder • Surgical Error?
- 32. Glenoid Anatomy
- 33. Anatomy Height, Width, Inclination & Version
- 34. Glenoid Height • Defined as the distance from the most superior and inferior points on the glenoid. • Mean Height: 35 - 39 mm • Checroun et al: 412 cadaveric scapulae • Mean height: 37.9 mm (31.2 - 50.1) • Iannotti et al: 70 shoulders, avg age 75 • Mean Height: 39 mm (30 - 48)
- 35. • Churchil et al: 344 cadaveric scapulae • Male: 37.5 mm (30.4 - 42.6) • Female: 32.6 mm (29.4 - 37) • Mallon et al: 28 cadaver • Male: 38 mm (33 - 45) • Female: 36.2 mm (32 - 43) Churchill et al: No difference in glenoid height between specimens from white and black patients
- 36. Glenoid Width • Distance from the most anterior and posterior points on the glenoid • Common shape is ‘PEAR’ but can be oval or elliptical • Checroun et al: 412 cadavers • 71% had pear shaped, rest elliptical • Upper Width & Lower Width
- 37. • Iannotti et al: • Mean Upper Width: 23 mm (18 - 30) • Mean Lower Width: 29 mm (21 - 35) • Kwon et al: 26.8 mm (22 - 35) • Mean articular surface area: • Males: 5.79 cm2 • Females: 4.68 cm2
- 38. Churchill et al: No difference in glenoid height between specimens from white and black patients • Churchill et al: • Males: 27.8 mm (24.3 - 32.5) • Females: 23.6 mm (19.7 - 26.3) • Mallon et al: • Males: 28.3 mm (24 - 32) • Females: 23.6 mm (17 - 27)
- 39. Glenoid Inclination • The slope of the glenoid articular surface along the superior - inferior axis • Wide variation • Superior Inclination: • Males: Avg 4o ( 7o to -15.8o ) • Females: Avg 4.5o (1.5o to -15.3o )
- 40. Glenoid Version • Is the angular orientation of the axis of the glenoid articular surface relative to the long (transverse) axis of the scapula • Average 2 - 9 degrees retroversion • Churchill et al: • Mean retroversion: 1.2 (9.5 anteversion - 10.5 retroversion) • Men slightly more retroverted than women
- 41. Measuring Glenoid Version • Conventional Radiographs vs CT scan • Nyffeler et al: • 50 patients, 25 each for instability & OA • CT measured 3o retroversion ( 7o - 16o ) • Plain radiograph - over estimated in 86% cases • Mean difference: 6.5o (0o to - 21o )
- 42. Glenoid Pathology • Frequently associated with Glenoid wear • OA: Posterior glenoid wear • Inflammatory arthritis: Central glenoid erosion & cysts • Anterior wear.
- 43. Glenoid Design • Dilemma • All Poly vs Metal Back • Pegged vs Keeled • Flat vs Curved Back • Thickness of Cement
- 44. •Boileau et al: • 39 patients, prospective study • Function better in cemented - but not clinically significant • Radiographic lucent lines •25% vs 85% uncemented vs cemented • Revision Surgery 1% vs 20%
- 45. •Wallace et al: • 32 cemented vs 26 uncemented • 5 yr follow up • No significant clinical difference • 5 revisions in uncemented vs 3, but not for loosening
- 46. •Martin et al: • 140 uncemented glenoid • 7.5 year follow up • 16 (11.4%) failed clinically • 38% radiolucent lines • 16 had broken screws • 10 yr predicted survival = 85% • Factors • Male Gender, • Post op pain • Presence of radiolucent lines
- 47. •Taunton et al: •83 TSA with metal back uncemented glenoid •40% radiographic loosening •25% siginficant polyethylene wear •5 yr survival = 87% •10 yr survival = 78.5%
- 48. Pegged vs Keeled Cemented • Lazarus et al: • 328 patients, 39 keeled, 289 pegged • Pegged glenoid - significantly better seating & fewer radiolucencies • Gartsman et al: • 29% keeled & 5% pegged glenoids had radio lucent lines at 6 weeks • Nuttall et al: • RSA study on 20 shoulders • Increased translation & rotation in keeled vs pegged
- 49. Flat vs Curved Back Cemented •Szabo et al: • 66 TSA in 63 patients • 65% vs 26% perfect seated glenoid in curved back • Radiolucency scores were worse in flat back
- 50. Flat vs Curved Back Cemented • Anglin et al: • Curved back glenoids are associated with nearly 50% less distraction than flat back • Iannotti et al: • Finite Element Analysis in 0o & 20o retroversion • Peak strains greater in flat back than curved back
- 51. • Radial Mismatch • Difference in the curvature • Increased conformity = Increased constraints = ? Less Shear • Less Conformity = Larger translation but low surface area • No consensus • Size of prosthesis
- 52. Terrier et al: JSES, 2006 Influence of glenohumeral conformity on glenoid stresses after total shoulder arthroplasty
- 53. Cement Fixation •Terrier et al: • FEA to assess stress in the bone & cement • 0.5, 1.0, 1.5 mm & 2.0 mm • 1 mm cement mantle thickness is ideal
- 54. Cement Fixation •Nyffeler et al: • Axial pull out test to assess cement thickness • 0.1 mm - 0.6 mm • Threaded pegs better than notched pegs • Roughened back glenoids better than smooth
- 55. Glenoid Loosening • 0% - 96% • Normal excursion • Mechanism: • Repetitive Eccentric Loading = Rocking Horse
- 56. Assessment of Glenoid Wear • Plain Radiographs - often suboptimal - axillary view • Axial CT with 3D reconstruct • Scalise et al: • Mean glenoid retroversion: 17o +/- 2.2o • Posterior bone loss: 9 +/- 2.3 mm
- 57. Walch et al: A Morphologic study of the glenoid in primary glenohumeral osteoarthritis J Arthroplasty; 1999; 14; 756 - 60 • A: Central Erosion, Head Central
- 58. • B: Posterior Marginal Glenoid Wear • Posterior Glenoid Retroversion / Dysplasia
- 59. Technical Tips • Challenging • Paralysing anaesthesia • Adequate Humeral Cut • Appropriate soft tissue releases • Arm & Retractor Positioning • Posterior, Anterior, Superior & Inferior
- 61. • Remove all labrum circumferentially • Size & Mark glenoid • Mark centre of glenoid • Guide Wire • Serial Reaming
- 63. What Do I need from instrumentation? • Simple • Follows a sensible path • Access is easier • Ergonomic
- 73. M/52, Suspected Cuff Tear with OA
- 76. Reverse Shoulder
- 85. Thank You