How I Manage the Biconcave Glenoid in the 79-Year-Old Rancher: - - PowerPoint PPT Presentation

How I Manage the Biconcave Glenoid in the 79-Year-Old Rancher: Eccentric Reaming is Enough for Me: Keep it Simple

Eric T. Ricchetti, MD Ortho Summit 2017: Evolving Techniques Las Vegas, NV December 8, 2017

I have something to disclose.

Detailed disclosure information is available via: “My Academy” app; Printed Final Program; or AAOS Orthopaedic Disclosure Program on the AAOS website at http://www.aaos.org/disclosure

My Academy

• Correction of glenohumeral pathology:
• Glenoid version
• Glenoid joint line
• Balancing of the soft tissues: centering of

the humeral head

• Is this possible with moderate to severe

posterior glenoid bone loss (B2 glenoid)?

• Is there a clinical consequence to

incomplete correction?

Goals of Anatomic TSA

Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid

• Mild bone loss:
• Eccentric reaming
• Moderate to severe bone loss:
• Eccentric reaming
• Use of a posterior augment: bone

graft vs. augmented component

• Reverse TSA ± bone graft
• Achieve goals of anatomic

correction with eccentric reaming alone?

• Eccentric reaming: Limit of

15-20o correction of retroversion

• Cases that exceed this limit

(B2 glenoid):

• Full correction leads to

excessive bone removal, joint line medialization and/or peg perforation, narrowed glenoid

• Incomplete correction may

have negative consequences

Clavert et al, JSES 2007; Gillespie et al, Orthopedics 2009; Nowak et al, JSES 2009; Iannotti et al, JSES 2012; Walch et al, JSES 2012; Ho et al, JBJS 2013

Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid

Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid

• Glenoid version on 3-D CT in scapular plane: -24.9o

• Version correction: -24.9o to -7o
• 6 mm more joint line medialization with

standard vs. augmented glenoid (7 mm step)

Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid

Posterior Augmentation

• Posterior glenoid bone grafting:
• Technically demanding, variable graft

size & quality

• Mixed results in small case series:
• Variable outcome scores,

radiolucency rates

• Complications with graft preparation,

fixation, and incorporation

• Augmented glenoid components:
• Early clinical series show favorable

clinical & radiographic outcomes, but:

• Small cohorts, short-term follow-up
• Technically demanding, learning

curve for implant placement

Iannotti et al JSES 2013, Knowles et al, JSES 2015; Wright et al Bull Hosp Jt Dis 2015, Favorito JSES 2016, Stephens et al JBJS 2015; Stephens et al JSES 2016

Technically demanding, limited clinical data

• Version correction: -24.9o to -7o
• 6 mm more joint line medialization with

standard vs. augmented glenoid (7 mm step)

What is the Consequence of Incomplete Correction?

• Version correction: -24.9o to -15o
• 3.5 mm more joint line medialization with

standard vs. augmented glenoid (7 mm step)

What is the Consequence of Incomplete Correction?

• Ho et al, JBJS 2013: Significance of retroverted glenoid

component

• 66 TSA cases with press-fit center peg glenoid component
• Mean f/u: 3.8±1.8 yrs (range, 2-7)
• 20 cases (30%) with osteolysis of center peg
• ≥15o of component retroversion had a 5.23 odds ratio for developing

center peg osteolysis (p=0.019)

• No correlation to worse clinical outcome

What is the Consequence of Incomplete Correction?

• Service et al, CORR 2017: Significance of

retroverted glenoid component

• Conservative reaming to single concavity in all

cases without version correction

• Mean f/u: 2.5±0.6 yrs (range, 1.5-3)
• 71 TSA cases with press-fit center peg component:
• <15o component retroversion: 50 cases
• ≥15o component retroversion: 21 cases
• No differences between groups:
• Clinical outcome scores (SST), revision surgery
• Radiographic outcomes: center peg osteolysis,

radiolucency scores, HH centering

What is the Consequence of Incomplete Correction?

• Eccentric (high-side) reaming is a reliable
• ption in B2 glenoid:
• Simple, reproducible technique.
• Can apply to mild, moderate, or severe bone loss:
• Mild bone loss: Eccentric reaming to fully correct

retroversion

• Moderate to severe bone loss: Eccentric reaming to

partially correct retroversion

• Literature not show clear evidence of inferior

clinical outcomes with a retroverted glenoid component.

Conclusions

Keep it Simple