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
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Goals of Anatomic TSA • 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?
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?
Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid • Eccentric reaming: Limit of 15-20 o 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 • Glenoid version on 3-D CT in scapular plane: -24.9 o
Options for Correction of Posterior Glenoid Bone Loss in B2 Glenoid • Version correction: -24.9 o to -7 o • 6 mm more joint line medialization with standard vs. augmented glenoid (7 mm step)
Posterior Augmentation • Posterior glenoid bone grafting: - Technically demanding, variable graft size & quality - Mixed results in small case series: • Variable outcome scores, radiolucency rates Technically • Complications with graft preparation, fixation, and incorporation demanding, limited • Augmented glenoid components: clinical data - 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
What is the Consequence of Incomplete Correction? • Version correction: -24.9 o to -7 o • 6 mm more joint line medialization with standard vs. augmented glenoid (7 mm step)
What is the Consequence of Incomplete Correction? • Version correction: -24.9 o to -15 o • 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 ≥15 o 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: • <15 o component retroversion: 50 cases • ≥ 15 o component retroversion: 21 cases - No differences between groups: • Clinical outcome scores (SST), revision surgery • Radiographic outcomes: center peg osteolysis, radiolucency scores, HH centering
Conclusions • Eccentric (high-side) reaming is a reliable option 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 Keep it Simple partially correct retroversion • Literature not show clear evidence of inferior clinical outcomes with a retroverted glenoid component.
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