Article

Patient-Specific Guides/Instrumentation in Shoulder Arthroplasty

Publish date: February 26, 2018

References

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GLENOSPHERE PLACEMENT

The most common indication for reverse TSA is rotator cuff arthropathy characterized by rotator cuff dysfunction and end-stage glenohumeral arthritis.¹² These patients require accurate and reproducible glenoid placement to optimize their postoperative range of motion and stability and minimize scapular notching.

Ideal glenosphere placement is the location and orientation that maximizes impingement-free ROM and stability while avoiding notching. Individual patient anatomy determines ideal placement; however, several guidelines for placement include inferior translation on the glenoid with neutral to inferior inclination. Gutiérrez and colleagues¹³ developed a computer model to assess the hierarchy of surgical factors affecting the ROM after a reverse TSA. They found that lateralizing the center of rotation gave the largest increase in impingement-free abduction, followed closely by inferior translation of the glenosphere on the glenoid.

Avoiding scapular notching is also a very important factor in ideal glenosphere placement. Scapular notching can be described as impingement of the humeral cup against the scapular neck during arm adduction and/or humeral rotation. Gutiérrez and colleagues¹³ also found that decreasing the neck shaft angle to create a more varus proximal humerus was the most important factor in increasing the impingement-free adduction. Roche and colleagues¹⁴ reviewed the radiographs of 151 patients who underwent primary reverse TSA at a mean follow-up of 28.3 months postoperatively; they found that 13.2% of their patients had a notch and that, on average, their patients who had no scapular notch had significantly more inferior glenosphere overhang than those who had a scapular notch. Poon and colleagues¹⁵ found that a glenosphere overhang of >3.5 mm prevented notching in their randomized control trial comparing concentrically and eccentrically placed glenospheres. Multiple other studies have demonstrated similar results and recommended inferior glenoid translation and inferior glenoid inclination to avoid scapular notching.^16,17 Lévigne and colleagues¹⁸ retrospectively reviewed 337 reverse TSAs and observed a correlation between scapular notching and radiolucencies around the glenosphere component, with 14% of patients with scapular notching displaying radiolucencies vs 4% of patients without scapula notching displaying radiolucencies.

Several studies have also focused on the ideal amount of inferior glenoid inclination to maximize impingement-free ROM. Li and colleagues¹⁷ performed a computer simulation study on the Comprehensive Reverse Shoulder System (Zimmer Biomet) to determine impingement-free internal and external ROM with varying amounts of glenosphere offset, translation, and inclination. They found that progressive glenosphere inferior inclination up to 30° improved impingement-free rotational ROM at all degrees of scaption. Gutiérrez and colleagues¹⁹ used computer modeling to compare concentrically placed glenospheres in neutral inclination with eccentrically placed glenospheres in varying degrees of inclination. They found that the lowest forces across the baseplate occurred in the lateralized and inferiorly inclined glenospheres, and the highest forces occurred in the lateralized and superiorly inclined glenospheres. Together, these studies show that inferior glenoid inclination increases impingement-free ROM and, combined with lateralization, may result in improved glenosphere longevity due to significantly decreased forces at the RSA glenoid baseplate when compared to that at superiorly inclined glenoids.

The ideal amount of mediolateral glenosphere offset has not been well defined. Grammont design systems place the center of rotation of the glenosphere medial to the glenoid baseplate together with valgus humeral component neck shaft angles of around 155°. These design elements are believed to decrease shear stresses through the glenoid baseplate to the glenoid interface and improve shoulder stability, but they are also associated with reduced impingement-free ROM and increased rates of scapular notching.¹³ This effect is accentuated in patients with preexisting glenoid bone loss and/or congenitally short scapular necks that further medialize the glenosphere. Medialization of the glenosphere may also shorten the remaining rotator cuff muscles and result in decreased implant stability and external rotation strength. Several implant systems have options to vary the amount of lateral offset. The correct amount of lateral offset for each patient requires the understanding that improving patients’ impingement-free ROM by increasing the amount of lateral offset comes at the price of increasing the shear forces experienced by the interface between the glenoid baseplate and the glenoid. As glenoid fixation technology improves increased lateralization of glenospheres without increased rates of glenoid baseplate, loosening should improve the ROM after reverse TSA.

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