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

28. Immediate Post op

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

64. Access Instrumenation

73. M/52, Suspected Cuff Tear with OA

76. Reverse Shoulder

85. Thank You