Article

Patient-Specific Guides/Instrumentation in Shoulder Arthroplasty

Publish date: February 26, 2018

References

1. Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg. 2001;10(4):327-332. doi:10.1067/mse.2001.115269.

2. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002;11(2):130-135. doi:10.1067/mse.2002.121146.

3. Mullaji AB, Beddow FH, Lamb GH. CT measurement of glenoid erosion in arthritis. J Bone Joint Surg Br. 1994;76(3):384-388.

4. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999;14(6):756-760.

5. RJ Friedman, KB Hawthorne, BM Genez. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg. 1992;74(7):1032-1037. doi:10.2106/00004623-199274070-00009.

6. Yian EH, Werner CM, Nyffeler RW, et al. Radiographic and computed tomography analysis of cemented pegged polyethylene glenoid components in total shoulder replacement. J Bone Joint Surg. 2005;87(9):1928-1936. doi:10.2106/00004623-200509000-00004.

7. Hasan SS, Leith JM, Campbell B, Kapil R, Smith KL, Matsen FA. Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg. 2002;11(5):431-441.

8. Hopkins AR, Hansen UN, Amis AA, Emery R. The effects of glenoid component alignment variations on cement mantle stresses in total shoulder arthroplasty. J Shoulder Elbow Surg. 2004;13(6):668-675. doi:10.1016/S1058274604001399.

9. Iannotti JP, Greeson C, Downing D, Sabesan V, Bryan JA. Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty. J Shoulder Elbow Surg. 2012;21(1):48-55. doi:10.1016/j.jse.2011.02.011.

10. Nyffeler RW, Jost B, Pfirrmann CWA, Gerber C. Measurement of glenoid version: conventional radiographs versus computed tomography scans. J Shoulder Elbow Surg. 2003;12(5):493-496. doi:10.1016/S1058274603001812.

11. Hoenecke HR, Hermida JC, Flores-Hernandez C, D'Lima DD. Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(2):166-171. doi:10.1016/j.jse.2009.08.009.

12. Wall B, Nové-Josserand L, O'Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485. doi:10.2106/JBJS.F.00666.

13. Gutiérrez S, Comiskey 4, Charles A, Luo Z, Pupello DR, Frankle MA. Range of impingement-free abduction and adduction deficit after reverse shoulder arthroplasty. hierarchy of surgical and implant-design-related factors. J Bone Joint Surg Am. 2008;90(12):2606-2615. doi:10.2106/JBJS.H.00012.

14. Roche CP, Marczuk Y, Wright TW, et al. Scapular notching and osteophyte formation after reverse shoulder replacement: Radiological analysis of implant position in male and female patients. Bone Joint J. 2013;95-B(4):530-535. doi:10.1302/0301-620X.95B4.30442.

15. Poon PC, Chou J, Young SW, Astley T. A comparison of concentric and eccentric glenospheres in reverse shoulder arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(16):e138. doi:10.2106/JBJS.M.00941.

16. Nyffeler RW, Werner CML, Gerber C. Biomechanical relevance of glenoid component positioning in the reverse delta III total shoulder prosthesis. J Shoulder Elbow Surg. 2005;14(5):524-528. doi:10.1016/j.jse.2004.09.010.

17. Li X, Knutson Z, Choi D, et al. Effects of glenosphere positioning on impingement-free internal and external rotation after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(6):807-813. doi:10.1016/j.jse.2012.07.013.

18. Lévigne C, Boileau P, Favard L, et al. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17(6):925-935. doi:10.1016/j.jse.2008.02.010.

19. Gutiérrez S, Walker M, Willis M, Pupello DR, Frankle MA. Effects of tilt and glenosphere eccentricity on baseplate/bone interface forces in a computational model, validated by a mechanical model, of reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2011;20(5):732-739. doi:10.1016/j.jse.2010.10.035.

20. Verborgt O, De Smedt T, Vanhees M, Clockaerts S, Parizel PM, Van Glabbeek F. Accuracy of placement of the glenoid component in reversed shoulder arthroplasty with and without navigation. J Shoulder Elbow Surg. 2011;20(1):21-26. doi:10.1016/j.jse.2010.07.014.

21. Throckmorton TW, Gulotta LV, Bonnarens FO, et al. Patient-specific targeting guides compared with traditional instrumentation for glenoid component placement in shoulder arthroplasty: A multi-surgeon study in 70 arthritic cadaver specimens. J Shoulder Elbow Surg. 2015;24(6):965-971. doi:10.1016/j.jse.2014.10.013.

22. Kircher J, Wiedemann M, Magosch P, Lichtenberg S, Habermeyer P. Improved accuracy of glenoid positioning in total shoulder arthroplasty with intraoperative navigation: a prospective-randomized clinical study. J Shoulder Elbow Surg. 2009;18(4):515-520. doi:10.1016/j.jse.2009.03.014.

23. Levy JC, Everding NG, Frankle MA, Keppler LJ. Accuracy of patient-specific guided glenoid baseplate positioning for reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(10):1563-1567. doi:10.1016/j.jse.2014.01.051.

24. Walch G, Vezeridis PS, Boileau P, Deransart P, Chaoui J. Three-dimensional planning and use of patient-specific guides improve glenoid component position: an in vitro study. J Shoulder Elbow Surg. 2015;24(2):302-309. doi:10.1016/j.jse.2014.05.029.

25. Eraly K, Stoffelen D, Vander Sloten J, Jonkers I, Debeer P. A patient-specific guide for optimizing custom-made glenoid implantation in cases of severe glenoid defects: an in vitro study. J Shoulder Elbow Surg. 2016;25(5):837-845. doi:10.1016/j.jse.2015.09.034.

26. Gauci MO, Boileau P, Baba M, Chaoui J, Walch G. Patient-specific glenoid guides provide accuracy and reproducibility in total shoulder arthroplasty. Bone Joint J. 2016;98-B(8):1080-1085. doi:10.1302/0301-620X.98B8.37257.

27. Dallalana RJ, McMahon RA, East B, Geraghty L. Accuracy of patient-specific instrumentation in anatomic and reverse total shoulder arthroplasty. Int J Shoulder Surg. 2016;10(2):59-66. doi:10.4103/09736042.180717.

28. Hendel MD, Bryan JA, Barsoum WK, et al. Comparison of patient-specific instruments with standard surgical instruments in determining glenoid component position: a randomized prospective clinical trial. J Bone Joint Surg. 2012;94(23):2167-2175. doi:10.2106/JBJS.K.01209.

29. Iannotti JP, Weiner S, Rodriguez E, et al. Three-dimensional imaging and templating improve glenoid implant positioning. J Bone Joint Surg. 2015;97(8):651-658. doi:10.2106/JBJS.N.00493.

30. Denard PJ, Provencher MT, Lädermann A, Romeo AA, Dines JS. Version and inclination obtained with 3D planning in total shoulder arthroplasty: do different programs produce the same results? SECEC-ESSSE Congress, Berlin 2017. 2017.

The ideal placement of the glenoid to maximize function, ROM, and implant longevity is in a mechanically neutral alignment with no superoinferior inclination¹ and neutral version with respect to the transverse axis of the scapula.⁵

Improper glenoid positioning has an adverse effect on the functional results of shoulder arthroplasty. Yian and colleagues⁶ evaluated 47 cemented, pegged glenoids using standard radiography and CT scans at a mean follow-up of 40 months. They observed a significant correlation between increased glenoid component retroversion and lower Constant scores. Hasan and colleagues⁷ evaluated 139 consecutive patients who were dissatisfied with the result of their primary arthroplasty and found that 28% of them had at least 1 substantially malpositioned component identified either on radiography or during a revision surgery. They also found a significant correlation between stiffness, instability, and component malposition in their cohort.

Glenoid longevity is also dependent on proper component positioning, with the worst outcomes coming if the glenoid is malaligned with either superior or inferior inclination. Hasan and colleagues⁷ found that of their 74 patients with failed TSAs, 44 patients (59%) demonstrated mechanical loosening of their glenoid components either radiographically or during revision surgery, and 10 of their 44 patients with loose glenoids (23%) also had a malpositioned component. Using finite element analysis, Hopkins and colleagues⁸ analyzed the stresses through the cement mantle in glenoid prostheses that were centrally aligned, superiorly inclined, inferiorly inclined, anteverted, and retroverted. They found that malalignment of the glenoid increases the stresses through the cement mantle, leading to increased likelihood of mantle failure compared to that of centrally aligned glenoids, especially if there is malalignment with superior or inferior inclination or retroversion.

The accuracy of traditional methods of glenoid placement using an initial guide pin is limited and decreases with increasing amounts of glenoid deformity and retroversion. Iannotti and colleagues⁹ investigated 13 patients undergoing TSA with an average preoperative retroversion of 13° and evaluated them using a 3-dimensional (3-D) surgical simulator. They found that the postoperative glenoid version was within 5° of ideal version in only 7 of their 13 patients (54%) and within 10° of ideal version in only 10 of their 13 patients (77%). In their study, the ideal version was considered to be the version as close to perpendicular to the plane of the scapula as possible with complete contact of the back side of the component on glenoid bone and maintenance of the center peg of the component within bone. In addition, they found that of their 7 patients with preoperative retroversion >10°, only 1 patient (14%) had a postoperative glenoid with <10° of retroversion with regard to the plane of the scapula and that all 6 of their patients with preoperative glenoid retroversion of <10° had a postoperative glenoid version of <10°.

Preoperative CT scans are much more accurate at determining glenoid version and thus how much glenoid correction is required to reestablish neutral version than plain radiography. Nyffeler and colleagues¹⁰ compared CT scans with axillary views for comparing glenoid version in 25 patients with no shoulder prosthesis present and 25 patients with a TSA in place. They found that glenoid retroversion was overestimated on plain radiographs in 86% of their patients with an average difference between CT and plain radiography of 6.4° and a maximum difference of 21°. They also found poor interobserver reliability in the plain radiography group and good interobserver reliability in the CT group, with coefficients of correlation of 0.77 for the plain radiography group and 0.93 for the CT group. Thus, they concluded that glenoid version cannot be accurately measured by plain radiography and that CT should be used. Hoenecke and colleagues¹¹ subsequently evaluated 33 patients scheduled for TSA and found that CT version measurements made on 2-dimensional (2-D) CT slices compared with 3-D-reconstructed models of the same CT slices differed by an average of 5.1° because the axial CT slices were most often made perpendicular to the axis of the patient’s torso and not perpendicular to the body of the scapula. Accurate version assessment is critically important in planning for the degree of correction required to restore neutral glenoid version, and differences of 6.4° between CT assessment and plain radiography, and 5.1° between 2-D and 3-D CT scan assessments may lead to inadequate version correction intraoperatively and inferior postoperative results.

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