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BACKGROUND The importance of anatomic reconstruction of the proximal humerus on shoulder biomechanics and kinematics after anatomic total shoulder replacement (aTSR) has been highlighted by a number of investigations. The humeral head designs of current-generation shoulder arthroplasty emphasize either anatomic or soft-tissue balancing total shoulder arthroplasty (sbTSR) philosophies. The purpose of this study was to compare the postoperative anatomy of TSR systems used to treat primary glenohumeral osteoarthritis. METHODS This was a matched cohort study of 60 patients treated with either press-fit aTSR or sbTSR by two shoulder surgeons. The analysis of postoperative true AP radiographs was performed to calculate multiple representative anatomic parameters of the TSR. RESULTS A significant difference was observed in the average measurements between the sbTSR and aTSR designs about the humeral head center offset (5.2 ± 0.4 mm versus 3.9 ± 0.3 mm; P = 0.02), implant-humeral shaft angle (0.3 ± 0.3 varus versus 1.7 ± 0.3 valgus, P < 0.001), and humeral head to tuberosity height (8.8 ± 0.4 mm versus 6.2 ± 0.4, P < 0.001), respectively. No significant difference was observed in the average measurements between the two systems' designs regarding the head-shaft angle (133.4° ± 0.8° versus 135.0° ± 1.0°, P = 0.16) and the relation of humeral head to lateral humeral cortex (0.15 ± 0.6 mm inside the lateral cortex versus 0.19 ± 0.6 outside the lateral cortex; P = 0.69), respectively. CONCLUSIONS Despite differing design philosophies of these systems, and some notable differences, the absolute differences between the measured anatomic parameters were small and not likely clinically relevant. Anatomic and soft-tissue balancing humeral arthroplasty implants can both reliably reconstruct proximal humeral anatomy.

Health-related quality-of-life (HRQoL) scores are required for cost-effectiveness and health-care value analysis. We evaluated HRQoL scores and patient-reported outcome measures (PROMs) in patients with advanced glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty to establish values of HRQoL scores that can be used for cost-effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs.We analyzed 145 patients (145 shoulders) with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty; 93 patients had 1-year follow-up. Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). HRQoL score validity was determined through correlations between the PROMs and HRQoL scores. The responsiveness of HRQoL scores was measured through the effect size and the standardized response mean.There were significant improvements in all PROMs and HRQoL scores (p0.001) at 1 year after the surgical procedure. The changes in VAS QoL and EQ-5D were significantly correlated (weak to moderate) with the changes in all PROMs except the SST, demonstrating comparably acceptable validity. The VAS QoL had a large effect size (1.833) and standardized response mean (1.603), and the EQ-5D also had a large effect size (1.163) and standardized response mean (1.228), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores. The change in SF-6D had only a moderate effect size and standardized response mean and was not significantly correlated with the change in any of the PROMs.PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. The findings of this study provide data on HRQoL scores that are specific to the treatment of advanced glenohumeral osteoarthritis with anatomic total shoulder replacement and can be used for future cost-effectiveness and value analysis studies.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Fatty infiltration of the rotator cuff evaluated with CT has been associated with asymmetric glenoid wear and humeral head subluxation in patients with glenohumeral arthritis. The relationship between rotator cuff pathologic findings and abnormal glenoid wear plays an important role in determining the optimal surgical management of advanced glenohumeral osteoarthritis. Compared with CT, MRI has increased sensitivity for identifying rotator cuff conditions; therefore, prior studies using CT may have underestimated the association between fatty infiltration of the rotator cuff and abnormal glenoid wear. QUESTIONS/PURPOSES: (1) Compared with Type A glenoids, which muscles in which Walch subtypes have a greater degree of fatty infiltration using Goutallier scores? (2) What glenoid type is associated with greater imbalance in fatty infiltration, as measured by comparing Goutallier scores between the posterior and anterior rotator cuff muscles? (3) What is the correlation between glenoid version and fatty infiltration of the rotator cuff muscles? (4) Comparing Type B2 and B3 glenoids with Type A glenoids, after accounting for age and sex, is there an increase in fatty infiltration of the infraspinatus muscle? METHODS: A total of 129 shoulders from 129 patients undergoing anatomic total shoulder arthroplasty to treat primary glenohumeral osteoarthritis were retrospectively reviewed. Patients had an average age of 66.4 ± 9.3 years and an average BMI of 30.6 ± 6.7 kg/m(2), and 53% (69 of 129) were men. All patients underwent MRI within 12 months before total shoulder arthroplasty to assess glenoid morphology and rotator cuff pathologic findings. Three reviewers assessed the images, and glenoid morphology was assigned using the modified Walch classification system (Types A1, A2, B1, B2, B3, C, and D). Fatty infiltration of the rotator cuff was classified using Goutallier scores. The examiners demonstrated moderate-to-good reliability using these classification systems; the Walch classification system had interrater reliability kappa coefficients (κ) from 0.54 to 0.69 and intrarater reliability κ from 0.60 to 0.64. Goutallier scores using the simplified classification system had interrater reliability κ from 0.64 to 0.68 and intrarater reliability κ from 0.64 to 0.79. Thirty-six percent (46 of 129) of the shoulders had posterior wear patterns (18% [23] were Type B2 glenoids; 18% [23] were Type B3 glenoids). The average Goutallier scores for each rotator cuff muscle were determined, and the amount of fatty infiltration was compared between the various Walch subtypes using independent t-tests. Axial-plane imbalance in fatty infiltration of the rotator cuff was assessed by determining the difference in the average fatty infiltration of the posterior rotator cuff muscles (infraspinatus and teres minor) and anterior rotator cuff muscles (subscapularis) and comparing the differences among the Walch subtypes using independent t-tests. The association between glenoid version and fatty infiltration was assessed using Pearson correlations. Finally, a multivariate logistic regression model was used to assess fatty infiltration of the rotator cuff among the various Walch subtypes while accounting for patient age and sex. RESULTS: Compared with Type A1 glenoids, Type B2 and B3 glenoids had an increased amount of fatty infiltration of the infraspinatus (1.6 ± 0.7 versus 0.7 ± 0.4; mean difference 0.9 [95% CI 0.7-1.2]; p < 0.001 and 1.8 ± 0.4 versus 0.7 ± 0.4; mean difference 1.1 [95% CI 0.9-1.4]; p < 0.001, respectively) and teres minor (1.3 ± 0.7 versus 0.6 ± 0.5; mean difference 0.7 [95% CI 0.4-1.0]; p < 0.001 and 1.6 ± 0.6 versus 0.6 ± 0.5; mean difference 1.0 [95% CI 0.7-1.2]; p < 0.001, respectively). There was greater imbalance in fatty infiltration between the posterior and anterior rotator cuff muscles for Type B2 (0.5 ± 0.3) and B3 (0.6 ± 0.5) glenoids than for Type A1 (0.1 ± 0.3) and A2 (0.1 ± 0.6) glenoids (p < 0.001). Only the infraspinatus’s fatty infiltration was strongly correlated with glenoid version (r = 0.64; p < 0.001), while fatty infiltration of the other muscles only correlated weakly or moderately. After accounting for age and sex, fatty infiltration in the infraspinatus was associated with Type B2 (OR 66.1 [95% CI 7.6-577.9]; p < 0.001) and Type B3 glenoids (OR 59.5 [95% CI 5.4-661.3]; p < 0.001) compared with Type A glenoids. CONCLUSION: Compared with concentric wear, posteriorly worn glenoids had an imbalance in axial-plane rotator cuff fatty infiltration and an increased amount of fatty infiltration of the infraspinatus and teres minor compared with the subscapularis. These imbalances may contribute to the higher rates of failure after anatomic total shoulder arthroplasty in patients with posterior wear compared with those with concentric wear. Future research should be directed toward investigating the temporal relationship of these findings, as well as understanding the clinical outcomes for patients undergoing anatomic total shoulder arthroplasty who have posteriorly worn glenoids with a high degree of fatty infiltration of the posterior rotator cuff musculature. CLINICAL RELEVANCE: Providers should consider the increased likelihood of higher-grade fatty infiltration of the posterior rotator cuff in the setting of posteriorly worn glenoids, particularly when treating patients without using MRI. These patients have higher rates of failure postoperatively and may benefit from closer monitoring and altered postoperative rehabilitation protocols that target the posterior rotator cuff.

Total shoulder arthroplasty (TSA) and reverse TSA have provided an effective treatment for glenohumeral osteoarthritis; however, longevity of the procedure may be limited by osteolysis and polyethylene wear. In TSA, glenoid component failure occurs through several mechanisms, the most common being aseptic loosening and polyethylene wear. Newer bearing surfaces such as highly cross-linked ultra-high-molecular-weight polyethylene, vitamin E processing, ceramic heads, and pyrolytic carbon surfaces have shown improved wear characteristics in biomechanical and some early clinical studies. The purpose of this review is to provide a historical perspective and current state of the art of bearing surface technology in anatomic and reverse TSA.

CASE A 41-year-old, former world-champion, mixed martial arts fighter presented with debilitating pain and loss of motion because of severe glenohumeral osteoarthritis (GHOA) in the setting of a previous shoulder instability stabilization procedure. Multiple conservative treatments failed to provide permanent relief, and he elected to undergo a comprehensive arthroscopic management (CAM) procedure for his GHOA. CONCLUSION At 2-year follow-up, the CAM procedure was effective in returning them to fighting at a professional level. The CAM procedure can be considered in young and highly active patients to restore function, preserve anatomy, and delay progression to prosthetic arthroplasty.

» The glenohumeral (GH) joint ranks third on the list of the large joints that are most commonly affected by osteoarthritis, after the knee and the hip. » General nonsurgical modalities, including changes in daily activities, physical therapy, pharmacotherapy, and corticosteroid injections, constitute the mainstay of treatment. Most of these options, however, have shown moderate and short-term effectiveness. » Arthroplasty techniques have proven to be successful for elderly patients. Nevertheless, replacement options are not optimal for younger patients because their functional demands are higher and prostheses have a finite life span. » This has led to the search for new nonoperative treatment options to target this subgroup of patients. It has been suggested that orthobiologic therapies, including platelet-rich plasma (PRP) and cell therapies, present great promise and opportunity for the treatment of GH osteoarthritis. » Despite the promising results that have been shown by cell therapies and PRP for treating degenerative joint conditions, additional studies are needed to provide more definitive conclusions.

OSTEOARTHRITIS CAN LEAD TO MOVEMENT LIMITATIONS, WHICH ARE A BARRIER FOR STRENGTH TRAINING. IN SOME INSTANCES WHERE IMPROVED STRENGTH IS KNOWN TO DECREASE SYMPTOMS AND IMPROVE PATIENT REPORTED FUNCTION, THERE EXISTS A DIFFICULTY IN DEVELOPING TRAINING ROUTINES THAT ADDRESS THE WEAKNESS WITHOUT SYMPTOM AGGRAVATION. THIS ARTICLE AIMS TO DESCRIBE A TECHNIQUE TO DECREASE PAIN AND IMPROVE JOINT MOTION WHILE STRENGTHENING THE ROTATOR CUFF IN INDIVIDUALS WITH OSTEOARTHRITIS OF THE GLENOHUMERAL JOINT. A DESCRIPTION OF THE EXERCISE IS PROVIDED USING MANUAL DISTRACTION TO REDUCE COMPRESSIVE AND SHEAR FORCES WHILE ALLOWING FOR PAIN-FREE PERFORMANCE AND STRENGTHENING OF THE ROTATOR CUFF.

In this review, we describe the history of the Critical Shoulder Angle (CSA), the utility of the CSA in identifying rotator cuff tears and glenohumeral osteoarthritis, and the association between the CSA and patient-reported outcomes. Additionally, we address some of the controversies surrounding th

This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

Restoration of native, premorbid glenoid anatomy may be a goal in component placement during total shoulder arthroplasty. However, if patients with unilateral glenohumeral osteoarthritis are predisposed to the development of arthritis owing to abnormal native glenoid anatomy, this recommendation may be inappropriate.The purpose of this study was to determine if patients with glenohumeral osteoarthritis have abnormal premorbid glenoid version or inclination, thereby predisposing them to subsequent glenoid disorders. We specifically tested whether: (1) premorbid glenoid version or inclination in the pathologic shoulder of patients with unilateral osteoarthritis, as determined by the glenoid vault model, is different from glenoid version or inclination in the contralateral nonpathologic shoulder of these patients; (2) there are differences between glenoid version or inclination in normal cadaver shoulders and the nonpathologic side of patients with unilateral osteoarthritis; and (3) there are differences between glenoid version or inclination in normal cadaver shoulders and the premorbid glenoid version and inclination in the pathologic shoulder of patients with unilateral osteoarthritis, as determined by the glenoid vault model.Bilateral CT scans were obtained in 27 patients with unilateral glenohumeral osteoarthritis. Thirty normal cadaver control shoulders also underwent CT scans. Premorbid glenoid version and inclination in the pathologic shoulder, as measured by the glenoid vault model, were compared with the contralateral nonpathologic shoulder and the normal cadaver control shoulders. Glenoid version and inclination of the normal shoulders were compared with the nonpathologic side from patients with unilateral osteoarthritis. Measurements were made by two different methods using three-dimensional surgical simulation software: (1) a direct measurement technique and (2) measurements derived from placement of a glenoid vault model. Mean differences in these parameters were compared between shoulder groups using paired and unpaired Student's t-tests.Premorbid glenoid version and inclination in the pathologic shoulder as measured by the vault model averaged -7° (SD, 5) and 10° (SD, 6), respectively, compared with -7° (SD, 5) and 12° (SD, 6) as directly measured on the nonpathologic side, and -7° (SD, 4) and 12° (SD, 5) as directly measured in the normal cadaver control shoulders. There were no differences in glenoid version or inclination between the normal shoulders and the nonpathologic side of patients with unilateral osteoarthritis or between these shoulders and the premorbid version and inclination of the arthritic shoulder as measured by the vault model.Patients with glenohumeral osteoarthritis do not appear to have abnormal premorbid glenoid retroversion or inclination. The glenoid vault model can be used to determine premorbid glenoid version and inclination.The glenoid vault model may be a clinically useful tool to estimate patient-specific premorbid glenoid anatomy, which may help in preoperative or intraoperative surgical planning for total shoulder arthroplasty.

Background: Chronic locked shoulder dislocations account for 2% to 5% of all shoulder dislocations. There is little information regarding the mid-term to long-term results of anatomic shoulder arthroplasty for treatment of this problem. Methods: Thirty-two shoulder arthroplasties were performed in thirty-two patients who had chronic locked posterior dislocation of the shoulder. Eighteen patients were treated with a hemiarthroplasty and fourteen, with a total shoulder arthroplasty. Inclusion criteria included moderate or severe pain and functional limitations. Structural indications included an impression fracture involving ≥45% of the humeral head, fibrosis of the articular cartilage, and/or severe osteopenia of the humeral head. When one-third or more of the glenoid was devoid of articular cartilage, a glenoid component was placed. All patients were followed for a minimum of two years (mean, 8.2 years) or until a reoperation. Results: The operations led to pain relief, with the median pain score decreasing from 4 (on a 5-point scale) preoperatively to 3 postoperatively (p < 0.01), and improvement in shoulder external rotation, from a preoperative median of −15° to a postoperative median of 50° (p < 0.001). Instability recurred in three patients in the early postoperative period. Nine patients underwent a reoperation for various reasons. According to a modified Neer rating system, there were four excellent, fifteen satisfactory, and thirteen unsatisfactory outcomes. Conclusions: Although shoulder arthroplasty for locked posterior dislocation can provide pain relief, improved shoulder external rotation, and a low risk of recurrent instability, the overall rate of satisfaction is inferior to that following anatomic arthroplasty for treatment of glenohumeral osteoarthritis. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Peer Review This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

[Introduction][1] Our technique to treat a biconcave glenoid (severe B2 subtype) with reverse total shoulder arthroplasty corrects the humeral head subluxation and associated posterior glenoid bone loss, both of which are difficult to address with a conventional anatomic arthroplasty procedure. ![Figure][2] [Step 1: Preoperative Planning][3] Obtain a preoperative computed tomography (CT) scan and make a detailed preoperative plan for reaming and bone-grafting. [Step 2: Surgical Approach][4] Perform a standard deltopectoral approach. [Step 3: Humeral Preparation][5] Prepare the humerus in a way that allows you to retain the humeral head for bone-grafting, being careful not to make an overly conservative first cut that effectively splits the intended bone graft. [Step 4: Glenoid Exposure][6] Proper glenoid exposure is an essential element of this operation and even more difficult for the B2 glenoid than in a standard total shoulder replacement. [Step 5: Glenoid Preparation][7] Having adequately visualized the glenoid, ream the anterior aspect of the glenoid in a way that executes your preoperative plan; do not ream >1 cm. ![Figure][2] [Step 6: Glenoid Fixation][8] Use the screws to compress the bone graft between the metaglene and the native glenoid. [Step 7: Closure][9] Proceed with your standard closure. [Results][10] We presented our results of this procedure in twenty-seven shoulders in twenty-seven patients with a mean duration of follow-up of fifty-four months (range, twenty-four to 139 months). [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] ![Figure][2] ![Figure][2] [Introduction][1] Our technique to treat a biconcave glenoid (severe B2 subtype) with reverse total shoulder arthroplasty corrects the humeral head subluxation and associated posterior glenoid bone loss, both of which are difficult to address with a conventional anatomic arthroplasty procedure. ![Figure][2] [Step 1: Preoperative Planning][3] Obtain a preoperative computed tomography (CT) scan and make a detailed preoperative plan for reaming and bone-grafting. [Step 2: Surgical Approach][4] Perform a standard deltopectoral approach. [Step 3: Humeral Preparation][5] Prepare the humerus in a way that allows you to retain the humeral head for bone-grafting, being careful not to make an overly conservative first cut that effectively splits the intended bone graft. [Step 4: Glenoid Exposure][6] Proper glenoid exposure is an essential element of this operation and even more difficult for the B2 glenoid than in a standard total shoulder replacement. [Step 5: Glenoid Preparation][7] Having adequately visualized the glenoid, ream the anterior aspect of the glenoid in a way that executes your preoperative plan; do not ream >1 cm. ![Figure][2] [Step 6: Glenoid Fixation][8] Use the screws to compress the bone graft between the metaglene and the native glenoid. [Step 7: Closure][9] Proceed with your standard closure. [Results][10] We presented our results of this procedure in twenty-seven shoulders in twenty-seven patients with a mean duration of follow-up of fifty-four months (range, twenty-four to 139 months). [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] ![Figure][2] ![Figure][2] [1]: #sec-10 [2]: pending:yes [3]: #sec-11 [4]: #sec-12 [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #sec-18 [11]: #sec-20 [12]: #sec-21 [13]: #sec-22

Forty-eight shoulders with glenohumeral osteoarthritis were treated by hemireplacement arthroplasty with a Vitallium humeral-head prosthesis in forty-seven patients, twenty-nine of whom were women. The results in an average follow-up of six years (range, one to twenty years) showed relief of pain and restoration of good function in nearly all patients. Recovery of adequate strength was slow, and continued fatigability was noted by some. Total shoulder-joint surface replacement was performed in one patient in this series with good early results.