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Glenoid Bone Grafting With Reverse Total Shoulder

Paul J. Cagle, Jr, MD, Dave R. Shukla, MD, and Evan L. Flatow, MD

Several techniques have been described to restore glenoid bone

Abstract: Reverse total shoulder arthroplasty has demonstrated stock in total shoulder arthroplasty. Options currently include
excellent results for patients with glenohumeral arthritis and a deficient the use of impacted cancellous graft, iliac crest autograft,
rotator cuff. Patients requiring a reverse total shoulder arthroplasty femoral and humeral head bulk allografts, and femoral neck
with substantial glenoid erosion pose a difficult problem. The operative corticocancellous hybrid grafting.
surgeon must correct the version of the glenoid while maintaining With emerging outcomes data and increased use of the
secure glenoid fixation. Techniques demonstrating this are currently reverse prosthesis, the importance of properly addressing gle-
lacking in the literature. We present a case of an elderly patient with noid bone defects during either primary or revision reverse
glenoid erosion causing a significantly abnormal glenoid version. In shoulder arthroplasty cannot be overstated. The use of humeral
this technique, the cut portion of the humeral head was utilized as bone head bulk autograft obtained during the time of surgery has
graft. The head was shaped to restore the glenoid version, and the graft been described for total shoulder arthroplasty.7–10 Although
was held in place with glenoid insertion techniques. The patient surgeons use this technique to address glenoid bone defects
described recovered quickly after the surgery, and she has demon- during reverse shoulder arthroplasty, the technique has not
strated excellent results. These results are similar to those seen by the been the focus of any publication, to our knowledge.
senior author while utilizing this technique. This is currently our pre- Our aim was to provide a technical guide on the use of
ferred method of addressing glenoid version abnormalities in reverse humeral head grafting in the setting of reverse shoulder
total shoulder arthroplasty. arthroplasty, with presentation of the method which is cur-
Key Words: glenoid bone graft, glenoid bone loss, reverse shoulder rently used by the senior author.
arthroplasty, shoulder arthroplasty
(Tech Should Elb Surg 2014;15: 134–138) MATERIALS AND METHODS
The patient was an 83-year-old female who presented
with shoulder pain. Her symptoms had been refractory to

R everse shoulder arthroplasty has evolved since its initial

introduction by Grammont in 1991. It is commonly used to
address degenerative arthritis in the presence of a massive,
conservative treatment including physical therapy, non-
steroidal anti-inflammatory medications, and 2 corticosteroid
injections. Her pain was preventing activities of daily living.
irreparable rotator cuff tear. The indications for its use are Initial active and passive forward elevation and external rota-
expanding, and reverse arthroplasty can also be performed to tion was 130 and 30 degrees, respectively. No external lag sign
manage proximal humerus fractures, inflammatory arthro- was present, and appropriate subscapularis function was
pathy, and in the revision setting following total shoulder
Good results have been demonstrated with reverse total
shoulder arthroplasty.1–3
Secure glenoid fixation is critical to ensure reverse total
shoulder implant longevity. Studies have emphasized the
importance of surgical technique in optimizing reverse
shoulder implant biomechanics.4–6 Adequate glenoid bone
stock is required to anchor the glenosphere, and must be suf-
ficient to withstand the physiological loads of the shoulder.
When glenoid deficiencies exist, technical adjustments can be
performed, such as asymmetrically reaming, restoring bone
stock through the use of grafts, using a customized component,
altering glenosphere size, or using a composite biological and
prosthetic solution.
The need to address glenoid bone loss is frequently
encountered during both primary and revision arthroplasty.

From the Department of Orthopaedic Surgery, Icahn School of Medicine at

Mount Sinai, New York, NY.
All work was completed at Department of Orthopaedic Surgery, Icahn
School of Medicine at Mount Sinai.
E.L.F. received royalties from Zimmer and Innomed. The other authors
declare no conflict of interest.
Reprints: Paul J. Cagle Jr, MD, Department of Orthopaedic Surgery, Icahn
School of Medicine at Mount Sinai, 5 East 98th Street, 9th Floor,
New York, NY 10029 (e-mail: FIGURE 1. Grashey view showing advanced degenerative
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134 | Techniques in Shoulder & Elbow Surgery  Volume 15, Number 4, December 2014
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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 4, December 2014 Bone Graft Reverse Shoulder Arthroplasty

appreciated. Magnetic resonance imaging and 4 radiographic

views were obtained. Figures 1 and 2 demonstrate Grashey and
axillary radiographs. Figures 3–5 demonstrate magnetic reso-
nance imaging showing a compromised rotator cuff and sig-
nificant glenoid erosion. A reverse total shoulder arthroplasty
with glenoid bone graft was planned.
Before induction, the anesthesia team placed an indwel-
ling interscalene catheter. The patient underwent induction
with anesthesia and intubation. The patient was positioned in
the beach-chair position. A pneumatic arm holder assisted with
arm position control. A standard deltopectoral approach was
utilized, and a subscapularis tenotomy was performed. A 360-
degree subscapularis release and a capsular release were
completed following standard humeral preparation. The
resected portion of the humeral head was saved for bone graft,
and remaining cartilage was removed from the bone graft with
a curette.
Upon visualizing the glenoid, the degree of retroversion
was examined both visually and by reference palpation of the
anterior glenoid neck and scapula. Any remaining cartilage
was removed to allow for a true view of the bony glenoid FIGURE 3. MRI illustrating glenoid erosion and a compromised
surface. The version was compared with the preoperative rotator cuff.
imaging assessment. With the assistance of an anterior refer-
encing guide, a guidewire was placed as demonstrated
in Figure 6. The guidewire should just penetrate the anterior screws were placed with locking caps, and a glenosphere was
cortex so that the long post (25 or 30 mm) peg will lodge in the seated onto the baseplate in a standard manner. Humeral
far cortex. Anterior referencing and visualization are combined implantation was performed in a standard manner. Closed
to choose the appropriate amount of correction while placing suction drainage was utilized with a subcuticular closure.
the guidewire. Subsequently, the glenoid is drilled and reamed Postoperatively, hand and elbow range of motion were
to prepare the surface for the bone graft and baseplate. A long started immediately. At 6 weeks postoperatively, active
central post glenoid implant was utilized. The central hole was assisted range of motion and passive range of motion were
drilled slightly deeper to just penetrate the anterior cortex. started with organized physical therapy. Muscle strengthening
Attention was turned to the resected humeral head. The was allowed at 12 weeks.
head was placed onto the reamed glenoid to understand the
shape necessary to correct the version, and a rongeur was used
to shape the bone graft. A center hole for the baseplate peg was RESULTS
drilled and reamed in the bone graft, and a humeral shaft At the 3-month follow-up visit, the patient reported
reamer was utilized to dilate the hole as illustrated in Figures 7 complete pain relief. Her postoperative active and passive
and 8. The graft was again examined against the glenoid to forward elevation and external rotation were 140 and 30
assess proper positioning and rotation. This is illustrated degrees, respectively. The incision had healed, and she
in Figure 9. Care was taken to ensure the graft would pass on to reported compliance with therapy recommendations. Final
the baseplate central peg. The graft was placed on the base- radiographs are demonstrated in Figures 12 and 13.
plate with the appropriate rotation as illustrated in Figure 10.
The position was carefully maintained as the baseplate was
impacted as illustrated in Figure 11. Complete seating of the
graft and baseplate was examined circumferentially. Two

FIGURE 2. Axillary view showing advanced degenerative FIGURE 4. MRI image demonstrating fatty infiltration of the
change. rotator cuff muscles.

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Cagle et al Techniques in Shoulder & Elbow Surgery  Volume 15, Number 4, December 2014

FIGURE 8. Bone graft preparation: reaming of central hole to

allow the graft to easily fit onto glenoid baseplate central

FIGURE 5. MRI illustrating glenoid erosion.

FIGURE 9. Assessing rotational placement of bone graft on the

glenoid surface.

FIGURE 6. Placement of the glenoid guide pin.

FIGURE 7. Preparing the glenoid with drilling for central FIGURE 10. Placing bone graft on baseplate in correct
peg. rotation.

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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 4, December 2014 Bone Graft Reverse Shoulder Arthroplasty

FIGURE 11. Impacting baseplate with bone graft.

Glenoid bone loss poses a significant problem for patients
requiring a reverse total shoulder arthroplasty. Adequate gle-
noid bone stock is critical for minimizing the likelihood of
glenoid component loosening and failure, and has received
considerable attention in the setting of the total shoulder
arthroplasty. Neer and Morrison7 reported the use of humeral
head corticocancellous graft in 20/463 total shoulder arthro-
plasties with glenoid defects secondary to a multitude of eti-
ologies. The Mayo group recently reported on the results of
structural humeral head autografting, with a mean of 8.7-year
follow-up, inclusive of their preliminary data from 13 years
prior. Although clinical outcomes were favorable, the authors
recognized the technique’s limitations and note worrisome
radiographic deterioration of the glenoid fixation.8,10
FIGURE 13. Postoperative scapula lateral radiograph view.

The same group also reported on the use of impaction

cancellous grafting to restore glenoid bone stock. Antuna
et al11 proposed a classification based on the intraoperative
assessment of remaining glenoid bone stock following glenoid
component removal in revision total shoulder arthroplasty. The
authors advocated bone grafting with central or combined
deficiencies, with the advantages being the construction of a
glenoid surface that articulates more closely to the humeral
component, and the establishment of improved bone stock for
later construction if necessary. The reported cases included
those managed with component removal, bone graft place-
ment, and glenoid reimplantation at a later date. Although
glenoid bone stock at the time of reimplantation was not equal
to that at the index total shoulder arthroplasty, it was restored
enough to allow glenoid component reimplantation.12 Follow-
up data confirmed their earlier findings, although the group
noted that motion could not reliably be improved with this
course of management.13
Neyton and colleagues found that iliac crest cortico-
cancellous grafting after glenoid component removal due to
loosening provides more structure and decreases the chance of
humeral head medialization more than cancellous graft alone,
as performed by Antuna and colleagues. This technique was
used as a salvage procedure for the restoration of glenoid bone
stock, although it allows for later implantation of a glenoid
As compared with reports on total shoulder arthroplasty,
there are comparatively fewer studies that focus on the man-
agement of glenoid bone loss in reverse shoulder arthroplasty.
Bone grafting during reverse shoulder arthroplasty has been
extrapolated from the reported experiences involving total
FIGURE 12. Postoperative Grashey radiograph view. shoulder arthroplasty. Sirveaux et al14 emphasized the risk of

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Cagle et al Techniques in Shoulder & Elbow Surgery  Volume 15, Number 4, December 2014

glenoid baseplate positioning being too superior in cases of 5. Kelly JD II, Humphrey CS, Norris TR. Optimizing glenosphere
superior glenoid deficiency, potentially leading to impinge- position and fixation in reverse shoulder arthroplasty, part one: the
ment. Neyton et al15 used either humeral head or iliac crest twelve-mm rule. J Shoulder Elbow Surg. 2008;17:589–594.
corticocancellous autograft in 9 patients, with their cohort 6. Harman M, Frankle M, Vasey M, et al. Initial glenoid component
encompassing both primary and revision patients cases. At a fixation in “reverse” total shoulder arthroplasty: a biomechanical
mean of 31 months, they observed no radiographic evidence of evaluation. J Shoulder Elbow Surg. 2005;14:S162–S167.
component loosening, graft lysis, or graft compression. 7. Neer CS, Morrison DS. Glenoid bone-grafting in total shoulder
Bateman and Donald16 reported on a novel technique that arthroplasty. J Bone Joint Surg Am. 1988;70-A:1154–1162.
addresses glenoid deficiency using a hybrid corticocancellous
8. Steinmann SP, Cofield RH. Bone grafting for glenoid deficiency
graft, with a femoral neck allograft acting as a cortical bushing
in total shoulder replacement. J Shoulder Elbow Surg. 2000;9:
to prevent medialization, filled with impacted cancellous 361–367.
autograft. Klein et al17 demonstrated that comparable short-
term clinical outcomes can be achieved in the setting of gle- 9. Hill JM, Norris TR. Long-term results of total shoulder arthroplasty
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reported methods including the adjustment of glenosphere size
or bone grafting. 10. Klika BJ, Wooten CWW, Sperling JW, et al. Structural bone grafting
Our technique addresses the problem of restoring glenoid for glenoid deficiency in primary total shoulder arthroplasty.
version with an autograft from the humeral head. This provides J Shoulder Elbow Surg. 2013;23:1066–1072.
an excellent source of bone stock, and the curvature of the 11. Antuna SA, Sperling JW, Cofield RH, et al. Glenoid revision surgery
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graft with the glenoid, and our experience has shown excellent component after component removal and allograft bone grafting: a
results with this technique. We recommend this to address report of 3 cases. J Shoulder Elbow Surg. 2002;11:637–641.
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