Technique for Reverse Total Shoulder Arthroplasty
for Primary Glenohumeral Osteoarthritis with a
Biconcave Glenoid
Mena Mesiha, MD, Pascal Boileau, MD, and Gilles Walch, MD
Based on an original article: J Bone Joint Surg Am. 2013 Jul 17;95(14):1297-304.
Introduction
Our technique to treat a biconcave glenoid (severe B2
subtype [Fig. 1]) 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
procedure1-10.
Multiple authors have found unsatisfactory re-
sults with conventional total shoulder replacement in this
setting1-9. Most recently, one of us (G.W.) and colleagues
reported on ninety-two anatomic total shoulder arthro-
plasties in the setting of a biconcave glenoid and dem-
onstrated acceptable objective and subjective results but
an unacceptably high rate of complications11. At a mean
of seventy-seven months postoperatively, radiographic
loosening of the glenoid component was observed in
20.6% of the cases and posterior instability occurred
in 5.5%. When preoperative glenoid retroversion was
≥27°, there was a 44% rate of loosening or instability
with use of an anatomic total shoulder replacement com-
bined with asymmetric reaming in most cases, seven
of which required structural bone graft. Similarly, 60%
of the postoperative dislocations occurred in patients in
whom preoperative subluxation of the humeral head had
been ≥80%.
Reverse shoulder arthroplasty is most com-
monly indicated for glenohumeral arthritis with severe
rotator cuff insufficiency. Yet, features of the reverse
shoulder arthroplasty may be particularly useful in the
setting of a biconcave glenoid. The semiconstrained
design of a reverse shoulder prosthesis may provide a
solution to the static posterior instability of the humeral
head. Additionally, when the surgeon is attempting to
achieve glenoid component stability, the screw fixation of
the glenoid baseplate in a reverse shoulder arthroplasty
may be advantageous compared with the cemented
polyethylene glenoid typically used in an anatomic total
doi:10.2106/JBJS.ST.M.00048 2013, 3(4):e21
shoulder arthroplasty.
The steps to treat a shoulder with an arthritic B2
glenoid with use of the Aequalis reverse total shoulder
arthroplasty (Tornier, Edina, Minnesota) are as follows.
Step 1: Preoperative Planning
Obtain a preoperative computed tomography (CT) scan
and make a detailed preoperative plan for reaming and
bone-grafting.
• Obtain a preoperative CT scan (see Appendix,
CT Protocol).
• Plan to implant the metaglene (metallic glenoid
baseplate of the reverse prosthesis) with 0° to
10° retroversion (Video 1).
• Plan to not ream eccentrically >10 mm in order
to avoid issues with (1) insufficient residual gle-
noid bone stock for adequate metaglene fixation
and (2) overmedialization of the glenosphere
(metallic glenoid hemisphere that is attached to
the metaglene), resulting in rotator cuff weak-
ness as a function of loss of tension.
• Details on planning the bone graft include
(Video 1):
o For a glenoid that is 30 mm in the
anteroposterior direction, our recommended
maximum of 10 mm of eccentric reaming
results in a correction of 20° of retroversion.
If your preoperative plan requires additional
correction, then use bone graft from the
humeral head, if available, or the iliac crest,
if necessary.
o We discourage using grafts with a
mediolateral thickness larger than 10 mm in
order to avoid problems with healing. In the
example of a 30-mm glenoid, a 10-mm bone
graft will result in a maximal correction of an
1
 additional 20° of retroversion. That means
that if you accept a maximum of 10° of
retroversion for the baseplate, it is possible
to implant all components in a one-stage
operation if the glenoid retroversion is ≤50°
(correct 20° with eccentric reaming + 20°
with an asymmetric graft + 10° of “accepted”
baseplate retroversion).
o If the retroversion to be corrected is >50°,
we suggest you perform a two-stage
operation: one surgical procedure to
reconstruct the glenoid with iliac crest bone
graft fixed with two metallic screws, and a
second surgical procedure to implant the
reverse total shoulder arthroplasty with now
more adequate glenoid bone stock.
Step 2: Surgical Approach
Perform a standard deltopectoral approach.
• Perform a standard deltopectoral approach,
including a release of the superior 2 cm of the
pectoralis major tendon.
• Tenotomize the subscapularis tendon at the
level of the anatomical neck or use your pre-
ferred method for taking down the subscapular-
is. Retain the supraspinatus and infraspinatus, if
present.
Step 3: Humeral Preparation
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.
• Retain the supraspinatus and infraspinatus ten-
dons if possible, but do not attempt to repair any
tears discovered intraoperatively.
• Dislocate and cut the humeral head either ac-
cording to the “anatomic” retroversion with a
155° guide or after harvesting a bone graft if you
use a BIO-RSA (bony increased-offset reverse
shoulder arthroplasty), which is the proprietary
Tornier structural glenoid bone-grafting
system12.
• Perform the humeral preparation before or after
the glenoid preparation, depending on your
preference.
Step 4: Glenoid Exposure
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.
• Before attempting an advanced reconstruction
2013, 3(4):e21
of a B2 glenoid, perfect your glenoid exposure
technique on less challenging glenoids.
• For the present technique, retract the humerus
posteriorly with a humeral head retractor that
sits on the posterior lip of the glenoid. We do this
prior to the humeral head cut (Video 2).
• Using the traction stitches of the subscapularis,
draw it into the joint to stretch the middle gle-
nohumeral ligaments to allow it to be cut with
scissors (Video 2).
• Identify the inferior glenohumeral ligament just
behind the muscular inferior part of the subscap-
ularis to allow it to be cut safely from anterior to
posterior (Video 2).
• After ensuring that the subscapularis is released
superiorly from the subcoracoid adhesions, pos-
teriorly from the middle glenohumeral ligament
and the glenoid, and inferiorly from the inferior
glenohumeral ligament, bury it in the subscapu-
laris fossa with a sponge and an anterior gle-
noid retractor. At this point you should be able
to visualize the anterior aspect of the glenoid
(Video 2).
• Excise the subcoracoid bursa, biceps tendon,
and anterosuperior aspect of the labrum
(Video 3).
• Release the labrum and the inferior glenohu-
meral ligament off the glenoid from 5 o’clock to 7
o’clock, making sure to stay in contact with bone
to avoid injury to the axillary nerve. As you do
this, the humeral head glenoid retractor should
have less tension and the posterior exposure of
the glenoid should improve (Video 3).
• If the posterior glenoid exposure is poor, try re-
leasing more of the inferior labrum and a portion
of the triceps muscle, which is often tight. If the
exposure is still poor, try repositioning the arm
and the humeral head retractor.
Step 5: Glenoid Preparation
Having adequately visualized the glenoid, ream the an-
terior aspect of the glenoid in a way that executes your
preoperative plan; do not ream >1 cm.
• Implant the guide pin by aiming it at the “center-
ing point” described by Matsen et al.13 (Video 4).
• In addition to correcting retroversion, make sure
to include inferior tilt in the positioning of the
guidewire so that reaming will leave the final
glenoid construct in 10° of inferior tilt (Fig. 2).
• Ream down the anterior aspect of the glenoid
according to your preoperative plan (Video 5),
stopping periodically to evaluate the extent of
reaming (Video 6), and finish reaming to coin-
cide with your preoperative plan (Video 7). In
2
 most cases reaming should proceed until slightly
more than the anterior 50% of the glenoid face
is reamed, which leaves the posterior half of the
glenoid unreamed to receive the bone graft.
• Drill the hole for the central post with a cannu-
lated drill on the guide pin (Video 8) and use a
small drill to create several peripheral holes. We
believe that this enhances osseous ingrowth into
the graft (Video 9).
• Place the bone graft onto the central post of the
metaglene component and fashion it to conform
to the prepared glenoid (Video 10).
• Insert the metaglene with the attached bone
graft into the glenoid (Video 11).
• In the setting of bone-grafting, it is important
to use a metaglene with a long central peg (25
mm) that penetrates the native glenoid and not
only the bone graft.
Step 6: Glenoid Fixation
Use the screws to compress the bone graft between the
metaglene and the native glenoid.
• In contrast to the “off axis” screw placement of-
ten suggested for standard reverse arthroplasty,
we advocate screw placement that is perpen-
dicular to the bone graft in order to gain maximal
compression.
• The inferior screw, in particular, should be hori-
zontal and not angled inferiorly in order to avoid
issues with notching (Video 12).
• After tightening these compressive screws
sequentially (Video 13), finish your fixation by
placing anterior and posterior locking screws
(Video 14).
• Insert the glenosphere onto the metaglene.
Make sure to seat the Morse taper properly
before sequentially impacting and screwing in
the glenosphere several times to ensure appro-
priate fixation (Video 15). This is another step
where proper exposure is critical, as it allows the
surgeon to visualize the metaglene well enough
to remove any soft tissue and line up the gleno-
sphere “in axis” with the metaglene. We recom-
mend using a 36-mm glenosphere in women
and a 42-mm glenosphere in men.
Step 7: Closure
Proceed with your standard closure.
• Reduce the humerus and, if possible, repair the
subscapularis tendon with transosseous nonab-
sorbable sutures.
• Perform a soft-tissue biceps tenodesis into the pec-
toralis major tendon if the tendon is still present.
2013, 3(4):e21
• Close the skin with your preferred method.
Results
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)14. Four patients (15%) experienced a
complication, and one of these complications illustrates
perfectly a very important technical point—the baseplate
loosened because the central peg was only 15 mm and
did not anchor into native scapular bone. Two patients
had transient postoperative nerve palsy, and one patient
had a permanent ulnar nerve palsy. There were no
instances of postoperative instability.
The mean total Constant score increased from
30.6 points preoperatively to 76.3 points postoperatively
(p < 0.05)15. In addition, all Constant subscores were sig-
nificantly improved. At the time of final follow-up, twenty-
one patients (78%) were very satisfied, four (15%) were
satisfied, and two (7%) were disappointed.
No correlation was observed between any of
the angles of glenoid retroversion and the postopera-
tive Constant score or postoperative range of motion.
Likewise, no correlation was observed between the per-
centage of posterior subluxation and the postoperative
Constant score or postoperative range of motion. Finally,
there was no significant correlation between bone-graft-
ing or notching and the functional outcome.
Radiographs made at the time of follow-up dem-
onstrated grade-1 or 2 notching in 37% of the patients,
with no grade-3 or 4 notching. All grafts but one healed.
What to Watch For
Indications
• Humeral head subluxation of >80% with respect
to Friedman’s line (Fig. 3).
• Intermediate glenoid retroversion of >27°
(Fig. 4).
Contraindications
• Infection.
• Glenoid retroversion of >50°, which requires a
two-step procedure.
Pitfalls & Challenges
• Preoperative planning with high-quality CT imag-
ing is essential when preparing for this proce-
dure, as it is very difficult to make a reasonable
assessment of glenoid version intraoperatively.
• Exposure of the posterior aspect of the glenoid
is critical for this procedure. Inadequate visual-
ization of the posterior aspect of the glenoid will
3
 result in poor placement of the bone graft and
early failure of the glenoid construct. Appendix

CT Scan Protocol
Clinical Comments
• We have suggested that this procedure is ap-
propriate for patients with posterior subluxation
of >80% or glenoid retroversion of ≥27°. Do you
agree? If not, what criteria help you decide to
perform a reverse total shoulder arthroplasty for
a B2 glenoid?
• What are your criteria for deciding between one-
stage and two-stage glenoid bone-grafting?
• Do you have any technical pearls for preopera-
tive planning?
• Do you have any technical pearls for posterior
glenoid exposure?
• Do you have any technical pearls for graft
preparation?
• Cuts of <0.6 mm and a field of view of <20 cm.
• Reconstruction cuts with a hard filter (carbon
filter).
• Inclusion of original scan cuts on the CD-ROM.
• Cuts in neutral rotation.
• Measurement of glenoid retroversion, with the
need to visualize the entire scapula to the medial
border of the spine.
• Quantification of fatty degeneration of the infra-
spinatus muscle, subscapularis, and teres minor.
• Assessment of ruptured tendons (supraspinatus,
infraspinatus, subscapularis, and biceps).
• Measurement of humeral retroversion. (Make
three cuts at the elbow.)

Mena Mesiha, MD
Massachusetts General Hospital, 55 Fruit Street, Yawkey 3G, Boston, MA 02114. E-mail address: mesiham@gmail.com
Pascal Boileau, MD
Hôpital de L’Archet, 2, 151, Route de Saint-Antoine de Ginestière, 06202 Nice, France. E-mail address: boileau.p@chu-nice.fr
Gilles Walch, MD
Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008 Lyon, France. E-mail address: walch.gilles@wanadoo.fr

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from
a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial
relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to
influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in
any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete
Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

References

1. Walch G, Boulahia A, Boileau P, Kempf JF; The Aequalis Group. Primary glenohumeral osteoarthritis: clinical and radiographic clas-
sification. Acta Orthop Belg. 1998;64 Suppl 2:46-52.
2. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty.
1999 Sep;14(6):756-60, doi:10.1016/S0883-5403(99)90232-2.
3. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D. Cemented polyethylene versus uncemented metal-backed gle-
noid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg. 2002 Jul-
Aug;11(4):351-9, doi:10.1067/mse.2002.125807.
4. Gerber C, Costouros JG, Sukthankar A, Fucentese SF. Static posterior humeral head subluxation and total shoulder arthroplasty.
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):505-10. Epub 2009 May 29.
5. Godenèche A, Boileau P, Favard L, Le Huec JC, Lévigne C, Nové-Josserand L, Walch G, Edwards TB. Prosthetic replace-
ment in the treatment of osteoarthritis of the shoulder: early results of 268 cases. J Shoulder Elbow Surg. 2002 Jan-Feb;11(1):11-8,
doi:10.1067/mse.2002.120140.
6. Iannotti JP, Norris TR. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone
Joint Surg Am. 2003 Feb;85-A(2):251-8.
7. Neer CS 2nd, Morrison DS. Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg Am. 1988 Sep;70(8):1154-62.

2013, 3(4):e21 4
8. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder
Elbow Surg. 2002 Mar-Apr;11(2):130-5, doi:10.1067/mse.2002.121146.
9. Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. A prospective functional outcome study of shoulder arthroplasty for osteoarthri-
tis with an intact rotator cuff. J Shoulder Elbow Surg. 2003 May-Jun;12(3):214-21, doi:10.1016/S1058-2746(02)86882-3.
10. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU. Hemiarthroplasty for glenohumeral osteoarthritis:
results correlated to degree of glenoid wear. J Shoulder Elbow Surg. 1997 Sep-Oct;6(5):449-54, doi:10.1016/S1058-2746(97)70052-1.
11. Walch G, Moraga C, Young A, Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with
biconcave glenoid. J Shoulder Elbow Surg. 2012 Nov;21(11):1526-33. Epub 2012 Mar 23.
12. Boileau P, O’Shea K, Moineau G, Roussane Y. Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) for cuff tear
arthropathy. Oper Tech Orthop. 2011 Mar 1;21(1):69-78.
13. Matsen FAI, Rockwood CAJ, Wirth MA, Lippitt SB. Glenohumeral arthritis and its management. In: Rockwood CA Jr, Masten FA III,
editors. The shoulder. 2nd ed. Philadelphia: Saunders; 1998. p 840-960.
14. Mizuno N, Denard PJ, Raiss P, Walch G. Reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis in patients
with a biconcave glenoid. J Bone Joint Surg Am. 2013 Jul 17;95(14):1297-304.
15. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987 Jan;(214):160-4.

Figures

Fig. 1
Glenoid classification.

Fig. 2
Line diagram of an anteroposterior coronal view of the right scapula. Make sure to include inferior tilt in the positioning of
the guidewire so that reaming will leave the final glenoid construct in 10° of inferior tilt. This will help both in tensioning the
deltoid and using the implant to create compressive forces, which will aid in healing of the bone graft.

Fig. 3
The degree of humeral head subluxation is calculated by first drawing a perpendicular line through Friedman’s line (a line
drawn from the medial border of the scapula to the center of the glenoid) at the widest point of the humeral head. Then
the length of the portion of this line that lies posterior to Friedman’s line (y) is divided by the total length of the line (x + y).

Fig. 4
Intermediate glenoid retroversion is defined as the angle between the scapular body and a line drawn from the anterior
lip of the glenoid to the posterior lip of the glenoid. This is contrasted here with the paleoglenoid (considering only the
anterior concavity) and the neoglenoid (considering only the posterior, or secondary, concavity).

Fig. 1 Fig. 2

2013, 3(4):e21 5
Fig. 3

Fig. 4

2013, 3(4):e21 6