Glenoid reconstruction with autologous humeral head for glenoid dysplasia in reverse shoulder arthroplasty

Reverse total shoulder arthroplasty (rTSA) is one management option that has been successful for treating glenohumeral arthritis with and without rotator cuff tears.1Ansok C.B. Muh S.J. Optimal management of glenohumeral osteoarthritis.Orthop Res Rev. 2018; 10: 9-18https://doi.org/10.2147/ORR.S134732Crossref PubMed Scopus (19) Google Scholar,3Black E.M. Roberts S.M. Siegel E. Yannopoulos P. Higgins L.D. Warner J.J. Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger.J Shoulder Elbow Surg. 2014; 23: 1036-1042https://doi.org/10.1016/j.jse.2014.02.019Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar,6Ek E.T. Neukom L. Catanzaro S. Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years.J Shoulder Elbow Surg. 2013; 22: 1199-1208https://doi.org/10.1016/j.jse.2012.11.016Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar,12Ozgur S.E. Sadeghpour R. Norris T.R. Revision shoulder arthroplasty with a reverse shoulder prosthesis: use of structural allograft for glenoid bone loss.Orthopade. 2017; 46 (English): 1055-1062https://doi.org/10.1007/s00132-017-3494-3Crossref PubMed Scopus (7) Google Scholar,16Shapiro T.A. McGarry M.H. Gupta R. Lee Y.S. Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.J Shoulder Elbow Surg. 2007; 16: S90-S95https://doi.org/10.1016/j.jse.2006.07.010Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar,19Walch G. Badet R. Boulahia A. Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis.J Arthroplasty. 1999; 14: 756-760Abstract Full Text PDF PubMed Scopus (664) Google Scholar,20Walters J.D. Barkoh K. Smith R.A. Azar F.M. Throckmorton T.W. Younger patients report similar activity levels to older patients after reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2016; 25: 1418-1424https://doi.org/10.1016/j.jse.2016.01.011Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Initially used exclusively for rotator cuff tear arthropathy, rTSA indications have expanded to include pseudoparalysis caused by irreparable rotator cuff tears, immunologic arthritis, proximal humerus fractures, failed shoulder arthroplasty, and glenohumeral arthritis with substantial glenoid bone loss.7Familiari F. Rojas J. Nedim Doral M. Huri G. McFarland E.G. Reverse total shoulder arthroplasty.EFORT Open Rev. 2018; 3: 58-69https://doi.org/10.1302/2058-5241.3.170044Crossref PubMed Scopus (37) Google Scholar,9Muh S.J. Streit J.J. Wanner J.P. Lenarz C.J. Shishani Y. Rowland D.Y. et al.Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger.J Bone Joint Surg Am. 2013; 95: 1877-1883https://doi.org/10.2106/JBJS.L.10005Crossref PubMed Scopus (105) Google Scholar,11Otto R.J. Clark R.E. Frankle M.A. Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up.J Shoulder Elbow Surg. 2017; 26: 792-797https://doi.org/10.1016/j.jse.2016.09.051Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,15Sershon R.A. Van Thiel G.S. Lin E.C. McGill K.C. Cole B.J. Verma N.N. et al.Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.J Shoulder Elbow Surg. 2014; 23: 395-400https://doi.org/10.1016/j.jse.2013.07.047Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar Although initial contraindications for the procedure included insufficient glenoid bone stock, this has become a relative contraindication with better understanding of glenoid reconstruction. The management of glenoid bone loss is particularly challenging in the setting of rTSA. Drake et al5Drake G.N. O'Connor D.P. Edwards T.B. Indications for reverse total shoulder arthroplasty in rotator cuff disease.Clin Orthop Relat Res. 2010; 468: 1526-1533https://doi.org/10.1007/s11999-009-1188-9Crossref PubMed Scopus (132) Google Scholar noted that severe glenoid bone erosion was considered a contraindication owing to insufficiency stock for baseplate fixation. High complication rates have been associated with rTSA and severe glenoid wear.14Sears B.W. Johnston P.S. Ramsey M.L. Williams G.R. Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management.J Am Acad Orthop Surg. 2012; 20: 604-613https://doi.org/10.5435/JAAOS-20-09Crossref PubMed Scopus (0) Google Scholar,16Shapiro T.A. McGarry M.H. Gupta R. Lee Y.S. Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.J Shoulder Elbow Surg. 2007; 16: S90-S95https://doi.org/10.1016/j.jse.2006.07.010Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar The most common complications of rTSA and glenoid bone loss include glenosphere malpositioning, component instability, scapular notching from prosthesis impingement, pain, loss of function, decreased range of motion, and arthroplasty failure. In the setting of severe glenoid wear patterns, component malpositioning can lead to excessive retroversion. In turn, alteration of the balanced forces of the shoulder may result in clinical dysfunction. Shapiro et al16Shapiro T.A. McGarry M.H. Gupta R. Lee Y.S. Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.J Shoulder Elbow Surg. 2007; 16: S90-S95https://doi.org/10.1016/j.jse.2006.07.010Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar performed a cadaveric study looking at shoulder forces with glenoid components in neutral position as well as in 15 degrees of retroversion. Force changes were noted in the retroverted group that predisposed them to glenoid loosening and wear. The Walch classification, later expanded in 2016 by Bercik et al,2Bercik M.J. Kruse 2nd, K. Yalizis M. Gauci M.O. Chaoui J. Walch G. A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-dimensional imaging.J Shoulder Elbow Surg. 2016; 25: 1601-1606https://doi.org/10.1016/j.jse.2016.03.010Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar described glenoid bone loss seen in osteoarthritic shoulders as a method of quantifying resultant abnormal glenoid morphology.2Bercik M.J. Kruse 2nd, K. Yalizis M. Gauci M.O. Chaoui J. Walch G. A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-dimensional imaging.J Shoulder Elbow Surg. 2016; 25: 1601-1606https://doi.org/10.1016/j.jse.2016.03.010Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 19Walch G. Badet R. Boulahia A. Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis.J Arthroplasty. 1999; 14: 756-760Abstract Full Text PDF PubMed Scopus (664) Google Scholar The severity of the deformity was subdivided to provide reproducible understanding of the pathology and potentially aid in devising appropriate treatment plans. Walch B2 and B3 glenoids demonstrate acquired posterior bone loss, and Walch C demonstrates severe retroversion of the glenoid of > 25° and the result of glenoid dysplasia (Fig. 1).16Shapiro T.A. McGarry M.H. Gupta R. Lee Y.S. Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.J Shoulder Elbow Surg. 2007; 16: S90-S95https://doi.org/10.1016/j.jse.2006.07.010Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar Walch B3 and C glenoids are more challenging because of both substantial glenoid retroversion and medialization. Reports of glenoid bone grafting during rTSA have mixed results. Namdari et al retrospectively reviewed 44 patients who underwent structural allografting for bone loss with rTSA with a minimum of 1-year follow-up. They concluded that this procedure yielded higher than previously reported baseplate looseing.8Ho J.C. Thakar O. Chan W.W. Nicholson T. Williams G.R. Namdari S. Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss.J Shoulder Elbow Surg. 2020; 29: 550-560https://doi.org/10.1016/j.jse.2019.07.035Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Conversely, Walch et al examined a similar cohort at 2 years both radiographically and clinically and found no evidence of baseplate loosening or graft failure.10Neyton L. Boileau P. Nové-Josserand L. Edwards T.B. Walch G. Glenoid bone grafting with a reverse design prosthesis.J Shoulder Elbow Surg. 2007; 16: S71-S78https://doi.org/10.1016/j.jse.2006.02.002Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Variability in graft selection and technique may be reasons for disparate results.13Paul R.A. Maldonado-Rodriguez N. Docter S. Khan M. Veillette C. Verma N. et al.Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review.J Shoulder Elbow Surg. 2019; 28: 2447-2456https://doi.org/10.1016/j.jse.2019.05.011Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,17Tashjian R.Z. Broschinsky K. Stertz I. Chalmers P.N. Structural glenoid allograft reconstruction during reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2020; 29: 534-540https://doi.org/10.1016/j.jse.2019.07.011Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Boileau et al4Boileau P. Morin-Salvo N. Gauci M.O. Seeto B.L. Chalmers P.N. Holzer N. et al.Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion.J Shoulder Elbow Surg. 2017; 26: 2133-2142https://doi.org/10.1016/j.jse.2017.05.024Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar described their technique for increasing glenoid offset and correction of glenoid dysplasia in the setting of shoulder arthroplasty. Angled bony-increased offset-reserve shoulder arthroplasty used humeral head autografting with great success to both lateralize and correct severe dysplasia of the glenoid. The purpose of this manuscript is to describe our preferred technique to manage glenoid dysplasia using humeral head autograft for single-stage glenoid bone grafting in primary rTSA. Unique to our technique is the combination of preoperative computed tomography (CT) planning with utilization of an entire humeral head autograft fixated through baseplate compression. Preoperative imaging, consisting of anterior-posterior and axillary radiographs (Fig. 2, A and B), as well as a CT scan (Fig. 3) was obtained. A review of these images revealed a Walch type C glenoid, with approximately 49° of retroversion. The CT images were uploaded to a preoperative planning software program (TRUMATCH, Rayhnam, MA, USA). This system allows optimal virtual placement of the glenoid baseplate and bone graft using 2-dimensional (Fig. 4) and 3-dimensional images (Fig. 5).Figure 3Preoperative axial CT scan of a right shoulder demonstrating excessive posterior glenoid wear. CT, computed tomography.View Large Image Figure ViewerDownload (PPT)Figure 4Axial CT scan with superimposed glenoid baseplate for positioning optimization. CT, computed tomography.View Large Image Figure ViewerDownload (PPT)Figure 5Posterior view from 3D imaging software program. Glenoid baseplate with extended central post traversing the graft (yellow) and native glenoid. 3D, 3-dimensional.View Large Image Figure ViewerDownload (PPT) A standard deltopectoral approach is used. The anterior humerus is exposed. When necessary, a biceps tenodesis is performed. A subscapularis peel is preferred although a tenotomy could be performed. The subscapularis tendon and capsule are divided from their insertion on the lesser tuberosity and a traction suture is placed. The proximal humerus is circumferentially exposed. Any remaining humeral articular cartilage is removed with a motorized barrel bur, and punctate bleeding is created (Fig. 6, A). Care is taken to avoid removal of excessive subchondral bone. Component system variability may influence the osteotomy. In cases of a very small humeral head, a free-hand cut may be performed. If the head is large, an entry hole is made in the proximal humerus directly above the humeral diaphysis. After humeral diaphyseal preparation, guides may be attached for osteotomy. Once osteotomized, the humeral head autograft is protected on the back table. A protector plate is placed on the resected humeral surface to safeguard the bone during retraction for glenoid exposure. A lamina distractor is placed between the glenoid and humeral protector plate. With the humerus distracted laterally and the axillary nerve well protected by placing a finger between the capsule and the nerve, the well-visualized inferior capsule is divided to the 9:00 position of the glenoid. Periarticular soft tissue releases are performed to circumferentially expose the glenoid (Fig. 6, B). Owing to the substantial retroversion, it will be challenging to have a perpendicular, en face view of the glenoid. If a coracoid-based patient-specific guide has been fabricated from preoperative planning, the coracoid is exposed as well. The glenoid defect is prepared by gently decorticating the eburnated bone to create a bleeding surface. Either the glenoid base plate or patient-specific guide is used to insert the guide pin eccentrically into the glenoid articular surface. The guide pin should exit just anterior to the scapular body. A small portion of the noneroded, anterior glenoid may be prepared with a circular power reamer. A cannulated drill stop then creates the center hole. The graft is fashioned from the resected humeral head (Fig. 6, C). It may be preferable to use the portion of the humeral head that corresponds to the glenoid defect. The graft is contoured to fit within the glenoid defect and restore glenoid version and/or inclination. The graft should be large enough peripherally that it can be provisionally secured with guide pins and proud enough laterally that excellent compression and baseplate support will be achieved (Fig. 6, D). A guide pin is placed through the graft and into the center drill hole in the glenoid. The graft is reamed for the baseplate (Fig. 6, E), then drilled for the central base plate hole (Fig. 6, F). The glenoid baseplate with an extended central post is impacted so that is sits securely on the paleoglenoid and compresses the bone graft. Peripheral screws are placed, through and outside the graft, as needed (Fig. 6, G). The definitive glenosphere is attached to the metaglene. The humeral portion of the procedure is completed followed by subscapularis management and wound closure. A sling with abduction pillow is placed. Radiographs are obtained at the first office visit approximately 2 weeks postoperatively, then at 6 weeks, 3 months, and yearly. The sling is removed at 2 weeks, and full, unrestricted range of motion is allowed. Preoperative retroversion of 49° was corrected to approximately 18° degrees. Postoperative radiographs (Fig. 7, A and B) at 1 year demonstrate complete incorporation of the graft without evidence of baseplate loosening. Yearly follow-up with radiographing evaluation is recommended thereafter. Glenoid bone loss presents unique challenges when performing rTSA.5Drake G.N. O'Connor D.P. Edwards T.B. Indications for reverse total shoulder arthroplasty in rotator cuff disease.Clin Orthop Relat Res. 2010; 468: 1526-1533https://doi.org/10.1007/s11999-009-1188-9Crossref PubMed Scopus (132) Google Scholar Failure to recognize the significance of the bone loss may result in unsatisfactory outcomes because of persistent pain, loss of motion, component instability, or prosthesis loosening. Structural bone grafting provides a biologic alternative for patients with deficient glenoid bone stock. Glenoid bone graft with humeral head autograft for primary total and reverse shoulder arthroplasty has demonstrated promising results to date. Tashjian et al18Tashjian R.Z. Granger E. Chalmers P.N. Structural glenoid grafting during primary reverse total shoulder arthroplasty using humeral head autograft.J Shoulder Elbow Surg. 2018; 27: e1-e8https://doi.org/10.1016/j.jse.2017.07.010Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar reported on 14 patients who underwent primary rTSA with concomitant humeral head autografting for glenoid deficiency. At an average of 2.6-year follow-up (range, 2.0-5.4 years), mean inclination correction was 19° ± 12° (range, 3°-35°). There was 100% radiographic graft incorporation, and 13 of 14 (93%) of the baseplates were stable. Global improvement was seen in motion and patient-reported outcomes. One of the largest series using humeral head autografting was reported by Boileau et al4Boileau P. Morin-Salvo N. Gauci M.O. Seeto B.L. Chalmers P.N. Holzer N. et al.Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion.J Shoulder Elbow Surg. 2017; 26: 2133-2142https://doi.org/10.1016/j.jse.2017.05.024Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar in their description of the bony-increased offset-reserve shoulder arthroplasty. At a mean follow-up of 36 months (range 24-81 months), 54 patients underwent glenoid correction for either E2/E3, B2/C, or combined vertical and horizontal wear patterns. Inclination correction in the E2/E3 group improved from 37° (range, 14° to 84°) to 10.2° (range −28° to 36°, P < .001). Among B2/C glenoids, retroversion improved from −21° (range, −49° to 0°) to −10.6° (−32° to 4°, P = .06). They reported complete radiographic incorporation of the graft in 51 of 54 (94%). Of the 3 that did not incorporate, there was 1 infection and 2 cases of aseptic baseplate loosening. In some cases, such as revisions after primary shoulder arthroplasty, the humeral head is not available. In other circumstances after proximal humeral fractures or if large humeral head cysts are present, the humeral head may not be a satisfactory graft source. Chalmers et al reported on the outcomes of 19 patients who underwent structural femoral head allografting with rTSA.13Paul R.A. Maldonado-Rodriguez N. Docter S. Khan M. Veillette C. Verma N. et al.Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review.J Shoulder Elbow Surg. 2019; 28: 2447-2456https://doi.org/10.1016/j.jse.2019.05.011Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar At a minimum of 2-year clinical follow-up, they noted high rates of bony incorporation and low rates of loosening. Furthermore, improvement was found in American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, and forward flexion and coronal plane motion. Norris et al used a variety of allograft sources in 20 patients (24 surgeries) for their glenoid vault reconstruction.12Ozgur S.E. Sadeghpour R. Norris T.R. Revision shoulder arthroplasty with a reverse shoulder prosthesis: use of structural allograft for glenoid bone loss.Orthopade. 2017; 46 (English): 1055-1062https://doi.org/10.1007/s00132-017-3494-3Crossref PubMed Scopus (7) Google Scholar Eight allograft femoral shafts, 11 allograft femoral neck/head, and 5 allograft proximal humerus were performed. The procedure was considered successful if there were 12 months of clinical and radiographic follow-up without subsequent surgical removal of the graft or radiographic failure. At an average of 24-month follow-up, 7 of the femoral shaft allografts were deemed to have failed. It was often noted in revision surgery that graft was cracked where peripheral screws had been drilled. Paul et al13Paul R.A. Maldonado-Rodriguez N. Docter S. Khan M. Veillette C. Verma N. et al.Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review.J Shoulder Elbow Surg. 2019; 28: 2447-2456https://doi.org/10.1016/j.jse.2019.05.011Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar performed a large meta-analysis consisting of 11 studies and 393 patients examining both autograft and allograft techniques. Their analysis demonstrated glenoid bone grafting during primary rTSA results in excellent early-term clinical outcomes, low complication and revision rates, and high rates of graft union across both graft options. Other considerations include the preference of single- versus two-staged grafting procedures and eccentric versus concentric grafting.10Neyton L. Boileau P. Nové-Josserand L. Edwards T.B. Walch G. Glenoid bone grafting with a reverse design prosthesis.J Shoulder Elbow Surg. 2007; 16: S71-S78https://doi.org/10.1016/j.jse.2006.02.002Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar,13Paul R.A. Maldonado-Rodriguez N. Docter S. Khan M. Veillette C. Verma N. et al.Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review.J Shoulder Elbow Surg. 2019; 28: 2447-2456https://doi.org/10.1016/j.jse.2019.05.011Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The work of Boileau et al,4Boileau P. Morin-Salvo N. Gauci M.O. Seeto B.L. Chalmers P.N. Holzer N. et al.Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion.J Shoulder Elbow Surg. 2017; 26: 2133-2142https://doi.org/10.1016/j.jse.2017.05.024Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Chalmers, and others have demonstrated good to excellent outcomes with both autografting and allografting of glenoids with excessive (>25°) wear.17Tashjian R.Z. Broschinsky K. Stertz I. Chalmers P.N. Structural glenoid allograft reconstruction during reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2020; 29: 534-540https://doi.org/10.1016/j.jse.2019.07.011Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,18Tashjian R.Z. Granger E. Chalmers P.N. Structural glenoid grafting during primary reverse total shoulder arthroplasty using humeral head autograft.J Shoulder Elbow Surg. 2018; 27: e1-e8https://doi.org/10.1016/j.jse.2017.07.010Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar However, this degree of success has not been reported consistently. Namdari et al retrospectively reviewed 44 patients who underwent rTSA with structural bone grafting for glenoid bone loss.8Ho J.C. Thakar O. Chan W.W. Nicholson T. Williams G.R. Namdari S. Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss.J Shoulder Elbow Surg. 2020; 29: 550-560https://doi.org/10.1016/j.jse.2019.07.035Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Thirty seven patients underwent primary rTSA and 7 had revision rTSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Baseplate failures were associated with anteverted glenoids (11° correction in anteversion in failures vs. 0° in nonfailures) and larger degrees of retroversion (−26° vs. −15°, [P = .06]). Nevertheless, improvement in postoperative forward flexion, American Shoulder and Elbow Surgeons scores, SST scores, and SANE scores were noted. Baseplate failure was associated with graft resorption, more retroversion correction, and worse Single Assessment Numeric Evaluation scores. Their results highlight higher clinical failure rates than previously reported with structural grafting. The surgical technique presented here demonstrates the authors' preferred method for performing glenoid bone grafting and single-stage rTSA in the setting of a glenoid dysplasia. The describing author (PF) has performed approximately 75 cases as described previously with excellent success. To his knowledge, there are no known graft failures within that cohort over a 5-year period of performing this technique. In time, a formal outcome article may be warranted. The technique also may be applicable for Walch type B2, B3, or C glenoids. Some tips for successful completion of the procedure include optimizing glenoid exposure through systematic capsular releases, proper graft contouring for optimal compression, preparing the glenoid for biologic incorporation, and using a base plate with a central post or screw that traverses both the graft and most of the native glenoid (Table I). Several components of the describe technique make this procedure unique. Preoperative 3-dimensional CT planning software was used to allow for optimal preparation of the graft and baseplate placement. The whole humeral head was incorporated to allow for lateralization and provide maximal baseplate coverage. Finally, the graft was fixated to the native glenoid and maintained in position through the compression of the baseplate stem. Cortical and locking screws were placed through the baseplate and graft into the native glenoid; however, fixation outside of the baseplate was not required.Table 1Pearls and pitfalls.PearlsPitfalls1.Prepare humeral head before osteotomyExcessive humeral head or bone removal.2.Excellent exposure and capsular releases to allow perpendicular access to the glenoidPoor glenoid exposure, particularly posteriorly may force pin placement off target3.Prepare glenoid defect with high speed bur or drill bitInsufficient humeral head graft (humeral head cyst, deformity, avascular necrosis)4.Contour graft to fit within glenoid defectA baseplate with central post or screw that does not have secure fixation in the native glenoid5.Oversize graft to allow peripheral fixation with or preoperative planning and/or guides may of guide pin placement Open in a The recognize that the optimal treatment for the management of severe glenoid dysplasia in the setting or rTSA is Preoperative of the pathology and imaging evaluation is to and postoperative head autografting low low relative and needed to correct posterior and glenoid R.Z. Broschinsky K. Stertz I. Chalmers P.N. Structural glenoid allograft reconstruction during reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2020; 29: 534-540https://doi.org/10.1016/j.jse.2019.07.011Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Paul a for The that a for not use the planning system described in the article and did not or from this The other their and with they are have not or other from to the of this was by the

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