Review Article 

Surgical Management of Glenohumeral Osteoarthritis With Glenoid Erosion and Static Posterior Subluxation (Walch B2): Techniques, Outcomes, and Survivorship Rates

Ajaykumar Shanmugaraj, BHSc; Mohamed Sarraj, MD; Ryan P. Coughlin, MD, FRCSC; Evan M. Guerrero, MD; Seper Ekhtiari, MD; Olufemi R. Ayeni, MD, PhD, FRCSC; Grant E. Garrigues, MD


The purpose of this study was to systematically assess the surgical techniques and outcomes related to the management of Walch B2 glenoids. PubMed, Medline, and Embase were searched from inception to July 2018. Overall, 24 studies (787 B2 glenoids) were identified. Revision-free survivorship was highest for reverse total shoulder arthroplasty (98.6%) and anatomic total shoulder arthroplasty with asymmetric reaming and a non-augmented glenoid implant (95.6%). Walch B2 glenoids are most commonly managed by asymmetric reaming in the context of anatomic total shoulder arthroplasty, and by the ream-and-run technique in hemiarthroplasty. The optimal treatment strategy remains elusive due to a lack of high-quality, comparative studies with long-term surveillance. [Orthopedics. 2020;43(4):e191–e201.]


The purpose of this study was to systematically assess the surgical techniques and outcomes related to the management of Walch B2 glenoids. PubMed, Medline, and Embase were searched from inception to July 2018. Overall, 24 studies (787 B2 glenoids) were identified. Revision-free survivorship was highest for reverse total shoulder arthroplasty (98.6%) and anatomic total shoulder arthroplasty with asymmetric reaming and a non-augmented glenoid implant (95.6%). Walch B2 glenoids are most commonly managed by asymmetric reaming in the context of anatomic total shoulder arthroplasty, and by the ream-and-run technique in hemiarthroplasty. The optimal treatment strategy remains elusive due to a lack of high-quality, comparative studies with long-term surveillance. [Orthopedics. 2020;43(4):e191–e201.]

Shoulder arthroplasty has been established as a safe and effective surgical intervention for glenohumeral arthritis.1 The Walch classification, which uses axial computed tomography to classify glenoid morphology in the setting of primary glenohumeral arthritis, is widely employed.2 Type B2 glenoids, present in up to 44% of all glenoids treated with shoulder arthroplasty, are characterized by both static posterior subluxation of the humeral head and biconcavity (posterior erosion) of the glenoid.2,3

Once considered a contraindication to arthroplasty,4 glenoid bone loss remains a significant surgical challenge, with no clear consensus between hemiarthroplasty (with and without glenoid reaming), anatomic total shoulder arthroplasty (aTSA) with eccentric reaming and a non-augmented glenoid implant (NAG), aTSA with bone grafting to the glenoid, aTSA with a posterior augmented glenoid component (PAG), and reverse total shoulder arthroplasty (rTSA).4 Hemiarthroplasty using the “ream-and-run” technique avoids the problem of glenoid component loosening; however, similar to other hemiarthroplasty options, it may lead to residual glenoid-based pain and glenoid erosion, especially without careful patient selection.3,5–7 Anatomic total shoulder arthroplasty with a standard glenoid implant is an excellent option for many patients with glenohumeral arthritis with an intact rotator cuff. In patients with Walch B2 glenoids, however, the results have been sobering. Iannotti and Norris8 reported a 3-fold increase in the risk of glenoid loosening when erosion is present. Walch et al9 reported a 21% rate of glenoid loosening at mean follow-up of 6 years. Anatomic total shoulder arthroplasty with concomitant bone grafting has demonstrated mixed results. Neer and Morrison10 reported excellent clinical and radiographic outcomes, but multiple other studies reported high rates of complications, including graft resorption and residual instability.11–13 Anatomic total shoulder arthroplasty with a PAG has emerged as an option to allow version correction without the excessive bone removal and joint-line medialization required for aTSA with a traditional glenoid implant and asymmetric glenoid reaming, but it is not clear which patients will experience resubluxation and potential early glenoid failure.14–16 Reverse total shoulder arthroplasty, a well-established treatment for cuff tear arthropathy, has also emerged as a surgical treatment option in glenohumeral arthritis with eccentric glenoid wear; however, concerns exist regarding its use in younger patients.17,18

Compared with other glenoid subtypes, arthroplasty in patients with B2 (biconcave) glenoids has yielded more complications and mixed clinical outcomes, with no single surgical approach demonstrating clear superiority.8,9,19,20 To the best of the current authors' knowledge, this represents the first systematic review to evaluate the full spectrum of current shoulder arthroplasty management options to address cases of bone loss. Thus, the aims of this systematic review were to (1) determine the revision-free survivorship of shoulder arthroplasty for Walch B2 glenoids and (2) assess the clinical outcomes of the various techniques. The authors hypothesized that rTSA would have a higher revision-free survivorship rate than most techniques, and that all arthroplasty techniques would yield similar outcomes.

Materials and Methods

Search Strategy

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed in the development and execution of this study.21 Three online databases—Embase, Medline, and PubMed—were searched for literature addressing arthroplasty management of Walch B2 glenoids from their inception to July 10, 2018. Examples of search terms included “shoulder,” “glenohumeral joint,” and “glenoid bone loss.” A broad search strategy was used to encompass all relevant articles. The research question and inclusion and exclusion criteria were established a priori. Studies with levels I through IV evidence; about shoulder arthroplasty (ie, anatomic, reverse, and hemiarthroplasty); reporting clinical outcomes; in English; and involving humans were included. Studies reporting non-surgical treatment, with fewer than 5 patients, and about arthroscopy were excluded.

Study Screening

A systematic screening approach in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses was employed in duplicate by 2 independent reviewers (A.S., E.M.G.) from title to full-text screening stages. Discrepancies at the title and abstract stages were resolved by automatic inclusion to ensure that relevant articles were not missed. Discrepancies at the full-text stage were resolved by consensus between the reviewers. A third, senior reviewer (R.P.C.) was consulted if consensus could not be reached. Search terms were entered onto Google Scholar and references of included studies were also screened using the same systematic approach to capture any additional relevant articles.

Quality Assessment of Included Studies

The Methodological Index for Non-Randomized Studies (MINORS) appraisal tool was used to assess the quality of the included, nonrandomized studies (eg, case reports, case series, cohorts) by 2 independent reviewers (A.S., M.S.), with discrepancies resolved by consensus discussion.22 A score of 0, 1, or 2 is given for each of the 12 items on the MINORS checklist, with a maximum score of 16 for non-comparative studies and 24 for comparative studies. Methodologic quality was categorized a priori as follows: a score of 0 to 8 or 0 to 12 was considered poor quality, 9 to 12 or 13 to 18 was considered fair quality, and 13 to 16 or 19 to 24 was considered excellent quality, for non-comparative and comparative studies, respectively.

Data Abstraction

Two reviewers (A.S., M.S.) independently extracted relevant data from included articles and recorded the data onto a spreadsheet designed a priori. Study characteristics including author, year of publication, sample size, study design, level of evidence,23 patient demographics (eg, sex, age), and details of surgical technique were extracted. Furthermore, any information regarding rehabilitation protocols, postoperative outcomes (surgical and radiographic), concomitant lesions, associated procedures, and complications was documented.

Statistical Analysis

On consultation with the study statistician, the high statistical and methodological heterogeneity among included studies precluded performing a meta-analysis. Descriptive statistics such as mean, range, and measures of variance (eg, standard deviations, 95% confidence intervals [CI]) are presented where applicable. An intra-class correlation coefficient (ICC) was used to evaluate inter-reviewer agreement for the MINORS score. A kappa (κ) statistic was used to evaluate inter-reviewer agreement at all screening stages. Agreement was categorized a priori as follows: ICC/κ of 0.81 to 0.99 was considered almost perfect agreement; ICC/κ of 0.61 to 0.80 was substantial agreement; ICC/κ of 0.41 to 0.60 was moderate agreement; ICC/κ of 0.21 to 0.40 was fair agreement; and ICC/κ of 0.20 or less was slight agreement.24



The initial search yielded 8158 studies, of which 21 full-text articles met the inclusion criteria (Figure 1). On review of the references of the included studies and a search on Google Scholar, 3 additional studies were retrieved from the references and included in the review for a total of 24 studies. Of the 24 included studies published between 2007 and 2018, there were 4 prospective cohorts, 7 retrospective cohorts, and 13 case series (Table 1).

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram.

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram.

Study Characteristics

Table 1:

Study Characteristics

Patient Characteristics

A total of 787 B2 glenoids were included in this study, with the patients having a mean age of 65.8±6.6 years; 9 studies did not stratify mean age for patients with B2 glenoids.3,25–32 In this systematic review, included patients underwent aTSA with asymmetric reaming and a NAG (62.3%; n=490; mean age, 66.6±2.3 years; mean follow-up, 62.2±17.6 months), hemiarthroplasty (12.7%; n=100; mean age, 53.3±4.2 years; mean follow-up, 32.5±10.3 months), aTSA with a PAG (11.3%; n=89; mean age, 65.4±0.8 years; mean follow-up, 32.4±19.4 months), rTSA (9.1%; n=72; mean age, 72.5±1.6 years; mean follow-up, 46.3±9.5 months), and aTSA with a humeral head autograft (4.6%; n=36; mean age, 61.1±5.8 years; mean follow-up, 68.5±14.8 months). The mean follow-up across included studies was 45.5±17.4 months; 8 studies did not stratify mean follow-up for patients with B2 glenoids.25–31,33 The mean sample size per included study was 32.8 patients (range, 5 to 92 patients) (Table 1).

Study Quality

The majority of the studies in this systematic review were of level IV evidence (n=13; 54%) (Table 1). There was excellent agreement between reviewers at the title (κ=0.76; 95% CI, 0.74 to 0.78) and the abstract (κ=0.77; 95% CI, 0.74 to 0.82) screening stages and almost perfect agreement at the full-text (κ=0.92; 95% CI, 0.88 to 0.97) screening stage. There was a substantial level of agreement for quality assessment scores using the MINORS criteria (ICC=0.989; 95% CI, 0.973 to 0.995). The mean MINORS scores for non-comparative and comparative studies were 12.3±2.3 and 15.8±2.3, respectively, indicating fair quality of evidence for nonrandomized studies (Table 1). The areas of best performance based on the MINORS checklist were a clearly stated aim and the use of endpoints appropriate to aim, both of which were found in all studies. The area of worst performance was unbiased assessment of endpoints, which was found in only 1 of the 24 included studies (4%).

Surgical Techniques

Common methods for correction of glenoid version and/or posterior bone loss varied between arthroplasty techniques: ream and run (100%; n=100) for hemiarthroplasty; asymmetric reaming (55.6%; n=40), humeral head autograft (25.0%; n=18), and asymmetric reaming and a humeral head autograft (19.4%; n=14) for rTSA; and asymmetric reaming and a NAG (79.7%; n=490), a PAG (14.5%; n=89), and humeral head auto-grafts (5.8%; n=36) for aTSA. None of the included studies reported changing the version of the humeral component (ie, increasing anteversion) to compensate for posterior subluxation. The surgical techniques and rehabilitation protocol of the included studies are summarized in Table 2.

Surgical Techniques and Rehabilitation ProtocolSurgical Techniques and Rehabilitation ProtocolSurgical Techniques and Rehabilitation ProtocolSurgical Techniques and Rehabilitation Protocol

Table 2:

Surgical Techniques and Rehabilitation Protocol

Patient-Reported Outcomes

Patients with B2 glenoid morphology undergoing arthroplasty demonstrated general improvements in patient-reported outcomes. Three studies (n=98)17,20,34 found significant improvements (P<.001) in pain scores (ie, visual analog scale, Constant, and Penn, respectively); 2 studies (n=71)20,34 were aTSA, whereas the remaining study (n=27) was rTSA.17 Four studies (n=128)6,17,20,34 found significant improvements (P<.05) in function scores (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, and Penn, respectively); 1 study was aTSA with asymmetric reaming (n=59),20 1 study was aTSA with a humeral head autograft (n=12),34 1 study was rTSA (n=27),17 and 1 study was hemiarthroplasty (n=30).6 Of 7 studies (n=230) reporting postoperative range of motion,17,32,34–38 3 studies (n=53) found significant improvements (P<.03).17,34,38 One study (n=12)34 using aTSA with a humeral head found significant improvements in external rotation, whereas another study (n=14)38 had significant improvements in active abduction for those patients undergoing aTSA with asymmetric reaming. One study (n=27) treating patients with rTSA found a significant improvement in active forward flexion, active external rotation, and internal rotation.17

One study (n=74) comparing posteriorly augmented and non-augmented glenoids in aTSA found no significant differences in any of the measured postoperative clinical outcomes (eg, Constant, ASES, SST score) or any difference in improvement between the two groups.35 One study (n=14) comparing aTSA with a PAG and rTSA found significantly better SST scores in aTSA (10.6 vs 8.5; P=.01).38 One study (n=92)9 found that patients who underwent a posterior capsulorrhaphy adjunct to aTSA with asymmetric reaming had significantly worse outcomes regarding active elevation (P=.006) and the mobility component of the Constant score (P=.008). Moreover, patients receiving a posterior humeral head autograft to the glenoid (n=7) were statistically associated with worse outcomes for active elevation (P=.001), Constant score (P=.001), mobility (P=.001), activities of daily living (P=.02), and strength (P=.001).9 Finally, 1 study (n=24) determined that patients with A2 glenoids achieved better Constant and Murley scores than patients with B2 glenoids (P=.007).32 However, there were no differences in postoperative shoulder function between B1 and B2 glenoids in that study.32

Radiographic Outcomes

Six studies (n=278) reported the incidence of radiolucent lines on postoperative radiographs.17,19,20,31,35,36 Of those having radiolucent lines (n=108), most patients underwent aTSA with asymmetric reaming (73.1%; n=79; mean follow-up, 52.1±23.0 months), followed by aTSA with a PAG (25.4%; n=27; mean follow-up, 27.3±3.8 months) and rTSA (1.9%; n=2; mean follow-up, 54 months [range, 24–139 months]). Meanwhile, radiographic evidence of postoperative subluxation was reported in 4 studies (n=77),32,38–40 affecting patients undergoing aTSA with a humeral head autograft (n=4), aTSA with a PAG (n=4), aTSA with asymmetric reaming (n=4), and aTSA with asymmetric reaming or humeral head autograft (n=2) (ie, data are not stratified by version correction).39 There were no reports of radiographic postoperative subluxation in the studies of hemiarthroplasty (or rTSA, although this is obviated by the semi-constrained design). Scapular notching was reported in 2 studies (n=32) and evident in 18.1% of those patients undergoing rTSA (n=13).17,26 Finally, radiographic incidence of glenoid loosening was reported in 2 studies (n=170)9,27 and evident in 4.6% (n=28) of all patients undergoing aTSA with asymmetric reaming; no glenoid loosening was reported for patients undergoing rTSA.

Revision-Free Survivorship and Complications

The overall revision-free survivorship rate at final follow-up (mean, 45.5±17.4 months) across included studies was 95.2% (n=749). Revision-free survivorship rates among the techniques were also similar: rTSA (98.6%; n=71; mean follow-up, 46.3±9.5 months), aTSA with asymmetric reaming and a NAG (95.6%; n=469; mean follow-up, 62.2±17.6 months), aTSA with a PAG (96.6%; n=86; mean follow-up, 32.4±19.4 months), hemiarthroplasty (92.0%; n=92; mean follow-up, 32.5±10.3 months), and aTSA with a humeral head autograft (86.1%; n=31; mean follow-up, 68.5±14.8 months). The overall complication rate in this systematic review was 5.3% (n=42). The most common complication was the need for revision surgery (4.8%; n=38), followed by postoperative nerve palsies (0.38%; n=3) and an unspecified complication in a patient receiving aTSA using a NAG component.35 Between arthroplasty techniques, complication rates were highest among aTSA with a humeral head autograft (13.9%; n=5), followed by hemiarthroplasty (8.0%; n=8), rTSA (5.6%; n=4), aTSA with asymmetric reaming (4.5%; n=22), and aTSA with a PAG (3.4%; n=3). Of the hemiarthroplasty patients undergoing revision surgery, 87.5% (n=7) underwent revision to aTSA, whereas the remaining 12.5% (n=1) underwent revision hemiarthroplasty with capsular excision.


Key Findings

The most pertinent finding of this systematic review was the high revision-free survivorship rate across all arthroplasty techniques (94.9% at a mean follow-up of 45.5±17.4 months). The highest survivorship rate was in patients undergoing rTSA (98.6%; mean follow-up, 46.3±9.5 months). These findings should be taken with caution given the relatively short to mid-term follow-up in the setting of arthroplasty and the smaller samples. Moreover, complication rates were similar across all techniques, with the highest rate in those patients undergoing aTSA with a humeral head autograft (13.9%). The most common complication in those patients undergoing hemiarthroplasty was a revision to aTSA (87.5%). Currently in the literature, the most common treatment strategy for this condition is aTSA (78.1%) with asymmetric reaming (79.7%) to correct glenoid retroversion. Finally, the a priori hypothesis that those patients undergoing an rTSA would have a higher revision-free survivorship rate than those patients undergoing most techniques and that all arthroplasty techniques would yield similar outcomes was confirmed.

Although most commonly indicated for cuff tear arthropathy, rTSA has emerged as an alternative to aTSA for treating B2 glenoids.17 The semi-constrained design addresses the static posterior subluxation while the glenoid-sided fixation appears to be robust.27 Gallusser and Farron39 found similar results between patients who received either an aTSA or a rTSA and suggested that rTSA can be an effective alternative regardless of rotator cuff status. In a retrospective cohort, Alentorn-Geli et al37 also found similar clinical outcomes between patients who underwent aTSA vs rTSA. However, these authors expressed strong concern with aTSA given its high rates of radiographic glenoid loosening, cuff insufficiency, and recurrent posterior subluxation.37 Mizuno et al17 found no technical difficulties associated with rTSA and outcomes comparable to those of aTSA, while preventing the recurrence of posterior subluxation of the humeral component. Hence, these authors suggested that rTSA can be used for older patients with a severe biconcave glenoid.17

On the contrary, humeral hemiarthroplasty has been proposed for younger and/or highly active patients with B2 glenoids because of concerns over glenoid component loosening associated with TSA.7,41,42 This technique should theoretically enable patients to engage in activity levels beyond those of TSA; this is important for this patient population, although concerns over glenoid erosion and glenoid-based pain remain.43 As an adjunct to hemiarthroplasty in patients with B2 glenoids, the ream-and-run technique can medialize the humeral head through concentric spherical contouring of the osseous glenoid surface.3 The results of this review indicate that young patients diagnosed with arthritic shoulders and a retroverted biconcave glenoid can be effectively treated with the ream-and-run technique.6,7 However, the authors of these included studies remain concerned over the longevity and durability of hemiarthroplasty for young, active patients, who are theoretically susceptible to low survivorship rates.6,7 Hence, studies with long-term follow-up are required to determine the most effective treatment strategy for young patients with B2 glenoids and methods to reduce intraoperative complications and technical difficulties that may arise during subsequent revision procedures. Although there is some debate regarding whether patients undergoing hemiarthroplasty with the ream-and-run procedure have higher rates of postoperative pain and stiffness, the current authors were unable to compare results with those of patients undergoing aTSA and/or rTSA due to a lack of comparative studies.

Glenoid reconstruction with humeral head bone autograft may be considered when the amount of bone loss present prevents the placement of a standard implant.4,44–46 This strategy is contraindicated when the amount of bone loss is so severe that a stable graft–implant construct is unattainable.4 In a case series of 25 patients (28 shoulders), Steinmann and Cofield11 performed glenoid bone grafting with humeral head autografts for segmental glenoid wear during aTSA. These authors reported that glenoid erosion is often found in patients with primary or secondary osteoarthritis. Posterior glenoid bone loss was identified in 25 of the 28 shoulders. Almost 70% of the patients had good or excellent clinical results; however, 14% had complete graft lucency. In this review, patients treated with a bone graft primarily underwent revision due to either septic necrosis of the bone graft,39 aseptic glenoid loosening,40 or issues with graft healing/fixation.9,34 Included patients showed improvements in clinical outcomes postoperatively, with conflicting findings in radiographic outcomes.34,40

Anatomic total shoulder arthroplasty with a PAG is another alternative to asymmetric reaming and bone grafting for those patients with posterior bone loss; this theoretically offers improved biomechanical properties, less joint-line medialization, preservation of glenoid bone stock, and less shear stress at the implant–bone interface.14,15,47,48 Moreover, ensuring precise and reliable component seating can prevent implant loosening that is caused by edge loading, which causes lifting of the opposite edge of the component away from the bone.42,49 Although asymmetric reaming is more commonly performed, there may be a limit to the degree of correction, as greater than 15° of correction can compromise the subchondral bone anteriorly and result in the penetration of the glenoid pegs beyond the glenoid vault.44,50–52 Luedke et al53 conducted a systematic review assessing the outcomes of aTSA in patients with B2 glenoids. In contrast to the current review, Luedke et al53 did not include studies evaluating rTSA or hemiarthroplasty. In their review, PAGs appeared to have better outcomes with fewer complications compared with glenoid bone grafting and asymmetric reaming. In the current review, 2 studies compared PAGs with non-augmented glenoids, both finding no statistical clinical differences in outcomes at a minimum of 2-year follow-up.35,36 However, patients undergoing aTSA with a PAG experienced a higher incidence of radiolucent lines.35,36 Stephens et al49 also investigated the use of PAGs for patients with posterior bone loss with varying degrees of glenoid retroversion (ie, Walch B2/C morphology). These authors found that PAGs led to improved short-term (ie, 2-year follow-up) clinical outcomes without any evidence of complications or implant failure. Unfortunately, none of the included studies in this review compared aTSA using a PAG with rTSA.17


This review was limited by the quality of evidence available. Most notably, included studies had poor documentation of data (ie, failing to stratify results by glenoid type), were primarily of level III evidence, had moderate follow-up, and had small samples. Consequently, the current authors' ability to assess outcomes, complications (eg, revision-free survivorship), and effectiveness in treating B2 glenoids during shoulder arthroplasty was limited. An optimal arthroplasty technique (ie, anatomic arthroplasty, reverse arthroplasty, or hemiarthroplasty) for this patient population was also difficult to ascertain because included studies did not report the indications for such techniques based on the amount of bone loss and/or retroversion. Moreover, although studies describing patients as having a B2 glenoid explicitly or implicitly (ie, posterior glenoid bone loss, with the humeral head retroverted and posteriorly subluxated) were included, some studies published prior to the widespread adaptation of the Walch classification and recognition of the importance of humeral head subluxation and posterior glenoid erosion certainly could have been excluded if the text was not specific regarding the glenoid pathology of treated patients. Furthermore, the difference in average patient age of included studies suggests that surgeons in the published studies tended to use rTSA for their older patients (mean, 72.5±1.6 years), aTSA for patients who were slightly younger (asymmetric reaming and a NAG: mean, 66.6±2.3 years; PAG: mean, 65.4±0.8 years; and humeral head autograft: mean, 61.1±5.8 years), and hemiarthroplasty (mean, 53.3±4.2 years) more frequently for the youngest patients. Clearly, this should be taken as a caveat when the authors directly compared outcomes between the various arthroplasty strategies. Some additional limitations of this review given the nature of the specific patient population were expertise bias and the generalizability of the results. Finally, the high statistical and methodological heterogeneity among included studies precluded a meta-analysis.

Future Directions

Future studies should prioritize thorough data reporting (eg, demographics, surgical techniques, patient-reported outcomes, and complications) for patients undergoing shoulder arthroplasty by glenoid type specified through explicit clinical and/or radiographic criteria. Although asymmetric reaming was commonly reported in this review, studies comparing different arthroplasty techniques (eg, aTSA vs rTSA) and/or methods of glenoid retroversion correction (eg, aTSA with asymmetric reaming vs a PAG or aTSA with a PAG vs rTSA) were few. More are required to better guide clinicians treating this patient population.


Walch B2 glenoids are most commonly managed by asymmetric reaming in the context of aTSA, and by ream and run in hemiarthroplasty. The optimal treatment strategy remains elusive because high-quality, comparative studies with long-term surveillance are lacking.


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Study Characteristics

Study (Year)Study Design (Level of Evidence)No. in Total SampleNo. of B2 GlenoidsMaleMean Age (SD or Range), yMean Follow-up (SD or Range), moConsensus MINORS Scorea
Orvets et al20 (2018)Case series (IV)595961%65 (38–94)50 (24–97)13/16
Alentorn-Geli et al37 (2018)Retrospective cohort (III)3131NR71.5 (1.4)38.8 (5.4)13/24
Harmsen et al33 (2017)Case series (IV)291662%70.1 (46–87)34.6 (23.7–88.9)b13/16
Getz et al7 (2017)Case series (IV)2424100%50 (32–62.3)44.4 (28.8–58.8)9/16
Somerson et al3 (2017)Case series (IV)1114695%b60 (35–80)b2411/16
Service et al54 (2017)Prospective cohort (III)2012556%67.4 (41.8–81.3)30.8 (23.2–43.2)17/24
Wright et al35 (2017)Retrospective cohort (III)747468%65NR, minimum 2412/24
Leschinger et al25 (2017)Prospective cohort (III)1032724%b66 (37–83)b77.6 (36–140)b10/16
McFarland et al26 (2016)Retrospective cohort (III)53545%b71 (53–89)b36 (24–66)b11/16
Chin et al19 (2015)Retrospective cohort (III)1124839%68.760 (23–120)16/24
Matsen et al6 (2015)Case series (IV)30307%56 (8)36 (24–110.4)11/16
Wright et al36 (2015)Retrospective cohort (III)484871%65.8 (11.5)29.5 (0.1)14/24
Hussey et al27 (2015)Prospective cohort (III)3447872%67 (37–88)b50.7 (24–110)b19/24
Gallusser and Farron39 (2014)Case series (IV)272771%70 (47–85)43 (24–69)13/16
Klika et al40 (2014)Case series (IV)251242%67.183.6412/16
Cil et al28 (2014)Case series (IV)3514NR65 (34–84)b87.6 (24–228)b15/24
Mizuno et al17 (2013)Retrospective cohort (III)272719%74.1 (66–82)54 (24–139)17/24
De Wilde et al29 (2013)Case series (IV)342126%b68 (52–79)b28.3 (24–48)b13/16
Denard et al30 (2013)Case series (IV)521156%b50.5 (35–55)b115.5 (60–211)b11/16
Greiner et al31 (2013)Case series (IV)932226%b66.6 (30–85)b58.8 (31.2–92.5)b10/16
Sabesan et al34 (2013)Case series (IV)121292%55.8 (8.4, 46–74)53 (28, 26–110)12/16
Walch et al9 (2012)Case series (IV)929239%68 (50–85)77 (14–180)13/16
Rice et al38 (2008)Retrospective cohort (III)141492%66 (52–78)60 (25.2–96)13/16
Habermeyer et al32 (2007)Prospective cohort (II)772439%b67.6 (47–85)b24 (12–84)17/24

Surgical Techniques and Rehabilitation Protocol

StudyArthroplasty TechniqueGlenoid Version CorrectionRehabilitation ProtocolComplications and Treatment
Orvets et al20aTSAAsymmetric, high side reamingNot reportedOne patient underwent revision to a reverse shoulder arthroplasty for a symptomatic posterosuperior rotator cuff tear
Harmsen et al33rTSAShaped humeral head autograftImmobilized with sling and abduction pillow for 4 to 6 weeks Physiotherapy after 4 to 6 weeks and progression of activities as toleratedNot reported
Getz et al7HAReam and runPassive supine elevation (140°) and external rotation (40°) on the first postoperative day Home exercises first 4 to 6 weeks and then outpatient therapy, with full passive and active assisted ROM Posterior cuff strengthening 6 weeks postoperatively Deltoid strengthening 3 months postoperatively6 required revision surgery 5 of 6 underwent aTSA, 1 of 6 underwent revision HA with capsular excision; no other complications
Somerson et al3HAReam and runNot reportedNot reported
Service et al54aTSAAsymmetric reamingImmediate supine active assisted forward elevation exercises to 150° and progressed to strengthening exercises at 6 weeks postoperatively2 revision surgeries
Wright et al35aTSAPAG (n=37), NAG glenoid (n=37)Not reported1 complication for the NAG group, not specified
Alentorn-Geli et al37aTSA (n=15) rTSA (n=16)aTSA: Asymmetric reaming rTSA: Asymmetric reaming; humeral head autograft (n=4)Not reportedNot reported
Leschinger et al25aTSAAsymmetric glenoid reamingNot reportedNot reported
McFarland et al26rTSAAsymmetric glenoid reamingFinger, wrist, and elbow motion on the first postoperative day and pendulum exercises after 2 weeks All exercises performed on own Avoid heavy lifting or using the arms repetitively over the shoulder levelNot reported
Chin et al19aTSAAsymmetric glenoid reamingSling with an abduction pillow to wear for 4 weeks1 revision due to failed subscapular repair
Matsen et al6HAReam and runPrescriptions for physical therapy provided when necessary Exercises done on own Return to desired activities progressively as tolerated No limits on physical activities after 3 months2 requested revision to aTSA within 1 year due to dissatisfaction with rehabilitation
Wright et al36aTSAPAG (n=24), NAG (n=24)Not reportedNot reported
Hussey et al27aTSAAsymmetric glenoid reamingPostoperative day 1—passive pendulum exercises Immobilizer worn at all times for first 6 weeks Passive and active assisted ROM for first 6 weeks Progressive strengthening at 12 weeks postoperatively Formal physical therapy not routinely usedNot reported
Gallusser and Farron39aTSA (n=19) rTSA (n=8)aTSA—Anterior reaming (n=14) or humeral head autograft (n=5) rTSA—Anterior reaming (n=6) or humeral head autograft (n=2)Not reported2 aTSA patients required revision One patient, treated with asymmetric reaming for glenoid correction, had recurrent posterior subluxation at 6 weeks and complete dislocation at 3 months. Revised with rTSA and good final outcome. The other due to septic necrosis of bone graft, treated with debridement and removal of all implants and cement, followed by implantation of a cement spacer with antibiotics. Evolution was satisfactory during 3 years and the patient refused reimplantation of an rTSA.
Klika et al40aTSAStructural bone grafting with a humeral head autograft and screw fixationNot reported2 revision aTSAs, both for aseptic glenoid loosening and pain
Cil et al28aTSANon-standard glenoid componentaNot reported3 revisions, 1 due to infection, 2 due to early postoperative instability with persistent posterior dislocation not able to correct with nonstandard glenoid components 3 clinical failures, 1 radiographic failure
Mizuno et al17rTSAAsymmetric glenoid reaming with or without humeral head autograft (n=10)Immobilized with a simple sling in internal rotation for 4 weeks to protect the subscapularis repair Sling removed for hygiene and patient allowed to use hand for simple activities of daily living No lifting allowed Pendulum exercises initiated 3 days after surgery Sling discontinued 4 weeks postoperatively and activity allowed as tolerated4 patients had complications 1 of 4 was a revision due to glenoid component loosening resolved with an HA 3 patients with postoperative nerve palsies 1 patient had a transient axillary nerve palsy resolved 12 months postoperatively 2 patients had an ulnar nerve palsy; 1 patient had a transient palsy of sensory function and 1 had a permanent palsy of motor and sensory function
De Wilde et al29aTSAAnterior glenoid reamingBeyond the limits of pain sensation, no limits of forward elevation, neither lifting of the shoulder nor external rotation were advocated, and no sling was used A suction drain was removed after 24 hours At 6 weeks, a physical therapy and strengthening program, if desired, could be startedNot reported
Denard et al30aTSAGlenoid reaming followed by compaction of a keel slot or avoiding reaming and by using a curettage techniqueNot reportedGlenoid survival rate at final follow-up was 10 of 11 (90.9%). This patient required removal of the glenoid.
Greiner et al31aTSAConsecutive eccentric reamingRehabilitation program started on the first post-operative day with passive exercises After 6 to 8 weeks, active rehabilitation was startedNot reported
Sabesan et al34aTSAHumeral head autograftDelay in starting cross-body adduction stretching (at 6 weeks rather than at 2 weeks) Wear a small pillow abduction sling for 2 to 4 weeks, after which passive supine forward flexion and external rotation stretching is started 6 weeks after surgery, passive cross-body adduction, active elevation, and short arc Thera-Band (Hygenic, Akron, Ohio) strengthening exercises are begun More advanced strengthening was progressed on an individualized basis2 shoulders had complications associated with healing of the graft and graft fixation that required revision surgery Both had their glenoid components removed and revised with HA; 1 revised with tricortical iliac crest bone graft and antibiotic cement
Walch et al9aTSAAsymmetric glenoid reaming (n=85), humeral head autograft (n=7)In the postoperative period, patients wore either a brace in neutral rotation (if shoulder was posteriorly unstable in internal rotation) or a simple sling. Discontinued after 4 weeks. Patients underwent rehabilitation, consisting of passive ROM exercises and hydrotherapy, with an outpatient physiotherapist or at an inpatient rehabilitation facility15 shoulders underwent revision for a complication; 11 of these shoulders underwent revision with implant revision 6 shoulders had revision performed because of glenoid loosening: 3 revised with structural tricortical iliac crest bone graft and HA; 2 had removal of glenoid component; and 1 revised with iliac crest bone graft and rTSA 5 shoulders had revision performed due to posterior prosthesis dislocation: 3 underwent revision surgery to reorient the glenoid and perform a posterior capsulorraphy with eventual removal of glenoid components; and 2 presented with late posterior instability and underwent glenoid reconstruction and revision to reverse shoulder arthroplasty 4 had complications requiring reoperations without implant revision: 1 had refractory capsulitis and underwent arthrolysis 12 months postoperatively; 1 had a traumatic subscapularis tear, which was repaired at 6 weeks after the arthroplasty; 1 with a persistent painful shoulder underwent a biceps tenotomy; and 1 was diagnosed with impingement syndrome and had an arthroscopic subacromial decompression
Rice et al38aTSAPAGThe limb was then protected in a shoulder immobilizer or sling for 5 to 6 weeks A passive motion program for the shoulder was started on day 1 within limits The active assisted motion program started at 5 to 6 weeks, as did isometric strengthening At 2 to 3 months, stretching and more progressive strengthening beganNot reported
Habermeyer et al32aTSADid not distinguish between B1 and B2 glenoids Eccentric reaming with or without bone graft for these patientsNot reportedNot reported

The authors are from the Division of Orthopaedic Surgery, Department of Surgery (AS, RPC, SE, ORA), DeGroote School of Medicine (MS), and the Department of Health Research Methods, Evidence, and Impact (OAR), McMaster University, Hamilton, Ontario, Canada; the Department of Orthopaedic Surgery (EMG), Duke University Medical Center, Durham, North Carolina; and Midwest Orthopaedics at Rush (GEG), Rush University Medical Center, Chicago, Illinois.

Mr Shanmugaraj, Dr Sarraj, Dr Coughlin, Dr Guerrero, and Dr Ekhtiari have no relevant financial relationships to disclose. Dr Ayeni is on the speaker's bureau of Smith & Nephew and Conmed. Dr Garrigues is a paid consultant for DJO, Mitek, and Wright Tornier; is a paid presenter for DJO and Wright Tornier; has received research support from Wright Tornier, Arthrex, DJO, and South Tech; receives royalties from DJO and Wright Tornier; and holds stock in Genesys.

Correspondence should be addressed to: Grant E. Garrigues, MD, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612 ( grant.garrigues@rushortho.com).

Received: March 06, 2019
Accepted: May 06, 2019
Posted Online: April 23, 2020


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