How To Repair Worn Out Glenoid Cavity

Curr Rev Musculoskelet Med. 2022 Dec; four(iv): 191–199.

The glenoid in total shoulder arthroplasty

Mark Schrumpf

Infirmary for Special Surgery, 535 E 70th St., New York, NY 10021 USA

Travis Maak

Infirmary for Special Surgery, 535 E 70th St., New York, NY 10021 USA

Sommer Hammoud

Hospital for Special Surgery, 535 Due east 70th St., New York, NY 10021 United states of america

Edward V. Craig

Infirmary for Special Surgery, 535 E 70th St., New York, NY 10021 The states

Abstruse

Direction of glenohumeral arthrosis with a total shoulder prosthesis is becoming increasingly mutual. All the same, failure of the glenoid component remains one of the nearly common causes for failure. Our understanding of this trouble has evolved greatly since the first implants were placed in the 1970's. However glenoid failure remains a challenging problem to address and manage. This commodity reviews the current noesis regarding the glenoid in total shoulder arthroplasty touching on anatomy, component pattern, implant fixation, causes of implant failure, direction of glenoid failure and alternatives to glenoid replacement.

Keywords: Total shoulder arthroplasty, Glenoid component, Hybrid glenoid, Radiolucent lines, Glenoid loosing, Glenoid component failure

Introduction

Shoulder arthroplasty dates back to 1893 when Jules-Émile Péan, a French surgeon, implanted a platinum and prophylactic prosthesis to replace a glenohumeral joint that had been destroyed past tuberculosis [1]. Very little progress was made in pattern and function until 1951 when Charles Neer developed an unconstrained Vitallium prosthesis for the treatment of proximal humerus fractures [2, 3]. Over fourth dimension Neer sought to develop a shoulder prosthesis that would besides afford patients with glenohumeral arthritis pain relief and introduced a glenoid resurfacing component.

Influenced by the success of total hip arthroplasty, Neer adult the outset modern full shoulder prosthesis, the Neer Ii (Smith & Nephew, Memphis, TN). The Neer II was introduced in 1974 and consisted of a redesigned humeral component and an all-polyethylene glenoid resurfacing component. Over 70 different shoulder prosthetic systems have been developed since the introduction of Neer's initial design in 1974.

Indications for shoulder arthroplasty currently include severe proximal humeral fractures, main glenohumeral osteoarthritis, post-traumatic arthritis, shoulder girdle tumors, osteonecrosis, and failed shoulder arthroplasty. Although Charles Neer'due south original prosthesis underwent several modifications, the Neer type humeral component has largely persisted [two, 4–10].

Native glenoid anatomy

Anatomic parameters of the glenoid relevant to prosthesis design and placement include glenoid elevation, width, inclination, and shape, and version. The considerable natural variability in these parameters, as demonstrated in cadaveric studies, affects prosthesis design, instrumentation, and intraoperative implantation techniques.

The normal glenoid crenel is shaped like an inverted comma, with a narrow upper superior field (the tail of the comma) and a broad inferior field (the head of the comma) [eleven]. Glenoid height is defined as the altitude from the virtually superior and inferior points on the glenoid where as width is the altitude from most anterior to posterior points. Hateful glenoid elevation has been reported to range from 35.ane to 39 mm [12–xv]. Churchill et al. and Mallon both reported on gender differences in glenoid size with Churchill concluding that in that location is an average difference of iv.9 mm while Mallon concluded that the difference is only 1.viii mm [16, 17]. Iannotti et al. reported a hateful upper glenoid width of 23 mm (range, 18–30 mm) and a mean lower glenoid width of 29 mm (range, 21–35 mm) [xiv]. Other authors accept reported widths ranging from 28.3 mm to 23.6 [13, 16, 17].

Glenoid version is defined as the athwart orientation of the axis of the glenoid articular surface relative to the long (transverse) centrality of the scapula. Churchill et al. reported that on average the glenoid has 1.2° of retroversion (range, 9.5° anteversion-10.5° retroversion), while Saha noted that 75% of shoulders had retroverted glenoids and 25% were anteverted [sixteen, xviii].

Patho-beefcake

Glenoid habiliment frequently accompanies glenoid arthritis. Walch et al. classified the various glenoid wear patterns in the arthritic glenoid [19]. Posterior subluxation of the humeral caput was observed in 45% of the cases. The main glenoid types were defined every bit Types A, B, and C. Type A (59%) features a well-centered humeral caput with symmetric erosion and the absence of humeral head subluxation. Blazon B (32%) is characterized by posterior humeral head subluxation with a posterior glenoid habiliment blueprint. Type C (9%) was defined by glenoid retroversion of more than than 25°, regardless of erosion.

Cofield and Matsen have described posterior glenoid wear with varying degrees of posterior subluxation of the humeral head as the most common pattern of glenoid wear for master osteoarthritis [20, 21]. An internal rotation contracture oftentimes develops as the condition progresses increasing contact of the humeral head with the posterior aspect of the glenoid. Posteriorly worn glenoids are also associated with posterior instability [4, 20, 22, 23].

Glenoid involvement varies with respect to the blazon of arthritic procedure affecting the glenohumeral joint [xx, 21] Inflammatory arthritis is often associated with cardinal, symmetric glenoid erosion, which may be accompanied by cysts inside the glenoid vault [twenty]. Anterior glenoid erosion may as well be encountered, but is much less mutual. Assessment of extent and location of glenoid wear should be done preoperatively with axillary radiographs, axial CT scans, and 3D CT reconstructions.

The techniques generally used to address nonconcentric glenoid wear include eccentric anterior reaming of the glenoid or the use of bone grafting to correct glenoid version and meliorate fixation. Augmented glenoid designs have besides been proposed [24]. In lodge to appraise the corporeality of correction that can be achieved with eccentric anterior reaming, Gillespie et al. conducted a cadaveric analysis of 8 specimens [25]. They institute that anterior reaming to correct a posterior defect of 10° resulted in a meaning decrease in glenoid diameter (26.7 ± 2.5 mm to 23.8 ± 3.one mm, p = 0.006). Furthermore, afterwards correcting for fifteen° of posterior bone loss, placement of a glenoid prosthesis was non possible in 50% of the specimens. Their results led them to recommend os grafting with defects requiring more than 10° of inductive correction [25]. Clavert et al., in a like study, concluded that glenoid retroversion of 15° or more cannot be satisfactorily corrected simply by reaming to lower the anterior border of the glenoid and restore neutral version when using a glenoid component with peripheral pegs [26].

Management of the glenoid

When the determination has been fabricated to replace or resurface the glenoid many choices remain about the all-time means to reach long-term hurting free shoulder. The anatomy of the glenoid vault makes achieving stable fixation a challenge even in the all-time circumstances. Implant loosing continues to be a common trouble. The options on how to accost the glenoid range from biologic solutions to ream and run to polyethylene and metal components. Well-nigh traditional total shoulder designs rely on some combination of polyethylene and metal. In the following sections we will review some of the major factors in implant design and placement.

Component types

There are two major shapes for glenoid component that are currently bachelor—anatomic and oval. In that location are minimal data demonstrating performance for either type, while both have theoretical advantages. An anatomically shaped glenoid simulates the normal, pear-shaped glenoid. The theoretical advantage of this component design is to avoid internal impingement of soft tissues on the polyethylene component. Nevertheless, this pear shape as well reduces the contact surface area and may increment the risk of dislocation [27]. The oval design, on the other manus, mimics the arthritic glenoid and theoretically utilizes the pathologically enlarged glenoid to maximize articular surface expanse. The increased superior wall peak may decrease the run a risk for dislocation [28, 29].

Glenohumeral implant conformity

Conformity of the glenohumeral total shoulder articulation has significant touch on the biomechanics of the joint, specifically loading and stability. The degree of conformity is direct related to the relative matching the surface of the glenoid and humeral caput components. An equal convexity and concavity volition result in a humeral head position that is directly dictated by pinch into the glenoid concavity [21, 30]. The conforming design has the theoretical reward that information technology more evenly distributes load to the glenoid. However, this compression constrains the humeral component such that translation cannot occur without glenohumeral separation and edge loading of the glenoid [31]. A number of authors accept suggested that a glenoid radius of curvature greater than that of the humeral component ("radial mismatch") may decrease the risk of glenoid loosening [28, 31–37], [38•]. Nho et. al. reported on a retrieval study comparing conforming and non-conforming glenoid components where they showed a loosing score of iii.2 in the conforming grouping compared to 2.4 in the not-conforming group [38•]. This reduced loosening may be due to a reduction in edge loading.

However a balance must exist achieved betwixt over- and under-befitting articulations, as prior data have documented increased polyethylene habiliment, fracture and decreased articulation stability with minimally conforming designs [31]. Walch et al. evaluated radiolucent lines and Constant scores in 319 TSAs with four dissimilar radial mismatch groups [31]. The groups studied were: <4 mm, 4.five–five.5 mm, six–7 mm, and vii–10 mm. The fewest radiolucent lines were seen in the 7–10 mm group and the highest hateful Constant scores were documented in the six–seven mm group. These information led the authors to conclude that the optimal radial mismatch both clinically and radiographically is 6–7 mm.

Component fixation

The techniques that take been described to set the glenoid component include cemented all poly components with keels and pegs, metallic backed components with and without in-growth designs, screws and finally hybrid designs that utilise both cemented poly and in-growth metal [39]. No one single fixation modality has become the standard method, reflecting the continued interest in developing a more durable construct with greater implant longevity.

Clinical results for glenoid replacement

Optimizing component design has been extensively studied through many retrospective studies. The experience of the Mayo Clinic was recently reviewed for half-dozen different of implant designs placed at the same institution over xx years [40••]. These included the Neer 2 all poly, Neer II metal-backed, Cofield I metal backed in-growth (Smith & Nephew, Memphis, TN), Cofield I all poly, Cofield II all poly keeled and Cofield II all poly pegged (Smith & Nephew, Memphis, TN). One hundred twenty-five shoulders were revised due to glenoid failure. Survival rates for the different designs ranged from 95% to 67%. The authors concluded that glenoid component type was significantly associated with revision. The poorest survival seen for the Cofield 1 metal backed components while the best results were seen with the all Poly Neer II.

In another comparing between metal backed implants and all poly keeled components Boileau et al. performed a prospective randomized controlled study using the same organisation with two different glenoid designs [41]. Forty shoulders were randomized to keeled vs metal backed designs with expansion screws. At 3 yr follow up the authors documented a 20% failure of the metal group vs 0% in the keeled group. Additional studies have also institute troublingly high rates of both clinical and radiographic failure for metal backed components. Taunton, et al. studied metal backed glenoid components with a mean 9.v-year follow-up. The documented five-year survival of 79.nine% and 10-year survival of 51.9% led the authors to raise significant concerns regarding the employ of metal backed, non-cemented glenoid components [42•].

Alternatively, meliorate results have been reported for some metal backed designs. Specifically, Cloudless et al. showed a 91.vii% 5 twelvemonth survival and a 89% 10 year survival in rheumatoid patients using the Bio-modular (Biomet Warsaw, Indiana) implant [43]. They posited that the apply of a screw construct, a fully coated bone in-growth surface at the bone interface and a depression profile tray were disquisitional factors in their improved survival. Likewise Castagna reported promising results in a series of 35 glenoids stabilized with screws and a big hallow central peg with a bone in-growth surface [44]. They had no patients who needed revision of their glenoid components during their follow upwardly.

Cemented all poly designs

The feel with metal backed designs tin at all-time exist described every bit mixed. An alternative to metallic backed designs is a traditional all poly cemented design. This style of glenoid implant has been used for many years with good clinical success. The first total shoulder arthroplasty implanted by Dr. Neer in the early 1970's used an all poly keeled cemented component. He observed no loosing the glenoid component; though he merely had 37 months of follow upwardly and he observed 30% rate of clear-cut lines the majority of which were seen on the initial post operative x-rays [4]. Similar results have been shown by Cofield who showed 19.2% of glenoids 2 weeks afterwards implantation had lucent lines and an additional 31.v% develop in the offset ii months [5].

Gartsman et al. prospectively compared pegged and keeled components and documented periprosthetic radiolucency in 39% of keeled components, every bit compared to just v% of pegged components at half dozen week follow-upwardly [45]. Moreover, the extent of radiolucency was greater with the keeled components. Prior two-year follow-upwardly information has demonstrated that keeled components experienced significantly increased translation and rotation, equally compared to pegged components [46].

In add-on to pegs and keels component fixation is likewise influenced by the geometry of the glenoid component-os articulation. Flat and curve-backed cemented components take been studied in this regard. Two-yr follow-up radiographic data from 66 TSAs documented optimal component seating in 65% of curved dorsum, equally compared to 26% of flat-back components [47]. Moreover, at terminal follow-up, increased radiolucency was documented in apartment-backed components. These information were further substantiated past laboratory and finite element analyses that documented both reduced lark and peak strains with curved-dorsum glenoid components [22, 32].

One caption for the observed early radiolucency has been offered by Churchill. They posit that the estrus generated with the exothermic reaction during the curing of poplymethylmethacrylate cement is responsible for os necrosis [48]. They showed that during curing of the cement that the temperature reached an boilerplate of 64.7°Centigrade. These observed temperatures were well in excess of the 56°Centigrade known to cause bone necrosis.

An alternative explanation for the lucency is cementing technique. "Modern" technique has been shown to improve radiographic results simply the verbal definition of modern technique remains somewhat unclear. A number of authors including Norris, Mileti and Kasten have all written on the "modern" technique for fixation though there is considerable variation in what that ways [49–51]. Common elements to modern technique include lavage and drying of the vault and cement pressurization into the glenoid with a syringe [52].

Hybrid glenoid

As an alternative to either a metal backed component or an all poly cemented glenoid the senior author (EVC) prefers to use a hybrid glenoid. Hybrid fixation is a combination of the 2 main forms of fixation, cemented and metal backed in-growth [39]. Our preferred component for primary osteoarthritis uses 3 outer pegs with a porous titanium in-growth primal peg [Encounter Fig.1]. Nosotros believe that this design combines the benefits of a cemented all poly pegged construct with multiple points of firsthand fixation that resist sheer forces and the characteristic of long term incorporation with an in-growth metal peg. We feel that with expert incorporation of the porous cardinal peg the issues that have been observed with osteolysis and loosing over the long term will be avoided. Additionally, the outer cemented pegs with their power to immediately resist sheer forces allow for a stable environment where solid bony incorporation can occur forth the cardinal in-growth peg. Preliminary information from this glenoid has shown improved clinical scores for both UCLA and SST, and range of motion at ii year follow upward on 54 shoulders [53]. Further forth the central os in-growth peg in that location were no lucencies greater than 1 mm [53]. All of the titanium porous in-growth implants showed radiographic bear witness of incorporation past ane yr [53]. Finally, at 2 yr follow up no patients showed either clinically significant or progressive lucency though longer follow up is clearly needed [53].

Preferred glenoid implant of the senior author (EVC) using a titanium pourous ingrowth central peg with 3 outer pegs fixed with cement. Radiograph shows incorporation of the primal peg at ii year follow upward

Ane boosted author has published on a glenoid component which also uses a combination of minimal cement and biologic incorporation. Their implant uses radial fins on the central peg that are packed with bone graft from the glenoid reaming and peripherally cemented pegs [54]. They used CT scans to evaluate the os implant interface in 35 patients, they were able to testify bone between the fins in a half dozen compartments in 23/35 shoulders and on average iv.5/vi compartments had os. By apparently radiographs the hateful Lazarus radiolucency scores were 0.45 at 43 months. A similar written report with promising results was also recently reported by Churchill with 5 twelvemonth follow upwardly, though CT scans were not used to evaluate the os implant interface [55]. The use of minimally cemented glenoid components with some grade of in-growth potential is an exciting tendency in glenoid fixation. We volition have to await more than data before the efficacy of this hybrid concept tin can be fully adamant.

Long term complications

Glenoid failure tin can be broken downwardly into a number of distinct categories. These include component failure, inadequate seating the component, failure of fixation, and osteolysis. Glenoid loosing can bulldoze many symptoms including increased pain, decreased shoulder function and may eventually pb to the need for revision surgery. Loosing occurs in equally many as 96% per centum of implanted glenoids if we assume that lucent lines are indicative of loosening [39]. The charge per unit of revision due to symptomatic loosing is significantly lower, even so the rate is still troublingly high with published rates equally high as 13% [40••].

Component failure is typified by changes in the poly portion of the component after implantation. These changes include pitting and tertiary torso clothing which has been shown to be associated with osteolysis [56]. Additionally, cold menses and wear contribute to the thinning and eventual failure of the poly in the glenoid components [57]. Catastrophic failure of the poly can occur from these processes though they are more commonly associated with sterilization by radiation in air [58].

When the bone stock of the glenoid has non been adequately prepared or when the component fails to fully seat on the surface the risk of micromotion, fatigue and eventual clinical loosing is pregnant. It has been shown that when the surface has been prepared thoroughly and the component seats the risk of wobble and warp are minimized [29]. In a clinical series of 328 glenoids Lazarus showed that 1/3 were poorly seated. Further they showed that the keeled implants seated more poorly than the pegged versions [59].

Matsen has popularized the concept of "the rocking equus caballus glenoid" phenomenon which is believed to exist a significant source of glenoid loosing [60]. The phenomenon is acquired by eccentric loading on one edge of the component causing the opposite edge to lift off the glenoid bone. This machinery is thought to lead to loosening in the setting of rotator cuff tears equally well as component mal positioning. Component positioning primarily varies in a superior-inferior dimension such that placement of the glenoid or humeral components in suboptimal positions may increase the risk of glenoid border loading and the resultant "rocking horse" miracle. Farron reported on a finite chemical element analysis that lends acceptance to Matsen'southward rocking horse theory [61]. They showed that glenoid retroversion lead to a 700% increase in micro-motion and a 326% increase in stress at the os-cement interface compared to neutrally oriented components. Hopkins too reported on a finite element analysis examining the office of implant position on stability. Those implanted centrally had the lowest potential for failure. Where equally those implanted superiorly or inferiorly inclined have the greatest potential for failure [62].

Rotator gage insufficiency likewise leads to eccentric loading and the rocking equus caballus phenomenon. Anteroposterior eccentric loading can occur with massive subscapularis ruptures, or more commonly, failure of the operative repair of the subscapularis [63–65]. Massive supraspinatus and infraspinatus insufficiency tin produce superior migration of the humeral component producing a relative malpositioning and eccentric loading of the glenoid [9, 29, 32, 60, 66, 67].

In addition to poor seating, eccentric loading, and failure of the poly, resorption of the bony support for the glenoid also leads to implant failure. As has been well documented, radiolucent lines are unremarkably seen at the bone cement interface in many glenoid components [39, forty••, 42•, 44, 48, 50, 51, 54, 55, 57, 60, 62]. The postulated causes of this os loss are motility, oestrus induced necrosis, and infection. Kepler has shown that osteolysis is most associated with screw fixation of the glenoid component and third torso ware [56]. When the loss becomes farthermost it may result of the loss stability of the glenoid component.

Predictors of failure

Some authors take isolated predictive factors that pb to glenoid failure. In one series of mid to long term follow-up Play a trick on et. al. were able to show that in improver to specific implants with poorer rails records, male person gender, and post-traumatic or avascular necrosis (as opposed to degenerative arthritis) lead to increased rates of revision [forty••]. In their multiple regression assay male person gender had a gamble ratio(60 minutes) of 2.two, postal service-traumatic arthritis had a HR of 1.8 and avascular necrosis had a HR of 2.vii. Additionally, it has been observed that patients with deficient rotator cuffs have increased rates of glenoid failure, as well equally glenohumeral instability [57, 60]. 1 concluding group of patients who are observed to have increased rates of failure are those patients who rely on their upper extremities for ambulation (through the utilize of a cane or crutches) [57].

Managing a failed glenoid

When deciding to attempt to manage a loose glenoid, i has a number of choices which range from arthroscopic removal of the component to complete revision with structural allograft of the glenoid vault. The least invasive selection is to remove the glenoid component via arthroscopic methods. When the component is frankly loose it can be extracted through an enlarged anterior portal [68, 69]. The component can exist removed whole or moralized. In some cases removal of the loose component can adequately address the symptoms. Equally Antuna described in their 4.nine year follow up of shoulders that underwent revision glenoid surgery, 66% of patients had satisfactory pain relief with removal alone [63]. Still this same report also revealed a greater rate of success in those patients who underwent reimplanation where the authors observed 86% pain relief. Raphael et al. addressed a similar series of patients with symptomic loose glenoid components [69]. They noted that while functional scores were slightly higher in the reimplantation grouping, patient satisfaction was equally loftier in both the resection and reimplantation groups.

Prior to placing a new glenoid component the remaining vault must be accessed. This is all-time accomplished via a CT scan with 3-D reconstructions [seventy]. If there is inadequate bone, grafting tin can be performed with canellous graft in a ii stage procedure equally described by Cheung [71]. If at that place is a big cavitary defect with loss of the wall of the glenoid vault a structural allograft is probable indicated where bulk femoral caput is contoured to the defect [72]. It is necessary to use these structural grafts when the wall is compromised as cancallous graft cannot exist contained in these cases.

Clinically a number of authors accept all found that reimplantation of a glenoid component provides superior results to resection of the failed glenoid component lone [63, 69, 71, 73]. The improvements include greater relief of hurting and increased external rotation.

Other resurfacing options

Significant challenges exist in the setting of poor glenoid bone stock or glenohumeral arthrosis in young patients. In these settings, placement of a prosthetic glenoid component may not exist a favorable option. Fortunately, other resurfacing options exist including the "ream-and-run" procedure and biologic resurfacing.

Ream-and-run process

Concentric reaming of the glenoid to a radius of curvature of 1 to ii mm greater then the prosthetic humeral head component has been termed the "ream-and-run" process [74]. This concentric reaming is designed to re-profile the glenoid to better glenohumeral stability and reduce the eccentric erosion and subsequent instability that has been previously associated with isolated humeral hemiarthroplasty [75]. Prior information has documented healing and glenoid remodeling potential following the ream-and-run procedure [76]. In add-on, cadaveric model biomechanical information demonstrated increased glenohumeral stability following the ream-and-run procedure, as compared to a glenoid with denuded articular cartilage [77]. While some data suggest favorable outcomes following this procedure, in the current authors' opinion, this process should be reserved for use simply in the setting of salvage, every bit results that take been reported for the brusque and mid term have been inconsistent.

Biologic resurfacing

Biologic resurfacing has been employed primarily in the setting of younger patients. Many different types of interposition graft resurfacing have been attempted including joint sheathing, fascia lata, Achilles tendon allograft, lateral meniscal allograft, and candy human dermis (GraftJacket, Wright Medical Ltd, Arlington, TN, USA) [78]. These methods are used in concert with placement of a humeral hemiarthroplasty in an attempt to eliminate both the high failure risk of the glenoid component in TSA and the poor or inconsistent outcomes that have been associated with hemiarthroplasty alone [79, 80].

Long term follow-up information with mixed interpositional graft types demonstrated excellent, satisfactory and unsatisfactory results in eighteen, 13 and v out of 36 shoulders, respectively [81]. The authors identified re-injury, infection, and apply of sheathing as interposition material as the causes of unsatisfactory results. Additionally, they identified Achilles tendon allograft as leading to fantabulous to satisfactory results. Additional data using lateral meniscal allograft resurfacing has documented improvements in ASES scores from 38 to 69 at eighteen-month follow-up [iii]. However a 17% revision rate was documented in the showtime post-operative year. Savoie et al. documented statistically significant improvements for young patients with arthroscopic glenoid resurfacing with the Restore patch (Restore, DePuy Orthopaedics, Warsaw, IN, U.s.a.) at three to six-yr follow-up [82]. Other data from capsule, fascia lata and Achilles tendon interposition grafts demonstrated ASES mean improvement scores from 39 to 91 at a mean seven-twelvemonth follow-upward [81]. Like to prior studies, inductive sheathing interposition graft was associated with poor results [22, 83]. These data led the authors to recommend Achilles tendon allograft as the best selection.

Elhassan et al., however, studied 13 patients with a mean age of 36 years, eleven of which were treated with Achilles tendon allograft glenoid resurfacing [84••]. 77% of patients required revision to TSA at a mean of 14 months due to pain and decreased range of motion. Therefore, these authors concluded that Achilles allograft glenoid resurfacing was not a reliable method of treatment in the young, agile patient. Information technology is as well the senior authors' (EVC) experience that biologic glenoid resurfacing does not produce satisfactory outcomes and thus primary resurfacing of the glenoid should be performed whenever possible.

Conclusion

Arthrosis of the glenoid continues to offer challenges to the treating surgeon. The glenoid with its variable anatomy, minimal os stock and inherent instability makes addressing the glenoid i the nearly hard procedures in orthopedics. The continuing evolution of implant design offers the hope that nosotros will exist able to achieve a stable, long lasting and predictable solution to glenoid resurfacing for patients of all ages. In the mean time understanding and managing failed glenoid components provides the shoulder surgeon with challenges that continue to fuel hereafter implant pattern.

Acknowledgments

Disclosures M. Schrumpf: none; T. Maak: none; S. Hammoud: none; E. Craig: consultant to Biomet, Inc. for shoulder prosthesis, receives royalties from Biomet, Inc. for shoulder prosthesis.

Contributor Information

Mark Schrumpf, Phone: +1-212-6061466, Fax: +i-212-6061477, Email: ude.ssh@mfpmurhcs.

Travis Maak, Email: ude.ssh@tkaam.

Sommer Hammoud, Email: ude.ssh@sduommah.

Edward Five. Craig, Email: ude.ssh@egiarc.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3261247/

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