55.1 Goals of Procedure

The primary goal of this procedure is to relieve shoulder pain and dysfunction attributed to glenoid loosening after a total shoulder arthroplasty in a minimally invasive fashion that allows removal of the glenoid component in a way that is atraumatic to the subscapularis tendon. Previous literature has shown good outcomes after glenoid component removal for aseptic loosening in total shoulder arthroplasty. ¹ Although this approach is intended for cases of presumed glenoid loosening, previous literature has shown the difficulty in diagnosing low-grade chronic shoulder infections such as those with Propionibacterium acnes. Clinical signs and symptoms, inflammatory markers, diagnostic imaging, and shoulder aspiration lack sensitivity and specificity to accurately diagnose periprosthetic shoulder infections, and the gold standard remains multiple intraoperative cultures and biopsies. ² This arthroscopic approach allows the surgeon to easily assess the glenohumeral joint and take multiple cultures and biopsies from multiple locations with minimal morbidity if warranted. These results can then be used to guide further treatment if necessary.

A secondary goal of this procedure is to restore glenoid bone stock after component removal. Many times, there remains a contained cavitary defect around the central peg. The following technique describes a simple way of preparing and bone grafting contained lesions arthroscopically. This can be performed in the hope to prevent excessive medialization of the glenohumeral joint line after glenoid removal and subsequent conversion to hemiarthroplasty. ³ We have not and do not recommend arthroscopically bone grafting uncontained glenoid bone defects.

55.2 Advantages

The main advantages of the arthroscopic technique over an open technique revolve around preservation of the subscapularis tendon attachment. This prevents the complications associated with detaching the subscapularis tendon whether it be with a lesser tuberosity osteotomy, peel, or tenotomy. This advantage also translates to easier postoperative rehabilitation since protecting the subscapularis repair is not necessary. Other advantages include less intraoperative blood loss, decreased postoperative pain, and the ability to easily perform other indicated procedures such as synovectomy, capsular release, and rotator cuff repair.

55.3 Indications

The primary indication for arthroscopic glenoid component removal and glenoid bone grafting is a painful total shoulder arthroplasty with radiographic evidence of glenoid loosening in a patient who is not a candidate or willing to undergo glenoid component revision. The presumed diagnosis should be aseptic glenoid loosening and as such all preoperative infection workup should be negative for any obvious periprosthetic shoulder infection. Occasionally, the glenoid component has become dislodged from the glenoid cavity and this can also be an indication to retrieve the glenoid component arthroscopically.

55.4 Contraindications

Contraindications include any patient who is a candidate and willing to undergo open revision of the glenoid component. Active, ongoing infection is another contraindication to arthroscopic management. Finally, any contraindication related to the use of a hemiarthroplasty such as component instability or massive rotator cuff tears where the patient may be best suited for a reverse shoulder arthroplasty is a contraindication for this procedure.

55.5 Preoperative Preparation/Positioning

A standard radiographic examination of the shoulder is necessary to make the diagnosis of a loose glenoid component. The appearance of circumferential radiolucent lines or a change in glenoid implant position leads to diagnosis. ⁴ CT aids in the ability to gauge the size and extent of any associated glenoid bone loss. As with any planned revision shoulder arthroplasty or painful shoulder arthroplasty, a standardized approach to assess for the presence of a periprosthetic shoulder infection is imperative.

We prefer the beach-chair position and utilization of general anesthesia with an interscalene block for postoperative pain control. Standard prepping and draping occurs. If intraoperative cultures or biopsies are planned, preoperative antibiotics are held until after these have been taken.