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Glenoid Component Placement Assisted by Augmented Reality Through a Head-Mounted Display During Reverse Shoulder Arthroplasty

Open AccessPublished:April 21, 2022DOI:https://doi.org/10.1016/j.eats.2021.12.046

      Abstract

      Component positioning is a key factor for avoiding complications and improving functional outcomes in reverse shoulder arthroplasty. Preoperative planning can improve component positioning. However, translating the preoperative plan into the surgical procedure can be challenging. This is particularly the case for the glenoid component positioning in severe deformity or limited visualization of the scapula. Different computational-assisted techniques have been developed to aid implementation of the preoperative plan into the surgical procedure. Navigated augmented reality (AR) refers to the real world augmented with virtual real-time information about the position and orientation of instruments and components. This information can be presented through a head-mounted display (HMD), which enables the user to visualize the virtual information directly overlaid onto the real world. Navigated AR systems through HMD have been validated for shoulder arthroplasty using phantoms and cadavers. This article details a step-by-step guide use of a navigated AR system through HMD, in the placement of the glenoid bony-augmented component.

      Technique Video

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      We present a 72-year-old female patient with primary osteoarthritis of the right shoulder confirmed by preoperative radiograph of the shoulder (axial, anteroposterior, and Neer views). Computed tomography (CT) scan shows in the axial view, 27° of retroversion and 75% of posterior head subluxation. Before the procedure, a virtual preoperatory 3-dimensional planning is performed. In this case, it was planned for bony-augmented reverse total shoulder arthroplasty (RSA). The patient is placed in a beach-chair position. A traditional delto-pectoral approach is performed. The bone graft for the bony augmentation should be harvested prior to the humeral head osteotomy. Using a guide, a K-wire is placed over the head and through the K-wire, a reamer is used to remove the remaining cartilage of the humeral head. With a trephine, the circumferential cut of the graft is made. Finally, the central peg hole is done using a drill. Using a standard guide with 135° inclination an osteotomy with the desired retrotorsion is performed using an oscillating saw. After this, the humeral canal is prepared using reamers and a broach, and a cut protector is placed over the humeral trial. The glenoid is then exposed. We suggest performing a careful posterior capsulotomy with the aid of a laminar spreader. The coracoid is then exposed and using a double guide, 2 K-wires are placed into the coracoid. The tracker is then mounted through the case through this 2 K-wires. Care must be taken to ensure that the case is secured to the K-wires securely. The sensor is then placed into the case. The head-mounted display (HMD) will allow the surgeon to see important information in real-time for each step. First, the glenoid is registered using a marker and 30 points are mapped across the glenoid and coracoid. The glenoid preparation is performed using standard instruments with mounted sensors and trackers. After the central K-wire placement is inserted, reaming of the glenoid surface and the drilling of the central hole is performed. Real-time information regarding inclination, depth and version is displayed into the HMD. The bone graft that was harvested before this is then prepared for implantation. Bone graft is fashioned to represent the surgical plan. The graft is then implanted onto the glenoid baseplate. The baseplate, together with the graft, are placed into the glenoid that has been prepared. The sensor mounted onto the guide, an impactor, will allow careful placement. Using a drill mounted with a sensor, drill holes are made through the graft into the native glenoid and screws are inserted to secure the baseplate. The glenosphere is then inserted and, if eccentricity is used, this can be delved in using the next augmented reality system. The glenosphere is then secured. Multiple transosseous sutures are placed for the subscapularis repair, prior to the insertion of the humeral component. Once the humeral component is implanted and the polyethylene liner is inserted, the shoulder is reduced and the subscapularis repair is completed. The postoperative radiograph and computed tomography scan (anteroposterior and axial views) show an optimal placement of the glenoid component. The preliminary results show a deviation of the planned and postoperative values of less than 2° in orientation and 2 mm in entry point.

      Technique Video

      See video under supplementary data.

      The use of reverse shoulder arthroplasty (RSA) is increasing, and its indications are continuingly expanding.
      • Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)
      Hip, Knee & Shoulder Arthroplasty: 2020 Annual Report, Adelaide; AOA, 2020: 1-474.
      Accurate component positioning has been described to be a key factor to avoid complications,
      • Zumstein M.A.
      • Pinedo M.
      • Old J.
      • Boileau P.
      Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review.
      achieve better biomechanical performance,
      • Shapiro T.A.
      • McGarry M.H.
      • Gupta R.
      • Lee Y.S.
      • Lee T.Q.
      Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.
      and improve functional outcomes.
      • Lädermann A.
      • Denard P.J.
      • Collin P.
      • et al.
      Effect of humeral stem and glenosphere designs on range of motion and muscle length in reverse shoulder arthroplasty.
      ,
      • Lädermann A.
      • Denard P.J.
      • Boileau P.
      • Farron A.
      • Deransart P.
      • Walch G.
      What is the best glenoid configuration in onlay reverse shoulder arthroplasty?.
      Two-dimensional and 3-dimensional (3D) preoperative planning is crucial for accurate intraoperative placement of the glenoid component.
      • Iannotti J.P.
      • Weiner S.
      • Rodriguez E.
      • et al.
      Three-dimensional imaging and templating improve glenoid implant positioning.
      Severe deformities and limited exposure of the scapula are some factors that can result in an inaccurate positioning of the glenoid during the surgical procedure.
      • Iannotti J.P.
      • Greeson C.
      • Downing D.
      • Sabesan V.
      • Bryan J.A.
      Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty.
      ,
      • Lädermann A.
      • Lo E.Y.
      • Schwitzguébel A.J.
      • Yates E.
      Subscapularis and deltoid preserving anterior approach for reverse shoulder arthroplasty.
      Several options have been developed to aid the surgeon in executing their preoperative plan into the surgical procedure. These options include patient-specific instrumentation
      • Walch G.
      • Vezeridis P.S.
      • Boileau P.
      • Deransart P.
      • Chaoui J.
      Three-dimensional planning and use of patient-specific guides improve glenoid component position: An in vitro study.
      (PSI), mixed-reality systems,
      • Gregory T.M.
      • Gregory J.
      • Sledge J.
      • Allard R.
      • Mir O.
      Surgery guided by mixed reality: Presentation of a proof of concept.
      navigation,
      • Sadoghi P.
      • Vavken J.
      • Leithner A.
      • Vavken P.
      Benefit of intraoperative navigation on glenoid component positioning during total shoulder arthroplasty.
      ,
      • Aminov O.
      • Regan W.
      • Giles J.W.
      • Simon M.J.K.
      • Hodgson A.J.
      Targeting repeatability of a less obtrusive surgical navigation procedure for total shoulder arthroplasty.
      and navigated augmented-reality (AR) systems.
      • Jud L.
      • Fotouhi J.
      • Andronic O.
      • et al.
      Applicability of augmented reality in orthopedic surgery—A systematic review.
      The advantages of navigation and navigated AR systems over PSI and mixed-reality systems are that they allow real-time visualization of the plan during the surgical procedure.
      • Jahic D.
      • Suero E.M.
      • Marjanovic B.
      The use of computer navigation and patient specific instrumentation in shoulder arthroplasty: Everyday practice, just for special cases or actually teaching a surgeon?.
      They also provide immediate and real-time feedback to the surgeon about glenoid component placement.
      Navigated AR allows the real world to be augmented with virtual real-time information regarding the position and orientation of instruments and glenoid components.
      • Jud L.
      • Fotouhi J.
      • Andronic O.
      • et al.
      Applicability of augmented reality in orthopedic surgery—A systematic review.
      This information may be presented through a head-mounted display (HMD), which enables the user to visualize essential information directly overlaid onto the surgical field. A type of navigated AR through HMD was recently validated for glenoid K-wire placement in 3D-printed scapula models
      • Kriechling P.
      • Roner S.
      • Liebmann F.
      • Casari F.
      • Fürnstahl P.
      • Wieser K.
      Augmented reality for base plate component placement in reverse total shoulder arthroplasty: A feasibility study.
      ,
      • Schlueter-Brust K.
      • Henckel J.
      • Katinakis F.
      • et al.
      Augmented-reality-assisted K-wire placement for glenoid component positioning in reversed shoulder arthroplasty: A proof-of-concept study.
      and cadavers.

      Kriechling P, Loucas R, Loucas M, Casari F, Fürnstahl P, Wieser K. Augmented reality through head-mounted display for navigation of baseplate component placement in reverse total shoulder arthroplasty: A cadaveric study [published online July 2, 2021]. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-04025-5

      To the best of our knowledge, no technical description of in vivo glenoid component placement with navigated AR system through a HMD has been published. This article aimed to describe a step-by-step glenoid component placement technique using a navigated AR system through HMD in an in vivo setting.

      Surgical Technique (With Video Illustration)

      Preoperative Glenoid Planning

      A computed tomography (CT) scan of the scapula and the proximal humerus is required. The CT scan images are imported using Digital Imaging and Communications in Medicine (DICOM) format to the MyShoulder software (Medacta International, Castel San Pietro, Switzerland). The surgeon then constructs their preferred 3D preoperative plan. The CT scan images and the 3D preoperative plan are then imported to the navigated AR system NextAR (Medacta International). This navigated AR system includes a control unit (CU), which is a medical-grade computer loaded with the patient’s complete 3D preoperative plan. The CU receives real-time information from the tracking system that includes a tracker (fixed on the patient’s coracoid) and a camera (attachable to the different instruments). This tracking system tracks and sends information to the CU in real time. This position and orientation of instruments and glenoid components in relation to the scapula is visualized via the heads-up display, allowing the surgeon to maintain focus on the surgical field (Fig 1, Video 1).
      Figure thumbnail gr1
      Fig 1(A) The tracking system (TS) uses infrared (IR) disposable sensors (a tracker and a camera) to track the instrument’s position with respect to the anatomical structures in real-time. (B) The control unit (CU) receives information from the TS via Bluetooth and integrates this information with the planning. (C) The head-mounted display receives the information from the CU via Bluetooth. The visualization of the surgical actions superimposed on the operation area allows the surgeon to stay focused on the patient.

      Patient Positioning and Anesthesia

      Perioperative antibiotic prophylaxis is administered intravenously 20 minutes before the incision. The procedure is performed with the patient under general anesthesia, with or without an interscalene block, in a semi–beach-chair position. It is necessary to confirm that full extension and adduction of the shoulder is achievable before the preparation and draping of the arm begins.

      Approach

      A standard deltopectoral approach is performed. After marking with electrocautery, a superficial osteotomy of the lesser tuberosity is performed with an osteotome,
      • Gerber C.
      • Pennington S.D.
      • Yian E.H.
      • Pfirrmann C.A.W.
      • Werner C.M.L.
      • Zumstein M.A.
      Lesser tuberosity osteotomy for total shoulder arthroplasty.
      and the capsular release is completed with electrocautery. Then, the subscapularis is tagged with 2 SutureTape sutures (Arthrex, Naples, FL). The humeral capsular release is then completed in the anteroinferior portion, whereas the humerus is progressively externally rotated until being able to fully rotate and dislocate the humeral head (Fig 2, Video 1).
      Figure thumbnail gr2
      Fig 2Right shoulder, beach-chair position. The humeral capsular release is performed while the humerus is progressively externally rotated until being able to fully rotate and dislocate the humeral head (HH). The osteophytes should be removed until the native humeral calcar (HC) is exposed.

      Humerus Preparation

      The bone graft is harvested before humeral head osteotomy. Using a guide, a K-wire is placed over the humeral head and fixed in the lateral cortex of the humerus, with caution not to penetrate the lateral cortex excessively due to the proximity of the axillary nerve. Through the K-wire, a reamer is used to remove the remaining cartilage of the humeral head until the diameter of the planned bone graft is achieved. The circumferential cut of the graft is made using a trephine until the planned depth. The central peg hole is then drilled.
      Using a standard cutting guide, a 135° inclination osteotomy with the desired retrotorsion is performed with an oscillating saw. Humeral canal preparation is then performed using progressively larger reamers and broachers. Finally, a cut protector for the metaphyseal bone is put in place before undertaking glenoid preparation.

      Glenoid Preparation

      A circumferential release of the labrum and a 270° capsulotomy is performed to achieve an adequate glenoid exposure. To allow for a complete posterior dislocation of the head, a careful posterior capsulotomy and capsulectomy can be performed, with the help of a laminar spreader between the glenoid and the humeral metaphysis (Fig 3, Video 1). Removal of the cartilage to the underlying subchondral bone is achieved with a curette.
      Figure thumbnail gr3
      Fig 3Right shoulder, beach-chair position. A posterior capsular (PC) release is essential to reach a wide exposure of the glenoid. For this step, a spreader is recommended between the glenoid (G) and the humeral metaphysis (HM).

      Coracoid Tracker Placement

      A blunt Hohmann retractor is used to expose the coracoid adequately. The coracoid process body and tip should be identified. Using the double guide, 2 K-wires are placed into the coracoid process, taking particular caution not to violate the inferior structures (Fig 4, Video 1). If the patient has a small coracoid, the posterior K-wire can be placed pointing to the base of the coracoid. This allows for better fixation of the tracker. The tracker unit is then placed and fixed on the K-wires. The camera should be adjusted such that it faces the receiver unit of the different instrumentation (Fig 5, Video 1).
      Figure thumbnail gr4
      Fig 4Right shoulder, beach-chair position. Using a double guide (DG), 2 K-wires (KW) are placed on the coracoid process (CP), with special caution taken to not hit the conjoint tendon (CT) and inferior structures.
      Figure thumbnail gr5
      Fig 5Right shoulder, beach-chair position. The tracker (T) is then placed and fixed on the K-wires (KW) onto the coracoid process (CP), in line with the camera (C) placed in the different instrumentations. (CT, conjoint tendon; G, glenoid.).

      Augmented Reality System

      The navigated AR system shows the scapular registration in 2 stages and the different instrumentation of the glenoid placement in 6 stages. Each stage is visualized consecutively. The HMD will show the surgeon important information during each stage of the procedure.

      Scapular Registration

      Scapular registration is performed using the navigated pointer. The first stage consists of marking four points on the posterior, superior, anterior, and inferior borders of the glenoid. (Fig 6, Video 1). The second stage is to mark 30 unique points around the glenoid surface (15 points) and the coracoid (15 points) (Fig 6, Video 1). It is important to note that the plan is derived from a CT scan, meaning that only bony anatomy is segmented. If there is remaining cartilage on the glenoid surface, the cartilage must be penetrated until the bone surface is reached.
      Figure thumbnail gr6
      Fig 6(A) A rough orientation of the system is made marking four points on the posterior (Po), superior (Su), anterior (An), and inferior (In) borders of the glenoid. (B) The glenoid registry is completed placing 30 points around the glenoid (G) surface and the coracoid process (CP).

      Glenoid K-Wire Placement

      The glenoid K-wire is placed using the guide. The navigated AR system gives the surgeon the planned and real-time insertion points, alignment, inclination, and version values (Fig 7, Video 1). Once the desired position is achieved, a central 2.5-mm K-wire is inserted.
      Figure thumbnail gr7
      Fig 7(A) Right shoulder, beach-chair position. The glenoid K-wire (KW) is placed using the specific guide. (B) The navigated augmented reality system gives the surgeon the planned (PL) and real-time (RT) insertion points, alignment and the inclination and retroversion values. On the right side of the image, 2-dimensional computed tomography scan images show the PL (green line) and RT (blue line) direction in the axial (superior) and coronal (inferior) planes. (G, glenoid.)

      Glenoid Reaming

      Glenoid reaming is performed after checking the correct inclination and retroversion. The navigated AR system gives the surgeon the planned and real-time depth, inclination, and version values (Fig 8, Video 1).
      Figure thumbnail gr8
      Fig 8(A) Right shoulder, beach-chair position. The glenoid reaming is performed after checking the correct inclination and retroversion. (B) The navigated augmented reality system gives the surgeon the planned (PL) and real-time (RT) depth, inclination and retroversion values. On the right side of the image, 2-dimensional computed tomography scan images show the PL (green) and RT (blue) baseplate position in the axial (superior) and coronal (inferior) planes. (G, glenoid; R, reamer.)

      Glenoid Central Hole

      The glenoid central hole for the central peg of the baseplate is drilled through the K-wire. The navigated AR system gives the planned and real-time inclination and version values (Fig 9, Video 1).
      Figure thumbnail gr9
      Fig 9(A) Right shoulder, beach-chair position. The glenoid central hole for the central peg of the baseplate is drilled trough the K-wire. (B) The navigated augmented reality system gives the planned (PL) and real-time (RT) inclination and retroversion values. On the right side of the image, 2-dimensional CT scan images show the PL (green line) and RT (blue line) direction in the axial (superior) and coronal (inferior) planes. (D, drill; G, glenoid.)

      Glenoid Baseplate Placement

      Bone graft preparation is performed on the back table (Fig 10, Video 1). The graft is inserted together with the glenoid baseplate using an impactor. The navigated AR system provides the surgeon with baseplate depth, inclination and version (Fig 11, Video 1).
      Figure thumbnail gr10
      Fig 10The bone graft (BG) preparation is performed following the preoperative planning.
      Figure thumbnail gr11
      Fig 11(A) Right shoulder, beach-chair position. The glenoid baseplate (BP) with the bone graft (BG) are impacted. (B) The navigated AR system gives the planned (PL) and real-time (RT) depth, inclination and retroversion values. On the right side of the image, 2-dimensional computed tomography scan images show the PL (green) and RT (clue) baseplate position in the axial (superior) and coronal (inferior) planes. (G, glenoid.)

      Screw Drill

      With the navigated drill sleeve, the surgeon can determine the optimal direction and length of each baseplate screw (Fig 12, Video 1).
      Figure thumbnail gr12
      Fig 12The drill for the screws is made using navigated augmented reality (AR) system. The navigated AR system shows the direction and length of each screw (Sc) inside the bone. On the right side of the image, 2-dimensional computed tomography scan images show the screw position in an axial (superior) and coronal (inferior) planes.

      Glenosphere Placement

      The navigated AR system gives the surgeon real-time information regarding the position and rotation of the glenosphere, enabling optimal and easier implantation (Fig 13, Video 1). A secure screw is used after the placement, followed by the glenosphere impaction.
      Figure thumbnail gr13
      Fig 13(A) Right shoulder, beach-chair position. Finally, the glenosphere (GS) is put in place, impacted and secured. (B) The navigated augmented reality system gives planned (PL) and precise real-time (RT) information regarding the position and rotation of the GS. (G, glenoid.)

      Humeral Component Placement

      Standard humeral component implantation is then performed. The humeral protector and the broach are extracted, and the trial humeral diaphysis is placed. The metaphysis is reamed through a guide on the humeral trial. The definitive implant is then impacted, the chosen liner is inserted, and the implant is reduced. Finally, the subscapularis is reattached via multiple transosseous sutures.
      The advantages and disadvantages of this technique are described in Table 1. The tips and pitfalls of this technique are presented in Table 2.
      Table 1Advantages and Disadvantages
      Advantages
       Real-time information of glenoid component placement according to planning.
       Information through head-mounted display allows the surgeons to stay focused on the patient.
       Easy to position trackers and calibration of the navigated augmented reality system.
      Disadvantages
       Dispensable sensors for the tracking system add extra cost.
       Theoretical risk of coracoid fracture when placing the tracker.
      Table 2Pearls and Pitfalls
      Pearls
       Careful planification by the surgeon and explanation to the rest of the surgical team allows a more fluent surgery.
       Meticulous release of the posterior and anterior glenohumeral capsule is essential to have a complete glenoid exposure.
       To have a better fixation of the tracker, the K-wire for the tracker holder must be directed to the base on the coracoid, especially in small coracoids.
       Pin placement for tracker holder on the coracoid with precaution of not going too medial or too deep. Control by touching the inferior border of the coracoid.
       Place tracker should be calibrated aligned to the camera.
       If a graft is planned for lateralizing the glenoid, a long peg baseplate (25 mm) should be used.
      Pitfalls
       A loose placement of tracker will give wrong information regarding instrument position.
       A lack of soft-tissue release will hinder the procedure on the glenoid.

      Postoperative Rehabilitation

      The patient is placed in a sling for 6 weeks. Passive range of motion is begun immediately. Active and active-assisted range of motion is allowed 3 weeks after surgery. A standard postoperative rehabilitation protocol for RSA with progression to early strengthening and full strengthening exercises is prescribed. The first follow-up with standard radiographs is performed 6 weeks postoperatively (Fig 14, Video 1).
      Figure thumbnail gr14
      Fig 14(A) Postoperative anteroposterior view, (B) Neer view, and (C) axillar view of the right shoulder shows a proper placement of the glenoid component according to the preoperative planning.

      Discussion

      This article describes glenoid component placement using a navigated AR system through HMD. The navigated AR system allows for a seamless transfer of the preoperative plan into surgical procedure. Intraoperative navigation allows for accurate glenoid placement, specifically when it is correlated in real-time with patient images.
      • Sadoghi P.
      • Vavken J.
      • Leithner A.
      • Vavken P.
      Benefit of intraoperative navigation on glenoid component positioning during total shoulder arthroplasty.
      Sprowls et al.
      • Sprowls G.R.
      • Wilson C.D.
      • Stewart W.
      • et al.
      Intraoperative navigation and preoperative templating software are associated with increased glenoid baseplate screw length and use of augmented baseplates in reverse total shoulder arthroplasty.
      evaluated a computational navigation system combined with patients’ preoperatory images in real time. The authors confirmed that a better placement of baseplate screws was achieved. Their specific navigation system has similarities with the one used in this study; however, the information was not visualized through an HMD. Usage of the HMD allows the surgeon to maintain focus on the surgical field. The use of HMD has been described in various medical fields including orthopaedics.
      • Rahman R.
      • Wood M.E.
      • Qian L.
      • Price C.L.
      • Johnson A.A.
      • Osgood G.M.
      Head-mounted display use in surgery: A systematic review.
      There is limited literature regarding the usage of HMD in RSA. Gregory et al.
      • Gregory T.M.
      • Gregory J.
      • Sledge J.
      • Allard R.
      • Mir O.
      Surgery guided by mixed reality: Presentation of a proof of concept.
      published their experience with one in vivo patient using a HMD with mixed reality technology. In this study, patient information was available during the procedure, but the system did not allow for real-time feedback on component placement.
      The use of navigated AR system through HMD in shoulder arthroplasty has recently been published in an in vitro setting.
      • Kriechling P.
      • Roner S.
      • Liebmann F.
      • Casari F.
      • Fürnstahl P.
      • Wieser K.
      Augmented reality for base plate component placement in reverse total shoulder arthroplasty: A feasibility study.
      • Schlueter-Brust K.
      • Henckel J.
      • Katinakis F.
      • et al.
      Augmented-reality-assisted K-wire placement for glenoid component positioning in reversed shoulder arthroplasty: A proof-of-concept study.

      Kriechling P, Loucas R, Loucas M, Casari F, Fürnstahl P, Wieser K. Augmented reality through head-mounted display for navigation of baseplate component placement in reverse total shoulder arthroplasty: A cadaveric study [published online July 2, 2021]. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-04025-5

      Kriechling et al.
      • Kriechling P.
      • Roner S.
      • Liebmann F.
      • Casari F.
      • Fürnstahl P.
      • Wieser K.
      Augmented reality for base plate component placement in reverse total shoulder arthroplasty: A feasibility study.
      described a feasibility study of a navigated AR system through HMD in 3D-printed scapula models showing a mean deviation of 2.3 mm and 2.7°. Recently, the same group evaluated the same system in cadavers reporting 3.5 mm and 3.8° deviation.

      Kriechling P, Loucas R, Loucas M, Casari F, Fürnstahl P, Wieser K. Augmented reality through head-mounted display for navigation of baseplate component placement in reverse total shoulder arthroplasty: A cadaveric study [published online July 2, 2021]. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-04025-5

      The authors used navigation only for K-wire placement, without information regarding depth, rotation, glenoid placement, or screw position and length. These findings suggest that the usage of navigated AR systems through HMD for shoulder arthroplasty is promising. Navigated AR systems allow accurate placement of the screws. In this circumstance, alternative modalities such as PSI are not feasible.

      Conclusions

      Using a navigated augmented reality system through a head-mounted display for placement of the glenoid component in RSA is viable in an in vivo setting.

      Supplementary Data

      • Loading ...

      References

        • Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)
        Hip, Knee & Shoulder Arthroplasty: 2020 Annual Report, Adelaide; AOA, 2020: 1-474.
        (Accessed February 25, 2022)
        • Zumstein M.A.
        • Pinedo M.
        • Old J.
        • Boileau P.
        Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review.
        J Shoulder Elbow Surg. 2011; 20: 146-157https://doi.org/10.1016/j.jse.2010.08.001
        • Shapiro 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: 90-95https://doi.org/10.1016/j.jse.2006.07.010
        • Lädermann A.
        • Denard P.J.
        • Collin P.
        • et al.
        Effect of humeral stem and glenosphere designs on range of motion and muscle length in reverse shoulder arthroplasty.
        Int Orthop. 2020; 44: 519-530https://doi.org/10.1007/s00264-019-04463-2
        • Lädermann A.
        • Denard P.J.
        • Boileau P.
        • Farron A.
        • Deransart P.
        • Walch G.
        What is the best glenoid configuration in onlay reverse shoulder arthroplasty?.
        Int Orthop. 2018; 42: 1339-1346https://doi.org/10.1007/s00264-018-3850-x
        • Iannotti J.P.
        • Weiner S.
        • Rodriguez E.
        • et al.
        Three-dimensional imaging and templating improve glenoid implant positioning.
        J Bone Joint Surg Am. 2015; 97: 651-658https://doi.org/10.2106/JBJS.N.00493
        • Iannotti J.P.
        • Greeson C.
        • Downing D.
        • Sabesan V.
        • Bryan J.A.
        Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty.
        J Shoulder Elbow Surg. 2012; 21: 48-55https://doi.org/10.1016/j.jse.2011.02.011
        • Lädermann A.
        • Lo E.Y.
        • Schwitzguébel A.J.
        • Yates E.
        Subscapularis and deltoid preserving anterior approach for reverse shoulder arthroplasty.
        Orthop Traumatol Surg Res. 2016; 102: 905-908https://doi.org/10.1016/j.otsr.2016.06.005
        • Walch G.
        • Vezeridis P.S.
        • Boileau P.
        • Deransart P.
        • Chaoui J.
        Three-dimensional planning and use of patient-specific guides improve glenoid component position: An in vitro study.
        J Shoulder Elbow Surg. 2015; 24: 302-309https://doi.org/10.1016/j.jse.2014.05.029
        • Gregory T.M.
        • Gregory J.
        • Sledge J.
        • Allard R.
        • Mir O.
        Surgery guided by mixed reality: Presentation of a proof of concept.
        Acta Orthop. 2018; 89: 480-483https://doi.org/10.1080/17453674.2018.1506974
        • Sadoghi P.
        • Vavken J.
        • Leithner A.
        • Vavken P.
        Benefit of intraoperative navigation on glenoid component positioning during total shoulder arthroplasty.
        Arch Orthop Trauma Surg. 2015; 135: 41-47https://doi.org/10.1007/s00402-014-2126-1
        • Aminov O.
        • Regan W.
        • Giles J.W.
        • Simon M.J.K.
        • Hodgson A.J.
        Targeting repeatability of a less obtrusive surgical navigation procedure for total shoulder arthroplasty.
        Int J Comput Assist Radiol Surg. 2021; 17: 283-293https://doi.org/10.1007/s11548-021-02503-0
        • Jud L.
        • Fotouhi J.
        • Andronic O.
        • et al.
        Applicability of augmented reality in orthopedic surgery—A systematic review.
        BMC Musculoskelet Disord. 2020; 21: 1-13https://doi.org/10.1186/s12891-020-3110-2
        • Jahic D.
        • Suero E.M.
        • Marjanovic B.
        The use of computer navigation and patient specific instrumentation in shoulder arthroplasty: Everyday practice, just for special cases or actually teaching a surgeon?.
        Acta Inform Medica. 2021; 29: 130-133https://doi.org/10.5455/AIM.2021.29.130-133
        • Kriechling P.
        • Roner S.
        • Liebmann F.
        • Casari F.
        • Fürnstahl P.
        • Wieser K.
        Augmented reality for base plate component placement in reverse total shoulder arthroplasty: A feasibility study.
        Arch Orthop Trauma Surg. 2021; 141: 1447-1453https://doi.org/10.1007/s00402-020-03542-z
        • Schlueter-Brust K.
        • Henckel J.
        • Katinakis F.
        • et al.
        Augmented-reality-assisted K-wire placement for glenoid component positioning in reversed shoulder arthroplasty: A proof-of-concept study.
        J Pers Med. 2021; : 11https://doi.org/10.3390/jpm11080777
      1. Kriechling P, Loucas R, Loucas M, Casari F, Fürnstahl P, Wieser K. Augmented reality through head-mounted display for navigation of baseplate component placement in reverse total shoulder arthroplasty: A cadaveric study [published online July 2, 2021]. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-04025-5

        • Gerber C.
        • Pennington S.D.
        • Yian E.H.
        • Pfirrmann C.A.W.
        • Werner C.M.L.
        • Zumstein M.A.
        Lesser tuberosity osteotomy for total shoulder arthroplasty.
        J Bone Joint Surg. 2006; 88: 170-177https://doi.org/10.2106/JBJS.F.00407
        • Sprowls G.R.
        • Wilson C.D.
        • Stewart W.
        • et al.
        Intraoperative navigation and preoperative templating software are associated with increased glenoid baseplate screw length and use of augmented baseplates in reverse total shoulder arthroplasty.
        JSES Int. 2021; 5: 102-108https://doi.org/10.1016/j.jseint.2020.09.003
        • Rahman R.
        • Wood M.E.
        • Qian L.
        • Price C.L.
        • Johnson A.A.
        • Osgood G.M.
        Head-mounted display use in surgery: A systematic review.
        Surg Innov. 2020; 27: 88-100https://doi.org/10.1177/1553350619871787