Abstract:
A method of shoulder arthroplasty in one embodiment includes accessing a scapula, identifying an inferior glenoid circle center of the scapula, preparing a glenoid fossa of the scapula to receive a prosthesis, selecting a glenoid component, and implanting the selected glenoid component based upon the identified inferior glenoid circle center in the prepared glenoid fossa.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is related to U.S. patent application Ser. No. ______ [attorney number 1671-0480], entitled “Combination Reamer/Drill Bit for Shoulder Arthroscopy”, which was filed on Mar. 18, 2011, U.S. patent application Ser. No. ______ [attorney number 1671-0481], entitled “Device and Method for Retroversion Correction for Shoulder Arthroscopy”, which was also filed on Mar. 18, 2011, and U.S. patent application Ser. No. ______ [attorney number 1671-0482], entitled “Revision Glenoid Device and Method”, which was also filed on Mar. 18, 2011, the contents of which are each incorporated herein by reference. 
     
    
     TECHNICAL FIELD OF THE INVENTION 
       [0002]    The present invention relates generally to the field of orthopedics, and, more particularly, to glenoid component apparatuses for shoulder arthroplasty and methods for using them. 
       BACKGROUND 
       [0003]    As depicted in  FIG. 1 , a typical shoulder or glenohumeral joint is formed in a human body where the humerus  10  movably contacts the scapula  12 . The scapula  12  includes a glenoid fossa  14  that forms a socket against which the head of the humerus  10  articulates. At this socket, the scapula  12  includes cartilage  16  that facilitates such articulation. Beneath the cartilage is subchondral bone  18  that forms a wall of a glenoid vault  20  that defines a cavity which contains cancellous bone  22 . The subchondral bone  18  that forms the glenoid vault  20  defines a glenoid rim  24  at a periphery of the glenoid vault  20  that is attached to the cartilage  16 . During the lifetime of a patient, the glenoid fossa  14  may become worn, especially at its posterior and/or superior portions thereby causing severe shoulder pain and limiting the range of motion of the patient&#39;s shoulder joint. To alleviate such pain and increase the patient&#39;s range of motion, a shoulder arthroplasty may be performed. Arthroplasty is the surgical replacement of one or more bone structures of a joint with one or more prostheses. 
         [0004]    Shoulder arthroplasty often involves replacement of the glenoid fossa of the scapula with a prosthetic glenoid component. The conventional glenoid component typically provides a generally laterally or outwardly facing generally concave bearing surface against which a prosthetic humeral head (or, alternatively, the spared natural humeral head in the case of a glenoid hemi-arthroplasty) may bear during operation of the joint. The conventional glenoid component typically also includes a generally medially or inwardly projecting stem for fixing the glenoid component in a cavity constructed by suitably resecting the glenoid fossa  14  and suitably resecting cancellous bone  22  from the glenoid vault  20 . 
         [0005]    The goal of shoulder arthroplasty is to restore normal kinematics to the shoulder. Accordingly, known systems attempt to replicate the normal kinematics by carefully controlling the geometry of the articulating surfaces in the joint as well as the positioning of the prostheses in the bones in which the prostheses are implanted. Thus, the articulating surface of a humeral component is typically spherical and positioning of the humeral component is accomplished by using the anatomical neck of the humerus as the reference plane for reconstruction of the humeral head. 
         [0006]    Traditionally, shoulder joints have been understood to exhibit translation of the humeral component on the glenoid component in addition to rotation. Thus, the articulating surface of the glenoid is typically formed with a radius of curvature that is much larger than the radius of curvature of the humeral component. The increased radius of curvature of the glenoid articulating surface can be from 2-6 mm larger than the radius of curvature for the humeral component in these systems. 
         [0007]    In known systems, the glenoid component is positioned in the geometric center of the glenoid fossa. The geometric center is established by generating a line from the most superior point of the glenoid rim to the most inferior point of the glenoid rim (“Saller&#39;s line”). A second line is generated between the most posterior point of the glenoid rim and the most anterior point of the glenoid rim. The intersection of the two generated lines is considered to be the geometric center of the area circumscribed by the glenoid rim. By way of example,  FIG. 2  depicts a sagittal view of the scapula  12 . In  FIG. 2 , Saller&#39;s line  30  extends between the most superior point  32  of the glenoid rim  24  to the most inferior point  34  of the glenoid rim  24 . A second line  36  extends from the most posterior point  38  of the glenoid rim  24  and the most anterior point  40  of the glenoid rim. The geometric center  42  of the glenoid fossa  14  is located at the intersection of the line  36  and Saller&#39;s line  30 . As used herein, the terms anterior, posterior, superior, and inferior, unless otherwise specifically described, are used with respect to the orientation of the scapula  12  as depicted in  FIG. 2 . 
         [0008]    While known systems achieve varying degrees of success in replicating normal kinematics, the systems are susceptible to various modes of failure. One mode of failure is known as the “rocking horse” effect. In this failure mode, high shear forces on the glenoid component are experienced as the humeral component translates to the edges of the glenoid component. The unbalanced loading of the glenoid component results in loosening of the component. 
         [0009]    There remains a need for a glenoid component that allows for establishing normal kinematics. There is a further need for a technique that facilitates positioning of such a component. A glenoid component that can be positioned in a manner that reduces the potential for rocking horse failure of the component is also needed. 
       SUMMARY OF THE INVENTION 
       [0010]    The present invention in one embodiment provides a method of shoulder arthroplasty including accessing a scapula, identifying an inferior glenoid circle center of the scapula, preparing a glenoid fossa of the scapula to receive a prosthesis, selecting a glenoid component, and implanting the selected glenoid component based upon the identified inferior glenoid circle center in the prepared glenoid fossa. 
         [0011]    In an alternative embodiment, a method of implanting a glenoid component includes obtaining an image of a scapula, identifying an inferior glenoid circle center of the scapula based upon the image, selecting a glenoid component, preparing a glenoid fossa of the scapula to receive a prosthesis, and implanting the selected glenoid component in the prepared glenoid fossa based upon the identified inferior glenoid circle center. 
         [0012]    The above-noted features and advantages of the present invention, as well as additional features and advantages, will be readily apparent to those skilled in the art upon reference to the following detailed description and the accompanying drawings, which include a disclosure of the best mode of making and using the invention presently contemplated. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0013]      FIG. 1  depicts a coronal view of an anatomically normal shoulder joint. 
           [0014]      FIG. 2  depicts a sagittal view of the shoulder joint of  FIG. 1 ; 
           [0015]      FIG. 3  depicts a bottom perspective view of a circular glenoid component that may be implanted in a scapula in accordance with principles of the invention; 
           [0016]      FIG. 4  depicts a bottom plan view of the circular glenoid component of  FIG. 3 ; 
           [0017]      FIG. 5  depicts a side plan view of the circular glenoid component of  FIG. 3 ; 
           [0018]      FIG. 6  depicts a medical procedure that may be used to implant the circular glenoid component of  FIG. 3  into a scapula based upon identifying an inferior glenoid circle center of the scapula; 
           [0019]      FIG. 7  depicts the sagittal view of the shoulder joint of  FIG. 2  with different coordinate systems defined thereon; and 
           [0020]      FIG. 8  depicts the circular glenoid component of  FIGS. 3-5  implanted into the scapula of  FIG. 1 . 
       
    
    
     DETAILED DESCRIPTION 
       [0021]    Like reference numerals refer to like parts throughout the following description and the accompanying drawings. 
         [0022]      FIGS. 3-5  depict a glenoid component  100 . The glenoid component  100  includes a body portion  102  including a spherical articulating surface  104  and an opposite bone contacting surface  106 . An outer wall  108  extends away from the bone contacting surface  106  and defines an outer periphery of the body portion  102 . The bone contacting surface  106  is generally convex. A finned center peg  110  extends away from the nadir of the bone contacting surface  106  as viewed in  FIG. 5 . Three offset pegs  112 ,  114 , and  116  extend away from the bone contacting surface  106  at locations between the center peg  110  and the outer wall  108 . The nadir  118  of the spherical articulating surface  104  is located on the centerline  120  of the glenoid component  100 . 
         [0023]    The glenoid component  100  in this embodiment is an integrally formed unit made from a durable biocompatible plastic or any other suitable durable biocompatible material. For example, the glenoid component  100  may be made from a polyethylene. One particular polyethylene that is well suited for glenoid component  100  is a high molecular weight polyethylene, for example ultra-high molecular weight polyethylene (“UHMWPE”). One such UHMWPE is sold as by Johnson &amp; Johnson of New Brunswick, N.J. as MARATHON™ UHMWPE and is more fully described in U.S. Pat. Nos. 6,228,900 and 6,281,264 to McKellop, which are incorporated herein by reference. 
         [0024]    In embodiments wherein the articulating surface  104  and the other portions of the glenoid component  100  are made from different materials, the portions of the glenoid component  100  other than the articulating surface  104  may be made from a suitable biocompatible metal such as, for example, a cobalt chromium alloy, a stainless steel alloy, a titanium alloy, or any other suitable durable material. In these embodiments, the articulating surface  104  is secured to the body portion  102  in any suitable manner. For example, articulating surface  104  may be bonded to body portion  102 , or articulating surface  104  could be made from polyethylene and compression molded to body portion  102 . Alternately, the articulating surface  104  may be glued to the body portion  102  by, for example, an adhesive. Alternatively, articulating surface  104  may be mechanically interlocked to the body portion  102  by taper locking or otherwise press-fitting the articulating surface  104  into the body  102  and the body  102  may include any other suitable interlocking features, for example, rib(s), lip(s), detent(s), and/or other protrusion(s) and mating groove(s), channel(s), or indent(s) (not shown). 
         [0025]    In alternative embodiments, one or more of the outer wall  108 , the bone contacting surface  106 , the center peg  110  and the offset pegs  112 ,  114 , and  116  may include a porous coating to facilitate bone in-growth into the glenoid component  100 . The porous coating may be any suitable porous coating and may for example be POROCOAT®, a product of Johnson &amp; Johnson of New Brunswick, N.J. and more fully described in U.S. Pat. No. 3,855,638 to Pilliar, which is incorporated herein by reference. 
         [0026]    The glenoid component  100  may be implanted into the scapula  12  in accordance with a procedure  150  depicted in  FIG. 6 . In accordance with the procedure  150 , a scapula  12  is accessed at block  152  in accordance with a desired surgical approach. At block  154 , the center of an inferior glenoid circle, further described below, is identified for the scapula. While visual identification of the inferior glenoid circle and hence the center of the inferior glenoid circle is possible once the scapula  12  is accessed at block  152 , the center of the inferior glenoid circle may alternatively be identified prior to or after incising a patient with the aid of imaging or other techniques. 
         [0027]    By way of example, a CT scanner such as a Somatom Volume Zoom commercially available from Siemens Medical Solutions USA, Inc. of Malvern, Pa. may be used. The CT scanner may be set for matrix: 512/Kv: 140/eff. mAs: 350. The scan field of view (SFOV) may be set for 500, with the field of view (FOV) adapted to the individual patient, maximally 500 for both shoulders and minimally 150 for one shoulder. To obtain the desired images, the patient is then positioned in the CT-scanner tunnel in a dorsal recumbency, with a cushion on the belly and a strap around the body and the cushion to keep the arm adducted in the coronal plane and the forearm flexed in the sagittal plane of the body. The glenohumeral joint may then be scanned with 1.5 mm slices. 
         [0028]    In order to facilitate analysis of the images obtained from the CT scanner, the images may be imported into a medical imaging computer software such as Mimics® 11.02 for Intel X86 Platform V11.2.2.11992-2007 commercially available from Materialise Inc., Haasrode Belgium. The imported images may be used to create three dimensional images of the shoulder which allow the bones of the joint to be digitally separated and different views of the bones may be obtained. 
         [0029]    Once a sagittal view of the scapula  12  is obtained in the foregoing fashion, the inferior point  34 , the posterior point  38 , and the anterior point  40  may be identified (see  FIG. 2 ). Then, a best fit circle defined by the inferior point  34 , the posterior point  38 , and the anterior point  40  is identified. The best fit circle is the inferior glenoid circle, such as inferior glenoid circle  156  depicted in  FIG. 7 . Once the best fit inferior glenoid circle  156  is identified, the center  158  of the inferior glenoid circle  156  is defined. As shown in  FIG. 7 , the center  158  of the inferior glenoid circle  156  is located inferiorly and posteriorly to the geometric center  42 . 
         [0030]    Identification of the inferior glenoid circle center  158  at block  154  is performed in order to better position a glenoid component  100  as compared to traditional points of reference such as the geometric center  42 . Specifically, while known prosthetic systems are designed to allow for translation of the humeral component with respect to the glenoid component, the inventors hypothesize that in normal kinematics of the shoulder joint the humerus  10  does not exhibit translation along the glenoid fossa  14 . Rather, such observed translation indicates that normal kinematics have not been achieved. If a normal shoulder does not exhibit translation, then restoration of normal kinematics would entail configuring and positioning a glenoid component such that an unloaded humeral component would simply spin on the glenoid component. 
         [0031]    The location at which the humeral component would spin on the glenoid component, the “spinning point” would thus be defined as a point in a plane defined by the glenoid fossa  14  at which a line from the origin (R) of the humeral component, which is assumed to be spherical, to the defined plane is orthogonal to the defined plane. Proof of the usefulness in identifying the inferior glenoid circle center  158  in locating the spinning point of a shoulder joint was obtained by analysis of Ct scans of 152 shoulders using the CT scanner and parameters described above. 
         [0032]    Once the scans of the 152 shoulders were obtained and imported into the medical imaging computer software described above, two different Cartesian coordinate systems were defined to assess the usefulness of identifying the inferior glenoid circle in determining the location of the spinning point of a shoulder joint. Both systems were based upon a plane defined by the inferior point  34 , the posterior point  38 , and the anterior point  40 . This plane was selected for consideration since the plane defined by those points has been proven to exhibit the least variation between individuals as compared to planes defined by other reference points on the scapula. The two systems are described with reference to  FIG. 7  and  FIG. 2 . 
         [0033]    In one system, defined as a linear-point system, an origin is defined as the intersection of the line  36  and Saller&#39;s line  30  on a plane defined by the inferior point  34 , the posterior point  38 , and the anterior point  40 . The origin of the linear-point coordinate system is thus the geometric center  42  (see  FIG. 2 ). The Y-axis in this system is defined as a line extending between the geometric center  42  and the inferior point  34 . The Y-axis is thus Saller&#39;s line  30 . The X-axis  160  in this system is defined as a line perpendicular to the Y-axis (Saller&#39;s line  30 ) which includes the geometric center  42 , as well as including an anterior point  162  and posterior point  164  both of which are located on the glenoid rim  24 . The Z-axis is defined as a line perpendicular to the defined plane and including the origin, geometric center  42 . 
         [0034]    A circular coordinate system was also defined. In the circular system, the origin is defined as the inferior glenoid circle center  158 . The Y-axis  164  in this system is defined as a line including the inferior glenoid circle center  158  and the inferior point  34 . The X-axis  166  in this system is defined as a line perpendicular to the Y-axis  164  which includes the inferior glenoid circle center  158 , as well as including an anterior point  168  and posterior point  170  both of which are located on the glenoid rim  24 . The Z-axis is defined as a line perpendicular to the defined plane and including the origin, inferior glenoid circle center  158 . 
         [0035]    In analyzing the obtained scans, the humeral articulating surface is assumed to be a spherical surface with an origin (R). Thus, for each reference system the “spinning point” is defined to be the location on the defined plane at which a line directly between the R and the plane forms a ninety degree angle. In both of the above defined coordinate systems, a projection superior to the respective X-axis is defined to be greater than 90 degrees and a projection posterior to the respective Y-axis is defined to be greater than 90 degrees. 
         [0036]    Using the above described circular coordinate system, the obtained images were analyzed to quantify any offset between the spinning point and the inferior glenoid circle center  158 . Analysis was also performed using the linear-point coordinate system to quantify any offset between the spinning point and the geometric center  42  since the geometric center  42  is a commonly used reference point for positioning of a glenoid component. 
         [0037]    Quantification of the offset between the spinning point and the geometric center was obtained by measuring the length of the line between the R and the geometric center  42  and determining the angulation of that line based upon the above described linear point coordinate system for each of the shoulders (the “intersecting-point measurement”). Quantification of the offset between the spinning point and the inferior glenoid circle center  158  was obtained by measuring the length of the line between the R and the inferior glenoid circle center  158  and determining the angulation of that line based upon the above described circular coordinate system for each of the shoulders (the “circular measurement”). 
         [0038]    The results of the foregoing measurements were statistically analyzed using one-sample t-tests, by hypothesizing that the mean angle did not deviate from 90 degrees. Means and variances of angles and distances were compared between the intersecting-point measurements and the circular measurements using paired two-sample t-tests and modified Levene tests. Paired t-tests were also used to compare corresponding distances within each of the measurement techniques. Mixed model analysis was applied to the results to adjust for age, sex, and side of the subjects. For continuous, normally distributed outcome measures, intra- and inter-observer reliability was assessed by intra-class correlation coefficients (ICC) based upon two-way random effect models using an absolute agreement definition. All statistical analyses were performed using IBM SPSS statistics, version 18, commercially available form SPSS, Inc. of Chicago, Ill. 
         [0039]    Using three independent reviewers, the mean length of the longitudinal or craniocaudal axis (between the inferior point  34  and the superior point  32 ) was 35 mm (95% Cl 34.87 mm-35.83 mm). The mean length of the anteroposterior axis (between the posterior point  38  and the anterior point  40 ) was 27.02 mm (95% Cl 26.55 mm-27.5 mm). The mean diameter of the inferior glenoid circle  156  was 25.87 mm (95% Cl 25.45 mm-26.30 mm). 
         [0040]    Based upon the intersecting-point measurement, the actual spinning point when projected onto the defined plane was located inferiorly to the craniocaudal axis (89.11 degrees, 95% Cl 88.38°-89.86°) and posteriorly to the anteroposterior axis (95.30 degrees, 95% Cl 94.48°-96.13°). The length of the line between the geometric center  42  and R was 24.77 mm (95% Cl 24.41 mm-25.13 mm). 
         [0041]    Based upon the circular measurement, the actual spinning point when projected onto the defined plane was located superiorly to the craniocaudal axis (91.86 degrees, 95% Cl 91.35°-93.37°) and posteriorly to the anteroposterior axis (91.86 degrees, 95% Cl 91.17°-92.46°). The length of the line between the center  158  of the inferior glenoid circle  156  and R was 24.72 mm (95% Cl 24.35 mm-25.08 mm). 
         [0042]    In obtaining the foregoing results, the intra- and inter-observer variability was considered very good to acceptable. Reliability was assessed using inter- and intra-observer concordance, expressed as interclass correlation coefficients. 
         [0043]    Consequently, identifying the inferior glenoid circle center  158  of the inferior glenoid circle  156  for a particular patient provides a good estimation of the location of the spinning point for the patient since the line between the inferior glenoid circle center  158  and the origin of the humeral component is nearly perpendicular to the defined plane. If desired, an offset slightly superior and posterior to the center  158  may be incorporated to attempt to more accurately define the spinning point. 
         [0044]    Returning to the procedure  150  of  FIG. 6 , once the center of the inferior glenoid circle is identified at block  154 , the glenoid fossa  14  is prepared to receive the selected glenoid component  100  at block  176 . Preparation of the glenoid fossa  14  may include planarization of the glenoid fossa  14 , and drilling holes to receive a particular glenoid component, such as the center peg  110 , and the offset pegs  112 ,  114 , and  116 . Preparation of the glenoid fossa  14  may be computer assisted, including the use of computer aided procedures to position a guide wire in the glenoid fossa  14  based upon the identified inferior glenoid circle center  158 . If desired, the guide wire may be positioned on the glenoid fossa  14  at a location slightly offset from the inferior glenoid circle center  158  in a posterior and superior direction. 
         [0045]    Once the glenoid fossa  14  is prepared, a glenoid component  100  is selected at block  178 . In one embodiment, a circular glenoid component  100  sized to fit within the area circumscribed by both the glenoid rim  24  and the inferior glenoid circle  156  with the nadir  118  at or slightly posterior and superior to the center  158  of the inferior glenoid circle  156  is selected. Selection of the glenoid component  100  may be based upon a variety of other factors. Such factors include the availability of bony structures which can be used to anchor the glenoid component  100 . Accordingly, in a kit including a number of different glenoid components  100 , a variety of differently sized glenoid components  100  may be provided along with a variety of peg configurations. The kit may further include glenoid components  100  that do not include any pegs. Some of the glenoid components  100  which do not include pegs may be configured for use with bone screws. 
         [0046]    After the glenoid fossa  14  is prepared, and the glenoid component is selected, then, at block  180 , the selected glenoid component  100  is implanted in the prepared glenoid fossa  14  resulting in the configuration depicted in  FIG. 8 . 
         [0047]    The procedure  150  may be modified in a number of ways. By way of example, while in the above example the glenoid component  100  was implanted with the nadir  118  aligned with the inferior glenoid circle center  158  at block  180 , the nadir  118  may alternatively be offset from the inferior glenoid circle center  158 . For example, the analysis described above indicated that a line from the origin R of the humeral component that is perpendicular to the plane defined by the inferior point  34 , the posterior point  38 , and the anterior point  40  (see  FIG. 2 ) is typically offset from the inferior glenoid circle center by about 1.1 mm in a direction superiorly and posteriorly from the inferior glenoid circle center  158 . Accordingly, the nadir  118  may be positioned based upon location of the inferior glenoid circle center  158  at a location about 1.1 mm superiorly and posteriorly from the inferior glenoid circle center  158 . Imaging and computer based systems may be used to assist in the positioning of the glenoid component at this location. 
         [0048]    Alternatively, the spinning point of a particular shoulder may be identified such as by use of a CT scanner as described above. In this embodiment, identification of the inferior glenoid circle center  158  and quantification of the offset of the inferior glenoid circle center  158  from the spinning point of the shoulder may occur prior to surgically accessing the shoulder. Then, the glenoid component  100  may be implanted such that the nadir  118  is aligned with the determined spinning point. 
         [0049]    Moreover, while a specific sequence was described in the procedure  150 , many of the steps may be performed in a different order and/or simultaneously with other of the steps. For example, in certain instances, the specific anatomy will dictate the manner in which the glenoid fossa can be prepared, which will in turn dictate or influence the glenoid component that may be selected. In other instances, the anatomy may allow for different types of glenoid components to be used. In such instances, the selected glenoid component may influence the manner in which the glenoid fossa is prepared to receive the selected glenoid component. 
         [0050]    In accordance with the methods described above, a glenoid component with a spherical articulating surface is implanted at or very near to the spinning point of a shoulder. Because of the location of the glenoid component, a humeral component with a radius of curvature matched to the radius of curvature of the articulating surface may be used to provide a constrained fit. As used herein, the term “matched” means a difference in the radii of curvature of the articulating surfaces of less than 2 mm. 
         [0051]    The foregoing description of the invention is illustrative only, and is not intended to limit the scope of the invention to the precise terms set forth. Further, although the invention has been described in detail with reference to certain illustrative embodiments, variations and modifications exist within the scope and spirit of the invention as described and defined in the following claims.