RU2787706C2 - Individual 3d implant for shoulder joint replacement in shoulder defects and method of shoulder joint endoprosthetics in shoulder defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to oncology, traumatology and orthopedics, in particular to reconstructive plastic surgery when performing replacement of defects in the scapula. A 3D implant is made using the technology of layer-by-layer fusion of finely dispersed metal powder DMLS from Ti64ELI material. The 3D implant contains a body, a base, and an anatomical or reverse plastic glenoid made of ultra-high molecular weight polyethylene, and the body contains: three longitudinal through holes for screws with fixing plugs, a coracoid process with holes for fixing muscles and ligaments, as well as anterior and posterior plates with transverse holes for screws, and the surface of the body adjacent to the bone has a rough surface 1 mm thick in the form of a three-dimensional mesh structure with pores of 1 mm, and the base has the shape of a cone with a seat for the installation of glenoid. Before installing a 3D implant, a plastic try-in template is used to determine the resection border, a try-on is performed with the installation of a product template, after resection, the plane of contact with the implant is finalized, after resection planes are finalized according to the product template and the necessary fit is achieved, a designer template is installed on the scapula, holes are made under the screws, the implant is fixed to the bone using four fixing screws, and three fixing screws have fixing plugs, the front and back linings of the body are attracted to the scapula with two long and one short screws through the holes, then the base is installed on the body and fixed through the hole to body with a fixing screw, after which it is blocked with a cork, bone cement is applied to the surface of the base and a glenoid is installed. Moreover, during resection of the head of the humerus, a reverse glenoid is installed, and if resection of the head of the humerus is not performed, then an anatomical one.

EFFECT: proposed method makes it possible to design an endoprosthesis in such a way that, after its installation and fixation, the geometric parameters correspond as much as possible to the shape and symmetry of a healthy scapula, and the area of fixation and attachment of the device to the scapular bone exactly repeats its shape, which ensures a snug fit of the device to the bone, and the use of individually designed templates for resection and templates-constructors allows to accurately prepare and execute a seat for the device, to reduce the time of the operation.

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Description

The invention relates to medicine, namely to oncology, traumatology and orthopedics, in particular to reconstructive plastic surgery when performing replacement of defects in the scapula.

A bone defect can occur as a result of arthrosis or an oncological process, or as a result of a previous operation. The bone defect can be replaced with special implant options, eccentric processing of the glenoid, or the use of bone grafting with an allograft. Accurate information about the volume of the bone defect after the planned removal of the tumor of the scapula is important for successful arthroplasty.

Destruction of the articular surface of the scapula as a result of the tumor process complicates the process of defect reconstruction. There are many methods of plasty of the glenoid surface of the scapula with massive bone defects, however, these methods have the following disadvantages:

- the supporting thickness and area of the glenoid surface of the scapula decreases;

- medialization of the center of rotation with a high risk of developing coracoid and acromial impingement syndrome;

- high risk of nonunion and aseptic necrosis of the bone graft;

- unstable fixation.

Over the past decade, the frequency of arthroplasty has increased exponentially, and this has led to an increase in the number of complications and revisions, which requires special attention when replacing defects in the scapula.

Proper surgical management of bone defects of the scapula is essential for a successful long-term outcome. Understanding the causes of their occurrence allows for the necessary surgical planning, which includes optimal processing of the scapula and the correct positioning of the scapular component.

There are lateralized and displaced glenospheres that allow the center of rotation to be corrected relative to the defective glenoid. But the most important are serial scapular components with augments to fill various defects and individual components that can be obtained using 3D modeling based on preoperative 3D visualization.

However, extended components have the following disadvantages:

- do not restore natural bone stock and therefore may complicate future revisions.

- if the bone graft is fully integrated, the impact on the component is reduced by reducing the leverage. However, with the extended component, these forces are kept large due to the constantly large leverage.

The question of choosing a technique for processing and replacing a defect of the scapula is taken individually for each patient, but in case of large defects, preference is given to massive bone autoplasty or specialized implants.

Known modular reversible shoulder orthopedic implant and method of implantation (RU2712801C2)), which contains an elongated shoulder component in the form of a leg, made with the possibility of implantation in the patient's humerus; a component that replaces a broken epiphysis that can be separated from the shoulder component in the form of a stem, containing a cup-shaped body having an annular rim formed at its upper end, a lateral sewing cuff extending outward from the annular rim of the cup-shaped body within the segment of the annular rim formed by the extreme anterior point of the rim and the extreme rear point of the rim, an anteromedial sewing cuff extending outward from the annular rim of the cup body within the segment of the annular rim formed by the extreme anterior point of the rim and the extreme medial point of the rim, and a posterior medial sewing cuff extending outward from the annular rim within the segment of the annular a rim formed by a rearmost point of the rim and an extreme medial point of the rim, wherein the lateral sewing cuff, the anteromedial sewing cuff, and the posteromedial sewing cuff are separated from each other; a locking screw attached to the humeral stem component and the fractured epiphysis component and the humerus cap component attached to the fractured epiphysis component, the humeral cap component having a concave bearing surface articulated with a rounded surface of the head of the glenoid spherical component, in which the outer surface of the cup-shaped body of the component replacing the broken epiphysis has grooves for the thread formed at its rear end.

The disadvantages of the design are:

- limited use, since the size of the bone defect of the articular surface of the scapula is not the same in all patients;

- unstable fixation;

- lack of precise positioning of the glenoid implant;

- lack of conditions for secondary osseointegration - non-porous surface of the implant at the points of contact with bone tissue.

Known modular glenoid prosthesis (US20130333187A1). The method includes the use of a base having two sides. The first side includes a plurality of connecting elements arranged in an array. The method further includes using a plurality of articular attachment elements, wherein each of the plurality of articular attachment elements has a locking mechanism. One of the connecting elements of the glenoid is selected and connected to the base by means of a locking mechanism of the selected one of the plurality of elements for attaching the glenoid to one of the connecting elements of the base. In this embodiment, the locking mechanism is a ball-shaped element, and each connecting piece is basically a ball-shaped receiver, the size and shape of which allows you to fix the ball-shaped element in place. As described above, the generally spherical receivers are arranged in an array. In this embodiment, all connectors are the same size, allowing the user to place glenoid connectors anywhere in the array. By giving the user this flexibility, the best location for attaching the bone-based elements can be selected. In addition, since the locking mechanism and the connecting elements are mostly spherical (balls and sockets, respectively), the user can insert the anchor pin and/or cemented pins at different angles.

The disadvantage of this type of prosthesis and assembly method is the instability of the design due to the many modules and individual articulation is not achieved.

As a prototype, the method of primary total arthroplasty of the shoulder joint with post-traumatic deformities of the glenoid surface of the scapula with an individual endoprosthesis (EN 2702014 C1) was chosen. The endoprosthesis is a single block of the glenoid component and the augment, made according to a three-dimensional model created using hybrid parametric modeling and topological optimization, taking into account the parameters of the bone defect of the glenoid surface of the scapula according to computed tomography of the shoulder joint on an SLS 3D printer made of titanium-aluminum-vanadium alloy ( Ti6Al4V). The said endoprosthesis has an outer porous surface for osseointegration, holes for insertion in a given direction of two screws for the coracoid process, four screws for the acromial process, and three screws for the spine of the scapula. When implementing the method, an endoprosthesis of the head with a stem is used. When implementing the method, a deltopectoral approach is performed, the tendon of the subscapularis muscle is released, the head of the humerus is resected, the glenoid surface of the scapula is rimmed, the coracoid and acromial processes of the scapula are processed with a drill, after which the individual endoprosthesis is fixed to the scapula with bone screws, and two screws are inserted into the coracoid process, four - in the acromial process and three - in the spine of the scapula. Install the cement cup without additional positioning. Next, the bone canal of the humerus is processed with reamers, the templates of the shoulder component of the endoprosthesis are installed to determine the level of immersion of the endoprosthesis stem and the tension of soft tissues, followed by the installation of the endoprosthesis stem with the head on the bone cement, after which the endoprosthesis is reduced and testing for instability, refixation of the subscapularis muscle, layer-by-layer wound suture. EFFECT: invention provides strong fixation and precise positioning of the glenoid component of the endoprosthesis, complete reconstruction of the bone defect area, reduction of the operation time due to previously known directions of insertion and sizes of bone screws, restoration of the biomechanics of the shoulder joint, normal interaction of the rotator cuff muscles.

The disadvantage of the design is the need for resection of the head of the humerus, which leads to additional surgical trauma and increases the risk of postoperative complications.

The disadvantages of the above methods are their limitations and, in some cases, the impossibility of their use in oncological practice in tumor and metastatic lesions of the scapula. Different extent of the lesion, the presence of the soft tissue component of the tumor, as well as damage to nearby structures are factors that do not allow achieving radical and ablastic surgery using standard methods for processing and replacing a bone defect in the scapula. Serial components, unlike individual ones, even with augments, do not provide the possibility of an add-on and “does not fit all sizes”, which requires the surgeon to additionally remove the bone for a complete fit to the component.

All of the above indicates the relevance of the search for new ways to replace scapular bone defects in cancer patients.

The technical solution is a method for reconstructing the shoulder joint in case of scapular defects with high accuracy of congruence, reducing the risk of postoperative complications, reducing the total operation time, reducing the volume of surgical trauma and reducing the time for implementing a personalized approach in the treatment of patients with defects in the shoulder joint.

The technical solution is achieved by the fact that, as in the known method, the endoprosthesis is performed according to a three-dimensional model created using hybrid parametric modeling and topological optimization, taking into account the parameters of the bone defect of the glenoid surface of the scapula according to computed tomography of the shoulder joint.

A feature of the proposed method is that the 3D implant is made using the layer-by-layer metal powder fusion technology - DMLS from the Ti64ELI material; The 3D implant contains a body, a base, and an anatomical or reverse plastic glenoid made of ultra-high molecular weight polyethylene, and the body contains: three longitudinal through holes for screws with fixing plugs, a coracoid process with holes for fixing muscles and ligaments, as well as anterior and posterior plates with holes for screws, and the surface of the body adjacent to the bone has a surface 1 mm thick in the form of a mesh structure with pores of 1 mm, and the base has the shape of a cone with a seat for the installation of glenoid. Before installation, a prefabricated plastic resection template is used, which is installed in the area of the defect, the bone tissue is removed, and the adjoining of the resection plane to the template is finalized; screws; then, 8 of the 3D implant according to claim 1 is fastened to the blade through the holes made on the surface of its body using four fixing screws, three of which have fixing plugs; then, the front and rear plates of the 3D implant body are attracted to the blade, by inserting three screws into the holes of each plate, the base of the 3D implant is installed on the body and fixed through the hole to the body with a fixing screw, after which the screw is blocked with a stopper, on the surface of the base 3D- implant, bone cement is applied and the glenoid is placed. Moreover, during resection of the head of the humerus, a reverse glenoid is installed, and if resection of the head of the humerus is not performed, then an anatomical one.

The invention is illustrated by a detailed description, a clinical example and illustrations, which show:

Fig. 1 - Model of the scapular bone element after 3D processing: a) in red - the level of resection; b) 1 - template for resection.

Fig. 2 - Model of the scapular bone element after the planned resection.

Fig.3 - Model of the scapular element after the planned resection of the defect: a) in direct projection: 2 - template-constructor for fixing screws; b) in the lateral projection: 2 - template-designer for fixing screws; 3 - drill holes ∅ 5 mm; 4 - drill holes ∅ 3.2 mm; 5 - hole for drill ∅ 2 mm.

Fig. 4 - Model of the scapular element after the planned resection of the defect: 6 - product template.

Fig. 5 – Device model: a) front view: 7 – case; 8a - front pad; 9 - holes in the lining; 10 - holes in the body, 11 - screws with fixing plugs; 12 - fixing plug; 23 - rough surface of the body adjacent to the bone; b) rear view: 7 - body; 8b - rear pad; 9 - holes in the lining; 10 - holes in the body,

Fig.6 - Attraction of the lining with fasteners: a) front view: 7- body; 8a - front pad; 9 - holes in the lining; 10 - holes in the body; 13 – long screw; 14 - short screw; 22 - holes for muscle fixation b) rear view: 7 - body; 8b - rear pad; 9 - holes in the overlay; 10 - holes in the body; 13 – long screw; 14 - short screw; 21 - coracoid process.

Fig.7 - Installation of the base: 7 - housing; 15 - base; 16 - hole for the fixing screw; 17 - screw for attaching the base to the body.

Fig. 8 - Installation of the base: 15 - base; 18 - plug blocking the screw fixing the base.

Fig. 9 - Installation of the lining: 18 - plug blocking the screw fixing the base; 19 - plastic glenoid (anatomical glenoid) from UHMW (ultra high molecular weight polyethylene).

Fig. 10 - Model of the device in combination with a scapular bone element.

Fig.11 - 3D device for the reconstruction of the shoulder joint: 19 - anatomical plastic glenoid from UHMW (ultra-high molecular weight polyethylene).

Fig. 12 - Assembled 3D device for reconstruction of the shoulder joint: 20 - reverse plastic glenoid made of UHMW (ultra high molecular weight polyethylene); 21 - coracoid process; 22 - holes for fixing muscles.

Fig.13 - Photo illustrations during the operation: installation of the device.

Fig.14 - radiograph of the patient D., using the device: a) axial projection; b) direct projection.

The method is carried out as follows.

In the preoperative period, computed tomography of the scapula is performed, an additional program for processing the obtained scans is performed, and the shape and size of the bone defect are determined.

The device is designed in accordance with the geometry of the edge of the bone defect of the scapular component according to anthropometric data, covering the defect, absolutely repeating the anatomy along the edge of the defect, and the length of the fixing screws is determined when fixing the structure to the bone tissue, taking into account the thickness and density of the bone tissue.

After planning, the implant is 3D printed using a 3D printer by direct laser sintering by 3D printing. As a result, the device is a one-piece structure that accurately follows the contours of the defect and has mounting holes.

The 3D implant is made using the technology of layer-by-layer fusion of finely dispersed metal powder - DMLS from Ti64ELI material.

The device contains a body 7 (Fig. 5 a, b), a base 15 (Fig. 7) and a plastic glenoid made of ultra-high molecular weight polyethylene (UHMWPE) of two types: anatomical 19 (Fig. 11) or reverse 20 (Fig. 12).

Housing 7 has a coracoid process 21 has holes 22 for fixing muscles and ligaments. The body 7 contains both the front 8a and the back 8b pads that firmly press the implant against the body of the scapula with three fixing screws 13 and 14 through the holes 9 (Fig.6 a, b). The body 7 also contains holes 10 for screws 11 with fixing plugs 12, and the surface of the body 7 adjacent to the bone has a rough surface 23 1 mm thick, in the form of a three-dimensional mesh structure with 1 mm pores, for strong consolidation with the bone (Fig. 5 a, b).

A base 15 is installed on the body 7, which has the shape of a cone and is fixed to the body with a screw 17 through the hole 16 (Fig.7). Moreover, at the base 15 there is a seat for the installation of glenoid of two types: anatomical 19 (Fig. 9, Fig. 11), if resection of the head of the humerus is performed and reverse 20 (Fig. 12), if the resection of the head of the humerus not be carried out.

The method of arthroplasty of the shoulder joint with defects of the scapula is performed as follows.

Using a prefabricated template 1 (Figure 1 b) plan the level of resection of the scapular bone defect (Figure 1 a) so that the device is congruently combined with the scapula after removal of the defect.

During the operation, access to the segment of the scapula affected by the tumor is standard.

Resection template 1 (Fig. 1b) is installed in the area of the defect (Fig. 2). Remove part of the bone tissue (Fig. 1a). After resection, the plane of adjunction to the implant is finalized; a product template 6 is used for fitting (Fig. 4).

After finalizing the resection planes according to the product template 6 (Fig. 4), and achieving the necessary fit, a designer template 2 (Fig. 3 a, b) is installed on the blade to drill holes 3-5 (Fig. 3 b) for screws 11 ( Fig.5).

The 3D implant is attached to the bone using four fixing screws 11 (Fig. 5) through holes 3 (Fig. 3 b) made on the surface of the device. Moreover, three fixing screws 11 have fixing plugs 12 (Fig. 5). Holes 3 are made for fasteners, focusing on the thickness and density of the patient's bone. The front 8a and 8b rear pads are attracted to the shoulder blade with two long screws 13 and one short screw 14 through the holes 9 (Fig.6).

A base 15 is installed on the body 7 (Fig. 7) and fixed through the hole 16 with a fixing screw 17 to the body 7, after which it is blocked with a stopper 18 (Fig.8-9).

Before installing the anatomical 19 (Fig. 9, Fig. 11) or reverse 20 glenoid (Fig. 12), bone cement is applied to the surface of the base 15 (Fig. 8), after which the glenoid is installed.

Thus, due to the use of resection templates, design templates and a product template, the directions and sizes of the fixing screws are known in advance, the reconstruction of the bone defect zone is performed with high accuracy, which reduces the operation time.

Clinical example 1.

Patient D., aged 28, diagnosed with C40.1 Epithelioid hemangioendothelioma of the right scapula, cT2N0M0G1, stage IB. Surgical treatment: oncological arthroplasty of the articular process of the right scapula on March 31, 2021

Associated diseases: no.

For the first time, the symptoms of the disease appeared in June 2020, when pains in the area of the right shoulder blade began to bother. The patient sought medical care at the place of residence. Conservative therapy without effect. Process malignancy is suspected. An SCT study was performed on 07/08/2020, according to the results of which, in the area of the coracoid process and the neck of the scapula on the right, the formation of soft tissue density, heterogeneous structure, with uneven and fuzzy contours, with destruction of the cortical plate, without involvement of neighboring structures in the process, with dimensions of 28x20x25 mm. Conclusion: CT picture of the tumor formation of the coracoid process and the neck of the scapula on the right. The patient underwent a trephine biopsy of the formation of the right scapula. The diagnosis of epithelioid hemangioendothelioma was verified.

03/31/2021 surgical treatment: resection of the articular process of the right scapula with removal of the tumor, endoprosthesis replacement of the articular process of the scapula with an individual implant.

Progress of the operation: With the patient lying on the left side of the two accesses, a skin incision along the outer edge of the right shoulder blade to the projection of the acromioclavicular joint, the second access along the anterior surface of the right shoulder joint in the projection of the palpable coracoid process. Bluntly and sharply divorced soft tissues in the projection of the shoulder joint cut off the scapular muscles from the places of attachment. Muscles attached to the coracoid process were cut off. The capsule of the shoulder joint was dissected along the anterior and posterior surfaces. The articular process of the scapula is exposed. A resection template was installed on the articular process of the scapula. Resection of the articular process was performed.

After resection, a template for drilling holes for screws was installed on the scapula. The holes are drilled with drills with a diameter of 3.2 mm and 5 mm. The implant was placed and secured with 3 4.5mm screws with fixation plugs. The implant overlay is closed along the outer surface of the scapula and fixed with two screws and two cerclage sutures. Installed overlay (anatomical) glenoid 19 (Fig.11) on a cement base. The endoprosthesis is assembled. The head of the shoulder joint is set into the joint (Fig. 13). Movement test. 2 Gentocoll sponges are placed in the implant area. The joint capsule was sutured. Vacuum drainage. The muscles were sutured in stages to the coracoid process from the anterior approach, to the scapula from behind. Layered sutures on the wound. Stitches on the skin. Aseptic sticker. Bandage on the arm.

At the moment, there is no data for a relapse of the underlying disease (Fig. 14 a, b), the observation period is 6 months.

Clinical example 2.

Patient M., 32 years old with a diagnosis of C40.0 Osteosarcoma of the right humerus with a secondary lesion of the articular process of the scapula, urT2N0M0G3, stage IIB. Combined treatment: Neo- and adjuvant courses of PCT according to the AR scheme. Surgical treatment: segmental resection of the upper third of the right humerus and the articular process of the scapula with arthroplasty on 04/14/2021.

Associated diseases: no.

In October 2020, pain appeared in the area of the right shoulder joint, aggravated at night and during physical activity. The patient sought medical help at the place of residence to a traumatologist. A diagnosis of scapulohumeral periarthritis on the right was established. Conservative therapy without effect. An CT scan of the right shoulder joint was performed on December 7, 2020 - a focus of lytic destruction was detected in the region of the upper third of the humerus with a soft tissue component extending to the articular process of the scapula. The formation of a heterogeneous structure, with uneven and fuzzy contours, with destruction of the cortical plate, dimensions 58x70x85 mm. Conclusion: CT picture of a tumor formation in the upper third of the right humerus with a secondary lesion of the articular process of the scapula on the right. The patient underwent a trephine biopsy of the formation of the right humerus. The diagnosis of G3 osteosarcoma was verified.

At the first stage, the patient underwent 3 courses of PCT according to the AR scheme in the neoadjuvant mode from January to March 2021. During the control examination of the CT scan of the right shoulder joint dated March 25, 2021. there is a compaction of the structure of the tumor, the dimensions are the same - the stabilization of the process.

04/14/2021 surgical treatment in the amount of segmental resection of the upper third of the right humerus and the articular process of the scapula with endoprosthetics with an individual implant.

Progress of the operation: In the position of the patient lying on his back along the anterior surface of the right shoulder joint along the delto-pectoral line with the transition to the lateral surface of the shoulder. Bluntly and sharply separated soft tissues in the projection of the shoulder joint, the muscles forming the rotator cuff of the shoulder were cut off from the places of attachment. The capsule of the shoulder joint was dissected along the anterior surface. The articular process of the scapula and the upper third of the humerus with a tumor are exposed. A segmental resection of the upper third of the humerus was performed, 5 cm away from the visible edges of the tumor. A resection template was installed on the articular process of the scapula. Resection of the articular process was performed.

After resection, a template for drilling holes for screws was installed on the scapula. The holes are drilled with drills with a diameter of 3.2 mm and 5 mm. The implant was placed and secured with 3 4.5mm screws with fixation plugs. The implant overlay is closed along the outer surface of the scapula and fixed with two screws and two cerclage sutures. Installed inverse overlay glenoid (reverse) 20 (Fig.12) on a cement base. The bone marrow canal of the humerus was treated step by step with rimmers 8-11 mm in diameter, the canal was treated with a 12 mm rasp. A cementless fastening leg 75x12 mm is installed. A shoulder component of the endoprosthesis with an inverse head of the endoprosthesis was installed. The shoulder component of the endoprosthesis is set into the scapular component, the endoprosthesis is assembled, a test for movement. 2 Gentocoll sponges are placed in the implant area. The joint capsule was sutured. Vacuum drainage. If possible, the rotator cuff muscles were sutured. Layered sutures on the wound. Stitches on the skin. Aseptic sticker. Bandage on the arm.

At the moment, there is no data for a relapse of the underlying disease, the follow-up period is 12 months.

The proposed method of endoprosthesis replacement of the shoulder joint in case of scapular defects allows designing the endoprosthesis in such a way that after its installation and fixing, the geometric parameters correspond as much as possible to the shape and symmetry of a healthy scapula, and the area of fixation and attachment of the device to the scapula exactly repeats its shape, which ensures a snug fit of the device to the bone, and the use of individually designed templates for resection and templates-constructors allows you to accurately prepare and execute a seat for the device, to reduce the time of the operation.

Claims (3)

1. An individual 3D implant for replacing the shoulder joint with scapular defects, including the execution of a three-dimensional model created using hybrid parametric modeling and topological optimization, taking into account the parameters of the bone defect of the glenoid surface of the scapula according to computed tomography of the shoulder joint, characterized in that the 3D implant are made using the technology of layer-by-layer fusion of metal powder DMLS from Ti64ELI material; The 3D implant contains a body, a base, and an anatomical or reverse plastic glenoid made of ultra-high molecular weight polyethylene, and the body contains: three longitudinal through holes for screws with fixing plugs, a coracoid process with holes for fixing muscles and ligaments, as well as anterior and posterior plates with holes for screws, and the surface of the body adjacent to the bone has a surface 1 mm thick in the form of a mesh structure with pores of 1 mm, and the base has the shape of a cone with a seat for the installation of glenoid. 2. A method of shoulder joint arthroplasty for defects of the scapula, characterized in that a prefabricated plastic resection template is used, which is installed in the area of the defect, bone tissue is removed and the adjoining of the resection plane to the template is finalized, after the resection planes fit to the template, a template is installed on the scapula -constructor for drilling holes in the bone and make holes for the screws; then, the 8 3D implant according to claim 1 is fastened to the blade through the holes made on the surface of its body, using four fixing screws, three of which have fixing plugs; then, the front and rear plates of the 3D implant body are attracted to the shoulder blade by inserting three screws into the holes of each plate, the base of the 3D implant is installed on the body and fixed through the hole to the body with a fixing screw, after which the screw is blocked with a stopper, on the surface of the base of the 3D implant bone cement is applied and the glenoid is placed. 3. The method according to claim 2, characterized in that during resection of the head of the humerus, the reverse glenoid is installed, and if the resection of the head of the humerus is not performed, then it is anatomical.

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