Uncemented fixation of a monoblock ingrowth polyethylene glenoid: early follow-up

Bone support correlation of X-Ray and CT for a new PE-glenoid

INTRODUCTION

The radiographic evaluation of novel cementless anatomic polyethylene (PE) glenoid components featuring a titanium-coated back is still unclear. This study explores potential radiolucent lines (RLL) between the radiopaque titanium layer and sclerotic convex reamed bone in an intermodal comparison analysis with computed tomography (CT) scans.

MATERIALS AND METHODS

Eight RM pressfit vitamys glenoids (Mathys®) were implanted into cadaveric scapulae. In the CT scans, glenoids were quantified by evaluating ideal complete bony support (NO GAP) and gap between bone and titanium coating (GAP). X-rays were in perfect 0-degree projection and tilted in ± 10° and ± 20° mediolateral (ml) and craniocaudal (cc) directions. Radiographs evaluated were graded as NO RLL, RLL (gap > 1 mm) or DL (double line, gap < 1 mm) in an intermodal comparison of CT and X-ray findings.

RESULTS

The inter-rater (Cohen's = 0.643) and intra-rater reliability (Cohen's = 0.714) were good. The overall evaluation showed a significant agreement between (NO) RLL on X-ray and (NO) GAP on CT (p < 0.001). The - 10-degree ml projection showed good agreement between CT and X-ray (Cohen's = 0.628). Adequate agreement was shown at 0 degrees (Cohen's = 0.386), + 10 degrees ml (Cohen's = 0.338), and + 20 degrees cc (Cohen's = 0.327). Compared to the scenario DL = NO RLL, the true a.p. view showed better sensitivity when the DL is classified as RLL. Conversely, the true a.p. view demonstrated both better specificity and significant agreement between the X-ray and CT findings in scenario when DL = No RLL.

CONCLUSION

Standard true a. p. projections are reliable in ruling out gaps when no RLL or DL is visible and the detection of RLL shows high intermodal agreement. Varying agreement across tilting angles emphasizes the importance of a comprehensive approach in evaluating bone support and CT is indispensable for a scientifically reliable assessment.

LEVEL OF EVIDENCE

Level III Treatment Study.

Comparison of long-term clinical and radiological outcomes for cemented keel, cemented peg, and hybrid cage glenoids with anatomical total shoulder arthroplasty using the same humeral component

Aims

The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system.

Methods

We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217).

Results

Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%).

Conclusion

These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids.

Clinical and radiographic outcomes following anatomic total shoulder arthroplasty utilizing an inset glenoid component at 2-year minimum follow-up: a dual center study

BACKGROUND

Anatomic total shoulder arthroplasty (aTSA) is a successful and reproducible treatment for patients with painful glenohumeral arthritis. However, long-term outcomes using traditional onlay glenoid components have been tempered by glenoid loosening. Inset components have been proposed to minimize glenoid loosening by reducing edge-loading and opposite-edge lift-off forces with humeral translation. Successful short- and long-term outcomes have been reported while using inset glenoid implants. The current study is the largest study presenting a minimum of 2-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI, USA).

METHODS

A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by 2 fellowship-trained shoulder surgeons at 2 separate institutions from August, 2016, to August, 2019, was performed. Minimum follow-up was 2 years. Range of motion (ROM), visual analog scale (VAS) pain scores, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores were obtained. Radiographic outcomes, including central peg lucency and glenoid loosening, were assessed by 3 independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up.

RESULTS

Seventy-five shoulders were included for the final analysis. The mean age of the entire cohort was 64 (±11.4) years. Twenty-one (28%) glenoids were type A1, 10 (13.3%) were type A2, 13 (17.3%) were type B1, 22 (29.3%) were type B2, 6 (8%) were type B3, and 3 (4%) were type D. At a minimum follow-up of 24 months (mean: 28.7 months), a significant improvement in ROM in all planes was observed. Significant improvements in VAS (5.1-0.9, P < .001), SANE (39.5-91.2, P < .001), and ASES (43.7-86.6, P < .001) scores were observed. There were 4 (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) case of glenoid loosening. No revisions were performed for glenoid loosening.

CONCLUSION

At a minimum of 2 years postoperatively, there were significant improvements in ROM, VAS, SANE, and ASES scores with very low rates of central peg lucency and glenoid loosening in patients undergoing aTSA with an inset glenoid component. Further work is needed to determine the long-term benefit of this novel implant.

Glenoid Prosthesis Design Considerations in Anatomic Total Shoulder Arthroplasty

Total shoulder arthroplasty is an increasingly popular option for the treatment of glenohumeral arthritis. Historically, the effectiveness of the procedure has largely been determined by the long-term stability of the glenoid component. Glenoid component loosening can lead to clinically concerning complications including pain with movement, loss of function, and accumulation of debris which may require surgery to revise. In response, there has been a push to optimize the design of the glenoid prosthesis. Traditional contemporary glenoid components use pegs for fixation and are made entirely of polyethylene. Variations on the standard implant include keeled, metal-backed, hybrid, augmented, and inlay designs. There is a wealth of biomechanical and clinical studies that report on the effectiveness of these different designs. The purpose of this review is to summarize existing literature regarding glenoid component design and identify key areas for future research. Knowledge of the rationale underlying glenoid design will help surgeons select the best component for their patients and optimize outcomes following TSA.

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review

BACKGROUND

As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed.

QUESTIONS/PURPOSES

We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?

METHODS

The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]).

RESULTS

The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]).

CONCLUSION

There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty.

CLINICAL RELEVANCE

Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.

Comparison of press-fit versus peripherally cemented hybrid glenoid components in anatomic total shoulder arthroplasty: minimum 5-year follow-up

Background

A common complication of anatomic total shoulder arthroplasty (aTSA) is aseptic glenoid loosening. Monoblock polyethylene glenoid components with backside ingrowth or on-growth utilize hybrid fixation, with cementation of the peripheral pegs and central ingrowth or on-growth of bone have been designed to decrease glenoid loosening. However, there is a paucity of midterm data comparing cementation of the peripheral peg holes versus all press-fit implantation for hybrid glenoid constructs. The purpose of this study is to compare the minimum five-year clinical and radiographic outcomes of a press-fit hybrid glenoid component with a peripherally cemented hybrid glenoid component in aTSA.

Methods

Between years 2013-2015, we reviewed a total of 169 patients who underwent primary aTSA, with follow-up data spanning a minimum of five years, from an international multi-institutional database. There were 61 press-fit and 108 peripherally cemented glenoids. Shoulders were evaluated for outcome measures, which included clinical outcome scores, radiographic outcomes, and complication rates.

Results

Postoperatively, there were no statistically significant differences in patient satisfaction, shoulder function, pain scoring, the Simple Shoulder Test, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California–Los Angeles score, nor the Shoulder Pain and Disability Index, between the two cohorts. There were no significant differences in adverse events (P = .791) or revision rates (P = .592). At the final radiographic follow-up, there were no significant differences between the two groups with regard to the incidence of radiolucent lines on the glenoid (P = .210) or humeral side (P = .282).

Conclusion

At a minimum of 5-year follow-up, aTSA with a press-fit glenoid implant demonstrates no difference in clinical or radiographic outcomes when compared with a glenoid cohort where the peripheral pegs are cemented. In addition, there is no increased rate of aseptic glenoid loosening or need for revision surgery between the two groups with a lower rate of radiolucency detected than prior midterm data studies. Uncemented press-fit glenoid fixation with a cage component appears to be a safe and effective treatment option for patients undergoing primary aTSA at a minimum of 5-year follow-up.

Articular surface failure in hybrid anatomic glenoid components: a unique failure mechanism

PURPOSE

Glenoid loosening is a common failure mechanism of anatomic total shoulder arthroplasty (TSA). New hybrid fixation glenoids allow bony ingrowth and decrease the rates of glenoid loosening. The purpose of this study is to describe a new failure mode of polyethylene dissociation from the ingrowth cage in a single implant design.

METHODS

A retrospective review was performed using an institutional shoulder arthroplasty database of a single hybrid cage glenoid (Exactech, Gainesville, FL). Implants demonstrating this failure mechanism were investigated.

RESULTS

Five out of 206 (2.4%) primary TSAs with cage glenoids performed at our institution and 2 referred for revision suffered glenoid articular face failure. Mean age was 57 (range 38-67 years). Two of 7 failures (29%) occurred secondary to trauma. Failure occurred at mean 14 months after index arthroplasty (range 0-30 months). Revision occurred at mean 24 months after index arthroplasty (range 6-39 months). Six of the 7 patients (86%) had posteriorly augmented glenoids. All 6 patients who had available pre-failure radiographs demonstrated off-axis deviation between the peripheral pegs and central cage (mean 4.8°, range 3°-6°), which may predispose the implant to failure by pre-stressing the material interface.

CONCLUSION

Failure between the glenoid articular face and the central ingrowth cage is a unique failure mechanism to modular hybrid ingrowth glenoids. We hypothesize that this is predisposed by off-axis drilling leading to pre-stressing of the material interface. Surgeons should be aware of the existence of this failure mechanism, particularly when seeing patients with acute pain after an otherwise unproblematic TSA.

Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty

BACKGROUND

Publications regarding anatomic total shoulder arthroplasty (TSA) have consistently reported that they provide significant improvement for patients with glenohumeral arthritis. New TSA technologies that have been introduced with the goal of further improving these outcomes include preoperative computed tomography (CT) scans, 3-dimensional preoperative planning, patient-specific instrumentation, stemless and short-stemmed humeral components, as well as metal-backed, hybrid, and augmented glenoid components. The benefit of these new technologies in terms of patient-reported outcomes is unknown.

METHODS

We reviewed 114 articles presenting preoperative and postoperative values for commonly used patient-reported metrics. The results were analyzed to determine whether patient outcomes have improved over the 20 years during which new technologies became available.

RESULTS

The analysis did not identify evidence that the results of TSA were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes.

CONCLUSIONS

Additional research is required to document the clinical value of these new technologies to patients with glenohumeral arthritis.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.