Central-peg radiolucency progression of an all-polyethylene glenoid with hybrid fixation in anatomic total shoulder arthroplasty is associated with clinical failure and reoperation

Current Role of Reverse Total Shoulder Arthroplasty in the Management of Glenohumeral Osteoarthritis

Reverse total shoulder arthroplasty (RSA) was historically reserved for the elderly, low-demand patient with rotator cuff arthropathy (RCA) or as a salvage procedure after failed primary arthroplasty. Surgeon expertise and the advancement of implant design has allowed RSA to now become commonplace not only for RCA but also for glenohumeral osteoarthritis. RSA provides a robust glenoid baseplate fixation, which allows for easier and more reliable bone grafting or augmentation when needed. For patients with severe glenoid bone loss, RSA has been shown to have superior or equivalent patient-reported outcomes and shoulder range of motion when compared with total shoulder arthroplasty.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review

BACKGROUND

Correction of glenoid retroversion is commonly performed in anatomic total shoulder arthroplasty (TSA) to increase component contact area and decrease eccentric loading of the glenoid component. Despite demonstrated biomechanical advantages, limited information exists on the clinical benefit of correcting glenoid retroversion. The purpose of this systematic review is to critically evaluate the existing literature on the effect of preoperative and postoperative glenoid retroversion on clinical functional and radiologic outcomes in patients who underwent anatomic TSA.

METHODS

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, Embase, and Cochrane Library evaluating the impact of glenoid retroversion on clinical and radiologic outcomes of TSA. English-language studies of level I through IV evidence were included. Blinded reviewers conducted multiple screens and methodological quality was appraised using the Modified Coleman Methodology Score.

RESULTS

Sixteen studies, including 3 level III and 13 level IV studies (1211 shoulders), satisfied all inclusion criteria. To address glenoid retroversion, 9 studies used corrective reaming techniques, and 4 studies used posteriorly augmented glenoids. Two studies used noncorrective reaming techniques. Mean preoperative retroversion ranged from 12.7° to 24° across studies. Eleven studies analyzed the effect of glenoid retroversion on clinical outcomes, including patient-reported outcome scores (PROs), range of motion (ROM), or clinical failure or revision rates. Most studies (8 of 11) did not report any significant association of pre- or postoperative glenoid retroversion on any clinical outcome. Of the 3 studies that reported significant effects, 1 study reported a negative association between preoperative glenoid retroversion and PROs, 1 study reported inferior postoperative abduction in patients with postoperative glenoid retroversion greater than 15°, and 1 study found an increased clinical failure rate in patients with higher postoperative retroversion. Ten studies reported radiographic results (medial calcar resorption, Central Peg Lucency [CPL] grade, Lazarus lucency grade) at follow-up. Only 1 study reported a significant effect of pre- and postoperative retroversion greater than 15° on CPL grade.

CONCLUSION

There is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required.

Anatomic glenohumeral arthroplasty: State of the art

Anatomical total shoulder arthroplasty in its modern form where it reproduces the normal shoulder has been utilized clinically for more than half a century. As the technology and the designs have changed to recreate the humeral and glenoid sides of the joint, the sophistication of design has resulted in the growing number of cases annually worldwide. This increase is due in part to the increasing number of indications that the prosthesis can treat with successful results. On the humeral side, there have been design changes to better reflect the proximal humeral anatomy, and humeral stems are increasingly placed safely without cement. Platform systems which allow conversion of a failed arthroplasty to a reverse configuration without stem extraction is another design change. Similarly, there has been increasing utilization of short stem and stemless humeral components. Extensive experience with shorter stem and stemless devices, however, has yet to demonstrate the purported advantages of these devices, as recent studies have demonstrated equivalent blood loss, fracture rates, operative times, and outcome scores. Easier revision with these shorter stems remains to be definitively established, with only one study comparing the ease of revision between stem types. On the glenoid side, hybrid cementless glenoids, inlay glenoids, cementless all-polyethylene glenoids, and augmented glenoids have all been investigated; however, the indications for these devices remain unclear. Lastly, innovative surgical approaches to implanting shoulder arthroplasty and the use of patient specific guides and computerized planning, while interesting concepts, still await validation before they are utilized on a widespread basis. While reverse shoulder arthroplasty has been increasingly used to reconstruct the arthritic shoulder, anatomic glenohumeral replacement maintains a significant role in the armamentarium of the shoulder surgeon.

Comparing outcomes of central ingrowth peg vs. noningrowth pegged glenoid components during revision to reverse total shoulder arthroplasty

Background

One innovation to reduce glenoid loosening in total shoulder arthroplasty (TSA) is a large, central ingrowth peg. However, when bone ingrowth fails to occur, there is often increased bone loss surrounding the central peg which may increase complexity of subsequent revisions. Our goal was to compare outcomes between central ingrowth pegs and noningrowth pegged glenoid components during revision to reverse total shoulder arthroplasty.

Methods

In a comparative retrospective case series, all patients who underwent TSA-to-reverse TSA revision between 2014 and 2022 were reviewed. Demographic varibles as well as clinical and radiographic outcomes were collected. Ingrowth central peg and noningrowth pegged glenoid groups were compared using t-test, Mann-Whitney U, Chi-Square, or Fisher's exact tests where indicated.

Results

Overall, 49 patients were included: 27 underwent revision from noningrowth and 22 from central ingrowth components. Females more commonly had noningrowth components (74% vs. 45%, P = .04) and preoperative external rotation was higher in central ingrowth components (P = .02). Time to revision was significantly earlier in central ingrowth components (2.4 vs. 7.5 years, P = .01). Structural glenoid allografting was required more with noningrowth components (30% vs. 5%, P = .03) and time to revision in patients ultimately requiring allograft reconstruction was significantly later (9.96 vs. 3.68 years, P = .03).

Conclusion

Central ingrowth pegs on glenoid components were associated with decreased need for structural allograft reconstruction during revision; however, time to revision was earlier in these components. Further research should focus on whether glenoid failure is due to glenoid component design, time to revision, or both.

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.

Survivorship of Anatomic Total Shoulder Arthroplasty

Anatomic total shoulder arthroplasty provides pain relief and improved quality of life for patients suffering from glenohumeral arthritis. The 10-year survival rate for these implants has been most recently reported at 96%. As the number of shoulder arthroplasties per year increases, it is important to evaluate factors associated with failure. Patient-specific variables such as age, sex, medical comorbidities, a history of previous shoulder surgery, and rotator cuff integrity can influence implant survival. Both surgeon and hospital volume have been shown to affect perioperative outcomes. Implant design and glenoid pathoanatomy are important structural considerations because both have a causal relationship with survivorship. Modifiable factors, such as smoking, body mass index, and alcohol or opioid consumption, should be addressed preoperatively when possible. Modifiable factors that pertain to surgery are equally as important; it is the responsibility of the surgeon to be aware of the reported outcomes for varying implants and technique-related pearls and pitfalls. For those perioperative factors that are nonmodifiable, it is prudent to counsel patients accordingly because these individuals may be more likely to require an eventual revision procedure.

The Definition of Periprosthetic Osteolysis in Shoulder Arthroplasty: A Systematic Review of Grading Schemes and Criteria

BACKGROUND

Periprosthetic osteolysis is a known complication after shoulder arthroplasty that may lead to implant loosening and revision surgery. To date, there is no consensus in the shoulder arthroplasty literature regarding the definition of osteolysis or the grading criteria, thus making it difficult to quantify and compare outcomes involving this complication. The purpose of this study was to perform a systematic review of the literature to assess how periprosthetic osteolysis in shoulder arthroplasty is defined and evaluated radiographically.

METHODS

A systematic review of MEDLINE, Scopus, Cochrane, and CINAHL was performed in August 2021 for studies that provided a definition and/or grading criteria for osteolysis in shoulder arthroplasty. Only studies with a minimum of 2 years of radiographic follow-up were included.

RESULTS

Thirty-four articles met the inclusion criteria. After consolidating studies by the same primary author that included the same grading criteria, 29 studies were examined for their definition and grading criteria for osteolysis. Of these, 19 (65.5%) evaluated osteolysis surrounding the glenoid and 18 (62.1%) evaluated osteolysis surrounding the humerus. There was considerable heterogeneity in the systems used to grade periprosthetic osteolysis surrounding the glenoid, whereas humeral periprosthetic osteolysis was often categorized via visualization into binary or categorical groups (e.g., presence versus absence; mild, moderate, or severe; partial versus complete). Four studies (13.8%) provided novel measurements for assessing either glenoid or humeral osteolysis.

CONCLUSIONS

Considerable heterogeneity exists in the assessment and grading of periprosthetic osteolysis in shoulder arthroplasty. The most common grading systems were binary and used qualitative visual interpretation, making them relatively subjective and prone to bias. Quantitative measurements of osteolysis were infrequently utilized. A standardized method of assessing osteolysis would be of value to facilitate communication and research efforts.

CT-based and morphological comparison of glenoid inclination and version angles and mineralisation distribution in human body donors

Background

For optimal prosthetic anchoring in omarthritis surgery, a differentiated knowledge on the mineralisation distribution of the glenoid is important. However, database on the mineralisation of diseased joints and potential relations with glenoid angles is limited.

Methods

Shoulder specimens from ten female and nine male body donors with an average age of 81.5 years were investigated. Using 3D-CT-multiplanar reconstruction, glenoid inclination and retroversion angles were measured, and osteoarthritis signs graded. Computed Tomography-Osteoabsorptiometry (CT-OAM) is an established method to determine the subchondral bone plate mineralisation, which has been demonstrated to serve as marker for the long-term loading history of joints. Based on mineralisation distribution mappings of healthy shoulder specimens, physiological and different CT-OAM patterns were compared with glenoid angles.

Results

Osteoarthritis grades were 0-I in 52.6% of the 3D-CT-scans, grades II-III in 34.3%, and grade IV in 13.2%, with in females twice as frequently (45%) higher grades (III, IV) than in males (22%, III). The average inclination angle was 8.4°. In glenoids with inclination ≤10°, mineralisation was predominantly centrally distributed and tended to shift more cranially when the inclination raised to > 10°. The average retroversion angle was − 5.2°. A dorsally enhanced mineralisation distribution was found in glenoids with versions from − 15.9° to + 1.7°. A predominantly centrally distributed mineralisation was accompanied by a narrower range of retroversion angles between − 10° to − 0.4°.

Conclusions

This study is one of the first to combine CT-based analyses of glenoid angles and mineralisation distribution in an elderly population. The data set is limited to 19 individuals, however, indicates that superior inclination between 0° and 10°-15°, and dorsal version ranging between − 9° to − 3° may be predominantly associated with anterior and central mineralisation patterns previously classified as physiological for the shoulder joint. The current basic research findings may serve as basic data set for future studies addressing the glenoid geometry for treatment planning in omarthritis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04660-4.

Subluxation in the Arthritic Shoulder

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The term "subluxation" means partial separation of the joint surfaces. In the arthritic shoulder, "arthritic glenohumeral subluxation" refers to displacement of the humeral head on the surface of the glenoid.

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The degree of arthritic glenohumeral subluxation can be measured using radiography with standardized axillary views or computed tomography (CT).

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Shoulders with a type-B1 or B2 glenoid may show more posterior subluxation on an axillary radiograph that is made with the arm in an elevated position than on a CT scan that is made with the arm at the side.

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The degree of arthritic glenohumeral subluxation is not closely related to glenoid retroversion.

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The position of the humeral head with respect to the plane of the scapula is related to glenoid retroversion and is not a measure of glenohumeral subluxation.

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Studies measuring glenohumeral subluxation before and after arthroplasty should clarify its importance to the clinical outcomes of shoulder reconstruction.

Clinical and Radiographic Outcomes of Total Shoulder Arthroplasty With a Nonspherical Humeral Head and Inlay Glenoid in Elite Weight Lifters: A Prospective Case Series

Background:

Weight lifting after total shoulder arthroplasty (TSA) can place significant stresses on implants that could lead to instability, loosening, and increased wear. A TSA system with nonspherical humeral head resurfacing and inlay glenoid—which improves the biomechanics and thus reduces instability, wear, and potential loosening—may be able to tolerate repetitive loads from weight lifting.

Purpose:

To determine clinical and radiographic outcomes after TSA in weight lifters.

Study Design:

Case series; Level of evidence, 4.

Methods:

We prospectively enrolled 16 weight lifters (mean ± SD age, 57.2 ± 7.8 years; 15 male) undergoing primary anatomic TSA (n = 17 shoulders, 1 staged bilateral) with nonspherical humeral head resurfacing and inlay glenoid replacement for glenohumeral osteoarthritis between February 2015 and February 2019. Exclusion criteria were rotator cuff deficiency, revision TSA, post-traumatic arthritis, and inflammatory arthritis. Outcome measures included the rate of return to weight lifting, results of patient-reported outcome measures (Penn Shoulder Score, Kerlan-Jobe Orthopaedic Clinic, and 12-Item Veterans RAND Health Survey), radiographic outcomes, and complication rate.

Results:

Follow-up was obtained on all patients at a mean of 38 months (range, 14-63 months). All patients returned to competitive weight lifting at 15.6 ± 6.9 weeks. Compared to the preoperative weight lifting level, at last follow-up patients reported performance at the following level: lighter weight, 1 (6%); same weight, 8 (50%); heavier weight, 7 (44%). Preoperative eccentric posterior glenoid wear was common (71% Walch B2 classification; 12/17), but posterior humeral subluxation improved at follow-up according to the Walch index (mean, 55.5% preoperative vs 48.5% postoperative; P < .001) and contact point ratio (mean, 63.9% preoperative vs 50.1% postoperative; P < .001). Pre- to postoperative improvements were seen in Penn Shoulder Score (44.3 vs 82.6; P < .001), Kerlan-Jobe Orthopaedic Clinic (50.6 vs 91.1; P < .001), and 12-Item Veterans RAND Health Survey physical component score but not mental component score. No signs of radiographic loosening were detected in follow-up images, nor were there any postoperative instability episodes or revision surgeries.

Conclusion:

There were substantial improvements in shoulder function and a high rate of return to weight lifting after TSA with a nonspherical humeral head resurfacing and inlay glenoid component. Radiographically, the humeral head centralized on the glenoid after surgery, and there was no evidence of component loosening at a mean 38-month follow-up.