Design Evolution of the Glenoid Component in Total Shoulder Arthroplasty

Recent Advances in the Design and Application of Shoulder Arthroplasty Implant Systems and Their Impact on Clinical Outcomes: A Comprehensive Review

Purpose of Review

This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions.

Recent Findings

The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA's 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations.

Summary

Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.

Stability of small pegs for cementless implant fixation

Most glenoid implants rely on large centrally located fixation features to avoid perforation of the glenoid vault in its peripheral regions. Upon revision of such components there may not be enough bone left for the reinsertion of an anatomical prosthesis. Multiple press-fit small pegs would allow for less bone resection and strong anchoring in the stiffer and denser peripheral subchondral bone. This study assessed the fixation characteristics, measured as the push-in (P_in ) and pull-out (P_out ) forces, and spring-back, measured as the elastic displacement immediately after insertion, for five different small press-fitted peg configurations manufactured out of UHMWPE cylinders (5 mm diameter and length). A total of 16 specimens for each configuration were tested in two types of solid bone substitute: Hard (40 PCF, 0.64 g/cm³ , worst-case scenario of P_in ) and soft (15 PCF, 0.24 g/cm³ , worst-case scenario of spring-back and P_out ). Two different diametric interference-fits were studied. Geometries with lower stiffness fins (large length to width aspect ratio) were the best performing designs in terms of primary fixation stability. They required the lowest force to fully seat, meaning they are less damaging to the bone during implantation, while providing the highest P_out /P_in ratio, indicating that when implanted they provide the strongest anchoring for the glenoid component. It is highlighted that drilling of chamfered holes could minimize spring-back displacements. These findings are relevant for the design of implants press-fitted pegs because primary fixation has been shown to be an important factor in achieving osseointegration and longevity of secondary fixation. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2765-2772, 2017.

Parametric analysis of glenoid implant design and fixation type

Common post-operative problems in shoulder arthroplasty such as glenoid loosening and joint instability may be reduced by improvements in glenoid design, shape, material choice, and fixation method. A framework for parametric analysis of different implant fixation configurations was developed in order to efficiently sift through potential glenoid component designs. We investigated the influence of design factors such as fixation type, component thickness, and peg position, number, diameter, and length in a multi-factorial design investigation. The proposed method allowed for simultaneous comparison of the mechanical performance of 344 different parametric variations of 10 different reference geometries with either large central fixation features or small peripheral pegs, undergoing four different worst-case scenario loading conditions, and averaging 64.7 s per model. The impact of design parameters were assessed for different factors responsible for post-operative problems in shoulder arthroplasty, such as bone volume preservation, stresses in the implant, central displacement or fixation stability, and the worst performing geometries all relied on conventional central fixation. Of the remaining geometries, four peripheral fixation configurations produced von Mises stresses comfortably below the material's yield strength. We show that the developed method allows for simple, direct, rapid, and repeatable comparison of different design features, material choices, or fixation methods by analyzing how they influence the bone-implant mechanical environment. The proposed method can provide valuable insight in implant design optimization by screening through multiple potential design modifications at an early design evaluation stage and highlighting the best performing combinations according to the failure mechanism to mitigate. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:775-784, 2017.

Analysis of severely fractured glenoid components: clinical consequences of biomechanics, design, and materials selection on implant performance

BACKGROUND

The longevity of total shoulder replacement is primarily limited by the performance of the ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid component in vivo. Variations in glenoid design (conformity, thickness), biomechanics (joint kinematics), and UHMWPE material selection (sterilization, cross-linking) distinguish total shoulder replacements from hip and knee arthroplasty devices. These variables can lead to severe mechanical failures, including gross fracture.

METHODS

Sixteen retrieved glenoids with severe fracture were analyzed. The explant cohort included 3 material groups (gamma-sterilized Hylamer; gamma-sterilized UHMWPE; and gas plasma-sterilized, remelted, highly cross-linked UHMWPE [HXL]) and a range of conformities (0- to 10-mm radial mismatch). Analysis included fractography (optical and scanning electron microscopy) and Fourier transform infrared spectroscopy for oxidative analysis.

RESULTS

Fracture primarily occurred along the exterior rim for all 16 explants. Fourier transform infrared analysis and fractography revealed significant oxidative embrittlement for all gamma-sterilized glenoids. Fatigue striations and internal flaws were evident on the fracture surface of the HXL glenoid, with little oxidation detected.

CONCLUSIONS

Fracture initiated at the external rim of all devices. Elevated oxidation levels and visible material distortion for representative gamma-sterilized conventional and Hylamer devices suggest oxidative embrittlement as a driving force for crack inception and subsequent fracture. Brittle fracture of theHXL glenoid resulted from a combination of elevated contact stress due to a nonconforming surface, an internal flaw, and reduced resistance to fatigue crack growth. This demonstrates that glenoid fracture associated with oxidation has not been eliminated with the advent of modern materials (HXL) in the shoulder domain.

LEVEL OF EVIDENCE

Basic Science Study; Implant Retrieval Study.

Posterior augmented glenoid implants require less bone removal and generate lower stresses: a finite element analysis

HYPOTHESIS

Glenoid retroversion can be corrected with standard glenoid implants after anterior-side asymmetric reaming or by using posterior augmented glenoid implants with built-in corrections. The purpose of this study was to compare 2 augmented glenoid designs with a standard glenoid design, measure the amount of bone removed, and compute the stresses generated in the cement and bone.

METHODS

Finite element models of 3 arthritic scapulae with varying severities of posterior glenoid wear were each implanted with 4 different implant configurations: standard glenoid implant in neutral alignment with asymmetric reaming, standard glenoid implant in retroversion, glenoid implant augmented with a posterior wedge in neutral alignment, and glenoid implant augmented with a posterior step in neutral alignment. The volume of cortical and cancellous bone removed and the percentage of implant back surface supported by cortical bone were measured. Stresses and strains in the implant, cement, and glenoid bone were computed.

RESULTS

Asymmetric reaming for the standard implant in neutral version required the most bone removal, resulted in the lowest percentage of back surface supported by cortical bone, and generated strain levels that risked damage to the most bone volume. The wedged implant removed less bone, had a significantly greater percentage of the back surface supported by cortical bone, and generated strain levels that risked damage to significantly less bone volume.

CONCLUSIONS

The wedged glenoid implants appear to have various advantages over the standard implant for the correction of retroversion.

LEVEL OF EVIDENCE

Basic Science Study; Computer Modeling.