Radiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty

doi:10.1016/j.jse.2009.09.012

Journal of Shoulder and Elbow Surgery

Volume 19, Issue 4, June 2010, Pages 588-595

https://doi.org/10.1016/j.jse.2009.09.012 Get rights and content

Hypothesis

This study analyzed clinical, radiographic, and histologic data from failed total shoulder arthroplasties (TSAs) to determine factors associated with osteolysis.

Materials and methods

From 1985 to 2005, 52 patients (mean age, 61.6 years) underwent revision TSA at a single institution at a mean of 4.3 years after their index surgery. Patients were retrospectively assigned to 2 cohorts based on the presence (n = 10) or absence (n = 42) of osteolysis around their implants on the last prerevision surgery radiographs. Clinical information, associated histopathology from tissues obtained at revision surgery, and polyethylene wear data from the retrieved glenoid components were compared between groups.

Results

In the osteolysis group, 20% had screw fixation compared with 2.5% without osteolysis (P = .039). The radiolucency score was significantly higher in the osteolysis group: 12.7 ± 2.0 vs 8.7 ± 3.7 (P = .003). Wear analysis of the osteolysis group demonstrated significant increases in third-body particles compared with those implants without osteolysis (P = .004). Histology available from retrieved implants demonstrated particulate debris in 62% of patients with osteolytic lesions vs 67% without osteolytic lesions (P > .05).

Discussion

Significant differences were found in patients with osteolytic lesions compared with patients undergoing TSA revision surgery without such lesions, specifically with regard to glenoids that used adjuvant screw fixation, the presence of increased radiolucent lines, and an abundance of third-body wear. No significant differences were found in particulate wear debris despite the prevailing notion that osteolysis is associated with particulate debris from implant wear.

Conclusion

Screw fixation and third-body wear were associated with osteolysis after TSA.

Section snippets

Materials and methods

This study was approved by the Hospital for Special Surgery Institutional Review Board (Study No. 24097) in December 2007.

From 1985 to 2005, 52 consecutive patients with a mean age of 61.6 ± 11.9 years underwent revision TSA at a single institution at a mean of 4.3 ± 4.7 years after the index surgery. The inclusion criteria were patients who underwent revision TSA with availability of prerevision surgery radiographs and availability of the explanted components for evaluation of wear patterns.

Clinical information and demographics

Overall, 10 of 52 patients (19%) had radiographic evidence of osteolysis surrounding the glenoid component. No significant differences existed between the patients with osteolytic lesions and those without significant lesions (Table I) with regard to age, concordance of operative side with dominant hand, smoking history, primary diagnosis, length of implantation, range of motion, concurrent rotator cuff tear, and subjective instability.

Components

The implant system used did not demonstrate significant

Conclusions

This study examined demographic, clinical, radiographic, and retrieval analysis characteristics associated with osteolysis around TSA components on prerevision radiographs. We found metal-backed glenoid components were associated with osteolysis, consistent with the findings of other studies. Third-body embedded metallic particles into the polyethylene surface and thicker radiolucent lines were also significantly associated with the presence of osteolysis. Further insight into associations

Acknowledgments

Partial support from the Clark and Kirby Foundations is gratefully appreciated.

Disclaimer

The authors Christopher Kepler, Shane Nho, Manjula Bansal, Owen Ala, and Timothy Wright, their immediate families, and any research foundations with which they are affiliated, have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Edward Craig has a royalty agreement with Biomet. Russell Warren has royalty agreements with Biomet and Smith & Nephew, stock considerations with Zimmer, is a paid consultant for KFx, and receives

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Biomechanical comparison of a novel circular glenoid with peripheral ring fixation to a standard anchor pegged glenoid in total shoulder arthroplasty
2024, Seminars in Arthroplasty JSES
Current standard total shoulder pegged glenoid component designs have a high rate of loosening, which accounts for the most common long-term reason for surgical failure. Glenoid design, method of fixation, and implantation version all play a role in component stability. This study aimed to evaluate the biomechanical stability of a novel circular glenoid with peripheral ring fixation and compare to a standard anchor pegged glenoid both directly and to historical biomechanical data. Additionally, we compared the estimated bone removal for the glenoid design types.
Biomechanical testing was performed to assess the circular glenoid with peripheral ring fixation with regards to stability and resistance to “rocking horse” effect, torsional loosening, resistance to torque dissociation, and axial pullout strength. This was compared directly (pullout strength) and to historical (“rocking horse”) biomechanical data obtained for a standard anchor pegged glenoid. A 3D Computer-Aided Design model of five different scapula sizes and shapes was also utilized to estimate volume bone removed when using implant specific prep instrumentation for each glenoid system.
Tensile displacement of the worst-case ring fixation component (size medium) after dynamic rocking was 0.060 mm requiring an average peak torque of 6.21N-m to dissociate the glenoid. The ring fixation component demonstrated a mean pullout strength of 1367 N compared with 645 N for the standard anchor pegged glenoid component. The ring fixation component revealed no loosening when placed under torsional stress. The peripheral ring fixation glenoid preparation on average removed 45% less bone than a standard anchor pegged glenoid.
The circular glenoid with peripheral ring fixation demonstrated superior maximum pullout strength and more bone preservation with glenoid preparation when compared to the standard pear-shaped, pegged glenoid components. Compared to published standard pegged glenoid component controls, the glenoid with peripheral ring fixation demonstrated diminished “rocking horse” displacement. Despite the circular anchor ring design, there was no evidence of loosening under torsional stress. Initial biomechanical data is overall promising for this novel glenoid design.
Effect of vitamin E–enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene
2024, Journal of Shoulder and Elbow Surgery
Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component’s mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E–enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E–enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component.
Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated.
The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05).
A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E–enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.
Comparing bone resorption after anatomical shoulder arthroplasty between various surgical procedures using a single-stem model
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In shoulder arthroplasty, bone resorption around the stem can lead to stem loosening and makes surgery difficult at the time of revision. Proximal bone resorption after reverse shoulder arthroplasty can cause instability because of a decrease of deltoid wrapping effect. As factors of the stem itself, such as stem coating, shape, length, and use of bone cement, may also affect bone resorption, a single-stem model should be used to compare bone resorptions between different pathologies and surgical procedures. However, to date, a few reports have compared these differences in detail using a single-stem model. Therefore, we investigated the prevalence and location of humeral bone resorption in a single-stem model.
The study included 100 shoulders that underwent anatomical total shoulder arthroplasty (TSA) or humeral head replacement (HHR) with a single uncemented humeral stem from 2008 to 2018. The patients were 31 men and 69 women. The mean age at surgery was 72.9 years (range, 41-86 years). The patients were divided into three groups: especially, 25, 61, and 14 shoulders received TSA for primary osteoarthritis without rotator cuff tears (TSA group), HHR using an anatomical head with rotator cuff repair for cuff tear arthropathy (CTA) (HHR group), and HHR using a CTA head without rotator cuff repair (CTA group), respectively. Patients were monitored for a mean of 56 months (range, 12-98 months). The location of bone resorption was divided into seven zones as follows: zone 1, greater tuberosity; zone 2, lateral diaphysis; zone 3, lateral diaphysis beyond the deltoid tuberosity; zone 4, tip of the stem; zone 5, medial diaphysis beyond the deltoid tuberosity; zone 6, medial diaphysis; and zone 7, calcar region. The degree of bone resorption was classified from grade 0 to 4.
Bone resorption of grade 3 or higher was significantly more frequent at the greater tuberosity in the HHR and CTA groups (P < .001 and P < .001, respectively) than that in the TSA group. Grade 4 bone resorption was significantly more frequent in the CTA than that in the TSA and HHR groups in zone 1 (P = .016 and P = .041, respectively).
The state of attachment of the rotator cuff to the greater tuberosity might affect bone resorption at the greater tuberosity, such as the greater tuberosity after shoulder arthroplasty. In cases of shoulder arthroplasty for arthropathy with rotator cuff tear, performing rotator cuff repair might prevent bone resorption.
Level IV; Prognosis Study
ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update
2022, Journal of the American College of Radiology
Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Proximal humeral osteolysis and glenoid radiolucent lines in an anatomic shoulder arthroplasty: a comparison of a ceramic and a metal humeral head component
2020, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Numerous proinflammatory cytokines have been identified as contributors to a chronic inflammatory response influenced by implant-derived wear particles.11,13 Osteolysis after TSA is thought to occur by much the same mechanism as in the hip.17 Bone resorption around the glenoid component in TSAs has been the main focus of study until recently, whereas humeral osteolysis has now gained more attention in the literature.6,9,15,16,28,30,31
In vitro wear studies demonstrate decreased polyethylene wear with a ceramic compared with a metal humeral head. In this in vivo study, we analyzed prospectively collected 5-year data, comparing the outcomes of 2 types of humeral implants.
Sixty-two anatomic total shoulder arthroplasties (TSAs) (59 patients) were performed using the same glenoid component and 2 types of modular humeral implants (metal-head long-stem prosthesis in group A vs. ceramic-head stemless prosthesis in group B). Radiographic analysis for proximal humeral osteolysis and glenoid component radiolucent lines was performed at an average of 5.5 years. Functional outcomes were prospectively evaluated according to the visual analog scale score for pain; satisfaction level; American Shoulder and Elbow Surgeons score; active elevation; Shoulder Pain and Disability Index score; and Disabilities of the Arm, Shoulder and Hand score.
There were 39 TSAs in group A (mean age, 68.1 years) and 23 TSAs in group B (mean age, 67 years). Clinical improvement was similar for both groups. Some proximal humeral osteolysis occurred in 56% of all TSAs. Group A showed increased osteolysis compared with group B (72% vs. 30%, P = .005). Glenoid radiolucent lines were far more frequent in group A, and group A showed a direct relationship between the extent of humeral osteolysis and the severity of glenoid radiolucent lines (P < .001).
The stemless ceramic-head replacements showed fewer glenoid radiolucent lines and less humeral osteolysis than the long-stem metal-head replacements. In the group with metal-head replacements, correlation was shown between glenoid radiolucent lines and humeral osteolysis.
The effect of vitamin E–enhanced cross-linked polyethylene on wear in shoulder arthroplasty—a wear simulator study
2019, Journal of Shoulder and Elbow Surgery
Wear of the polyethylene glenoid component and subsequent particle-induced osteolysis remains one of the most important modes of failure of total shoulder arthroplasty. Vitamin E is added to polyethylene to act as an antioxidant to stabilize free radicals that exist as a byproduct of irradiation used to induce cross-linking. This study was performed to assess the in vitro performance of vitamin E–enhanced polyethylene compared with conventional polyethylene in a shoulder simulator model.
Vitamin E–enhanced, highly cross-linked glenoid components were compared with conventional ultrahigh-molecular-weight polyethylene glenoids, both articulating with a ceramic humeral head component using a shoulder joint simulator over 500,000 cycles. Unaged and artificially aged comparisons were performed. Volumetric wear was assessed by gravimetric measurement, and wear particle analysis was also subsequently performed.
Vitamin E–enhanced polyethylene glenoid components were found to have significantly reduced wear rates compared with conventional polyethylene in both unaged (36% reduction) and artificially aged (49% reduction) comparisons. There were no differences detected in wear particle analysis between the 2 groups.
Vitamin E–enhanced polyethylene demonstrates improved wear compared with conventional polyethylene in both unaged and artificially aged comparisons and may have clinically relevant benefits.

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ShoulderRadiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty

Hypothesis

Materials and methods

Results

Discussion

Conclusion

Section snippets

Materials and methods

Clinical information and demographics

Components

Conclusions

Acknowledgments

Disclaimer

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J Bone Joint Surg Am

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J Bone Joint Surg Br

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J Bone Joint Surg Am

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Clin Orthop Relat Res

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Radiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty