Bone presence between the central peg's radial fins of a partially cemented pegged all poly glenoid component suggest few radiolucencies

doi:10.1016/j.jse.2010.05.025

Journal of Shoulder and Elbow Surgery

Volume 20, Issue 2, March 2011, Pages 315-321

https://doi.org/10.1016/j.jse.2010.05.025 Get rights and content

Background

Cement penetration problems and/or cement-induced bone necrosis may contribute to glenoid component failures. An all polyethylene component was developed that promotes biologic fixation between radial fins of its central peg and utilizes minimal cement fixation for its peripheral pegs, but it has little published data. We hypothesized better bone presence between the radial fins would be associated with less overall radiolucencies. This study's purpose was to utilize computed tomography (CT) and plain films to assess for bone between the central peg's radial fins and to assess overall component radiolucencies.

Materials and methods

Thirty-five of 48 consecutively performed total shoulder arthroplasties (TSA) for primary glenohumeral osteoarthritis were in patients able to participate a minimum 2 years after surgery. All had reamed humeral head bone packed between radial fins of the central peg and minimal cement for the peripheral pegs. Thin cut (0.625 mm) CT scans, standardized plain films, Simple Shoulder Tests (SST), and Constant scores were obtained. A musculoskeletal radiologist calculated Yian CT scores, bone presence between fins on CT, and Lazarus radiolucency scores.

Results

At a mean of 43 months, by CT: 1) better Yian scores correlated with more bone between fins, and 2) bone was present in 6/6 inter-fin compartments in 23/35 shoulders, averaging 4.5/6 overall. Mean Lazarus radiolucency score was 0.45. Mean SST and Constant scores were 10.3 and 81.3, respectively.

Conclusion

TSA utilizing autologous bone in inter-fin compartments of the central peg and minimal peripheral peg cement maintained bone presence a minimum 2 years post-op. More bone imparted fewer overall component radiolucencies.

Section snippets

Materials and methods

We asked patients in whom the senior author (EVF) had performed primary total shoulder replacements for primary glenohumeral arthritis without previous surgery to return a minimum of 2 years, following their procedures performed between July of 2003 and July of 2007.

All patients had been invited to participate; but, because of distance to travel (some >200 miles), illness, lack of financial resources, or unwillingness to participate in a study that required nearly ≥½ day of the patient's time,

Statistical analysis

A statistical analysis was then performed to test the hypotheses that: 1) more bone between the central peg's radial fins was associated with better (lower) modified Yian scores, and 2) less bone was associated with increasing age. As a baseline for future study, we also obtained absolute Constant and SST scores. We wished to see whether absolute Constant and SST scores were associated with more bone and whether those scores depended on the Yian score in this medium-term follow-up period.

Results

Having a dataset with a mean patient age at the time of surgery of 70 years (range, 49-89) and with measurements collected at an average 43 months (range, 24-66) after surgery, the following results (Table III) were found with respect to each proposed hypothesis: 1) By CT, better bone presence between the radial fins of the central peg was associated with better (lower) Yian scores (P < .001) (Figure 7). Also by CT, bone was present in 6/6 radial fin compartments in 23/35 shoulders. On average

Discussion

Glenoid component loosening remains a major concern following total shoulder arthroplasty.8, 35 Wirth et al designed the all polyethylene glenoid described in our study that utilizes less bone cement at the time of its implantation and encourages bone growth between the radial fins of its central peg.³⁷ Despite this component's widespread use in humans, limited literature exists regarding its radiographic and/or clinical outcomes, and the radiographic studies were confined to plain radiographs.⁶

Conclusion

Primary total shoulder arthroplasty for primary glenohumeral osteoarthritis utilizing minimal glenoid peripheral peg cement and autologous reamings placed between radial fins of the central peg allowed for persistent central peg bone presence at a minimum 2 years after surgery. Better bone presence imparted fewer overall component radiolucencies.

Disclaimer

Dr. Edward V. Fehringer has received benefits from a commercial entity related to the subject of this article but not for the component studied in this paper. None of the remaining authors, nor any member of their immediate family, received any financial payments or benefits from any commercial entity related to the subject of this article.

References (39)

P. Boileau et al.
Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study
J Shoulder Elbow Surg
(2002)
A.D. Boyd et al.
Total shoulder arthroplasty versus hemiarthroplasty. Indications for glenoid resurfacing
J Arthroplasty
(1990)
J. Brems
The glenoid component in total shoulder arthroplasty
J Shoulder Elbow Surg
(1993)
R.S. Churchill et al.
Clinical and radiographic analysis of a partially cemented glenoid implant: Five-year minimum follow-up
J Shoulder Elbow Surg
(2010)
R.H. Cofield et al.
Total shoulder arthroplasty with a tissue-ingrowth glenoid component
J Shoulder Elbow Surg
(1992)
T.J. Fox et al.
Survival of the glenoid component in shoulder arthroplasty
J Shoulder Elbow Surg
(2009)
J.L. Franklin et al.
Glenoid loosening in total shoulder arthroplasty
J Arthroplasty
(1988)
G.M. Gartsman et al.
Radiographic comparison of pegged and keeled glenoid components
J Shoulder Elbow Surg
(2005)
O. Levy et al.
Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder
J Shoulder Elbow Surg
(2004)
F.A. Matsen et al.
Shoulder arthroplasty: the socket perspective
J Shoulder Elbow Surg
(2007)

J. Mileti et al.

Radiographic analysis of polyethylene glenoid components using modern cementing techniques

J Shoulder Elbow Surg

(2004)

R.R. Richards et al.

A standardized method for the assessment of shoulder function

J Shoulder Elbow Surg

(1994)

J.W. Sperling et al.

Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger

J Shoulder Elbow Surg

(2004)

K.D. Stone et al.

Stress analyses of glenoid components in total shoulder arthroplasty

J Shoulder Elbow Surg

(1999)

I. Szabo et al.

Radiographic comparison of flat-back and convex-back glenoid components in total shoulder arthroplasty

J Shoulder Elbow Surg

(2005)

M.E. Torchia et al.

Total shoulder arthroplasty with the Neer prosthesis: long-term results

J Shoulder Elbow Surg

(1997)

M.A. Wirth et al.

Radiologic, mechanical, and histologic evaluation of 2 glenoid prosthesis designs in a canine model

J Shoulder Elbow Surg

(2001)

W.P. Barrett et al.

Total shoulder arthroplasty

J Bone Joint Surg Am

(1987)

R.S. Churchill et al.

Glenoid cementing may generate sufficient heat to damage surrounding bone

Clin Orthop Relat Res

(2004)

Cited by (45)

Central-peg radiolucency progression of an all-polyethylene glenoid with hybrid fixation in anatomic total shoulder arthroplasty is associated with clinical failure and reoperation
2021, Journal of Shoulder and Elbow Surgery
Glenoid component loosening is a common cause of failure after anatomic total shoulder arthroplasty. Prior studies of all-polyethylene glenoid implants with hybrid fixation did not show early glenoid radiolucency to be clinically significant. The purpose of this study was to determine the clinical significance of progression of radiolucency around the central peg of the glenoid component.
We identified 73 shoulders that underwent primary anatomic total shoulder arthroplasty between January 1995 and May 2015 for osteoarthritis with an all-polyethylene pegged glenoid, with a minimum follow-up interval of 2 years between early and late follow-up. Demographic, radiographic (central-peg osteolysis [CPO] and central-peg grading [CPG]), and outcome variables comprising the Penn Shoulder Score (PSS) and revision surgery were collected. Clinical failure was defined as a PSS decrease >11.4 points (ie, PSS failure) or revision surgery.
The average patient age at surgery was 65 ± 7 years, and 63% of patients were men. The median initial follow-up period was 14 months (interquartile range, 12-25 months), and the final median follow-up period was 56 months (interquartile range, 47-69 months). Revision surgical procedures were performed in 4 patients, and 17 PSS failures occurred. We found that CPO at final follow-up, CPG progression, and worse PSS at follow-up were associated with revision surgery (P < .05). We also found younger age at surgery, CPO at final follow-up, CPG progression, and greater glenoid component retroversion at final follow-up to be associated with clinical failure (PSS failure or revision surgery) (P < .05). Multivariate analysis found only CPG progression to be associated with clinical failure (P < .001).
CPO and CPG progression were associated with clinical failure, defined as decreasing clinical outcome scores or revision surgery.
Surgical rationale and controversies of glenoid replacement in osteoarthritis: How to choose the glenoid implant?
2021, Journal of Arthroscopy and Joint Surgery
Total shoulder arthroplasty is an effective procedure in restoring anatomy and biomechanics of the arthritic shoulder. It provides excellent clinical results, and its use is increasing worldwide. Glenoid loosening is the weak link in shoulder replacement, accounting for nearly one third of all total shoulder arthroplasty complications. Its causes and possible solutions have been object of extensive investigation. To strengthen glenoid fixation and provide long-term survival to the implant, several technical improvements have been proposed, different materials have been tested and various prosthetic glenoid designs have been developed, including cemented and uncemented all-polyethylene components, metal-backed, hybrid, inlay and augmented components. Thus, the surgeon has been provided with many options, but no clear superiority of one implant over the others has been proved. The choice of the right implant requires careful evaluation of patient’s pathology, anatomy and expectation and a thorough understanding of prosthetic shoulder biomechanics and of mechanisms of failure. The aim of this review is to discuss the available options for glenoid implants in TSA, describe the causes of failure and report author’s preferences in glenoid replacement.
Clinical and radiographic outcomes of an all-polyethylene fluted central peg glenoid component, implanted utilizing an off-label, uncemented technique, at a minimum 5-year follow-up
2020, Journal of Shoulder and Elbow Surgery
Glenoid component loosening remains an important concern in anatomic total shoulder arthroplasty. The aim of this study was to evaluate the clinical and radiographic results of a fully uncemented all-polyethylene fluted central peg bone-ingrowth glenoid component at a minimum 5-year follow-up.
Thirty-five shoulders in 31 patients (mean age, 73 years) with a mean follow-up of 100 months were retrospectively evaluated at an early and mid-term time point for Constant score (CS). Computed tomography visualized glenoid component fixation at both time points.
Mean CS improved from 40 preoperatively to 66 postoperatively at latest follow-up (P < .001). A mean CS of 74 at early follow-up remained consistent with a mean CS of 66 at latest follow-up (P = .158), with only strength demonstrating a decrease over time (P < .001). An initial osseointegration rate of 81% at early follow-up decreased to 71% at latest follow-up with 74% of the shoulders demonstrating progressive radiolucent lines, resulting in a radiographic loosening rate of 31%. Of the 35 shoulders, 4 were revised (survival rate of 88%), of which 2 due to symptomatic aseptic loosening.
Uncemented fixation of an all-polyethylene central peg bone-ingrowth glenoid was associated with satisfactory clinical and radiographic scores, and an acceptable revision rate at mid- to long-term follow-up. Despite initial bony osseointegration in the majority of cases, radiographic loosening over time remains a concern, potentially jeopardizing long-lasting fixation of this type of glenoid component when implanted in an off-label uncemented fashion.
A comparison of pegged vs. keeled glenoid components regarding functional and radiographic outcomes in anatomic total shoulder arthroplasty: a systematic review and meta-analysis
2019, JSES Open Access
The number of total shoulder arthroplasties (TSAs) performed is increasing annually, with a continued effort to improve outcomes using new techniques and materials. In anatomic TSAs, the main options for glenoid fixation currently involve keeled or pegged components. The aim of this review was to determine which fixation option provides optimal long-term functional outcomes with decreased rates of revision surgery and radiolucency.
The MEDLINE, Embase, PubMed, and Cochrane databases were searched from 2007 to July 10, 2017, for all articles that examined TSAs using either pegged or keeled glenoid fixations. All studies were screened in duplicate for eligibility. Two separate analyses were completed examining noncomparative and comparative studies independently.
A total of 7 comparative studies and 25 noncomparative studies were included in the final analysis. Included in the analysis were 4 randomized (level I) studies, 1 level II study, 8 level III studies, and 19 level IV studies. Meta-analysis of the comparative studies demonstrated a higher rate of revision surgery with keeled fixations compared with pegged fixations (odds ratio, 6.22; 95% confidence interval [CI], 1.38-28.1; P = .02). No significant difference was found with respect to functional outcomes, such as the American Shoulder and Elbow Surgeons score (mean difference, 9.54; 95% CI, –8.25 to 27.34; P = .29) and Constant score (mean difference, 5.31; 95% CI, –12.28 to 22.89; P = .55), as well as radiolucency rates (odds ratio, 1.89; 95% CI, 0.56−6.39; P = .30).
Pegged glenoid fixation may result in a decreased risk of revision TSAs, but no significant differences in patient-reported outcomes have been identified to date.
Glenoid component lucencies are associated with poorer patient-reported outcomes following anatomic shoulder arthroplasty
2019, Journal of Shoulder and Elbow Surgery
High rates of radiographic glenoid loosening following anatomic total shoulder arthroplasty (TSA) are documented at midterm follow-up. Small studies remain conflicted on the impact of lucent lines on clinical outcomes. This study assesses the impact of radiolucent lines on function and patient-reported outcomes (PROs) following TSA.
We retrospectively evaluated 492 primary TSAs performed between February 2005 and April 2016. Radiographs were evaluated for glenoid loosening according to the Lazarus grade at a mean of 5.3 years (range, 2-12 years). Clinical outcome measures included range of motion and American Shoulder and Elbow Surgeons, Constant, University of California–Los Angeles, Simple Shoulder Test, and Shoulder Pain and Disability Index scores. Outcomes were compared between patients with and patients without glenoid lucent lines and in relation to lucency grade.
At most recent follow-up, 308 glenoids (63%) showed no radiolucent lines (group 0) and 184 demonstrated peri-glenoid lucencies (group 1). The groups were similar regarding age, sex, body mass index, comorbidities, and prior surgery. At follow-up, group 1 demonstrated significantly lower improvements in forward elevation (P = .02) and all PROs (P ≤ .005). Subgroup analysis by radiolucency grade showed that forward elevation diminished with increasing radiolucent score and exceeded the minimal clinically important difference (MCID) above grade 2 lucencies. A similar decline in PROs was observed with increasing lucency grade. These differences did not exceed the MCID below grade 5 lucencies.
Peri-implant glenoid lucencies following TSA are associated with lower forward elevation and PROs. Lucencies above grade 2 are associated with clinically important losses in overhead motion. However, differences below the MCID are maintained for PROs below grade 5 glenoid lucencies.
Five-year minimum clinical and radiographic outcomes of total shoulder arthroplasty using a hybrid glenoid component with a central porous titanium post
2018, Journal of Shoulder and Elbow Surgery
To determine the effectiveness of hybrid glenoid components in reducing the frequency of glenoid component loosening, we evaluated clinical and radiographic outcomes at a minimum 5-year follow-up in 45 shoulders that underwent total shoulder arthroplasty (TSA) using a system with a central porous titanium post to augment the cemented peripheral pegs.
Function and pain were evaluated with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment score, visual analog scale, active shoulder range of motion, and strength. Postoperative radiographs were analyzed for radiolucent lines, progressive loosening, and at-risk signs.
The mean American Shoulder and Elbow Surgeons score improved from 40.4 to 83.7 (P < .0001) and the mean visual analog scale from 5.9 to 0.8 (P < .0001). Forward elevation improved from 113° to 151° (P < .001), internal rotation from 49° to 60° (P = .035), and mean external rotation from 36° to 50° (P = .0006). Radiographs showed glenoid component radiolucency in 29 shoulders. Radiolucencies were confined to the area under the glenoid faceplate in 6 and were only around the central post in 13. Nine TSAs (20%) demonstrated 2 or more columns of involvement but were not judged to be at-risk. One implant (2.2%) had glenoid component failure and was revised to a hemiarthroplasty.
Anatomic TSA using a hybrid glenoid component with a central porous titanium post demonstrated a low rate of mechanical failure and a rate of radiolucent lines comparable to reports of all polyethylene implants. Further evaluations are needed to demonstrate the long-term durability of these implants and to determine the significance and fate of the radiolucent lines, particularly relative to the central post.

View all citing articles on Scopus

: IRB # 391-07-FB University of Nebraska Medical Center.

View full text

ShoulderBone presence between the central peg's radial fins of a partially cemented pegged all poly glenoid component suggest few radiolucencies

Background

Materials and methods

Results

Conclusion

Section snippets

Materials and methods

Statistical analysis

Results

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

J Arthroplasty

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Arthroplasty

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Total shoulder arthroplasty

J Bone Joint Surg Am

Glenoid cementing may generate sufficient heat to damage surrounding bone

Clin Orthop Relat Res

Shoulder
Bone presence between the central peg's radial fins of a partially cemented pegged all poly glenoid component suggest few radiolucencies