Original Research

Managing Glenoid Bone Deficiency—The Augment Experience in Anatomic and Reverse Shoulder Arthroplasty

Publish date: March 5, 2018

References

1. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. J Bone Joint Surg Br. 2004;86(3):388-395. doi:10.1302/0301-620X.86B3.

2. Churchill RS, Spencer Jr EE, Fehringer EV. Quantification of B2 glenoid morphology in total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(8):1212-1217. doi:10.1016/j.jse.2015.01.007.

3. Bercik MJ, Kruse K, Yalizis M, Gauci MO, Chaoui J, Walch G. A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-dimensional imaging. J Shoulder Elbow Surg. 2016;25(10):1601-1606. doi:10.1016/j.jse.2016.03.010.

4. Klika BJ, Wooten CW, Sperling JW, et al. Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(7):1066-1072. doi:10.1016/j.jse.2013.09.017.

5. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3(1):39-46.

6. Hermida JC, Flores-Hernandez C, Hoenecke HR, D’Lima DD. Augmented wedge-shaped glenoid component for the correction of glenoid retroversion: a finite element analysis. J Shoulder Elbow Surg. 2014;23(3):347-354. doi:10.1016/j.jse.2013.06.008.

7. Ho JC, Sabesan VJ, Iannotti JP. Glenoid component retroversion is associated with osteolysis. J Bone Joint Surg Am. 2013;95(12):e82. doi:10.2106/JBJS.L.00336.

8. Denard PJ, Walch G. Current concepts in the surgical management of primary glenohumeral arthritis with a biconcave glenoid. J Shoulder Elbow Surg. 2013;22(11):1589-1598. doi:10.1016/j.jse.2013.06.017.

9. Jones RB, Wright TW, Roche CP. Bone grafting the glenoid versus use of augmented glenoid baseplates with reverse shoulder arthroplasty. Bull Hosp Jt Dis (2013). 2015;73(suppl 1):S129-S135.

10. Hsu JE, Ricchetti ET, Huffman GR, Iannotti JP, Glaser DL. Addressing glenoid bone deficiency and asymmetric posterior erosion in shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(9):1298-1308. doi:10.1016/j.jse.2013.04.014.

11. Cil A, Sperling JW, Cofield RH. Nonstandard glenoid components for bone deficiencies in shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(7):e149-e157. doi:10.1016/j.jse.2013.09.023.

12. Rice RS, Sperling JW, Miletti J, Schleck C, Cofield RH. Augmented glenoid component for bone deficiency in shoulder arthroplasty. Clin Orthop Relat Res. 2008;466(3):579-583. doi:10.1007/s11999-007-0104-4.

13. Sabesan V, Callanan M, Sharma V, Iannotti JP. Correction of acquired glenoid bone loss in osteoarthritis with a standard versus an augmented glenoid component. J Shoulder Elbow Surg. 2014;23(7):964-973. doi:10.1016/j.jse.2013.09.019.

14. Davis DE, Acevedo D, Williams A, Williams G. Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients. J Shoulder Elbow Surg. 2016;25(8):1354-1361. doi:10.1016/j.jse.2015.12.010.

15. Kersten AD, Flores-Hernandez C, Hoenecke HR, D'Lima DD. Posterior augmented glenoid designs preserve more bone in biconcave glenoids. J Shoulder Elbow Surg. 2015;24(7):1135-1141. doi:10.1016/j.jse.2014.12.007.

16. Favorito PJ, Freed RJ, Passanise AM, Brown MJ. Total shoulder arthroplasty for glenohumeral arthritis associated with posterior glenoid bone loss: results of an all-polyethylene, posteriorly augmented glenoid component. J Shoulder Elbow Surg. 2016;25(10):1681-1689. doi:10.1016/j.jse.2016.02.020.

17. Sandow M, Schutz C. Total shoulder arthroplasty using trabecular metal augments to address glenoid retroversion: the preliminary result of 10 patients with minimum 2-year follow-up. J Shoulder Elbow Surg. 2016;25(4):598-607. doi:10.1016/j.jse.2016.01.001.

18. Wright TW, Roche CP, Wright L, Flurin PH, Crosby LA, Zuckerman JD. Reverse shoulder arthroplasty augments for glenoid wear: A comparison of posterior augments to superior augments. Bull Hosp Jt Dis. 2015;73(suppl 1):S124-S128.

19. Boileau P, Morin-Salvo N, Gauci MO, et al. Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management glenoid bone loss and erosion. J Shoulder Elbow Surg. 2017;26(12):2133-2142. doi:10.1016/j.jse.2017.05.024.

Glenoid bone deficiency in arthritic or cuff-deficient shoulder has been reported in up to 50% of shoulder defect cases.^1,2 The type and severity of glenoid deformities vary depending on the underlying pathology and time of manifestation. Osteoarthritis with bone loss typically results in posterior or posterior inferior glenoid wear and is commonly classified as Walch types B1 or B2 (biconcave). In cases of severe erosion, B3 classification has been proposed; in this classification, bone loss becomes extremely severe, progressing to resemble a type C glenoid. Unlike primary osteoarthritis, inflammatory arthropathy more commonly causes central loss of glenoid bone (Walch A2). With the rotator cuff insufficiency, superior migration of the humeral head occurs. As these conditions progress, cuff tear arthropathy (CTA) changes result in superior or posterior-superior bone loss.¹ Anterior bone loss (type D) will be rarely encountered due to recurrent anterior instability.³

Classically, with anatomic total shoulder arthroplasty (aTSA), the surgeon considers several options for managing glenoid deficiencies. The most commonly employed technique involves eccentrically reaming the glenoid and correcting the deformity. This procedure is relatively easy but features significant drawbacks, such as sacrificing the subchondral bone, medializing the glenohumeral joint line, and secondarily shrinking the glenoid surface area. Other options include structural bone grafting behind the glenoid component. Most anatomic prosthetic glenoids prove to be unsuitable for fixation of structural bone graft. Therefore, the graft is first internally fixed, followed by placement of the glenoid component. Cement, which is commonly used for glenoid fixation, may potentially inhibit bone-graft healing. Reports using this technique documented high radiographic failure rate of up to 40% at midterm follow-up.⁴ Although leaving the glenoid component retroverted may be considered, surgeons should develop awareness of the possibility of peg penetration of the anterior glenoid neck. Additionally, retroversion in excess of 5°may increase the risk of recurrent posterior subluxation, resulting in early glenoid loosening.^5-7 Results of aTSA under significant glenoid deficiency are inferior to those of aTSA patients without glenoid deficiency.⁸ Such findings have been extremely inferior in patients with significant glenoid wear, prompting numerous surgeons to abandon aTSA in this population in favor of reverse TSA (RTSA) due to improved bony fixation.

In 2010, augmented anatomic glenoids were first introduced as a wedge (Exactech) and as a step shortly thereafter (DePuy Synthes; Figures 1A-1C). More recently, hemi-wedges have been introduced (Wright Medical Group). Augments have gained popularity due to improved range of motion vs reverse shoulder arthroplasty (RSA). However, debates remain regarding the use of posteriorly augmented components in the setting of posterior glenoid bone loss.⁸ Augments serve as another viable option for handling glenoid bone deficiency in aTSA.

Glenoid bone loss in RTSA presents similar options to aTSA. However, screw fixation of the glenoid component offers several distinct advantages. Baseplate fixation can readily be used with bone grafting and with a highly anticipated success rate. With multiple screw options, 100% support of the baseplate is not mandatory. Although bony increase offset RSAs (BIO-RSAs) have shown success, augmentation with allograft or autograft increases operative time and relies on osseous integration for long-term implant success.⁹ Metal augmented baseplates were first introduced in 2011 (Exactech) as a means of managing glenoid bone loss without structural grafting. Although initial results have been encouraging, additional studies are needed to assess the longevity of these implants (Figures 1A-1C).

aTSA AUGMENTS

aTSA augments were introduced as a means of correcting acquired glenoid bone deficiency, restoring native glenoid version, correcting humeral subluxation, and preserving the native subchondral bone. Compared with glenoid bone grafting, augmented glenoid components decrease operative time, allow for a technically easier operation, and require no bone healing for clinical success. Early and midterm results are encouraging, showing similar findings comparable to those of aTSA in non-glenoid deficient shoulders.^10-12

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References

2. Churchill RS, Spencer Jr EE, Fehringer EV. Quantification of B2 glenoid morphology in total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(8):1212-1217. doi:10.1016/j.jse.2015.01.007.

5. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3(1):39-46.

7. Ho JC, Sabesan VJ, Iannotti JP. Glenoid component retroversion is associated with osteolysis. J Bone Joint Surg Am. 2013;95(12):e82. doi:10.2106/JBJS.L.00336.

9. Jones RB, Wright TW, Roche CP. Bone grafting the glenoid versus use of augmented glenoid baseplates with reverse shoulder arthroplasty. Bull Hosp Jt Dis (2013). 2015;73(suppl 1):S129-S135.

11. Cil A, Sperling JW, Cofield RH. Nonstandard glenoid components for bone deficiencies in shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(7):e149-e157. doi:10.1016/j.jse.2013.09.023.

Managing Glenoid Bone Deficiency—The Augment Experience in Anatomic and Reverse Shoulder Arthroplasty

References

aTSA AUGMENTS

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