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• W2951712962 abstract "BackgroundAugmented glenoid components restore the native joint line and preserve bone in shoulders with posterior glenoid bone loss. The purpose of this study was to compare the clinical and radiographic outcomes of augmented total shoulder arthroplasties (TSAs) vs. case-matched shoulders with standard implants to assess the early performance of a full-wedge augmented glenoid component.MethodsBetween 2010 and 2015, all TSAs using a full-wedge posteriorly augmented glenoid component with a minimum 2-year follow-up from a single institution were retrospectively reviewed. A total of 37 augmented TSAs were matched with 37 control shoulders with unaugmented glenoid components. The primary outcomes were revision and radiographic glenoid lucencies. Secondary outcomes included range of motion (ROM) and patient-reported outcomes (PROs).ResultsBoth augmented and standard TSAs produced similar improvements in all ROM and PRO measures. Patients with augmented glenoid components were more likely to have type B2 or B3 deformities (P = .004). At final follow-up, 54% of augmented glenoids showed implant lucencies compared with 46% of control shoulders (P = .5). The mean Lazarus score remained similar between groups (1.5 vs. 1.2, P = .8). When 8° and 16° augmentations were compared, the 16° augmentation demonstrated a significantly higher mean Lazarus score (4.2 vs. 1.1, P = .03). Reoperation rates were similar between groups (5% vs. 3%, P = .6).DiscussionPatients with posteriorly augmented glenoid components demonstrate similar improvements in ROM and PROs to patients with standard anatomic glenoid components. Radiographic loosening and revision rates were similar. However, a higher failure rate was seen with the 16° full-wedge augmentation, which is no longer used in our practice. Augmented glenoid components restore the native joint line and preserve bone in shoulders with posterior glenoid bone loss. The purpose of this study was to compare the clinical and radiographic outcomes of augmented total shoulder arthroplasties (TSAs) vs. case-matched shoulders with standard implants to assess the early performance of a full-wedge augmented glenoid component. Between 2010 and 2015, all TSAs using a full-wedge posteriorly augmented glenoid component with a minimum 2-year follow-up from a single institution were retrospectively reviewed. A total of 37 augmented TSAs were matched with 37 control shoulders with unaugmented glenoid components. The primary outcomes were revision and radiographic glenoid lucencies. Secondary outcomes included range of motion (ROM) and patient-reported outcomes (PROs). Both augmented and standard TSAs produced similar improvements in all ROM and PRO measures. Patients with augmented glenoid components were more likely to have type B2 or B3 deformities (P = .004). At final follow-up, 54% of augmented glenoids showed implant lucencies compared with 46% of control shoulders (P = .5). The mean Lazarus score remained similar between groups (1.5 vs. 1.2, P = .8). When 8° and 16° augmentations were compared, the 16° augmentation demonstrated a significantly higher mean Lazarus score (4.2 vs. 1.1, P = .03). Reoperation rates were similar between groups (5% vs. 3%, P = .6). Patients with posteriorly augmented glenoid components demonstrate similar improvements in ROM and PROs to patients with standard anatomic glenoid components. Radiographic loosening and revision rates were similar. However, a higher failure rate was seen with the 16° full-wedge augmentation, which is no longer used in our practice. Total shoulder arthroplasty (TSA) provides lasting pain relief and improved function in patients with end-stage glenohumeral arthritis. Survival rates of 93% at 10 years and 87% at 15 years have been reported.29Torchia M.E. Cofield R.H. Settergren C.R. Total shoulder arthroplasty with the Neer prosthesis: long-term results.J Shoulder Elbow Surg. 1997; 6: 495-505Abstract Full Text PDF PubMed Scopus (542) Google Scholar However, increased osteolysis has been shown in cases with more severe glenoid component retroversion,8Ho J.C. Sabesan V.J. Iannotti J.P. Glenoid component retroversion is associated with osteolysis.J Bone Joint Surg Am. 2013; 95: e82https://doi.org/10.2106/JBJS.L.00336Crossref PubMed Scopus (170) Google Scholar and this may impact component survival. In addition, patients with preoperative posterior subluxation demonstrate lower American Shoulder and Elbow Surgeons (ASES) scores, more pain, and less external rotation than patients without shoulder subluxation.11Iannotti J.P. Norris T.R. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis.J Bone Joint Surg Am. 2003; 85-A: 251-258Crossref PubMed Scopus (318) Google Scholar Various strategies exist to address glenoid retroversion and posterior subluxation. Eccentric reaming can correct small deficits up to 10°.10Iannotti J.P. Greeson C. Downing D. Sabesan V. Bryan J.A. Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty.J Shoulder Elbow Surg. 2012; 21: 48-55https://doi.org/10.1016/j.jse.2011.02.011Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 23Sabesan V. Callanan M. Sharma V. Iannotti J.P. Correction of acquired glenoid bone loss in osteoarthritis with a standard versus an augmented glenoid component.J Shoulder Elbow Surg. 2014; 23: 964-973https://doi.org/10.1016/j.jse.2013.09.019Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Primary bone grafting with an anatomic glenoid component has demonstrated variable results7Hill J.M. Norris T.R. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid.J Bone Joint Surg Am. 2001; 83-A: 877-883Crossref PubMed Scopus (213) Google Scholar, 14Klika B.J. Wooten C.W. Sperling J.W. Steinmann S.P. Schleck C.D. Harmsen W.S. et al.Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty.J Shoulder Elbow Surg. 2014; 23: 1066-1072https://doi.org/10.1016/j.jse.2013.09.017Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 20Neer C.S. Morrison D.S. Glenoid bone-grafting in total shoulder arthroplasty.J Bone Joint Surg Am. 1988; 70: 1154-1162Crossref PubMed Scopus (174) Google Scholar, 21Nicholson G.P. Cvetanovich G.L. Rao A.J. O'Donnell P. Posterior glenoid bone grafting in total shoulder arthroplasty for osteoarthritis with severe posterior glenoid wear.J Shoulder Elbow Surg. 2017; 26: 1844-1853https://doi.org/10.1016/j.jse.2017.03.016Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 31Walch G. Moraga C. Young A. Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid.J Shoulder Elbow Surg. 2012; 21: 1526-1533https://doi.org/10.1016/j.jse.2011.11.030Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar and is often associated with clinical and radiographic failure.7Hill J.M. Norris T.R. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid.J Bone Joint Surg Am. 2001; 83-A: 877-883Crossref PubMed Scopus (213) Google Scholar, 9Iannotti J.P. Frangiamore S.J. Fate of large structural allograft for treatment of severe uncontained glenoid bone deficiency.J Shoulder Elbow Surg. 2012; 21: 765-771https://doi.org/10.1016/j.jse.2011.08.069Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 14Klika B.J. Wooten C.W. Sperling J.W. Steinmann S.P. Schleck C.D. Harmsen W.S. et al.Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty.J Shoulder Elbow Surg. 2014; 23: 1066-1072https://doi.org/10.1016/j.jse.2013.09.017Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 31Walch G. Moraga C. Young A. Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid.J Shoulder Elbow Surg. 2012; 21: 1526-1533https://doi.org/10.1016/j.jse.2011.11.030Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar Alternatively, surgeons may choose to place the glenoid in a retroverted position to avoid reaming native bone stock or augmenting with humeral head autograft. However, retroversion beyond 15° leads to a decreased contact area and increased contact pressures, which place the glenoid at higher risk of failure.25Shapiro T.A. McGarry M.H. Gupta R. Lee Y.S. Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty.J Shoulder Elbow Surg. 2007; 16: S90-S95https://doi.org/10.1016/j.jse.2006.07.010Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar The initial results reported in the literature with augmented glenoid components were concerning for early failure. Rice et al22Rice R.S. Sperling J.W. Miletti J. Schleck C. Cofield R.H. Augmented glenoid component for bone deficiency in shoulder arthroplasty.Clin Orthop Relat Res. 2008; 466: 579-583https://doi.org/10.1007/s11999-007-0104-4Crossref PubMed Scopus (111) Google Scholar published the midterm results of 14 patients at a single center undergoing TSA with a posteriorly augmented keeled glenoid (Cofield 2; Smith & Nephew, Memphis, TN, USA). At a mean follow-up of 3.9 years, persistent moderate to severe posterior subluxation was noted in 3 of 14 shoulders. Because of the poor results in this study, the authors chose to abandon use of the implant. More recently, augmented glenoid components have been redesigned in an effort to restore the native joint line while preserving bone and avoiding the need for backside graft support. These components are available in step, hemi-wedge, and full-wedge configurations. Biomechanical studies have shown that full-wedge augmented glenoid components provide significantly more cortical support than eccentric reaming when performed for type B2 glenoids.1Allred J.J. Flores-Hernandez C. Hoenecke Jr, H.R. D'Lima D.D. Posterior augmented glenoid implants require less bone removal and generate lower stresses: a finite element analysis.J Shoulder Elbow Surg. 2016; 25: 823-830https://doi.org/10.1016/j.jse.2015.10.003Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar However, there remain few clinical reports studying augmented anatomic glenoid components.3Cil A. Sperling J.W. Cofield R.H. Nonstandard glenoid components for bone deficiencies in shoulder arthroplasty.J Shoulder Elbow Surg. 2014; 23: e149-e157https://doi.org/10.1016/j.jse.2013.09.023Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 4Favorito P.J. Freed R.J. Passanise A.M. Brown M.J. 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: 1681-1689https://doi.org/10.1016/j.jse.2016.02.020Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 22Rice R.S. Sperling J.W. Miletti J. Schleck C. Cofield R.H. Augmented glenoid component for bone deficiency in shoulder arthroplasty.Clin Orthop Relat Res. 2008; 466: 579-583https://doi.org/10.1007/s11999-007-0104-4Crossref PubMed Scopus (111) Google Scholar, 28Stephens S.P. Spencer E.E. Wirth M.A. Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.J Shoulder Elbow Surg. 2017; 26: 798-803https://doi.org/10.1016/j.jse.2016.09.053Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The majority of these studies have evaluated the StepTech glenoid (DePuy, Warsaw, IN, USA), which has been shown to take more bone and diminish the quality of bone providing backside support compared with other designs.4Favorito P.J. Freed R.J. Passanise A.M. Brown M.J. 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: 1681-1689https://doi.org/10.1016/j.jse.2016.02.020Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 13Kersten A.D. Flores-Hernandez C. Hoenecke H.R. D'Lima D.D. Posterior augmented glenoid designs preserve more bone in biconcave glenoids.J Shoulder Elbow Surg. 2015; 24: 1135-1141https://doi.org/10.1016/j.jse.2014.12.007Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 15Knowles N.K. Ferreira L.M. Athwal G.S. Augmented glenoid component designs for type B2 erosions: a computational comparison by volume of bone removal and quality of remaining bone.J Shoulder Elbow Surg. 2015; 24: 1218-1226https://doi.org/10.1016/j.jse.2014.12.018Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 28Stephens S.P. Spencer E.E. Wirth M.A. Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.J Shoulder Elbow Surg. 2017; 26: 798-803https://doi.org/10.1016/j.jse.2016.09.053Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The clinical advantages of increased cortical support provided by full-wedge components remain unevaluated. Concern remains regarding the ability to complete correction of the associated bony and soft-tissue deformities associated with posterior bone loss, with some authors preferring reverse shoulder arthroplasty for posterior glenoid bone loss in the setting of an intact rotator cuff.19Mizuno N. Denard P.J. Raiss P. Walch G. Reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis in patients with a biconcave glenoid.J Bone Joint Surg Am. 2013; 95: 1297-1304https://doi.org/10.2106/JBJS.L.00820Crossref PubMed Scopus (247) Google Scholar Failure to adequately re-center the head would then place increased stresses on these augmented components secondary to a rocking-horse defect.6Franklin J.L. Barrett W.P. Jackins S.E. Matsen 3rd, F.A. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency.J Arthroplasty. 1988; 3: 39-46Abstract Full Text PDF PubMed Scopus (504) Google Scholar The reported clinical performance of a full-wedge augmentation for TSA remains limited, despite increased use.18Michael R.J. Schoch B.S. King J.J. Wright T.W. Managing glenoid bone deficiency—the augment experience in anatomic and reverse shoulder arthroplasty.Am J Orthop (Belle Mead NJ). 2018; 47https://doi.org/10.12788/ajo.2018.0014PubMed Google Scholar The purpose of this study was to assess the clinical and radiographic outcomes of augmented TSAs compared with case-matched shoulders undergoing TSAs with standard implants. We hypothesized that shoulders with augmented glenoid components would have similar range of motion (ROM) and patient-reported outcome (PRO) scores without an increased rate of glenoid loosening or revision. Between 2010 and 2015, all primary TSAs with an augmented glenoid component were identified through a single institution's shoulder arthroplasty database. Three fellowship-trained surgeons performed all operations. Shoulders were included if they met the following criteria: minimum of 2-year follow-up with radiographs and availability of preoperative radiographs, as well as preoperative advanced imaging. Shoulders with a preoperative diagnosis of an acute fracture, fracture sequelae, infection, or tumor or with revision arthroplasty were excluded. All arthroplasties were performed using the Equinoxe shoulder system (Exactech, Gainesville, FL, USA). This system has 2 augmented glenoid components: an all-polyethylene full-wedge component and a full-wedge polyethylene component with an ingrowth central cage (Fig. 1). Augmentations are available in 8°, 12°, and 16° full wedges. The augmentation size was chosen based on computed tomography (CT) scans when available, with the goal of restoring the joint line to within 5° of neutral version. Prior to CT scans being routinely used, preoperative radiographs were used to estimate the version, with final implant selection made intraoperatively after visualization of the amount of posterior glenoid bone loss relative to the paleo-glenoid. After application of the inclusion and exclusion criteria, a study population of 37 shoulders was identified. Augmentations used included 8° in 32 shoulders, 12° in 1, and 16° in 4. Using the same arthroplasty database, we identified 1 control patient for each study shoulder, attempting to match for length of follow-up, age, sex, and implant type (all polyethylene pegged vs. ingrowth central cage). All shoulders were evaluated preoperatively and at a minimum of 2 years after surgery. Shoulders were routinely followed on an annual basis with ROM measurements and validated questionnaires. Forward elevation and external rotation (in degrees) were evaluated using a goniometer. Internal rotation was assessed according the scale of Flurin et al,5Flurin P.H. Roche C.P. Wright T.W. Marczuk Y. Zuckerman J.D. A comparison and correlation of clinical outcome metrics in anatomic and reverse total shoulder arthroplasty.Bull Hosp Jt Dis (2013). 2015; 73: S118-S123PubMed Google Scholar and the rating was based on internal rotation reaching up the spine: 0, 0°; 1, hip; 2, buttocks; 3, sacrum; 4, L4 to L5; 5, L1 to L3; 6, T8 to T12; and 7, T7 or higher. Strength was assessed according the manual muscle test scale.5Flurin P.H. Roche C.P. Wright T.W. Marczuk Y. Zuckerman J.D. A comparison and correlation of clinical outcome metrics in anatomic and reverse total shoulder arthroplasty.Bull Hosp Jt Dis (2013). 2015; 73: S118-S123PubMed Google Scholar All ROM and strength measurements were obtained by a single research coordinator (A.M.S.) in a standardized fashion. From the questionnaire, the normalized Constant score,12Katolik L.I. Romeo A.A. Cole B.J. Verma N.N. Hayden J.K. Bach B.R. Normalization of the Constant score.J Shoulder Elbow Surg. 2005; 14: 279-285https://doi.org/10.1016/j.jse.2004.10.009Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar ASES score, University of California–Los Angeles score, average daily visual analog scale (VAS) pain score, and maximum VAS pain score were calculated. Demographic data were collected on the patients preoperatively, including age, sex, hand dominance, height, weight, body mass index, and operative side. Reoperations were also recorded. Preoperatively, plain radiographs were obtained for all patients, including Grashey and axillary views (Fig. 2). Advanced imaging (CT or magnetic resonance imaging) was reviewed preoperatively when available. Three fellowship-trained orthopedic surgeons evaluated all preoperative and postoperative images, using consensus agreement. Preoperative imaging was evaluated for glenoid bone loss using the Walch classification.2Bercik M.J. Kruse II, K. Yalizis M. Gauci M.O. 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: 1601-1606https://doi.org/10.1016/j.jse.2016.03.010Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar, 30Walch G. Badet R. Boulahia A. Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis.J Arthroplasty. 1999; 14: 756-760Abstract Full Text PDF PubMed Scopus (746) Google Scholar Postoperative radiographs were evaluated for glenoid component lucencies according to the Lazarus score.16Lazarus M.D. Jensen K.L. Southworth C. Matsen 3rd, F.A. The radiographic evaluation of keeled and pegged glenoid component insertion.J Bone Joint Surg Am. 2002; 84-A: 1174-1182Crossref PubMed Scopus (59) Google Scholar Humeral loosening was assessed according to Sanchez-Sotelo et al.24Sanchez-Sotelo J. O'Driscoll S.W. Torchia M.E. Cofield R.H. Rowland C.M. Radiographic assessment of cemented humeral components in shoulder arthroplasty.J Shoulder Elbow Surg. 2001; 10: 526-531Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 27Sperling J.W. Cofield R.H. O'Driscoll S.W. Torchia M.E. Rowland C.M. Radiographic assessment of ingrowth total shoulder arthroplasty.J Shoulder Elbow Surg. 2000; 9: 507-513Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar Shoulders were divided into 2 groups according to the use of augmented components. Data were analyzed using JMP software (SAS Institute, Cary, NC, USA). The Student t test was used to compare normal data between groups. The Mann-Whitney U test was used for nonparametric comparisons between groups. The χ2 test was used to analyze categorical data. We analyzed 74 shoulders (37 augmented and 37 control) at a mean follow-up of 3.2 years (range, 2-6 years). The groups were matched according to age, sex, and length of follow-up. Full demographic information is shown in Table I.Table IDemographic characteristics for augmented and control TSAsAugmentedControlP valueAge, yr64.1 (37-78)65.5 (42-77).4Follow-up, yr3.3 (2-6)3.1 (2-6).3Sex, n Male2626 Female1111BMI29.8 (20.9-38.3)30.8 (22.0-39.1).5Blood loss, mL317 (200-400)362 (100-600).009TSA, total shoulder arthroplasty; BMI, body mass index.Data are presented as mean (range) unless otherwise indicated. Open table in a new tab TSA, total shoulder arthroplasty; BMI, body mass index. Data are presented as mean (range) unless otherwise indicated. Preoperative abduction was significantly greater in shoulders with an augmented component, and external rotation was significantly greater in shoulders with unaugmented glenoids. The groups were otherwise similar regarding forward elevation and internal rotation with the arm at the side (Table II). Average daily VAS pain scores were lower in shoulders treated with augmented components (5.0 vs. 6.3, P = .01); however, when rating their worst pain, the groups were similar (8.8 vs. 9.1, P = .3). Augmented shoulders demonstrated significantly greater preoperative PROs; however, all of these remained below the minimal clinically important difference.26Simovitch R. Flurin P.H. Wright T. Zuckerman J.D. Roche C.P. Quantifying success after total shoulder arthroplasty: the substantial clinical benefit.J Shoulder Elbow Surg. 2018; 27: 903-911https://doi.org/10.1016/j.jse.2017.12.014Abstract Full Text Full Text PDF PubMed Scopus (88) Google ScholarTable IIPreoperative and postoperative ROM and PROs by groupPreoperativePostoperativeAugmentedControlP valueAugmentedControlP valueConstant score47.6 ± 15.041.2 ± 13.0.0882.7 ± 12.975.1 ± 13.2.016ASES score45.3 ± 12.337.4 ± 12.8.01286.8 ± 14.778.6 ± 18.4.04UCLA score16.1 ± 3.514.8 ± 3.0.131.3 ± 4.928.4 ± 5.6.03Forward flexion, °103 ± 20.493 ± 28.6.08141 ± 17. 6132 ± 21.4.07Abduction, °97 ± 24.285 ± 26.0.05134 ± 29.8126 ± 19.8.2Internal rotation3.1 ± 2.02.3 ± 1.4.095.3 ± 1.54.8 ± 1.6.2External rotation, °18 ± 20.321 ± 17.5.0548 ± 15.846 ± 14.4.5VAS score Average5.0 ± 1.86.3 ± 2.0.011.1 ± 1.72.2 ± 2.3.01 Maximum8.8 ± 1.19.1 ± 1.0.32.9 ± 3.43.3 ± 3.0.5ROM, range of motion; PRO, patient-reported outcome; ASES, American Shoulder and Elbow Surgeons; UCLA, University of California–Los Angeles; VAS, visual analog scale.Data are presented as mean ± standard deviation. Open table in a new tab ROM, range of motion; PRO, patient-reported outcome; ASES, American Shoulder and Elbow Surgeons; UCLA, University of California–Los Angeles; VAS, visual analog scale. Data are presented as mean ± standard deviation. Because of differences in ROM and PROs prior to surgery, improvements in ROM and PROs (change from preoperative to postoperative values) were compared between controls and augmented shoulders. At similar early follow-up, both groups demonstrated similar improvements in pain, ROM, and PROs (Table III).Table IIIClinical improvement by groupAugmentedControlP valueChange in Constant score36.0 ± 15.937.1 ± 15.1.8Change in ASES score41.5 ± 18.544.6 ± 18.5.5Change in UCLA score15.2 ± 5.914.7 ± 6.1.7Change in forward flexion, °38.6 ± 19.939.2 ± 34.6.9Change in abduction, °37.4 ± 34.141.2 ± 32.6.6Change in external rotation, °31.1 ± 19.123.9 ± 16.0.09Change in internal rotation2.2 ± 2.22.5 ± 1.9.7Change in average VAS score4.0 ± 2.74.4 ± 2.4.4Change in maximum VAS score5.8 ± 3.26.0 ± 2.9.8ASES, American Shoulder and Elbow Surgeons; UCLA, University of California–Los Angeles; VAS, visual analog scale.Data are presented as mean ± standard deviation. Open table in a new tab ASES, American Shoulder and Elbow Surgeons; UCLA, University of California–Los Angeles; VAS, visual analog scale. Data are presented as mean ± standard deviation. Preoperative Walch scores were obtained for both groups using advanced 2-dimensional axial imaging. A higher proportion of type B2 or B3 glenoids was found in the augmented group than in the control group (86% vs. 51%, P = .004; Table IV).Table IVWalch classification by groupA1A2B1B2B3CDAugmented, n12127510Control, n78411700 Open table in a new tab At final follow-up, 54% of augmented glenoid components had documented lucencies compared with 46% of control shoulders (P = .5). The mean Lazarus score was 1.5 for augmented glenoids compared with 1.2 for the control group (P = .8). Grade 4 or 5 lucencies were more common in the augmented group (22% vs. 13%, P = .4). Humeral lucencies were similar between groups (19% vs. 8%, P = .2). One humeral stem in the control group was grossly loose with radiolucencies in 6 contiguous zones. Table V shows full radiographic results.Table VRadiographic outcomes by groupAugmented, nControl, nP valueHumeral line: yes/no7/303/34.2Glenoid line: yes/no17/2020/17.5Lazarus score.4 01720 178 232 322 420 565 Open table in a new tab Within the augmented group, grade 4 or 5 lucencies were most common in the shoulders receiving a 16° augmentation (3 of 4 shoulders), accounting for 50% of all at-risk glenoids in this study. Compared with shoulders receiving an 8° augmentations, 16° augmented shoulders were more likely to have a glenoid line (100% vs. 47%, P = .05), a higher Lazarus score (4.2 vs. 1.1, P = .03), and a Lazarus score of 4 or 5 (80% vs. 12% , P = .003). Revision surgery was performed in 2 augmented shoulders (5%). In the first shoulder, an acute hematogenous infection was diagnosed 2.5 years after surgery secondary to a foot wound. The patient was treated with resection arthroplasty and placement of a pre-molded antibiotic spacer with 6 weeks of intravenous antibiotics. In the second shoulder, symptomatic glenoid component loosening developed, and revision to a hemiarthroplasty was performed 3 years after index arthroplasty because of lack of glenoid bone stock. Both shoulders that underwent revision in the augmented group received the largest augmentation available (16°). In addition, 1 shoulder in the control group (3%) underwent revision 4 years after index arthroplasty for loosening of the humeral and glenoid components. The patient had previously undergone an arthroscopic rotator cuff repair and labral repair and underwent conversion to a reverse shoulder arthroplasty. Cultures at the time of revision were positive for coagulase-negative Staphylococcus (2 of 6). Overall, the revision rates were similar between groups (P = .6). Posterior glenoid bone loss remains a common finding in primary osteoarthritis. Failure to correct glenoid version can result in persistent posterior subluxation and progressive glenoid loosening. Full-wedge augmented TSAs have the biomechanical advantages of increased backside support and decreased bone strain. Despite the biomechanical advantages, the clinical performance of a full-wedge TSA glenoid remains unproven despite increased use. In this series, augmented glenoid components improved both pain and ROM with a 5% reoperation rate at a mean follow-up of 3.3 years. When the 16° augmented components were eliminated, no other augmented TSA required revision surgery. The newer generation of augmented glenoid components has attempted to improve glenoid fixation compared with the original designs. In the original Cofield 2 augmented component, the keel was angled in line with the neo-glenoid face, thus directing fixation toward the anterior neck of the glenoid. Newer implants have placed vault fixation angled with the paleo-glenoid in an effort to improve fixation. In addition, further attention has been placed on limiting posterior soft-tissue releases to optimize soft-tissue balancing in shoulders with preoperative posterior glenoid bone loss. Favorito et al4Favorito P.J. Freed R.J. Passanise A.M. Brown M.J. 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: 1681-1689https://doi.org/10.1016/j.jse.2016.02.020Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar reported on 22 StepTech glenoids at an average follow-up of 36 months. Postoperative instability occurred in 2 patients (1 anterior and 1 posterior), and 1 of those patients ultimately underwent conversion to a reverse TSA. Stephens et al28Stephens S.P. Spencer E.E. Wirth M.A. Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.J Shoulder Elbow Surg. 2017; 26: 798-803https://doi.org/10.1016/j.jse.2016.09.053Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar reported on 21 shoulders with the same implant and reported no revisions at a mean follow-up of 35 months. In our series, the revision rate using a full-wedge augmentation (5%) was similar to that of Favorito et al. However, this rate of revision remains higher than that of Stephens et al. The failure rate in our series was likely affected by the inclusion of the largest augmentation (16°), which accounted for both revisions. We have since discontinued the use of this augmentation and now prefer to treat greater posterior bone loss with reverse shoulder arthroplasty.18Michael R.J. Schoch B.S. King J.J. Wright T.W. Managing glenoid bone deficiency—the augment experience in anatomic and reverse shoulder arthroplasty.Am J Orthop (Belle Mead NJ). 2018; 47https://doi.org/10.12788/ajo.2018.0014PubMed Google Scholar Using full-wedge TSA augmentation, glenoid lucencies were documented in 46% of shoulders at final follow-up. This is similar to the finding of Favorito et al,4Favorito P.J. Freed R.J. Passanise A.M. Brown M.J. 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: 1681-1689https://doi.org/10.1016/j.jse.2016.02.020Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar who reported a 47% incidence of lucent lines after augmented TSA at a mean follow-up of 3 years. However, the mean Lazarus score was higher in this group (1.5) than in the study of Favorito et al, who reported a mean score of 0.53. The higher score in our study is partially related to inclusion of the all-polyethylene 16° augmentation, which had a high rate of postoperative radiographic loosening compared with smaller augmentations. Both Favorito et al4Favorito P.J. Freed R.J. Passanise A.M. Brown M.J. 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: 1681-1689https://doi.org/10.1016/j.jse.2016.02.020Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar and Stephens et al28Stephens S.P. Spencer E.E. Wirth M.A. Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.J Shoulder Elbow Surg. 2017; 26: 798-803https://doi.org/10.1016/j.jse.2016.09.053Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar reported significant improvements in ROM following TSA with augmented glenoid components. In our study, augmented components demonstrated similar improvement in external rotation compared with the series reported by Stephens et al (31° vs. 32°). However, improvements were smaller for both the ASES score (41.5 vs. 52.3) and forward flexion (39° vs. 50°) in our series compared with theirs. There are multiple limitations to the study. First, the follow-up remains short term but is consistent with early reports on the StepTech glenoid component. With unaugmented anatomic glenoids, loosening has been shown to increase over time, with over 40% of pegged glenoid components having a grade 4 or 5 lucency and/or shift in component position at a mean follow-up of 7 years.17McLendon P.B. Schoch B.S. Sperling J.W. Sánchez-Sotelo J. Schleck C.D. Cofield R.H. Survival of the pegged glenoid component in shoulder arthroplasty: part II.J Shoulder Elbow Surg. 2017; 26: 1469-1476https://doi.org/10.1016/j.jse.2016.12.068Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar However, our results are able to show that early failures are uncommon with a full-wedge augmented glenoid. Second, the overall number of cases is small, which leads to potential sampling bias. In addition, the high failure rate with the 16° augmentation may have artificially inflated the failure rate of augmented glenoid components as an entire group. It is possible that the soft-tissue changes associated with increasing bone loss requiring larger augmentations may affect patient outcomes. Larger studies are needed to further address this issue. Third, preoperative version and postoperative version were unable to be assessed. Early in the study period, CT imaging was not uniformly obtained. We used magnetic resonance imaging scans to determine the Walch classification in some patients but did not attempt to calculate version because of this limitation. It is possible that the lucency and revision rates may have been affected by preoperative version. Similarly, postoperative correction was unable to be assessed with CT scans, which we are unable to routinely obtain because of concerns of radiation and cost. Prior studies have shown higher osteolysis rates with postoperative glenoid retroversion in excess of 15°.8Ho J.C. Sabesan V.J. Iannotti J.P. Glenoid component retroversion is associated with osteolysis.J Bone Joint Surg Am. 2013; 95: e82https://doi.org/10.2106/JBJS.L.00336Crossref PubMed Scopus (170) Google Scholar It is likely that patients in both groups were treated with components placed outside of the planned neutral version, which may have led to progressive glenoid loosening. However, we are unable to assess the effect of postoperative version on outcomes given our institutional constraints on obtaining multiplanar imaging postoperatively. Finally, the lucency rate of augmented anatomic glenoid components may be affected by the presence or absence of the ingrowth cage. Longer follow-up is needed to further evaluate the effect of this design alteration. Posteriorly augmented glenoid components demonstrate similar clinical improvements and a similar rate of radiographic failure to standard anatomic glenoid components at early follow-up. However, a higher rate of clinical and radiographic failure was seen with the use of the 16° all-polyethylene, pegged, full-wedge augmentation, which is no longer used in our practice." @default.
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