Glenoid Radiolucent Lines in Anatomic Total Shoulder Arthroplasty are Unaffected by Thrombin Glenoid Preparation
It is recognized that Glenoid component lucencies are associated with poorer patient-reported outcomes following anatomic shoulder arthroplasty.
These authors identified patients undergoing primary anatomic TSA using two glenoid types. Group A glenoids had a cemented central peg without peripheral peg cementation
and Group B glenoids had cemented peripheral pegs without central peg cementation
After reaming the glenoid, all glenoids were irrigated with pulsatile lavage and suction dried. Next, all glenoids in Groups A and B had either Surgicel (Ethicon, Johnson & Johnson, Somerville, NJ) alone or Surgicel soaked in thrombin for preparation. The Surgicel was placed into the peg holes that were to be cemented and then removed prior to cementing. Polymethyl methacrylate cement (Simplex, Stryker, Kalamazoo, MI) was applied using a catheter-tipped syringe for pressurization.
All patients had the same glenoid preparation except some had the addition of thrombin as a preparation agent. Group A glenoids were implanted by the same surgeon at three different hospitals, one where thrombin was used and two where thrombin was not used. Group B glenoids were implanted by one surgeon who routinely used thrombin and another surgeon who did not at the same hospital.
The first postoperative radiograph was assessed for radiolucent lines.
They identified 83 Group A glenoids with and 63 without thrombin glenoid preparation, and 109 Group B glenoids with and 48 without thrombin preparation.
None of the Group A glenoids had radiolucent lines and 5 (3%) Group B glenoids had radiolucent lines.
Use of thrombin showed no difference in early radiolucencies (p=1.00) in either Group.
Comment: It seems likely that radiolucent lines are the result of failure to remove fluid or clot from the holes and failure to adequately pressurize the cement.
In this study the surgical technique combining Surgicel hemostasis and pressurization of each hole effectively minimized postoperative radiolucent lines.
An alternative to Surgicel for removing blood from the peg holes prior to cement pressurization is the use of a carbon dioxide spray to dry each hole immediately before pressurizing the cement assuring that no fluid or clot remains.
This technique, like that of the authors, routinely yields glenoid fixation without radiolucent lines as shown below.
There are other elements that are essential for securing the glenoid component as shown in this link.The importance of minimizing glenoid component lucencies is demonstrated in this article
These authors point out the high rates of radiographic glenoid loosening following anatomic total shoulder arthroplasty (TSA). They studied the association of radiolucent lines with shoulder function and patient-reported outcomes (PROs) in 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) after surgery.
All-polyethylene keeled components (below left) were used in 186 shoulders All-polyethylene pegged glenoids (below right) were used in 306 shoulders.
An example of radiographic loosening is shown below.
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 with peri-glenoid lucency's demonstrated significantly lower improvements in forward elevation (P .02) and all PROs (P .005). The improvement in Simple Shoulder Test averaged 7.3 for the 308 shoulders without radiolucent lines and 5.6 for the 184 shoulders with radiolucent lines.
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; the differences exceeded the MCID for grade 5 lucencies.
Complications and reoperations were more common in group 1 (16% vs. 5% [P < .001] and 11% vs. 3% [P < .001], respectively). Glenoid component loosening was the most common cause of reoperation in group 1, representing the indication for revision in 14 of 21 reoperations.
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Shoulder arthritis - what you need to know (see this link) The smooth and move for irreparable cuff tears (see this link) The total shoulder arthroplasty (see this link). The ream and run technique is shown in this link. The cuff tear arthropathy arthroplasty (see this link). The reverse total shoulder arthroplasty (see this link).
Shoulder rehabilitation exercises (see this link).
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