The stepped glenoid component

In their classic article, Stepped Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for B2 and B3 Glenoid Pathology, the authors demonstrate that a stepped augmented glenoid component can restore premorbid glenoid anatomy in patients with asymmetric biconcave glenoid bone loss (Walch B2), with short-term clinical and radiographic results equivalent to those for patients without glenoid bone loss (Walch A1) treated with a non-augmented component. 

They found a greater risk of osteolysis around the central peg in patients with moderate-to-severe B3 glenoid pathology with this stepped augmented glenoid component. As demonstrated in the technique guide, use of this component involves reaming of the posterior glenoid to fit the step, which may diminish the bony support for the back of the component.

Should this component fail, the posterior bone stock available for conversion to a reverse total shoulder may be compromised. 

A recent paper, Total Shoulder Arthroplasty for Glenohumeral Arthritis Associated with Posterior Glenoid Bone Loss: Midterm Results of an All-Polyethylene, Posteriorly Augmented, Stepped Glenoid Component,  presented a 5 year followup of 35 shoulders receiving a stepped glenoid for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. The average preoperative glenoid retroversion was 21.6˚. Although postoperative CT scans were obtained, the postoperative glenoid retroversion was not presented.
Two patients (6%) experienced prosthetic instability requiring revision.

The average Lazarus score (0 no radiolucency to 5 gross loosening) was 0.72. The average Yian score (0 no radiolucency to 18 radiolucent line around entire component) was 2.6. There was an increase in Lazarus score and decrease in Wirth score between 2- and 5-year follow-up. The severity of radiographic loosening correlated with patient-reported pain levels. 

The authors point out that these results are not inferior to those achieved with standard glenoid components in the treatment of glenohumeral arthritis with posterior bone loss.

Comment: Since posterior reaming removes posterior bone and the stepped component adds posterior polyethylene, it would be of interest to know the net change in glenoid retroversion in these patients.

Two figures from this series seem to suggest that substantial retroversion remains after insertion of the stepped component.

As pointed out in the two posts referenced below, future research is needed to determine the clinical value and means of "correcting" glenoid retroversion.

What happens when glenoid version and inclination are "corrected"?

Glenoid version: acceptors and correctors

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Total shoulder arthroplasty - do we know when augmented glenoid components are needed?

Biomechanical comparison of 2 augmented glenoid designs: an integrated kinematic finite element analysis


These authors compared two augmented glenoid implants (wedge and step) using finite element analysis (FEA) under maximum physiological loading.

Models of the implants were virtually implanted in a scapula model to correct 20° of retroversion. Simulation of shoulder abduction was performed using the FEA shoulder model.

The force ratio was 0.56 for the wedge design and 0.87 for the step design. Micromotion (com- bination of distraction, translation, and compression) was greater for the step design than the wedge design. Distraction measured 0.05 mm for the wedge design and 0.14 mm for the step component. Both implants showed a similar pattern for translation; however, compression was almost 3 times greater for the step component. Both implants showed high stress levels on the cement mantle. At the glenoid vault and on the implants, the stress levels were 1.65 MPa and 6.62 MPa, respectively, for the wedge design and 3.78 MPa and 13.25 MPa, respectively, for the step design.

The authors concluded that the augmented wedge design provides better implant fixation and stress profiles with less micromotion.


Comment: While this model did show differences in load characteristics between the two components, we cannot be sure how these results relate to the clinical situation or, more importantly, how these load characteristics compare to those of non-augmented components. It is of note that both designs require extra polyethylene to provide the restraint to translation that is normally provided in vivo by soft tissues, muscle forces, and glenoid anatomy. The clinical benefit and survivorship of these implants in comparison to standard implants has yet to be determined.

For some types of implant there is a concern about the amount of bone that is removed during insertion (see below).

In viewing the example of an "average type B2 glenoid" shown in this article (see below), this pathology is typical of what we routinely manage with a standard (non-augmented) glenoid component.

In the introduction, the article states, "Augmented glenoid implants are available to help restore the biomechanics of the glenohumeral joint with excessive retroversion".  Do the images above show a shoulder with "excessive retroversion"?

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Shoulder arthritis - what is the role of the augmented glenoid component?

Biomechanical comparison of 2 augmented glenoid designs: an integrated kinematic finite element analysis 

These authors used finite element analysis (FEA) to conduct an in vitro comparison of 2 augmented glenoid designs—wedge and step—created per the manufacturers’ specifications and virtually implanted in a scapula model to correct 20° of retroversion. Simulation of shoulder abduction was performed using the FEA shoulder model. 

Both components showed high levels of stress measured on the cement mantle, which exceeded the endurance limit for cement fracture. 

Comment: As demonstrated in this study, the constraint provided by posteriorly augmented glenoid components results in excessive levels of stress in the cement mantle, potentially predisposing the cement to fracture with loosening of the component.

The authors present the example below as a "type B2 glenoid based on Walch classification showing bone loss in posteroinferior quadrant". However, the measured glenoid retroversion in this case is <15 degrees. Thus, this is the type of glenoid that many surgeons would manage with a conventional, non-augmented component without attempting to change glenoid version.

Two studies recent studies demonstrate the successful management of B2 glenoids using a standard glenoid component with minimal change of version. (see this link and this link)

It would have been interesting to see the results of this model for a standard glenoid component inserted with minimal reaming (i.e. just enough to enable a close bony fit with the back of the component).

At present it seems that the role of posteriorly augmented glenoid remains undefined.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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Posteriorly augmented glenoid components - an update

Radiographic results of augmented all polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty

These authors evaluated the clinical and radiographic results of an augmented all-polyethylene glenoid used in 21 patients for the treatment of glenoid osteoarthritis with an average posterior glenoid bone loss of 4.7 mm.

Inclusion criteria: any patient undergoing total shoulder arthroplasty for a diagnosis of glenohumeral osteoarthritis with a Walch B2 or C type glenoid morphology, glenoid retroversion of a minimum of 12°, presence of humeral head subluxation greater than 10%, posterior glenoid bone loss, intact rotator cuff and implantation of an augmented glenoid with minimum of 2-year follow- up.

The augmented glenoid component 

was inserted after posterior preparation by removing sclerotic bone with a high-speed bur and then placing a corresponding sized rasp guide. An oscillating rasp was used to finalize preparation of the posterior glenoid surface.

Significant improvements were demonstrated for American Shoulder and Elbow Surgeons Shoulder Assessment (52.3), Simple Shoulder Test (8.1), forward flexion (50°), external rotation (32°), and pain.

Preoperative retroversion averaged 20.8° (range, 12°-37°), humeral scapular alignment averaged 30% (range, 15%-50%), and humeral glenoid alignment averaged 8% (range, 0%-23.0%.). 

Postoperative retroversion averaged 9° (range, 0°-32°), humeral scapular alignment averaged 6.98% (range, 0%-23%), and humeral glenoid alignment averaged − 0.24% (range, − 8% to 3.5%). 

Central peg ingrowth was demonstrated in all patients, and complete component seating was achieved in 19 patients. No complications were encountered, and no clinical or radiographic failures were identified.

Comment: This is a well done study. As the authors point out and as pointed out in this post, Failure of a total shoulder glenoid component occurs after two years, longer term followup of these implants will be of great interest.

This study can be compared to other recent studies with two year followup on posteriorly augmented glenoid components as presented below.

First

Augmented glenoid component for bone deficiency in shoulder arthroplasty.

These authors report on 14 shoulders having shoulder arthroplasty with an augmented glenoid component to treat posterior glenoid bone deficiency associated with advanced osteoarthritis.

According to a modified Neer result rating system, 36% of patients had an excellent result, 50% a satisfactory result, and 14% an unsatisfactory result.

At the most recent radiographs, four of the 12 shoulders that could be evaluated radiographically had more than mild glenohumeral subluxation. Three shoulders had moderate posterior subluxation, one shoulder had severe anterior subluxation. All of the shoulders with postoperative subluxation had some degree of subluxation present prior to surgery. 

The shoulder with severe anterior subluxation postoperatively had moderate posterior subluxation prior to surgery. This patient had Parkinsonism and sustained anterior instability resulting in dislocation, treated with closed reduction, followed by immobilization and physical therapy. 

There was no periprosthetic lucency in four shoulders, periprosthetic lucency was grade 1 in seven shoulders and grade 5 in one shoulder, and the glenoid component had shifted in position. This shoulder also had moderate posterior subluxation, and this glenoid component was considered radiographically loose.

The authors concluded, "Our results suggest patients undergoing total shoulder arthroplasty with an asymmetric glenoid component for osteoarthritis achieve satisfactory mid-term pain relief and improvement in function; however, instability is not always corrected. The advantage of this component seems marginal, and its use has been discontinued."


Second
Preliminary Results of a Posterior Augmented Glenoid Compared to an all Polyethylene Standard Glenoid in Anatomic Total Shoulder Arthroplasty

These authors report on 24 patients having total shoulder arthroplasty using a posteriorly augmented glenoid for arthritis with posterior glenoid wear. The degree of posterior wear and retroversion before surgery are not presented.

At two years after surgery, 60% of the shoulders had a periglenoid radiolucent line with an average radiographic line score of 1.10.

One glenoid was radiographically loose. 

Two shoulders demonstrated superior subluxation. 

Three were anteriorly subluxated.

Comment: These results speak to the challenges inherent in the use of posteriorly augmented components.

One of the rarely discussed concerns is the effects of using thick posterior polyethylene to manage the   posteriorly directed loads applied when the arm is elevated to the functional position of forward elevation, which is known to create the risk of functional decentering.

This is best explained by noting that when the arm is at the side with a posteriorly augmented glenoid, the net humeral joint reaction force (red arrow) is centered.

However, when the arm is elevated to a functional position, the net humeral joint reaction force (red arrow) is directed posteriorly against the posteriorly augmented polyethylene, subjecting it to the risk of cold flow.

 Furthermore, the point of application of the net humeral joint reaction force of the elevated arm creates an increased glenoid loosening moment (blue line), when the posterior polyethylene is thick.

It is possible that these mechanisms contributed to the development of lucent lines and instability with posteriorly augmented glenoid components in the series presented.

Another concern with removal of the posterior sclerotic glenoid bone for the insertion of an augmented component (as shown below)

 is that should the augmented component fail, the amount of posterior bone loss may compromise revision surgery.

Our approach to the retroverted glenoid is simple - see this link..

(1) We do not rely on preoperative CT scans because they cannot image the shoulder in the functional  position of forward elevation. Instead we prefer the simple standardized axillary view taken with the arm elevated 90 degrees in the plane of the scapula as shown below (this shoulder demonstrates the bad arthritic triad).

(2) We do not use preoperative planning software or patient specific drill guides, but rather ream the glenoid conservatively without trying to 'normalize' glenoid version as shown in this link.

(3) Finally, in a total shoulder arthroplasty for a retroverted glenoid, we place a standard glenoid component on the conservatively reamed glenoid, using an anteriorly eccentric humeral humeral head component if necessary to achieve centering of the articulation. 

This type of reconstruction is shown below on an axillary view taken with the arm in the functional position of forward elevation. Note the centered humeral head and the lack of glenoid lucent lines after two years of implantation.

This approach preserves the maximal amount of glenoid bone in contrast to what is required to fit the bone to a more complex back side geometry as explained in this link.

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When should we use a stepped posteriorly augmented glenoid component?

Total shoulder arthroplasty for glenohumeral arthritis associated with posterior glenoid bone loss: results of an all-polyethylene, posteriorly augmented glenoid component

Between May 2011 and January 2013, 22 shoulders in 19 patients (15 men and 4 women) underwent primary TSA by a single surgeon. In all cases, an all-polyethylene, posteriorly augmented, stepped glenoid component was implanted. 

In these cases preoperative glenoid retroversion measured 15 degrees or greater (14 of these cases had retroversion of 25 degrees or less).

At a mean follow-up of 36 months, 12 shoulders had osseous integration between the central-peg flanges, 6 had bone adjacent to the central-peg flanges but without identifiable osseous integration, and 1 showed osteolysis. 

While the overall clinical results showed improvement, two patients sustained a total of 3 episodes of humeral dislocation, one anterior and two posterior.

The authors point out that " implantation of a stepped glenoid component requires removal of some posterior bone. In glenoids in which there is both retroversion and glenoid medialization, there may be insufficient subchondral bone, volume, and/or density after preparation to support the posterior component." This is shown by the figure below.

Comment: In the osteoarthritic shoulder with posterior wear, the bone and cartilage have failed to hold up under the loads applied by the humeral head. With a posteriorly augmented glenoid component, the hope is that the thickened posterior polyethylene will be able to hold up under these same loads. 

This report shows that achieving prosthetic balance with this prosthesis can be difficult, even in the hands of an experienced surgeon.

The indications for the use of the stepped prosthesis remain to be determined. Many of the shoulders in this series had relatively low amounts of preoperative retroversion that are in the range usually managed with conventional components and soft tissue balancing.

Should this implant fail, the bone defect would be greater than that present before the arthroplasty as diagrammed below.

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Augmented glenoid component - requires removal of posterior glenoid bone

There is a lot to be learned about evaluation and management of the arthritic glenoid as shown in a recent article. In this article the x-rays below illustrate some of these. The figure below shows the implantation of a 7 mm posteriorly augmented glenoid component  'recommended' by a three dimensional imaging and templating system. Note that this implantation requires removal of about half of the dense bone in the posterior glenoid.

This bone removal is also shown in the figures below copyrighted by Steve Lippitt comparing the bone loss with the StepTech to that of the conservative glenoid reaming approach that we embrace (using anteriorly augmented humeral head components and rotator interval plication if necessary to manage posterior instability).

      

 

It is apparent that if a stepped posterior glenoid component fails, the bone loss will greatly complicate any additional reconstruction.

Here are the eccentric heads used in conduction with conservative reaming.

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Posteriorly augmented glenoid components - computing how much bone is lost on insertion

Augmented glenoid component designs for type B2 erosions: a computational comparison by volume of bone removal and quality of remaining bone

These authors used a computational modeling was to compare the volume of glenoid bone that would need to be removed in the implantation of three different designs of posteriorly augmented glenoid components in the management of B2 genoid erosion. They 'virtually implanted' a full-wedge, a posterior-wedge, and a posterior-step in 3-D reconstructions of 16 patients with B2 glenoids, correcting retroversion to 0° and 10°.

Importantly the amount of bone removed with these implants ranged from 1500 to 3000 cubic millimeters. When correcting to 0°, the posterior-wedge implant removed less bone than the posterior-step and the full-wedge. 

The residual glenoid bone density with the posterior-wedge was significantly greater than with the posterior-step.

Comment: This is an interesting study, suggesting that bone removal is necessary for fitting posteriorly augmented glenoids to the pathoanatomy encountered in glenohumeral arthritis. 

We have posted this concern previouslyl

Their implant fitting was virtual and not actual: implants could be manipulated to rotate (clockwise/ counterclockwise and superoinferior) and to translate (anteroposterior and superoinferior). The instrumentation for fitting the glenoid bone to the back of the glenoid component would seem to be quite complex. While the authors suggest that it would be best to use computerized

preoperative planning software making use of 3D CT-based models of the glenoid with properly sized implants, the problem of developing instrumentation to implement the plan remains.

While the authors conclude that " Augmented components can provide a bone-preserving option for B2 glenoid management." that statement is only correct if B2 glenoid management involves correction of retroversion. Our approach is manage the B2 glenoid by conservatively reaming only enough to convert the biconcavity to a single concavity without attempting to change version. See also this related article. this one, and this one as well.

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Do special glenoid components solve the problem of glenoid bone deficiency?

Nonstandard glenoid components for bone deficiencies in shoulder arthroplasty

As in the prior post, these authors grapple with the issue of glenoid bone deficiency in total shoulder arthroplasty. In this article, they evaluated the clinical and radiographic outcomes in 38 patients having a primary or revision anatomic shoulder arthroplasty with one of 3 nonstandard glenoid components: a polyethylene component with an angled keel for posterior glenoid wear without posterior subluxation; a polyethylene component with 2 mm of extra thickness for central glenoid erosion; or a posteriorly augmented metal-backed glenoid component for posterior glenoid wear and posterior subluxation. The average clinical follow-up was 7.3 years (range, 2-19 years) or until revision surgery.

While overall the patients were improved, thirteen had moderate or severe subluxation preoperatively, and 11 had subluxation at follow-up. Three glenoid components had loosened and 3 were at risk for loosening at an average 5.5 years of follow-up. Seven patients had revision surgery: 4 for instability, 1 for osteolysis, 1 for component loosening with osteolysis, and 1 for a periprosthetic fracture. Three additional patients had removal of glenoid components, 2 for infection and 1 for loosening. Ten-year survival rate free of revision or removal of the angled keel component was 73%; of the extra thick (+2 mm) component; and of the posteriorly augmented metal-backed glenoid component, 31%.

Comment: This article again stresses the difficulty in managing deficient glenoid bone in performing total shoulder arthroplasty. If there is insufficient bony support the component is at risk for failure.

We refer to the combination of posterior humeral subluxation on the glenoid, glenoid retroversion and a biconcave glenoid as the bad arthritic triad (BAT).

We have used the ream and run procedure for carefully selected patients with this type of glenohumeral pathoanatomy, avoiding the risk of glenoid component failure in the bad arthritic triad (BAT).

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Consultation for those who live a distance away from Seattle.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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The Steptech glenoid - is this TV Spot accurate?

This blog post was prompted by phone calls from patients who wanted to know if we "can do the Step tech for them instead of a total shoulder" after seeing the spot on TV.

Here's the text from the spot that seems to have patients with shoulder arthritis confused.  We placed some footnotes to shed some additional light on potentially confusing statements. We have removed the names of the persons from the ad. We doubt that the physicians had any intent to mislead patients.

"Osteoarthritis can lead to severe shoulder pain, wearing down the joint so much that simple movements become unbearable.

Now, a new shoulder replacement surgery is giving patients their reach back. (1) One of the developers is a local doctor.

To watch him swing, you wouldn’t know Mr. X's shoulder ever gave him trouble. He has lived with shoulder pain for years, until it become debilitating.

"One of the things that, for example, my wife and I do is cuddle at night, and I just couldn't get my arm up and around,” said Mr. X.(1)

That’s when he opted for a new shoulder replacement surgery. In Mr. X's case, there was virtually no cartilage left, just bone on bone. (2) Dr. XX says that made Mr. X an ideal candidate for the Steptech surgery.  (3) 

"I think that this will be one of those milestones that will help us address significant shoulder arthritis with bone loss," said Dr. XX, an orthopedic surgeon (3). "What we do is we make a very precise cut in the bone and then instead of implanting a slanted socket, we can implant a more orientated anatomic socket, which we believe will have better results in the long term." (4)

The surgery has put Mr. X back in the game.

"Pain?” said Mr. X. “I have no pain. I have no pain at all." (5)

One of the benefits of Steptech is that it allows surgeons to make a 90 degree cut, preserving as much bone as possible. (6)

Dr. XXX was one of the developers of the Steptech device. He's also one of the few doctors in the country who does this procedure." (7) 

Another version of this 'announcement' is titled "New shoulder replacement easier on patients" (8)

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Footnotes

(1) For decades now shoulder joint replacement  has been successfully returning patients with osteoarthritis of the shoulder to activities such as golf, tennis, swimming, and cuddling - "giving them their reach back". This not in any way 'new'. 

(2) Loss of articular cartilage is always present in osteoarthritis, as shown in these typical x-rays.

(3) Dr. XX and Dr. XXX are on the speakers' bureau and make paid presentations for the company that manufactures the Steptech. 

(4) There are no substantial clinical followup studies with the Steptech glenoid. The clinical results to date do not indicate it gives any better results than a standard total shoulder for which there are many decades of followup data showing reproducible and long lasting improvements in comfort and function.

(5) This is a typical result from a standard total shoulder.

(6) Bone can best be preserved by not making a cut at all, but rather by gently reaming the glenoid to the proper shape. The clinical value of special glenoid components, bone grafting and excessive reaming has not been demonstrated.

(7)  The Steptech glenoid is commercially available glenoid prosthesis that has more plastic on its posterior aspect. Shoulder joint replacement with a Stephtech is still a "total shoulder" and not something else. Its use is not restricted to 'a few doctors in the country'.

(8) No data are presented to support this claim. For example, the video states that patients are able to start moving their shoulders 24 hours after the procedure. The standard practice in many centers with a standard total shoulder is to move the shoulder the evening of the shoulder replacement.

Note that for individuals with bone loss desiring a higher than average level of function, a ream and run procedure may be a consideration as shown here .

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