Biomechanical Impact of Posterior Glenoid Wear on Anatomic Total Shoulder Arthroplasty

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1 S5 Biomechanical Impact of Posterior Glenoid Wear on Anatomic Total Shoulder Arthroplasty Christopher P. Roche, M.S., M.B.A., Phong Diep, B.S., Sean G. Grey, M.D., and Pierre-Henri Flurin, M.D. Abstract Introduction: This study quantified bone removed to correct three different sizes of posterior glenoid defects and also quantified the change in rotator cuff muscle length resulting from correction of each defect using three different glenoid designs. Methods: A 3-D computer model quantified the cortical and cancellous bone removed when correcting three sizes of posterior glenoid defects and simulated internal/external rotation to quantify changes in rotator cuff muscle length when correcting glenoid retroversion in three sizes of posterior glenoid defects using three different glenoid prostheses: 1. eccentric reaming using a non-augmented glenoid (Equinoxe standard pegged), 2. 8, 12, and 16 Equinoxe posterior augment glenoid (wedge), and 3. 3 mm, 5 mm, and 7 mm Global Step-Tech posterior augment glenoid (step). Results: For small defects, the 8 wedge and 3 mm step posterior augment glenoids conserves 50% (1.295 cm 3 ) and 23% (1.704 cm 3 ) more bone than eccentric reaming (2.147 cm 3 ), respectively. For medium defects, the 12 wedge and 5 mm step glenoids conserves 69% more (1.295 cm 3 ) and 2% less (2.720 cm 3 ) bone than eccentric reaming (2.655 cm 3 ), respectively. For large defects, the 16 wedge and 7 mm step glenoids conserve 48% more (1.852 cm 3 ) and 36% less (4.343 cm 3 ) bone than eccentric reaming (3.736 cm 3 ), respectively. For each size defect, muscle shortening was observed for both eccentric reaming and each augmented glenoid design. Christopher P. Roche, M.S., M.B.A., and Phong Diep, B.S., are employed by Exactech, Gainesville, Florida. Sean G. Grey, M.D., is at the Orthopaedic Center of the Rockies, Fort Collins, Colorado. Pierre-Henri Flurin, M.D., is at the Bordeaux-Merignac Clinique du Sport, Merignac, France. Correspondence: Christopher P. Roche, M.S., M.B.A., Exactech, Inc., 2320 NW 66th Court, Gainesville, Florida 32653; chris. roche@exac.com. Eccentric reaming medialized the humerus and resulted in additional muscle shortening (wedge: 2.0%, 2.9%, and 3.6%; step: 1.2%, 1.7%, and 1.7%) in each size defect, respectively. Discussion and Conclusions: Both step and wedge augmented glenoid designs conserved more anterior glenoid bone and were associated with less muscle shortening than correction with eccentric reaming. However, wedge posterior augment glenoids medialized the humerus less and were observed to be more bone conserving than step posterior augment glenoids, particular in large glenoid defects. Posterior glenoid wear is common in glenohumeral osteoarthritis. Contracture of the anterior capsule and tightening of the subscapularis and anterior musculature of the shoulder causes posterior humeral head subluxation and a posterior load concentration on the glenoid. This reduced contact area results in glenoid wear and eventually posterior instability. Farron and coworkers demonstrated that glenoid prostheses implanted in scapula with posterior glenoid defects are associated with increased stress in the bone, cement, and implant and are also associated with increased implant micromotion, all of which could lead to one of the most common complications of total shoulder arthroplasty: aseptic glenoid loosening. 1 To correct a posterior glenoid defect, shoulder surgeons typically eccentrically ream the anterior glenoid to recenter the humeral head prior to resurfacing with a prosthesis. Unfortunately, the technique of eccentric reaming undermines prosthesis support by removing the stronger (non-worn) anterior glenoid cortical bone. This removal of bone creates a functional limit of 10 to 15 of eccentric correction prior to the bone being too small to support the implant or cement fixation becomes compromised due to peg perforation. 2-4 Additionally, by removing the anterior glenoid bone, eccentric reaming further medializes the joint line, which has implications on muscle tensioning and joint stability (Fig. 1). Roche CP, Diep P, Grey SG, Flurin PH. Biomechanical impact of posterior glenoid wear on anatomic total shoulder arthroplasty. Bull Hosp Jt Dis. 2013;71(Suppl 2):S5-11.

2 S6 Bulletin of the Hospital for Joint Diseases 2013;71(Suppl 2):S5-11 Figure 1 Glenohumeral joint tensioning of a normal shoulder (left), a shoulder with posterior glenoid wear (left middle), eccentrically reamed anatomic total shoulder arthroplasty implanted in posteriorly worn glenoid (right middle), off-axis reamed anatomic total shoulder arthroplasty with an augmented glenoid implanted in a posteriorly worn glenoid (right). As a result of these challenges, orthopaedic device manufacturers have developed posterior augment glenoid implants to minimize the removal of anterior glenoid bone when attempting to restore glenoid normal version and recenter the humeral head when performing total shoulder arthroplasty in patients with posterior glenoid defects. These augmented glenoid implants are provided in two general design styles: wedge (Equinoxe posterior augment glenoid; Exactech, Inc.; Gainesville, FL) and step (Global Step-Tech; Depuy, Inc.; Warsaw, IN), (Fig. 2). This computer analysis compares three different glenoid prosthesis designs: 1. eccentric reaming using a non-augmented glenoid (Equinoxe standard pegged), 2. 8, 12, and 16 Equinoxe posterior augment glenoid, and 3. 3 mm, 5 mm, and 7 mm Global Step-Tech posterior augment glenoid. The purpose of this comparative study is two-fold: 1. Quantify the amount of cortical and cancellous glenoid bone removed to correct three different sizes of posterior glenoid defects using each glenoid design, and 2. Quantify the change in rotator cuff muscle length (relative to a non-worn or normal shoulder) resulting Figure 2 Representative Images of the Exactech Equinoxe 8, 12, and 16 posterior augment glenoid (top row, left to right, respectively) and the Depuy Global Step-Tech 3 mm, 5 mm, and 7 mm posterior augment glenoid (bottom row, left to right, respectively).

3 S7 from three different sizes of posterior glenoid defects using each glenoid design. Methods As described previously, 5-7 a computer model was developed to: 1. quantify the cortical and cancellous bone removed when correcting three sizes of posterior glenoid defects and 2. simulate internal/external rotation and quantify rotator cuff muscle length when correcting glenoid retroversion in three sizes of posterior glenoid defects using three different glenoid prostheses. Digital models of all three glenoid implants were created in a 3-D computer modeling software (Unigraphics; Siemens PLM; Plano, TX, USA). A cortical/ cancellous digital scapula and humerus (Pacific Research, Inc.; Vashon, WA) were assembled to simulate a normal shoulder; the humeral head was centered on the glenoid and offset by 4 mm from the center of the glenoid to account for the thickness of the cartilage and labrum. The digital scapula and humerus had a uniform thick 1 mm shell to simulate cortical bone. Three sizes of posterior glenoid defects (small, medium, and large) were created in the digital scapula by posteriorly shifting the humeral head by 11 mm (until greater tuberosity impingement with acromion), superiorly shifting the humerus by 1.5 mm, and then medially translating the humeral head by 7.0 mm, 8.5 mm, and 10.0 mm into the scapula, respectively. The size of each defect was determined by volume calculations of each cortical and cancellous scapula model relative to the non-worn scapula. The same size of each posterior augment glenoid implant design type was then seated in each corresponding glenoid defect size; cortical and cancellous bone were removed from the bone model to restore the retroversion of the original scapula and permit fully-seating of each glenoid implant. To clarify, the 8 wedge and 3 mm step posterior augment glenoids were seated in the small defect scapula, the 12 wedge and 5 mm step posterior augment glenoids were seated in the medium defect scapula, and the 16 wedge and 7 mm step posterior augment glenoids were seated in the large defect scapula. The standard pegged glenoid acted as the control in this analysis by quantifying bone removed to simulate eccentric reaming to correct each size defect. To only isolate differences in the glenoid preparation methods between the three glenoid styles, bone was not removed to prepare each implant s pegs as each device has pegs of different lengths, which could confound the results. After simulated implantation in each size glenoid defect and calculation of the cortical and cancellous bone removed, the humerus was internally/externally rotated from 0 to 40 with the humerus at the side (e.g., 0 abduction) to quantify changes in muscle length. The computer model simulated five muscles; these analyzed muscles are the supraspinatus, subscapularis, infraspinatus, teres major, and teres minor. Each muscle was simulated as three lines from origin to insertion except for the subscapularis, which was simulated as three lines that wrapped around the anterior glenoid and lesser tuberosity of the humerus. Muscle lengths were measured as the average length of the three lines simulating each muscle at each degree of rotation and compared to that at the corresponding arm position for the normal shoulder without defect to quantify the percentage change in muscle length for each configuration. Results The cortical and cancellous bone removed to correct a small (Fig. 3), medium (Fig. 4), and large (Fig. 5) posterior glenoid defect using the three different prosthesis designs are Figure 3 Lateral and inferior views of the glenoid bone remaining after correction of small defect: small defect (left), eccentric ream (middle left), 8 wedge (middle right), and 3 mm step (right).

4 S8 Bulletin of the Hospital for Joint Diseases 2013;71(Suppl 2):S5-11 Figure 4 Lateral and inferior views of the glenoid bone remaining after correction of medium defect: medium defect (left), eccentric ream (middle left), 12 wedge (middle right), and 5 mm step (right). Figure 5 Lateral and inferior views of the glenoid bone remaining after correction of large defect: large defect (left), eccentric ream (middle left), 16 wedge (middle right), and 7 mm step (right). described in Tables 1 through 3, respectively. For the small defect, the 8 wedge posterior augment glenoid conserves 58% more cancellous bone, 26% more cortical bone, and 50% more bone overall than that using eccentric reaming. For the medium defect, the 12 wedge posterior augment glenoid conserves 72% more cancellous bone, 55% more cortical bone, and 69% more bone overall than that using eccentric reaming. For the large defect, the 16 wedge posterior augment glenoid conserves 48% more cancellous bone, 49% more cortical bone, and 48% more bone overall than that using eccentric reaming. For the small defect, the 3 mm step posterior augment glenoid conserves 25% more cancellous bone, 18% more cortical bone, and 23% more bone overall than that using eccentric reaming. For the medium defect, the 5 mm step posterior augment glenoid removes 4% more cancellous bone, conserves 7% more cortical bone, and removes 2% more bone overall than that using eccentric reaming. For the large defect, the 7 mm step posterior augment glenoid removes 39% more cancellous bone, 22% more cortical bone, and 36% more scapula bone overall than that using eccentric reaming.

5 S9 Table 1 Comparison of Scapula Bone Removed to Correct a Small Glenoid Defect Using Three Different Prosthesis Designs Bone Removed (cm 3 ) Cortical Bone Volume Cancellous Bone Volume Total Bone Volume Small Defect Size Non-augmented glenoid and eccentric reaming Wedge mm Step Percent Difference (Wedge vs. Step) 8.0% 34.6% 27.3% Percent Difference (Wedge vs. Standard) 25.5% 58.1% 49.5% Percent Difference (Step vs. Standard) 17.5% 24.7% 23.0% Table 2 Comparison of Scapula Bone Removed to Correct a Medium Glenoid Defect Using Three Different Prosthesis Designs Bone Removed (cm 3 ) Cortical Bone Volume Cancellous Bone Volume Total Bone Volume Medium Defect Size Non-augmented glenoid and eccentric reaming Wedge mm Step Percent Difference (Wedge vs. Step) 47.6% 75.9% 71.0% Percent Difference (Wedge vs. Standard) 54.5% 72.1% 68.9% Percent Difference (Step vs. Standard) 7.4% -4.4% -2.4% Table 3 Comparison of Scapula Bone Removed to Correct a Large Glenoid Defect Using Three Different Prosthesis Designs Bone Removed (cm 3 ) Cortical Bone Volume Cancellous Bone Volume Total Bone Volume Large Defect Size Non-augmented glenoid and eccentric reaming Wedge mm Step Percent Difference (Wedge vs. Step) 68.9% 82.6% 80.4% Percent Difference (Wedge vs. Standard) 49.1% 47.5% 47.8% Percent Difference (Step vs. Standard) -21.6% -38.9% -36.1% Comparing posterior augment glenoid designs for the small defect, the 8 wedge posterior augment glenoid conserves 35% more cancellous bone, 8% more cortical bone, and 27% more bone overall than that using the 3 mm step posterior augment glenoid. For the medium defect, the 12 wedge posterior augment glenoid conserves 76% more cancellous bone, 48% more cortical bone, and 71% more bone overall than that using the 5 mm step posterior augment glenoid. For the large defect, the 16 wedge posterior augment glenoid conserves 83% more cancellous bone, 69% more cortical bone, and 80% more bone overall than that using the 7 mm step posterior augment glenoid. As depicted in Tables 4 through 6, muscle shortening was observed for each muscle for each size defect, with larger size defects causing more humeral medialization and greater muscle shortening. The supraspinatus and teres major were associated with the most muscle shortening, and the infraspinatus and teres minor were associated with the least muscle shortening for each size defect. The subscapularis was observed to wrap around the anterior glenoid rim during internal rotation and with the arm at neutral for each size uncorrected defect (Fig. 6). Both eccentric reaming and each design of posterior augmented glenoids successfully recentered the humeral head and eliminated subscapularis wrapping around the anterior glenoid rim in each size defect. However, shortening of each muscle was observed for both eccentric reaming and each augmented glenoid design for each size defect. Eccentric reaming medialized the humerus and resulted in 2.0%, 2.9%, and 3.6% additional muscle shortening relative to the wedge augmented glenoids and 1.2%, 1.7%, and 1.7% additional muscle shortening relative to the step augmented glenoids in each size defect, respec-

6 S10 Bulletin of the Hospital for Joint Diseases 2013;71(Suppl 2):S5-11 Table 4 Impact of a Small Posterior Glenoid Defect on Average Rotator Cuff Muscle Length Relative to the Normal (Non-worn) Shoulder when Rotated from 40 Internally to 40 Externally with the Arm at 0 Abduction Small Posterior Defect Supraspinatus Subscapularis Infraspinatus Major Minor Uncorrected Normal Shoulder -6.2% -5.6% -4.1% -6.8% -5.4% Eccentric Reaming with Non-augmented Glenoid -3.9% -3.7% -3.2% -5.0% -4.8% Off-axis Reaming with 8 Augmented Glenoid -1.7% -2.1% -1.6% -2.9% -2.4% 3 mm Step Augmented Glenoid -2.6% -2.8% -2.3% -3.6% -3.5% Table 5 Impact of a Medium Posterior Glenoid Defect on Average Rotator Cuff Muscle Length Relative to the Normal (Non-worn) Shoulder When Rotated from 40 Internally to 40 Externally with the Arm at 0 Abduction Medium Posterior Defect Supraspinatus Subscapularis Infraspinatus Major Minor Uncorrected Normal Shoulder -8.0% -6.8% -5.1% -8.2% -6.6% Eccentric Reaming with Non-augmented Glenoid -4.9% -4.9% -4.1% -6.3% -6.2% Off-axis Reaming with 12 Augmented Glenoid -1.8% -2.1% -1.6% -3.1% -2.5% 5 mm Step Augmented Glenoid -3.2% -3.3% -2.8% -4.4% -4.3% Table 6 Impact of a Large Posterior Glenoid Defect on Average Rotator Cuff Muscle Length Relative to the Normal (Non-worn) Shoulder when Rotated from 40 Internally to 40 Externally with the Arm at 0 Abduction Large Posterior Defect Supraspinatus Subscapularis Infraspinatus Major Minor Uncorrected Normal Shoulder -9.9% -8.0% -6.1% -9.7% -7.8% Eccentric Reaming with Non-augmented Glenoid -6.1% -5.9% -5.0% -7.3% -7.7% Off-axis Reaming with 16 Augmented Glenoid -2.3% -2.6% -2.1% -3.6% -3.3% 7 mm Step Augmented Glenoid -4.4% -4.3% -3.8% -5.4% -5.8% tively. Finally, the additional bone removed to implant the step augmented glenoids slightly medialized the humerus and resulted in 0.8%, 1.4%, and 2.0% additional muscle shortening relative to the wedge augmented glenoids in each size defect, respectively. Figure 6 Shoulder with posterior glenoid wear in neutral (left) and external rotation (right); note the resulting joint laxity from humeral medialization and the subscapularis wrapping. Discussion The results of this study demonstrate that posterior glenoid wear medializes the humerus, shortens each of the rotator cuff muscles, and alters the angle of the subscapularis so that it wraps around the anterior glenoid rim with the arm in neutral and during internal rotation. Both eccentric reaming and the use of augmented glenoid implants successfully recentered the humeral head and eliminated subscapularis wrapping around the anterior glenoid rim; however, each resulted in humeral medialization and muscle shortening relative to the non-worn glenoid. Both wedge and step posterior augment glenoid designs better restored the native joint line and were associated with less (1.2% to 3.6%) muscle shortening than that of eccentric reaming. Additionally, both the wedge and step posterior augment glenoid designs conserve anterior glenoid bone when correcting glenoid retroversion in small and medium sized posterior glenoid defects relative to that of eccentric reaming.

7 S11 However, the wedge posterior augment glenoids removed less cortical, cancellous, and total bone than did the step posterior augment glenoid in each size defect; where the wedge glenoid removed 27%, 71%, and 80% less overall bone than the step glenoid in each size defect, respectively. For medium and large glenoid defects, only the wedge posterior augment glenoid conserved glenoid bone relative to the eccentric reaming technique; the step posterior augment glenoid removed 2% more bone in medium glenoid defects and 36% more scapula bone in large glenoid defects than did eccentric reaming. The functional impact of this additional bone removed to implant the step posterior augment glenoid is humeral medialization and 0.8% to 2.0% additional muscles shortening relative to the wedge posterior augment glenoid. This study has some limitations. Regarding the calculation of bone removed, this study only compared bone removed by three glenoid designs in one medium-sized glenohumeral anatomy having three different sizes of posterior glenoid defects; therefore, it does not account for all possible anatomical and morphological variations in which these devices can be implanted. Additionally, this study only quantified bone removed at the face of the glenoid; bone removed by drilling out the glenoid pegs was not considered, as the step posterior augment glenoid has longer pegs than the wedge posterior augment glenoid, the total bone actually removed by the step glenoid is expected to be larger. It should be noted that the step posterior augment glenoid perforated the anterior scapula in the medium and large defect, and the wedge posterior augment glenoid perforated the anterior scapula only in the large defect. Regarding the calculation of muscle lengths, the computer model limited motion of the scapula and did not simulate wrapping of each muscle around the humerus or scapula (only wrapping of the subscapularis was simulated). Because muscle wrapping of the other four muscles was not modeled, their muscle lengths may be slightly underestimated. Finally, muscle lengths can be impacted by a variety of other factors, including glenoid placement on the scapula, the size of the humeral osteotomy, the retroversion of the humeral or glenoid component, and the thickness of humeral head. Conclusions Augmented glenoid implants are a bone conserving option to recenter the humeral head, correct glenoid retroversion, and minimize muscle shortening when performing total shoulder arthroplasty in patients with posterior glenoid defects. Augmented glenoids conserved more anterior glenoid bone and were associated with less muscle shortening than the conventional technique of eccentric reaming since the removal of anterior glenoid bone caused humeral medialization. While both wedge and step posterior augment glenoid designs restored the joint line better than did eccentric reaming, wedge posterior augment glenoids medialized the humerus less and were observed to be more bone conserving than step posterior augment glenoids, particular in large glenoid defects where the wedge glenoid removed 80% less bone than the step glenoid. While the fixation of the 8, 12, and 16 cemented wedge posterior augment glenoid has been presented previously, 8 future work should evaluate the fixation differences associated with each design type given the differences in bone volume removed to correct each defect. Additionally, future work should investigate the clinical significance of the observed muscle shortening and evaluate the functional impact of subscapularis wrapping around the anterior glenoid rim. Finally, longer term clinical follow-up is necessary to confirm that augmented glenoid implants can maintain the joint line and keep the humeral head centered on the glenoid. Disclosure Statement Funding for this study was provided by Exactech, Inc., Gainesville, Florida. Christopher P. Roche and Phong Diep are employed by Exactech, Inc. Sean G. Grey, M.D., and Pierre-Henri Flurin, M.D. are consultants for Exactech, Inc., and receive royalties on products related to this article. References 1. Farron A, Terrier A, Buchler P. Risks of loosening of a prosthetic glenoid implanted in retroversion. J Shoulder Elbow Surg Jul-Aug;15(4): Gillespie R, Lyons R, Lazarus M. Eccentric reaming in total shoulder arthroplasty: a cadaveric study. Orthopedics Jan;32(1): Clavert P, Millet PJ, Warner JJ. Glenoid Resurfacing: What are the limits to asymmetric reaming for posterior erosion? J Shoulder Elbow Surg Nov-Dec;16(6): Nowak DD, Bahu MJ, Gardner TR, et al. Simulation of surgical glenoid resurfacing using three-dimensional computed tomography of the arthritic glenohumeral joint: the amount of glenoid retroversion that can be corrected. J Shoulder Elbow Surg. 2009;Sep-Oct;18(5): Roche C, et al. Computer assessment of scapula cortical and cancellous bone removal when correcting a posterior defect using 3 different glenoid prosthesis designs. Transactions of the 59th Annual ORS Meeting. San Antonio, Texas, January 26-29, Roche C, et al. Asymmetric tensioning of the rotator cuff by changing humeral retroversion in reverse shoulder arthroplasty. Transactions of the 59th Annual ORS Meeting. San Antonio, Texas, January 26-29, Roche C, et al. Biomechanical analysis of 3 commercially available reverse shoulder designs in a normal and medially eroded scapula. Transactions of the 59th Annual ORS Meeting. San Antonio, Texas, January 26-29, Roche C, et al. Glenoid fixation using an 8, 12, and 16 posteriorly augmented cemented glenoid prosthesis. Presented at the Congress of the European Society for Surgery of the Shoulder and the Elbow (SECEC-ESSSE). Dubrovnik, Croatia, September 19-22, 2012.

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