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Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation
J Shoulder Elbow Surg (2013) 22, 745-751
www.elsevier.com/locate/ymse
Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation Nicolas Bonnevialle, MDa, Barbara Melis, MDa, Lionel Neyton, MDb, Luc Favard, MDc, Daniel Mole, MDd, Gilles Walch, MDb, Pascal Boileau, MDa,* a
H^ opital de L’Archet 2, Nice, France Centre Medical Santy, Lyon, France c Centre Hospitalier Universitaire de Tours, Tours, France d Clinique de Traumatologie, Nancy, France b
Hypothesis and background: Reimplantation of a new glenoid component for symptomatic glenoid failure after total shoulder arthroplasty (TSA) is a well-established surgical strategy. In case of aseptic glenoid loosening or failure, revision of TSA by reimplantation of a cemented glenoid implant would be a reliable therapeutic option. Materials and methods: This retrospective multicenter study included 42 TSAs with symptomatic failed glenoids revised by reimplantation of an all–polyethylene (PE), cemented glenoid component. All patients were reviewed clinically and radiologically, with a mean follow-up of 74 months. Results: The failed initial glenoid component was metal backed in 32 cases and PE cemented in 10. The main cause of glenoid failure was component loosening in 19 cases (46%) and PE wear or dissociation in 23 (54%). Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. At follow-up, the mean Constant score was 57 points (gain of 16 points) and the mean active anterior elevation was 125 (gain of 19 ). Conclusion: This study suggests that revision of a TSA with reimplantation of an all-PE cemented glenoid component does not solve the problem of glenoid loosening. Soft-tissue failure and prosthetic instability are underestimated preoperatively and may explain, in part, the high rate of recurrent glenoid loosening. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Glenoid loosening; revision; shoulder arthroplasty
Patients gave their permission to be included in this study. *Reprint requests: Pascal Boileau, MD, H^opital de L’Archet 2, 151 route de St Antoine de Ginestiere, 06200, Nice, France. E-mail address: [email protected] (P. Boileau).
The number of total shoulder arthroplasties (TSAs) implanted for degenerative pathologies affecting the shoulder joint has increased dramatically during the last decades.4,8,16 The glenoid component remains the ‘‘weak
1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2012.08.009
746 link’’ in the survival of TSA.1,11,14 The main complication of cemented all–polyethylene (PE) glenoid components at long-term follow-up is aseptic loosening. The use of metalbacked (MB) uncemented components has been associated with other modes of failure, such as PE liner wear and dissociation.3,6,11,15,24 Glenoid component reimplantation is one potential therapeutic option that can be used when revising TSA for symptomatic glenoid loosening or failure. However, few reports concern the functional and radiologic outcomes after this procedure, which appears to be associated with high rates of failure.2,5,6,10,22 Therefore, we hypothesized that, in cases of glenoid loosening or failure, revision of TSA by reimplantation of a new cemented glenoid component would solve the glenoid problem.
Material and methods Study design A retrospective multicenter study was performed with the participation of 8 different centers with a special interest in shoulder surgery. The inclusion criteria were (1) revision of a TSA performed between 1991 and 2006, (2) aseptic glenoid failure, (3) glenoid reimplantation, and (4) minimum radiologic and clinical followup of 2 years. Revisions using other therapeutic options such as (1) glenoid removal without reimplantation, (2) isolated glenoid bone grafting, (3) reverse shoulder arthroplasty, or (4) resection arthroplasty were excluded. Among 137 TSAs revised for an aseptic glenoid failure, 48 had glenoid components reimplanted. Three patients were lost to follow-up, and 3 patients died before the minimum 2-year followup. Thus, 42 arthroplasties (41 patients) were included in this study.
Patients The procedure was performed in 15 men and 26 women with a mean age of 60 years (range, 35-77 years) at the time of primary TSA and 66 years (range, 40-84 years) at revision surgery. The right shoulder and the dominant side were involved in 26 cases. Indications for primary TSA were osteoarthritis in 33 cases, rheumatoid arthritis in 4, post-instability arthropathy in 3, sequela of fracture in 1, and avascular necrosis in 1. Preoperative computed tomography (CT) scans (or arthroCT scans) were available in all cases of primary osteoarthritis. The glenoid morphology according to the Walch classification was type A1 in 17 cases, type A2 in 6, type B1 in 4, and type B2 in 6.25
Surgical technique and implants All procedures were performed by senior surgeons who were specialists in shoulder surgery. The mean interval between
N. Bonnevialle et al. Table I Complications associated with glenoid loosening or failure at time of revision procedure Complications
N
Subscapularis tear or insufficiency Preoperative (clinical and/or radiologic) Intraperative (partial- or full-thickness tear) Supraspinatus and/or infraspinatus tear Prosthetic instability Anterior subluxation Posterior subluxation
17 (40%) 6 11 2 (5%) 8 (19%) 3 5
primary TSA and revision was 67 months (range, 4-131 months). Four patients were operated on for glenoid loosening or failure before the end of the first postoperative year. Through a deltopectoral approach, the status of the rotator cuff tendons was assessed and any partial- or full-thickness lesions were systematically repaired after prosthetic implantation. Several intraperative samples of bone and tissue were obtained for a systematic bacteriologic analysis. The humeral stem was removed in 19 shoulders to assist the glenoid exposure. An humeral osteotomy was required in 3 cases. The glenoid component was removed, and the presence and extent of glenoid bone loss were evaluated. Defects were present in 37 shoulders (86%). Of these, 25 were classified as central and 12 were combined (central and peripheral). The new glenoid implanted was an all-PE, keeled and cemented Aequalis component (Tornier, Montbonnot, France). The backside geometry was flat in 26 cases and convex in 16. In 10 cases (25%), an associated bone graft procedure was performed to improve component stability and fill encountered osseous defects. Seven structural iliac crest bone grafts (3 for central and 4 for combined defects), 2 allografts (1 for a central defect and 1 for a combined defect), and 1 cancellous impacted graft (for a central defect) were used. Revision was carried out as a 1-stage procedure in all cases except for one with a delay of 6 months between grafting and glenoid reimplantation. The graft was stabilized with screws in 5 shoulders, whereas impaction was sufficient to achieve primary graft stability in the others.
Clinical and radiologic evaluation Patients gave their agreement to have all data concerning their prosthesis used to carry out this study. They were reviewed clinically and radiologically with a mean follow-up of 74 months (range, 24-138 months) by independent observers. Preoperatively and at last follow-up, range of motion was recorded for active anterior elevation, external rotation with the arm at the side, and internal rotation (ie, the spinous process reached by the patient’s thumb). The Constant score, which was adjusted for age and gender, was used at the same time and before every new surgical procedure.7 At last follow-up, subjective results were assessed by asking the patients whether they were very satisfied, satisfied, disappointed, or unhappy with the outcome after the intervention. Subscapularis function was specifically evaluated as part of the preoperative and postoperative clinical examination using the
Revision in total shoulder arthroplasty Table II
747
Postoperative complications and reoperations
Complications (n ¼ 19) (45%) Implant Glenoid loosening (n ¼ 7)
Soft-tissue disorders Stiffness (n ¼ 1)
Reoperations (n ¼ 9) (21%) Comments Conversion to RSA (n ¼ 3) Conversion to HA (n ¼ 3) Resection arthroplasty
Mean CS, 30 points at FU Mean CS, 23 points at FU Late deep infection
Open arthrolysis
History of instability arthropathy for index TSA; CS, 55 points at FU Mean CS, 48 points at FU No revision because of low functional demand (mean CS, 23 points at FU) Mean CS, 34 points at FU Loose bodies of cement with glenoid component still in place
Subscapularis tear (anterior subluxation) (n ¼ 3) d Infraspinatus tear (upward migration) (n ¼ 5) d Posterior subluxation (n ¼ 2) Loose bodies (n ¼ 1)
d Arthroscopic debridement
CS, Constant score; FU, follow-up; RSA, reverse shoulder arthroplasty; HA, hemiarthroplasty.
liftoff test and belly-press test. The degree of subscapularis muscle fatty infiltration was assessed on the preoperative CT scans.12 The radiographic analysis consisted of anteroposterior views in neutral rotation and an axillary view. Glenoid periprosthetic radiolucencies were scored according to the Mole classification.17 Clear migration of the component or a score above 12 points was considered indicative of glenoid loosening. Loosening was not registered as a complication unless its presence had resulted in a revision procedure being performed. Finally, glenohumeral superior and anteroposterior subluxation was evaluated on anteroposterior and axillary views, respectively.
Post-revision complications and reoperations
Statistical methods
Evaluation according to the Constant score for the 35 shoulders with the glenoid implant still in place are summarized in Table III. The mean follow-up was 74 months (range, 24-138 months). Significant improvements were related to pain, activity, absolute and adjusted Constant score, and active anterior elevation. The subjective results were evaluated for the entire series. The outcome was considered to be very satisfactory in 18 cases and satisfactory in 10. Nine patients were disappointed and 4 were unhappy with the result.
The distribution of data was analyzed with the d’Agostino-Pearson test. The preoperative and postoperative data were analyzed for statistically significant differences between means; paired values were compared by use of a paired t test, and unpaired results were compared with the Mann-Whitney test. The c2 test and Fisher exact test for small numbers were used to compare categorical data. The significance level was set at P ¼ .05. We used MedCalc software, version 8.0 (MedCalc Software, Mariakerke, Belgium).
The overall complication rate was 45% (19 of 42) postoperatively. They were classified as affecting either the implant directly or the periarticular soft tissues. When both occurred in combination, the complication related to the implant was presented (Table II). Among 9 patients (21%) who needed a reoperation, 7 (17%) had recurrent glenoid loosening with poor clinical outcomes leading to a re-revision of the implant.
Functional results
Results
Radiologic results
The revised glenoid component was MB in 32 cases, all-PE cemented flat in 8, and convex in 2. Of the glenoid failures, 19 (46%) were due to component loosening and 23 (54%) occurred as a result of PE wear or dissociation from an MB baseplate. Associated complications were present in 23 patients before revision (14 had >1 complication). Descriptive data are shown in Table I.
At a mean follow-up of 74 months, the overall rate of recurrent glenoid loosening was 67% (28 of 42): 21 patients had clear radiologic loosening with a Mole score above 12 points (Fig. 1) and 7 others (17%) required further revision for recurrent glenoid loosening. No humeral stem met the radiographic criteria for being loose, although proximal radiolucent lines were observed in 19 cases (50%) at last follow-up.
19.3 42.8 (–90 to 140) 1 22.1 (–50 to 50) 0.5 2.6 (–6 to 8) 125.4 35.9 (60 to 180) 29.7 19.6 (–20 to 60) 5.2 2.4 (0 to 10) 106.1 41 (30 to 180) 28.7 21.3 (0 to 80) 4.7 2.9 (0 to 10)
<.0001 <.0001 .2 .0056 .0003 <.001 54 5.1 6.5 3.8 12.3 1.3 4.5 15.4 22.7 23.7 33.5
Constant score Pain (out of 15 points) Activity (out of 20 points) Mobility (out of 40 points) Strength (out of 25 points) Absolute Constant score (out of 100 points) Adjusted Constant score (%) Active mobility Anterior elevation ( ) External rotation at side ( ) Internal rotation (points)
6.2 3 9.3 4.6 21.9 11 3.8 3.7 41.3 19.9 54.2 25.4
(0 to 15) (0 to 20) (4 to 40) (11 to 83) (0 to 16) (14 to 119)
(3 to 15) (4 to 20) (0 to 38) (0 to 15) (18 to 85) (26 to 127) 11.2 3.6 14.4 5 25.7 10.7 5 3.2 56.7 19.09 79.3 29.7
(–4 to 11) (–6 to 20) (–22 to 34) (–8 to 10) (–32 to 67) (–47 to 107)
P value Gain (range) At latest follow-up (range) Before revision (range)
Functional results: Constant score and active mobility (n ¼ 35) Table III
.04 (t test) .8 (t test) .43 (t test)
N. Bonnevialle et al. (t test) (t test) (t test) (Mann-Whitney test) (t test) (t test)
748
Among the 10 cases of glenoid bone graft, there was a complete resorption of the graft in 4 cases and a partial resorption in 6. At last follow-up, the glenoid component was loose in 6 cases (60%) and further surgery had been performed in 3 cases, as previously reported: 2 patients with symptomatic glenoid loosening underwent revision to a reverse prosthesis without bone graft (Fig. 2) and 1 patient had a late deep infection develop, requiring resection arthroplasty with insertion of an antibiotic-impregnated cement spacer.
Correlations Clinical results between patients with and without recurrent glenoid loosening are compared in Table IV. Recurrence of loosening was responsible for a significant increase in pain (mean reduction of 3.3 points in pain score). However, with the number available, there was no significant difference in the absolute and adjusted Constant scores between the 2 categories of patients. Soft-tissue disorders (rotator cuff insufficiency, prosthesis instability) were recorded in 2 different groups: group I (n ¼ 28) with associated glenoid loosening (rerevised or not) and group II (n ¼ 14) without associated glenoid loosening. Soft-tissue problems were more frequently observed in group I (n ¼ 16, 57%) than in group II (n ¼ 2, 14%) (P ¼ .02, c2 test). No correlation were found between glenoid loosening and age, gender, arm dominance, native glenoid morphology (Walch classification), or preoperative type of implant.
Discussion Our study highlights that revision of an anatomic TSA by reimplantation of a new glenoid component does not solve the problem of glenoid loosening or failure because of recurrent implant loosening and bone graft failure or lysis. Indeed, in our series, the overall rate of recurrent glenoid loosening or failure after reimplantation of a new glenoid implant was 67% (28 of 42) at a mean follow-up of 74 months. Seven patients (17%) had to undergo re-revision for recurrent glenoid loosening associated with poor clinical outcomes. We found that associated complications (such as rotator cuff insufficiency or prosthetic instability) were frequently underestimated and, therefore, poorly treated at the time of revision surgery. After a meticulous analysis of the series, we retrospectively found that soft-tissue failures were often evident preoperatively: 40% of cases of subscapularis insufficiency and 19% of anteroposterior prosthetic subluxations were present before revision surgery. Postoperatively, there was a significant correlation between recurrent glenoid loosening and the presence of soft-tissue disorders. Previously, Deutsch et al9 compared clinical outcomes of revision TSA in groups with and without
Revision in total shoulder arthroplasty
749
Figure 1 (A) A 68-year-old woman in whom a TSA was revised for glenoid loosening with medialization and inferior tilt of the component. (B) A cemented all-PE glenoid was reimplanted without bone graft. (C, D) At 4 years of follow-up, the radiolucent line is clearly identified around the glenoid implant, which is loose (Mole score, 18 points).
preoperative prosthetic anteroposterior instability. They concluded that soft-tissue horizontal imbalance was predictive of postoperative outcome. Even if the clinical diagnosis is difficult to formulate in patients with painful shoulders, every effort should be made to identify soft-tissue imbalance not only vertically but also horizontally. Meticulous clinical examination and CT scan have to precisely define the status of subscapularis tendon and muscle, before revision procedure, because it clearly compromises reimplantation of a new glenoid component. The glenoid bone defect is a real technical challenge in revision of a TSA with glenoid reimplantation. This defect is mainly because of the cement mantle removal from the glenoid vault or baseplate removal when the failure is due to PE dissociation in an MB implant without loosening. Glenoid bone grafting in primary TSA was already described in case of asymmetric glenoid wear with satisfactory results.13,18,21,23 In revision surgery, little experience with bone glenoid reconstruction had been reported in the literature. Deutsch et al9 reported 15 cases of glenoid reimplantation in a series of 32 revision TSAs. For 7 patients, the glenoid bone defect
required a graft, including cancellous allograft and autograft from the humeral head. Antuna et al2 used a cancellous bone allograft in only 5 cases out of 48 revision TSAs with glenoid reimplantation. None of these series described the results of real structural bone reconstruction. In case of major bone defect, grafting with structural or cancellous bone of the glenoid vault seems not to be a reliable option. At follow-up, 6 glenoid components (of 10) had recurrent loosening and partial or total resorption of the graft did not provide lasting structural stability of the component. One explanation for the graft lysis is that the graft was placed between the native bone of the scapula and the cement mantle of the new glenoid implant, which is probably not the best biological and mechanical condition for bone healing. Because the bone graft was in compression under the glenoid baseplate of a reverse shoulder arthroplasty, several authors did not report rates of graft resorption as high as ours.19,20 In our study, 21% of patients who had already undergone revision required further surgery, mainly for recurrent glenoid failure. This result is commonly reported in the literature.2,5,6,9,10,13,22 However, the rate remains low in comparison to the rate of radiologic loosening identified
750
N. Bonnevialle et al.
Figure 2 (A) A 62-year-old man in whom glenoid bone grafting with an iliac crest was performed, in addition to a cemented glenoid reimplantation. (B) At 1 year of follow-up, the graft did not heal and recurrent loosening was identified. (C) The patient decided to undergo re-revision, and a reverse prosthesis was placed.
Table IV
Correlations between radiologic glenoid loosening and Constant score (n ¼ 35) (follow-up, 74 months)
Pain (points) Mobility (points) Activity (points) Strength (points) Constant score (points) Adjusted Constant score (%)
Radiologic glenoid loosening (n ¼ 21)
No radiologic glenoid loosening (n ¼ 14)
P value
10 3.8 22.4 12.1 13.2 5.3 4.4 3.8 52.1 21.7 72.4 29.8
13.3 1.9 26.6 11.2 15.6 4.2 6 1.5 63.7 14.3 89.6 25.6
.007 .28 .16 .14 .09 .08
(3 to 15) (0 to 38) (4 to 20) (0 to 15) (18 to 85) (26 to 123)
(67%). One potential explanation is that as the age of the patient increases with follow-up, the functional demands decrease correspondingly. This clinical and radiographic investigation has the weaknesses inherent to a multicenter retrospective study. However, this series represents the largest consecutive cohort reported in the literature to date. Moreover, all prostheses were systematically explored with clinical examination and radiographs at follow-up with
(10 to 15) (0 to 38) (8 to 20) (4 to 8) (41 to 81) (53 to 127)
(t-test) (t test) (t test) (t test) (t test) (t test)
a standardized method to analyze loosening, with a mean follow-up of 74 months.
Conclusion This study suggests that revision of a TSA for glenoid failure or loosening with reimplantation of a cemented
Revision in total shoulder arthroplasty all-PE glenoid component does not solve the problem of glenoid loosening. Soft-tissue insufficiency and instability are preoperatively underestimated and may explain the high rates of recurrent glenoid loosening. Other therapeutic options should be looked for in patients with severe glenoid bone defects, soft-tissue problems, and/or prosthetic instability.
Acknowledgment The authors thank Christophe Levigne MD, T. Bradley Edwards, MD, and Franc¸ois Sirveaux, MD for providing patient data.
Disclaimer Luc Favard, Daniel Mole, Gilles Walch, and Pascal Boileau have received benefits (royalties) from a commercial entity (Tornier) related to the subject of this article. All other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Adams JE, Sperling JW, Hoskin TL, Melton LJ III, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg 2006;15:50-5. http:// dx.doi.org/10.1016/j.jse.2005.04.009 2. Antuna SA, Sperling JW, Cofield RH, Rowland CM. Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001; 10:217-24. 3. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Mole D. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg 2002;11:351-9. http://dx. doi.org/10.1067/mse.2002.125807 4. Boileau P, Sinnerton RJ, Chuinard C, Walch G. Arthroplasty of the shoulder. J Bone Joint Surg Br 2006;88:562-75. http://dx.doi.org/10. 1302/0301-620X.88B5 5. Cheung EV, Sperling JW, Cofield RH. Revision shoulder arthroplasty for glenoid component loosening. J Shoulder Elbow Surg 2008;17: 371-5. http://dx.doi.org/10.1016/j.jse.2007.09.003 6. Cofield RH. Uncemented total shoulder arthroplasty: a review. Clin Orthop Relat Res 1994;307:86-93. 7. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.
751 8. Day JS, Lau E, Ong KL, Willams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20. http://dx.doi.org/10.1016/j.jse.2010.02.009 9. Deutsch A, Abboud JA, Kelly J, Mody M, Norris T, Ramsey ML, et al. Clinical results of revision shoulder arthroplasty for glenoid component loosening. J Shoulder Elbow Surg 2007;16:706-16. http://dx.doi. org/10.1016/j.jse.2007.01.007 10. Dines JS, Fealy S, Strauss EJ, Allen A, Craig EV, Warren RF, et al. Outcomes analysis of revision total shoulder replacement. J Bone Joint Surg Am 2006;88:1494-500. http://dx.doi.org/10.2106/JBJS.D.02946 11. Fox TJ, Cil A, Sperling JW, Sanchez-Sotelo J, Schleck CD, Cofield RH. Survival of the glenoid component in shoulder arthroplasty. J Shoulder Elbow Surg 2009;17:859-63. http://dx.doi.org/10. 1016/j.jse.2008.11.020 12. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304:78-83. 13. Hawkins RJ, Greis PE, Bonutti PM. Treatment of symptomatic glenoid loosening following unconstrained shoulder arthroplasty. Orthopedics 1999;22:229-34. 14. Hill JM, Norris TR. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid. J Bone Joint Surg Am 2001; 83:877-83. 15. Kasten P, Pape G, Raiss P, Bruckner T, Rickert M, Zeifang F, et al. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. J Bone Joint Surg Br 2010;92:387-92. http://dx.doi.org/10.1302/0301-620X.92B3.23073 16. Kozak LJ, DeFrances CJ, Hall MJ. National Hospital Discharge Survey: 2004 annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 13. 2006; 162:1-209. 17. Mole D, Roche O, Riand N. Cemented glenoid component. In: Walch G, Boileau P, editors. Shoulder arthroplasty. Berlin: Springer; 1999. p. 163-71. 18. Neer CS, Morrison DS. Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg Am 1988;70:1154-62. 19. Neyton L, Boileau P, Nove-Josserand L, Edwards TB, Walch G. Glenoid bone grafting with a reverse design prosthesis. J Shoulder Elbow Surg 2007;16(Suppl):S71-8. http://dx.doi.org/10.1016/j.jse. 2006.02.002 20. Norris TR, Kelly JD, Humphrey CS. Management of glenoid bone defects in revision shoulder arthroplasty: a new application of the reverse total shoulder prosthesis. Tech Shoulder Elbow Surg 2007;8: 37-46. http://dx.doi.org/10.1097/BTE.0b013e318030d3b7 21. Rice RS, Sperling JW, Miletti J, Schleck C, Cofield RH. Augmented glenoid component for bone deficiency in shoulder arthroplasty. Clin Orthop Relat Res 2008;466:579-83. http://dx.doi.org/10.1007/s11999007-0104-4 22. Sajadi KR, Kwon YW, Zuckerman JD. Revision shoulder arthroplasty: an analysis of indications and outcomes. J Shoulder Elbow Surg 2010; 19:308-13. http://dx.doi.org/10.1016/j.jse.2009.05.016 23. Steinmann SP, Cofield RH. Bone grafting for glenoid deficiency in total shoulder replacement. J Shoulder Elbow Surg 2000;9:361-7. 24. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am 2008;90:2180-8. http://dx.doi.org/10.2106/JBJS.G.00966 25. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty 1999; 14:756-60.
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Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation Nicolas Bonnevialle, MDa, Barbara Melis, MDa, Lionel Neyton, MDb, Luc Favard, MDc, Daniel Mole, MDd, Gilles Walch, MDb, Pascal Boileau, MDa,* a
H^ opital de L’Archet 2, Nice, France Centre Medical Santy, Lyon, France c Centre Hospitalier Universitaire de Tours, Tours, France d Clinique de Traumatologie, Nancy, France b
Hypothesis and background: Reimplantation of a new glenoid component for symptomatic glenoid failure after total shoulder arthroplasty (TSA) is a well-established surgical strategy. In case of aseptic glenoid loosening or failure, revision of TSA by reimplantation of a cemented glenoid implant would be a reliable therapeutic option. Materials and methods: This retrospective multicenter study included 42 TSAs with symptomatic failed glenoids revised by reimplantation of an all–polyethylene (PE), cemented glenoid component. All patients were reviewed clinically and radiologically, with a mean follow-up of 74 months. Results: The failed initial glenoid component was metal backed in 32 cases and PE cemented in 10. The main cause of glenoid failure was component loosening in 19 cases (46%) and PE wear or dissociation in 23 (54%). Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. At follow-up, the mean Constant score was 57 points (gain of 16 points) and the mean active anterior elevation was 125 (gain of 19 ). Conclusion: This study suggests that revision of a TSA with reimplantation of an all-PE cemented glenoid component does not solve the problem of glenoid loosening. Soft-tissue failure and prosthetic instability are underestimated preoperatively and may explain, in part, the high rate of recurrent glenoid loosening. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Glenoid loosening; revision; shoulder arthroplasty
Patients gave their permission to be included in this study. *Reprint requests: Pascal Boileau, MD, H^opital de L’Archet 2, 151 route de St Antoine de Ginestiere, 06200, Nice, France. E-mail address: [email protected] (P. Boileau).
The number of total shoulder arthroplasties (TSAs) implanted for degenerative pathologies affecting the shoulder joint has increased dramatically during the last decades.4,8,16 The glenoid component remains the ‘‘weak
1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2012.08.009
746 link’’ in the survival of TSA.1,11,14 The main complication of cemented all–polyethylene (PE) glenoid components at long-term follow-up is aseptic loosening. The use of metalbacked (MB) uncemented components has been associated with other modes of failure, such as PE liner wear and dissociation.3,6,11,15,24 Glenoid component reimplantation is one potential therapeutic option that can be used when revising TSA for symptomatic glenoid loosening or failure. However, few reports concern the functional and radiologic outcomes after this procedure, which appears to be associated with high rates of failure.2,5,6,10,22 Therefore, we hypothesized that, in cases of glenoid loosening or failure, revision of TSA by reimplantation of a new cemented glenoid component would solve the glenoid problem.
Material and methods Study design A retrospective multicenter study was performed with the participation of 8 different centers with a special interest in shoulder surgery. The inclusion criteria were (1) revision of a TSA performed between 1991 and 2006, (2) aseptic glenoid failure, (3) glenoid reimplantation, and (4) minimum radiologic and clinical followup of 2 years. Revisions using other therapeutic options such as (1) glenoid removal without reimplantation, (2) isolated glenoid bone grafting, (3) reverse shoulder arthroplasty, or (4) resection arthroplasty were excluded. Among 137 TSAs revised for an aseptic glenoid failure, 48 had glenoid components reimplanted. Three patients were lost to follow-up, and 3 patients died before the minimum 2-year followup. Thus, 42 arthroplasties (41 patients) were included in this study.
Patients The procedure was performed in 15 men and 26 women with a mean age of 60 years (range, 35-77 years) at the time of primary TSA and 66 years (range, 40-84 years) at revision surgery. The right shoulder and the dominant side were involved in 26 cases. Indications for primary TSA were osteoarthritis in 33 cases, rheumatoid arthritis in 4, post-instability arthropathy in 3, sequela of fracture in 1, and avascular necrosis in 1. Preoperative computed tomography (CT) scans (or arthroCT scans) were available in all cases of primary osteoarthritis. The glenoid morphology according to the Walch classification was type A1 in 17 cases, type A2 in 6, type B1 in 4, and type B2 in 6.25
Surgical technique and implants All procedures were performed by senior surgeons who were specialists in shoulder surgery. The mean interval between
N. Bonnevialle et al. Table I Complications associated with glenoid loosening or failure at time of revision procedure Complications
N
Subscapularis tear or insufficiency Preoperative (clinical and/or radiologic) Intraperative (partial- or full-thickness tear) Supraspinatus and/or infraspinatus tear Prosthetic instability Anterior subluxation Posterior subluxation
17 (40%) 6 11 2 (5%) 8 (19%) 3 5
primary TSA and revision was 67 months (range, 4-131 months). Four patients were operated on for glenoid loosening or failure before the end of the first postoperative year. Through a deltopectoral approach, the status of the rotator cuff tendons was assessed and any partial- or full-thickness lesions were systematically repaired after prosthetic implantation. Several intraperative samples of bone and tissue were obtained for a systematic bacteriologic analysis. The humeral stem was removed in 19 shoulders to assist the glenoid exposure. An humeral osteotomy was required in 3 cases. The glenoid component was removed, and the presence and extent of glenoid bone loss were evaluated. Defects were present in 37 shoulders (86%). Of these, 25 were classified as central and 12 were combined (central and peripheral). The new glenoid implanted was an all-PE, keeled and cemented Aequalis component (Tornier, Montbonnot, France). The backside geometry was flat in 26 cases and convex in 16. In 10 cases (25%), an associated bone graft procedure was performed to improve component stability and fill encountered osseous defects. Seven structural iliac crest bone grafts (3 for central and 4 for combined defects), 2 allografts (1 for a central defect and 1 for a combined defect), and 1 cancellous impacted graft (for a central defect) were used. Revision was carried out as a 1-stage procedure in all cases except for one with a delay of 6 months between grafting and glenoid reimplantation. The graft was stabilized with screws in 5 shoulders, whereas impaction was sufficient to achieve primary graft stability in the others.
Clinical and radiologic evaluation Patients gave their agreement to have all data concerning their prosthesis used to carry out this study. They were reviewed clinically and radiologically with a mean follow-up of 74 months (range, 24-138 months) by independent observers. Preoperatively and at last follow-up, range of motion was recorded for active anterior elevation, external rotation with the arm at the side, and internal rotation (ie, the spinous process reached by the patient’s thumb). The Constant score, which was adjusted for age and gender, was used at the same time and before every new surgical procedure.7 At last follow-up, subjective results were assessed by asking the patients whether they were very satisfied, satisfied, disappointed, or unhappy with the outcome after the intervention. Subscapularis function was specifically evaluated as part of the preoperative and postoperative clinical examination using the
Revision in total shoulder arthroplasty Table II
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Postoperative complications and reoperations
Complications (n ¼ 19) (45%) Implant Glenoid loosening (n ¼ 7)
Soft-tissue disorders Stiffness (n ¼ 1)
Reoperations (n ¼ 9) (21%) Comments Conversion to RSA (n ¼ 3) Conversion to HA (n ¼ 3) Resection arthroplasty
Mean CS, 30 points at FU Mean CS, 23 points at FU Late deep infection
Open arthrolysis
History of instability arthropathy for index TSA; CS, 55 points at FU Mean CS, 48 points at FU No revision because of low functional demand (mean CS, 23 points at FU) Mean CS, 34 points at FU Loose bodies of cement with glenoid component still in place
Subscapularis tear (anterior subluxation) (n ¼ 3) d Infraspinatus tear (upward migration) (n ¼ 5) d Posterior subluxation (n ¼ 2) Loose bodies (n ¼ 1)
d Arthroscopic debridement
CS, Constant score; FU, follow-up; RSA, reverse shoulder arthroplasty; HA, hemiarthroplasty.
liftoff test and belly-press test. The degree of subscapularis muscle fatty infiltration was assessed on the preoperative CT scans.12 The radiographic analysis consisted of anteroposterior views in neutral rotation and an axillary view. Glenoid periprosthetic radiolucencies were scored according to the Mole classification.17 Clear migration of the component or a score above 12 points was considered indicative of glenoid loosening. Loosening was not registered as a complication unless its presence had resulted in a revision procedure being performed. Finally, glenohumeral superior and anteroposterior subluxation was evaluated on anteroposterior and axillary views, respectively.
Post-revision complications and reoperations
Statistical methods
Evaluation according to the Constant score for the 35 shoulders with the glenoid implant still in place are summarized in Table III. The mean follow-up was 74 months (range, 24-138 months). Significant improvements were related to pain, activity, absolute and adjusted Constant score, and active anterior elevation. The subjective results were evaluated for the entire series. The outcome was considered to be very satisfactory in 18 cases and satisfactory in 10. Nine patients were disappointed and 4 were unhappy with the result.
The distribution of data was analyzed with the d’Agostino-Pearson test. The preoperative and postoperative data were analyzed for statistically significant differences between means; paired values were compared by use of a paired t test, and unpaired results were compared with the Mann-Whitney test. The c2 test and Fisher exact test for small numbers were used to compare categorical data. The significance level was set at P ¼ .05. We used MedCalc software, version 8.0 (MedCalc Software, Mariakerke, Belgium).
The overall complication rate was 45% (19 of 42) postoperatively. They were classified as affecting either the implant directly or the periarticular soft tissues. When both occurred in combination, the complication related to the implant was presented (Table II). Among 9 patients (21%) who needed a reoperation, 7 (17%) had recurrent glenoid loosening with poor clinical outcomes leading to a re-revision of the implant.
Functional results
Results
Radiologic results
The revised glenoid component was MB in 32 cases, all-PE cemented flat in 8, and convex in 2. Of the glenoid failures, 19 (46%) were due to component loosening and 23 (54%) occurred as a result of PE wear or dissociation from an MB baseplate. Associated complications were present in 23 patients before revision (14 had >1 complication). Descriptive data are shown in Table I.
At a mean follow-up of 74 months, the overall rate of recurrent glenoid loosening was 67% (28 of 42): 21 patients had clear radiologic loosening with a Mole score above 12 points (Fig. 1) and 7 others (17%) required further revision for recurrent glenoid loosening. No humeral stem met the radiographic criteria for being loose, although proximal radiolucent lines were observed in 19 cases (50%) at last follow-up.
19.3 42.8 (–90 to 140) 1 22.1 (–50 to 50) 0.5 2.6 (–6 to 8) 125.4 35.9 (60 to 180) 29.7 19.6 (–20 to 60) 5.2 2.4 (0 to 10) 106.1 41 (30 to 180) 28.7 21.3 (0 to 80) 4.7 2.9 (0 to 10)
<.0001 <.0001 .2 .0056 .0003 <.001 54 5.1 6.5 3.8 12.3 1.3 4.5 15.4 22.7 23.7 33.5
Constant score Pain (out of 15 points) Activity (out of 20 points) Mobility (out of 40 points) Strength (out of 25 points) Absolute Constant score (out of 100 points) Adjusted Constant score (%) Active mobility Anterior elevation ( ) External rotation at side ( ) Internal rotation (points)
6.2 3 9.3 4.6 21.9 11 3.8 3.7 41.3 19.9 54.2 25.4
(0 to 15) (0 to 20) (4 to 40) (11 to 83) (0 to 16) (14 to 119)
(3 to 15) (4 to 20) (0 to 38) (0 to 15) (18 to 85) (26 to 127) 11.2 3.6 14.4 5 25.7 10.7 5 3.2 56.7 19.09 79.3 29.7
(–4 to 11) (–6 to 20) (–22 to 34) (–8 to 10) (–32 to 67) (–47 to 107)
P value Gain (range) At latest follow-up (range) Before revision (range)
Functional results: Constant score and active mobility (n ¼ 35) Table III
.04 (t test) .8 (t test) .43 (t test)
N. Bonnevialle et al. (t test) (t test) (t test) (Mann-Whitney test) (t test) (t test)
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Among the 10 cases of glenoid bone graft, there was a complete resorption of the graft in 4 cases and a partial resorption in 6. At last follow-up, the glenoid component was loose in 6 cases (60%) and further surgery had been performed in 3 cases, as previously reported: 2 patients with symptomatic glenoid loosening underwent revision to a reverse prosthesis without bone graft (Fig. 2) and 1 patient had a late deep infection develop, requiring resection arthroplasty with insertion of an antibiotic-impregnated cement spacer.
Correlations Clinical results between patients with and without recurrent glenoid loosening are compared in Table IV. Recurrence of loosening was responsible for a significant increase in pain (mean reduction of 3.3 points in pain score). However, with the number available, there was no significant difference in the absolute and adjusted Constant scores between the 2 categories of patients. Soft-tissue disorders (rotator cuff insufficiency, prosthesis instability) were recorded in 2 different groups: group I (n ¼ 28) with associated glenoid loosening (rerevised or not) and group II (n ¼ 14) without associated glenoid loosening. Soft-tissue problems were more frequently observed in group I (n ¼ 16, 57%) than in group II (n ¼ 2, 14%) (P ¼ .02, c2 test). No correlation were found between glenoid loosening and age, gender, arm dominance, native glenoid morphology (Walch classification), or preoperative type of implant.
Discussion Our study highlights that revision of an anatomic TSA by reimplantation of a new glenoid component does not solve the problem of glenoid loosening or failure because of recurrent implant loosening and bone graft failure or lysis. Indeed, in our series, the overall rate of recurrent glenoid loosening or failure after reimplantation of a new glenoid implant was 67% (28 of 42) at a mean follow-up of 74 months. Seven patients (17%) had to undergo re-revision for recurrent glenoid loosening associated with poor clinical outcomes. We found that associated complications (such as rotator cuff insufficiency or prosthetic instability) were frequently underestimated and, therefore, poorly treated at the time of revision surgery. After a meticulous analysis of the series, we retrospectively found that soft-tissue failures were often evident preoperatively: 40% of cases of subscapularis insufficiency and 19% of anteroposterior prosthetic subluxations were present before revision surgery. Postoperatively, there was a significant correlation between recurrent glenoid loosening and the presence of soft-tissue disorders. Previously, Deutsch et al9 compared clinical outcomes of revision TSA in groups with and without
Revision in total shoulder arthroplasty
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Figure 1 (A) A 68-year-old woman in whom a TSA was revised for glenoid loosening with medialization and inferior tilt of the component. (B) A cemented all-PE glenoid was reimplanted without bone graft. (C, D) At 4 years of follow-up, the radiolucent line is clearly identified around the glenoid implant, which is loose (Mole score, 18 points).
preoperative prosthetic anteroposterior instability. They concluded that soft-tissue horizontal imbalance was predictive of postoperative outcome. Even if the clinical diagnosis is difficult to formulate in patients with painful shoulders, every effort should be made to identify soft-tissue imbalance not only vertically but also horizontally. Meticulous clinical examination and CT scan have to precisely define the status of subscapularis tendon and muscle, before revision procedure, because it clearly compromises reimplantation of a new glenoid component. The glenoid bone defect is a real technical challenge in revision of a TSA with glenoid reimplantation. This defect is mainly because of the cement mantle removal from the glenoid vault or baseplate removal when the failure is due to PE dissociation in an MB implant without loosening. Glenoid bone grafting in primary TSA was already described in case of asymmetric glenoid wear with satisfactory results.13,18,21,23 In revision surgery, little experience with bone glenoid reconstruction had been reported in the literature. Deutsch et al9 reported 15 cases of glenoid reimplantation in a series of 32 revision TSAs. For 7 patients, the glenoid bone defect
required a graft, including cancellous allograft and autograft from the humeral head. Antuna et al2 used a cancellous bone allograft in only 5 cases out of 48 revision TSAs with glenoid reimplantation. None of these series described the results of real structural bone reconstruction. In case of major bone defect, grafting with structural or cancellous bone of the glenoid vault seems not to be a reliable option. At follow-up, 6 glenoid components (of 10) had recurrent loosening and partial or total resorption of the graft did not provide lasting structural stability of the component. One explanation for the graft lysis is that the graft was placed between the native bone of the scapula and the cement mantle of the new glenoid implant, which is probably not the best biological and mechanical condition for bone healing. Because the bone graft was in compression under the glenoid baseplate of a reverse shoulder arthroplasty, several authors did not report rates of graft resorption as high as ours.19,20 In our study, 21% of patients who had already undergone revision required further surgery, mainly for recurrent glenoid failure. This result is commonly reported in the literature.2,5,6,9,10,13,22 However, the rate remains low in comparison to the rate of radiologic loosening identified
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N. Bonnevialle et al.
Figure 2 (A) A 62-year-old man in whom glenoid bone grafting with an iliac crest was performed, in addition to a cemented glenoid reimplantation. (B) At 1 year of follow-up, the graft did not heal and recurrent loosening was identified. (C) The patient decided to undergo re-revision, and a reverse prosthesis was placed.
Table IV
Correlations between radiologic glenoid loosening and Constant score (n ¼ 35) (follow-up, 74 months)
Pain (points) Mobility (points) Activity (points) Strength (points) Constant score (points) Adjusted Constant score (%)
Radiologic glenoid loosening (n ¼ 21)
No radiologic glenoid loosening (n ¼ 14)
P value
10 3.8 22.4 12.1 13.2 5.3 4.4 3.8 52.1 21.7 72.4 29.8
13.3 1.9 26.6 11.2 15.6 4.2 6 1.5 63.7 14.3 89.6 25.6
.007 .28 .16 .14 .09 .08
(3 to 15) (0 to 38) (4 to 20) (0 to 15) (18 to 85) (26 to 123)
(67%). One potential explanation is that as the age of the patient increases with follow-up, the functional demands decrease correspondingly. This clinical and radiographic investigation has the weaknesses inherent to a multicenter retrospective study. However, this series represents the largest consecutive cohort reported in the literature to date. Moreover, all prostheses were systematically explored with clinical examination and radiographs at follow-up with
(10 to 15) (0 to 38) (8 to 20) (4 to 8) (41 to 81) (53 to 127)
(t-test) (t test) (t test) (t test) (t test) (t test)
a standardized method to analyze loosening, with a mean follow-up of 74 months.
Conclusion This study suggests that revision of a TSA for glenoid failure or loosening with reimplantation of a cemented
Revision in total shoulder arthroplasty all-PE glenoid component does not solve the problem of glenoid loosening. Soft-tissue insufficiency and instability are preoperatively underestimated and may explain the high rates of recurrent glenoid loosening. Other therapeutic options should be looked for in patients with severe glenoid bone defects, soft-tissue problems, and/or prosthetic instability.
Acknowledgment The authors thank Christophe Levigne MD, T. Bradley Edwards, MD, and Franc¸ois Sirveaux, MD for providing patient data.
Disclaimer Luc Favard, Daniel Mole, Gilles Walch, and Pascal Boileau have received benefits (royalties) from a commercial entity (Tornier) related to the subject of this article. All other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Adams JE, Sperling JW, Hoskin TL, Melton LJ III, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg 2006;15:50-5. http:// dx.doi.org/10.1016/j.jse.2005.04.009 2. Antuna SA, Sperling JW, Cofield RH, Rowland CM. Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001; 10:217-24. 3. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Mole D. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. J Shoulder Elbow Surg 2002;11:351-9. http://dx. doi.org/10.1067/mse.2002.125807 4. Boileau P, Sinnerton RJ, Chuinard C, Walch G. Arthroplasty of the shoulder. J Bone Joint Surg Br 2006;88:562-75. http://dx.doi.org/10. 1302/0301-620X.88B5 5. Cheung EV, Sperling JW, Cofield RH. Revision shoulder arthroplasty for glenoid component loosening. J Shoulder Elbow Surg 2008;17: 371-5. http://dx.doi.org/10.1016/j.jse.2007.09.003 6. Cofield RH. Uncemented total shoulder arthroplasty: a review. Clin Orthop Relat Res 1994;307:86-93. 7. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.
751 8. Day JS, Lau E, Ong KL, Willams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20. http://dx.doi.org/10.1016/j.jse.2010.02.009 9. Deutsch A, Abboud JA, Kelly J, Mody M, Norris T, Ramsey ML, et al. Clinical results of revision shoulder arthroplasty for glenoid component loosening. J Shoulder Elbow Surg 2007;16:706-16. http://dx.doi. org/10.1016/j.jse.2007.01.007 10. Dines JS, Fealy S, Strauss EJ, Allen A, Craig EV, Warren RF, et al. Outcomes analysis of revision total shoulder replacement. J Bone Joint Surg Am 2006;88:1494-500. http://dx.doi.org/10.2106/JBJS.D.02946 11. Fox TJ, Cil A, Sperling JW, Sanchez-Sotelo J, Schleck CD, Cofield RH. Survival of the glenoid component in shoulder arthroplasty. J Shoulder Elbow Surg 2009;17:859-63. http://dx.doi.org/10. 1016/j.jse.2008.11.020 12. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304:78-83. 13. Hawkins RJ, Greis PE, Bonutti PM. Treatment of symptomatic glenoid loosening following unconstrained shoulder arthroplasty. Orthopedics 1999;22:229-34. 14. Hill JM, Norris TR. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid. J Bone Joint Surg Am 2001; 83:877-83. 15. Kasten P, Pape G, Raiss P, Bruckner T, Rickert M, Zeifang F, et al. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. J Bone Joint Surg Br 2010;92:387-92. http://dx.doi.org/10.1302/0301-620X.92B3.23073 16. Kozak LJ, DeFrances CJ, Hall MJ. National Hospital Discharge Survey: 2004 annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 13. 2006; 162:1-209. 17. Mole D, Roche O, Riand N. Cemented glenoid component. In: Walch G, Boileau P, editors. Shoulder arthroplasty. Berlin: Springer; 1999. p. 163-71. 18. Neer CS, Morrison DS. Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg Am 1988;70:1154-62. 19. Neyton L, Boileau P, Nove-Josserand L, Edwards TB, Walch G. Glenoid bone grafting with a reverse design prosthesis. J Shoulder Elbow Surg 2007;16(Suppl):S71-8. http://dx.doi.org/10.1016/j.jse. 2006.02.002 20. Norris TR, Kelly JD, Humphrey CS. Management of glenoid bone defects in revision shoulder arthroplasty: a new application of the reverse total shoulder prosthesis. Tech Shoulder Elbow Surg 2007;8: 37-46. http://dx.doi.org/10.1097/BTE.0b013e318030d3b7 21. Rice RS, Sperling JW, Miletti J, Schleck C, Cofield RH. Augmented glenoid component for bone deficiency in shoulder arthroplasty. Clin Orthop Relat Res 2008;466:579-83. http://dx.doi.org/10.1007/s11999007-0104-4 22. Sajadi KR, Kwon YW, Zuckerman JD. Revision shoulder arthroplasty: an analysis of indications and outcomes. J Shoulder Elbow Surg 2010; 19:308-13. http://dx.doi.org/10.1016/j.jse.2009.05.016 23. Steinmann SP, Cofield RH. Bone grafting for glenoid deficiency in total shoulder replacement. J Shoulder Elbow Surg 2000;9:361-7. 24. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am 2008;90:2180-8. http://dx.doi.org/10.2106/JBJS.G.00966 25. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty 1999; 14:756-60.