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Glenoid Component ‐ None, Poly, Metal ‐What Will Last the Longest? 

Charles M. Jobin, MDAssociate Professor Orthopedic Surgery

Residency Program Director

Shoulder & Elbow Surgery

Columbia University

New York, NY

Winter SKS: Shoulder, Knee, and Sports MeetingFriday, Feb 23rd, 2018 7:10am

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Disclosures

Consultant – Acumed, Wright/Tornier, Zimmer/Biomet

JSES, JBJS, JAAOS, JOR, JSEA – Reviewer

JAAOS Shoulder/Elbow Deputy Editor

Orthobullets.com – Author

Big Problem = Opportunity for Big Impact

Glenoid component frequently (70%) develops lucent lines and loosening

TSA projected 333% increase 2011-30 (Padegimas CORR 2015)

Ethical Dilemma: balancing new technology vs proven techniques

Revision burden will be large

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New Technology

New:

Glenoid designs

Fixation concepts

Materials

Studied biomechanically, in animal models, and in patients

…But long term superiority over existing techniques is relatively unknown…

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Poly vs Metal‐Backed: Survivorship

Mayo registry, 1542 TSAs with 6 glenoid typesRevision Survivorship: 5, 10, 15 years

Neer II all-poly (n=99): 96%, 96%, and 95% Neer II metal-backed (n=316): 96%, 94%, and 89%Cofield 1 metal-backed ingrowth (n=314): 86%, 79%, and 67% Cofield 2 all-poly keeled (n=497): 99%, 94%, and 89% Cofield 2 all-poly pegged (n=358): 99% at 5 years only

Conclusions: Survival best with cemented all-polyethylene (Fox JSES 2009)

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Mid‐Long Term Pegged Poly Outcomes

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330 TSA, 7.2 yrs f/u

Revision free survival99% at 5 years83% at 10 years

Radiographic poly survival92% at 5 years43% at 10 years

Failure risk: Walch A2, B2, C, <65 yrs old

High mid-term Xray and clinical failure for pegged poly

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Glenoid Fixation Options : Current Market

Cemented Pegs (in-line or spread)

Cemented Keel

Ingrowth Metal (pegs, post, cage...)

Hybrid Cement pegs and Ingrowth metal

Metal backed (ingrowth post + screws)

Posterior Augment (wedge, step, half-wedge)

Metal: is it Back?

“metal backed” in-growth glenoids had 50% failure by 10 years (Cofield JBJS 2008)

New designs: metal-poly technology (“hybrid”)

...are we repeating history?

...or is this the holy grail?

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42% of TSA patients are B2 (Churchill JSES 2015)

Posterior erosion

Posterior subluxation

Laxity of posterior capsule

Posterior wear = Worse functionGlenoid looseningPosterior instability(Walch JSES 2010)

Can Glenoid Fixation overcome Retroversion/Wear?

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Reaming to Correct Posterior Wear: “ream the high side”

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Partial version correction: bone preservation

Full version correction: bone removalB2 Arthritic Wear

Aggressive reaming / version correction21% glenoid loosening at 8 years

Conclusion: Less reaming better, preserve bone!

But Less Reaming = Uncorrected Retroversion

Post-op retroversion >15 deg5x odds of osteolysis around peg(Iannotti JBJS 2013)

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Solution: Hemi for Arthritis?

969 shoulders

TSA 97% satisfied

HHR 80% satisfied

TSA poly revision (<2%)

Convert painful hemi to TSA (8%)0

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HHR TSA

Sat

Unsat

Radnay JSES 2007

“Ream and Run” – Concentric Reaming

Matsen series: 176 shoulders>5 yrs f/u (ave 10 years)

16% revisionSST 10 ± 2.6 (89% improved >30%)

Rothman Experience: 24 shoulders>2yr follow up, (ave 3.7years)

25% revision at 2.7 yrsSurvivors: SANE 74%, PSS 82.9, SST10.4

Columbia Experience: 29 shouldersave 17 yrs f/u.

26% revisionSurvivors: ASES 70, Neer satisfaction 25%Improved with concentric >> eccentric glenoid

Solution: Glenoid FixationPeg “Around Growth” Fins ‐ Outcomes

Churchill JSES 2010: 20 TSA, 5 yrs, 75% bone growth between fins

Groh JSES 2010: 83 TSA, 2 yrs, 29% bone growth between fins

Arnold JSES 2011: 35 TSA, 3.5 yrs, CT. 91% bone growth between fins

Wirth JBJS Am 2012: 44 TSA, 3 yrs, 68% bone growth between fins

Vidil EJOST 2013: 26 TSA, 80% bone growth between fins.

Parks JSES 2016: 76 TSA 3 yr XR follow up 50% bone growth around fins

Conclusions: Bone grows around poly fins in 30-90% at mid-term follow up

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98 TSA with 2nd Gen TM glenoid (2011 – 2015)

3 centers, postoperative Xrays: 0, 1, 2 yrs, and latest follow up

Early Outcomes of a 2nd Generation Porous Tantalum‐Backed Glenoid: A Multi‐Center Cohort Study

2015 CSES Biennial Meeting David Kovacevic, Charles M. Jobin, Janice J. He, Rolando Izquierdo, Ryan J. Krupp, Craig C. Satterlee, Jonathan K. Kazam, William N. Levine

Solution: Glenoid Ingrowth Fixation ‐ Outcomes

RLL at 2 years 0.6±1.1

28% no RLL change

57% decrease in RLL score from

post-op = INGROWTH

Metal debris 11% at 2.8yrs

Debris despite solid ingrowth

2% with catastrophic failure

metal fragmentation

RLL Grade 1 1 Year Follow-Up

Radiolucency and Metal Debris

68 TSA, 2 yr, no cement

92% min or zero RLL

44% with metallic debris, increased with time

no component dissociation

(Endrizzi JBJS 2016)

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Grade 1: debris

Grade 2: axillary debris

Grade 3: breakage

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Does Glenoid Bone Ingrow?

6 of 351 glenoids retrieved at 1.2 years during revision not for glenoid failure

Histology: significant evidence of bone ingrowth

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Outcomes: Hybrid Ingrowth central peg

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83 TSA, > 2 yr, Ave FU 3.2 yrs

Retrospective Case Control

40 all-poly pegged vs 43 ingrowth hybrid

RLL similar: hybrid, 1.0 ± 0.4 vs pegged, 1.6 ± 0.3

Complications similar 2-7% (not glenoid)

Hybrid Ingrowth Glenoid 

Retrospective case-control: 92 TSA (46 hybrid cage, 46 UHMW pegged), >2yr FU

No dissociation of poly to cage, 1 aseptic UHMWPE peg loose

RLLHybrid cage (14%), ave RLL score 0.2UHMW pegged (28%), ave RLL score 0.6

Hybrid cage equal to UHMWPE pegged in short-mid term

(Bull HJD 2015)

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Normal Posterior B2 wear TSA with anterior “high-side” reaming

TSA with posterior augmented glenoid

Posterior Augment: Correction to “Normal” Theory

• Restore Balance

• Restore cuff tension / joint line

• Preserve glenoid vault bone

• Sheer to compression

Sabesan et al, JSES 2013

Posterior Augment Wedge

24 TSA w posterior wedge 2 years follow-up

Control: historic TSA

Pain, ROM and Outcomes Scores = no differences

Augment: 60% RLL, ave score 1.1

Non-Augment: 33% RLL, ave score of 0.4

(Bull HJD 2015)

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Posterior Augment Outcomes

22 TSA, Case Series, 3 yr follow up

Pre-op retroversion 23.5° (CT)

Xray: 66% had bone between central peg fins28% had no bone6% had osteolysis

Mean RLL score 0.5

3 episodes of prosthetic instability

Conclusions: Early results are encouraging

(Favorito JSES 2016)

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Posterior Wedge Augment ‐ Outcomes?

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Half-wedge implant mimic B2 to preserve subchondral bone and minimize bone removal during reaming.

Clinical outcomes: no published outcomes to date

Knowles JSES 2015Churchill JSES 2015

Increased critical shoulder angle (CSA) -> more vertical deltoid pull -> superior loading -> glenoid component loosening

61 TSA, 5.0 +/- 2.2 yr follow up

Critical Shoulder Angle >35 deg = 4x risk glenoid loosening

Superior Edge Loading?

Glenoid Technology Hype Outcome data Survivorship~10 year

Metal Backed low Long term – poor results 50%

All Poly Peg/Keel medium Long term – moderate results

85%

Metal Ingrowth medium Short‐mid term – excellent ingrowth but debris + catastrophic failures

?

Hybrid Metal Ingrowth

high Short term – good results ?

Posterior Augment high Short term ? ?

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Putting It All Together

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Need for USA Registry

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Capture everyone’s outcomes

Removes some biases

Informed decisions from large numbers

Thank You!

jobin@columbia.edu

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