Abstract
Glenoid bone loss presents a challenging dilemma, particularly in the setting of failed arthroplasty requiring conversion to a reverse total shoulder arthroplasty (rTSA). The aim of our systematic review was to examine the success and failure of biologic glenoid bone grafting to address vault deficiencies in the setting of shoulder arthroplasty conversion to rTSA. Twelve articles were included and a complete PUBMED search. Inclusion criteria included glenoid bone grafting for conversion of failed arthroplasty and a minimum of 12 months follow-up. Exclusion criteria included grafting for primary rTSA, and re-revision for infection or humeral loosening. Failures were defined as failure of the graft to radiographically incorporate, symptomatic base plate loosening, and need for further surgical re-revision. Two hundred patients were identified across the 12 articles. Eighteen percent (36/200) of all cases demonstrated failure to radiographically incorporate. Thirteen percent (25/200) of all grafting cases required re-revision due to symptomatic failure (pain or functional deterioration). Femoral shaft demonstrated the highest failure rate at 88% (7/8). Grafting for glenoid bone loss in the setting of conversion to rTSA has an 82% rate of success across autograft and allograft utilization. Further studies are needed to better define the success of autografting versus allografting in the setting of shoulder arthroplasty conversion to rTSA with glenoid bone loss.
Keywords: Anatomic total shoulder arthroplasty, Reverse total shoulder arthroplasty, Revision shoulder arthroplasty, Glenoid bone loss, Bone grafting, Biologic graft augmentation
Anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are two of the most common surgical treatments for a variety of degenerative conditions of the shoulder.1, 2, 3, 4 Although clinical improvement after both procedures has been well-documented, complications can be devastating.2,8,11,13 The increasing number of shoulder arthroplasties portends a subsequent increase in the number of complications including infection, osteolysis, instability, fracture, loss of motion, humeral bone loss, glenoid bone loss, and continued pain. Revision arthroplasty to address these complications presents a new array of difficulties.
One particular challenge is the management of glenoid bone loss during revision of aTSA to rTSA. Complications of revision to rTSA in the setting of glenoid bone loss include scapular notching, glenoid baseplate loosening, component instability, persistent pain, reduced function, and potentially catastrophic failure.1,13,15,17,19 Current options for addressing this deformity include eccentric reaming, biologic glenoid bone grafting, metallic glenoid augments, and custom baseplates. There is a paucity of peer reviewed literature evaluating biologic glenoid bone grafting in the setting of revision to rTSA. The purpose of this study was to review the available literature and evaluate the success of different grafts and techniques.
Methods
Search strategy
The present study was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.9 A systematic review of the literature using a PUBMED search of articles related to revision to reverse shoulder arthroplasty, bone grafting, and glenoid bone loss was performed. Articles were identified and after abstract review, 21 papers were fully reviewed, resulting in 12 papers relevant to the topic (Figure 1).
Figure 1.
PUBMED search flow chart.
Study eligibility criteria
Studies were selected on the basis of the following criteria: (1) study population: patients requiring bone grafting for conversion of failed arthroplasty; (2) minimum of 12 months follow-up; (3) studies written in English. Failures were defined as failure of the graft to radiographically incorporate, symptomatic baseplate loosening, and need for further surgical revision.
Studies were excluded if (1) bone grafting for primary rTSA; (2) rerevision for infection or aseptic humeral hardware loosening.
Quality assessment
The reliability of results depends on the extent to which potential sources of bias have been avoided. To adopt the same method to evaluate all selected studies, three reviewers independently applied the “assessing risk of bias” table to assess the risk of bias in each included study. The following biases were assessed: selection bias, performance bias, attrition bias, detection bias, reporting bias, and other bias. Disagreements were resolved through discussion between the reviewers
Statistical analysis
The compilation of this study was determined by documenting the methodological distinctions among several studies by analyzing the data extraction tables. In all cases, P values <.05, were considered statistically significant.
Results
Two-hundred patients were identified to have met inclusion criteria across the 12 selected articles.2,5, 6, 7, 8,10,11,13, 14, 15,17,19 Seventy-three cases utilized autograft, including 43 structural grafts and 31 nonstructural cortico-cancellous grafts. Structural autografts included tricortical iliac crest and proximal humerus. Non-structural cortico-cancellous grafts included iliac crest. One-hundred twenty one patients underwent allografting, including 81 structural and 40 nonstructural. Structural allografts included the tricortical iliac crest, humeral head, femoral head/neck, proximal humerus, and fibula. Six patients had hybrid autograft/allografting (Table I).
Table I.
Types of grafts used by article
| Author | Shoulder revisions (N) | Autograft | Allograft | Hybrid |
|---|---|---|---|---|
| Bitzer et al2. | 11 | 9 Nonstructural cortico-cancellous 2 Structural 2 Tricortical iliac crest |
0 | 0 |
| Ho et al5. | 7 | 0 | 7 Structural 4 Tricortical iliac crest 1 Femoral head 1 Humeral head 1 Fibular strut |
0 |
| Iannotti et al6. | 4 | 0 | 4 Structural 4 Femoral head |
0 |
| Jones et al7. | 9 | 1 Structural 1 Tricortical iliac crest |
8 Structural 8 Femoral head |
0 |
| Kelly et al8. | 12 | 0 | 12 Structural 12 Tricortical iliac crest |
0 |
| Lopiz et al10. | 13 | 0 | 13 Structural 11 Tibial plateau 2 Proximal femur |
0 |
| Mahylis et al11. | 30 | 15 Structural 15 Tricortical iliac crest |
15 Nonstructural | 0 |
| Melis et al13. | 29 | 5 Nonstructural cortico-cancellous 21 Structural 21 Tricortical iliac crest |
3 Nonstructural | 0 |
| Neyton et al14. | 6 | 6 Structural 6 Tricortical iliac crest |
0 | 0 |
| Ozgur et al15. | 24 | 0 | 24 Structural 11 Femoral neck/head 8 Femoral shaft 5 Proximal humerus |
0 |
| Wagner et al17.∗ | 40 | 14 Structural/nonstructural Tricortical iliac crest |
20 Structural/Nonstructural Humerus CanPac DBM |
6 |
| Walker et al19. | 15 | 0 | 10 Structural 10 Femoral head 5 Nonstructural |
0 |
DBM, demineralized bone matrix.
Did not specify how many of structural vs. nonstructural grafts were used in the autograft vs. allograft groups.
Of the shoulders requiring grafting for glenoid bone loss, 18% (36/200) demonstrated failure to radiographically incorporate within the 2 year follow-up period. Twenty-five of 200 (13%) patients required revision due to instability caused by failure of components to incorporate or aseptic loosening after initial incorporation. The most common autograft utilized was tricortical iliac bone graft. Allografts commonly used were femoral neck and cortico-cancellous chips or putty. Femoral shaft allografts demonstrated the highest failure rate at 88% (7/8), primarily due to graft fracture. Other associated factors for failure seen among the articles included short stemmed baseplates and nonlocking screws for the baseplate.5,7,13 Scapular notching did not show definitive association with failure. Overall, there was an 82% success rate of biological graft utilization.
Discussion
Glenoid bone loss is frequently encountered in glenohumeral osteoarthritis and may be seen in acute shoulder trauma2,8,13,17 and may create challenges in primary glenohumeral arthroplasty. Treatment options include adjustments in prosthesis positioning, asymmetric glenoid reaming, glenoid bone grafting or augmented glenoid components.
When aTSA fails secondary to glenoid component loosening, the resulting bone loss is often substantial and may impact revision procedures. In cases with large glenoid bone defects, bone grafting may be required for component fixation and prosthetic stability. Currently, there is no consensus about the choice of bone graft for glenoid reconstruction.
Autograft
Structural grafting is usually indicated when less than 50% of the baseplate can be supported by native glenoid bone.16 In the 12 studies reviewed, iliac crest bone autograft (ICBA) was the most common autograft used.2,11,13,14,17 A piece of tricortical bone is harvested and burred to create a uniform shape with the remaining glenoid. Long peripheral screws are used to set the baseplate to ensure screws pass through the graft into the native glenoid vault. This type of bone graft allows for improved implant support and multiple points of fixation, allowing for greater stability. Limitations of harvesting bone graft depend on the patient’s bone quality.
Allograft
Allografts for glenoid bone loss can also be structural or nonstructural. Nonstructural allograft bone chips, demineralized bone matrix, and proprietary grafting were used in the studies reviewed.11,17,19 The most common structural allografts used were the tricortical iliac crest, femoral neck, proximal humerus, humeral head, tibia, and fibula.5, 6, 7, 8,10,15,19
The purpose of this study was to analyze the limited data that is available currently to determine what type of grafting produces more successful outcomes in the setting of revision aTSAto rTSA. In studies directly comparing ICBA to nonstructural bone allograft, ICBA had no increased risk of component failure, radiographic or clinical complications, or worse clinical outcomes.12,13 Scapular notching in patients with ICBA occurred in 8%-54%.11,13,17 Resorption of the graft ranged from 21% to 40%.5,11,13,17 Although there was some baseplate shifting in both groups, all were clinically stable at 1 and 2 years postoperatively. Overall complications seen with ICBA were approximately 17%.2,7,11,13,14,17 Neyton et al had a group of 6 patients undergoing ICBA during revision procedure. Although all 6 patients demonstrated incorporation of graft at the 2 year follow-up, the sample size is small and the results may not be extrapolated to a larger group.14
Three studies reported on revision rTSA and allograft glenoid reconstruction.8,11,15 Ozgur et al studied 20 patients undergoing 24 revision with various structural allografts. Patients received an allograft when they had glenoid bone loss of Walch classification18 grade IIB or higher or needed the increased offset for stability. Nineteen patients (79.2%) were femoral shaft (8) and femoral neck (11). Fourteen (58.3%) of the grafts failed to incorporate, leading to overall surgical failure and need for further surgical intervention. They concluded that in patients with substantial glenoid bone loss, femoral neck allografts are option, but use of femoral shaft allografts is not recommended (12.5% incorporation rate). Walker et al reported rTSA with iliac crest allograft use.19 Of the 15 patients requiring bone grafting at the time of revision, only 2 reported unsatisfactory scores with pain and function (9%). One of which had graft incorporation without resorption and one had no radiographic component failure. The overall complication rate was 22.7%, consistent with results seen with autograft.13,17 In the 30 revision to rTSAs reported by Kelly et al, 12 patients required iliac crest allograft in the setting of revision.8 When comparing those who received bone allograft, there were no differences in outcomes amongst patients, except for the American Shoulder and Elbow Surgeons pain score, which was higher in the ICBA group. Only 1 allograft surgery failed, but the overall complication rate was higher due to infection and intraoperative fracture.
When glenoid bone loss is less than 50%, nonstructural bone grafting may be considered. Bitzer et al used nonstructural cortico-cancellous bone chips as grafts in 9 of 11 patients requiring bone grafting.2 Fourteen percent of nonstructural bone grafting led to aseptic glenoid baseplate loosening. The high rate of loosening may be attributed to the lack of fixation in morselized bone. Wagner et al had a variety of patients using both structural and nonstructural grafting.17 One of the 5 structural autografts showed severe glenoid loosening at follow-up and poor American Shoulder and Elbow Surgeons scores. Eight of the 35 nonstructural autografts had glenoid loosening and required further surgical intervention. Like Bitzer, it was thought that majority of glenoid loosening in nonstructural autografts was sure to poor fixation and lack of component support.
Our study had certain limitations. Many of the articles reviewed that looked at both autograft and allograft failed to clarify which type of graft led to the failures reported. Multiple grafting surgical techniques and baseplate fixation methods were also used despite commonality of graft selection. There was also variability of implant design (Grammont vs. non-Grammont), as well as glenosphere size in the rTSAs. This systematic review did not address the option for metal augments as a solution for glenoid deficient conversion arthroplasties. Lastly, none of the articles specifically looked at autografting vs. allografting in the setting of revising aTSA to rTSAs.
Conclusion
Glenoid bone grafting may be required in revision of aTSA to rTSA. There is no clear difference between failure rates of autograft vs. allograft to address these defects. Nonstructural grafting may be effective for smaller defects, while larger defects may require structural grafts. To be successful, both autografts and allografts must incorporate and not resorb. However, reported results following these procedures are extremely variable with incorporation rates and patient outcomes. Further investigation into specifically using biologic bone graft for the conversion of aTSA to rTSA in the setting of glenoid bone loss needs to be completed to definitively conclude which type of grafting may lead to the optimal outcome.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: The 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.
Footnotes
Institutional review board approval was not required for this review article.
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