Original Research

Reliability of 3-Dimensional Glenoid Component Templating and Correlation to Intraoperative Component Selection

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Although implant-specific intraoperative targeting devices for glenoid sizing exist, a validated method for preoperatively templating glenoid component size in primary total shoulder arthroplasty (TSA) based on digital imaging does not.

We conducted a study to determine if 3-dimensional (3-D) digital imaging could be used for preoperative templating of glenoid component size and to compare templated glenoid sizes with implanted glenoid sizes. We created 3-D digital models from 3 glenoid component implant sizes and preoperative scapular computed tomography scans of 24 patients who underwent primary TSA. In study arm 1, surgeons templated the 3-D components using only 2 df (superior-inferior and anterior-posterior planes). In study arm 2, surgeons templated the 3-D components using 6 df (superior-inferior, anterior-posterior, and rotational planes).

Overall intraobserver agreement was substantial (0.67) in study arm 1 (P < .001) and moderate (0.58) in study arm 2 (P < .001). 

In arm 1, overall interobserver agreement was fair (0.36) for trial 1 (P < .001) and fair (0.32) for trial 2 (P < .001). In arm 2, overall interobserver agreement was moderate (0.54) for trial 1 (P < .001) and moderate (0.43) for trial 2 (P < .001). In both arms, surgeons tended to template glenoid components smaller than those implanted intraoperatively, particularly for female patients.

Our findings show that 3-D digital models can be consistently and reliably used for preoperative templating of glenoid com­ponent size.


 

References

Take-Home Points

  • Guidelines regarding glenoid component size selection for primary TSA are lacking.
  • Intraoperative in situ glenoid sizing may not be ideal.
  • 3-D digital models may be utilized for preoperative templating of glenoid component size in primary TSA.
  • 3-D templating that allows for superior-inferior, anterior-posterior, and rotational translation can lead to consistent and reproducible templating of glenoid component size.
  • 3-D templating may reduce the risks of implant overhang, peg penetration, and decreased stability ratio.

In 1974, Neer 1 introduced the shoulder prosthesis. In 1982, Neer and colleagues 2 found significant improvement in shoulder pain and function in patients with glenohumeral osteoarthritis treated with the Neer prosthesis. Since then, use of total shoulder arthroplasty (TSA) has increased. Between 1993 and 2007, TSA use increased 319% in the United States. 3 Long-term outcomes studies have found implant survivorship ranging from 87% to 93% at 10 to 15 years. 4

Although TSA is a successful procedure, glenoid component failure is the most common complication. 5-10 Outcomes of revision surgery for glenoid instability are inferior to those of primary TSA. 11 Recent research findings highlight the effect of glenoid size on TSA complications. 12 A larger glenoid component increases the stability ratio (peak subluxation force divided by compression load). 12 However, insufficient glenoid bone stock, small glenoid diameter, and inability to fit a properly sized reamer owing to soft-tissue constraints may lead surgeons to choose a smaller glenoid component in order to avoid peg penetration, overhang, and soft-tissue damage, respectively. Therefore, preoperative templating of glenoid size is a potential strategy for minimizing complications.

Templating is performed for proximal humeral components, but glenoid sizing typically is deferred to intraoperative in situ sizing with implant-specific targeting guides. This glenoid sizing practice arose out of a lack of standard digital glenoid templates and difficulty in selecting glenoid size based on plain radiographs and/or 2-dimensional (2-D) computed tomography (CT) scans. However, targeting devices are sporadically used during surgery, and intraoperative glenoid vault dimension estimates derived from visualization and palpation are often inaccurate. Often, rather than directly assess glenoid morphology, surgeons infer glenoid size from the size and sex of patients. 13

Three-dimensional (3-D) CT can be used to accurately assess glenoid version, bone loss, and implant fit. 14-19 We conducted a study to determine if 3-D digital imaging can be consistently and reproducibly used for preoperative templating of glenoid component size and to determine if glenoid sizes derived from templating correlate with the sizes of subsequently implanted glenoids.

Materials and Methods

This retrospective study was conducted at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University Medical Center in New York City and was approved by our Institutional Review Board. Included in the study were all patients who underwent primary TSA for primary glenohumeral osteoarthritis over a 12-month period. Patients were required to have preoperative CT performed according to our study protocol. The CT protocol consisted of 0.5-mm axial cuts of the entire scapula and 3-D reconstruction of the scapula, glenoid, glenohumeral articulation, and proximal humerus. Patients were excluded from the study for primary TSA for a secondary cause of glenohumeral osteoarthritis, inflammatory arthritis, connective tissue disease, prior contralateral TSA, and prior ipsilateral scapula, glenoid, and proximal humerus surgery. Ultimately, 24 patients were included in the study.

CT data were formatted for preoperative templating. The CT images of each patient’s scapula were uploaded into Materialise Interactive Medical Image Control System (Mimics) software. Mimics allows 3-D image rendering and editing from various imaging modalities and formats. The software was used to create the 3-D scapula models for templating. Prior studies have validated the anatomical precision of 3-D models created with Mimics. 20

Mimics was also used to digitize in 3-D the glenoid components from the Bigliani-Flatow Shoulder System (Zimmer Biomet). Glenoid components of 3 different sizes (40 mm, 46 mm, 52 mm) were used. (The Bigliani glenoid component was digitized, as this implant system was used for primary TSA in all 24 patients.) Each glenoid component was traced in 3-D with a Gage 2000 coordinate-measuring machine (Brown & Sharpe) and was processed with custom software. The custom software, cited in previous work by our group, 17 created the same coordinate system for each scapula based on anatomical reference points. These digitized 3-D images of glenoid components were uploaded with the digitized 3-D scapulae derived from patients’ CT scans to the Magics software. Magics allows for manipulation and interaction of multiple 3-D models by creating electronic stereolithography files that provide 3-D surface geometry.

Three fellowship-trained shoulder surgeons and

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