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Does computer-assisted navigation improve baseplate screw configuration in reverse shoulder arthroplasty? A systematic review and meta-analysis of comparative studies
∗Corresponding author: Ausberto Velasquez Garcia. velasquezgarcia.ausberto@mayo.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Navigation technologies have improved accuracy and precision in positioning glenoid components during shoulder arthroplasty. The influence of navigation on baseplate screw placement has not been independently investigated. This study aimed to evaluate and synthesize the best scientific evidence on the influence of intraoperative navigation on the length and number of screws for primary baseplate fixation in reverse total shoulder arthroplasty procedures.
In August 2022, PubMed, Scopus, and Embase databases were accessed. We analyzed the screw purchase length, the number of screws required for the fixation of the baseplate, and the proportion of cases fixed with two screws in all clinical trials, comparing navigation to standard instrumentation for reverse shoulder arthroplasty. Following an evaluation of the heterogeneity of the studies, DerSimonian-Laird random-effects models were utilized to merge data from separate studies.
The systematic search revealed a total of 2034 articles. After excluding duplicates and irrelevant studies, 633 shoulder arthroplasties from 6 trials were included in the analysis. The pooled mean difference in screw purchase length was 5.839 mm (95 %CI 4.496 to 7. 182) in favor of navigation (P < .001). In addition, significant differences were also found in the number of screws per case (- 0.547, 95 %CI -0.890 to −0.203, P = .002) and in the proportion of cases fixed with two screws (Odds Ratio 3.182 95 %CI 1.057 to 9.579, P = .040) in favor of the navigation group.
Intraoperative navigation improves the baseplate screw placement, allowing for a greater screw purchase length and fewer screws to achieve primary fixation of the glenoid component during reverse shoulder arthroplasty. It is unclear whether these improvements will increase the longevity of the prosthesis or the clinical outcomes of the patients.
Keywords
Reverse shoulder arthroplasty
Computer-assisted navigation surgery
Computer-aided surgery
Preoperative planning
Baseplate fixation
Screw
2S
CT
MINORS
PRISMA
RSA
SI
SPL
1 Introduction
For patients with various shoulder pathologies, reverse shoulder arthroplasty (RSA) might reduce pain and restore mobility.1 Initial fixation and placement of the glenoid baseplate play a crucial role in the success of the RSA procedure.2–5 Several anatomical and biomechanical investigations have analyzed many features of screw implantation for optimal fixation of the glenoid component in an effort to establish technical standards.2,6–10
A significant association between screw length and higher pullout strength has been reported in the orthopedic literature.11,12 In experimental models of RSA, screw purchase length (SPL) has also been demonstrated to impact baseplate fixation and micromotion substantially.13,14 Therefore, shoulder surgeons seek to secure the baseplate with the longest screws, targeting the regions with the highest bone quality to maximize the purchase into the bone.15 However, overestimating the length of the screw during fixation can damage structures beyond the glenoid fossa, resulting in many potential complications.16 Although 4 screws might provide better fixation than 2, unnecessary screws could reduce the bone stock available to provide adequate baseplate support for the initial fixation and raise the risk of neurologic injuries, particularly if the screws are oversized or not properly positioned.17
Consequently, optimizing the configuration of peripheral screws, particularly length and number, seems crucial to attaining the strongest and most stable construction while decreasing the risk of potential injuries.7,18 Furthermore, the RSA using standard instrumentation (SI) is being improved due to the development of specific instruments to position the central peg and screws.19 On the other hand, intraoperative navigation (NAV) provides visual input to accurately guide instrument placement, allowing for visualization of a custom screw trajectory in the glenoid vault, potentially maximizing SPL, and optimizing the number of peripheral screws required for primary fixation.20
An increase in precision and accuracy in the location of the glenoid baseplate has previously been reported when NAV is used during RSA operations.21–26 However, the effects of NAV systems on the placement of the baseplate screws have not been the subject of any independent study. Therefore, the purpose of this research was to assess and synthesize the current state of evidence on the effect of intraoperative CT-based NAV on the number and length of screws used for the initial fixation of the baseplate in reverse total shoulder arthroplasty.
2 Materials and methods
2.1 Eligibility criteria
We seek articles comparing radiographic or intraoperative quantitative data related to screw implantation of the glenoid component after primary RSA with CT-based intraoperative NAV versus SI. Studies reporting robotic and imageless navigation methods or using patient-specific instrumentation were excluded. The review was carried out exclusively with clinical investigations published in peer-reviewed journals. Animal, biomechanical, computational, cadaveric, and other in vitro studies were not included. Only articles written in English were eligible. Reviews, expert opinions, letters, conference abstracts, unpublished manuscripts, and editorials were not considered. Clinical studies reporting data on RSA revisions were not considered. Eligible studies were restricted to those that provided data on relevant outcomes.
2.2 Search strategy
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines were followed throughout the study.27,28 We searched the following databases (PubMed/Medline, Scopus, and EMBASE) using specific keywords to identify possibly relevant studies: “computer-assisted surgery,” “surgical navigation,” “image-guided surgery,” “total shoulder arthroplasty,” “shoulder replacement,” “reverse shoulder arthroplasty,” “reverse total shoulder,” and “reverse shoulder.” Articles published up to and including July 2022 were considered eligible for inclusion in this study's scope. Finally, we searched the reference lists of all publications that met the study criteria and systematic reviews and meta-analyses to find any further references that could be relevant to the topic.
2.3 Selection and data collection process
A comprehensive and systematic literature review was conducted to determine whether the documents met the qualifying criteria. Automated tools were used to exclude non-English articles and animal studies. Two authors (AVG, GA) assessed and cross-checked the eligibility of the studies separately. The reviewers first examined the titles and abstracts and performed a full-text review. Any differences were addressed through discussion.
2.4 Data items and effect measures
Two separate reviewers (AVG, GA) collected the data from the included studies and entered them into a customized Microsoft Excel spreadsheet. Journal titles, authors' names, publication dates, methodologies, sample sizes, numbers of patients, and demographics were recorded throughout the research. When reported, preoperative data from relevant diagnoses were recorded. Intraoperative data, such as preoperative planning approach, navigation system, and implant type, were also recorded. The outcomes were recorded by collecting operative data on the screw configuration for the fixation of the glenoid baseplate. Specific quantitative data were analyzed using the weighted means for the SPL and the number of screws used per case. Dichotomous data (cases with two screws) were reported using Odds Ratio.
2.5 Methodological quality
Both authors (AVG and GA) independently evaluated the potential for bias and the quality of the study methodology using the Methodological Index for Non-Randomized Studies (MINORS).29 When evaluating comparative studies, a perfect score of 24 indicates the highest possible methodological quality for non-randomized research with the lowest possible risk of bias.
2.6 Synthesis methods
Data from each study were collected in a Microsoft Excel database and exported to Meta Analyst software for analysis of SPL, the number of screws per case, and the proportion of cases operated with 2 screws for the intraoperative CT-based NAV and SI groups. The pooled effect size was calculated at the 95% confidence level using the DerSimonian and Laird random effect model.30 The mean difference between the NAV and SI groups was determined to analyze continuous data. For dichotomous outcomes, the Odds Ratio was determined. The effect sizes were presented in Forest plots. Statistical significance was assumed at a P value of < .05.
2.7 Assessment of heterogenicity
Cochran's Q test (χ2)was performed to determine the degree of variation between studies.31 The inconsistency was quantified by calculating I2 and was interpreted as follows: 25% (low), 50% (medium), and 75% (high) heterogeneity.32
3 Results
3.1 Selection and characteristics of the study
Through the electronic search, a total of 2034 articles were retrieved. Nine hundred and seventy-six out of the total number of articles were duplicates or published in a language other than English. The screening of 366 titles and abstracts generated 38 publications that met the eligibility requirements for full-text review and evaluation. A total of six articles met the inclusion criteria.15,20,26,33–35 A flowchart illustrates the literature search findings, study screening, and study selection (Fig. 1). Four retrospective case-control studies and two retrospective cohort studies met our inclusion criteria. Fifty percent of the articles reported a standardized preoperative CT scan acquisition method. Five of the six studies15,26,33,34,36 did not mention whether they used preoperative CT scans for patients who underwent surgery with SI. The evaluation of glenoid baseplate screw implantation was recorded intraoperatively in most studies (83%). Table 1 summarizes the characteristics and design of the study, the individual risk of bias for each study, and the characteristics of the surgical procedure.
| Reference | Designs | MINORS | Implant design | Preoperative CT Protocol | Preoperative planning platform (NAV) | NAV system | Screw implantation assessment |
| Giorgini et al. 202133 | Retrospective case-control | 17 | Equinoxe RSP (Exactech) | NR | Equinoxe Planning App | ExactechGPS | Intraoperative navigation |
| Holzgrefe et al. 202220 | Retrospective cohort study | 19 | Equinoxe RSP (Exactech) | NR | Equinoxe Planning App | ExactechGPS | Intraoperative navigation |
| Hones et al. 202134 | Retrospective cohort study | 18 | Equinoxe RSP (Exactech) | NR | Equinoxe Planning App | ExactechGPS | Intraoperative navigation |
| Moreschini et al. 202015 | Retrospective case-control study | 17 | Equinoxe RSP (Exactech, | Standardized | Equinoxe Planning App | ExactechGPS | Intraoperative navigation |
| Nashikkar et al. 201926 | Retrospective case-control study | 20 | Equinoxe RSP (Exactech) | Standardized | Equinoxe Planning App | ExactechGPS | PostoperativeCT scan (Intraosseous length) |
| Sprowls et al. 202135 | Retrospective case-control study | 18 | Equinoxe RSP (Exactech) | Standardized | Equinoxe Planning App | ExactechGPS | Intraoperative navigation |
3.2 Demographic information
The total number of RSA procedures included was 663 (329 NAV and 334 SI). A standard deltopectoral approach was used in all cases in which a surgical approach was documented. Table 2 summarizes the demographic of the articles included.
| Number of shoulders | Mean age ± SD (range) | Female (%) | Surgical indications | ||||
| Reference | NAV | SI | NAV | SI | NAV | SI | |
| Giorgini et al. 202133 | 18 | 15 | 75 (62–87) | NR | 77.78 | NR | OA, RA, RCA post-traumatic arthritis, locked posterior dislocation, proximal humeral fracture, two-stage revision arthroplasty. |
| Holzgrefe et al. 202220 | 113 | 113 | 71 ± 7.8 | 71 ± 8.1 | 51.38 | 50.44 | OA, MIRCT, RCA |
| Hones et al. 202134 | 100 | 100 | 70 (28–87) | 70 (49–87) | 45 | 45 | OA, RCA, AVN, MIRCT, post-traumatic arthritis, proximal humeral fracture, chronic dislocation. |
| Moreschini et al. 202015 | 20 | 20 | 75 ± 5.9 (58–84) | 72 ± 4.9 (64–80) | 85 | 80 | Eccentric shoulder OA or RCA |
| Nashikkar et al. 201926 | 27 | 23 | 72 | 73 | 51.85 | 47.83 | OA, RCA |
| Sprowls et al. 202135 | 51 | 63 | 72 ± 7.1 | 72 ± 7.1 | 45.10 | 60.90 | RCA, proximal humeral fracture, hardware complication, chronic shoulder dislocation |
3.3 Results of syntheses
Four studies directly compared SPL using intraoperative NAV versus SI during RSA.15,33–35Table 3 shows the pooled data of the included patients and the weighted means of SPL. In the three studies eligible for meta-analysis,15,33,35 the final effect was significantly different (5.839 mm; 95 %CI 4.496 to 7. 182; P < .001) between the two groups (Fig. 2), showing a higher SPL in the NAV group.
Fewer screws were required to fix the baseplate in the NAV group. Four studies compared the number of screws used per case during RSA guided by NAV (284 cases) versus SI (293 cases)15,20,34,35 (Table 3). The final effect was statistically significant (- 0.547; 95 %CI -0.890 to −0.203; P = .002), indicating the difference between the two groups in the three studies included in the meta-analysis15,20,35 (Fig. 3).
The proportion of cases in which only 2 screws were necessary to fix the baseplate was compared in two studies.15,35 Most patients (73%) operated with CT-based NAV required only 2 screws for baseplate fixation. In less than half (49%) of the cases operated with SI, the baseplate was also fixed using only 2 screws (Table 3). The final effect was significantly different (Odds Ratio 3.182 95 %CI 1.057 to 9.579, P = .040) between the groups in the two studies included in the meta-analysis15,35 (Fig. 4).
Between studies, heterogeneity was not statistically significant for SPL (p = .402) with an I2 of 0% or for the proportion of cases fixed with 2 screws (p = .171, I2 = 46.61%). The heterogeneity between the studies for the number of screws per case was not statistically significant (p = .134). However, 50.16% of the variability across studies may be attributable to between-study variation.
3.4 Reporting biases
The average MINORS score for comparative clinical studies was 17.8. A total of 6 articles reporting clinical studies compared NAV with the SI technique as a control (Table 1).
4 Discussion
This systematic review and meta-analysis offers evidence that the CT-based intraoperative NAV system optimizes the configuration of the screw for the initial fixation of the glenoid component during primary RSA in terms of length and number compared to the SI technique. The success of glenoid baseplate fixation in RSA depends on the ability of the primary fixation to restrict micromotion and provide an optimal biologic environment for osseointegration.8,9,13,17,37,38
Baseplate failure is a severe complication, as it affects the longevity of the prosthesis, leading to potential revision surgery.39 Several parameters, including bone density, glenoid morphology, baseplate position, screw length, number of peripheral screws, screw angular position, and central peg length, have been considered among the factors affecting glenoid stability.14,40,41 The literature repeatedly shows that implantation of a glenoid component on a bone with a higher density significantly improves fixation.2,14 Furthermore, the positioning of the baseplate concerning the version, inclination, rotational alignment, and height continues to be the main surgeon-controlled strategy to improve the stability of the baseplate on the native glenoid41,42
However, in addition to the orientation of the baseplate and bone characteristics, the number and length of peripheral screws used to achieve primary fixation of the baseplate have a significant impact on long-term stability, especially in older patients, generally osteoporotic, in whom the RSA procedure is performed more frequently.13,14,17,42 Optimal screw placement has been defined as maximizing screw length, achieving far cortical fixation, and ensuring screw purchase in good bone stock.43 Despite the wide variety of implant sizes and designs, the required screw length and the optimal number of screws for fixation in RSA are not well-defined.13
In general, longer screws have been found to provide significantly better fixation before and after cyclic loading tests.13,14 In an RSA in vitro model, Roche et al. found that 18 mm screws allow much more loosening of the baseplate than 30 mm or 46 mm screws.13 Loosening under superoinferior loading was also much higher for larger sizes of the glenoid component fixed with 30 mm screws compared to those with 46 mm screws.13 In this systematic review and meta-analysis, we identified a considerable increase in SPL (5.8 mm) when using the NAV system compared to SI in controlled studies (P < .001). However, we cannot estimate the clinical significance of this change.
Several authors have suggested an ideal orientation for screw placement.6,37,43,44 However, due to the complex anatomy of the scapula, especially in cases where bone stock is compromised, glenoid exposure and visualization of anatomical landmarks are often challenging. As a result, proper orientation of screws towards the highly dense bone located at the base of the coracoid, the scapular spine, and the scapular pillar is challenging.19,43 Screws improperly placed can be harmful to surrounding structures.6,16 Hart et al. found that the anterior and posterior screws have a lower SPL (13 mm ± 6 and 15 mm ± 8, respectively) than the superior and inferior screws (29 mm ± 8 and 28 mm ± 7, respectively) and also pose a risk to the subscapularis muscle and suprascapular nerve and artery at the spinoglenoid notch.6
James et al. evaluated using two (placed on the upper and lower holes) and four screws in an experimental model.17 The authors found no significant variations in micromotion and displacement between the two groups.17 In a model with homogeneous bone density, Lung et al. found that increasing the number of screws from 2 to 4 did not enhance the initial stability of the baseplate.14 However, there is no agreement on the ideal number of screws needed for the fixation of the baseplate, as conflicting results were reported in other biomechanics models that evaluated this variable.13–15
Because a higher number of screws can decrease the bone stock available for baseplate fixation,14 the increased the risk of neurovascular complications,6,16 and the fact that recent evidence suggests that the inferior and superior screws are the longest and most important to resist micromotion,14 an approach has been adopted that seeks optimal fixation using a lower number of peripheral screws, to decrease possible soft tissue damage and complications.
In this study, the NAV system increased efficiency in reducing the number of screws necessary for fixation per case (0.5 fewer screws, P = .002). In the included studies, surgeons tried to place the fewest number of peripheral screws determined by intraoperative implant stability assessment.15,20,35 We believe that the certainty about the screw trajectory and the ability to achieve greater length provided by the NAV system may increase surgeon confidence in fixation with fewer implants. Although a possible reduction in surgical time34 and cost could be suggested by reducing the number of implants, this approach's ultimate clinical and economic impact could not be determined in this study.
Our study has potential limitations. First, as with any meta-analysis, the validity of our findings depends on the validity of the primary research. The level 3 design of the included articles reflects their associated limitations and potential biases. Specifically, there were no randomized controlled trials included. Moreover, the absence of randomization increases the risk of bias and allocation. Second, although there are few publications in this field, the clinical heterogeneity was relatively limited. Furthermore, our formal assessment of heterogeneity revealed that a meta-analysis of the available data is doable and valid.
Third, stratification by glenoid version and morphology has not been possible. Stratified outcome studies may be valuable in finding effective intraoperative approaches for various patterns of glenoid version. Fourth, the studies, except one, did not include clinical follow-up. Thus, the clinical outcomes and postoperative complications are unknown. Finally, we did not investigate the impact of the NAV procedures on the duration of surgical time. Additionally, these novel techniques must demonstrate greater survivability and long-term functional outcomes to establish a cost-effectiveness analysis.
5 Conclusions
Intraoperative CT-based NAV improves the screw placement of the glenoid baseplate, providing greater SPL and using fewer screws to achieve primary fixation during RSA. The magnitude of improvement in NAV over SI was significant; however, it is unclear whether these improvements will enhance prosthesis longevity or patient functional results.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Informed consent
N/A.
Institutional ethical committee approval
N/A (no individual patient data/details required as this is a systematic review and meta-analysis).
Authors statement
Ausberto Velasquez Garcia: Conceptualization, Formal Analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing - Original Draft, Writing - Review & Editing, Visualization, Project Administration.
Glen Abdo: Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Visualization, Writing - Original Draft, Writing - Review & Editing, Visualization.
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