Radiographic comparison of flat-back and convex-back
glenoid components in total shoulder arthroplasty
Istvan Szabo, MD,a Florent Buscayret, MD,b T. Bradley Edwards, MD,c Chantal Nemoz, PhD,d
Pascal Boileau, MD,e and Gilles Walch, MD,b Pécs, Hungary, Lyon and Nice, France, and Houston, TX
The purpose of this study was to compare the radio-
graphic results of 2 different glenoid component de-
signs. This series consisted of 66 shoulder arthroplas-
ties with primary osteoarthritis divided into 2 groups
based on glenoid component type. One group com-
prised shoulders receiving cemented flat-back polyeth-
ylene glenoid implants. The other group comprised
shoulders receiving cemented convex-back polyethyl-
ene glenoid implants. Immediate postoperative and
2-year postoperative radiographs were evaluated for
the presence and progression of periglenoid radiolu-
cencies, and the 2 groups were compared. Radiolu-
cent line scores were calculated and compared for
each group. The keeled, convex-back glenoid compo-
nent was radiographically better than the keeled, flat-
back glenoid component. (J Shoulder Elbow Surg
2005;14:636-642.)
T otal shoulder arthroplasty has been established as
an effective procedure for the treatment of degenera-
tive and inflammatory arthropathies of the glenohu-
meral joint. Consistent pain relief and improved mo-
bility have been documented in many series of
From the aDepartment of Orthopaedic Surgery, University of Pécs
School of Medicine, Pécs, bDepartment of Orthopaedic Surgery,
Clinique Sainte Anne Lumière, and dDepartment of Biostatistics,
Hôpitaux de Lyon, Lyon, cFondren Orthopedic Group, LLP, Hous-
ton, and eDepartment of Orthopaedic Surgery, Hôpital de
l’Archet, Nice.
One or more of the authors has received or will receive benefits for
personal or professional use from a commercial party related
directly or indirectly to the subject of this article. In addition,
benefits have been or will be directed to a research fund,
foundation, educational institution, or other nonprofit organiza-
tion with which one or more of the authors is associated. Funds
were received in total or partial support of the research or clinical
study presented in this article. The funding source was a grant
from the Association pour le Développement de la Pathologie de
l’Épaule.
Reprint requests: T. Bradley Edwards, MD, Fondren Orthopedic
Group, LLP, 7401 S Main St, Houston, TX 77030-4509 (E-mail:
bemd@fondren.com).
Copyright © 2005 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2005/$30.00
doi:10.1016/j.jse.2005.05.004
*References 3, 5, 6, 8, 11, 12, 17, 18, 21, 25, 26.
636
patients.3,7,8,18 A major concern in total shoulder
arthroplasty is the presence and progression of radio-
lucencies at the glenoid component– cement– bone
interface, although the clinical significance of this
finding has been reported less frequently. The fre-
quency of periglenoid component radiolucencies var-
ies between 30% and 96%, and progression of
radiolucent lines occurs with increasing length of
follow-up.* Several studies have reported a direct
relationship between the presence of radiolucent lines
and the development of radiographic or clinical loos-
ening.3,8,12
Others have compared the biomechanical behav-
ior of different glenoid components in an effort to
design the optimal glenoid implant.2,10,13 Prosthetic
glenoid design parameters such as implant material,
implant shape, method of fixation, and the use of
metal backing have been evaluated by means of
experimental studies. Despite an abundance of these
studies, there remains no consensus for the ideal
glenoid component design. Furthermore, it remains
unclear which type of component (cemented or unce-
mented, keeled or pegged, convex back or flat back)
yields the lowest loosening rate and hence the best
potential for good long-term results. The purpose of
this study was to compare the radiographic results of
2 different glenoid component designs by analyzing
periglenoid radiolucencies. Although biomechanical
reports have demonstrated preferential performance
of convex polyethylene glenoid components over
their flat-back counterparts,2,13 this is the first in vivo
study to investigate whether convex-back glenoid im-
plants have a lower incidence and progression of
periglenoid component radiolucencies.
MATERIALS AND METHODS
The study group included primary total shoulder arthro-
plasties performed by the 2 senior authors using a single
type of shoulder arthroplasty system. All patients in this
series underwent shoulder arthroplasty for primary osteoar-
thritis, as described by Neer,16 during 1997 to 1999. To
maintain a pure series of primary osteoarthritis, shoulders
with an inflammatory arthropathy (rheumatoid arthritis, sys-
temic lupus erythematosis, ankylosing spondylitis), osteo-
chondromatosis, acromegaly, Paget’s disease, postinfec-
tious arthropathy, skeletal dysplasia, neurologic problems
J Shoulder Elbow Surg
Volume 14, Number 6
(Charcot’s arthropathy, Parkinson’s disease), and osteone-
crosis (posttraumatic, radiation-induced, idiopathic) were
excluded. Additional exclusion criteria included any shoul-
der with a history of shoulder trauma (fracture or soft-tissue
injury), instability (surgically or nonsurgically treated), or a
prior shoulder surgery. Lastly, shoulders with marked rotator
cuff pathology as indicated by acromiohumeral arthritis, a
massive rotator cuff tear, or a rotator cuff tear involving the
infraspinatus as displayed on imaging or at the time of
surgery were excluded, because it could not be concluded
that the etiology of the disease was primary glenohumeral
osteoarthritis. Further inclusion criteria included a complete
preoperative radiographic evaluation including an antero-
posterior radiograph, as well as computed tomographic
arthrography, for analysis of the rotator cuff and glenoid
morphology. Patients with glenoid bone erosion requiring
bone grafting at the time of arthroplasty were excluded. All
patients during this study period underwent glenoid bone
preparation with the compaction technique as described by
Gazielly.4 With this technique, rather than removing can-
cellous bone, the glenoid component was implanted after
the cancellous bone was compacted with a glenoid punch
of the same dimensions as the keel. For inclusion, patients
were required to have an immediate postoperative antero-
posterior radiograph (within 3 days of surgery) and a
2-year postoperative anteroposterior radiograph available.
All patients had complete operative records and a minimum
2-year follow-up without revision surgery for reasons other
than component fixation problems.
In total, 66 arthroplasties performed in 63 patients met
the criteria for inclusion. The mean age at the time of the
surgery was 67.3 years (range, 43-83 years). Of the
patients, 25 were men and 38 were women. The operation
involved the dominant extremity in 36 cases, and 3 patients
were ambidextrous. Of the 63 patients, 19 underwent
bilateral arthroplasty; however, both shoulders met inclu-
sion criteria in only 3 (1 woman and 2 men). The reasons
for exclusion of the remaining 16 cases were an incomplete
set of postoperative radiographs (1 case), insufficient
follow-up (10 cases), insertion of a glenoid component of a
design other than the types being studied (2 cases with a
metal-back uncemented glenoid component), use of a dif-
ferent glenoid preparation technique (burr with curettage)
(2 cases), and arthroplasty for an etiology other than pri-
mary osteoarthritis (1 case of rotator cuff tear arthropathy).
By use of the preoperative computed tomographic ar-
throgram with subsequent surgical confirmation, the rotator
cuff was found to be intact in 56 shoulders whereas 4 had
an articular-side partial-thickness supraspinatus tear and 8
had a small (⬍1 cm) full-thickness supraspinatus tendon
tear, none of which were repaired at the time of arthro-
plasty. Bursal-side partial-thickness tears were not evaluated
in this study because it is not possible to diagnose these
tears with arthrography and we do not expose the bursal
surface of the rotator cuff during shoulder arthroplasty (ie,
we do not perform a subacromial bursectomy). Glenoid
morphology was determined by the classification of Walch
et al22 as follows: A1 in 34 cases, A2 in 1 case, B1 in 11
cases, B2 in 17 cases, and C in 3 cases.
All patients in this series underwent primary total shoul-
der arthroplasty by use of the Aequalis prosthesis (Tornier,
Mont Bonnot, France). Seven different sizes of prosthetic
Szabo et al 637
humeral head diameter, varying between 39 mm and 50
mm, were used, and 3 different sizes of glenoid compo-
nents were used with radii of curvature of 27.5 mm, 30 mm,
and 32.5 mm. The flat-back and convex-back, polyethyl-
ene, pear-shaped glenoid components used in this study are
equipped with a keel that is 4 mm thick and 15 mm in length
and is designed for cementation into the medullary canal of
the glenoid. The dimensions of the keel are the same for all
glenoid component sizes. The manufacturer’s recommenda-
tion states that a preferential association exists for this
prosthetic system (head sizes 39/14 and 41/15 are best
coupled with a small glenoid, head sizes 43/16 and
46/17 are best coupled with a medium glenoid, and head
sizes 48/18, 50/16, and 50/19 are best coupled with a
large glenoid). However, the system permits the use of any
head size with any glenoid size, resulting in a radial
prosthetic mismatch between 0 and 12 mm.23
An identical surgical technique was used in all patients.
In all shoulders the glenoid keel slot was prepared by
compacting the cancellous bone with a glenoid punch of
the same dimensions of the keel of the glenoid implant. The
first group (35 shoulders) underwent glenoid resurfacing
with a cemented flat-back, polyethylene glenoid component
(Figure 1, A). The second group (31 shoulders) underwent
glenoid resurfacing with a cemented convex-back, polyeth-
ylene glenoid component (Figure 1, B). The type of implant
was randomly selected by the operating surgeon at the time
of the procedure without any specific indication. With the
numbers available, no statistically significant differences
existed between the groups with regard to follow-up, pa-
tient age, patient gender, patient hand dominance, rotator
cuff condition, glenoid morphology, or glenohumeral pros-
thetic mismatch.
All radiographs in this series were performed via a
standardized fluoroscopic technique, such that the x-ray
beam was perpendicular to the plane of the implant-bone
interface, determined by use of a wire marker embedded in
the polyethylene as described by Kelleher et al.11 Three
independent observers evaluated the radiographs on 3
different occasions with specific emphasis on the presence
and progression of radiolucent lines at the bone-cement
interface. The extent of radiolucent lines—whether complete
or incomplete and whether affecting the faceplate (the
portion of the glenoid implant perpendicular to the keel), the
keel, or both—was analyzed. Radiolucencies were consid-
ered to be present when identified by at least 2 of 3
observers.20
Glenoid radiolucencies were scored according to the
previously validated system of Molé et al15 by use of
anteroposterior radiographs (0 points for no radiolucency
to 18 points for radiolucencies exceeding 2 mm in 6
zones). A numeric value was assigned to each zone as
determined by the thickness of the radiolucent line in that
zone—that is, 0 points for no radiolucent line, 1 point for a
radiolucent line less than 1 mm thick, 2 points for a radio-
lucent line at least 1 mm thick but less than or equal to 2 mm
thick, or 3 points for a radiolucent line more than 2 mm
thick. The scores for each zone were added to yield the total
radiolucent line score (Figure 2). In addition, the radiolu-
cent line scores were also calculated in the 3 zones of the
keel and in the 3 zones of the faceplate by use of the same
method, creating the keel radiolucent line score and the
638 Szabo et al J Shoulder Elbow Surg
November/December 2005

Figure 1 Two different glenoid components used in study: flat-

back design (A) and convex-back design (B).

faceplate radiolucent line score. Radiographic data ob-

tained were used to determine the interobserver and in-
traobserver reliability of the radiolucent line score evalua-
tion. Whereas the intraobserver reliability was found to be
good (10% contribution of total variance and 80% ␬ coef-
ficient), the interobserver reliability was less satisfactory
(52% contribution of total variance and 39% ␬ coefficient),
suggesting subjectivity of the radiolucent line score analy-
sis. To minimize this subjectivity, the mean of the 9 radiolu-
cent line scores for each radiograph (3 observers evaluat-
ing each radiograph on 3 different occasions) was used in
the evaluation of glenoid component radiolucencies.
The 2 groups of patients with different glenoid implants
were compared regarding the presence and extent of radio- Figure 2 Technique of Molé et al15 for formulation of radiolucent
lucent lines (whether complete or incomplete and whether line (RL) score. A, Six zones for evaluation. B, Representative
affecting the faceplate or keel), the radiolucent line score, radiograph. C, Tabulation of radiolucent line score for this
the progression of radiolucent lines around the entire gle- example.
J Shoulder Elbow Surg Szabo et al 639
Volume 14, Number 6

noid component, the progression of radiolucent lines

around the keel, and the progression of radiolucent lines
behind the faceplate. In addition, factors that could poten-
tially contribute to the development of radiolucent lines
(patient gender, patient age, patient hand dominance,
condition of the rotator cuff, glenoid morphology, compo-
nent size, glenohumeral component mismatch) were ana-
lyzed.
Standard statistical methods were used. Descriptive sta-
tistics, including means and SDs, or counts and percentages
were calculated. In the evaluation of quantitative values,
analysis of variance was performed to determine statistical
significance. If the variance between groups was unequal,
the Wilcoxon nonparametric test was used to determine
significance. For qualitative values, the ␹2 test was used.
The Pearson correlation coefficient was calculated to eval-
uate correlation between several entities. The influence of
various factors on the presence and progression of radiolu-
cent lines was analyzed by use of a multifactorial analysis
of variance. Significance was set at P ⬍ .05.

RESULTS
On the immediate postoperative radiographs, no
radiolucent lines were observed in any zone around
the glenoid components in 9 of 35 shoulders (26%) in
the flat-back group and 20 of 31 (65%) in the convex-
back group (P ⫽ .006). When present, radiolucency
was incomplete in all cases. A statistically significant
association existed between the glenoid component
type and the incidence of radiolucency under the
faceplate on the immediate postoperative radio-
graphs. Of the cases with a radiolucent line present
on the immediate postoperative radiographs, radiolu-
cent lines of any thickness and extent were found
under the faceplate in 22 of 35 shoulders (63%) in the
flat-back group and only 9 of 31 (29%) in the convex-
back group (P ⫽ .01). No differences existed with the
numbers available between the groups regarding
immediate radiolucencies around the keel.
On the 2-year postoperative radiographs, radiolu-
cent lines in at least 1 zone of any thickness were
observed around all glenoid components. Radiolu-
cent lines were incomplete in 29 of 35 shoulders
(83%) in the flat-back group and in 28 of 31 (90%) in
the convex-back group; this difference was not signif-
icant with the numbers available. On the 2-year post-
operative radiographs, radiolucent lines were limited
to the faceplate in 15 of 35 shoulders (43%) in the
flat-back group and in 18 of 31 (58%) in the convex-
back group; this difference was not significant with
the numbers available (Figures 3-5).
On the immediate postoperative radiographs, the
mean total radiolucent line score was 1.67 in the
flat-back group and 0.98 in the convex-back group
(P ⬍ .0005). The mean keel radiolucent line score
was 0.26 in the flat-back group and 0.32 in the
convex-back group; this difference was not significant
with the numbers available. The mean faceplate ra-
Figure 3 Immediate postoperative radiograph (A) and 2-year
postoperative radiograph (B) with flat-back glenoid component.
Note the radiolucency behind the faceplate. No progression is
noted during the follow-up period.
diolucent line score was 1.41 in the flat-back group
and 0.66 in the convex-back group (P ⬍ .0005). On
the immediate postoperative radiographs, no signifi-
cant differences were discovered between the 2
groups with the numbers available in superior-zone (1
and 2) radiolucencies or inferior-zone (4 and 5)
radiolucencies.
On the 2-year postoperative radiographs, the
mean total radiolucent line score was 4.19 in the
flat-back group and 3.23 in the convex-back group
(P ⫽ .02). The mean keel radiolucent line score was
1.33 in the flat-back group and 1.14 in the convex-
back group; this difference was not significant with
the numbers available. The mean faceplate radiolu-
cent line score was 2.86 in the flat-back group and
2.09 in the convex-back group (P ⬍ .0005). On the
2-year postoperative radiographs, no significant dif-
ferences were discovered between the 2 groups with
the numbers available in superior-zone radiolucen-
cies or inferior-zone radiolucencies.
640 Szabo et al
Figure 4 Immediate postoperative radiograph (A) and 2-year post-
operative radiograph (B) with convex-back glenoid component.
To analyze the progression of the radiolucencies,
differences in the total radiolucent line scores be-
tween the immediate postoperative radiographs and
the 2-year postoperative radiographs were calcu-
lated for each group. The mean progression was
2.49 points in the flat-back group and 2.32 points in
the convex-back group. Progression for each group
was statistically significant (P ⬍ .0005). Statistically
significant progression occurred in both groups in the
keel radiolucent line score (1.14 points for the flat-
back group and 0.84 points for the convex-back
group, P ⬍ .0005) and the faceplate radiolucent line
score (1.49 points for the flat-back group and 1.52
points for the convex-back group, P ⬍ .0005).
Comparison of the 2 groups demonstrated similar
progression in the total radiolucent line score (P ⫽
.894), the faceplate radiolucent line score (P ⬎ .999),
and the keel radiolucent line score (P ⫽ .341).
When factors potentially contributing to the devel-
opment and progression of radiolucent lines were
analyzed, patients with a radiolucent line score be-
tween 7 and 12 points were significantly younger in
J Shoulder Elbow Surg
November/December 2005
Figure 5 Convex-back glenoid with no radiolucencies on imme-
diate postoperative radiograph (A) and faceplate radiolucency on
2-year postoperative radiograph (B).
the flat-back group and in the 2 populations overall
(P ⫽ .038), but otherwise, age had no statistically
significant influence on the immediate or 2-year
follow-up radiolucent lines scores. Progression of the
radiolucent line score was greater in younger patients
in the convex-back group (P ⫽ .012); however, this
trend was not observed in the flat-back group or in the
2 groups considered together. With the numbers
available, patient gender, patient hand dominance,
the presence of rotator cuff disease, glenoid morphol-
ogy, or glenohumeral prosthetic mismatch did not
statistically influence the frequency and size of the
immediate or 2-year glenoid radiolucencies in the 2
populations.
DISCUSSION
A major concern in total shoulder arthroplasty is
the presence and progression of radiolucent lines at
the glenoid component– cement– bone interface. Al-
though clinically significant component loosening oc-
J Shoulder Elbow Surg
Volume 14, Number 6
curs less often, several studies have reported a direct
relationship between the presence of radiolucent lines
and the development of radiographic or clinical loos-
ening.3,8,12 This study has demonstrated that the ap-
pearance of early periglenoid radiolucent lines can
be influenced by glenoid component design.
Findings in this series are not comparable to the
existing literature on glenoid radiolucencies for multi-
ple reasons. First, because this study was an early
follow-up comparison of 2 different types of glenoid
components, the length of follow-up is substantially
shorter than that in other investigations. Multiple au-
thors have demonstrated a propensity for the progres-
sion of early-appearing radiolucent lines, thus yield-
ing validity to this study despite its relatively short-term
follow-up.3,5,6,8,12,14,18,20,21 Second, lack of unifor-
mity within the literature in the classification and
grading of radiolucent lines explains the great
variability in reported prevalence. Norris and
Lachiewicz19 used a modification of a method origi-
nally described by Amstutz et al1 in which a radiolu-
cency was considered to be present only if it occupied
more than 50% of any zone, with the keel considered
as a single zone, perhaps underestimating the prev-
alence of radiolucencies. We used the system of Molé
et al15 in the evaluation of radiolucencies, which
considers the keel as 3 different zones and places no
minimum percentage value on what constitutes a ra-
diolucency in any one zone. Third, all of our patients
had fluoroscopically controlled radiographs, which
has been shown to be important for reproducibil-
ity.6,11,15 We did not evaluate radiolucencies on
axillary radiographs because of the inability to stan-
dardize these views fluoroscopically. Many existing
series evaluating glenoid radiolucencies do not use
fluoroscopic control. In a recent investigation, Lazarus
et al14 excluded a full one third of patients because of
radiographs of insufficient quality to evaluate glenoid
radiolucencies. In addition, the use of fluoroscopy
perhaps explains the substantially higher incidence of
radiolucencies in this series compared with other
series.8,12,15,17
In cases having incomplete radiolucencies, the
faceplate was the zone principally affected. Other
authors have demonstrated this phenomenon as well.
Wilde et al24 discovered that most radiolucencies
involved the faceplate region on postoperative radio-
graphs. Molé et al15 have questioned the use of
cement behind the faceplate and have stated that the
appearance of a radiolucent line in this region is
almost inevitable because of the gradient in modulus
of elasticity between polyethylene, polymethylmethac-
rylate, and subchondral bone. Collins et al9 investi-
gated factors of bone preparation that may enhance
fixation and reported that physiologic eccentric loads
can be minimized by proper reaming to ensure im-
Szabo et al 641
proved conformity between the glenoid component
and glenoid bone.
Glenoid component design can also play an im-
portant role in improving conformity between the
glenoid component and glenoid bone. Anglin et al,2
in a biomechanical study, found that convex-back
glenoid prosthetic design results in stresses being
transmitted more in compression than in shear. In
addition, they discovered that shear is better resisted
by convex-back designs. The convex-back shape also
avoids a stress concentration at the junction of the
faceplate and the keel and preserves more bone
during implantation.
Lacaze et al13 biomechanically compared flat-
back glenoid components with convex-back glenoid
components. They demonstrated superior pullout
strength with the convex-back implant, although the
difference was not statistically significant. Using ec-
centric loading studies, they further demonstrated less
tilt and displacement with the convex-back glenoid
component than with the flat-back glenoid compo-
nent.
No clinical study exists to date demonstrating the
superiority of one design over the other. In our study,
2 different polyethylene glenoid designs were radio-
graphically compared to examine the influence of the
glenoid implant design on the appearance and pro-
gression of periglenoid component radiolucencies.
The 2 groups of shoulders used to investigate these 2
different glenoid component designs were statistically
comparable and homogenous with regard to preop-
erative variables. The compaction glenoid prepara-
tion technique was used in all cases for both groups,
providing a more solid base for the glenoid keel. In
addition, the reaming technique was meticulous to
ensure improved conformity between the glenoid
component and glenoid bone as proposed by Collins
et al.9 To further minimize any confounding variables,
we included only patients with primary osteoarthritis,
as described by Neer.16
This comparative study confirms the effect of the
glenoid component design on radiolucencies occur-
ring on the immediate postoperative radiographs.
The percentage of radiolucencies in at least one area
of the glenoid component was significantly greater
with the flat-back glenoid implants. As no statistically
significant difference existed between the 2 groups in
the degree of keel involvement, it seems that radiolu-
cencies affecting the faceplate are more related to the
glenoid component design. The radiolucent line score
analysis showed a statistically significant difference
between the 2 designs in favor of the convex-back
component on the immediate postoperative radio-
graphs, demonstrating that the convex-back glenoid
component provides more conformity between the
glenoid component and glenoid bone, perhaps result-
ing in better initial fixation. The keel radiolucent line
642 Szabo et al
score was similar in the 2 groups and can be ex-
plained by use of the same glenoid preparation tech-
nique in each group.
The better radiographic results of the convex-back
glenoid component are also apparent on the 2-year
postoperative radiographs. This is most obvious in the
radiolucent line score evaluation.
In this study, the progression of radiolucencies was
similar in the 2 groups. Statistical analysis of potential
contributing factors did not yield any insight into a
potential explanation. Because this study is relatively
short term, we do not know what the long-term impli-
cations of this progression will be.
This study is not without limitations. Although the
surgical technique was standardized in this series, 2
different surgeons performed the procedures. In addi-
tion, interobserver reliability of the radiographic eval-
uation was suboptimal; however, this was combated
by use of mean radiolucent line scores. Furthermore,
the numbers available for analysis in this study were
small, perhaps hindering observation of the influence
of other factors on development of radiolucencies
reported in other investigations, such as patient gen-
der and prosthetic mismatch.21,23 We tend to agree
with O’Driscoll et al20 that the development of perigle-
noid radiolucencies and glenoid component loosen-
ing is probably multifactorial, although the numbers
in this study were insufficient to show it. Finally, it is
possible that differences observed in faceplate radio-
lucencies may have been caused by inherent differ-
ences in radiographic evaluation of flat-back glenoid
components and convex-back glenoid components.
However, we believe that these differences more
likely reflect the biomechanical advantage of convex-
back glenoid components to resist shear forces.2,13
Despite these limitations, the results suggest that gle-
noid design plays an important role in the develop-
ment of periglenoid radiolucencies during short-term
follow-up.
In conclusion, this is the first clinical study to dem-
onstrate fewer radiolucencies with a convex-back gle-
noid component design than with a flat-back design.
Although the convex-back design had lower radiolu-
cency rates in the immediate postoperative period
and 2-year postoperative period, progression of ra-
diolucencies was similar for both designs.
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