The TESS reverse shoulder arthroplasty without a stem in the treatment of cuff-deficient shoulder conditions: clinical and radiographic results

Varus-valgus alignment of humeral short stem in reverse total shoulder arthroplasty: does it really matter?

BACKGROUND

The utilization of short humeral stems in reverse total shoulder arthroplasty has gained attention in recent times. However, concerns regarding the risk of misalignment during implant insertion are associated with their use.

METHODS

Eight fresh-frozen cadaveric shoulders were prepared for dissection and biomechanical testing. A bespoke humeral implant was fabricated to facilitate assessment of neutral, varus, and valgus alignments using a single stem, and 10° was established as the maximum permissible angle for misalignments. Shift in humerus position and changes in deltoid length attributable to misalignments relative to the neutral position were evaluated using a Microscribe 3DLx system. The impingement-free range of motion, encompassing abduction, adduction, internal rotation, and external rotation (ER), was gauged using a digital goniometer. The capacity for abduction was evaluated at maximal abduction angles under successive loading on the middle deltoid. A specialized traction system coupled with a force transducer was employed to measure anterior dislocation forces.

RESULTS

Relative to the neutral alignment, valgus alignment resulted in a more distal (10.5 ± 2.4 mm) and medial (8.3 ± 2.2 mm) translation of the humeral component, whereas the varus alignment resulted in the humerus shifting more superiorly (11.2 ± 1.3 mm) and laterally (9.9 ± 0.9 mm) at 0° abduction. The valgus alignment exhibited the highest abduction angle than neutral alignment (86.2°, P < .001). Conversely, the varus alignment demonstrated significantly higher adduction (18.4 ± 7.4°, P < .001), internal rotation (68.9 ± 15.0°, P = .014), and ER (45.2 ± 10.5°, P = .002) at 0° abduction compared to the neutral alignments. Anterior dislocation forces were considerably lower (23.8 N) in the varus group compared to the neutral group at 0°ER (P = .047). Additionally, abduction capability was markedly higher in varus alignment at low deltoid loads than the neutral alignment (5N, P = .009; 7.5 N, P = .007).

CONCLUSIONS

The varus position enhances rotational range of motion (ROM) but increases instability, while the valgus position does not significantly impact ROM or instability compared to the neutral position.

Evolution of Stemless Reverse Shoulder Arthroplasty: Current Indications, Outcomes, and Future Prospects

Reverse total shoulder arthroplasty (rTSA) is increasingly being used as a reliable option for various shoulder disorders with deteriorated rotator cuff and glenohumeral joints. The stemless humerus component for shoulder arthroplasties is evolving with theoretical advantages, such as preservation of the humeral bone stock and decreased risk of periprosthetic fractures, as well as clinical research demonstrating less intraoperative blood loss, reduced surgical time, a lower rate of intraoperative fractures, and improved center of rotation restoration. In particular, for anatomical total shoulder arthroplasty (aTSA), the utilization of stemless humeral implants is gaining consensus in younger patients. The current systematic review of 14 clinical studies (637 shoulders) demonstrated the clinical outcomes of stemless rTSA. Regarding shoulder function, the mean Constant-Murley Score (CS) improved from 28.3 preoperatively to 62.8 postoperatively. The pooled overall complication and revision rates were 14.3% and 6.3%, respectively. In addition, recent studies have shown satisfactory outcomes with stemless rTSA relative to stemmed rTSA. Therefore, shoulder surgeons may consider adopting stemless rTSA, especially in patients with sufficient bone quality. However, further long-term studies comparing survivorship between stemless and stemmed rTSA are required to determine the gold standard for selecting stemless rTSA.

Radiologic, clinical, and patient-reported outcomes in stemless reverse shoulder arthroplasty at a mean of 46 months

BACKGROUND

The humeral stem can be a cause of problems in shoulder arthroplasty, for example, loss of bone stock, intraoperative and postoperative periprosthetic fractures, or postoperative infections involving the medullary canal. Therefore, stemless reverse shoulder arthroplasty (slRSA) has gained popularity, particularly in terms of preserving bone stock. However, there are limited data available on the midterm outcomes of slRSA. The objective of this study was to evaluate the clinical, radiologic, and patient-reported outcomes of slRSA at a minimum follow-up period of 2 years.

METHODS

Data on all stemless reverse shoulder prostheses implanted between January 2016 and October 2020 were collected. Patients were followed up at 6 weeks and 6, 12, and 24 months postoperatively. Clinical and radiologic data as well as patient-reported outcome measures were assessed with validated questionnaires (University of California at Los Angeles Shoulder Score [UCLA], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Quick Disabilities of the Arm, Shoulder, and Hand questionnaire [Quick-DASH], visual analog scale [VAS] for pain, Subjective Shoulder Value [SSV], and Constant-Murley score [CS]). All patients had a minimum follow-up of 2 years.

RESULTS

During the observation period, 26 shoulders in 25 patients fulfilled the inclusion criteria. The mean follow-up was 46.8 months (range 25-66). The mean age was 70.1 years (range 59.9-86.4). At the most recent follow-up, a significant improvement was noted in the ASES score (55.9 ± 19.9 vs. 85.6 ± 10.7, P < .001), SSV (44.3 ± 18.7 vs. 85.3 ± 10.4, P < .001), Quick-DASH score (40.6 ± 22.0 vs. 17.8 ± 13.9, P < .001), VAS pain score (4.6 ± 3.2 vs. 0.9 ± 1.2, P < .001), and range of motion in flexion (66 ± 53 vs. 154 ± 22, P < .001) as well as in the absolute (44.1 ± 18.7 vs. 83.1 ± 10.1, P < .001) and relative CS (62.1 ± 27.8 vs. 111.9 ± 13.3, P < .001). Scapular notching was observed in 16% of cases, and radiolucent lines were detected in 28% of cases without symptoms of implant loosening. No revision was necessitated by any causes related to the stemless humeral component. Hence, implant survivorship was 100%.

CONCLUSIONS

With an ASES score showing a 30-point improvement and thus exceeding the minimal clinically important difference of 21 points and no revisions due to the stemless component, these results indicate that slRSA is a viable option, providing good to excellent midterm outcomes that are comparable to those of stemmed reverse shoulder prostheses, with the added advantage of bone stock preservation.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery.

METHODS

A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded.

RESULTS

There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear.

CONCLUSION

This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Influence of lateralized versus medialized reverse shoulder arthroplasty design on external and internal rotation: a systematic review and meta-analysis

BACKGROUND

Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA.

METHODS

We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model.

RESULTS

Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°-44°] vs. 27° [22°-32°], P<0.001) and postoperative improvement in ER (20° [15°-26°] vs. 10° [5°-15°], P<0.001). Lateralized implants with subscapularis repair or medialized implants without subscapularis repair had significantly greater postoperative ER and postoperative improvement in ER compared to globally medialized implants with subscapularis repair (P<0.001 for both). Mean postoperative IR was reported in 56% (n=18) of studies and achieved the minimum necessary IR in 51% of lateralized (n=325, 5 cohorts) versus 36% (n=177, 5 cohorts) of medialized implants.

CONCLUSIONS

Lateralized RSA produces superior axial rotation compared to medialized RSA. Lateralized RSA with subscapularis repair and medialized RSA without subscapularis repair provide greater axial rotation compared to medialized RSA with subscapularis repair. Level of evidence: 2A.

Does the stemless reverse arthroplasty compare to a conventional stemmed implant? Clinical and radiographic evaluation at 2 years' minimum follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a well-recognized treatment for many shoulder conditions, including rotator cuff arthropathy, primary glenohumeral joint arthritis, and rheumatoid arthritis, and can be used in both trauma and revision settings. Over the past 10 years, its popularity in New Zealand has been increasing, with a 6%-7% annual growth rate during this period. Stemless RSA designs have the following proposed advantages: They can preserve humeral bone stock, they can limit periprosthetic fractures, and they can be indicated in patients with abnormal diaphyseal humeral anatomy. To date, only 1 study has evaluated the outcomes of the Lima SMR Stemless implant. We present our data with an aim to report how the stemless reverse arthroplasty compares to a conventional stemmed implant.

METHODS

We performed a retrospective review of a consecutive series of patients treated at a single institution between 2015 and 2020. The endpoint was defined as final follow-up at a minimum of 2 years. Patients were excluded from the final analysis if they underwent revision. Thirty-three patients were identified as having undergone stemless RSA. Thirty patients had patient-reported outcome measures and radiographs at a minimum of 2 years' follow-up. Three patients had undergone revision within 2 years. The same sample size of stemmed RSAs (n = 33) was selected for comparison.

RESULTS

A total of 60 patients were included in the final analysis, of whom 30 underwent stemless RSA and 30 underwent stemmed RSA. The demographic characteristics of the 2 groups were comparable except age at operation, which showed a statistically significant difference (P = .001): 77 years (stemmed) vs. 65 years (stemless). The mean Oxford Shoulder Score was 40.1 in the stemless group vs. 40 in the stemmed group. The mean American Shoulder and Elbow Surgeons score was 72.9 in the stemless group vs. 79 in the stemmed group. Patient-reported outcome measures, pain scores, and satisfaction ratings were not statistically significantly different between the 2 groups. In terms of radiographic data, subsidence was observed in 2 patients in the stemless RSA group but the patients had no clinical symptoms. Also in the stemless RSA group, 1 patient had an acromial stress fracture and 1 patient had a superficial wound infection successfully treated with oral antibiotics. In terms of revisions in the stemless RSA group, 1 patient underwent revision owing to chronic infection, 1 underwent revision as a result of a periprosthetic fracture after a fall, and 1 underwent revision for gross instability.

CONCLUSIONS

The early results of sRSA are promising, and the stemless implant shows similar outcomes to a conventional stemmed implant.

Stemless Reverse Shoulder Arthroplasty

Since the Food and Drug Administration (FDA) approval nearly two decades ago, the indications for and utilization of reverse shoulder arthroplasty (RSA) have expanded considerably. Stemless RSA designs have been used in Europe since 2005, but have only recently been introduced in domestic Investigational Device Exemption trials. Potential advantages of stemless RSA are similar to those of stemless anatomic total shoulder arthroplasty, which may include fewer shaft-related complications, avoidance of stress shielding, bone preservation, and easier revision surgery. European data support similar outcomes between certain stemless RSA prostheses compared with that of stemmed RSA implants at early and mid-term follow-up. However, long-term outcomes remain to be seen and differences exist between the stemless RSA designs used in Europe and those being studied in domestic clinical trials. An understanding of the potential advantages and disadvantages of stemless RSA, differences between existing designs, and reported clinical outcomes is prudent for the safe and meaningful implementation of this new technology in the United States.

Stemless reverse shoulder arthroplasty: clinical and radiologic outcomes with minimum 2 years' follow-up

BACKGROUND

Recently, a stemless reverse shoulder arthroplasty (RSA) design was developed to preserve bone stock. Clinical and radiologic studies of this design in larger cohorts with >100 patients are not frequent. The purpose of this study was to present the clinical and radiologic results of a newly developed stemless RSA implant. The hypothesis was that this design would provide similar clinical and radiologic results to other stemless implants, as well as stemmed implants.

METHODS

Between September 2015 and December 2019, all patients who underwent primary RSA with a stemless Easytech prosthesis were considered eligible for inclusion in this prospective multicenter study. The minimum follow-up period was 2 years. Clinical outcomes consisted of the Constant score, adjusted Constant score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Subjective Shoulder Value, and American Shoulder and Elbow Surgeons shoulder score. Radiographic parameters included radiolucency, loosening, scapular notching, and specific geometric parameters.

RESULTS

Stemless RSA was performed in 115 patients (61 women and 54 men) at 6 different clinical centers. The average age at the time of surgery was 68.7 years. The average Constant score was 32.5 preoperatively and showed significant improvement to 61.8 at latest follow-up (P < .001). The Subjective Shoulder Value also demonstrated significant improvement postoperatively (from 27.0 to 77.5, P < .001). Scapular notching was observed in 28 patients (24.3%); humeral loosening, 5 (4.3%); and glenoid loosening, 4 (3.5%). The total complication rate was 17.4%. Eight patients (4 women and 4 men) underwent implant revision.

CONCLUSION

The clinical outcomes of the examined stemless RSA seem to be comparable to those of other humeral designs; however, the complication and revision rates are higher than those of historical controls. Surgeons should proceed with caution when using this implant until longer-term follow-up data are available.

How common is nerve injury after reverse shoulder arthroplasty? A systematic review

BACKGROUND

Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.

METHODS

A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.

RESULTS

After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.

CONCLUSION

Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Stemless shoulder arthroplasty

The concept of stemless shoulder arthroplasty was born in 2005. It is now a valid option in the context of either anatomical or reverse shoulder replacement. Several questions have come up over our 15 years of using this system: How was the stemless shoulder arthroplasty concept born? It was motivated by a desire to have epiphyso-metaphyseal fixation using a corolla-shaped impacted anchor design. What are the features of commercially available stemless shoulder arthroplasty implants? The stemless anatomical implants now available have either a cage or central peg that is impacted or a system that is screwed into the epiphysometaphyseal bone. Several companies have introduced stemless reverse implants, some of which have an onlay configuration. How do the results of stemless implants compare to those of traditional stemmed implants? At a mean follow-up of 10 years, the outcomes of stemless TSA can be superimposed with those of traditional stemmed TSA. What are the advantages of stemless shoulder implants? The advantages are their simple implantation, ability to adapt to patient morphology and any malunions, various orientation angles, no stress-shielding, reduced risk of infection and bleeding and less complex revision surgery (if needed). What are the limitations or drawbacks of using stemless implants? The two main limitations are insufficient metaphyseal bone stock and poor bone quality, especially for reverse configurations. What does the future hold for stemless shoulder arthroplasty? Like with traditional stemmed implants, the longevity of stemless shoulder arthroplasty depends on its tribology, which can still be improved. In the future, a stemless implant will need to be convertible like stemmed humeral implants, and if possible, provide an inlay reverse configuration.

The Role of Humeral Neck-Shaft Angle in Reverse Total Shoulder Arthroplasty: 155° versus <155°—A Systematic Review

The aim of this study was to have updated scrutiny of the influence of the humeral neck-shaft angle (HNSA) in patients who underwent reverse shoulder arthroplasty (RSA). A PRISMA-guided literature search was conducted from May to September 2021. Clinical outcome scores, functional parameters, and any complications were reviewed. Eleven papers were identified for inclusion in this systematic review. A total of 971 shoulders were evaluated at a minimum-follow up of 12 months, and a maximum of 120 months. The sample size for the "HNSA 155°" group is 449 patients, the "HNSA 145°" group involves 140 patients, and the "HSNA 135°" group comprises 291 patients. The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. Positive outcomes are described for all the 155°, 145°, and 135° HSNA groups. Among the different implant designs, the 155° group show a better SST score, but also the highest rate of revisions and scapular notching; the 145° cohort achieve the best values in terms of active forward flexion, abduction, ASES score, and CMS, but also the highest rate of infections; while the 135° design obtains the best results in the external rotation with arm at side, but also the highest rate of fractures. High-quality studies are required to obtain valid results regarding the best prosthesis implant.

Improved Clinical Outcomes After Lateralized Reverse Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Lateralized reverse shoulder arthroplasty (RSA) has emerged as an attempt to improve on some of the drawbacks of conventional RSA, such as glenoid notching and decrease in ROM. Although this new design is being used in clinical practice, the evidence is mostly limited to case series and has not been systematically reviewed.

QUESTIONS/PURPOSES

(1) How much did patient-reported outcome measures (PROMs) and ROM improve among patients who receive a lateralized RSA implant? (2) What proportion of shoulders experience complications, revision surgery, or scapular notching?

METHODS

The PubMed and EMBASE databases were searched from database inception to January 31, 2020. We included clinical studies that reported the PROMs and/or ROM of patients with insufficient rotator cuffs undergoing RSA with a lateralized implant. All other types of studies and those including patients with fractures, instability or escape, infection, rheumatologic disease, neurologic disease, or revision surgeries as an indication for RSA were excluded. PROMs and ROM were collected and are reported as mean values and ranges. Complications, revision surgery, and scapular notching are presented as proportions. The percentage of the mean change relative to the minimum clinically important difference (MCID) was calculated using the anchor-based value for each outcome. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. The initial search yielded 678 studies; 61 full-text articles were analyzed according to our eligibility criteria. After a detailed analysis, we included nine studies that evaluated 1670 patients (68% of whom [1130] were women) with a mean age of 71.8 ± 0.6 years. The mean follow-up period was 41.1 ± 5.6 months. The mean MINORS score was 12 ± 4.

RESULTS

Active ROM improved for forward flexion (mean change 47° to 82°; MCID 12°), abduction (mean change 43° to 80°; MCID 7°), external rotation (mean change 8° to 39°; MCID 3°), and internal rotation (mean change -2 to 1 points). PROM scores also improved, including the American Shoulder and Elbow Surgeons score (mean change 20 to 50; MCID 20.9 points), Constant score (mean change 28 to 40; MCID 5.7 points), Simple Shoulder Test score (mean change 3 to 7; MCID 2.4 points), and VAS score (mean change -1.8 to -4.9; MCID -1.6 points). The proportion of shoulders with complications ranged from 0% (0 of 44) to 21% (30 of 140), and the proportion of shoulders with scapular notching ranged from 0% (0 of 76) to 29% (41 of 140). The proportion of patients undergoing revision ranged from 0% (0 of 44) to 13% (10 of 76) at short-term follow-up.

CONCLUSION

Lateralized RSA is a reasonable alternative to medialized implants for patients with rotator cuff insufficiency because it might reduce the likelihood of scapular notching without apparently compromising PROMs or ROM. More studies are required to determine whether there is a direct correlation between the amount of lateralization and PROMs or ROM.

Stemless reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials in the United States with an investigational device exception with limited data.

METHODS

A systematic review on stemless reverse total shoulder arthroplasty was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search was conducted on November 25, 2020, using the MEDLINE/PubMed, Cochrane, and Embase databases. All articles were reviewed by 2 independent evaluators, with any conflicts or issues resolved by consensus or a final decision by the senior author. The primary outcomes extracted were complications, radiographic results, and outcome scores.

RESULTS

We evaluated 10 studies that used either the Total Evolutive Shoulder System (TESS) or Verso implant. There were 430 total patients and 437 total procedures; 266 patients in the TESS group underwent a total of 272 procedures, and 164 patients in the Verso group underwent a total of 165 procedures. The mean age at the time of surgery was 73.8 years (range, 38-93 years). The mean follow-up period ranged from 6.4 to 101.6 months per study. There was an overall trend of improved clinical outcome scores, a 0.2% humeral component loosening rate, and an 11.2% complication rate.

CONCLUSIONS

This review shows that the clinical and functional outcomes following stemless or metaphyseal reverse total shoulder arthroplasty are quite promising, especially with the low rate of humeral-sided complications. There continues to be a need for additional long-term studies and randomized clinical trials.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study

BACKGROUND

The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae.

METHODS

We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded.

RESULTS

The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group.

CONCLUSION

Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Lateralization in Reverse Shoulder Arthroplasty

Indications for Reverse Shoulder Arthroplasty (RSA) have been extended over the last 25 years, and RSA has become the most frequently implanted shoulder arthroplasty worldwide. The initial Grammont design with medialization of the joint center of rotation (JCOR), placement of the JCOR at the bone–implant interface, distalization and semi-constrained configuration has been associated with drawbacks such as reduced rotation and range of motion (ROM), notching, instability and loss of shoulder contour. This review summarizes new strategies to overcome these drawbacks and analyzes the use of glenoid-sided, humeral-sided or global bipolar lateralization, which are applied differently by surgeons and current implant manufacturers. Advantages and drawbacks are discussed. There is evidence that lateralization addresses the initial drawbacks of the Grammont design, improving stability, rates of notching, ROM and shoulder contour, but the ideal extent of lateralization of the glenoid and humerus remains unclear, as well as the maximal acceptable joint reaction force after reduction. Overstuffing and spine of scapula fractures are potential risks. CT-based 3D planning as well as artificial intelligence will help surgeons with planning and execution of appropriate lateralization in RSA. Long-term follow-up of lateralization with new implant designs and implantation strategies is needed.

Clinical and radiological outcomes of a stemless reverse shoulder implant: a two-year follow-up in 56 patients

Background

Since the introduction of stemless anatomic shoulder arthroplasty, many studies have been published on anatomic implants. For reverse stemless implants, however, there are only a few clinical follow-up studies available. The current clinical case series aims to present clinical and radiological outcomes of a new stemless reverse prosthesis system (Lima Shoulder Modular Replacement stemless).

Methods

We prospectively evaluated the outcome of 56 stemless total shoulder arthroplasties in 56 patients with a mean age of 61.2 years (46-76 years) at the time of implantation at a minimum follow-up of 24 months (range 24-41 months). All patients were physically and radiologically examined. Clinical outcomes were evaluated by using the Constant-Murley Score and the Subjective Shoulder Value.

Results

The mean Subjective Shoulder Value was 84.27% at the latest follow-up. Significant improvements from preoperative to latest follow-up were documented for Constant-Murley Score (34.9 pts to 74.43 pts, P < .001) and active range of motion (abduction 72° to 130°, flexion 36° to 138°, and external rotation 16°to 28°). There was one complete loosening of the humeral component without reoperation. Radiolucency lines were observed in anteroposterior or axial radiographs at the humeral component in 23% of the cases, most of them in anteroposterior view at the calcar region. Radiolucency line findings did not affect clinical outcomes. Major complications or revisions did not occur so far.

Conclusion

At short-term follow-up, stemless reverse shoulder systems show comparable clinical and radiological outcomes compared to stemmed reverse implants in the literature.

Stemless reverse total shoulder arthroplasty: a systematic review of short- and mid-term results

INTRODUCTION

Stemless reverse total shoulder arthroplasty is used to treat rotator cuff deficient arthropathies, rheumatoid arthritis, and osteoarthritis. It has several advantages over the stemmed implant including preservation of bone stock, reduced surgical time, and easier revision.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, PubMed, and CENTRAL to retrieve all relevant studies evaluating stemless reverse total shoulder arthroplasty.

RESULTS

The literature search identified 1993 studies out of which 7 studies were included in this review; 324 patients underwent stemless reverse total shoulder arthroplasty with a weighted mean age of 74.1 (SD = 8.6, range = 38 to 93) years and a weighted mean follow-up time of 44 (SD = 6.6, range = 3 to 95) months. The included studies reported significant improvements in range of motion and functional scores comparable to stemmed reverse total shoulder arthroplasty. The weight mean flexion and abduction was (135 ± 12)° and (131 ± 12)° post-operatively, respectively. The weighted mean constant score increased from (26.7 ± 5.2) Patients (pts) to (63.0 ± 8.0) pts post-operatively. Overall complication and revision rate were 12.3% and 5.2%.

CONCLUSION

Early and mid-term results indicate stemless reverse total shoulder arthroplasty has similar clinical outcomes to stemmed reverse total shoulder arthroplasty. There was no radiological evidence of humeral loosening at the latest follow-up.

Stemless reverse total shoulder arthroplasty: a systematic review of contemporary literature

PURPOSE

Reverse shoulder prostheses are increasingly used for treatment of rotator cuff tear arthropathy and other degenerative shoulder diseases. In recent years, aiming for bone stock preservation has led to the design of metaphyseal humeral components without a stem. The aims of this study were to evaluate the complication and reintervention rates, as well as the clinical and radiographic outcomes in patients who underwent reverse shoulder arthroplasty (RSA) with stemless implants.

METHODS

A systematic review of the literature was completed until May 2020 using PubMed, EMBASE, CINAHL and Cochrane databases, according to PRISMA guidelines.

RESULTS

The literature search revealed 2942 studies, of which 13 were included in this review, with a total of 517 patients and a mean follow-up between 6.4 and 101.6 months. The total complication rate was 6.5%, while 3.3% were humeral associated complications. Finally, the rate of shoulders that underwent a reintervention was 6.7%, with 1.4% relating to a humeral component reason. Stemless RSA led to substantial improvements in patient reported outcome measures and range of motion across all studies. Scapular notching was reported in 15.2%, and lucencies around humeral component were reported in 0.8% of shoulders.

CONCLUSION

Stemless RSA resulted in low complication and reintervention rates at the mid-term follow-up. The reported clinical and radiological outcomes showed that these prostheses have at least equivalent outcomes with their stemmed counterparts. Further studies are required to investigate the long-term longevity and performance of the stemless humeral implants.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Stemless Total Shoulder: A Review of Biomechanical Fixation and Recent Results

Introduction: Anatomic total shoulder arthroplasty is the replacement of the humeral head and glenoid surfaces with the goal of replicating normal anatomy. It is commonly utilized for patients with osteoarthritis, rheumatoid arthritis, and osteonecrosis, who have decreased range of motion (ROM), persistent pain, and loss of strength. Total shoulder Arthroplasty (TSA) is the third most common joint replacement in the United States. The incidence of TSA has been increasing, some data suggest that by the year 2025, TSA incidence may rise to 439,206 operations per year. In recent years, stemless total shoulder implants have become available. Results: These implants preserve bone stock while decreasing complications such as osteolysis, stress shielding and periprosthetic fracture. Stemless implants improve anatomic reconstruction and biomechanical function of the shoulder joint. Conclusion: Increasing amounts of data suggest stemless TSA to be a safe and effective technology that will become more common in the coming year.

An update on reverse total shoulder arthroplasty: current indications, new designs, same old problems

Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures.

After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement.

Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems.

The incidence of complications such as dislocation, notching and acromial fractures has also evolved.

Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled.

Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures.

Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

Results of stemless shoulder arthroplasty: a systematic review and meta-analysis

Stemless shoulder arthroplasty relies solely on cementless metaphyseal fixation and is designed to avoid stem-related problem such as intraoperative fractures, loosening, stress shielding or stress-risers for periprosthetic fractures.

Many designs are currently on the market, although only six anatomic and two reverse arthroplasty designs have results published with a minimum of two-year follow-up.

Compared to stemmed designs, clinical outcome is equally good using stemless designs in the short and medium-term follow-up, which is also the case for overall complication and revision rates.

Intraoperative fracture rate is lower in stemless compared to stemmed designs, most likely due to the absence of intramedullary preparation and of the implantation of a stem.

Radiologic abnormalities around the humeral implant are less frequent compared to stemmed implants, possibly related to the closer resemblance to native anatomy.

Between stemless implants, several significant differences were found in terms of clinical outcome, complication and revision rates, although the level of evidence is low with high study heterogeneity; therefore, firm conclusions could not be drawn.

There is a need for well-designed long-term randomized trials with sufficient power in order to assess the superiority of stemless over conventional arthroplasty, and of one design over another.

Cite this article: EFORT Open Rev 2021;6:35-49. DOI: 10.1302/2058-5241.6.200067

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae

HYPOTHESIS

The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS).

METHODS

The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years).

RESULTS

The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018).

CONCLUSION

The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.

Prospective, Blinded, Randomized Controlled Trial of Stemless Versus Stemmed Humeral Components in Anatomic Total Shoulder Arthroplasty: Results at Short-Term Follow-up

BACKGROUND

Stemless humeral components for anatomic total shoulder arthroplasty (aTSA) have several reported potential benefits compared with stemmed implants. However, we are aware of no Level-I, randomized controlled trials (RCTs) that have compared stemless implants with stemmed implants in patients managed with aTSA. We sought to directly compare the short-term clinical and radiographic outcomes of stemless and stemmed implants to determine if the stemless implant is noninferior to the stemmed implant.

METHODS

We performed a prospective, multicenter, single-blinded RCT comparing stemless and short-stemmed implants in patients managed with aTSA. Range-of-motion measurements and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was performed. Statistical analysis for noninferiority was performed at 2 years of follow-up for 3 primary end points: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time points as secondary measures.

RESULTS

Two hundred and sixty-five shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99% of the shoulders had a primary diagnosis of osteoarthritis. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for noninferiority test, <0.0001), the proportion of shoulders without device-related complications was 92% (107 of 116) for the stemless cohort and 93% (114 of 123) for the stemmed cohort (p value for noninferiority test, 0.0063), and no shoulder in either cohort had radiographic signs of loosening. Range-of-motion measurements and ASES, SANE, and Constant scores did not differ significantly between cohorts at any time point within the 2-year follow-up.

CONCLUSIONS

At 2 years of follow-up, the safety and effectiveness of the stemless humeral implant were noninferior to those of the stemmed humeral implant in patients managed with aTSA for the treatment of osteoarthritis. These short-term results are promising given the potential benefits of stemless designs over traditional, stemmed humeral components.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

Results

The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

Conclusions

Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part I

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI).

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ² or Fisher exact test.

Results

The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04).

Conclusions

Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.

Outcomes of reverse shoulder arthroplasty using a short stem through a superolateral approach

BACKGROUND

Reverse shoulder arthroplasties have progressed in recent decades to become the most popular type of arthroplasty. Short stems with metaphyseal fixation have been developed to preserve bone stock and facilitate possible revision. Accurate positioning of these implants can be challenging using the superolateral approach.

OBJECTIVE

This study aimed to evaluate the clinical and radiologic results of reverse short-stem arthroplasties using a superolateral approach with a minimum of 2 years' follow-up.

METHODS

Between January 2015 and December 2016, a total of 76 patients underwent reverse shoulder arthroplasty surgery (79 shoulders) using a short uncemented humeral stem for shoulder arthritis with irreparable rotator cuff tear. Arthroplasties for post-traumatic osteoarthritis were excluded. Functional outcomes were assessed using Constant Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and range of motion. Radiographic analysis was used to evaluate component loosening, implant position, and implant filling ratio.

RESULTS

The mean age was 70.8 years. At a mean of 38.8-month follow-up, there were significant improvements in Constant score (44.2 to 87.9, P < .001), ASES score (36.2 to 84.3, P < .001), and VAS score (6.8 to 0.4, P < .001). Forward flexion improved from 89°to 131°(P < .001), and external rotation improved from 25° to 36°(P < .001). No evidence of periprosthetic loosening was visible. Mean varus of the humeral stem was 1°(±6°). The mean glenoidal inclination was 98°(±7°), which corresponds to a lower tilt of 8°. The average filling ratio was between 50% and 60% in both the metaphysis and the diaphysis.

CONCLUSION

The clinical results obtained in this study were satisfying, with a significantly low complication rate. Hence, short-stem reverse shoulder arthroplasty using a superolateral approach, while taking particular care to protect the deltoid, remains our method of choice.

Stemless Humeral Implants in Total Shoulder Arthroplasty

Through an iteration of various advancements, both short stem and stemless options for humeral fixation have been proposed and have shown clinical promise. The proposed benefits of a stemless humeral implant include greater bone preservation, less stress shielding, less risk of a diaphyseal stress riser, decreased surgical time, and less intraoperative blood loss. Potential downsides include the dependence on proximal bone quality for fixation, increased cost, the dependence on the strength of subscapularis fixation, and pending FDA approval for multiple implants. The purpose of this article is to review the evidence behind stemless implants including the biomechanical advantages and disadvantages, surgical technique, and clinical outcomes.

Determination of humeral inclination in stemless shoulder arthroplasty using plain radiographs

Plain radiographs of the shoulder are routinely used to assess implant orientation after shoulder arthroplasty. Recently, humeral inclination has come into focus especially in reverse stemless shoulder arthroplasty. But, in X-ray projections not exactly parallel to the base of the humeral component, the humeral inclination angle cannot be determined precisely. Therefore, we established a mathematical algorithm to calculate the humeral neck shaft angle and counterchecked the formula using plain radiographs of a sawbone model containing a humeral head prosthesis. With increasing angles of retroversion, the base of the humeral component forms an ellipse in plain radiographs. Knowing the width and length of the ellipse as well as the inclination angle in a plain radiograph, the exact inclination angle can be determined using the equation reported below. Thus, independent from the viewing angle or angle of retroversion, the inclination angle of a stemless humeral head implant can be estimated with an accuracy of ±1.5-degree deviation. The algorithm proposed may be the basis for further research on the impact of humeral inclination in stemless shoulder arthroplasty.

Stemless shoulder arthroplasty: review of short and medium-term results

Background

The number of anatomic total shoulder (TSA), hemiarthroplasty (HA), and reverse total shoulder arthroplasties (RTSA) is rapidly increasing in the United States. Stemless shoulder arthroplasty has numerous theoretical advantages, including preserved bone stock, decreased operating time, reduced rate of intraoperative humerus fracture, and flexibility of anatomic reconstruction. Only recently studies with more than 5 years of mean follow-up have become available.

Methods

The MEDLINE database was systematically queried to identify all studies reporting outcomes regarding anatomic or reverse stemless shoulder arthroplasty. Studies were categorized according to mean reported follow-up. Outcome scores and range of motion measurements were compiled. Complication and revision rates due to failure of the humeral or glenoid components were summarized.

Results

Nineteen TSA and HA studies with a total of 1115 patients were identified, with 4 studies and 162 patients with a mean follow-up between 60 and 120 months. Six RTSA studies with a total of 346 patients were identified, all with a mean follow-up between 18 and 60 months. There was a reliable improvement in outcomes compared with preoperative scores across studies. A cumulative 0.7% (8 of 1115) humeral component complication rate was found for TSA and HA components. There was a cumulative 1.7% (6 of 346) humeral complication rate for RTSA prostheses.

Conclusions

In the studies reporting similar outcome measures, there were reliable improvements on par with stemmed counterparts. Aggregate complication rates appear similar to those published in the literature for stemmed components. Evidence supporting the utility and safety of stemless designs would be strengthened by longer-term follow-up and additional prospective comparative studies.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral prosthesis without a stem: survivorship, early to mid-term clinical and radiological outcomes in a prospective study from an independent centre

INTRODUCTION

The use of reverse total shoulder arthroplasty has increased for the management of cuff-deficient glenohumeral joint arthritis and fractures. With bone preservation being a major target in reverse shoulder arthroplasty, metaphyseal humeral components without a stem were developed. The aim of this study is to present the survivorship, functional and radiological outcomes of a novel short metaphyseal prosthesis without a diaphyseal stem from an independent centre.

METHODS

Clinical function and radiological features of patients undergoing stemless reverse shoulder arthroplasty were prospectively recorded. Patients' demographics, indications for surgery, complications, functional and radiological assessment at the final follow-up as well as survivorship with the end point of revision for any reason were recorded.

RESULTS

Between 2009 and 2016, 36 patients received 37 reverse shoulder arthroplasties with the stemless Verso prosthesis. Mean age of the patients was 76.9 years. The most common indication for surgery was cuff tear arthropathy. Mean follow-up was 3 years (range 1-7 years). Oxford shoulder score improved from an average of 11 pre-operatively (range 2-19) to 44 post-operatively (range 29-48) (p < 0.0001). There was one case of a deep post-operative infection that needed washout, liner exchange with retention of the prosthesis. Radiographic analysis showed no lucencies, or stress shielding around the humeral or glenoid components. Constant score at the final follow-up was on average 63 (range 35-86). Activities of daily living with requirement for internal and external rotation score (ADLEIR) was on average 12 pre-operatively (range 0-27) and 31 post-operatively (range 18-36) (p < 0.0001). There was 100% survivorship of the prosthesis in this early to mid-term study.

CONCLUSION

This early to mid-term prospective study demonstrates excellent survivorship and radiological results of the Verso reverse shoulder replacement. It needs a simple reproducible technique, and the results have been replicated at an independent centre. This study underlines its survivorship in the early to mid-term and confirms lower incidence of complications such as instability, notching, loosening and the need for revision surgery. Most importantly, it conserves the humeral bone stock for revision arthroplasties in the future. Our results are similar to those of the currently published literature.

Long-term results of the reverse Total Evolutive Shoulder System (TESS)

INTRODUCTION

Latest trends in shoulder replacement aim at bone stock preservation. Long-term results of stemless anatomical total shoulder implants compare favourably with stemmed designs in terms of function and survivorship. The Total Evolutive Shoulder System (TESS) has been one of the first designs offering a stemless implant not only for anatomical but also for reverse total shoulder arthroplasty with optional short stem attachment in cases with poor bone quality. The aim of the present study was to evaluate long-term results of the reverse Total Evolutive Shoulder System (TESS).

MATERIALS AND METHODS

Between 2006 and 2009, 49 shoulders in 47 patients were replaced using the Biomet reverse Total Evolutive Shoulder System (TESS). 29 shoulders in 27 patients who were aged 72.4 ± 6.7 (53-88) years were available for review at a mean follow-up of 101.6 ± 24.6 (75-142) months.

RESULTS

The implant survival rate was 93.1% at 101 months (8.4 years). The overall revision rate of the TESS implant was 17.2%. No implant associated complications to the reverse corolla implant could be observed. All reverse corolla implants showed solid fixation at follow-up. Scapular notching was found in 72.3% of the shoulders. Clinical scores significantly improved at long-term follow-up (VAS from 7.5 ± 1.2 to 1.4 ± 1.5, p < 0.001; quick-DASH from 70.9 ± 12.0 to 28.9 ± 22.9, p < 0.001 and Constant score from 13.0 ± 3.7 to 60.5 ± 16.8, p < 0.001).

CONCLUSIONS

In terms of clinical scores, radiographic loosening, complication rates and implant survivorship the reverse Total Evolutive Shoulder System provides results comparable to those of conventional stemmed reverse shoulder arthroplasty.

How common are acromial and scapular spine fractures after reverse shoulder arthroplasty?: A systematic review

AIMS

Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature.

MATERIALS AND METHODS

A systematic review using the search terms "reverse shoulder", "reverse total shoulder", or "inverted shoulder" was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design.

RESULTS

The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs.

CONCLUSION

Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627-634.

Reverse shoulder arthroplasty in young patient with achondroplasia - Ten year follow up: Case report

Skeletal dysplasia in achondroplasia can affect all body joints - including the glenohumeral joint - and is prone to develop to degenerative osteoarthritis (OA). This may cause pain and mobility problems at young age. Surgical treatment is challenging due to the dysplastic anatomy of the shoulder joint - with a dysplastic deformed short humerus, a small, hypoplastic medialized glenoid and lateralized acromion - and the long life expectancy of these patients. The indications for reverse shoulder arthroplasty (RSA) evolved during years with rotator cuff tears and rotator cuff arthropathy in combination with or without glenohumeral OA as the main indicator, with good short to mid-term results. Long term results of RSA are rarely found in literature, especially in young patients. The use of a RSA in glenohumeral OA with an intact rotator cuff has rarely been reported. In this case report we present the ten-year clinical and radiographic results of a RSA for the treatment of degenerative OA with glenohumeral dysplasia in a young patient with achondroplasia.

Shoulder Arthroplasty Imaging: What's New

Background

Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes.

Method

This article is a review article declining recent imaging processes for shoulder arthroplasty.

Results

Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation.

Conclusion

Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening.

Use of a shorter humeral stem in revision reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component.

METHODS

During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2).

RESULTS

At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P < .001), with a postoperative 91% satisfaction rate as well as postoperative American Shoulder and Elbow Surgeons score of 68 and Simple Shoulder Test score of 6.7. At most recent radiographic follow-up, 1 (5%) patient had grade 3 humeral lucency.

CONCLUSIONS

Preserving bone stock through conversion to a shorter reverse humeral stem in the revision setting is a reasonable option with good short- to intermediate-term results and low rates of humeral complications. Using the shorter stem components provides adequate stability and high rates of humeral component ingrowth.

The Humeral Implant in Shoulder Arthroplasty

Humeral hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse total shoulder arthroplasty all rely on a prosthetic articular surface fixed to the proximal humerus. Humeral implant designs have changed considerably as a result of improved understanding of proximal humeral anatomy and prosthetic biomechanics. Fixed, monoblock implants have been superseded by modular implants with variable inclination, offset, version, and stem length. Press-fit designs now commonly have surface coatings that allow bony ingrowth. Metaphyseal fixation is often favored over diaphyseal fixation. Both cemented and noncemented fixation continue to be used, and each of these techniques has advantages and disadvantages. Although aseptic loosening rarely requires revision, complications, such as osteolysis, stress shielding, radiolucent lines, and proximal humeral bone loss, can occur. Humeral periprosthetic fractures continue to be a disabling complication and are difficult to manage. Innovations such as short-stemmed implants, stemless implants, and platform stems are currently under clinical investigation.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study

BACKGROUND

Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem.

METHODS

Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions.

RESULTS

Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3).

CONCLUSIONS

The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

Stemless shoulder arthroplasty-current results and designs

Stemless shoulder arthroplasty was originally introduced in 2004 by a single manufacturer. Now, over a decade later, numerous designs are available outside the USA, but as yet, only one implant has been cleared by the Food and Drug Administration (FDA) and is available for use within the USA. Often referred to as "canal sparing," these implants are designed for metaphyseal fixation to minimize humeral bone removal, avoid intraoperative and postoperative humeral fracture complications, and to decrease morbidity associated with revision operations. Recently, the second generation of stemless arthroplasty, a convertible implant allowing use in either anatomic or reverse arthroplasty configuration, was released for use outside the USA. This paper will review the available designs, reported results, and raise potential concerns for this emerging technology.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.