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

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.

Does the proximal humeral bone quality influence alignment after reverse total shoulder arthroplasty with short humeral stems?

PURPOSE

When compared to standard-length humeral stem in reverse total shoulder arthroplasty (RTSA), short humeral stems in RTSA require good proximal humeral metaphyseal bone quality to gain proper and secure fixation during prosthetic implantation. Shorter humeral stems potentially carry more risk of misalignment than standard or long humeral stems. The hypothesis was that misalignment of the short humeral stems is influenced by regional bone quality.

METHODS

RTSA with a short curved humeral stem with neck-shaft angle (NSA) default of 132.5° was reviewed. The study group included 35 cases at a mean age of 75.97 (± 6.23) years. Deltoid-tuberosity index (DTI) was measured to evaluate proximal humeral bone quality. The deltoid tuberosity index was measured at immediately above position of the upper end of the deltoid tuberosity. Stem alignment was given by the angle measured in degrees between the intramedullary humeral shaft axis and the axis of the humeral implant stem.

RESULTS

The patient's mean DTI was 1.37 ± 0.16 (median, 1.32; range, 1.12-1.80). 22 patients had poor bone quality (DTI < 1.4), compared to 13 patients with acceptable bone quality (DTI > 1.4). After RTSA, ten humeral components (29%) were neutrally aligned, whereas 25 humeral components (71%) were misaligned. There was no correlation between misalignment and DTI (r = 0.117; p = 0.504). But there was a strong correlation between misalignment and the patient's own NSA (r = - 0.47; p = 0.004). The postoperative stem position and stem misalignment are not associated with functional outcomes (p > 0.05).

CONCLUSION

The misalignment of the short curved humeral stem frequently occurs. Poor reginal humeral bone quality does not influence misalignment after RTSA with a short humeral stem. Postoperative stem alignment is associated with the patient's preoperative NSA and method of neck cut. The misalignment does not affect functional outcomes for midterm follow-up. Further long-term follow-up studies are needed to confirm its clinical relevance.

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.

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.

Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty

INTRODUCTION

Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss.

MATERIALS AND METHODS

We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value (SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version.

RESULTS

Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6 years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up.

CONCLUSION

Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

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.

Validation of the distal filling ratio in uncemented convertible short-stem shoulder arthroplasty

INTRODUCTION

Radiographic stress shielding is a common finding in uncemented convertible short-stem shoulder arthroplasty (UCSSSA). The distal filling ratio (DFR) has been described as a predictor for the occurrence of stress shielding. A DFR > 70% was mentioned as a risk factor for the occurrence of stress shielding for some UCSSSA. However, measurements were only performed on conventional radiographs and no validation exists for 3D automated planning tools.

METHODS

DFR was manually measured on postoperative true ap radiographs of 76 shoulder arthroplasties using a standardized protocol and were compared to preoperative CT scans with an automated calculation of the DFR after virtual implantation of the stem.

RESULTS

The mean DFR measured on X-rays was 75.9% (SD = 8.7; 95% CI = 74-78) vs. 78.9% (SD = 9.1; 95% CI = 76.8-83) automatically measured on CT scans. This difference was significant (p < 0.001). In 7 out of 76 cases (9%) the difference between manual measurement on radiographs and computerized measurement on CT scans was > 10%.

CONCLUSION

Manual measurement of the DFR is underestimated on conventional radiographs compared to automated calculation on CT scans be a mean of 3%. Therefore, automated measurement of the DFR on CT scans seems to be beneficial, especially in cases with osteopenic cortices. Manual measurement of the DFR on conventional ap radiographs in cases without CT scans, however, is still a viable alternative.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Outcomes of different stem sizes in shoulder arthroplasty

Background

The successive refinement in implant design and operative technique alongwith improved understanding has resulted in increased incidence of total shoulder arthroplasty (TSA). Simultaneously, the indications of TSA have widened and include a range of shoulder pathologies.

Methods

Using the keywords and relevant literature, we have described an overview of the different stem sizes used in shoulder arthroplasty. Relevant description of clinical and radiological outcome is done with regards to different stem sizes.

Discussion

There are plethora of shoulder replacement systems, based on unique philosophy and having their own advantages and disadvantages. Additionally, the rise in ageing population had increased the need for revision TSA, thereby necessitating the judicious choice of implant at primary TSA. We further present the role of cemented and uncemented humeral stems and discuss the findings of finite element analysis. The choice of humeral stem size and use of cemented or uncemented stems have been reported to affect the clinical and radiological outcomes.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

Assessment of intraoperative bleeding in reverse shoulder arthroplasty - with or without a stem

INTRODUCTION

The functional results of stemless reverse shoulder prostheses are similar to those with stems. However, the operative time and the bleeding appear less significant because of the absence of humeral reaming. To date, the data amongst the literature regarding this subject is limited. Thus, we report a retrospective evaluation on these 2 types of prostheses by assessing their respective intraoperative blood loss.

HYPOTHESIS

Reverse shoulder arthroplasty without a stem leads to less blood loss, compared to arthroplasty with a stem.

MATERIALS AND METHODS

Twenty-three patients underwent an operation for a stemless prosthesis, while 37 patients had a prosthesis with a stem. The hemoglobin was measured preoperatively, as well as postoperatively. Drainage of the operative site was maintained for two to three days. In the stem group, the preoperative hemoglobin was 14g/dL (11.7-16.6), while it was 13.1g/dL (11-15.8) in the stemless group.

RESULTS

The intraoperative bleeding reached 223cm³ (80-530), with an operative duration of 81minutes (40-110) in the stemless group, compared to 260cm³ (50-1000) and 92minutes (33-110) in the stem group. On the first day postoperatively, 333cm³ (20-570) of blood had been collected by drainage for the stemless group, compared to 279cm³ (40-550) in the stem group. The amount decreased the second day, with 139cm³ (20-510) and 129cm³ (0-750) respectively. There was no difference between the two groups regarding the postoperative hemoglobin level (11g/dL).

DISCUSSION

There is no significant difference concerning the blood loss between reverse shoulder replacements with and without stems.

LEVEL OF EVIDENCE

III Retrospective case control study.

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.

The Evolution of Reverse Total Shoulder Arthroplasty-From the First Steps to Novel Implant Designs and Surgical Techniques

Purpose of Review: The purpose of this review is to summarize recent literature regarding the latest design modifications and biomechanical evolutions of reverse total shoulder arthroplasty and their impact on postoperative outcomes. Recent findings: Over the past decade, worldwide implantation rates of reverse total shoulder arthroplasty have drastically increased for various shoulder pathologies. While Paul Grammont’s design principles first published in 1985 for reverse total shoulder arthroplasty remained unchanged, several adjustments were made to address postoperative clinical and biomechanical challenges such as implant glenoid loosening, scapular notching, or limited range of motion in order to maximize functional outcomes and increase the longevity of reverse total shoulder arthroplasty. However, the adequate and stable fixation of prosthetic components can be challenging, especially in massive osteoarthritis with concomitant bone loss. To overcome such issues, surgical navigation and patient-specific instruments may be a viable tool to improve accurate prosthetic component positioning. Nevertheless, larger clinical series on the accuracy and possible complications of this novel technique are still missing.

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.

Anatomic and Reverse Stemless Shoulder Arthroplasty: Functional and Radiological Evaluation

Background

Stemless shoulder arthroplasty was developed to restore the glenohumeral centre of rotation without violation of the humeral shaft. It allows the preservation of humeral bone stock. Complications related to stem malalignment and periprosthetic fractures can be avoided.

Patient and methods

This is a prospective observational study that reports outcomes of 46 patients who received stemless shoulder arthroplasty “Comprehensive Nano implant ®.” The series includes Group (A): 30 anatomic and one hemiarthroplasty. Group (B): 15 reverse stemless replacement. Functional outcomes were assessed by visual analog score (VAS), satisfaction, range motion, Constant score, and American Shoulder and Elbow Score (ASES).

Results

The mean follow-up was 40.4  ±  12 months (range, 24 months to 60 months). Group (A): VAS and satisfaction improved by 5.3 and 67.5 points respectively. Constant score significantly improved from 28.5  ±  14.5 to 62.5  ±  23 P = <0.001. The radiological assessment showed the mean centre of rotation (COR) deviation was 2.8  ±  1.9 mm. 27% of patients have COR discrepancy of more than 4 mm. In Group (B), patients reported a significant improvement in VAS, Satisfaction, and ASES P  =  0.002, 0.002, and 0.003, respectively.

Complications include shoulder pain with progressive loss of movements, aseptic loosening early subscapularis rupture, glenohumeral dislocations, and humeral component migration.

Conclusion

Anatomic Stemless total shoulder arthroplasty offers acceptable results and improvement of overall functional outcomes.

Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review

Introduction

The reverse shoulder arthroplasty is nowadays a treatment option for a variety of shoulder problems. As its incidence rose, also the number of complications increased, including intraoperative fractures.

Significance

We performed a systematic review and critical analysis of the current literature following the PRISMA guidelines. Our purpose was to: 1) determine incidence, causes, and characteristics of intraoperative fractures; 2) evaluate their current treatment options, possible related complications, reoperation rates, and the patients’ outcome; and 3) determine the overall incidence of each complication related to reverse shoulder arthroplasty. The articles were selected from PubMed medical database in April 2020 using a comprehensive search strategy. Rayyan software was used to support the selection process of the records. A descriptive and critical analysis of the results was performed.

Results

The study group included a total of 13,513 reverse shoulder arthroplasty procedures. The total number of complications was 1647 (rate 12.1%). The most common complication was dislocation (340 cases, rate 2.5%). Forty-six studies reported a total of 188 intraoperative fractures among the complications (rate 1.4%). The intraoperative fracture rate was 2.9% and 13.6% in primary and revision settings, respectively. There were 136 humeral fractures, 60% of them occurred in revision RSAs, during the removal of the previous implant, and involved the shaft in the majority of cases (39%). Glenoid fractures were 51 and occurred mostly during the reaming of the glenoid. We observed 7 further related complications (rate of 4%) and 3 reoperations (rate of 1.5%). The outcome was satisfactory in the majority of cases.

Conclusions

A comprehensive review on intraoperative fractures in reverse shoulder arthroplasties is presented. Results suggest favorable outcomes for all treatment methods, with a modest further complication rate. This investigation may aid in the treatment decision-making for these complications.

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.

Mechanical complications and fractures after reverse shoulder arthroplasty related to different design types and their rates: part I

The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.Zumstein et al defined a 'complication' following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient's final outcome.High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture. Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039.

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.

Accelerated rehabilitation following reverse total shoulder arthroplasty

BACKGROUND

Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks.

MATERIALS AND METHODS

Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically.

RESULTS

Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization).

CONCLUSION

Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

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.

Reverse total shoulder arthroplasty clinical and patient-reported outcomes and complications stratified by preoperative diagnosis: a systematic review

OBJECTIVE

This systematic review aimed to investigate differences in clinical outcomes, patient-reported outcomes (PROs), and complication types and rates among preoperative diagnoses following reverse total shoulder arthroplasty (RTSA): rotator cuff tear arthropathy, primary osteoarthritis, massive irreparable rotator cuff tear, proximal humeral fracture, rheumatoid arthritis (RA), and revision of anatomic arthroplasty (Rev).

LITERATURE SEARCH

Three electronic databases were searched from inception to January 2020.

STUDY SELECTION CRITERIA

The inclusion criteria were (1) patients with a minimum age of 60 years who underwent RTSA for the stated preoperative diagnoses, (2) a minimum of 2 years' follow-up, and (3) preoperative and postoperative values for clinical outcomes and PROs.

DATA SYNTHESIS

Risk of bias was determined by the Methodological Index for Non-randomized Studies tool and the modified Downs and Black tool. Weighted means for clinical outcomes and PROs were calculated for each preoperative diagnosis.

RESULTS

A total of 53 studies were included, of which 36 (68%) were level IV retrospective case series. According to the Methodological Index for Non-randomized Studies tool, 33 studies (62%) showed a high risk of bias; the 3 randomized controlled trials showed a low risk of bias on the modified Downs and Black tool. RTSA improved clinical outcomes and PROs for all preoperative diagnoses. The Rev group had poorer final outcomes as noted by a lower American Shoulder and Elbow Surgeons score (69) and lower pain score (1.8) compared with the other preoperative diagnoses (78-82 and 0.4-1.4, respectively). The RA group showed the highest complication rate (28%), whereas the osteoarthritis group showed the lowest rate (1.4%).

CONCLUSION

Studies in the RTSA literature predominantly showed a high risk of bias. All preoperative diagnoses showed improvements; Rev patients showed the worse clinical outcomes and PROs, and RA patients showed higher complication rates. The preoperative diagnosis in RTSA patients can impact outcomes and complications.

Outcome of a metaphyseal reverse total shoulder replacement in rheumatoid arthritis

AIM

To assess the clinical and radiological results of a metaphyseal reverse total shoulder arthroplasty (rTSA) without diaphyseal stem, in rheumatoid arthritis (RA) patients.

METHODS

Forty-five shoulders in 36 consecutive RA patients (2005-2015) underwent rTSA with a bone impaction technique. Patients were assessed clinically and radiographically preoperatively, at 3 weeks, 3 months, 6 months, 12 months post-operatively, and yearly thereafter, using constant score (CS), pain score, subjective shoulder value (SSV) and patient satisfaction score.

RESULTS

Forty-four shoulders with mean follow-up of 67 months (range 24 m-146 m (12y)) were available for follow-up. Mean age at surgery was 68.7 years (range 39-86). CS improved from 17.5 ± 10.5(SD) (age/sex adjusted 23.9 ± 14.5(SD)) preoperatively to 60.9 ± 17.4 (SD) (age/sex adjusted 86.5 ± 24.5 (SD)) at last follow-up (P < 0.001). Pain score and SSV also significantly improved (p < 0.001). Mean range of movement improved to 140°active forward flexion, 134°active abduction, 47°active external rotation (AER) and 70°active internal rotation (AIR). The results were maintained over time. Combined early and late complication rate was 15.6%, which is lower than described in the literature for RA. No lucencies, loosening, subsidence or stress shielding were evident radiographically.

CONCLUSION

Metaphyseal rTSA without a diaphyseal stem is successful and safe in RA patients. Patients achieve good function and have high satisfaction rates.

LEVEL OF EVIDENCE

Case series: Level IV.

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

Use of reverse stemless shoulder arthroplasty in a patient with multiple hereditary exostosis

INTRODUCTION

Multiple hereditary exostosis (MHE) is the formation of benign, cartilage-capped bony outgrowths predominantly extending from the metaphysis of long bones that presents with reduction in growth, deformity, restricted motion, short stature and premature osteoarthritis.

AIM

To review the clinical and radiological results of a stemless reverse shoulder arthroplasty in a case of MHE.

CASE

81-year-old, right hand dominant short-statured retired male engineer with long standing shoulder pain and restricted movements on the background of an old proximal humeral fracture managed conservatively.The radiographs revealed osteoarthritis and a mal-united proximal humerus fracture on the background of MHE with 3 plane bone deformity and a lack of medullary canal.

RESULTS

The patient underwent a stemless reverse shoulder arthroplasty. At 6 months post operatively the patient had recovered well with a range of movement including: forward flexion 110°, external rotation 20° and abduction of 80°. Internal rotation remained limited to buttocks. Improved ADLIER, Subjective shoulder value and Constant Murley score compared to pre-operative figures.

CONCLUSION

The stemless humeral component relies on metaphyseal impaction for stability. When the humeral canal is malformed or in presence of malunited distal fractures, it circumvents the need of navigating a deformed diaphysis with encouraging postoperative results.

Onlay Uncemented Lateralized Reverse Shoulder Arthroplasty for Fracture Sequelae Type 1 with Valgus/Varus Malunion: Deltoid Lengthening and Outcomes

The successful treatment of proximal humeral fractures remains challenging for shoulder surgeons, and failure rates are high, regardless of initial treatment. This study aimed to analyze the clinical and radiographic midterm results of onlay lateralized cementless stem reverse shoulder arthroplasty (RSA) in patients with valgus/varus malunion proximal humerus fracture sequelae without metaphyseal osteotomy. We retrospectively studied 35 cases with the diagnosis of fracture sequelae of the proximal part of the humerus with valgus/varus malunion. The mean duration of follow-up was 4.6 years (range, 2 to 7 years), and the mean time between fracture and arthroplasty was 6 years (1 to 32 years). Seventeen patients (48.6%) had initially been treated nonoperatively. The Constant score (CS), active range of motion, and radiographs of the affected shoulders, as well as the acromion to greater tuberosity (AGT) distance and deltoid length (DL), were analyzed before surgery and at their latest follow-up. A total of thirty-three patients (94.3%) rated their outcome as very good or good. Mean CS, forward flexion, and external rotation improved significantly (p < 0.0001), as did internal rotation and pain (p < 0.05). AGT distance significantly increased postoperatively from 14.7 to 43.3 mm, as did DL from 143 to 170 mm (p < 0.05). There was no correlation between the outcomes and valgus/varus deformity, previous surgeries, or AGT distance/DL. A total of four complications occurred (11.4%): two dislocations were detected (5.7%) and successfully revised with a longer cemented stem. Onlay lateralized uncemented stem RSA improves clinical outcomes and decreases complications when treating valgus/varus malunion fracture sequelae, avoiding intraoperative technical challenges, such as tuberosities osteotomy conscious of bone loss and proper deltoid tensioning.

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.

Advances and Update on Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years.

RECENT FINDINGS

Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon's armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.

Reverse Total Shoulder Arthroplasty: Implant Design Considerations

PURPOSE OF REVIEW

Our understanding of the reverse total shoulder arthroplasty (RTSA) has grown exponentially since Grammont first introduced his design in 1985. There are a multitude of implant-related variables to consider when performing RTSA. The purpose of this article is to provide a review of these design considerations.

RECENT FINDINGS

Current literature demonstrates that the traditional Grammont prosthesis has over 90% survivorship at 10 years. Despite these promising results, there have been concerns raised over the significant rate of scapular notching observed. As a result, the traditional RTSA design has been modified to minimize this complication and maximize impingement-free motion. Modern RTSA designs with a cementless, curved, short-stemmed eccentric onlay humeral component combined with a large, lateralized glenosphere placed in 10° of inferior tilt with > 3.5 mm of inferior overhang have been found to provide excellent results. However, all implant design features must be considered on a case-by-case basis to optimize outcome for each patient. Humeral and glenoid implant design variables have evolved as the biomechanics of RTSA have been further elucidated. Consideration of these variables allows the surgeon to maximize joint efficiency, improve impingement-free range of motion, decrease the risk of scapular notching, preserve bone stock, and minimize the risk of instability.

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.

[Reversed total shoulder arthroplasty in rotator cuff defect arthropathy]

BACKGROUND

In a progredient rotator cuff tear with tendon retraction, fatty infiltration and atrophy of rotator cuff muscles the humerus cannot be centered and stabilized sufficiently in the glenohumeral joint. This leads to rotator cuff defect arthropathy as an eccentric osteoarthritis with acetabularization and wear of the acromion, as well as of the glenoid.

INDICATION

A painful pseudoparalysis of the shoulder indicates the implantation of a reversed total shoulder arthroplasty (rTSA) to reduce pain and restore active motion. The rTSA improves the motoric function of the deltoid muscle by medialization and caudalization of the center of rotation via an optimized lever arm and is also indicated in cranio-caudally centered osteoarthritis with static posterior humeral decentration due to a bi-concavely eroded glenoid.

THERAPY

Currently, humeral anatomical resection with an inclination of 135° and a humeral retrotorsion of 20-40°, in rTSA in contrast to 155° inclination, has been shown to lead to better glenohumeral motion without loss of stability. Additionally, a reduced glenohumeral offset should be restored by especially bony lateral augmentation of the glenoid. In a pre-operatively positive lag sign for external rotation caused by a rupture of the infraspinatus/teres minor tendon, a lateral latissimus/teres major muscle tendon transfer in rTSA can optimize active external rotation. The tendon of the subscapularis muscle should be re-fixated in the deltopectoral approach for rTSA whenever possible for better anterior stability of the glenohumeral joint. Larger diameters of the glenospheres have been shown to have more stability and better motion. Humeral metaphyseal metal liners with corresponding polyethylene glenospheres can avoid osteolysis of the inferior scapular neck caused by polyethylene debris due to impingement of the humeral liner at the scapular neck.

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.

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.

Acute versus delayed reverse total shoulder arthroplasty for the treatment of proximal humeral fractures in the elderly population: a systematic review and meta-analysis

BACKGROUND

Recent literature has shown that acute reverse total shoulder arthroplasty (RTSA) yields good outcomes in the treatment of displaced proximal humeral fractures, and there have also been recent studies showing that delayed RTSA can be successfully used for sequelae of proximal humeral fractures such as nonunion and malunion. The use of meta-analysis affords the opportunity to formally compare the outcomes of acute RTSA for fracture and delayed RTSA for fracture sequelae.

METHODS

We searched the MEDLINE, Embase, and Cochrane Library databases. We included all studies reporting on RTSA for the treatment of proximal humeral fracture sequelae with a comparison group of acute RTSA or with no comparison group in adults with a mean age older than 65 years and at least 2 years of follow-up. We calculated weighted mean differences for range of motion, standardized mean differences for clinical outcome scores, and relative risks for dichotomous outcomes.

RESULTS

Sixteen studies met the inclusion criteria, which comprised 322 patients undergoing RTSA for fracture sequelae. Of these studies, 4 were comparative (46 patients) whereas 12 were case series (276 patients). Among studies directly comparing acute versus delayed RTSA, no differences in forward flexion (P = .72), clinical outcome scores (P = .78), or all-cause reoperation (P = .92) were found between the 2 groups. Patients undergoing delayed RTSA achieved 6° more external rotation than those undergoing acute RTSA; this difference was significant (P = .01).

CONCLUSIONS

Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome.

Postoperative radiographic findings of an uncemented convertible short stem for anatomic and reverse shoulder arthroplasty

BACKGROUND

Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA.

METHODS

There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio.

RESULTS

At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014).

CONCLUSIONS

The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Cementless metaphyseal reverse shoulder arthroplasty: our preliminary experience

Reverse shoulder arthroplasty (rTSA) is a largely used procedure with a wide variety of indications. The incidence of this surgery is increased in recent years and the literature expects similar trend for the future. Metaphyseal stem rTSA seems to be a promising solution considering major objectives the preservation of humeral bone stock and ease of revision. In our study we analyzed 19 patients treated with cementless metaphyseal stem rTSA for osteoarthritis (group A) and acute fractures (group B). In group A (7 patients) the average Constant score improved from 21,57 (16-29) to 56,85 (38-72), the average SST improved from 2,29 (1-4) to 9,43 (8-12) and the mean VAS score improved from 14,29 to 4,86. In group B (12 patients) the mean Constant-Murlay score at last follow up was 42,17; the average SST was 7 and average pain score was 8,92. Overall active range-of-motion (ROM) improved significantly. Surgical considerations, clinical (analyzing Constant score and Simple Shoulder Test) and radiological short-term outcomes are encouraging, with low rate of complications. Long term follow-up studies are necessary to confirm our findings and the potential benefits related to these implants. (www.actabiomedica.it)

Grammont humeral design versus onlay curved-stem reverse shoulder arthroplasty: comparison of clinical and radiographic outcomes with minimum 2-year follow-up

BACKGROUND

There are few investigations comparing lateralized and medialized reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy. This study assessed the outcomes of 2 RTSA designs.

METHODS

Sixty-eight consecutive cuff tear arthropathy patients (74 shoulders) with a follow-up of at least 24 months received a Grammont or an onlay curved short-stem humeral component, with or without glenoid lateralization; a cementless humeral stem was implanted in >90%. Clinical outcome measures included active range of motion (anterior and lateral elevation, external and internal rotation), pain, and the Constant-Murley score. Radiologic outcomes included radiolucency, condensation lines, cortical thinning, spot weld, loosening and subsidence, and tuberosity resorption for the humeral component and radiolucency, scapular notching, formation of scapular bone spurs, ossifications, and loosening for the glenoid component.

RESULTS

Both prostheses provided significant differences between preoperative and postoperative scores and showed a similar complication rate. Scapular fractures were found only in the patients who received the curved short-stem implant. Glenoid bone grafting did not significantly affect clinical scores. Both implants provided similar postoperative shoulder mobility, even though the lateralized curved stem was associated with higher delta scores for external rotation (P = .002) and lower rates of scapular notching (P = .0003), glenoid radiolucency (P = .016), and humeral bone remodeling (P = .004 and P = .030 for cortical thinning and spot weld, respectively).

CONCLUSIONS

Medialized and short-stem lateralized RTSA implants provided similar midterm clinical outcomes and range of motion. The curved short stem was associated with higher delta scores for external rotation and a lower rate of radiographic risk factors.

Reverse shoulder arthroplasty for type 1 sequelae of a fracture of the proximal humerus

Aims

The aim of this study was to analyze the results of reverse shoulder arthroplasty (RSA) in patients with type 1 sequelae of a fracture of the proximal humerus in association with rotator cuff deficiency or severe stiffness of the shoulder.

Patients and Methods

A total of 38 patients were included: 28 women and ten men. Their mean age at the time of arthroplasty was 73 years (54 to 91). Before the RSA, 18 patients had been treated with open reduction and internal fixation following a fracture. A total of 22 patients had a rotator cuff tear and 11 had severe stiffness of the shoulder with < 0° of external rotation. The mean follow-up was 4.3 years (1.5 to 10). The Constant score and the range of movement of the shoulder were recorded preoperatively and at final follow-up. Preoperatively, radiographs in two planes were performed, as well as CT or arthro-CT scans; radiographs were also performed at final follow-up.

Results

The mean Constant score improved from 25 points (5 to 47) preoperatively to 57 points (15 to 81) postoperatively. The mean forward elevation of the shoulder increased from 73° (10° to 130°) preoperatively to 117° (15° to 170°) postoperatively. Previous surgery did not influence the outcome. Patients with rotator cuff tears had lower Constant scores than patients without (p = 0.037). Those with preoperative stiffness of the shoulder had lower postoperative external rotation compared with patients without stiffness (p = 0.046). There was no radiographic evidence of loosening. Three complications occurred, leading to revision surgery in two patients. In all, 17 patients rated their result as very good (45%), another 17 as good (45%), two as satisfactory (5%), and two as unsatisfactory (5%).

Discussion

RSA is an effective form of treatment for patients with type 1 sequelae of a fracture of the proximal humerus associated with rotator cuff deficiency or stiffness of the shoulder, with high rates of satisfaction. Rotator cuff tears and stiffness of the shoulder had an adverse effect on the clinical outcome. Cite this article: Bone Joint J 2018;100-B:318–23.

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.

Bilateral reverse total shoulder arthroplasty-functional outcome and activities of daily living

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs.

METHODS

Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient's satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits.

RESULTS

Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling).

CONCLUSION

Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities.