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Background: Mixed reality may offer an alternative for computer-assisted navigation in shoulder arthroplasty. The purpose of this study was to determine the accuracy and precision of mixed-reality guidance for the placement of the glenoid axis pin in cadaver specimens. This step is essential for accurate glenoid placement in total shoulder arthroplasty., Methods: Fourteen cadaveric shoulders underwent simulated shoulder replacement surgery by 7 experienced shoulder surgeons. The surgeons exposed the cadavers through a deltopectoral approach and then used mixed-reality surgical navigation to insert a guide pin in a preplanned position and trajectory in the glenoid. The mixed-reality system used the Microsoft Hololens 2 headset, navigation software, dedicated instruments with fiducial marker cubes, and a securing pin. Computed tomography scans obtained before and after the procedure were used to plan the surgeries and determine the difference between the planned and executed values for the entry point, version, and inclination. One specimen had to be discarded from the analysis because the guide pin was removed accidentally before obtaining the postprocedure computed tomography scan., Results: Regarding the navigated entry point on the glenoid, the mean difference between planned and executed values was 1.7 ± 0.8 mm; this difference was 1.2 ± 0.6 mm in the superior-inferior direction and 0.9 ± 0.8 mm in the anterior-posterior direction. The maximum deviation from the entry point for all 13 specimens analyzed was 3.1 mm. Regarding version, the mean difference between planned and executed version values was 1.6° ± 1.2°, with a maximum deviation in version for all 13 specimens of 4.1°. Regarding inclination, the mean angular difference was 1.7° ± 1.5°, with a maximum deviation in inclination of 5°., Conclusions: The mixed-reality navigation system used in this study allowed surgeons to insert the glenoid guide pin on average within 2 mm from the planned entry point and within 2° of version and inclination. The navigated values did not exceed 3 mm or 5°, respectively, for any of the specimens analyzed. This approach may help surgeons more accurately place the definitive glenoid component., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the timing and location of radiologic bone adaptations related to shoulder arthroplasty using a single type of cementless short-stem shoulder prosthesis., Methods: Uncemented short-stem shoulder arthroplasties were evaluated in 52 patients at a mean age of 71.6 years (range, 58.1-86.6) with a minimum clinical and radiologic follow-up of 2 years (mean, 32 months; range, 23-52 months). All radiographs were analyzed for inclination of the stem, filling ratio of metaphysis and diaphysis, bone remodeling around the stem, radiolucent lines around the glenoid, and subsidence of the humeral stem. Finally, the radiographic and clinical findings were compared between patients with low and high bone adaptations., Results: At final follow-up, no loosening, subsidence, or osteolysis was seen. High bone adaptations were present in 27 patients (51.9%). Cortical thinning and osteopenia in the medial cortex (82.7%) and spot welds in the lateral cortex (78.6%) were the most frequently occurring bone adaptations. Patients with high bone adaptations had significantly higher metaphyseal (0.60 ± 0.05 vs. 0.56 ± 0.06; P = .024) and diaphyseal filling ratio (0.66 ± 0.04 vs. 0.61 ± 0.06; P = .019) at 2-year follow-up than patients with low bone adaptations. Clinical outcome was not influenced by the radiographic changes., Conclusion: The clinical and radiologic results of the short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty. Higher filling ratios in the metaphysis and the diaphysis were significantly associated with the occurrence of high bone adaptations., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Tribocorrosion at the modular taper connections of total hip implants has been associated with trunnionosis and adverse local tissue reactions. Modularity is also widely used in shoulder arthroplasty implants, but little information exists about the potential for tribocorrosion. This study hypothesized that there would be mild or no tribocorrosion in a series of retrieved shoulder implants., Methods: A total of 28 implants with a mean implantation time of 6.2 ± 6.0 years were evaluated using a validated damage scoring method. Implant tapers on the head and stem were divided into upper (deepest) and lower zones and independently scored for fretting and corrosion damage from 1 (none) to 4 (severe)., Results: Corrosion was present on 32% of heads and 38% of stems, whereas fretting was present on 36% of heads and 46% of stems. There was significantly greater (P = .02) corrosion in the lower zone of the retrieved stems (1.4 ± 0.5) than there was in the upper zone (1.1 ± 0.3). Correlation between the head and stem corrosion for lower zone was moderate (r = 0.41; P = .04)., Discussion: Tribocorrosion was present on the heads and stems of some of the retrieved shoulder implants examined in this study. The incidence of tribocorrosion in shoulder implants was lower than in reported cases of retrieved hip implants. The greatest damage was in the lower zone of the taper, where the connection may be exposed to the surrounding joint fluid. It remains to be seen whether this leads to any clinical presentation of trunnionosis., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Increased critical shoulder angles consist of both the acromial cover and glenoid inclination and have been found in patients with rotator cuff pathology. The purpose of this study was to determine the correlation of the critical shoulder angle and glenoid inclination and to determine the difference in glenoid inclination between patients with osteoarthritis and massive rotator cuff tears., Methods: The critical shoulder angle and glenoid inclination were measured on anteroposterior radiographs, and glenoid inclination was also measured on a validated 3-dimensional computer software program of 50 shoulders undergoing primary total shoulder arthroplasty. Twenty-five shoulders had osteoarthritis and A1 glenoids, as defined by the Walch classification, and were undergoing anatomic shoulder arthroplasty. The other 25 shoulders had massive rotator cuff tears and E0 glenoids, as defined by the Favard classification. The 2 groups were compared., Results: Critical shoulder angle and glenoid inclination were significantly correlated (R(2) = 0.7426, P < .001). Shoulders with massive rotator cuff tears (E0) demonstrated increased glenoid inclination measurements than shoulders with osteoarthritis (A1). As measured by the 3-dimensional software, the massive rotator cuff group had a glenoid inclination of 13.6° ± 4.3° and the osteoarthritis group had a glenoid inclination of 4.7° ± 5.6°. When measured by anteroposterior radiographs, the average glenoid inclination was 13.6° ± 4.6° in the massive rotator cuff group and was 7.6° ± 5.01° in the osteoarthritic group ., Conclusion: Glenoid inclination is linearly correlated with the critical shoulder angle and is significantly increased in patients with massive rotator cuff tears., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The correct amount of arm lengthening in reverse shoulder arthroplasty is crucial to provide joint stability and good results. Determination has been proposed according to radiographs. However, radiographic measurements are error prone in regards to positioning of the arm with regard to the radiographic beam. The purpose of this study was to evaluate the precision of radiographic measurements compared to CT scans of the upper limb following reverse shoulder arthroplasty., Methods: Thirty patients undergoing onlay reverse shoulder arthroplasty with comparative radiographs and CT scans of both humeri were included in this study. Arm length, humeral length as well as the arm and humeral lengthening were evaluated on pre- and postoperative radiographs compared to postoperative CT scans following a previously validated protocol., Results: We found an excellent correlation for arm length and humeral length for radiographic and CT measurements (r > 0.90). The postoperative humeral and arm lengthening compared to the contralateral side was 0.1 (-1.2 to 1.2) cm and 2.8 (0.2 to 5.2) cm for the CT scans, and -0.6 (-4.1 to 2.0) cm and 1.9 (-2.3 to 5.0) cm for the radiographs. For arm lengthening, correlation coefficient was good (r = 0.7) even though radiographs indicated arm shortening in five cases whereas arm lengthening was observed on CT scans., Conclusions: Measurements on radiographs and CT scans are comparable in most of the cases. However, we observed some important variations that question the reliability of radiographic measurements in up to 20 % of cases. Therefore, a CT scan appears to be necessary in the event of postoperative complications (e.g., instability, neurological problems).

Purpose: The impacts of humeral offset and stem design after reverse shoulder arthroplasty (RSA) have not been well-studied, particularly with regard to newer stems which have a lower humeral inclination. The purpose of this study was to analyze the effect of different humeral stem designs on range of motion and humeral position following RSA., Methods: Using a three-dimensional computer model of RSA, a traditional inlay Grammont stem was compared to a short curved onlay stem with different inclinations (155°, 145°, 135°) and offset (lateralised vs medialised). Humeral offset, the acromiohumeral distance (AHD), and range of motion were evaluated for each configuration., Results: Altering stem design led to a nearly 7-mm change in humeral offset and 4 mm in the AHD. Different inclinations of the onlay stems had little influence on humeral offset and larger influence on decreasing the AHD. There was a 10° decrease in abduction and a 5° increase in adduction between an inlay Grammont design and an onlay design with the same inclination. Compared to the 155° model, the 135° model improved adduction by 28°, extension by 24° and external rotation of the elbow at the side by 15°, but led to a decrease in abduction of 9°. When the tray was placed medially, on the 145° model, a 9° loss of abduction was observed., Conclusions: With varus inclination prostheses (135° and 145°), elevation remains unchanged, abduction slightly decreases, but a dramatic improvement in adduction, extension and external rotation with the elbow at the side are observed.

Background: The aims of this study were to determine the survival of anatomic total shoulder arthroplasty with uncemented metal-backed (MB) glenoid components with a polyethylene (PE) insert in primary osteoarthritis, to assess the reasons for revision surgery, and to identify patients and diagnostic factors that influence failure rates., Methods: Between 1994 and 1999, 165 patients (mean age, 68 years) with primary osteoarthritis were treated with anatomic total shoulder arthroplasty using an uncemented MB/PE glenoid component. Outcomes were assessed both clinically and radiologically with a minimum of 2 years of follow-up. A prosthetic survival curve was constructed with the end point defined as either partial or complete revision, using 100% confidence intervals., Results: Survival rate free of revision was 46% (100% confidence interval, 32%-54%) at 12 years. At a mean follow-up of 8.5 years (range, 2-16 years), revision was required in 61 patients (37%); 80% of shoulders undergoing revision (49 of 61) had evidence of PE wear. Glenoid loosening (because of osteolysis secondary to wear debris), soft tissue deficiency, and prosthetic instability were the most common modes of failure. Younger patients and biconcave glenoids (with posterior humeral subluxation) have a negative effect on implant survival. Proximal humerus osteolysis was significantly more frequent in shoulders with PE wear. Exchange of the PE insert (with conservation of the MB tray) was possible in only 3% of the revised shoulders., Conclusion: Uncemented MB glenoid resurfacing is not a viable long-term therapeutic option because of accelerated PE wear leading to early revision surgery. Conservation of the MB tray with reinsertion of a new PE insert is rarely possible because of glenoid bone loss, implant loosening, soft tissue deficiency, and prosthetic instability. Younger patients and biconcave glenoids have a negative effect on implant survival., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Anatomic total shoulder arthroplasty (TSA) gives good outcome in the treatment of primary osteoarthritis, but it is not known whether this also applies to patients over 80 years old., Patients and Methods: We retrospectively assessed outcome in patients over the age of 80 after anatomic TSA, performed for primary osteoarthritis with a preoperative intact rotator cuff (group O, n = 32). We compared it with outcome in a group of patients under the age of 70 (group Y, n = 32). Subjective outcome, Constant score, and radiological findings were analyzed., Results: At a mean follow-up time of 7 years, there were no statistically significant differences between the groups. In group O, 24 patients were very satisfied and in group Y, 23 patients were very satisfied; the subjective shoulder value was 81% in both groups. Mean Constant score was 65 in group O and 67 in group Y. Moderate or severe radiological upper migration of the humeral head was detected in 1 patient in group O and in 3 patients in group Y. One patient in group Y was revised for glenoid loosening., Interpretation: Good to excellent results can be expected after anatomic TSA in patients over the age of 80. Our findings suggest that they have similar results to those in patients around 70 years of age.

Background: Glenoid component positioning is a key factor for success in total shoulder arthroplasty. Three-dimensional (3D) measurements of glenoid retroversion, inclination, and humeral head subluxation are helpful tools for preoperative planning. The purpose of this study was to assess the reliability and precision of a novel surgical method for placing the glenoid component with use of patient-specific templates created by preoperative surgical planning and 3D modeling., Methods: A preoperative computed tomography examination of cadaveric scapulae (N = 18) was performed. The glenoid implants were virtually placed, and patient-specific guides were created to direct the guide pin into the desired orientation and position in the glenoid. The 3D orientation and position of the guide pin were evaluated by performing a postoperative computed tomography scan for each scapula. The differences between the preoperative planning and the achieved result were analyzed., Results: The mean error in 3D orientation of the guide pin was 2.39°, the mean entry point position error was 1.05 mm, and the mean inclination angle error was 1.42°. The average error in the version angle was 1.64°. There were no technical difficulties or complications related to use of patient-specific guides for guide pin placement. Quantitative analysis of guide pin positioning demonstrated a good correlation between preoperative planning and the achieved position of the guide pin., Conclusion: This study demonstrates the reliability and precision of preoperative planning software and patient-specific guides for glenoid component placement in total shoulder arthroplasty., (Copyright © 2015. Published by Elsevier Inc.)

Background: Fracture sequelae of the proximal part of the humerus are challenging conditions, and various treatment options have been described. The purpose of this multicenter study was to analyze the clinical and radiographic outcomes as well as the complications following semiconstrained reverse total shoulder arthroplasty for the treatment of nonunion of a surgical neck fracture of the proximal part of the humerus., Methods: Thirty-two patients with a mean age of sixty-eight years (range, forty-eight to eighty-three years) managed with a reverse shoulder arthroplasty for the treatment of nonunion of a proximal humeral fracture were analyzed clinically and radiographically. The mean duration of follow-up was four years (range, two to twelve years). The Constant score, active shoulder mobility, all complications, and revision procedures were recorded., Results: The mean Constant score increased from 14.2 points (range, 2 to 35 points) to 46.6 points (range, 6 to 75 points) (p < 0.001). The mean shoulder flexion increased from 42.9° (range, 0° to 160°) to 109.7° (range, 0° to 170°) (p < 0.001), and the mean external rotation increased from 0.5° (range, -40° to 60°) to 13.1° (range, -30° to 60°) (p < 0.005). No component loosening occurred, but 50% (sixteen) of the patients had radiographic evidence of scapular notching. There were thirteen complications (41%) leading to nine revision surgical procedures (28%). The most common complication was a dislocation following reverse shoulder arthroplasty, which occurred in 34% (eleven) of the patients. An intraoperative resection of the humeral head fragment and the tuberosities was associated with increased risk of dislocation (p < 0.007)., Conclusions: Nonunions of the proximal part of the humerus can be treated with reverse shoulder arthroplasty. Although clinical outcomes improved significantly, we found an unacceptably high rate of dislocations associated with intraoperative resection of the tuberosities. The tuberosities and the attached rotator cuff should be preserved if possible to reduce the risk of dislocation after reverse total shoulder arthroplasty., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients., Methods: Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48-82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented., Results: Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery., Conclusions: Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.

Purpose: The purpose of this review is to provide a better understanding of biomechanical changes induced by reverse shoulder arthroplasty (RSA), discuss the different techniques of radiographic assessment of upper limb lengthening after RSA and determine the ideal soft tissue tension that provides the best functional outcome without increasing the risk of complications., Methods: Inclusion criteria were articles in which the primary interest was the technique of measuring upper-extremity lengthening after complications related to lengthening and its role in postoperative function; those written in English, French or German; and those that provided evidence levels I-IV relevant to search terms., Results: Seven articles met our inclusion criteria. Postoperatively, changes in humeral length varied from minus five to five millimetres, and changes in upper-extremity length varied from 15 mm to 27 mm. The acromiohumeral distance averaged 23 mm. Humeral and arm shortening increased the risk of dislocation and led to poor anterior active elevation. The type of surgical approach did not play a role in postoperative function. Subclinical neurological lesions were frequent., Conclusions: Studies in this systematic review indicate that deltoid tensioning by restoring humeral length and increasing the acromiohumeral distance is critical for adequate postoperative function and to prevent dislocation. Excessive arm lengthening should be avoided, with zero to two centimetres of lengthening being a reasonable goal to avoid postoperative neurological impairment.

Background: Our purposes were to analyze radiographic changes around humeral components and to determine the influence of these changes on the clinical outcome of shoulder arthroplasty., Methods: Three hundred and ninety-five shoulders with primary osteoarthritis were treated with a shoulder replacement and were analyzed clinically and radiographically with a standardized protocol. Radiographs were evaluated for osteolysis and stress-shielding of the proximal part of the humerus and loosening of the humeral and glenoid components. The arthroplasty configurations included (1) hemiarthroplasty with cement (thirty shoulders), (2) hemiarthroplasty without cement (thirty-six), (3) total shoulder replacement with a cemented stem and a cemented flat-backed glenoid component (eighty-nine), (4) total shoulder replacement with a cemented stem and a cemented convex-backed glenoid component (ninety-four), (5) total shoulder replacement with a cemented stem and an uncemented metal-backed glenoid component (seventy-nine), and (6) total shoulder replacement with an uncemented stem and a cemented convex-backed glenoid component (sixty-seven). The mean duration of follow-up was 8.2 years (range, four to eighteen years)., Results: The Constant score and shoulder motion were significantly greater at the latest follow-up examination than preoperatively (p < 0.001). One cemented stem loosened after a periprosthetic fracture, and another was judged to be at risk for loosening. Stress-shielding was noted only around uncemented stems in 63% of the shoulders with such stems. Osteolysis of the proximal part of the humerus occurred only with total shoulder arthroplasty in 43% of the shoulders. Patients with osteolysis had a poorer clinical outcome (p < 0.001). Shoulders with osteolysis around the proximal part of the humerus had more glenoid loosening and polyethylene wear (p < 0.001)., Conclusions: Glenoid issues have a substantial effect on humeral bone in shoulder arthroplasty. Polyethylene wear appears to be associated with the development of osteolysis of the proximal part of the humerus after total shoulder arthroplasty. With our implants, stress-shielding was only observed with uncemented humeral stems. The uncemented and cemented stem designs analyzed in this study appeared comparable and can be recommended for clinical use.

Background: There is little information about the long-term longitudinal outcomes of total shoulder arthroplasty. Moreover, long-term data on a single shoulder replacement system are lacking. The aim of this study was to analyze, at different time points during a follow-up period of fifteen to twenty years, the clinical and radiographic outcomes of patients treated with a third-generation total shoulder arthroplasty., Methods: Sixty-three total shoulder arthroplasties were performed in fifty-eight patients. Two patients were lost to follow-up, and sixteen patients died during the follow-up period, leaving a cohort of forty-five total shoulder arthroplasties in forty patients with a mean age of sixty-four years. Follow-up examinations were carried out at six months, one year, two years, three to four years, five to eight years, nine to fourteen years, and fifteen years or more. Preoperatively and at each follow-up visit, the Constant score as well as shoulder flexion and external rotation were assessed. Radiographs were analyzed for loosening and migration of the components at all time points., Results: There was a substantial improvement of all clinical parameters from baseline to the latest follow-up evaluation. Clinical results reached a plateau at one year, remained stable without substantial worsening for eight years, and then remained as good as the six-month results until fifteen years postoperatively. Compared with the outcomes at the six-month follow-up examination, the results were worse beyond fifteen years. The clinical outcome was not influenced by sex, age, hand dominance, glenoid morphology, glenoid loosening, or upward migration of the humeral head. Thirty-three (73%) of the forty-five shoulders had radiographic evidence of glenoid loosening at the time of final follow-up. Fourteen shoulders (31%) were revised: a soft-tissue revision was performed in one of them, and implant revision was necessary in thirteen., Conclusions: Although there is a significant and longitudinal improvement in shoulder function and pain relief after total shoulder replacement, long-term follow-up of fifteen to twenty years demonstrated a high revision rate in this cohort.

Glenoid morphology has an important impact on outcomes and complication rates after shoulder arthroplasty for primary glenohumeral arthritis. The B2 glenoid, or a biconcave glenoid with posterior humeral head subluxation, in particular has been associated with a poorer outcome with shoulder arthroplasty compared with other glenoid types. A variety of techniques may be used to address the bone deficiency and instability seen with this glenoid type. Studies suggest that total shoulder arthroplasty may have a reasonable result in the short term but be associated with a high complication rate in the mid term because of recurrence of instability and early glenoid loosening when neoglenoid retroversion is greater than 27° or posterior humeral head subluxation is greater than 80%. Particularly in older patients with a substantial B2 deformity, primary reverse shoulder arthroplasty may be a more predictable means of addressing bone deficiency and restoring stability., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The biconcave glenoid in patients with primary glenohumeral osteoarthritis represents a surgical challenge because of the associated static posterior instability of the humeral head and secondary posterior glenoid erosion. The purpose of the present study was to evaluate the clinical and radiographic results of reverse total shoulder arthroplasty for the treatment of primary osteoarthritis in patients with a biconcave glenoid without rotator cuff insufficiency., Methods: We performed a retrospective review of twenty-seven reverse shoulder arthroplasties that were performed from 1998 to 2009 for the treatment of primary glenohumeral osteoarthritis and biconcave glenoid. Eighty-one percent of the patients were female, and the mean age of the patients at the time of surgery was 74.1 years (range, sixty-six to eighty-two years). All patients had a preoperative computed tomography arthrogram to allow for the measurement of glenoid retroversion and humeral head subluxation. The mean preoperative retroversion was 32°, and the mean subluxation of the humeral head with respect to the scapular axis was 87%. Seventeen patients had a reverse shoulder arthroplasty without bone graft, whereas ten had an associated bone graft to compensate for posterior glenoid erosion. Clinical outcomes were evaluated with the Constant score and shoulder range of motion., Results: The mean duration of follow-up was fifty-four months (range, twenty-four to 139 months). The mean Constant score increased from 31 points preoperatively to 76 points at the time of the latest follow-up (p < 0.0001). Active forward flexion, external rotation, and internal rotation also significantly increased (p < 0.0001). Complications occurred in four patients (15%) and included early loosening of the glenoid component (one patient) and neurologic complications (three patients). No radiolucent lines were observed around the central peg or screws of the glenoid component. Grade-1 or 2 scapular notching was present in ten shoulders (37%). No recurrence of posterior instability was observed., Conclusions: Reverse shoulder arthroplasty for the treatment of primary glenohumeral osteoarthritis in patients with a biconcave glenoid without rotator cuff insufficiency can result in excellent clinical outcomes. Reverse shoulder arthroplasty is a viable surgical option to solve both the problem of severe static posterior glenohumeral instability and severe glenoid erosion.

Background: The purpose of this study was to examine the mid- to long-term functional outcome and implant survival of total shoulder arthroplasty (TSA) in adults aged 55 years or younger with primary glenohumeral arthritis. The hypothesis was that TSA would lead to improvement in functional outcome but that implant survival would decline between 5 years and 10 years postoperatively., Materials and Methods: Between 1992 and 2004, 52 TSAs were implanted in 8 centers for primary glenohumeral arthritis in patients aged 55 years or younger. Minimum follow-up of 5 years was available in 50 patients at a mean of 115.5 months postoperatively. Kaplan-Meier survivorship analysis was performed, and clinical outcome was assessed., Results: After TSA, adjusted Constant scores improved from 37.0% to 73.4% and forward flexion improved from 97° to 128° (P < .001). The adjusted Constant score was 80.0 in patients free of revision of the glenoid compared with 43.6 in the group requiring revision of the glenoid (P < .001). Survivorship of the glenoid component with revision surgery for glenoid loosening as the endpoint was 98% (95% confidence interval, 89.4%-100%) at 5 years and 62.5% (95% confidence interval, 40.6%-81.2%) at 10 years. Factors associated with survival of the glenoid included anatomic humeral component positioning and a compaction glenoid preparation technique., Conclusions: At 5 years' follow-up, TSA leads to improvement in functional outcome and a satisfactory implant survival rate of 98% in young adults with primary glenohumeral arthritis. However, the 10-year survival rate of TSA was only 62.5% in patients aged 55 years or younger at the time of surgery., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Hypothesis and Background: Reimplantation of a new glenoid component for symptomatic glenoid failure after total shoulder arthroplasty (TSA) is a well-established surgical strategy. In case of aseptic glenoid loosening or failure, revision of TSA by reimplantation of a cemented glenoid implant would be a reliable therapeutic option., Materials and Methods: This retrospective multicenter study included 42 TSAs with symptomatic failed glenoids revised by reimplantation of an all-polyethylene (PE), cemented glenoid component. All patients were reviewed clinically and radiologically, with a mean follow-up of 74 months., Results: The failed initial glenoid component was metal backed in 32 cases and PE cemented in 10. The main cause of glenoid failure was component loosening in 19 cases (46%) and PE wear or dissociation in 23 (54%). Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. At follow-up, the mean Constant score was 57 points (gain of 16 points) and the mean active anterior elevation was 125° (gain of 19°)., Conclusion: This study suggests that revision of a TSA with reimplantation of an all-PE cemented glenoid component does not solve the problem of glenoid loosening. Soft-tissue failure and prosthetic instability are underestimated preoperatively and may explain, in part, the high rate of recurrent glenoid loosening., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthroplasties have been limited., Materials and Methods: This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthroplasties, and 13 failed reverse TSAs., Results: Patients who underwent resection arthroplasty demonstrated significant improvement in visual analog scale pain score (6 ± 4 preoperatively to 3 ± 2 postoperatively). Mean active forward flexion and mean active external rotation decreased, but this difference was not significant. Subgroup analysis revealed that postoperative mean active forward flexion was significantly greater in patients undergoing resection arthroplasty after failed TSA than after reverse TSA (P = .01)., Conclusions: Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. Patients with resection arthroplasty for failed reverse shoulder arthroplasty have worse function than those with failed hemiarthroplasty or TSA. Surgeons should be aware of this when assessing postoperative function. There is no difference in functional outcome between hemiarthroplasty and TSA., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae., Methods: Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively., Results: Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion., Conclusions: Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

Background: Biconcave glenoids in primary osteoarthritis represent a challenge because of the associated static posterior instability of the humeral head and secondary posterior glenoid erosion. This study evaluated the influence of different preoperative radiographic measurements on the outcome of total shoulder arthroplasty (TSA), particularly regarding the development of complications., Materials and Methods: We retrospectively evaluated 92 anatomic TSAs performed in 75 patients with primary osteoarthritis and a biconcave glenoid. All patients underwent preoperative imaging with an axial computed tomography arthrogram. Measurements were taken for posterior bone erosion depth and ratio as well as humeral head subluxation. Clinical outcomes were evaluated with the Constant score., Results: At an average follow up of 77 months (range, 14-180 months), 15 revisions (16.3%) were performed for glenoid loosening (6.5%), posterior instability (5.5%), or soft tissue problems (4.3%). At the final follow-up, the mean Constant score improved significantly from 32.4 to 68.8 points (P = .0001). Subjectively, 66.3% of patients were very satisfied or satisfied. Glenoid loosening was observed in 20.6% and was significantly associated with posterior bone erosion in depth (P = .005) and wear ratio (P = .02), humeral head subluxation (P = .01), and neoglenoid (P = .002) and intermediate glenoid retroversion (P = .001). Dislocation was correlated only with neoglenoid retroversion (P = .01)., Conclusions: Performing TSA in patients with osteoarthritis and biconcave glenoids resulted in acceptable clinical outcomes but a very high rate of complications. We found that the preoperative measurement of the neoglenoid retroversion was best for predicting postoperative complications in terms of glenoid loosening and dislocation., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The goal of this study was to compare 2 consecutive series of 240 reverse total shoulder arthroplasties (TSA) in order to evaluate if the increase in surgeon experience modified the indications, clinical and radiographic results, and rate of complications., Material and Methods: Two hundred forty reverse TSA performed between July 2003 and March 2007 were clinically and radiographically evaluated by an independent examiner with a minimum follow-up of 2 years and compared with a previous published study (240 cases implanted by the same 2 surgeons between May 1995 and June 2003)., Results: The main etiology remained cuff tear arthropathy with an increase noted between the 2 studies. The rate of revision arthroplasty as an etiology decreased from 22.5% to 9.1%. Conversely, the rate of rheumatoid arthritis increased from 0.4% to 6.3%. The average postoperative Constant score was significantly better than the first series (66.9 vs 59.7, P < .001). The postoperative complication rate decreased with increased experience (from 19% to 10.8%), with dislocations reducing (from 7% to 3.2%), and infections reducing (from 4% to 0.9%). However, the number of nerve palsies increased. The revision rate decreased from 7.5% to 5%. The rate of glenoid notching remained stable, but the severity of notching decreased., Conclusion: Experience did not lead us to operate on younger patients, but significantly modified patient selection, results, and complications. Increased experience with the reverse shoulder arthroplasty did not reduce the rate of glenoid notching., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Secondary rotator cuff dysfunction is a recognized complication following shoulder arthroplasty. We hypothesized that the rate of secondary rotator cuff dysfunction would increase with follow-up and result in less satisfactory clinical and radiographic outcomes. Our aim was to investigate the rate of secondary rotator cuff dysfunction following shoulder arthroplasty for primary osteoarthritis and identify factors associated with the dysfunction., Methods: Between 1991 and 2003, in ten European centers, 704 total shoulder arthroplasties were performed for primary glenohumeral osteoarthritis. Complete radiographic and clinical follow-up of more than five years was available for 518 shoulders. The diagnosis of secondary rotator cuff dysfunction was made when moderate or severe superior subluxation of the prosthetic humeral head was present on radiographs. Multivariate logistic regression identified factors associated with the development of rotator cuff dysfunction. Kaplan-Meier survivorship analysis was performed, with the end point being secondary rotator cuff failure. Clinical outcome was assessed with use of the Constant score, a subjective assessment of the shoulder, and an evaluation of shoulder motion., Results: At an average of 103.6 months (range, sixty to 219 months) after shoulder arthroplasty, the rate of secondary rotator cuff dysfunction was 16.8%. Survivorship free of secondary cuff dysfunction was 100% at five years, 84% at ten years, and 45% at fifteen years. Duration of follow-up (p < 0.0001), implantation of the glenoid implant with superior tilt (p < 0.001), and fatty infiltration of the infraspinatus muscle (p < 0.05) were risk factors for the development of secondary cuff dysfunction. Patients with secondary rotator cuff dysfunction had significantly worse clinical outcomes (Constant score, subjective assessment, and range of motion; p < 0.0001) and radiographic results (radiolucent line score, radiographic loosening, glenoid component migration; p < 0.0001)., Conclusions: In this study, rates of secondary rotator cuff dysfunction with moderate or severe superior subluxation of the prosthetic humeral head increased with the duration of follow-up and significantly influenced the clinical and radiographic outcome of total shoulder arthroplasty performed for primary glenohumeral osteoarthritis. Preoperative fatty infiltration of the infraspinatus muscle and implantation of the glenoid component with superior tilt were prognostic factors.

Background: Reverse shoulder arthroplasty (RSA) can improve anterior active elevation (AAE) by lengthening of the deltoid and hence increasing its lever arm. However, evaluations of functional outcomes of RSA have shown variable improvements in the range of motion. The aim of our study was to correlate humeral and arm lengthening to postoperative AAE., Methods: We reviewed 183 RSAs with a minimum follow-up of 1 year. Lengthening of the humerus and the arm was evaluated in relation to the contralateral side., Results: We observed mean humeral lengthening of 0.2 ± 1.4 cm (range, -4.7 to +5.2 cm) and mean arm lengthening of 1.6 ± 1.9 cm (range, -5.1 to +5.4 cm). Postoperative AAE was 140° ± 27° (range, 30° to 180°). We found no significant correlation between lengthening or shortening of the humerus and AAE (P = .169). Shortening of the arm led to a mean AAE value of 122°; lengthening of 0 and 1 cm, mean AAE of 140°; lengthening of greater than 1 cm to 2.5 cm, mean AAE of 144°; and lengthening of greater than 2.5 cm, mean AAE of 147°. When we compared patients with lengthening of the arm and those with shortening, the postoperative AAE was significantly greater after arm lengthening, 145° versus 122°, with a mean difference of 23° (95% confidence interval, 13° to 33°) (P < .001)., Conclusion: This study shows that shortening of the arm reduced AAE. With respect to arm lengthening, a lengthening threshold was not found. An objective assessment of deltoid lengthening is possible preoperatively, intraoperatively, and postoperatively, and this measure seems to correlate with the functional outcome., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Deep infection after primary reverse total shoulder arthroplasty is a devastating event and has an increased incidence compared with anatomic total shoulder arthroplasty. Recent reports in the hip and knee arthroplasty literature suggest that antibiotic-loaded bone cement may lower infection rates for primary arthroplasties. We conducted a retrospective cohort study to evaluate the effect of antibiotic-loaded bone cement vs plain bone cement on the prevention of deep infection after primary reverse total shoulder arthroplasty., Materials and Methods: Four surgeons from their respective facilities participated in the retrospective cohort data collection. From 1999 to 2008, 501 consecutive primary reverse total shoulder arthroplasties were performed. Patients with revision of failed previous arthroplasties were excluded, and patients with any other previous shoulder procedure were included. Two groups were examined in this retrospective cohort: In group 1 (265 shoulders), the cement used for humeral fixation did not have antibiotics; in group 2 (236 shoulders), antibiotic-impregnated bone cement containing tobramycin, gentamycin, or vancomycin/tobramycin was used for fixation., Results: At an average postoperative follow-up of 37 months, no deep infection had developed in the 236 shoulders in group 2, whereas a deep infection had developed in 8 of the 265 shoulders (3.0%) in group 1. This difference between the groups was significant (P < .001)., Conclusions: Antibiotic-impregnated bone cement was effective in the prevention of postoperative deep infection after primary reverse total shoulder arthroplasty during short-term follow-up., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Introduction: Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option., Methods: Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104)., Results: Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another., Conclusion: Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The aim of this study was to radiographically analyze the long-term glenoid migration patterns following total shoulder arthroplasty to better understand the factors responsible for loosening., Methods: Complete radiographic follow-up of more than five years was available for 518 total shoulder arthroplasties performed for primary glenohumeral osteoarthritis with use of an anatomically designed prosthesis with a cemented, all-polyethylene, keeled glenoid component. Radiographs were assessed for humeral head subluxation, periprosthetic radiolucent lines, and shifting of the position of the glenoid component. The type of migration of the glenoid was defined according to the direction of tilt, or as subsidence in the case of medial migration., Results: Definite radiographic evidence of glenoid loosening was observed in 166 shoulders (32%) and was characterized by radiolucency of ≥2 mm over the entire bone-cement interface in thirty shoulders and by a migration of the glenoid component (shift or subsidence) in 136 shoulders. Three predominant patterns of migration of the glenoid component were observed: superior tilting in fifty-two shoulders (10%), subsidence in forty-one shoulders (7.9%), and posterior tilting in thirty-three shoulders (6.4%). Superior tilting of the glenoid was associated with three risk factors: low positioning of the glenoid component, superior tilt of the glenoid component on the immediate postoperative coronal plane radiographs, and superior subluxation of the humeral head (p < 0.05 for all). Subsidence of the glenoid component was associated with the use of reaming to optimize the seating and positioning of the glenoid component (p < 0.001). Posterior tilting of the glenoid component was associated with preoperative posterior subluxation (i.e., a Walch type-B glenoid) and with excessive reaming (p < 0.01 for both)., Conclusions: The three patterns of migration observed in this study underscore the potential importance of the supporting bone beneath the glenoid component. In some shoulders, use of a keel or pegs to provide fixation of a polyethylene component in the absence of good support from subchondral bone may not be sufficient to resist compressive and eccentric forces, resulting in loosening. Preserving subchondral bone may be important for long-term longevity of the glenoid component.

Reverse total shoulder arthroplasty was developed in the late 1980s for elderly patients with rotator cuff arthropathy. Several biomechanical advantages of the reverse shoulder arthroplasty result in improved deltoid function, which improves shoulder motion and function compared to other types of shoulder arthroplasty. The main indication for the reverse prosthesis is painful rotator cuff tear arthropathy. The indications for reverse shoulder arthroplasty have continued to expand since it was first performed in the United States in 2004. Although the results of reverse total shoulder arthroplasty have been generally favorable, the complication rate is higher than that of conventional total shoulder arthroplasty. Complications include those common to other shoulder procedures (infection, instability, and nerve injury) and those unique to reverse total shoulder arthroplasty (scapular notching, glenoid baseplate failure, component disassociation, and scapular stress fractures). It is helpful for orthopaedic surgeons to understand ways to avoid these complications and methods with which to treat them.

Background: Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up of 2 cemented all-polyethylene glenoid components with different backside design geometry and the effect on the presence and progression of radiolucent lines (RLLs)., Materials and Methods: Fifty-six TSAs were performed for primary osteoarthritis. Two surgeons used an identical technique to implant 32 flat-back and 24 convex-back glenoids. In particular, the glenoid components were cemented after a minimal reaming and bone compaction. Standardized postoperative radiologic and clinical follow-up was at 2 and 10 years. Three independent observers evaluated the x-ray images for RLLs around the base plate and keel. The results were analyzed for progression and influencing factors., Results: At 10 years, progression of RLL was seen in both components, but there was no difference between the 2 glenoid designs (P = .16). Younger patient age (P = .03), hand dominance (P = .017), and presence of early RLLs (P = .018) were significant factors for progression of RLLs. Constant scores deteriorated with progression of RLLs (P = .006). The glenoid revision rate at 10 years was 5%., Conclusion: At 10 years there was no difference in the presence or progression of RRLs between a flat-back and a convex-back glenoid all-polyethylene design. Young age, hand dominance, and poor implantation technique influence glenoid RLLs and affect the clinical result of TSA., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Rheumatoid arthritis affecting the shoulder is typically associated with rotator cuff compromise and can also result in severe glenoid erosion. Since reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenoid bone deficiencies, our aim was to evaluate the outcome of reverse shoulder arthroplasty in patients with rheumatoid arthritis and either or both of these associated conditions., Methods: We performed eighteen primary reverse total shoulder arthroplasties in sixteen patients with rheumatoid arthritis involving the shoulder as well as associated rotator cuff compromise and/or severe erosion of the glenoid bone between 2002 and 2007. Patients were assessed with use of the Constant score, patient satisfaction score, subjective shoulder value, range of shoulder motion, and imaging studies., Results: The mean Constant score improved from 22.5 to 64.9 points at a mean of 3.8 years (range, 2.1 to 7.0 years) postoperatively. The patients were either very satisfied or satisfied with the outcome of the surgery in seventeen of the eighteen shoulders. The mean subjective shoulder value was 68.6% postoperatively. Active forward elevation improved from 77.5° to 138.6°, and external rotation with the arm in 90° of abduction improved from 16.9° to 46.1°. The mean Constant score improved from 28.0 points to 74.3 points in shoulders in which the teres minor muscle was normal before the surgery, and it improved from 20.8 to 54.6 points in shoulders with an atrophic teres minor muscle. Scapular notching was observed in ten of the eighteen shoulders. A fracture involving the acromion, acromial spine, coracoid, or greater tuberosity was observed either intraoperatively or postoperatively in four of the eighteen shoulders. One case of transient axillary nerve injury was noted. There were no cases of dislocation, infection, or component loosening. None of the patients required revision surgery for any reason., Conclusions: Comparatively good outcomes were observed in the short to intermediate term after reverse shoulder arthroplasty in patients with rheumatoid arthritis. However, surgeons should be aware of the risk of intraoperative and postoperative fractures in this patient group.

Background: Scapular notching, erosion of the scapular neck related to impingement by the medial rim of the humeral cup during adduction, is a radiographic sign specific to reverse shoulder arthroplasty (RSA). Its clinical and radiological consequences remain unclear., Questions/purposes: Therefore, we: (1) determined the incidence of notching in a large series, (2) described the natural history of notching, (3) determined whether notching is related to functional scores or (4) radiographic signs of failure, and (5) identified factors related to notch development., Patients and Methods: We retrospectively reviewed 448 patients who underwent a Grammont-type RSA (461 shoulders) with a mean followup of 51 months (range, 24-206 months). RSA was implanted for cuff tear arthropathy or osteoarthritis with cuff deficiency. We assessed scapular notching using AP views standardized under fluoroscopy. Clinical assessment included Constant-Murley score and range of motion. Aside from notching, radiographic assessment included evaluation of humeral and glenoid radiolucent lines., Results: Notching occurred in 68% of cases. It appeared early, but its later evolution was variable. Notching was associated with followup, strength, passive and active elevation, humeral radiolucent lines, and glenoid lucent lines. It also correlated with a higher rate in patients with preoperative superior erosion., Conclusions: Scapular notching is frequent, generally progresses, and is associated with deterioration of some clinical parameters and radiolucent lines. We believe the preoperative pattern of glenoid erosion is of particular importance due to its influence on the surgeon's glenoid preparation and base-plate positioning. It is crucial to avoid cranial position and superior tilt., Levels of Evidence: Level IV, Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The development of modern shoulder replacement surgery started over half a century ago with the pioneering work done by CS Neer. Several designs for shoulder prostheses are now available, allowing surgeons to select the best design for each situation. When the rotator cuff is intact, unconstrained prostheses produce reliable and reproducible results, with prosthesis survival rates of 97% after 10 years and 84% after 20 years. In patients with three- or four-part fractures of the proximal humerus, the outcome of shoulder arthroplasty depends largely on healing of the greater tuberosity, which is therefore a major treatment objective. Factors crucial to greater tuberosity union include selection of the optimal prosthesis design, flawless fixation of the tuberosities, and appropriate postoperative immobilization. The reverse shoulder prosthesis developed by Grammont has been recognized since 1991 as a valid option for patients with glenohumeral osteoarthritis. Ten-year prosthesis survival rates are 91% overall (including trauma and revisions) and 94% for glenohumeral osteoarthritis with head migration. These good results are generating interest in the reverse shoulder prosthesis as a treatment option in situations where unconstrained prostheses are unsatisfactory (primary glenohumeral osteoarthritis with marked glenoid cavity erosion; comminuted fractures in patients older than 75 years; post-traumatic osteoarthritis with severe tuberosity malunion or nonunion; massive irreparable rotator cuff tears with pseudoparalysis; failed rotator cuff repair; and proximal humerus tumor requiring resection of the rotator cuff insertions)., (Copyright © 2010 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Background: Reverse shoulder arthroplasty requires a re-tensioning of the deltoid to obtain active elevation and implant stability. Currently, there is no objective and reliable technique described for the preoperative planning of reverse shoulder prosthesis or the postoperative evaluation of deltoid tension and arm lengthening. The purpose of this investigation was to outline a standardized technique for measuring deltoid length and to preoperatively plan a reverse shoulder arthroplasty, and to determine whether complications are related to inadequate deltoid lengthening., Methods: Fifty-eight patients were included in this radiographic review. Variations in humeral length, overall arm length, and the height of the subacromial space were evaluated before and after reverse shoulder arthroplasty., Results: The average postoperative lengthening of the humerus was 2 +/- 7 mm (range, -9-16, P = .243) and the arm was lengthened 23 +/- 12 mm (range, 1-47, P <.001). Measured preoperative and postoperative differences of the subacromial space were statistically significant when comparing the operated and contralateral arm (P < .0001). Lengthening was not correlated to sex (P = .242), acromial fractures, or neurological complications (P = .83). However, in cases of postoperative instability, both humeral and overall arm lengthening were statistically lower (P < .0001)., Conclusion: A technique to preoperatively plan adequate deltoid tensioning using radiographs of the contralateral arm is described. This technique is critical in challenging cases and postoperatively in cases of complication to assess the deltoid length. Subjective intraoperative criteria to evaluate deltoid tension should be replaced by objective measures to prevent insufficient or excessive deltoid tension., Level of Evidence: Level 3.

Background: The purpose is to report the results of reverse shoulder arthroplasty (RSA) after previous failed rotator cuff surgery., Materials and Methods: A retrospective multicenter study of 42 RSA in 40 patients (mean age, 71 years) with a mean follow-up of 50 months. Thirty shoulders presented with a pseudoparalytic shoulder and 12 with a painful shoulder with maintained active anterior elevation (AAE >or= 90 degrees)., Results: Five complications (12%) occurred and 2 patients (5%) underwent re-operation. In pseudoparalytic shoulders, AAE increased from 56 degrees to 123 degrees and 7% were disappointed or dissatisfied. In painful shoulders, AAE decreased from 146 degrees to 122 degrees and 27% were disappointed or dissatisfied., Discussion: RSA can improve function in patients with cuff deficient shoulders after failure of previous cuff surgery. However, results are inferior to primary RSA. RSA when the patient maintains greater than 90 degrees of preoperative AAE risks loss of AAE and lower patient satisfaction.

Hypothesis: Reverse shoulder prostheses depend on deltoid function. An injury to the acromion, either fracture or meso-acromion, or deltoid injury, may affect the outcomes of patients after receiving a reverse shoulder prosthesis., Methods: Four-hundred and fifty-seven consecutive reverse shoulder prostheses were implanted between January 1992 and June 2003 by one of seven surgeons in five separate centers. Forty-one patients were noted to have a pre-operative lesion of the acromion or scapular spine. Twenty-three presented with an os acromiale (meso-acromion). Seventeen had fracture or fragmentation of the acromion. One patient had a pseudarthrosis of the scapular spine., Results: Preoperative acromial pathology, surgical approach, and amount of inferior acromial tilt did not diminished postoperative range of motion, Constant score, or subjective results when compared to patients without acromial pathology. In contrast, the four patients with postoperative acromial spine fractures had inferior results with respect to functional and subjective results., Conclusion: Preoperative acromial lesions are not a contraindication to reverse shoulder arthroplasty. Postoperative fracture of the acromial spine has a significant effect on results and treatment is uncertain.

The causes and consequences of scapular notching after reverse shoulder arthroplasty (RSA) were investigated in 326 consecutive patients (337 shoulders) undergoing RSA between 1991 and 2003. Patients underwent 269 (80%) primary RSAs and 68 revisions of unconstrained shoulder prosthesis. At last follow-up (average, 47 months; range, 24-120 months) 62% had scapular notching. Notching frequency and extension were correlated to the length of follow-up (P = .0005). Notching was more frequent in cuff tear arthropathy (P = .0004), grade 3 or 4 fatty infiltration of the infraspinatus (P = .01), and narrowed acromiohumeral distance (P < .0001). Glenoids preoperatively oriented superiorly were more at risk for notching (P = .006). More notching occurred when the RSA was implanted using an anterosuperior approach vs a deltopectoral approach (P < .0001). Notching was correlated with humeral radiolucencies in proximal zones (P < .0001) and with glenoid radiolucent lines (P < .0001). Positioning of the baseplate definitely influences scapular notching. High positioning of the baseplate and superior tilting must be avoided.

A reverse total shoulder arthroplasty is a prosthesis that should be used in patients who have specific contraindications to the more conventional total shoulder prosthetic replacements. The patient and surgeon should understand that this reconstruction is technically more difficult and is associated with more complications than conventional shoulder reconstructions. The reverse total shoulder arthroplasty has been used in Europe more than in North America, and the experience in Europe is guiding its use in North America. An understanding of the mechanics of the reverse total shoulder arthroplasty and the technical details of its implantation will help in understanding its role in shoulder reconstruction.

Proximal humeral fractures occurring in elderly patients often lead to significant functional disability. The outcome of nonoperative management is disappointing. Treatment with open reduction and internal fixation may result in osteonecrosis of the humeral head, and pain. Hemiarthroplasty is often associated with tuberosity nonunion and poor function. Reverse shoulder arthroplasty is an attractive alternative because of the ability of the prosthesis to compensate for tuberosity complications. Early studies have shown promise in using the prosthesis to treat these difficult patients. The next step will require prospective, randomized studies to determine which patient groups derive any benefit from reverse shoulder arthroscopy. The technology should be used judiciously.

Background: Reverse total shoulder arthroplasty provides a surgical alternative to standard total shoulder arthroplasty for the treatment of selected complex shoulder problems. The purpose of the present study was to evaluate the effects of etiology on the results of reverse total shoulder arthroplasty., Methods: Between May 1995 and June 2003, 240 consecutive reverse total shoulder arthroplasties were performed in 232 patients with an average age of 72.7 years. Patients were grouped according to etiology, and the clinical and radiographic outcomes for each group were measured and compared., Results: One hundred and eighty-six patients with 191 retained reverse total shoulder arthroplasty prostheses were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 points before surgery to 60 points at the time of follow-up and 173 of the 186 patients were satisfied or very satisfied with the result. Although substantial clinical and functional improvement was observed in all etiology groups, patients with primary rotator cuff tear arthropathy, primary osteoarthritis with a rotator cuff tear, and a massive rotator cuff tear had better outcomes, on average, than patients who had posttraumatic arthritis and those managed with revision arthroplasty. Dislocation (fifteen cases) and infection (eight cases) were the most common complications among the 199 shoulders that were followed for two years or were revised prior to the minimum two-year follow-up. Patients who received the reverse prosthesis at the time of a revision arthroplasty had a higher complication rate than did those who received the reverse prosthesis at the time of a primary arthroplasty., Conclusions: The reverse total shoulder arthroplasty prosthesis can produce good results when used for the treatment of a number of other complex shoulder problems in addition to cuff tear arthropathy. Patients with posttraumatic arthritis and those undergoing revision arthroplasty may have less improvement and higher complication rates in comparison with patients with other etiologies. The advanced age of the patients in the present series and the relatively short duration of follow-up suggest that the prosthesis should continue to be used judiciously.

The purpose of this study was to evaluate the outcome of patients who underwent glenoid bone grafting and implantation of a reverse design prosthesis in 1 or 2 stages for the treatment of glenoid bone loss and rotator cuff insufficiency. Indications for the reverse prosthesis in this series included cuff tear arthropathy and revision arthroplasty. Nine patients were reviewed clinically and radiographically with a minimum 2-year follow-up (range, 24-41 months). Despite a low postoperative functional score (mean Constant score, 53 points [range, 22-79 points]), most patients were satisfied with their results primarily because of pain relief. (The mean pain score increased from 3 points preoperatively to 12.5 points postoperatively.) Radiographic evaluation did not demonstrate component loosening or evidence of graft failure. Six patients had radiographic evidence of an inferior scapular notch, which may be of concern in the future. Early results of this procedure are encouraging, but further clinical and radiologic assessment is necessary.

Background: Reverse total shoulder arthroplasty is currently being used to treat selected patients with disabling shoulder arthropathy. The purposes of this study were to investigate the medium-term results of reverse total shoulder arthroplasty and to analyze the influence of etiology on the result., Methods: We carried out a multicenter study with a minimum follow-up of five years and determined the survival rate of the prosthesis according to the initial etiology of the shoulder arthropathy. Eighty prostheses were implanted in seventy-seven patients between 1992 and 1998. Sixty-six shoulders had an arthropathy with a massive rotator cuff tear, and fourteen shoulders had a disorder with another etiology (rheumatoid arthritis, trauma, or revision arthropathy). At the time of review, eighteen patients had died and two were lost to follow-up. The remaining fifty-seven patients (sixty shoulders) were examined or interviewed by telephone at a mean follow-up of 69.6 months. Cumulative survival curves were generated with replacement of the prosthesis, glenoid loosening, and a functional Constant score of <30 as the end points., Results: The survival rate with replacement of the prosthesis and glenoid loosening as the end points were 91% and 84%, respectively, at 120 months, with shoulders that had arthropathy with a massive rotator cuff tear demonstrating a significantly better result than those that had a disorder with another etiology (p < 0.05). On the other hand, the survival rate with an absolute Constant score of <30 as an end point was 58% at 120 months, with no significant difference with respect to etiology. Two breaks were observed in the survival curves. The first concerned survival until replacement of the prosthesis and occurred at around three years, reflecting early loosening of the prosthesis. The curve then became stable. A second break started at around six years and reflected progressive deterioration of the functional result., Conclusions: Our findings indicate that the reverse total prosthesis should be reserved for the treatment of very disabling shoulder arthropathy with a massive rotator cuff rupture, and it should be used exclusively in patients over seventy years old with low functional demands.

Nine patients underwent removal of a loose glenoid component and corticocancellous iliac crest autografting of the bony defect. No revision glenoid components were inserted. Eight bony defects were large, central, and cavitary, and one had an additional peripheral component. Patients were evaluated with a subjective assessment, Constant score, and radiographs at a mean follow-up of 30 months (range, 24-39 months). By use of Neer criteria, the result was considered satisfactory in 5 patients and unsatisfactory in 4. Functional improvement was modest, with the mean Constant score increasing from 46.3 to 49.9 points. Radiographs revealed a mean 4.1 mm of medialization of the humeral head within the glenoid (range, 1-11 mm). Two cases showed wear of the bone graft, thought to be induced by eccentric glenoid loading due to rotator cuff insufficiency. No other case demonstrated wear or graft resorption. One patient required reoperation for a massive rotator cuff tear; at the time of surgery, excellent glenoid bone continuity was observed, allowing implantation of a reverse prosthesis. Corticocancellous autografting appears to be a reliable procedure for restoration of glenoid bone stock after removal of a loose glenoid component. Although functional gains were modest, restoration of the glenoid bone component allows implantation if deemed necessary.

Background: Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation., Methods: Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination., Results: The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6 degrees to 90.0 degrees . The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs., Conclusions: Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.

The purpose of this study was to compare the radiographic results of 2 different glenoid component designs. This series consisted of 66 shoulder arthroplasties with primary osteoarthritis divided into 2 groups based on glenoid component type. One group comprised shoulders receiving cemented flat-back polyethylene glenoid implants. The other group comprised shoulders receiving cemented convex-back polyethylene glenoid implants. Immediate postoperative and 2-year postoperative radiographs were evaluated for the presence and progression of periglenoid radiolucencies, and the 2 groups were compared. Radiolucent line scores were calculated and compared for each group. The keeled, convex-back glenoid component was radiographically better than the keeled, flat-back glenoid component.

We compared the prevalence of periglenoid radiolucencies between two glenoid component preparation techniques used in total shoulder arthroplasties. Seventy-two consecutive patients with primary osteoarthritis had total shoulder arthroplasties using one prosthetic system with flat-back keeled polyethylene glenoid components. Thirty-seven shoulders had glenoid implants that were cemented after standard curettage preparation of the keel slot. Thirty-five shoulders had glenoid implants that were cemented after using bone compaction to prepare the keel slot. The immediate postoperative and 2-year postoperative radiographs were examined to evaluate the presence and progression of periglenoid radiolucencies. The curettage group had a higher rate (38%) of keel radiolucencies than the compaction group (11%) seen on the immediate postoperative radiographs. Both groups had progression of periglenoid radiolucencies with time. Progression of the radiolucent lines was worse in the curettage group 2 years after arthroplasty. Preparation of the glenoid component keel slot with the bone compaction technique seems to achieve better fixation of flat-back keeled polyethylene glenoid components in total shoulder arthroplasties.

This study evaluated the effects of concomitant biceps tenodesis in patients undergoing shoulder arthroplasty for primary osteoarthritis. Six hundred eighty-eight shoulders that had undergone replacement for primary glenohumeral arthritis were reviewed at a mean 43 months postoperatively. One hundred twenty-one patients had undergone a biceps tenodesis at arthroplasty, while the remaining patients did not. Tenodesis was significantly better than no tenodesis in most outcome parameters. No difference was found between the groups in complication rate. Biceps tenodesis is a useful adjunct to shoulder arthroplasty in the treatment of primary osteoarthritis.

Fifteen shoulders with primary osteoarthritis and dysplastic glenoid morphology underwent shoulder arthroplasty (eleven total shoulder arthroplasties and four hemiarthroplasties). Patients were evaluated at a mean of 37 months after replacement with clinical examination, Constant score, subjective patient opinion, and radiographic examination. One glenoid component was loose, necessitating removal; the remainder of the prostheses were in place at latest follow-up. Significant improvement was observed in Constant score (32 points preoperatively vs 71 points postoperatively) and active mobility (anterior elevation, 89 degrees preoperatively vs 146 degrees postoperatively; external rotation, 7 degrees preoperatively vs 45 degrees postoperatively) after arthroplasty. This study demonstrates that the rare scenario of osteoarthritis coupled with a dysplastic glenoid can be treated successfully with shoulder arthroplasty.