Aims. The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years. Patients and Methods. We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score. Results. From the original cohort, 29 shoulders (35%) were treated conservatively, 27 shoulders (32%) were revised by revision of the glenosphere, and 28 shoulders (33%) were converted to hemiarthroplasty. At last follow-up, conservative treatment and glenoid revision significantly improved AAE, total Constant score, and pain, while hemiarthroplasty did not improve range of movement or clinical scores. Multivariable analysis confirmed that conservative treatment and glenoid revision achieved similar improvements in pain (glenoid revision vs conservative, beta 0.44; p = 0.834) but that outcomes were significantly worse following hemiarthroplasty (beta -5.00; p = 0.029). Conclusion. When possible, glenoid loosening after RSA should first be treated conservatively, then by glenosphere revision if necessary, and last by salvage hemiarthroplasty. Cite this article: Bone Joint J 2019;101-B:461–469

Aims. This study aimed to assess the impact of using the metal-augmented glenoid baseplate (AGB) on improving clinical and radiological outcomes, as well as reducing complications, in patients with superior glenoid wear undergoing reverse shoulder arthroplasty (RSA). Methods. From January 2016 to June 2021, out of 235 patients who underwent primary RSA, 24 received a superior-AGB after off-axis reaming (Group A). Subsequently, we conducted propensity score matching in a 1:3 ratio, considering sex, age, follow-up duration, and glenoid wear (superior-inclination and retroversion), and selected 72 well-balanced matched patients who received a standard glenoid baseplate (STB) after eccentric reaming (Group B). Superior-inclination, retroversion, and lateral humeral offset (LHO) were measured to assess preoperative glenoid wear and postoperative correction, as well as to identify any complications. Clinical outcomes were measured at each outpatient visit before and after surgery. Results. There were no significant differences in demographic data and preoperative characteristics between the two groups. Both groups showed significant improvements in patient-reported outcome measures (visual analogue scale for pain, visual analogue scale for function, American Shoulder and Elbow Surgeons, Constant, and Simple Shoulder Test scores) from preoperative to final assessment (p < 0.001). However, AGB showed no additional benefit. Notably, within range of motion, Group B showed significant postoperative decrease in both external rotation and internal rotation, unlike Group A (p = 0.028 and 0.003, respectively). Both groups demonstrated a significant correction of superior-inclination after surgery, while patients in Group B exhibited a significant decrease in LHO postoperatively (p = 0.001). Regarding complications, Group A experienced more acromial stress fractures (3 cases; 12.5%), whereas Group B had a higher occurrence of scapular notching (24 cases; 33.3%) (p = 0.008). Conclusion. Both eccentric reaming with STB and off-axis reaming with AGB are effective methods for addressing superior glenoid wear in RSA, leading to improved clinical outcomes. However, it is important to be aware of the potential risks associated with eccentric reaming, which include excessive bone loss leading to reduced rotation and scapular notching. Cite this article: Bone Joint J 2024;106-B(3):268–276

Objectives. To date, no study has considered the impact of acromial morphology on shoulder range of movement (ROM). The purpose of our study was to evaluate the effects of lateralization of the centre of rotation (COR) and neck-shaft angle (NSA) on shoulder ROM after reverse shoulder arthroplasty (RSA) in patients with different scapular morphologies. Methods. 3D computer models were constructed from CT scans of 12 patients with a critical shoulder angle (CSA) of 25°, 30°, 35°, and 40°. For each model, shoulder ROM was evaluated at a NSA of 135° and 145°, and lateralization of 0 mm, 5 mm, and 10 mm for seven standardized movements: glenohumeral abduction, adduction, forward flexion, extension, internal rotation with the arm at 90° of abduction, as well as external rotation with the arm at 10° and 90° of abduction. Results. CSA did not seem to influence ROM in any of the models, but greater lateralization achieved greater ROM for all movements in all configurations. Internal and external rotation at 90° of abduction were impossible in most configurations, except in models with a CSA of 25°. Conclusion. Postoperative ROM following RSA depends on multiple patient and surgical factors. This study, based on computer simulation, suggests that CSA has no influence on ROM after RSA, while lateralization increases ROM in all configurations. Furthermore, increasing subacromial space is important to grant sufficient rotation at 90° of abduction. In summary, increased lateralization of the COR and increased subacromial space improve ROM in all CSA configurations. Cite this article: A. Lädermann, E. Tay, P. Collin, S. Piotton, C-H Chiu, A. Michelet, C. Charbonnier. Effect of critical shoulder angle, glenoid lateralization, and humeral inclination on range of movement in reverse shoulder arthroplasty. Bone Joint Res 2019;8:378–386. DOI: 10.1302/2046-3758.88.BJR-2018-0293.R1

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

Aims. Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years. Patients and Methods. Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (. sd. 3.1)). Of these, 53 were lost to follow-up before two years and ten had died within two years of surgery, leaving 179 for analysis of survivorship, pain, motion, and strength at a minimum of two years or until revision surgery. All 242 patients were considered for the analysis of 90-day, one-year, and overall mortality, medical complications (90-day and overall), surgical complications, and reoperations. The indications for surgery included rotator cuff arthropathy, osteoarthritis, fracture, the sequela of trauma, avascular necrosis, and rheumatoid arthritis. A retrospective review of the medical records was performed to collect all variables. Survivorship free of revision surgery was calculated at two and five years. Results. One patient (0.4%) died within the first 90 days. A total of 45 patients (19%) were known to have died at the time of the final follow-up, with a median time to death of 67.7 months (interquartile range 40.4 to 94.7) postoperatively. Medical complications occurred in six patients (3%) and surgical complications occurred in 21/179 patients (12%). Survivorship free from revision was 98.9% at two years and 98.3% at five years; survivorship free from loosening was 99.5% at final follow-up. The presence of peripheral vascular disease correlated with a higher complication rate. Conclusion. Primary RSA was safe and effective in patients aged > 80 years, with a relatively low rate of medical and surgical complications. Thus, age alone should not be a contraindication to primary RSA in patients aged > 80 years. However, a careful evaluation of comorbidities is required in this age group when considering primary RSA. Cite this article: Bone Joint J 2019;101-B:1520–1525

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (. sd. ) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((. sd. 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (. sd. 9) and 24 points (. sd. 18) respectively before surgery to 28 (. sd. 11) and 61 (. sd. 24) points after surgery (p <  0.001). The mean pain at rest decreased from 5.3 (. sd. 2.8) to 1.5 (. sd. 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42. °. (. sd. 30) and 9. °. (. sd. 15) respectively pre-operatively to 78. °. (. sd. 39) and 24. °. (. sd. 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley–Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time. Cite this article: Bone Joint J 2014;96-B:936–42

Aims. Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods. We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results. Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion. Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98

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.

Aims. The aim of this study was to use national registry database information to estimate cumulative rates and relative risk of revision due to infection after reverse shoulder arthroplasty. Patients and Methods. We included 17 730 primary shoulder arthroplasties recorded between 2004 and 2013 in The Nordic Arthroplasty Register Association (NARA) data set. With the Kaplan–Meier method, we illustrated the ten-year cumulative rates of revision due to infection and with the Cox regression model, we reported the hazard ratios as a measure of the relative risk of revision due to infection. Results. In all, 188 revisions were reported due to infection during a mean follow-up of three years and nine months. The ten-year cumulative rate of revision due to infection was 1.4% overall, but 3.1% for reverse shoulder arthroplasties and 8.0% for reverse shoulder arthroplasties in men. Reverse shoulder arthroplasties were associated with an increased risk of revision due to infection also when adjusted for sex, age, primary diagnosis, and year of surgery (relative risk 2.41 (95% confidence interval 1.26 to 5.59); p = 0.001). Conclusion. The overall incidence of revision due to infection was low. The increased risk in reverse shoulder arthroplasty must be borne in mind, especially when offering it to men. Cite this article: Bone Joint J 2019;101-B:702–707

Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the axillary nerve due to traction, manipulation of the arm, aberrant retractor placement, or relative lengthening of the arm. Intraoperative fractures are relatively uncommon but include the greater tuberosity, acromion, and glenoid. Tuberosity fracture can be repaired intraoperatively with suture techniques, glenoid fractures may be insignificant rim fractures or jeopardise baseplate fixation and require abandoning RSA until glenoid fracture ORIF heals and then a second stage RSA. Periprosthetic infection after RSA ranges from 1 to 10% and may be higher in revision cases and frequently is Propionibacterium acnes and Staphylococcus epidermidis. Dislocation was one of the most common complications after RSA approximately 5% but with increased surgeon experience and prosthetic design, dislocation rates are approaching 1–2%. An anterosuperior deltoid splitting approach has been associated with increased stability as well as subscapularis repair after RSA. Scapular notching is the most common complication after RSA. Notching may be caused by direct mechanical impingement of the humerosocket polyethylene on the scapular neck and from osteolysis from polyethylene wear. Sirveaux classified scapular notching based on the defect size as it erodes behind the baseplate towards the central post. Acromial fractures are infrequent but more common is severely eroded acromions from CTA, with osteoporosis, with excessive lengthening, and with superior baseplate screws that penetrate the scapular spine and create a stress riser. Nonoperative care is the mainstay of acromial and scapular spine fractures. Recognizing preoperative risk factors and understanding component positioning and design is essential to maximizing successful outcomes

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. Standard RSA technique involves medialising the centre of rotation (COR) maximising the deltoid lever arm and compensating for rotator cuff deficiency. However reported complications include scapular notching, prosthetic loosening and loss of shoulder contour. As a result the use of Bony Increased Offset Reverse Shoulder Arthroplasty (BIO-RSA) has been gaining in popularity. The BIO-RSA is reported to avoid these complications by lateralising the COR using a modified base plate, longer central post and augmentation with cancellous bone graft harvested from the patients humeral head. Objectives. This study aims to compare the outcome in terms of analgesic effect, function and satisfaction, in patients treated with standard RSA and BIO-RSA. Methods. All cases were performed in a single centre by one of two upper limb consultant orthopaedic surgeons over a consecutive 2-year period. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Standard deltopectoral approach was performed. Standard and Bony increased offset Tournier reverse was the implant of choice (BIO-RSA). All patients underwent a standardised rehabilitation programme. Standard follow up was clinical review with radiographs at 2 weeks, 6weeks and 3months. Retrospective data was collected using case notes on patient reported stausfaction and oxford shoulder score, analgesia requirement at final follow up, and final range of movement. Results. A total of 60 patients (65 shoulders) were treated with reverse total shoulder replacements (RSA) within a 2-year period in a single centre for chronic complex shoulder conditions. Mean age at time of intervention was 74.1years (49.3 – 88.7). Mean follow up was 7.1 months (3.4 – 24). Average time to discharge 16.1 months (3.4 – 37.4). 43 patients currently under review. Of the 65 shoulders, 40 underwent BIO-RSA procedures. Indications for surgery were predominantly rotator cuff arthropathy (N=36). Other indications included severe osteoarthritis (N=1) and complex proximal humeral fracture (N=3). The remaining 25 patients treated with standard RSA were similar in terms of indication and basic demographics. In terms of range of movement, outcomes between the two groups were broadly similar. Patients receiving BIO-RSA demonstrated mean active forward flexion of 92.2° (70–120°) and abduction 93.3° (80–120°). The RSA group had mean forward flexion 90.5° (50–130°) and mean abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely pain free or requiring only occasional analgesia. The majority of patients were either very satisfied or satisfied with the outcome of the surgery. Mean Oxford shoulder score for the BIO-RSA group was 4.9 (0–13) preoperatively and 43.7 (36–48) postoperatively. The mean RSA pre-operative score was 7.9 (0–19) and postoperatively 40.2(32–48). In total three patients experienced complications; 1 haematoma (BIO-RSA), 1 brachial plexus contusion (BIO-RSA) and 1 deep infection (RSA). Conclusion. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA. Early results also suggest the Bio-RSA allows earlier improvement and conserves a larger bone stock. These early result are encouraging however a further study with longer follow-up is required

The indications for reverse shoulder arthroplasty (RSA) continue to be expanded. Associated impairment of the deltoid muscle has been considered a contraindication to its use, as function of the RSA depends on the deltoid and impairment of the deltoid may increase the risk of dislocation. The aim of this retrospective study was to determine the functional outcome and risk of dislocation following the use of an RSA in patients with impaired deltoid function. Between 1999 and 2010, 49 patients (49 shoulders) with impairment of the deltoid underwent RSA and were reviewed at a mean of 38 months (12 to 142) post-operatively. There were nine post-operative complications (18%), including two dislocations. The mean forward elevation improved from 50° (sd 38; 0° to 150°) pre-operatively to 121° (sd 40; 0° to 170°) at final follow-up (p < 0.001). The mean Constant score improved from 24 (sd 12; 2 to 51) to 58 (sd 17; 16 to 83) (p < 0.001). The mean Single Assessment Numeric Evaluation score was 71 (sd 17; 10 to 95) and the rate of patient satisfaction was 98% (48 of 49) at final follow-up.

These results suggest that pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. This form of treatment can yield reliable improvement in function without excessive risk of post-operative dislocation.

Cite this article: Bone Joint J 2013;95-B:1106–13.

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented

Aims. The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs). Methods. TDABC analysis based on the principles outlined by Kaplan and a clinical pathway that has previously been validated for this institution was used. Staffing cost, consumables, implants, and overheads were updated to reflect 2019/2020 costs. This was compared with the HRG reimbursements. Results. The mean cost of a RSA is £7,007.46 (£6,130.67 to £8,824.67). Implants and staffing costs were the primary cost drivers, with implants (£2,824.80) making up 40% of the costs. Staffing costs made up £1,367.78 (19%) of overall costs. The total tariff, accounting for market force factors and high comorbidities, reimburses £4,629. If maximum cost and minimum reimbursement is applied the losses to the trust are £4,828.67. Conclusion. RSA may be an effective and appropriate surgical option in the treatment of proximal humerus fractures; however, a cost analysis at our centre has demonstrated the financial burden of this surgery. Given its increasing use in trauma, there is a need to work towards generating an HRG that adequately reimburses providers. Cite this article: Bone Jt Open 2020;1-12:731–736

Hypothesis. Reverse shoulder arthroplasty has good mid-term results for rotator cuff deficient arthritic conditions. Methods and Analysis. 103 reverse shoulder arthroplasties were performed in 91 patients from January 2003 to September 2009. Twelve patients had bilateral reverse shoulder arthroplasties. Results. Average clinical follow-up was 13 months (range 3-72 months). There were 38% left and 62% right shoulders. Sixty-eight percent were women and 32% were men. The average age was 72 years (range 47-88 years). Indications included: rotator cuff arthropathies (79%), failed previous hemiarthroplasties and total shoulder arthroplasties (9%), rheumatoid arthritis (5%). Fractures accounted for 7% of cases, including acute 4-part fractures in the elderly, revision of fractures with deficient cuffs, malunion and nonunion cases with deficient cuffs. There was a significant improvement in quality of life. The Constant Score increased by an average of 46 points. 62 radiographs were reviewed. 75% of these showed notching of the inferior glenoid, 53% had notching of the posterior glenoid, 10 % had heterotrophic ossification inferior to the glenoid, and 40% had an inferior glenoid spur. Complications included: 2 dislocations, 1 massive heterotrophic ossification, 3 deep infections, 1 loose glenoid related to a fall, 3 acromial fractures, and 3 scapula spine fractures (all trauma related). Conclusion. Reverse shoulder arthroplasty is a good salvage procedure for cuff deficient arthritic conditions. Clinical mid-term results are good, but notching inferiorly and posteriorly may lead to deterioration over time. Fractures of the scapula appear to originate from either the superior or posterior screws which act as stress risers and an external rotation force of the greater tuberosity against the spine of the scapula in a fall may contribute to these fractures

Reverse Shoulder Arthroplasty (RSA) has been widely accepted for the treatment of rotator cuff arthropathy. There are a number of other shoulder pathologies where the reverse shoulder prosthesis can salvage previously untreatable shoulder conditions and restore function to the shoulder. This is a series of cases where RSA has been used to treat shoulder fractures. Material. Our indications for the reverse prosthesis in fracture management were:. Revision of failed fracture fixation with a deficient rotator cuff – 2 patients;. Acute 3 and 4 part fractures in the elderly, osteoporotic – 1 patient;. Acute 4 part fracture dislocation in elderly, osteoporotic – 1 patient;. Revision of non-union and malunions – 5 patients;. Revision of hemiarthroplasties which were initially done for fracture management – 5 patients. Results. There were a total of 14 cases treated for fractures out of 123 reverse shoulder arthroplasties performed. The average age for the fracture cases was 68 years (range 47–87) and for non-fracture RSA cases 73 years (range 51–88). The average follow-up Constant Score was 53 for fracture cases and 67 for non-fracture RSA cases. Complications included 1 dislocation and 1 deep infection. The problem with treatment of complex cases is there is an increased risk of complications. Problems encountered in the use of reverse shoulder arthroplasty in complex diagnoses include: instability, notching of scapula, scapula fractures, sepsis, lack of bone stock, poor quality soft-tissue and deficient deltoid muscle due to numerous previous surgical procedures, distortion of anatomy due to trauma, subscapularis deficiency and problems encountered from metal implants in situ. Conclusion. RSA is a good salvage procedure for cuff deficient shoulder fracture cases

The aim of the study was to assess the rate of greater tuberosity non union in reverse shoulder arthroplasty performed for proximal humerus fractures and to assess if union is related to type of fracture or the intraoperative reduction of the greater tuberosity. All cases of reverse shoulder arthroplasty for proximal humerus fractures at our institution over a three year period were retrospectively reviewed from casenotes and radiologically and the position of the greater tuberosity was documented at immediate post op, 6 months and 12 months. Any malunion or non union were noted. A total of 27 cases of reverse shoulder arthroplasty for proximal humeral fractures were identified. 4 cases did not have complete follow up xrays and were excluded from analysis. The average age at operation of the cohort of the 23 remaining patients was 79 years (range 70–91). The greater tuberosity was anatomically well positioned intraoperatively in 17 of the 23 cases. At the end of 12 months there were 4 cases of tuberosity non union (17%), all except one occurring in poorly intraoperatively positioned greater tuberosity. 50% (3 out of 6) of greater tuberosities displaced further and remained ununited if the intraoperative position was poor. Only 6% (1 out of 17) greater tuberosities did not unite if the greater tuberosities was reduced anatomically. Intra operatively position of the greater tuberosity was strongly associated with their union (Fischer's exact test p<0.05). Union of greater tuberosity was not statistically associated with fracture pattern (Fischer's exact test p=0.48). Our case series show a low rate of tuberosity malunion after reverse shoulder arthroplasty for proximal humerus fracture. Good positioning and fixation of the greater tuberosity intra operatively is a strong predictor of their uneventful union to shaft

Background:. While reverse shoulder arthroplasty has shown successful outcomes for a variety of shoulder pathologies, postoperative instability continues to be one of the most common complications limiting outcomes. In the literature, reports of instability range from 2.4%–31%. Many authors recommend an initial attempt at closed reduction followed by a period of immobilization for management of the initial dislocation episode while others may seek to rule out infection or other secondary causes; however there is little data to support either practice. The purpose of this study was to evaluate the outcomes of patients with postoperative dislocation following reverse shoulder arthroplasty managed with closed reduction. Methods:. A retrospective review of all reverse shoulder arthroplasties performed by a single surgeon (MF) from 2002-present was performed to identify all patients treated for postoperative dislocation treated with closed reduction, either in the office setting or under anesthesia in the operating room. A total of 21 patients were identified. Preoperative patient characteristics, implant selection, and time to initial dislocation episode were recorded. Final outcomes including recurrent instability need for revision surgery, ASES outcome score, and range of motion were evaluated. Results:. There were 9 male and 12 female patients. Nearly 50% (10/21) cases had previous surgery, with the vast majority of these being previous arthroplasty (8/10). The average time to first dislocation was 200 days (range: 2 days–961 days), with 62% (13/21) occurring in the first 90 days. At average follow-up of 28 months following the dislocation episode, 62% of these shoulders remained stable (13/21). Six shoulders (29%) required revision surgery for recurrent instability. The revision procedure included a larger glenosphere and socket in all cases. All of these patients remained stable at final follow-up (Ave 25.5 months). In those cases successfully treated with closed reduction the average time to dislocation was 188 days, whereas the average time to initial dislocation in cases requiring revision surgery was 224 days (p = 0.82). All of these patients remained stable at final follow-up. Two shoulders (9%) remained unstable and either declined or were medically unfit to undergo revision surgery. The average ASES score in patients treated with closed reduction for instability was 68.0, and 62.7 for those treated with revision surgery (p = 0.64). Conclusion:. This study shows that an initial dislocation episode following reverse shoulder arthroplasty can be successfully managed with closed reduction and temporary immobilization in over half of cases. The time to dislocation is not related to the likelihood of a successful closed reduction. Given that outcomes following revision surgery are not different from closed treatment we would continue to recommend an initial attempt at closed reduction in all cases of postoperative reverse shoulder arthroplasty dislocation

Reverse shoulder arthroplasty has a high complication rate related to glenoid implant instability and screw loosening. Better radiographic post-operative evaluation may help in understanding complications causes. Medical radiographic imaging is the conventional technique for post-operative component placement analysis. Studies suggest that volumetric CT is better than use of CT slices or conventional radiographs. Currently, post-operative CT use is limited by metal-artifacts in images. This study evaluated inter-observer reliability of pre-operative and post-operative CT images registration to conventional approaches using radiographs and CT slices in measuring reverse shoulder arthroplasty glenoid implant and screw percentage in bone. Pre-operative and post-operative CT scans, and post-operative radiographs were obtained from six patients that had reverse shoulder arthroplasty. CT scans images were imported into a medical imaging processing software and each scapula, glenoid implant and inferior screw were reconstructed as 3D models. Post-operative 3D models were imported into the pre-operative reference frame and matched to the pre-operative scapula model using a paired-point and a surface registration. Measurements on registered CT models were done in reference to the pre-operative scapula model coordinate frame defined by a computer-assisted designed triad positioned in respect to the center of the glenoid fossa and trigonum scapulae (medial-lateral, z axis) and superior and inferior glenoid tubercle (superior-inferior, y axis). The orthogonal triad third axis defined the anterior-posterior axis (x axis). A duplicate triad was positioned along the central axis of the glenoid implant model. Using a virtual protractor, the glenoid implant inclination was measured from its central axis and the scapula transverse plane (x - z axes) and version from the coronal plane (y - z axes). Inferior screw percentage in bone was measured from a Boolean intersection operation between the pre-operative scapula model and the inferior screw model. For CT slices and radiographic measurements, a first 90-degree Cobb angle, from medical records software, was positioned from the trigonum scapulae to the centre of the central peg. Using the 90-degree line as reference, a second Cobb angle was drawn from the most superior to the most inferior point of the glenoid implant for inclination and from of the most anterior to the most posterior point for version. Version can only be measured using CT slices. Screw percentage in bone was calculated from screw length measures collected with a distance-measuring tool from the software. For testing the inter-observer reliability of the three methods, measures taken by three qualified observers were analysed using an intra-class correlation coefficient (ICC) method. The 3D registration method showed excellent reliability (ICC > 0.75) in glenoid implant inclination (0.97), version (0.98) and screw volume in bone (0.99). Conventional methods showed poor reliability (ICC < 0.4); CT-slice inclination (0.02), version (0.07), percentage of screw in bone (0.02) and for radiographic inclination (0.05) and percentage screw in bone (0.05). This CT registration of post-operative to pre-operative novel method for quantitatively assessing reverse shoulder arthroplasty glenoid implant positioning and screw percentage in bone, showed excellent inter-observer reliability compared to conventional 2D approaches. It overcomes metal-artifact limitations of post-operative CT evaluation

Scapular notching is a common problem following reverse shoulder arthroplasty (RSA). This is due to impingement between the humeral polyethylene cup and scapular neck in adduction and external rotation. Various glenoid component strategies have been described to combat scapular notching and enhance impingement-free range of motion (ROM). There is limited data available detailing optimal glenosphere position in RSA with an onlay configuration. The purpose of this study was to determine which glenosphere configurations would maximise impingement free ROM using an onlay RSA prosthesis. A three-dimensional (3D) computed tomography (CT) scan of a shoulder with Walch A1, Favard E0 glenoid morphology was segmented using validated software. An onlay RSA prosthesis was implanted and a computer model simulated external rotation and adduction motion of the virtual RSA prosthesis. Four glenosphere parameters were tested; diameter (36mm, 41mm), lateralization (0mm, 3mm, 6mm), inferior tilt (neutral, 5 degrees, 10 degrees), and inferior eccentric positioning (0.5mm, 1.5mm. 2.5mm, 3.5mm, 4.5mm). Eighty-four combinations were simulated. For each simulation, the humeral neck-shaft angle was 147 degrees and retroversion was 30 degrees. The largest increase in impingement-free range of motion resulted from increasing inferior eccentric positioning, gaining 15.0 degrees for external rotation and 18.8 degrees for adduction. Glenosphere lateralization increased external rotation motion by 13. 6 degrees and adduction by 4.3 degrees. Implanting larger diameter glenospheres increased external rotation and adduction by 9.4 and 10.1 degrees respectively. Glenosphere tilt had a negligible effect on impingement-free ROM. Maximizing inferior glenosphere eccentricity, lateralizing the glenosphere, and implanting larger glenosphere diameters improves impingement-free range of motion, in particular external rotation, of an onlay RSA prosthesis. Surgeons’ awareness of these trends can help optimize glenoid component position to maximise impingement-free ROM for RSA. Further studies are required to validate these findings in the context of scapulothoracic motion and soft tissue constraints

The reverse ball and socket shoulder replacement, employing a humeral socket and glenosphere, has revolutionized the treatment of patients with arthritis and rotator cuff insufficiency. The RSP (DjO Surgical, Inc., Austin, Texas) is one such device, characterized by a lateral center of rotation and approved for use in the United States since 2004. Multiple studies by the implant design team have documented excellent outcomes and low revision rates for the RSP, but other published outcomes data are relatively sparse. The objective of this study is to report on the complications and early outcomes in the first consecutive 60 RSPs implanted in 57 patients by a single shoulder replacement surgeon between 2004 and 2010. Forty-four patients were female and mean age at the time of reverse shoulder arthroplasty was 75 years (range 54 to 92 years). The RSP was used as a primary arthroplasty in 42 shoulders and to revise a failed prosthetic shoulder arthroplasty in 18 shoulders. During the study period, 365 shoulder replacements were implanted so that the RSP was used selectively, accounting for only 17% of all shoulder arthroplasties (8.4% for 2004-2007, 24.2% for 2008-2010). Most patients had pseudoparalysis and profound shoulder dysfunction so that mean pre-operative active forward elevation was to 45°, active abduction to 43°, active internal rotation to the buttock, and the mean pre-operative Simple Shoulder Test (SST) score was 1 out of 12. At final follow-up, mean active forward elevation had improved to 101° (p<0.0001), active abduction to 91° (p<0.0001), active internal rotation to the lumbosacral junction (p<0.001), and the mean final SST score was 7 out of 12. There were 16 complications in 14 patients, including 7 reoperations in 6 patients (11%): 3 closed reductions for dislocation, 2 open revisions for instability and for a dissociated liner in the same patient, one evacuation of a hematoma, and one open reduction and internal fixation of a post-operative scapular spine fracture. Two additional scapular spine or acromion fractures and one acromioclavicular joint separation developed postoperatively that impacted outcome adversely but did not require re-operation. None of the glenoid baseplates or humeral stems has been revised and no deep infections have occurred. Experience with reverse shoulder arthroplasty appears to influence the reoperation rate, as 3 of the reoperations occurred following the first 15 reverse shoulder arthroplasties. Overall improvements in active motion and self-assessed shoulder function were comparable to those reported previously. Final active motion results were somewhat lower than those reported previously, which may relate to the selection of predominately pseudoparalytic patients for reverse shoulder arthroplasty in this series. Use of the RSP device for reverse shoulder arthroplasty leads to improved motion and function in carefully selected older patients with pseudoparalysis or a failed shoulder replacement. Re-operations and complications occur but the learning curve may not be as steep as previously reported. This may relate to specific features of the implant system used in this series, as well as to surgeon experience

Introduction. Reverse shoulder Arthroplasty is a successful treatment for gleno-humeral osteoarthritis. However, components loosening and painful prostheses, related to components wrong positioning, are still a problem for those patients who underwent this kind of surgery. Several new technology has been developed the improve the implant positioning. CT-based intraoperative navigation system is a suitable technology that allow the surgeon to prepare the implant site exactly as planned with preoperative software. Method. Thirty reverse shoulder prostheses were performed at Modena Polyclinic using GPS CT-based intraoperative navigation system (Exactech, Gainsville, Florida). Walch classification was used to assess glenoid type. Planned version and inclination of the glenoid component, planned seating, final version and inclination of the reamer were recorded. Intraoperative and perioperative complication were recorded. Planned positioning was conducted aiming to the maximum seating, avoiding retroversion >10° and superior inclination. Results. Eight patients were male, 22 were female. Mean age was 75 years old (range 58–87). 4 glenoid were type B3, four were B2, 10 cases were B1, 12 case were A1/A2. Posterior or superior augment was used in 15 cases. Mean planned seating was 93%. Mean preoperative version was -7.5±6.9°; Mean planned version was -2±2.8°; Mean intraoperative measured version was -1.9±2.8°; no statistical difference was found between planned and intraoperative version (p=0.16). Mean preoperative inclination was 1.8±6.°; Mean planned inclination was -2.2±2.4°; Mean intraoperative measured inclination was -2.1.9±2.3°; no statistical difference was found between planned and intraoperative version or inclination (respectively p=0.16 and p=0.32). Mean surgical time was 71 minute (range 51–82). Three cases of coracoid ruptures were reported, 1 failure of the system occurred. Discussion. GPS navigation system allows the surgeon to prepare the implant site as planned on Preoperative software in Reverse shoulder arthroplasty, with no statistical difference between planned orientation and intraoperative measured orientation. That means that even in the most difficult cases the surgeon is able to find a good positioning (93% seating)and to replicate it in the operative room. Only one failure of the system occurred, because too much time was passed between CT scan and surgery (9 months). Three coracoid fractures occurred in the first 10 cases: these could be addressed to a lack of confidence with the double lateralization of this prosthesis which increase tensioning on the coracoid and a lack of confidence in tracker positioning, which should be made as proximal as it is possible. Finally, the system needs several improvements to be considered a breakthrough technology, such as humeral component positioning and final control of the implant, but by now is a useful way to improve our surgery, especially in difficult cases

In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort. An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required. A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and axillary nerve injury were also noted at 4.2% each (1/24). Keeping in mind the immense difference in socioeconomical status and patient demographics in a third world country the RSA complication rate in this study correlates with the known international consensus. This also proves that RSA is still a suitable option for rotator cuff arthropathy and glenohumeral osteoarthritis even in an economically constrained environment like South Africa

Reverse shoulder arthroplasty has been used to treat arthritis of the shoulder with no rotator cuff. The purpose of this study is to review the short term outcome of reverse shoulder arthroplasty performed at North Shore Hospital. Between 2003 and 2007, 54 consecutive patients were treated with the SMR reverse shoulder prosthesis. Patients were assessed using the visual analogue pain score, patient satisfaction rating, the American Shoulder and Elbow Society Shoulder score, the Oxford shoulder score, the Short Form – 12, and by radiographs. We also reviewed clinical and radiographic complications. Nine patients underwent surgery for fracture, two for chronic dislocation and 43 for cuff tear arthropathy, including four revisions. The mean age at surgery was 77.8 years (range 54–91 years). 53 of the implanted prostheses were SMR (Lima Orthotec) and one was a Delta (De Puy). Patient assessment is still in progress, but findings so far show very favourable early outcomes. We report a large consecutive series of patients who had the reverse prothesis at North Shore hospital. To the best of our knowledge, there has been no previous publication of results of the SMR reverse prosthesis

Crosby and Colleagues described 24 scapula fractures in 400 reverse shoulder arthroplasties and classified scapula fractures after reverse shoulder arthroplasty into 3 types. Type 1 – true avulsion fracture of acromion related to a thinned out acromion (post-acromioplaty or cuff arthropathy). A small bone fragment dislodges during reduction of RSA. Type 2 – Acromial fracture due to Acromio-clavicular (AC) joint arthrosis. They feel the lack of movement at the AC joint leads to stresses across the acromion and cause it to fracture. They recommend AC joint resection and ORIF of acromion, if the acromion is unstable. Type 3 – true scapula spine fracture caused by the superior screw acting as a stress riser. This fracture occurs about 8 months after the arthroplasty and is a true stress fracture requiring open reduction and internal fixation. Of 123 reverse shoulder arthroplasties performed from Jan 2003 to Feb 2011, a total of 6 scapula fractures were encountered post-surgery. Three were acromial fractures and three were scapula spine fractures all related to trauma. The fractures of the spine occurred between 6 months and 4 years post arthroplasty. We feel the fractures were traumatic but did occur through the posterior or superior screws from the metaglen. where stress risers developed for a fracture to occur. We found that using a sliding osteotomy of the spine of the scapula to bridge the defect of the scapula and a double-plating technique using two plates at 90 degrees to each other provides a satisfactory outcome after 3–6 months where patients can start actively elevating again. This method of treatment will be presented

Aims. Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA). Patients and Methods. A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m. 2. (17.3 to 66.4). Results. Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred. Conclusion. Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610–614

Aims. The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. Methods. This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed. Results. Mean follow-up was 8.4 years (5 to 11). There were no significant differences in mean absolute (p = 0.125) or adjusted (p = 0.569) Constant, UCLA (p = 0.088), QuickDASH (p = 0.135), VAS-pain (p = 0.062), or range of movement at the final follow-up. However, patient satisfaction was significantly lower in the fracture group (p = 0.002). The complication rate was 1.5% (one patient) versus 9.3% (six patients), and the revision rate was 1.5% (one patient) versus 7.8% (five patients) in the fracture and arthropathy groups, respectively. The ten-year arthroplasty survival was not significantly different (p = 0.221). Conclusion. RSA may be used not only for patients with irreparable rotator cuff deficiencies, but also for those with acute complex proximal humeral fractures. We found that RSA provided similar functional outcomes and a low revision rate for both indications at long-term. However, satisfaction is lower in patients with an acute fracture. Cite this article: Bone Joint J 2020;102-B(11):1555–1559

Abstract. Background. The influence of diagnosis on outcomes after reverse shoulder arthroplasty (RSA) is not completely understood. The purpose of this study was to compare clinical outcomes of different pathologies. Methods. A total of 78 RSAs were performed for the following diagnoses: (1) rotator cuff tear arthropathy(RCA), (2) massive cuff tear(MCT) with osteoarthritis(OA), (3) MCT without OA, (4) arthritis, (5) acute proximal humerus fracture. Mean follow up 36 months (upto 5 years) Range of motion, Oxford Shoulder Score were obtained preoperatively and postoperatively. Results. Mean OSS was 30. The RCA, MCT-with-OA, MCT-without-OA, and arthritis groups all exhibited significant improvements in all outcome scores and in all planes of motion. After adjustment for age and compared with RCA, those with OA had significantly better abduction (P < .05), and those with fractures had significantly worse patient satisfaction (P < .05). Among male patients, those with MCTs without OA had significantly worse satisfaction (P < .05). Conclusion. RSA reliably provides improvement regardless of preoperative diagnosis. Although subtle differences exist between male and female patients, improvements in clinical outcome scores were apparent after RSA

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis. Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty. Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively. Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions

If a modular convertible total shoulder system is used as a primary implant for an anatomical total shoulder arthroplasty, failure of the prosthesis or the rotator cuff can be addressed by converting it to a reverse shoulder arthroplasty (RSA), with retention of the humeral stem and glenoid baseplate. This has the potential to reduce morbidity and improve the results. . In a retrospective study of 14 patients (15 shoulders) with a mean age of 70 years (47 to 83) we reviewed the clinical and radiological outcome of converting an anatomical shoulder arthroplasty (ASA) to a RSA using a convertible prosthetic system (SMR system, Lima, San Daniele, Italy). . The mean operating time was 64 minutes (45 to 75). All humeral stems and glenoid baseplates were found to be well-fixed and could be retained. There were no intra-operative or early post-operative complications and no post-operative infection. The mean follow-up was 43 months (21 to 83), by which time the mean visual analogue scale for pain had decreased from 8 pre-operatively to 1, the mean American Shoulder and Elbow Surgeons Score from 12 to 76, the mean Oxford shoulder score from 3 to 39, the mean Western Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and the mean Subjective shoulder value from 15 to 61. On radiological review, one patient had a lucency around the humeral stem, two had stress shielding. There were no fatigue fractures of the acromion but four cases of grade 1 scapular notching. . The use of a convertible prosthetic system to revise a failed ASA reduces morbidity and minimises the rate of complications. The mid-term clinical and radiological results of this technique are promising. Cite this article: Bone Joint J 2015;97-B:1662–7

Reverse shoulder arthroplasty (RSA) is commonly used to treat patients with rotator cuff tear arthropathy. Loosening of the glenoid component remains one of the principal modes of failure and is the main complication leading to revision. For optimal RSA implant osseointegration to occur, the micromotion between the baseplate and the bone must not exceed a threshold of 150 µm. Excess micromotion contributes to glenoid loosening. This study assessed the effects of various factors on glenoid baseplate micromotion for primary fixation of RSA. A half-fractional factorial experiment design (2k-1) was used to assess four factors: central element type (central peg or screw), central element cortical engagement according to length (13.5 or 23.5 mm), anterior-posterior (A-P) peripheral screw type (nonlocking or locking), and bone surrogate density (10 or 25 pounds per cubic foot [pcf]). This created eight unique conditions, each repeated five times for 40 total runs. Glenoid baseplates were implanted into high- or low-density Sawbones™ rigid polyurethane (PU) foam blocks and cyclically loaded at 60 degrees for 1000 cycles (500 N compressive force range) using a custom designed loading apparatus. Micromotion at the four peripheral screw positions was recorded using linear variable displacement transducers (LVDTs). Maximum micromotion was quantified as the displacement range at the implant-PU interface, averaged over the last 10 cycles of loading. Baseplates with short central elements that lacked cortical bone engagement generated 373% greater maximum micromotion at all peripheral screw positions compared to those with long central elements (p < 0.001). Central peg fixation generated 360% greater maximum micromotion than central screw fixation (p < 0.001). No significant effects were observed when varying A-P peripheral screw type or bone surrogate density. There were significant interactions between central element length and type (p < 0.001). An interaction existed between central element type and level of cortical engagement. A central screw and a long central element that engaged cortical bone reduced RSA baseplate micromotion. These findings serve to inform surgical decision-making regarding baseplate fixation elements to minimize the risk of glenoid loosening and thus, the need for revision surgery

Background. Glenoid baseplate fixation for reverse shoulder arthroplasty relies on the presence of sufficient bone stock and quality. Glenoid bone may be deficient in cases of primary erosions or due to bone loss in the setting of revision arthroplasty. In such cases, the best available bone for primary baseplate fixation usually lies within the three columns of the scapula. The purpose of this study was to characterise the relationship of the three columns of the scapula independent of glenoid anatomy and to establish the differences between male and female scapular anatomy. Methods. Fifty cadaveric scapulae (25 male, 25 female) were analysed using CT-based imaging software. The surface geometries of the coracoid, scapular spine and inferior scapular column were delineated in the sagittal plane. A linear best-fit line was drawn to establish the long axis of each column independent of the glenoid. The width of the glenoid was measured and points marked at the midpoint of each measurement. A best-fit line starting at the supra glenoid tubercle passing through the midpoints was chosen as the superior inferior (SI) axis of the glenoid. An orthogonal plane to the scapular plane was developed parallel to the glenoid face. The axis representing each of the three columns of the scapula and the SI axis of the glenoid, were projected onto this plane. The relationship between each column was analysed with respect to each other and with respect to the SI glenoid axis. Thus, measurements obtained gave the relationships of the three columns of the scapula (independent of the glenoid) and their relationships to the long axis of the glenoid (dependant on the glenoid). Comparisons were made between males and females using the independent t-tests. Results. The mean angle between the scapular spine and the coracoid column was 93±13° with no significant difference between males (91±15°) and females (95±10°) (p=0.29). The angle between the inferior scapular column and the scapular spine was 6.5° greater (p=0.03) in females (134±10°) than in males (128±11°). Similarly, the angle between the inferior scapular column and the coracoid column was 11° greater (p=0.009) in males (141±15°) than in females (130±12°). No significant sex difference was found between the acromion and inferior scapular pillar with respect to the SI glenoid axis. However, the female coracoid was found to be more horizontal than the male coracoid in relation to the SI axis of the glenoid (p=0.037). Conclusion. This study demonstrates that the relationship between the scapular spine and the coracoid column is independent of sex. However, sex has significant effects on the positions of the scapular spine and coracoid columns with respect to the inferior scapular column. The inferior scapular column is noted to be positioned more anterior (closer to the coracoid) in females than in males. Sex variations may be important when directing screws for baseplate fixation in bone deficient glenoids undergoing reverse shoulder arthroplasty

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour. At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results. Cite this article: Bone Joint J 2013;95-B:1551–5

Treatment of complex proximal humeral fractures remains controversial. In situations where accurate fracture reduction and fixation cannot be obtained, arthroplasty may be the preferred surgical option. The traditional operation of hemiarthroplasty in these situations is technically challenging, and a good functional outcome is dependent on reduction and healing of the tuberosities. Reverse Shoulder Arthroplasty (RSA) has been suggested as an alternative, and we sought to analyse and compare functional outcomes following the two procedures. Ten patients who underwent hemiarthroplasty for acute fracture of the proximal humerus between 1999 and 2003 were reviewed. All fractures were assessed intraoperatively for open reduction and internal fixation of the fracture, but deemed to be unsuitable for fixation. From 2003 our management in this clinical situation changed, and ten subsequent patients underwent reverse shoulder arthroplasty using the S.M.R. reverse shoulder prosthesis (Systema Multiplana Randell, Lima, Italy). Clinical and radiological follow up was carried out at a mean of 31 months (hemiarthroplasty patients) and 15 months (RSA patients) post operatively. Subjectively seven of 10 patients in the reverse group and seven of 10 patients in the hemiarthroplasty group rated their outcome as ‘very good’ or ‘excellent’. The mean ASES scores were 65 (range 40–88) in the reverse group and 67 (26–100) in the hemiarthroplasty group. The mean Oxford shoulder score was 29 (15–56) in the reverse group and 22 (12–34) in the hemiarthroplasty group. The mean active forward elevation in the hemiarthroplasty group was 108° (range 50–180) and in the reverse group 115° (45–40), and active external rotation 49° (5–105) and 48° (10–90) respectively. Differences in outcome scores between the two groups were not statistic ally significant (p value> 0.05). This study provides the first direct comparison between RSA and hemiarthroplasty for complex proximal humeral fractures. The expected functional gains with Reverse shoulder arthroplasty were not seen, suggesting its use as the primary treatment for acute fracture should remain guarded

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable. 24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching. Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients

Introduction:. Reverse shoulder arthroplasty (RSA) has proven to be a useful tool to manage a variety of pathologic conditions. However, inconsistent improvement in motion occurs in patients who have undergone RSA for revision shoulder arthroplasty, proximal humeral fracture sequelae, and treatment of infection. Additional factors that have been suggested to produce poor postoperative range of motion (ROM) may be associated with patient's factors such as poor preoperative range of motion and surgical factors such as inability to lengthen the arm. The purpose of this study was to analyze multiple factors which may be responsible in predicting motion after RSA. It is our hypothesis that intraoperative ROM is most predictive of postoperative ROM. Methods:. Between February 2003 and April 2011 566 patients (225 male and 341 female) treated with a RSA for 1) acute proximal humeral fracture (11), 2) Sequeala of proximal humeral fractures (31), 3) cuff tear arthropathy (278), 4) massive cuff tear without arthritis (78), 5) failed shoulder arthroplasty (168) and 6) infection (29) were evaluated with preoperative range of motion, intraoperative range of motion and range of motion at a minimum of 2-year postoperative follow up. A single observer recorded intraoperative flexion (IFF) in 30° increments. Preoperative and postoperative ROM was recorded by patient video or a previously validated patient performed outcome measure. Preoperative diagnosis was confirmed by radiographic and intraoperative information. 477 patients had preoperative and postoperative radiographs available for analysis of acromial-greater tuberosity distance change (AGT) which was utilized to calculate arm lengthening. A regression analysis was then performed to determine which factors were most influential in predicting postoperative active range of motion. Results:. IFF was the strongest predictor of final postoperative ROM, followed by gender and preoperative ROM. Age, AGT and treatment for the purposes of revision, infection or massive cuff tear were not significant independent predictors of postoperative ROM. Compared to patients with intraoperative forward elevation of ≤60 degrees, patients with intraoperative elevation of 90 degrees gained 16° in postoperative forward elevation (p = 0.029), patients with intraoperative elevation of 120 degrees gained roughly 38° in postoperative forward elevation (p < 0.001) and patients with intraoperative elevation of 150 degrees gained roughly 49 degrees in postoperative forward elevation (p < 0.001). Patients with 120° or more intraoperative elevation were nine times more likely (OR = 9.04, 95%CI: 4.96–16.47) than patients with 90° or less intraoperative elevation to have postoperative forward elevation of 150° or more (top 25% of postoperative results). Conclusions:. Intraoperative forward flexion is strongest predictor postoperative ROM. Surgeons are able to use intraoperative motion as a powerful tool in decision making regarding soft tissue tension in reverse shoulder arthroplasty, therefore by maximizing intraoperative motion, patients have a much greater likelihood of improvement in their final active motion

Manufacturers of reverse shoulder arthroplasty (RSA) implants have recently designed innovative implants to optimise performance in rotator cuff deficient shoulders. These advancements are not without tradeoff and can have negative biomechanical effects. The objective of this study was to develop an integrated FEA kinematic model to compare the muscle forces and joint reaction force (JRF) of 3 different RSA designs. A kinematic model of a normal shoulder joint was adapted from the Delft model and integrated with the OpenSim shoulder model. Static optimisations then allowed for calculation of the individual muscle forces, moment arms and JRF relative to net joint moments. Three dimensional computer models of humeral lateralised design (HLD), glenoid lateral design (GLD), and Grammont design (GD) RSA were integrated and parametric studies were performed. Overall there were decreases in deltoid and rotator cuff muscle forces for all 3 RSA designs. These decreases were greatest in the middle deltoid of the HLD model for abduction and flexion and in the rotator cuff muscles under both internal and external rotation. The joint reactive forces in abduction and flexion decreased similarly for all RSA designs compared to the normal shoulder model, with the greatest decrease seen in the HLD model. These findings demonstrate that the design characteristics implicit in these modified RSA prostheses result in kinematic differences most prominently seen in the deltoid muscle and overall joint reactive forces. Further research utilising this novel integrated model can help guide continued optimisation of RSA design and clinical outcomes

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. . An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72

Scapular notching is of concern in reverse shoulder arthroplasty and has been suggested as a cause of glenoid loosening. Our purpose was to analyze in a large series the characteristics and the consequences of the notch and then to enlighten the causes in order to seek some solutions to avoid it. 430 consecutive patients (457 shoulders) were treated by a reverse prosthesis for various etiologies between 1991 and 2003 and analyzed for this retrospective multicenter study. Adequate evaluation of the notch was available in 337 shoulders with a follow-up of 47 months (range, 24–120 months). The notch has been diagnosed in 62% cases at the last follow-up. Intermediate reviews show that the notch is already visible within the first postoperative year in 82% of these cases. Frequency and grade extension of the notch increase significantly with follow-up (p< 0.0001) but notch, when present, is not always evolutive. At this point of follow-up, scapular notch is not correlated with clinical outcome. There is a correlation with humeral radiolucent lines, particularly in metaphyseal zones (p=0.005) and with glenoid radiolucent lines around the fixation screws (p=0.006). Significant preoperative factors are: cuff tear arthropathy (p=0.0004), muscular fatty infiltration of infraspinatus (p=0.01), narrowing of acromio-humeral distance (p< 0.0001) and superior erosion of the glenoid (p=0.006). It was more frequent with superolateral approach than with deltopectoral approach (p< 0.0001) and with standard cup than with lateralized cup (p=0.02). We conclude that scapular notching is frequent, early and sometimes evolutive but not unavoidable. Preoperative superior glenoid erosion is significantly associated with a scapular notch, possibly due to the surgical tendency to position the baseplate with superior tilt and/or in high position which has been demonstrated to be an impingement factor. Preoperative radiographic planning and adapted glenoid preparation are of concern

BACKGROUND:. Few studies have evaluated at a medium-term follow-up the use of semiconstrained reverse shoulder arthroplasty (RSA) for primary glenohumeral osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy excluding any other shoulder disease. Moreover, data on patients' quality of life after this surgery are lacking. METHODS:. In this prospective cohort study, 80 patients were evaluated after an RSA for either primary osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy with the Constant-Murley score (CMS), ROM, and Short Form Health Survey (SF-36). A radiologic assessment was performed pre- and postoperatively. RESULTS:. At a mean 5-year follow-up, the cumulative survival rate was 97.3% and significant improvements in the CMS and ROM were observed when compared with the baseline values. The CMS was 93.2% of the sex- and age-matched normal values. The postoperative SF-36 scores showed no significant differences compared with normative data. Younger patients and subjects with worse preoperative conditions achieved the greatest benefit after RSA. A 70% scapular notching rate was noted and the length of follow-up was found to be associated with the severity of scapular notching. CONCLUSIONS:. This study introduces new predictors for surgical outcomes, and it shows that patients who had undergone RSA a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls

Background. The purpose of this study was to determine if thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgery (ASES) score exist that predict “excellent” patient s­atisfaction (PS) following reverse total shoulder arthroplasty (RSA). Methods. Patients undergoing RSA using a single implant system were evaluated pre-operatively and at a minimum 2-year follow-up. Receiver-operating-characteristic (ROC) curve analysis determined thresholds to predict “excellent” PS by evaluating the percentage of maximal improvement for SST and ASES. Pre-operative factors were analyzed as independent predictors for achieving SST and ASES thresholds. Results. 198 (SST) and 196 (ASES) patients met inclusion criteria. For SST and ASES, ROC analysis identified 61.3% (p<.001) and 68.2% (p<.001) maximal improvement as the threshold for maximal predictability of “excellent” satisfaction respectively. Significant positive correlation between the percentage of maximum score achieved and “excellent” PS for both groups were found (r=.440, p<.001 for SST score; r=0.417, p<.001 for ASES score). Surgery on the dominant hand, greater baseline VAS Pain, and cuff arthropathy were independent predictors for achieving the SST and ASES threshold. Conclusion. Achievement of 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement represent thresholds for the achievement of “excellent” satisfaction following RSA. Independent predictors of achieving these thresholds were dominant sided surgery and higher baseline pain VAS scores for SST, and rotator cuff arthropathy for ASES. Keywords. Percentage of maximal improvement; Predictors; American Shoulder and Elbow Surgery Score; Simply Shoulder Test; Reverse shoulder Arthroplasty; Satisfaction. Level of Evidence. Level III

Objective:. Evaluation of the early results of the implementation of reverse shoulder arthroplasty prosthesis “Comprehensive Reverse” in primary and revision shoulder arthroplasties. Material and Methods:. September 2010–December 2012, 48 patients (32 women, 16 men) underwent reverse shoulder arthroplasty using Comprehensive Reverse system. Average age of 69.88. A total of 46 patients were followed. In 22 patients the operation was performed for revision. Patients were pre-and postoperatively evaluated using Oxford, Constant, SF-12 scores, radiographs, pain and range of motion. Mean follow-up 13 months. Results:. In both groups there was an improvement in pain level from 7.9 to 3.2 in the primary replacement group and 7.8 to 5.3 in the revision group. Forward flexion has improved from 60 ° to 107 ° and from 53 ° to 95 ° respectively. Abduction has improved from 52 ° to 90 ° and 42 ° to 77 °, respectively. Significant improvement of Oxford Score from 13.77 to 33.30 in the first group and 12.27 to 21.20 in the second group. Constant score improved from 19.17 to 45.43 and 17.36 to 34.50 in both groups respectively. Furthermore, significant correlations were observed between the key variables. Post operative Complications includes separation of baseplate–glenosphere (one patient) required revision, large post operative hematoma in one patient and periprosthetic fracture type C in one case after a fall required revision using Mosaic Modular System. There was one case of superficial infection treated surgically and with antimicrobial treatment. Discussion:. The results of this study show a satisfactory short and acceptable result for the use of reverse shoulder prosthesis “Comprehensive” against primary disease of the shoulder and for revision with better results in the first group. Long-term monitoring is required to better and more complete clinical assessment of the reverse arthroplasty

Purpose of study:. Reverse shoulder arthroplasty is effective in the management of symptomatic arthritic shoulders with a non-reconstructable rotator cuff. Optimal orientation and initial fixation of the glenoid component is correlated with improved outcomes. This may be difficult to achieve with distorted glenoid morphology. The authors present a previously undescribed system for accurate, consistent and reliable screw placement for fixation of the glenoid component with the desired version during reverse shoulder arthroplasty. Description of methods:. The pre-operative CT scan images are used to construct a scapula model (Medical Image Processing software, CustomMed Orthopaedics)allowing the surgeon to determine the optimal position for screw placement based on available bone stock. A custom drill guide is made from polyamide, which is sterilized in an autoclave and fitted to the glenoid intra-operatively prior to reaming. The system minimizes the likelihood of malposition of glenoid components and is compatible with all arthroplasty systems. Summary of results:. The technique has been performed on 5 patients after informed consent. Post-operative CT images demonstrate intended component version and screw position in all cases. Patients are being recruited for a multicenter prospective trial. Conclusion:. The authors present a new technique for achieving optimal screw position in fixation of glenoid components. A prospective trial is underway which aims to prove through post-operative imaging that intended glenoid version and screw placement was achieved and show improved long term results

The use of shorter humeral stems in reverse shoulder arthroplasty has been reported as safe and effective. Shorter stems are purported to be bone preserving, easy to revise, and have reduced surgical time. However, a frequent radiographic finding with the use of uncemented short stems is stress shielding. Smaller stem diameters reduce stress shielding, however, carry the risk of varus or valgus malalignment in the metadiaphyseal region of the proximal humerus. The aim of this retrospective radiographic study was to measure the true post-operative neck-shaft (N-S) angle of a curved short stem with a recommended implantation angle of 145°. True anteroposterior radiographs of patients who received RTSA using an Ascend Flex short stem at three specialized shoulder centres (London, ON, Canada, Lyon, France, Munich, Germany) were reviewed. Radiographs that showed the uncemented stem and humeral tray in orthogonal view without rotation were included. Sixteen patients with proximal humeral fractures or revision surgeries were excluded. This yielded a cohort of 124 implant cases for analysis (122 patients, 42 male, 80 female) at a mean age of 74 years (range, 48 – 91 years). The indications for RTSA were rotator cuff deficient shoulders (cuff tear arthropathy, massive cuff tears, osteoarthritis with cuff insufficiency) in 78 patients (63%), primary osteoarthritis in 41 (33%), and rheumatoid arthritis in 5 (4%). The humeral component longitudinal axis was measured in degrees and defined as neutral if the value fell within ±5° of the humeral axis. Angle values >5° and < 5 ° were defined as valgus and varus, respectively. The filling-ratio of the implant within the humeral shaft was measured at the level of the metaphysis (FRmet) and diaphysis (FRdia). Measurements were conducted by two independent examiners (SA and TW). To test for conformity of observers, the intraclass correlation coefficient (ICC) was calculated. The inter- and intra-observer reliability was excellent (ICC = 0.965, 95% confidence interval [CI], 0.911– 0.986). The average difference between the humeral shaft axis and the humeral component longitudinal axis was 3.8° ± 2.8° (range, 0.2° – 13.2°) corresponding to a true mean N-S angle of 149° ± 3° in valgus. Stem axis was neutral in 70% (n=90) of implants. Of the 34 malaligned implants, 82% (n=28) were in valgus (mean N-S angle 153° ± 2°) and 18% (n=6) in varus position (mean N-S angle 139° ± 1°). The average FRmet and FRdiawere 0.68 ± 0.11 and 0.72 ± 0.11, respectively. No association was found between stem diameter and filling ratios (FRmet, FRdia) or cortical contact with the stem (r = 0.39). Operative technique and implant design affect the ultimate positioning of the implant in the proximal humerus. This study has shown, that in uncemented short stem implants, neutral axial alignment was achieved in 70% of cases, while the majority of malaligned humeral components (86%) were implanted in valgus, corresponding to a greater than 145° neck shaft angle of the implant. It is important for surgeons to understand that axial malalignment of a short stem implant does influence the true neck shaft angle

The purpose of this study is to quantify the distribution of bone density in the scapulae of patients undergoing reverse shoulder arthroplasty (RSA) to guide optimal screw placement. To achieve this aim, we compared bone density in regions around the glenoid that are targeted for screw placement, as well as bone density variations medial to lateral within the glenoid. Specimen included twelve scapula in 12 patients with a mean age of 74 years (standard deviation = 9.2 years). Each scapula underwent a computed tomography (CT) scan with a Lightspeed+ XCR 16-Slice CT scanner (General Electric, Milwaukee, USA). Three-dimensional (three-D) surface mesh models and masks of the scapulae containing three-D voxel locations along with the relative Hounsfield Units (HU) were created. Regions of interest (ROI) were selected based on their potential glenoid baseplate screw positioning in RSA surgery. These included the base of coracoid inferior and lateral to the suprascapular notch, an anterior and posterior portion of the scapular spine, and an anterosuperior and inferior portion of the lateral border. Five additional regions resembling a clock face, on the glenoid articular surface were then selected to analyze medial to lateral variations in bone density including twelve, three, six, and nine-o'clock positions as well as a central region. Analysis of Variance (ANOVA) tests were used to examine statistical differences in bone density between each region of interest (p < 0 .05). For the regional evaluation, the coracoid lateral to the suprascapular notch was significantly less dense than the inferior portion of the lateral border (mean difference = 85.6 HU, p=0.03), anterosuperior portion of the lateral border (mean difference = 82.7 HU, p=0.04), posterior spine (mean difference = 97.6 HU, p=0.007), and anterior spine (mean difference = 99.3 HU, p=0.006). For the medial to lateral evaluation, preliminary findings indicate a “U” pattern with the densest regions of bone in the glenoid most medially and most laterally with a region of less dense bone in-between. The results from this study utilizing clinical patient CT scans, showed similar results to those found in our previous cadaveric study where the coracoid region was significantly less dense than regions around the lateral scapular border and scapular spine. We also have found for medial to lateral bone density, a “U” distribution with the densest regions of bone most medially and most laterally in the glenoid, with a region of less dense bone between most medial and most lateral. Clinical applications for our results include a carefully planned trajectory when placing screws in the scapula, potentially avoiding the base of coracoid. Additionally, surgeons may choose variable screw lengths depending on the region of bone and its variation of density medial to lateral, and that screws that pass beyond the most lateral (subchondral) bone, will only achieve further purchase if they enter the denser bone more medially. We suspect that if surgeons strategically aim screw placement for the regions of higher bone density, they may be able to decrease micromotion in baseplate fixation and increase the longevity of RSA

Reverse shoulder arthroplasty (RSA) is increasingly performed recently. The patients seeking internet as a source of information may get misleading and a false sense of expectation. This study aimed at analysing patient information on internet and establish list of available quality websites to safely recommend to the patients. The study analysed 310 websites from 10 top search engines exploring the quality of patient information using an assessment tool. Search engines used were metasearch (Metacrawlers and Mamma), general search (Google, Altavista, Yahoo, MSN, AOL, Lycos) and health search engines (Medhunt and Excite Health). The study was undertaken by two independent researcher over a four-week period in November 2011. Each Website was evaluated according to RSA-specific content using a point value system with shoulder disease and surgery specific key words on an ordinal scale. Adequacy of the content was analysed in regard with description of diagnosis, procedure, alternate options, postoperative protocol, complications and prognosis. Excluding the repetitions 104 websites were analysed for accessibility, relevance, authenticity, adequacy of patient information and accountability. The median time since update was 12 months. More than 90% of the websites were found to be of poor quality. Only 25% sites targeted mainly people with shoulder problems. 8% of websites were from non profit organisations. Most of these websites were promoting either their service 80 (76%) or some product 12 (11%). The strength of association between two reviewers was very high (r = 0.899). Intra-rater reliability was significant (r = 0.955) with p level < 0.01. The reading level of most of websites were too high for average consumers. There is need for government organizations and professional societies to regulate the information provided by Internet. Until long-term data are available, patients should be warned when using the Internet as a source for health care information

The purpose was to evaluate the results of reverse shoulder arthroplasty (RSA) in proximal humerus fracture sequelae (FS). Multicenter retrospective series of forty-five consecutive patients operated between 1995 and 2003. Types of FS included: cephalic collapse and necrosis (n=8), chronic locked dislocation (n=5), surgical neck nonunion (n=7), severe malunion (twenty), and isolated greater tuberosity malunion (n=3). Twenty-six patients had surgical treatment of the initial fracture and seventeen had non-surgical treatment; thirty-three Delta and ten Aequalis reverse prosthesis were implanted. Mean age at surgery was seventy-three years (range, fifty-seven to eighty-six). Forty-three patients were available for clinical and radiologic evaluation with a mean follow-up of thirty-nine months (range, twenty-four to ninety-five). Nine re-operations (21%) and ten complications (23%) were encountered, including four infections (leading to two resection-arthroplasties), two instabilities, one glenoid fracture (converted to hemiarthroplasty) and one axillary nerve palsy. Thirty-six patients (83%) were satisfied or very satisfied with their result. The adjusted Constant score improved from 29% preoperatively to 75% postoperatively (p< 0.0001), the Constant score for pain from fou to twelve points (p< 0.0001), and active anterior elevation from 59° to 114° (p< 0.0001). Active rotations were limited. A positive postoperative hornblower test negatively influenced Constant score (forty-two points compared to 61.5 points, p=0.004) and external rotation (−6° compared to 15°, p=0.004). The lowest functional results were observed in surgical neck nonunions (with five complications) and isolated greater tuberosity malunions. In type four fracture sequelae, patients who had an osteotomy or resection of the GT (n=9) had better forward flexion (140° compared to 110°, p=0.026) and better Constant score (sixty-three points compared to forty-six points, p=0.07). RSA can be a surgical option in elderly patients with FS, specifically for those with severe malunion (type four fracture sequelae) where hemiarthroplasty gives poor results. By contrast, surgical neck nonunions (type three) and isolated greater tuberosity malunions are at risk for low functional results. The surgical technique and the remaining cuff muscles (teres minor) are important prognostic factors. Functional results are lower and complications/reoperations rates are higher than those reported for RSA in cuff tear arthritis

Introduction and Objective. In recent years, along with the extending longevity of patients and the increase in their functional demands, the number of annually performed RSA and the incidence of complications are also increasing. When a complication occurs, the patient often needs multiple surgeries to restore the function of the upper limb. Revision implants are directly responsible for the critical reduction of the bone stock, especially in the shoulder. The purpose of this paper is to report the use of allograft bone to restore the bone stock of the glenoid in the treatment of an aseptic glenoid component loosening after a reverse shoulder arthroplasty (RSA). Materials and Methods. An 86-years-old man came to our attention for aseptic glenoid component loosening after RSA. Plain radiographs showed a complete dislocation of the glenoid component with 2 broken screws in the neck of glenoid. CT scans confirmed the severe reduction of the glenoid bone stock and critical bone resorption and were used for the preoperative planning. To our opinion, given the critical bone defect, the only viable option was revision surgery with restoration of bone stock. We planned to use a bone graft harvested from distal bone bank femur as component augmentation. During the revision procedure the baseplate with a long central peg was implanted “on table” on the allograft and an appropriate osteotomy was made to customize the allograft on the glenoid defect according to the CT-based preoperative planning. The Bio-component was implanted with stable screws fixation on residual scapula. We decided not to replace the humeral component since it was stable and showed no signs of mobilization. Results. The new bio-implant was stable, and the patient gained a complete functional recovery of the shoulder. The scheduled radiological assessments up to 12 months showed no signs of bone resorption or mobilization of the glenoid component. Conclusions. The use of bone allograft in revision surgery after a RSA is a versatile and effective technique to treat severe glenoid bone loss and to improve the global stability of the implant. Furthermore, it represents a viable alternative to autologous graft since it requires shorter operative times and reduces graft site complications. There are very few data available regarding the use of allografts and, although the first studies are encouraging, further investigation is needed to determine the biological capabilities of the transplant and its validity in complex revisions after RSA