Aims. The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years. Methods. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders. Results. In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively). Conclusion. The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening. Cite this article: Bone Joint J 2023;105-B(9):1000–1006

Aims. This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH). Methods. A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42020193041). Results. A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies. Conclusion. This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J 2021;103-B(5):813–821

Aims. The liner design is a key determinant of the constraint of a reverse total shoulder arthroplasty (rTSA). The aim of this study was to compare the degree of constraint of rTSA liners between different implant systems. Methods. An implant company’s independent 3D shoulder arthroplasty planning software (mediCAD 3D shoulder v. 7.0, module v. 2.1.84.173.43) was used to determine the jump height of standard and constrained liners of different sizes (radius of curvature) of all available companies. The obtained parameters were used to calculate the stability ratio (degree of constraint) and angle of coverage (degree of glenosphere coverage by liner) of the different systems. Measurements were independently performed by two raters, and intraclass correlation coefficients were calculated to perform a reliability analysis. Additionally, measurements were compared with parameters provided by the companies themselves, when available, to ensure validity of the software-derived measurements. Results. There were variations in jump height between rTSA systems at a given size, resulting in large differences in stability ratio between systems. Standard liners exhibited a stability ratio range from 126% to 214% (mean 158% (SD 23%)) and constrained liners a range from 151% to 479% (mean 245% (SD 76%)). The angle of coverage showed a range from 103° to 130° (mean 115° (SD 7°)) for standard and a range from 113° to 156° (mean 133° (SD 11°)) for constrained liners. Four arthroplasty systems kept the stability ratio of standard liners constant (within 5%) across different sizes, while one system showed slight inconsistencies (within 10%), and ten arthroplasty systems showed large inconsistencies (range 11% to 28%). The stability ratio of constrained liners was consistent across different sizes in two arthroplasty systems and inconsistent in seven systems (range 18% to 106%). Conclusion. Large differences in jump height and resulting degree of constraint of rTSA liners were observed between different implant systems, and in many cases even within the same implant systems. While the immediate clinical effect remains unclear, in theory the degree of constraint of the liner plays an important role for the dislocation and notching risk of a rTSA system. Cite this article: Bone Jt Open 2024;5(10):818–824

Aims. The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). Methods. The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain. Results. The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%). Conclusion. Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J 2022;104-B(3):401–407

Aims. Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. Methods. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates. Results. Compared with non-stiff aTSAs, stiff aTSAs had poorer passive FE and active external rotation (ER), whereas there were no significant postoperative differences between stiff rTSAs and non-stiff rTSAs. There were no significant differences in preoperative function when comparing stiff aTSAs with stiff rTSAs. However, stiff rTSAs had significantly greater postoperative active and passive FE (p = 0.001 and 0.004, respectively), and active abduction (p = 0.001) compared with stiff aTSAs. The outcome scores were significantly more favourable in stiff rTSAs for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, and the Constant score, compared with stiff aTSAs. When comparing the proportion of stiff aTSAs versus stiff rTSAs that exceeded the minimal clinically important difference and substantial clinical benefit, stiff rTSAs achieved both at greater rates for all measurements except active ER. The complication rate did not significantly differ between stiff aTSAs and stiff rTSAs, but there was a significantly higher rate of revision surgery in stiff aTSAs (p = 0.007). Conclusion. Postoperative overhead ROM, outcome scores, and rates of revision surgery favour the use of a rTSA rather than aTSA in patients with glenohumeral OA, an intact rotator cuff and limited FE, with similar rotational ROM in these two groups. Cite this article: Bone Joint J 2023;105-B(12):1303–1313

Aims. Existing literature indicates that inferiorly inclined glenoid baseplates following reverse total shoulder arthroplasty (RSA) produce better outcomes compared to superiorly inclined baseplates. We aim to compare clinical outcomes for RSAs with superiorly and neutrally/inferiorly inclined lateralized glenospheres. Methods. We retrospectively reviewed 154 consecutive patients undergoing RSA between July 2015 and July 2017 by one single-fellowship trained surgeon (AJ). Two raters (KAM and MVS) independently measured glenoid inclination in preoperative and minimum two year follow-up radiographs (anteroposterior/Grashey) using the RSA angle. Inclination was then compared to patient-reported outcomes, range of motion (ROM), and independently assessed degree of scapular notching and staging of heterotopic ossification at two year follow-up. Results. Median postoperative inclination for each group was found to be -3.6° (interquartile range (IQR) -2.1 to -6.9) and 6.0° (3.2° to 10.1°) for the neutrally/inferiorly and superiorly inclined cohorts, respectively. Preoperative inclination was highly associated with postoperative inclination (p = 0.004). When comparing superiorly and neutrally/inferiorly inclined glenospheres, there were no differences in heterotopic ossification (p = 0.606), scapular notching (p = 0.367), American Shoulder and Elbow Surgeons score (p = 0.419), Single Assessment Numeric Evaluation (p = 0.417), Visual Analogue Scale (VAS) pain score (p = 0.290), forward elevation (p = 0.161), external rotation (p = 0.537), or internal rotation (p = 0.656). Conclusion. Compared to neutral and inferior inclination, up to 6° ± 3° of superior glenoid baseplate inclination on a lateralized RSA design produces no differences in postoperative ROM or patient-reported outcomes, and produces similar levels of scapular notching and heterotopic ossification. Additionally, the degree of preoperative inclination represents an important factor in surgical decision-making as it is strongly associated with postoperative inclination. It is important to note that the findings of this study are only reflective of lateralized RSA prostheses. Cite this article: Bone Joint J 2021;103-B(2):360–365

Abstract. Objective. To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Methods. This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59–82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2–4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results. The mean (range) duration of anaesthesia was 38.66 (20–60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130–210 and 75–145 mmHg, respectively (mean [range] drop, 74.13 [33–125] mmHg). Mean (range) propofol dose was 1.74 (1–3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20–50) min. The mean (range) postoperative recovery score (local scale, range 5–28 where lower values are superior) was 5.2 (5–8). The mean (range) length of stay was 8 (1–20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions. Our data demonstrate that rTSA under ISB-RA is safe, cost-effective and a potentially viable alternative for patients with multiple comorbidities. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours

Introduction & Aims. Over the last decade, sensor technology has proven its benefits in total knee arthroplasty, allowing the quantitative assessment of tension in the medial and lateral compartment of the tibiofemoral joint through the range of motion (VERASENSE, OrthoSensor Inc, FL, USA). In reversal total shoulder arthroplasty, it is well understood that stability is primarily controlled by the active and passive structures surrounding the articulating surfaces. At current, assessing the tension in these stabilizing structures remains however highly subjective and relies on the surgeons’ feel and experience. In an attempt to quantify this feel and address instability as a dominant cause for revision surgery, this paper introduces an intra-articular load sensor for reverse total shoulder arthroplasty (RTSA). Method. Using the capacitive load sensing technology embedded in instrumented tibial trays, a wireless, instrumented humeral trial has been developed. The wireless communication enables real-time display of the three-dimensional load vector and load magnitude in the glenohumeral joint during component trialing in RTSA. In an in-vitro setting, this sensor was used in two reverse total shoulder arthroplasties. The resulting load vectors were captured through the range of motion while the joint was artificially tightened by adding shims to the humeral tray. Results. For both shoulder specimens, the newly developed sensor provided insight in the load magnitude and characteristics through the range of motion. In neutral rotation and under a condition assessed as neither too tight nor too loose, glenohumeral loads in the range of 10–30lbs were observed. As expected, with increasing shim thickness these intra- articular load magnitudes increased. Assessing the load variations through the range of motion, high peak forces of up to 120 lbs were observed near the limits of the range of motion, most pronounced during external humeral rotation. Conclusions. In conclusion, this paper presents an intra-articular load sensor that can be used during the trialing phase in reverse total shoulder arthroplasty. A first series of cadaveric experiments provided evidence of realistic load ranges and load characteristics with respect to the end of the range of motion. Currently, effort is undertaken to develop a biomechanically validated load range that can serve as a target in surgery

Aims. Scapular notching is thought to have an adverse effect on the outcome of reverse total shoulder arthroplasty (RTSA). However, the matter is still controversial. The aim of this study was to determine the clinical impact of scapular notching on outcomes after RTSA. Methods. Three electronic databases (PubMed, Cochrane Database, and EMBASE) were searched for studies which evaluated the influence of scapular notching on clinical outcome after RTSA. The quality of each study was assessed. Functional outcome scores (the Constant-Murley scores (CMS), and the American Shoulder and Elbow Surgeons (ASES) scores), and postoperative range of movement (forward flexion (FF), abduction, and external rotation (ER)) were extracted and subjected to meta-analysis. Effect sizes were expressed as weighted mean differences (WMD). Results. In all, 11 studies (two level III and nine level IV) were included in the meta-analysis. All analyzed variables indicated that scapular notching has a negative effect on the outcome of RTSA . Statistical significance was found for the CMS (WMD –3.11; 95% confidence interval (CI) –4.98 to –1.23), the ASES score (WMD –6.50; 95% CI –10.80 to –2.19), FF (WMD –6.3°; 95% CI –9.9° to –2.6°), and abduction (WMD –9.4°; 95% CI –17.8° to –1.0°), but not for ER (WMD –0.6°; 95% CI –3.7° to 2.5°). Conclusion. The current literature suggests that patients with scapular notching after RTSA have significantly worse results when evaluated by the CMS, ASES score, and range of movement in flexion and abduction. Cite this article: Bone Joint J 2020;102-B(11):1438–1445

Purpose. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77(68–87)years old and mean follow-up period was 15.2(12–26)months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included. We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion(ROM). Results. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103°(30°–135°) in forward flexion, 93°(30°–135°) in abduction, 21°(0°–45°) in external rotation and L4 level in internal rotation. The complications were not shown in any cases except for resolved heterotropic ossification. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusions. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results

Aims. Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes. Methods. All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up. Results. The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%). Conclusion. We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333–1338

Purpose:. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods:. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77 years old and mean follow-up period was 15.2(12–26) months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included (Fig. 1, Fig. 2, Fig. 3). We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion (ROM). Results:. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103° in forward flexion, 93° in abduction, 21° in external rotation and L4 level in internal rotation. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusion:. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results. Key words: Shoulder, Proximal humerus fracture, Reverse total shoulder arthroplasty

Aims. The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different. Methods. A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six shoulder surgeons independently planned a rTSA in each model using prototype development software with the ability to adjust for scapulothoracic orientation, the starting position of the humerus, as well as kinematic planes in a global reference system simulating previously described posture types A, B, and C. ROM with and without posture adjustment was calculated and compared in all movement planes. Results. All movement planes showed significant differences when comparing protocols with and without adjustment for posture. The largest mean difference was seen in external rotation, being 62° (SD 16°) without adjustment compared to 25° (SD 9°) with posture adjustment (p < 0.001), with the highest mean difference being 49° (SD 15°) in type C. Mean extension was 57° (SD 18°) without adjustment versus 24° (SD 11°) with adjustment (p < 0.001) and the highest mean difference of 47° (SD 18°) in type C. Mean abducted internal rotation was 69° (SD 11°) without adjustment versus 31° (SD 6°) with posture adjustment (p < 0.001), showing the highest mean difference of 51° (SD 11°) in type C. Conclusion. The present study demonstrates that accounting for scapulothoracic orientation has a significant impact on simulated ROM for rTSA in all motion planes, specifically rendering vastly lower values for external rotation, extension, and high internal rotation. The substantial differences observed in this study warrant a critical re-evaluation of all previously published studies that examined component choice and placement for optimized ROM in rTSA using conventional preoperative planning software. Cite this article: Bone Joint J 2024;106-B(11):1284–1292

Glenoid bone grafting in reverse total shoulder arthroplasty (RTSA) has emerged as an effective method of restoring bone stock in the presence of complex glenoid bone loss, yet there is limited published evidence on efficacy. The aim of this study was to conduct an analysis of clinical and radiographic outcomes associated with glenoid bone grafting in primary RTSA. Patients who underwent a primary RTSA with glenoid bone grafting were retrospectively identified from the databases of two senior shoulder surgeons. Inclusion criteria included minimum of 12 months clinical and/or radiographical follow up. Patients underwent preoperative clinical and radiographic assessment. Graft characteristics (source, type, preparation), range of movement (ROM), patient-reported outcome measures (Oxford Shoulder Scores [OSS]), and complications were recorded. Radiographic imaging was used to analyse implant stability, graft incorporation, and notching by two independent reviewers. Between 2013 and 2021, a total of 53 primary RTSA procedures (48 patients) with glenoid bone grafting were identified. Humeral head autograft was used in 51 (96%) of cases. Femoral head allograft was utilised in two cases. Depending on the morphology of glenoid bone loss, a combination of structural (corticocancellous) and non-structural (cancellous) grafts were used to restore glenoid bone stock and the joint line. All grafts were incorporated at review. The mean post-operative OSS was significantly higher than the pre-operative OSS (40 vs. 22, p < 0.001). ROM was significantly improved post-operatively. One patient is being investigated for residual activity-related shoulder pain. This patient also experienced scapular notching resulting in the fracturing of the inferior screw. One patient experienced recurrent dislocations but was not revised. Overall, at short term follow up, glenoid bone grafting was effective in addressing glenoid bone loss with excellent functional and clinical outcomes when used for complex bone loss in primary RTSA. The graft incorporation rate was high, with an associated low complication rate

Currently, the consensus regarding subscapularis tendon repair during a reverse total shoulder arthroplasty (rTSA) is to do so if it is possible. Repair is thought to decrease the risk of dislocation and improve internal rotation but may also increase stiffness and improvement in internal rotation may be of subclinical benefit. Aim is to retrospectively evaluate the outcomes of rTSA, with or without a subscapularis tendon repair. We completed a retrospective review of 51 participants (25 without and 26 with subscapularis repair) who received rTSR by a single-surgeon using a single-implant. Three patient reported outcome measures (PROM) were assessed pre-operatively and post-operative at twelve months, as well as range of movement (ROM) and plain radiographs. Statistical analysis utilized unpaired t tests for parametric variables and Mann-Whitney U test for nonparametric variables. External Rotation ROM pre-operatively was the only variable with a significance difference (p=0.02) with the subscapularis tendon repaired group having a greater range. Pre- and post-operative abduction (p=0.72 & 0.58), forward flexion (p=0.67 & 0.34), ASES (p=0.0.06 & 0.78), Oxford (p=0.0.27 & 0.73) and post-operative external rotation (p=0.17). Greater external rotation ROM pre-operatively may be indicative of the ability to repair the subscapularis tendon intra-operatively. However, repair does not seem to improve clinical outcome at 12 months. There was no difference of the PROMs and AROMs between the subscapularis repaired and not repaired groups for any of the variables at the pre-operative or 12 month post operative with the exception of the external rotation ROM pre-operatively. We can conclude that from PROM or AROM perspective there is no difference if the tendon is repaired or not in a rTSR and indeed the patients without the repair may have improved outcomes at 12 months

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection. Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high. Cite this article: Bone Joint J 2014;96-B:1239–43

Introduction. Reverse total shoulder replacement is performed for the treatment of rotator cuff arthropathy, massive irreparable cuff tears and failed shoulder hemiarthroplasty with irreparable rotator cuff tears. The aim of this study was to assess the clinical and radiological outcome of single surgeon series of Equinoxe® reverse total shoulder replacement at a district general hospital. Materials/Methods. Consecutive patients who underwent Equinoxe® reverse total shoulder replacement at our unit from Jun 2008 to Dec 2010 were retrospectively reviewed. Indications for surgery, complications and radiological outcomes were assessed. Oxford shoulder score was used to assess the functional outcome. Results. Between Jun 2008 and Dec 2012, forty-one reverse total shoulder replacements were performed by the senior author in 37 patients. Of these, Equinoxe® prostheses were used in 27 operations (26 patients). These included 22 female and 4 male patients. Cuff arthropathy was the commonest preoperative diagnosis (23 patients), followed by proximal humeral fracture non-union (2 patients), failed hemiarthroplasty (one patient) and failed resurfacing (one patient). The mean follow up was 10 months (3 to 17 months). At the time of the study, three patients had died due to unrelated causes, two were not contactable and the remaining 21 patients were analysed. The mean oxford shoulder score was 35.8 (21–48). Nineteen patients (90.5%) graded their outcome a good to excellent while 2 patients (9.5%) graded as poor. Seventeen patients (81%) expressed that they would recommend this operation. One patient (4.7%) had infection and another had dislocation. Overall, there were 3 reoperations (14.3%); first washout, second change of humeral tray and third excision of lateral end of clavicle and reattachment of deltoid. Two patients (9.5%) had small glenoid notching. There was no loosening, neurovascular injury or postoperative haematoma. Conclusion. Early outcome of Equinoxe reverse shoulder replacement is promising. Longer follow-up is required to further assess the outcome

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Introduction. Reverse total shoulder arthroplasty (RTSA) is rapidly being adopted as the standard procedure for a growing number of shoulder arthropathies. Though short-term outcomes are promising, mid- and long-term follow-ups present a number of complications – among them, humeral stem and glenosphere component loosening. Though not the primary complication, previously reported aseptic loosening required revision in 100% of cases. As the number of patients undergoing RTSA increases, especially in the younger population, it is important for surgeons to identify and utilize prostheses with stable long-term fixation. It has previously been shown in the hip and knee literature that implant migration in the first two years following surgery is predictive of later failure due to loosening in the 5=10-year postoperative window. The purpose of this study is to, for the first time, evaluate the pattern and total magnitude of implant migration in reverse shoulder arthroplasty using the gold standard imaging technique radiostereometric analysis (RSA). Methods. Forty patients were prospectively randomized to receive either a cemented or press-fit humeral stem, and a glenosphere secured to the glenoid with either autologous bone graft or 3D printed porous titanium for primary reverse total shoulder arthroplasty. Following surgery, participants are imaged using RSA, a calibrated, stereo x-ray technique. Radiographs are acquired at 6 weeks (baseline), 3 months, 6 months, 1 year, and 2 years. Migration of the humeral stem and glenosphere at each time point is compared to baseline. Migration of the prostheses is independently compared between humeral stem fixation groups and glenosphere fixation groups using a two-way repeated measures ANOVA with Tukey's test for multiple comparisons. Results. Follow-ups are ongoing and preliminary results are presented. Significant differences were observed at the 6-month and 1-year time points for superior-inferior translation (p = 0.0067, p = 0.0048), and total three-dimensional translation (p = 0.0011, p = 0.0272) between humeral stems, with press-fit humeral stems subsiding significantly more than cemented stems. Migration between the 6-month and 1-year time points was minimal for both stem fixation groups (less than 0.2 mm). No significant differences were observed along any axis at any time point for the glenosphere fixation groups. Conclusion. There is a trend towards increased subsidence with the use of press-fit stems compared to cemented stems in the first six months postoperatively, as is expected. Both implant fixation techniques demonstrate stability from six months through one year, and this trend is expected through two-year follow-up. Similarly, both glenosphere fixation techniques demonstrate immediate and stable fixation through one year

Aims of the study: To assess the results of one-stage revision of infected reverse total shoulder arthroplasty as a new treatment for this major surgical complication. Materials: 11 consecutive patients with infected reverse shoulder prosthesis (DePuy International Ltd, Leeds, UK) were treated with a direct-exchange reverse total shoulder arthroplasty between March 2005 and June 2007. These patients were retrospectively followed. Methods: Via a superior extended deltoideopectoral, clavicular osteotomy approach, according to Redfern-Wallace, a removal of the prosthesis is performed. Multiple operative specimens (4 to 8) are taken and cultured. A thorough synovectomy is performed before implanting a new reverse total shoulder arthroplasty (7 Delta. ®. 3.2 tsp and 4 DeltaXtend. ®. tsp). A gentamycine (Duracol. ®. ) impregnated membrane is interpositioned between baseplate and glenosphere. Immediate postoperative passive and active mobilisation is permitted if no pain is present. Results: Clinical symptoms are seldom severe pain (3) or severe limitation of function (3). A fistula is mainly present (8) without alterating the function. No prosthetic loosening was present at the humeral and glenoid site confirming the absence of radiological infectious signs. All but one patient are considered free of infection at mean follow up of 24 months (12m – 36m) and without antibiotic treatment for minimum 6 months. In only 1 patient the infection persisted necessitating a two-stage revision, unfortunately without definitive cure. Only three early complications are seen (< 2 months: posterior dislocation, postoperative haematoma and clavicle fracture). The mean postoperative Constant-Murley score was 52 (14–81) at latest follow up. Peroperative samples identified Propionbacterium species (5), Coagulase-negative staphylococci (4), MRSA (1) and with E.Coli (1) infection. Monobacterial infection was seen in 6 shoulders, multibacterial in 2 shoulders and in 2 shoulders cultures were negative. Discussion: This cohort of patients has a different syndrome than the known infected anatomical prosthesis. This pathology seems to be rarely associated with severe pain (3) or limitation of function (3). Draining fistulas without alterating the function of the shoulder [CS: mean 43 (3–63)] are more frequently present making a preoperative diagnosis easier and more certain. Recurrence rate of infection is comparable to the classical two-stage revision. Preoperative stiff and painful shoulders seems to have a bad prognosis despite definite cure of the infection. Supple shoulders (mainly associated with a fistula) can be treated with a good functional result. Conclusion: One-stage revision arthroplasty is an attractive alternative treatment for infected reverse total shoulder arthroplasty