Total shoulder arthroplasty implants have evolved to include more anatomically shaped components that replicate the native state. The geometry of the humeral head is non-spherical, with the sagittal diameter of the base of the head being up to 6% (or 2.1-3.9 mm) larger than the frontal diameter. Despite this, many TSA humeral head implants are spherical, meaning that the diameter must be oversized to achieve complete coverage, resulting in articular overhang, or portions of the resection plane will remain uncovered. It is suspected that implant-bone load transfer between the backside of the humeral head and the cortex on the resection plane may yield better load-transfer characteristics if resection coverage was properly matched without overhang, thereby mitigating proximal stress shielding. Eight paired cadaveric humeri were prepared for reconstruction with a short stem total shoulder arthroplasty by an orthopaedic surgeon who selected and prepared the anatomic humeral resection plane using a cutting guide and a reciprocating sagittal saw. The humeral head was resected, and the resulting cortical boundary of the resection plane was digitized using a stylus and an optical tracking system with a submillimeter accuracy (Optotrak,NDI,Waterloo,ON). A plane was fit to the trace and the viewpoint was transformed to be perpendicular to the plane. To simulate optimal sizing of both circular and elliptical humeral heads, both circles and ellipses were fit to the filtered traces using the sum of least squares error method. Two extreme scenarios were also investigated: upsizing until 100% total coverage and downsizing until 0% overhang. Total resection plane coverage for the fitted ellipses was found to be 98.2±0.6% and fitted circles was 95.9±0.9%Cortical coverage was found to be 79.8 ±8.2% and 60.4±6.9% for ellipses and circles respectively. By switching to an ellipsoid humeral head, a small 2.3±0.3% (P < 0.001) increase in total coverage led to a 19.5±1.3%(P < 0.001) increase in cortical coverage. The overhang for fitted ellipses and circles was 1.7 ±0.7% and 3.8 ±0.8% respectively, defined as a percentage of the total enclosed area that exceeded the bounds of the humerus resections. Using circular heads results in 2.0 ±0.1% (P < 0.001) greater overhang. Upsizing until 100% resection coverage, the ellipse produced 5.4 ±3.5% (P < 0.001) less overhang than the circle. When upsizing the overhang increases less rapidly for the ellipsoid humeral head that the circular one (Figure 1). Full coverage for the head is achieved more rapidly when up-sizing with an ellipsoid head as well. Downsizing until 0% overhang, total coverage and cortical coverage were 7.5 ±2.8% (P < 0.001) and 7.9 ±8.2% (P = 0.01) greater for the ellipse, respectively. Cortical coverage exhibits a crossover point at −2.25% downsizing, where further downsizing led to the circular head providing more cortical coverage. Reconstruction with ellipsoids can provide greater total resection and cortical coverage than circular humeral heads while avoiding excessive overhang. Elliptical head cortical coverage can be inferior when undersized. These initial findings suggest resection-matched humeral heads may yield benefits worth pursuing in the next generation of TSA implant design. For any figures or tables, please contact the authors directly

The 2021 Australian Orthopaedic Association National Joint Replacement Registry report indicated that total shoulder replacement using both mid head (TMH) length humeral components and reverse arthroplasty (RTSA) had a lower revision rate than stemmed humeral components in anatomical total shoulder arthroplasty (aTSA) - for all prosthesis types and diagnoses. The aim of this study was to assess the impact of component variables in the various primary total arthroplasty alternatives for osteoarthritis in the shoulder. Data from a large national arthroplasty registry were analysed for the period April 2004 to December 2020. The study population included all primary aTSA, RTSA, and TMH shoulder arthroplasty procedures undertaken for osteoarthritis (OA) using either cross-linked polyethylene (XLPE) or non-cross-linked polyethylene (non XLPE). Due to the previously documented and reported higher revision rate compared to other anatomical total shoulder replacement options, those using a cementless metal backed glenoid components were excluded. The rate of revision was determined by Kaplan-Meir estimates, with comparisons by Cox proportional hazard models. Reasons for revision were also assessed. For a primary diagnosis of OA, aTSA with a cemented XLPE glenoid component had the lowest revision rate with a 12-year cumulative revision rate of 4.7%, compared to aTSA with cemented non-XLPE glenoid component of 8.7%, and RTSA of 6.8%. The revision rate for TMH was lower than aTSA with cemented non-XLPE, but was similar to the other implants at the same length of follow-up. The reason for revision for cemented aTSR was most commonly component loosening, not rotator cuff deficiency. Long stem humeral components matched with XLPE in aTSA achieve a lower revision rate compared to shorter stems, long stems with conventional polyethylene, and RTSA when used to treat shoulder OA. In all these cohorts, loosening, not rotator cuff failure was the most common diagnosis for revision

Recent studies have described safe outcomes for short-stays in the hospital after total shoulder arthroplasty. The purpose of this study is to identify pre-operative and operative risk factors for hospital admissions exceeding 24 hours. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2016 for the current procedural terminology (CPT) billing code related to total shoulder arthroplasty. Patients were then grouped as either having a length of stay (LOS) equal to or less than 24 hours or greater than 24 hours. Patients admitted to the hospital prior to the day of surgery were excluded. Patient demographics, co-morbidities, and operative time were then analyzed as risk factors for a hospital stay exceeding 24 hours. Pre-operative co-morbidities included body mass index (BMI), diabetes, smoking, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, dialysis, chronic steroid or immunosuppressant use, bleeding disorders, and American Society of Anesthesiologists (ASA) Classification. Univariate and multivariate analyses were then performed to identify risk factors associated with 30-day readmission. 14,339 patients met inclusion criteria and 6,507 (45.3%) had a hospital LOS less than or equal to 24 hours. The mean length of hospitalization was 1.95 ± 1.88 days, the average age was 69 ± 9.7 years old, and 56.9% of the patients were female. Following a risk adjusted multivariate analysis, increasing age (odds ratio [OR], 1.03, 95% confidence interval [CI], 1.02–1.03), ASA classification (OR, 1.50, 95% CI, 1.41–1.60), diabetes (OR, 1.69, 95% CI, 1.43–1.99), COPD (OR, 1.35, 95% CI, 1.16–1.57), CHF (OR, 2.67, 95% CI, 1.34–5.33), dialysis (OR, 2.47, 95% CI, 1.28, 4.77), history of a bleeding disorder (OR, 1.50, 95% CI, 1.20–1.88), or increasing operative time (OR, 1.01, 95% CI, 1.01–1.01) were identified as independent risk factors for hospital lengths of stay exceeding 24 hours. Male gender was identified as a protective factor for prolonged hospitalization (OR, 0.50, 95% CI, 0.46–0.53). This study identifies patient demographics, co-morbidities, and operative-relative risk factors that are associated with increased risk for a prolonged hospitalization following total shoulder arthroplasty. Female gender, increasing age, ASA classification, operative time, or a history of diabetes, COPD, CHF, or history of a bleeding disorder are risk factors hospitalizations exceeding 24 hours

Purpose. Total shoulder arthroplasty (TSA) has become a successful treatment option for degenerative shoulder disease. With the increasing incidence in primary TSA procedures during the last decades, strategies to improve implant longevity become more relevant. Implant failure is mainly associated with mechanical or biological causes. Chronic inflammation as a response to wear particle exposure is regarded as a main biological mechanism leading to implant failure. Metal ions released by fretting and corrosion at modular taper connections of orthopedic implants can cause cell-mediated hypersensitivity reactions and might lead to aseptic loosening. Modularity is also commonly used in total shoulder replacement. However, little is known about metal ion exposure in patients following TSA. The objective of this study was to determine in-vivo blood metal ion levels in patients after TSA and to compare blood metal ion levels to control subjects without metal implants. Methods. A total of 19 patients with anatomical total shoulder prosthesis (TSA group) and 20 patients with reverse total shoulder prosthesis (RSA group) who underwent unilateral total shoulder replacement at our hospital between March 2011 and December 2014 with no other metal implant or history of environmental metal ion exposure were recruited for analysis of blood metal ion concentrations of cobalt (Co), chromium (Cr) and titanium (Ti) at a mean follow-up period of 2.3 years (0.7–4.3). For comparison of metal ion concentrations blood samples were obtained in a healthy control group of 23 subjects without metal implants. Ethical approval and informed consent of each patient were obtained for this study. Results. Median cobalt ion levels were 0.14µg/l (range 0.03–0.48) in the TSA group, 0.18 µg/l (0.10–0.66) in the RSA group and 0.11µg/l (0.03–0.19) in the control goup. Median chromium ion levels were 0.34µg/l (0.09–1.26) in the TSA group, 0.48µg/l (0.17–2.41) in the RSA group and 0.14µg/l (0.04–0.99) in the control goup. Median titanium ion levels were 0.86µg/l (0.10–1.64) in the TSA group, 1.31µg/l (0.75–4.52) in the RSA group and 0.62µg/l (0.32–2.14) in the control goup. There was a statistically significant difference in chromium and titanium ion concentrations between both study groups and the control group (see figure 1–3). Conclusion. Patients with unilateral total shoulder replacement demonstrated elevated blood metal ion concentrations. Median blood metal ion levels were higher in the RSA group compared to the TSA group, which could be attributable to the modularity of the reverse total shoulder system. However, overall metal ion levels were relatively low compared to those seen in patients with metal-on-metal total hip replacements. The role of local metal ion exposure in the development of aseptic loosening or hypersensitivity reactions associated with total shoulder arthroplasty should be further investigated. For figures/tables, please contact authors directly.

Background. Tranexamic acid is an antifibrinolytic drug that has been shown to successfully reduce postoperative blood loss in total knee and hip arthroplasty. However, the efficacy of TXA following total shoulder arthroplasty has not been reported. Purpose. The purpose of the present study was to evaluate the impact of intravenous TXA on postoperative blood loss and transfusion rates in total shoulder reconstruction. Methods. Between July and December 2014, 50 patients scheduled for primary total shoulder arthroplasty of the shoulder were included in this blinded, randomized study. Patients received either 1000mg intravenous TXA within thirty minutes before skin incision and another 1000mg intravenously administered TXA during wound closure (group 1), or a placebo (group 2). The perioperative blood loss and the rate of blood transfusions were analyzed. Results. Early postoperative blood loss was 80.0±105.5ml in the TXA group (group 1), and 202.1±195.8ml in the placebo group (group 2). The administration of blood products was not necessary during the study period. Conclusion. The administration of intravenous tranexamic acid significantly reduced the postoperative blood loss following total shoulder arthroplasty

Arthroplasty implant modularity enables the surgeon to adapt the joint replacement construct to the patient's requirements, and often facilitates revision procedures. Total shoulder arthroplasty humeral modularity exists for many implant systems. Glenoid modularity with convertibility between anatomic and reverse shoulder arthroplasty is a recent development. Glenoid modularity is very useful when reconstructing glenoid bone deficiencies, or in providing a method for reverse shoulder arthroplasty joint lateralization. The live surgery will demonstrate a bio-reverse total shoulder arthroplasty (bRTSA). The humeral component is a modular press fit stem that can accommodate either reverse or anatomic metaphyseal components. The metaphyseal components can be exchanged without removing the stem or changing the humeral height. The glenoid base has three components. The trabecular titanium peg is available in two diameters, and four lengths for each diameter. The peg is fixed to a metal base plate via Morse taper. In revision settings, these components can be easily dissociated in situ, and a coring drill inserted over a well-fixed peg allows removal with minimal bone loss. Either a polyethylene component, or glenosphere can be attached to the baseplate to complete the glenoid construct. An innovative set of instruments have been developed to reliably prepare the glenoid and humeral bone graft. While the live surgery will demonstrate the grafting technique in a bRTSA, it can also be used to reconstruct glenoid deficiencies (eg, Walch B2). Implants have been developed to solve these issues, but often do so at the expense of very limited glenoid bone stock. Bone grafting actually creates a net increase in glenoid bone stock that may improve implant durability, and decrease revision complexity. The technique is quite simple and adds approximately ten minutes to operative time. I have used this technique for 5 years with no cases of graft failure

INTRODUCTION. Mechanically assisted crevice corrosion of taper interfaces was raised as a concern in total hip arthroplasty (THA) approximately 20 years ago (Gilbert 1993). In total shoulder replacement, however, comparatively little is known about the prevalence of fretting assisted crevice corrosion or the biomechanical and patient factors that influence this phenomenon. Given the comparatively lower loading experienced in the shoulder compared to the hip, we asked: (1) What is the prevalence of fretting assisted corrosion in modular total shoulder replacements, and (2) What patient and implant factors are associated with corrosion?. METHODS. Modular components were collected from 48 revision shoulder arthroplasties as part of a multi-center, IRB approved retrieval program. For anatomic shoulders, this included 40 humeral heads, 32 stems and four taper adapters from seven manufacturers. For reverse shoulders, there were eight complete sets of retrieved components from three manufacturers. The components were predominantly revised for instability, loosening and pain. Anatomical shoulders were implanted for an average of 3.1 years (st dev 3.8; range 0.1–14.5). Reverse shoulders were implanted for an average of 2.2 years (st dev 0.7; range 1.3–3.3). Modular components were disassembled and examined for taper damage. The modular junctions were scored for fretting corrosion using a semi-quantitative four-point scoring system adapted from Goldberg, et al. (Goldberg, 2002, Higgs 2013). The scoring system criteria was adapted from Goldberg and Higgs which is comprised of a one to four grading system (with one indicating little-to-no fretting/corrosion and four indicating extensive fretting/corrosion). The component alloy composition was determined using the manufacturer's laser markings and verified by x-ray fluorescence. Patient age, gender, hand dominance, alloy, flexural rigidity of the trunnion and taper geometry were assessed independently as predictors for fretting corrosion. RESULTS. Moderate to severe fretting corrosion (score > 2) was observed in 23% of the anatomic modular components (Figure 1) and 22% of the reverse shoulder components. An example with severe damage is included in Figure 1. There was no significant relation between corrosion scores and any of the assessed factors. DISCUSSION AND CONCLUSION. It has been suggested that fretting assisted crevice corrosion may be a concern in THA, particularly with large head metal-on-metal articulations. We have identified the presence of moderate to severe corrosion on approximately one quarter of all retrieved shoulder arthroplasties. This is similar to the proportion observed in retrieved modular hips (Goldberg, 2002). While the expected loading of the shoulder is less than that in the hip (Westerhoff, 2009), the offset between the effective center of the prosthetic humeral head and the taper connecter is often larger and the size of the taper is smaller. This can increase the effect of bearing surface loading on the taper. We were unable to detect significant associated biomechanical or patient factors. This was probably due to the limited sample size of our population. At the present time, the clinical effects of taper corrosion in shoulder arthroplasty remain unknown

Aim. Cutibacterium acnes (C. acnes) is the most cultured organism implicated in periprosthetic shoulder infections. Nevertheless, the clinical significance of its persistence on the skin surface and in the deep layers during shoulder arthroplasty surgery remains still unknown. The purpose of this study was to know if the C. acnes isolate present in deep tissues at the end of a primary shoulder arthroplasty could be responsible for shoulder arthroplasty infection. Method. Prospective study including 156 patients undergoing primary shoulder arthroplasty. In all the patients included 5 to 12 tissue samples were obtained and were specifically cultured to detect C. acnes presence. DNA was extracted from the C. acnes colonies selected with the QIAsymphony DSP Virus/Pathogen Midi Kit (Qiagen, Hilden, Germany). Libraries were prepared using Nextera XT kit (Illumina) and sequenced in an Illumina MiSeq sequencer. Sequencing files were pre-processed using The Microbial Genome Atlas pipeline. Samples that failed on QC analysis were discarded for further analysis. Isolate nucleotide distances were calculated using Genome-based distance matrix calculator from the enveomics collection. Comparative genomic analysis was performed between intra- and inter-patients’ isolates. Data analysis was performed using R 3.6.3. Results. For twenty-seven out of 156 patients (17.31%), C. acnes was present at the end of the primary surgery. Two of these patients (both male) developed a C. acnes periprosthetic shoulder infection after 6 and 4 months from the primary surgery. DNA from the C. acnes responsible for the periprosthetic infection was further analysed by whole genome sequencing (WGS). Average Nucleotide Identity (ANI) value was assessed, measuring the nucleotide-level genomic similarity between genome pairs. We found a clear ANI clustering in two major groups which corresponded, mainly, to the associated phylotype (97%–98% ANI). Moreover, when analysing both isolates that developed a periprosthetic shoulder infection, we found that all the revision-surgery isolates clustered nearer to their corresponding primary-surgery isolates (99.4% of similarity) than to the other independent bacterial isolates, supporting the causal relationship between the initial and the delayed infection. Conclusions. C. acnes present at the end of the primary surgery can be the cause of early- or delayed-periprosthetic joint infections in shoulder arthroplasty, revealing the potential route of infection. Therefore, efforts must be made in terms of antibiotic prophylaxis and skin preparation to limit infections of total shoulder arthroplasties

Patient Specific Instruments (PSIs) are becoming increasingly common in arthroplasty but have only been used with highly invasive surgical approaches that can result in significant complications. We have previously described a novel PSI for minimally invasive total shoulder arthroplasty and shown that it can accurately guide the creation of guide holes in the humerus and scapula. However, conducting shoulder replacement in a minimally invasive environment precludes the use of traditional instruments. In this work, we describe and evaluate the efficacy of a set of novel instruments that, in conjunction with our PSIs, enable accurate minimally invasive total shoulder arthroplasty to be achieved for the first time. The key components of this surgical procedure are: 1) a new minimally invasive posterior surgical approach that avoids the need for muscle transection; 2) a novel PSI that enables accurate guide tunnels to be simultaneously created in the humerus and scapula using a c- shaped drill guide that mates to the PSI; 3) a custom humeral head resection guide that uses the humeral guide tunnel; 4) a novel reamer and 3D metal printed gear mechanism for radial displaced drilling both powered by a central driver placed through the humeral head; and 5) custom impactors for glenoid and humeral implantation – the latter is achieved using a modular slap hammer that is guided by the central humeral drill hole. Accuracy of this system was assessed at each surgical step using an optical tracking camera and an iterative closest point registration method to map measurements to the pre-operative plan. The accuracy results for the physical PSI registration and guide hole drilling were found to be in line with our previously reported results: the intra-articular guide hole locations were 2.2mm and 3.9mm for the humerus and glenoid with angular errors of 2.8° and 8°, respectively. After humeral resection, the humeral cut plane had an angular error of 10.1°. The final humeral implant location had an error of 12.1° and 1.9mm. For the glenoid implant, the positional error was 3.8mm with angular errors of 3.3° ante-retroversion and 8.6° supero- inferior inclination. We believe that these initial results demonstrate that this minimally invasive PSI and instrumentation system can accurately guide total shoulder replacement while avoiding the complications of open surgery. A full cadaveric testing series is currently being completed

Total shoulder arthroplasty (TSA) is an effective treatment for end-stage glenohumeral arthritis. The use of high modulus uncemented stems causes stress shielding and induces bone resorption of up to 63% of patients following TSA. Shorter length stems with smaller overall dimensions have been studied to reduce stress shielding, however the effect of humeral short stem varus-valgus positioning on bone stress is not known. The purpose of this study was to quantify the effect of humeral short stem varus-valgus angulation on bone stresses after TSA. Three dimensional models of eight male cadaveric humeri (mean±SD age:68±6 years) were created from computed tomography data using MIMICS (Materialise, Belgium). Separate cortical and trabecular bone sections were created, and the resulting bone models were virtually reconstructed three times by an orthopaedic surgeon using an optimally sized short stem humeral implant (Exactech Preserve) that was placed directly in the center of the humeral canal (STD), as well as rotated varus (VAR) or valgus (VAL) until it was contacting the cortex. Bone was meshed using a custom technique which produced identical bone meshes permitting the direct element-to-element comparison of bone stress. Cortical bone was assigned an elastic modulus of 20 GPa and a Poisson's ratio of 0.3. Trabecular bone was assigned varying stiffness based on CT attenuation. A joint reaction force was then applied to the intact and reconstructed humeri representing 45˚ and 75˚ of abduction. Changes in bone stress, as well as the expected bone response based on change in strain energy density was then compared between the intact and reconstructed states for all implant positions. Both varus and valgus positioning of the humeral stem altered both the cortical and trabecular bone stresses from the intact states. Valgus positioning had the greatest negative effect in the lateral quadrant for both cortical and trabecular bone, producing greater stress shielding than both the standard and varus positioned implant. Overall, the varus and standard positions produced values that most closely mimicked the intact state. Surprisingly, valgus positioning produced large amounts of stress shielding in the lateral cortex at both 45˚ and 75˚ of abduction but resulted in a slight decrease in stress shielding in the medial quadrant directly beneath the humeral resection plane. This might have been a result of direct contact between the distal end of the implant and the medial cortex under loading which permitted load transfer, and therefore load-reduction of the lateral cortex during abduction. Conversely, when the implant was placed in the varus angulation, noticeable departures in stress shielding and changes in bones stress were not observed when compared to the optimal STD position. Interestingly, for the varus positioned implant, the deflection of the humerus under load eliminated the distal stem-cortex contact, hence preventing distal load transfer thus precluding the transfer of load

The glenoid is the ‘weak link’ in total shoulder arthroplasty. Concerns exist over loosening of all glenoid components. Metal back glenoid components have, in some reports, had early problems with liner dissociation, polyethylene wear, osteolysis and component fracture. In November 2003 the first metal back SMR total shoulder replacement was implanted in New Zealand (NZ). We reviewed the NZ joint registry information on anatomical total shoulder replacements over a 5-year period from the end of 2003. There were 192 metal back SMR prostheses (Lima) implanted and 484 cemented prostheses (all brands). 70% of patients in each group completed an Oxford score at 6 months. The mean score in both groups was 40.39. There was no statistically significant difference in the revision rate in this period for revisions of any kind (p=0.07). 6/192 metal back cases had a revision procedure, but none were for the glenoid component. 7/484 cemented cases had a revision procedure with 3 being for glenoid loosening. None of the metal back glenoids were revised in this period. 5 of the cemented glenoids were revised in this period. There was a higher revision rate for instability in the metal back group with 5 in the metal back group and 2 in the cemented group being revised for instability (p=0.01). In the metal back group there were 3 revisions to a reverse shoulder arthroplasty without removal of the metal back glenoid base plate. We have not identified an early cause for concern with the use of the metal back SMR prosthesis in anatomical total shoulder replacement in New Zealand. It is possible, but not proven, that the modularity of the implant may lower the revision threshold for some cases. Reassuringly, there were no revisions of the metal back glenoid in this early period

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

BACKGROUND. Stability of the glenoid component is essential to ensure successful long-term outcomes following Total shoulder arthroplasty (TSA), and may be improved through better glenoid component design. As such, this study assessed identical all-polyethylene glenoid components stability, having various fixation types, using component micromotion under simulated joint loading in an osteoarthritic patient cohort. METHODS. Five all-polyethylene glenoid component designs were compared (Keel, Central-Finned 4-Peg, Peripheral 4-Peg, Cross-Keel, and Inverted-Y). A cement mantle surrounded each fixation type, except the Central-Finned 4-Peg which was surrounded by bone. The humeral component had a non-conforming radius of curvature. Scapular models of six type A1 osteoarthritic male patients (mean: 61 years old, range: 48 to 76 years old) were assigned heterogeneous bone properties based on CT intensity. Each of the 30 scapula models were truncated and fully constrained on the medial scapular border. The bone/cement interface was fully bonded, and the fixation feature/cement interface was frictionally constrained. A ‘worst case’ load magnitude of 125% BW of a 50th percentile male was used. A purely compressive load was applied to the center of the glenoid component, followed by superior, superior-posterior, posterior, inferior-posterior, and inferior loads. Stability of the glenoid component based solely on the fixation type was determined using the mean and maximum normal (liftoff) and tangential (sliding) micromotion in six regions of the glenoid component. RESULTS. The greatest mean normal micromotion occurred for the Inverted-Y (90 ± 36 μm) in the anterior- inferior region of the component under a posterior-superior directed load. The mean normal micromotions were significantly less for the same region and loading direction in the Peripheral 4-peg (48 ± 16 μm; p < .001) and Central-Finned 4-Peg (35 ± 13 μm; p < .001), but not significantly different for the Keel (78 ± 37 μm; p = .029), or Cross-Keel (82 ± 32 μm; p = .143). The same region and loading direction produced the maximum normal micromotion in the Inverted-Y (109 ± 43 μm), which was significantly greater than the other four components (Peripheral 4-peg, 61 ± 25 μm; p < .001, Keel, 89 ± 36 μm; p < .001, Central-Finned 4-Peg, 47 ± 19 μm; p < .001, and Cross-Keel, 92 ± 37 μm; p = .002). The greatest mean tangential micromotion occurred for the Cross-Keel (100 ± 36 μm) in the posterior-superior region of the glenoid component under a posterior-superior directed load. The mean tangential micromotions for all other components were significantly less (p < .001) for the same region and loading direction (Peripheral 4-peg, 73 ± 19 μm, Keel, 73 ± 22 μm, Central-Finned 4-Peg, 73 ± 26 μm, and Inverted-Y, 83 ± 24 μm). The same region and loading direction for the maximum tangential micromotion was also in the Cross-Keel (146 ± 46 μm), which was significantly greater (p < .001) from the other four components (Peripheral 4-peg, 111 ± 21 μm, Keel, 115 ± 34 μm, Central-Finned 4-Peg, 111 ± 39 μm, and Inverted-Y, 117 ± 34 μm). DISCUSSION. This study addressed the contribution of all-polyethylene glenoid component fixation types on component stability under simulated joint loading. Pegged components were significantly more stable than keeled components. An inverse relationship between normal and tangential micromotion was observed, with the greatest sliding (tangential micromotion) occurring in the direction of the applied load, and the greatest liftoff (normal micromotion) occurring opposite the applied load. This likely occurs due to polyethylene deformation of both the fixation features and the component as a whole

Introduction. Total shoulder arthroplasty (TSA) is an effective treatment to restore shoulder function and alleviate pain in the case of glenohumeral arthritis [1]. Stress shielding, which occurs when bone stress is reduced due to the replacement of bone with a stiffer metallic implant, causes bone resorption of up to 9% of the humeral cortical thickness following TSA [2]. Shorter length stems and smaller overall geometries may reduce stress shielding [3], however the effect of humeral head backside contact with the resection plane has not yet been fully investigated on bone stress. Therefore, the purpose of this study was to quantify the effect of humeral head contact conditions on bone stresses following TSA. Methods. 3D models of eight male left cadaveric humeri (68±6 years) were generated from CT data using MIMICS. These were then virtually prepared for reconstruction by an orthopaedic surgeon to accept a short-stem humeral implant (Exactech Equinoxe® Preserve) that was optimally sized and placed centrally in the humeral canal. The humeral head was positioned in the inferior-medial position such that contact was achieved on the medial cortex, and no contact existed on the lateral cortex. Three different humeral head backside contact conditions were investigated (Figure 1); full backside contact (FULL), contact with only the inferior-medial half of the resection (INF), and contact with only the superior-lateral half of the resection (SUP). Cortical bone was assigned an elastic modulus of 20 GPa and a Poisson's ratio of 0.3. Trabecular bone was assigned varying stiffness based on CT attenuation [4]. A joint reaction force was then applied representing 45˚ and 75˚ of abduction [5]. Changes in bone stress, as well as the expected bone response based on change in strain energy density [6] was then compared between the intact and reconstructed states. Results. For cortical bone, the full backside contact altered bone stress by 28.9±5.5% compared to intact, which was significantly less than the superior (37.0±3.9%, P=0.022) and inferior (53.4±3.9%, P<0.001) backside contact conditions. Similar trends were observed for changes in trabecular bone stress relative to the intact state, where the full backside contact altered bone stress by 86.3±27.9% compared to intact, compared to the superior and inferior contact conditions, which altered bone stress by 115.2±45.0% (P=0.309) and 197.4±80.2% (P=0.024), respectively. In terms of expected bone response, both the superior and inferior contact resulted in an increase in bone volume with resorbing potential compared to the full contact (Figure 2). Discussion and Conclusions. The results of this study show that full humeral head backside contact with the humeral resection plane is preferable for short stem humeral TSA implants with the head in the inferior-medial position. As expected, the superior contact typically increased resorption potential in the medial quadrant due to the lack of load transfer, however interestingly the inferior contact increased resorption potential in both the lateral and medial quadrants. Analysis of implant micromotion showed that medial liftoff of the implant occurred, which resulted in a lack of load transfer in the most medial aspect of the resection plane. For any figures or tables, please contact the authors directly

Background. Glenoid component aseptic loosening is the most common source of total shoulder arthroplasty (TSA) revision. In an attempt to strengthen cemented glenoid component fixation, divergent pegged glenoids were designed. Divergent peg creation was intended to increase cement purchase and provide resistance to component rocking. Methods. Thirty-four patients who underwent divergent peg TSA had data collected prospectively. The data from these patients was retrospectively reviewed, primarily for radiographic evidence of glenoid component loosening. The endpoint was defined as the need for revision secondary to glenoid loosening. Secondary outcome measures such as SPADI (shoulder pain and disability index), active forward elevation, abduction, internal rotation, and external rotation were also collected. Data was obtained preoperatively and at the following postoperative intervals: 3 months, 6 months, and yearly. The last available postoperative radiographs were also reviewed and graded on a modified Franklin glenoid lucency scale described by Lazarus et al. Results. The mean follow-up was 5.6 years ± 2.44 (range, 2–10 years). Of the 34 patients in the study, 20 patients had radiographs available for review. Radiographs showed complete lucency around one or less pegs in 14/20 patients (grade 0–2). Six out of twenty glenoids had complete radiolucency around two or more pegs with gross loosening seen in one shoulder (grade 3–5). No secondary surgery was performed in any patients. Significant improvements were seen in active elevation 30.2 degrees ±44.3 (p=0.043) at the last follow up. Improvement was also seen in internal rotation of 4.3 levels ± 4.9 (p=0.016) at the last follow-up. The mean postoperative SPADI score decreased by 48.1 points (p=0.039). Conclusions. Patients with divergent pegged glenoid TSA showed significant improvement in postoperative shoulder elevation, internal rotation, and SPADI scores at final follow-up. No patients underwent revision. However, there were a significant number of patients with radiolucency seen around 2 or more pegs

Glenoid loosening is a major problem in total shoulder arthroplasty. Failure of osteointegration, osteolysis and loosening are potential problems with concerning reports of these complications with earlier metal back designs. CT scans have been reported as more accurate than plain x-rays in examining fixation of components. This study examines the medium term osteointegration of the SMR (Lima) metal back glenoid component. 20 consecutive patients operated on by the same surgeon (KM) were evaluated at a mean of 3 years 9 months (range 3-5 years) using CT analysis. Films were read by a musculoskeletal radiologist (AS). 8 zones were described and the interface graded as ‘osteointergrated’, ‘lucent zone < 1mm’, ‘lucent zone 1-2mm’, ‘lucent zone > 2mm osteolysis’. Loosening was defined as lucent line on all zones > 1mm or migration of implant. No components were loose. All components were osteointegrated around the central peg. Osteointegration was observed in 85% of zones. 4% of the zones were graded as osteolysis, all in the one patient. This patient had osteolysis 4 years post-surgery with superior subluxation of the humeral head and polyethlylene and metal wear. The glenoid component was not loose at revision surgery. Problems with this technique of assessment include radiation exposure and artefact. Small lucent zones often had a well contoured margin suggesting that the component did not seat perfectly on the bone surface in these areas. These results confirm that reliable medium term osteointegration does occur with the SMR metal back glenoid in anatomical total shoulder replacement. Osteolysis can occur and longer term follow up is ongoing

Shoulder arthroplasty, both primary (TSA) and reverse (RTSA), are common interventions for arthritis and cuff tear arthropathy. The effect of shoulder arthroplasty on shoulder motion is of particular interest in assessing the effectiveness of the procedure and the development and biomechanical testing of implants. A comparison of the arthroplasty shoulder to that of the non-operated contralateral shoulder provides insight into how well the reconstruction has restored natural shoulder motion. The purpose of this study was to ascertain the shoulder motion of patients who have undergone shoulder arthroplasty and to compare the motion of the reconstructed and contralateral natural sides. Eleven human subjects (70±9yrs) who had undergone total shoulder arthroplasty wore a custom instrumented shirt for the waking hours of one day. The 3D orientation of each humeral sensor was transformed with respect to the torso to allow for the calculation of humeral elevation and plane of elevation angles. Joint angles for each subject were then discretised, and the operative and contralateral normal (control) shoulders were then compared. The majority of both the arthroplasty and control shoulder elevation motions took place below 80° of elevation, totaling on average 1910±373 and 1887±312 motions per hour, respectively. Conversely, elevations greater than 80° were significantly less with occurrences totaling only 55±31 and 78±41 motions per hour for the arthroplasty and control shoulders, respectively (p<0.01). Both the arthroplasty and control shoulder were at elevations below 80° for 88±7% and 87±7% of the day, respectively. When the total motion of the arthroplasty and non-operative control shoulders were compared, no statistically significant difference was detected (p=0.8), although the non-operated side exhibited marginally more motion than the operated side, an effect which was larger at higher elevation angles (p=0.3). This study provides insight into the effects of shoulder arthroplasty on thoraco-humeral motion and compares it to the non-operative side. Interestingly, there were no significant differences measured between the arthroplasty and the control side, which may demonstrate the effectiveness of reconstruction on restoring natural shoulder motion. It is interesting to note that on average, each shoulder arthroplasty elevated above 80° approximately 55 times per hour, corresponding to just under 330,000 motions per year. Similarly, when elevations greater than 60° are extrapolated, the resulting yearly motions total approximately 1.5 million cycles (Mc), which suggests that the ‘duty cycle’ of the shoulder is similar to the hip, approximated to be between 1–2 Mc per year. Arthroplasty wear simulators should be calibrated to simulate these patterns of motion, and component design may be improved by understanding the kinematics of actual shoulder motion

PURPOSE. To validate the efficacy and accuracy of a novel patient specific guide (PSG) and instrumentation system that enables minimally invasive (MI) short stemmed total shoulder arthroplasty (TSA). MATERIALS AND METHODS. Using Amirthanayagam et al.'s (2017) MI posterior approach reduces incision size and eliminates subscapular transection; however, it precludes glenohumeral dislocation and the use of traditional PSGs and instruments. Therefore, we developed a PSG that guides trans-glenohumeral drilling which simultaneously creates a humeral guide tunnel/working channel and glenoid guide hole by locking the bones together in a pre-operatively planned pose and drilling using a c-shaped drill guide (Figure 1). To implant an Affinis Short TSA system (Mathys GmbH), novel MI instruments were developed (Figure 2) for: humeral head resection, glenoid reaming, glenoid peg hole drilling, impaction of cruciform shaped humeral bone compactors, and impaction of a short humeral stem and ceramic head. The full MI procedure and instrument system was evaluated in six cadaveric shoulders with osteoarthritis. Accuracy was assessed throughout the procedure: 1) PSG physical registration accuracy, 2) guide hole accuracy, 3) implant placement accuracy. These conditions were assessed using an Optotrak Certus tracking camera (NDI, Waterloo, CA) with comparisons made to the pre-operative plan using a registration process (Besl and McKay, 1992). RESULTS. 3D translational accuracy of PSG physical registration was: humeral PSG- 2.2 ± 1.1 mm and scapula PSG- 2.5 ± 0.7 mm. The humeral and scapular guide holes had angular accuracies of 6.4 ± 3.2° and 8.1 ± 5.1°, respectively; while the guide hole positional accuracies on the articular surfaces (which will control bone preparation translational accuracy) were 2.9 ± 1.2 mm and 2.8 ± 1.3 mm. Final implantation accuracy in translation was 2.9 ± 3.0 mm and 5.7–6.8 ± 2.2–4.0° across the implants’ three rotations for the humerus and in translation was 2.8 ± 1.5 mm and 2.3–4.3 ± 2.2–4.4° across the implants’ three rotations for the scapula (Figure 3). DISCUSSION. The overall implantation accuracy was similar to results of previously reported open, unassisted TSA (3.4 mm & 7–12°, Hendel et al., 2012, Nguyen et al., 2009). Analysis of the positional PSG registration accuracy very closely mirrors the final implantation accuracy (humerus:2.2 mm vs 2.9 mm, and scapula:2.2 mm vs 2.8mm), thus, this is likely the primary predictor of implantation accuracy. Furthermore, the greatest component of PSG registration error was mediolateral translation (i.e. along the guiding axis) and thus should not affect guide hole drilling accuracy. The drilled guide hole positional and angular error was low for the humerus (2.9 mm and 6.4°) but somewhat higher in rotation (8.1°) for the glenoid which may indicate a slight shift in the PSG prior to guide hole drilling due to the weight of the arm applied when the PSGs are locked together. In conclusion, this work has detailed the step-by-step surgical errors associated with the developed system and demonstrated that it achieves similar accuracy to open, unassisted TSA, while avoiding complications related to muscular transection and dislocation. Therefore, we believe this technique is worthy of clinical investigation

Background. Total Shoulder Arthroplasty (TSA) has been shown to improve the function and pain of patients with severe degeneration. Recently, TSA has been of interest for younger patients with higher post-operative expectations; however, they are treated using traditional surgical approaches and techniques, which, although amenable to the elderly population, may not achieve acceptable results with this new demographic. Specifically, to achieve sufficient visualization, traditional TSA uses the highly invasive deltopectoral approach that detaches the subscapularis, which can significantly limit post-operative healing and function. To address these concerns, we have developed a novel surgical approach, and guidance and instrumentation system (for short-stemmed/stemless TSA) that minimize muscle disruption and aim to optimize implantation accuracy. Development. Surgical Approach: A muscle splitting approach with a reduced incision size (∼6–8cm) was developed that markedly reduces muscle disruption, thus potentially improving healing and function. The split was placed between the infraspinatus and teres-minor (Fig.1) as this further reduces damage, provides an obvious dissection plane, and improves access to the retroverted articular surfaces. This approach, however, precludes the use of standard bone preparation methods/instruments that require clear visualization and en-face articular access. Therefore, a novel guidance technique and instrumentation paradigm was developed. Minimally Invasive Surgical Guidance: 3D printed Patient Specific Guides (PSGs) have been developed for TSA; however, these are designed for traditional, highly invasive approaches providing unobstructed access to each articular surface separately. As the proposed approach does not offer this access, a novel PSG with two opposing contoured surfaces has been developed that can be inserted between the humeral and scapular articular surfaces and use the rotator cuff's passive tension to self-locate (Fig.2). During computer-aided pre-operative planning/PSG design, the two bones are placed into an optimized relative pose and the PSG is constructed between and around them. This ensures that when the physical PSG is inserted intra-operatively, the bones are locked into the preoperatively planned pose. New Instrumentation Paradigm: With the constraints of this minimally invasive approach, a new paradigm for bone preparation/instrumentation was required which did not rely on en-face access. This new paradigm involves the ability to simultaneously create glenoid and humeral guide axes – the latter of which can guide humeral bone preparation and be a working channel for tools – by driving a short k-wire into the glenoid by passing through the humerus starting laterally (Fig.3). By preoperatively defining the pose produced by the inserted PSG as one that collinearly aligns the bones’ guide axes, the PSG and an attached c-arm drill guide facilitate this new lateral drilling technique. Subsequently, bone preparation is conducted using novel instruments (e.g. reamers and drills for creating holes radial to driver axis) powered using a trans-humeral driver and guided by the glenoid k-wire or humeral tunnel. Conclusion. To meet the expectations of increasingly younger TSA patients, advancements in procedural invasiveness and implantation accuracy are needed. This need was addressed by developing a novel, fully integrated surgical approach, PSG system, and instrumentation paradigm, the initial in-vitro results of which have demonstrated acceptable accuracy while significantly reducing invasiveness

Background. Accurate placement of the glenoid component in total shoulder arthroplasty (TSA) is critical to optimize implant longevity. Commercially available patient-specific instrumentation systems can improve implant placement, but may involve considerable expense and production delays of up to six weeks. The purpose of this study was to develop a novel technique for in-house production of 3D-printed, patient-specific glenoid guides, and compare the accuracy of glenoid guidepin placement between the patient-specific guide and a standard guide using a cadaveric model. Methods. Twenty cadaveric shoulder specimens were randomized to receive glenoid guidepin placement via standard TSA guide (Wright Medical, Memphis, TN) or patient-specific guide. Three-dimensional scapular models were reconstructed from CT scans with Mimics 20.0 imaging software (Materialise NV, Leuven, Belgium). A pre-surgical plan was created for all specimens for the central glenoid guidepin of 0º version and inclination angles. Central pin entry and exit points were also calculated. Patient-specific guides were constructed to achieve the planned pin trajectory in Rhino3D software (Robert McNeel & Associates, Seattle, WA). Guides were 3D-printed on a Form2 printer with Formlabs Dental SG Resin (Formlabs, Somerville, MA). Glenoid labrum and cartilage were removed with preservation of other soft tissues in all specimens to mimic intraoperative TSA conditions. A fellowship-trained, board-eligible orthopaedic surgeon placed a 2.5 mm diameter titanium guidepin into each glenoid using the assigned guide for each specimen. After pin placement, repeat CT scans were performed, and a blinded measurer used superimposed 3D scapular reconstructions to calculate deviation from the pre-surgical plan in version and inclination angles, dot product angle, and guide pin entry and exit points. Student's t tests were performed to detect differences between pin placements for the two groups. Results. Cadaver age, sex, and BMI did not differ between groups (p>0.05 for all). Average production cost and time for the patient-specific guides were $29.95 and 4 hours and 40 minutes per guide, respectively. Guidepin version deviation did not differ between the patient-specific and standard guides (1.59º ± 1.60º versus 2.88 º ± 2.11º, respectively, p=0.141). Guidepin inclination deviation was significantly lower in the patient-specific group (1.54º ± 1.58º versus 6.42º ± 5.03º, p=0.009), similarly the dot product angle was lower in the patient-specific compared to standard guide group (2.35º ± 1.66º versus 7.48º ± 4.76º, p=0.005). Glenoid entry site exhibited less deviation for the patient-specific compared to standard guide (0.75mm ± 0.54mm versus 2.05mm ± 1.19mm, p=0.006). Glenoid exit site also was closer to the target for the patient- specific compared to standard group (1.75mm ± 0.99mm versus 4.75mm ± 2.97mm, p=0.010). Conclusion. We present a novel technique for in-house production of 3D-printed, patient-specific glenoid guides for TSA glenoid pin placement. These patient-specific guides improved pin placement accuracy based on 3D-CT measurements compared to standard TSA guides in a cadaveric model. Our patient-specific glenoid guides can be produced on-demand, in-house, inexpensively, and with significantly reduced time compared to commercially available guides. Future studies are required to validate these findings in clinical applications and determine the potential impact on implant longevity