Despite the high success rates of Reverse Shoulder replacements, complications of instability & scapular notching are a concern. Factors reducing relative motion of implant to underlying bone which include lateral offset to centre of rotation, screw & central peg insertion angle and early osteo-integration are maximized in the Trabecular Metal Reverse total shoulder system. We present clinico-radiological outcomes over 72 months.

Analysis of a single surgeon series of 140 Reverse total shoulder replacements in 135 patients was done. Mean age was 72(range 58– 87 yrs); 81 females: 54 males. Indications were Rotator cuff arthropathy {n= 88} (63%); Osteo-arthritis with dysfunctional cuff {n= 22}(15%); post-trauma{n=23} (15%); revision from hemiarthroplasty {n=3} (2.4%) and from surface replacement {n=4} (2.8%)

All patients were assessed using pre-operative Constants and Oxford scores and clinical & radiographic reviews with standard X-Rays at 6 weeks, 3, 6,12 months and yearly thereafter. X rays included an AP view in 45 degrees of external rotation and modified axillary view. Inferior Scapular notching using the Nerot-Sirveaux grades and Peg Glenoid Rim Distance were looked into by a consultant musculoskeletal radiologist/ Orthopaedic surgeon/ Senior Fellow (post CCT) or a specialist Trainee (ST4 and above). Pain on the visual analogue scale decreased by 98% (9.1 to 0.8) (p<0.01). Constant score improved by 81.8% (12.4 to 68.1) (p<0.05), Oxford shoulder score by 76.7% (56 to 13) (p<0.05). 95.6% of Humeral stems had no radiolucent lines and 4.4% had < 2mm of lucency. Scapular notching was calculated using Sirveaux grades with Peg scapular base angle distance (PSBA) measurements on PACS with Siemens calibration (grade 1= 4 (2.8%); grade 2 =1; grade 3 =0; grade 4=0). 3.57% showed radiographic signs of scapular notching at 72 months. Range of Peg Glenoid Rim Distance was 1.66 to 2.31 cm. Power analysis showed 65 patients were needed to have an 80% power to detect relation of Peg Glenoid Rim Distance to Scapular notching. A likelihood ratio test from Logistic regression model to check correlation of Peg Glenoid Rim Distance to Scapular notching gave a p value of 0.0005. A likelihood ratio from Logistic regression gave a p value of 0.0004 for Infraglenoid Scapular spurs. Highest incidence of spurring was seen in Reverse Total Shoulder Replacements done for Trauma and lowest in patients who got the procedure for Osteoarthritis. Complications included two glenosphere revisions; two stitch abscesses and two Acromial fractures in patients who had a fall two years after the procedure. Improved surgical outcomes can be attributed to surgical technique and implant characteristics. Trabacular metal promotes early osteointegration which resists shearing action of Deltoid on Glenoid component. This allows early mobilisation. Deltoid split approach preserves integrity of Subscapularis and Acromial osteotomy and lateral clavicle excision improve exposure and prevent Acromion fracture. Positioning the Glenoid component inferiorly on the Glenoid decreases incidence of Scapular notching.

Our mid-term validated outcomes are promising with only 3.57% Grade I/II radiographic signs of scapular notching. Long term studies (10 year follow ups) are necessary to confirm its efficacy.

In 1902 Shenton described his “line” which, “is formed by the outlines of the upper margin of the obturator foramen and the inner margin of the neck of the femur” stating, “broken continuity of which infallibly indicates displacement or trouble in the hip region. Some 110 years later with significant advancements in Radiology, we assessed whether there is still a role in modern Orthopaedics.

We reviewed 900 anterior-posterior bilateral hips on pelvis radiographs and noted whether Shenton's line was intact or broken. We recorded the presence or absence of pathology in each hip along with age and sex of the patient. In addition 15 independent observers were asked to blindly independently review 15 pelvic radiographs on two separate occasions. They noted whether Shenton's line was intact or disrupted. From this data we analysed the intra and inter-observer reliability.

1547 hips were analysed. 63% (971/1547) had an intact Shenton's line, 37% (576/1547) had a disrupted line. Of 271 femoral neck fractures, 44 (16%) were seen to have an intact Shenton's line. Regarding other pathologies, 2% of osteoarthritic hips, 0.1% of dysplastic hips and 20% of prosthetic hips had a disrupted Shenton's line. No ‘normal’ hips had a broken line. There was significant inter-observer error yet little intra-observer error found.

Our evidence reaffirms Shenton's original work. With a disrupted line there is a high probability of pathology within the hip. However, there may still be a fracture with an intact line, suggesting that Shenton's line is highly sensitive yet not greatly specific.