Aims. Glenoid bone loss can be a challenging problem when revising a shoulder arthroplasty. Precise pre-operative planning based on plain radiographs or CT scans is essential. We have investigated a new radiological classification system to describe the degree of medialisation of the bony glenoid and that will indicate the amount of bone potentially available for supporting a glenoid component. It depends on the relationship between the most medial part of the articular surface of the glenoid with the base of the coracoid process and the spinoglenoid notch: it classifies the degree of bone loss into three types. It also attempts to predict the type of glenoid reconstruction that may be possible (impaction bone grafting, structural grafting or simple non-augmented arthroplasty) and gives guidance about whether a pre-operative CT scan is indicated. Patients and Methods. Inter-method reliability between plain radiographs and CT scans was assessed retrospectively by three independent observers using data from 39 randomly selected patients. . Inter-observer reliability and test-retest reliability was tested on the same cohort using Cohen's kappa statistics. Correlation of the type of glenoid with the Constant score and its pain component was analysed using the Kruskal-Wallis method on data from 128 patients. Anatomical studies of the scapula were reviewed to explain the findings. Results. Excellent inter-method reliability, inter-observer and test-retest reliability were seen. The system did not correlate with the Constant score, but correlated well with its pain component. . Take home message: Our system of classification is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. Cite this article: Bone Joint J 2016;98-B:374–80

Aims. Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA). Methods. A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion. Results. RSA analysis showed a small increase in all translation and rotational values up to six months postoperatively, consistent with settling of the implant. The mean values plateaued by 12 months, with no evidence of further migration. In four patients, there was significant variation outside the mean, which corresponded to postoperative complications. There was a significant improvement in the clinical and patient-reported outcomes from the preoperative values to those at two years postoperatively (p < 0.001). Conclusion. These findings show, using RSA, that a glenoid baseplate composite of a trabecular titanium peg with autograft stabilizes within the glenoid about 12 months after surgery, and reinforce findings from a previous study of this implant/graft with CT scans at two years postoperatively, indicating that this type of structural composite results in sound early fixation. Cite this article: Bone Joint J 2023;105-B(8):912–919

Aims. We evaluated clinical and radiographic outcomes of total shoulder arthroplasty (TSA) using the second-generation Trabecular Metal (TM) Glenoid component. The first generation component was withdrawn in 2005 after a series of failures were reported. Between 2009 and 2012, 40 consecutive patients with unilateral TSA using the second-generation component were enrolled in this clinical study. The mean age of the patients was 63.8 years (40 to 75) and the mean follow-up was 38 months (24 to 42). Methods. Patients were evaluated using the Constant score (CS), the American Shoulder and Elbow Surgeons (ASES) score and routine radiographs. Results. Significant differences were found between the pre- and post-operative CS (p = 0.003), ASES (p = 0.009) scores and CS subscores of pain (p < 0.001), strength (p < 0.001) and mobility items (p < 0.05). No glenoid or humeral components migrated. Posterior thinning of the keel and slight wear at the polyethylene-TM interface was observed in one patient but was asymptomatic. Radiolucent lines were found around three humeral (< 1.5 mm) and two glenoid components (< 1 mm) and all were asymptomatic. Discussion. TSA with the second-generation TM Glenoid component results in satisfactory to excellent clinical performance, function, and subjective satisfaction at a mean follow-up of about three years. Radiographic changes were few and did not affect the outcome. Take home message: This paper highlights that the second generation Trabecular Metal Glenoid has better outcomes than those reported with the first-generation component.  . Cite this article: Bone Joint J 2016;98-B:75–80

Aims. We report the clinical results of glenoid osteotomy in patients with atraumatic posteroinferior instability associated with glenoid dysplasia. Patients and Methods. The study reports results in 211 patients (249 shoulders) with atraumatic posteroinferior instability. The patients comprised 63 men and 148 women with a mean age of 20 years. The posteroinferior glenoid surface was elevated by osteotomy at the scapular neck. A body spica was applied to maintain the arm perpendicular to the glenoid for two weeks postoperatively. Clinical results were evaluated using the Rowe score and Japan Shoulder Society Shoulder Instability Score (JSS-SIS); bone union, osteoarthrosis, and articular congruity were examined on plain radiographs. Results. The Rowe score improved from 36 to 88 points, and the JSS-SIS improved from 47 to 81 points. All shoulders exhibited union without progression of osteoarthritis except one shoulder, which showed osteoarthritic change due to a previous surgery before the glenoid osteotomy. All but three shoulders showed improvement in joint congruency. Eight patients developed disordered scapulohumeral rhythm during arm elevation, and 12 patients required additional open stabilization for anterior instability. Conclusion. Good results can be expected from glenoid osteotomy in patients with atraumatic posteroinferior instability associated with glenoid dysplasia. Cite this article: Bone Joint J 2018;100-B:331–7

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

Aims. The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system. Methods. We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217). Results. Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%). Conclusion. These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids. Cite this article: Bone Joint J 2023;105-B(6):668–678

Aims. This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder. Methods. A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient’s shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid. Results. During the apprehension test, the centre of the humeral head was 1.0 mm (95% CI 0.0 to 2.0) more inferior on the glenoid for the ASI shoulder compared with the healthy shoulder. Furthermore, the contact point of the ASI shoulder was 1.4 mm (95% CI 0.3 to 2.5) more anterior and 2.0 mm (95% CI 0.8 to 3.1) more inferior on the glenoid compared with the healthy shoulder. The contact point of the ASI shoulder was 1.2 mm (95% CI 0.2 to 2.6) more anterior during the apprehension test compared to the relocation test. Conclusion. The humeral head centre was located more inferior, and the GHJ contact point was located both more anterior and inferior during the apprehension test for the ASI shoulders than the healthy shoulders. Furthermore, the contact point displacement between the apprehension and relocation test revealed increased joint laxity for the ASI shoulder than the healthy shoulders. These results contribute to existing knowledge that ASI shoulders with glenoid bone loss may also suffer from inferior shoulder instability. Cite this article: Bone Joint J 2024;106-B(10):1133–1140

Aims. The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. Methods. We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification. Results. The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05). Conclusion. Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence. Cite this article: Bone Joint J 2023;105-B(12):1314–1320

Aims. Rates of reverse total shoulder arthroplasty (rTSA) continue to grow. Glenoid bone loss and deformity remains a technical challenge to the surgeon and may reduce improvements in patients’ outcomes. However, there is no consensus as to the optimal surgical technique to best reconstruct these patients’ anatomy. This review aims to compare the outcomes of glenoid bone grafting versus augmented glenoid prostheses in the management of glenoid bone loss in primary reverse total shoulder arthroplasty. Methods. This systematic review and meta-analysis evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We performed searches of Medline (Ovid), Embase (Ovid), and PubMed from their dates of inception to January 2022. From included studies, we analyzed data for preoperative and postoperative range of motion (ROM), patient-reported functional outcomes, and complication rates. Results. A total of 13 studies (919 shoulders) were included in the analysis. The mean age of patients at initial evaluation was 72.2 years (42 to 87), with a mean follow-up time of 40.7 months (24 to 120). Nine studies with 292 rTSAs evaluated the use of bone graft and five studies with 627 rTSAs evaluated the use of augmented glenoid baseplates. One study was analyzed in both groups. Both techniques demonstrated improvement in patient-reported outcome measures and ROM assessment, with augmented prostheses outperforming bone grafting on improvements in the American Shoulder and Elbow Surgeons Score. There was a higher complication rate (8.9% vs 3.5%; p < 0.001) and revision rate among the bone grafting group compared with the patients who were treated with augmented prostheses (2.4% vs 0.6%; p = 0.022). Conclusion. This review provides strong evidence that both bone graft and augmented glenoid baseplate techniques to address glenoid bone loss give excellent ROM and functional outcomes in primary rTSA. The use of augmented base plates may confer fewer complications and revisions. Cite this article: Bone Joint J 2022;104-B(12):1334–1342

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

Aims. Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the ‘classic’ Friedman method. Methods. This was a retrospective study which evaluated 100 CT scans for patients who underwent a primary TSA. The glenoid version was measured using the Friedman and Ellipse methods by two senior observers. Statistical analyses were performed using the paired t-test for significance and the Bland-Altman plot for agreement. Results. The mean glenoid version was -3.11° (-23.8° to 17.9°) using the Friedman method and -1.95° (-29.8° to 24.6°) using the Ellipse method (p = 0.002). In 16 patients the difference between methods was greater than 5°, which we considered to be clinically significant. There was poor agreement between methods with relatively large 95% limits of agreement. There was excellent inter-rater agreement between the observers for the Ellipse method and similarly, the intrarater agreement was excellent with a repeatability coefficient of 0.94. Conclusion. We recommend the use of the Ellipse modification to define the mid glenoid point prior to measuring the glenoid version in patients undergoing TSA. Cite this article: Bone Joint J 2020;102-B(2):232–238

Aims. The Walch Type C dysplastic glenoid is characterized by excessive retroversion. This anatomical study describes its morphology. Patients and Methods. A total of 29 shoulders with a dysplastic glenoid were analyzed. CT was used to measure retroversion, inclination, height, width, radius-of-curvature, surface area, depth, subluxation of the humeral head and the Goutallier classification of fatty infiltration. The severity of dysplasia and deficiency of the posterior rim of the glenoid were recorded. Results. A type C glenoid occurred in 1.8% of shoulders referred to our tertiary centres. The mean retroversion, inclination, height, width, radius-of-curvature, surface area, and depth of the glenoid were 37°, 3°, 46 mm, 30 mm, 37°, 1284 mm. 3. , and 16 mm, respectively. The mean posterior subluxation was 90%. The Goutallier class was < 2 in 25 shoulders (86%). Glenoid dysplasia was mild in four, moderate in 14, and severe in 11 shoulders. The typical appearance of the posterior glenoid rim had a rounded or ‘lazy J’ morphology. The glenoid neck was deficient in 18 shoulders (62%). Conclusion. A dysplastic Type C glenoid characteristically has a uniconcave retroverted morphology, a deficient posteroinferior rim and scapular neck, and a reduced depth. These findings help to define the unique anatomical variations and may aid the planning of surgery and the development of components for these patients. Cite this article: Bone Joint J 2018;100-B:1074–9

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

Aims. The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up. Methods. Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening. Results. Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries. Conclusion. Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J 2022;104-B(1):83–90

Aims. The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA. Methods. A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity. Results. A total of 133 patients (95%) had synovial or chondral lesions. At the time of surgery, shoulders were graded as having mild, moderate, and severe OA in 55 (39.2%), 72 (51.4%), and six (4.2%) patients, respectively. A Hill-Sachs lesion and fibrillation affecting the anteroinferior glenoid cartilage were the most common findings. There was a significant positive correlation between the the severity of the development of glenohumeral OA and the patient’s age, their age at the time of the first dislocation, and the number of dislocations (p = 0.004, p = 0.011, and p = 0.031, respectively). Conclusion. Synovial inflammation and chondral damage associated with instability of the shoulder are more prevalent than previously reported. The classification using quadrants gives surgeons more information about the chondral damage, and could explain the pattern of development of glenohumeral OA after stabilization of the shoulder. As the number of dislocations showed a positive correlation with the development of OA, this might be an argument for early stabilization. Cite this article: Bone Joint J 2024;106-B(10):1125–1132

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

Aims. Patient-specific glenoid guides (PSGs) claim an improvement in accuracy and reproducibility of the positioning of components in total shoulder arthroplasty (TSA). The results have not yet been confirmed in a prospective clinical trial. Our aim was to assess whether the use of PSGs in patients with osteoarthritis of the shoulder would allow accurate and reliable implantation of the glenoid component. Patients and Methods. A total of 17 patients (three men and 14 women) with a mean age of 71 years (53 to 81) awaiting TSA were enrolled in the study. Pre- and post-operative version and inclination of the glenoid were measured on CT scans, using 3D planning automatic software. During surgery, a congruent 3D-printed PSG was applied onto the glenoid surface, thus determining the entry point and orientation of the central guide wire used for reaming the glenoid and the introduction of the component. Manual segmentation was performed on post-operative CT scans to compare the planned and the actual position of the entry point (mm) and orientation of the component (°). Results. The mean error in the accuracy of the entry point was -0.1 mm (standard deviation (. sd. ) 1.4) in the horizontal plane, and 0.8 mm (. sd. 1.3) in the vertical plane. The mean error in the orientation of the glenoid component was 3.4° (. sd. 5.1°) for version and 1.8° (. sd. 5.3°) for inclination. Conclusion. Pre-operative planning with automatic software and the use of PSGs provides accurate and reproducible positioning and orientation of the glenoid component in anatomical TSA. Cite this article: Bone Joint J 2016;98-B:1080–5

Aims. We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency. Patients and Methods. A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection. Results. Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines. Conclusion. The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique

Osteoarthritis results in changes in the dimensions of the glenoid. This study aimed to assess the size and radius of curvature of arthritic glenoids. A total of 145 CT scans were analysed, performed as part of routine pre-operative assessment before total shoulder replacement in 91 women and 54 men. Only patients with primary osteoarthritis and a concentric glenoid were included in the study. The CT scans underwent three-dimensional (3D) reconstruction and were analysed using dedicated computer software. The measurements consisted of maximum superoinferior height, anteroposterior width and a best-fit sphere radius of curvature of the glenoid. The mean height was 40.2 mm (. sd. 4.9), the mean width was 29 mm (. sd. 4.3) and the mean radius of curvature was 35.4 mm (. sd. 7.8). The measurements were statistically different in men and women and had a Gaussian distribution with marked variation. All measurements were greater than the known values in normal subjects. With current shoulder replacement systems using a unique backside radius of curvature for the glenoid component, there is a risk of undertaking excessive reaming to adapt the bone to the component resulting in sacrifice of subchondral bone or under-reaming and instability of the component due to a ’rocking horse‘ phenomenon. . Cite this article: Bone Joint J 2013;95-B:1377–82

Aims. Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair. Patients and Methods. Two finite element (FE) models were used to determine the risk of dislocation of the shoulder during 30 activities of daily living (ADLs) for the intact glenoid and after creating anterior osseous defects of increasing magnitudes. A Bankart repair was simulated for each size of defect, and the shoulder was tested under loading conditions that replicate in vivo forces during these ADLs. The critical size of a defect was defined as the smallest osseous defect that leads to dislocation. Results. The FE models showed a high risk of dislocation during ADLs after a Bankart repair for anterior defects corresponding to 16% of the length of the glenoid. Conclusion. This computational study suggests that bone grafting should be undertaken for an anterior osseous defect in the glenoid of more than 16% of its length rather than a solely soft-tissue procedure, in order to optimize stability by restoring the concavity of the glenoid

Our aim was to determine the most repeatable three-dimensional measurement of glenoid orientation and to compare it between shoulders with intact and torn rotator cuffs. Our null hypothesis was that glenoid orientation in the scapulae of shoulders with a full-thickness tear of the rotator cuff was the same as that in shoulders with an intact rotator cuff. We studied 24 shoulders in cadavers, 12 with an intact rotator cuff and 12 with a full-thickness tear. Two different observers used a three-dimensional digitising system to measure glenoid orientation in the scapular plane (ie glenoid inclination) using six different techniques. Glenoid version was also measured. The overall precision of the measurements revealed an error of less than 0.6°. Intraobserver reliability (correlation coefficients of 0.990 and 0.984 for each observer) and interobserver reliability (correlation coefficient of 0.985) were highest for measurement of glenoid inclination based on the angle obtained from a line connecting the superior and inferior points of the glenoid and that connecting the most superior point of the glenoid and the most superior point on the body of the scapula. There were no differences in glenoid inclination (p = 0.34) or glenoid version (p = 0.12) in scapulae from shoulders with an intact rotator cuff and those with a full-thickness tear. Abnormal glenoid orientation was not present in shoulders with a torn rotator cuff

Aims. Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively. Patients and Methods. We reviewed 24 patients with a mean age of 52 years (19 to 81) at a mean of 5.6 years (11 months to 18 years) after the injury. Results. At final follow-up, the mean Constant and Murley score was 79 points (18 to 98); the mean Western Ontario Shoulder Instability Index score (WOSI) was 77% (12 to 100) and the mean Rowe score was 93 points (50 to 100). Fractures with little intra-articular displacement (≤ 3 mm) had an uneventful outcome. Those with intra-articular displacement of ≤ 3 mm had a significant better mean Constant and Murley score than those with displacement of ≥ 5 mm and/or a fracture gap of ≥ 5 mm. Poor clinical results such as nonunion and post-traumatic osteoarthritis were associated with displaced or angulated glenoid fragments and significant intra-articular displacement. Conclusion. Glenoid fossa fractures with displacement of ≥ 5 mm should be treated surgically if the patient’s condition allows. Displacement and angulation can lead to nonunion and a poor outcome if the degree of displacement results in a persistent fracture gap in the glenoid fossa or if the angulation of fragments leads to malunion. Cite this article: Bone Joint J 2016;98-B:1074–9

Aims. Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery. Methods. A systematic review and meta-analysis was performed using the PubMed, EMBASE, Orthosearch, and Cochrane databases with the following search terms: ((shoulder or glenohumeral) and (dislocation or subluxation) and arthroscopic and (Bankart or stabilisation or stabilization) and (redislocation or re-dislocation or recurrence or instability)). Methodology followed the PRISMA guidelines. Data and outcomes were synthesized by two independent reviewers, and papers were assessed for bias and quality. Results. Overall, 35 studies including 7,995 shoulders were eligible for analysis, with a mean follow-up of 32.7 months (12 to 159.5). The rate of post-stabilization instability was 9.8% in first-time dislocators, 9.1% in recurrent dislocators, and 8.5% in a mixed cohort. A descriptive analysis investigated the influence of recurrent instability or age in the risk of instability post-stabilization, with an association seen with increasing age and a reduced risk of recurrence post-stabilization. Conclusion. Using modern arthroscopic techniques, patients sustaining an anterior shoulder dislocation without glenoid bone loss can expect a low risk of recurrence postoperatively, and no significant difference was found between first-time and recurrent dislocators. Furthermore, high-risk cohorts can expect a low, albeit slightly higher, rate of redislocation. With the findings of this study, patients and clinicians can be more informed as to the likely outcomes of arthroscopic stabilization within this patient subset. Cite this article: Bone Joint J 2024;106-B(10):1141–1149

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5° or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement

The aim of this study was to compare a third-generation cementing procedure for glenoid components with a new technique for cement pressurisation. In 20 pairs of scapulae, 20 keeled and 20 pegged glenoid components were implanted using either a third-generation cementing technique (group 1) or a new pressuriser (group 2). Cement penetration was measured by three-dimensional (3D) analysis of micro-CT scans. The mean 3D depth of penetration of the cement was significantly greater in group 2 (p < 0.001). The mean thickness of the cement mantle for keeled glenoids was 2.50 mm (2.0 to 3.3) in group 1 and 5.18 mm (4.4 to 6.1) in group 2, and for pegged glenoids it was 1.72 mm (0.9 to 2.3) in group 1 and 5.63 mm (3.6 to 6.4) in group 2. A cement mantle < 2 mm was detected less frequently in group 2 (p < 0.001). Using the cement pressuriser the proportion of cement mantles < 2 mm was significantly reduced compared with the third-generation cementing technique

Aim. We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate. Patients and Methods. We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up. Results. There were statistically significant improvements in the mean range of movement and Oxford Shoulder Score (p < 0.001). Kaplan-Meier survivorship at five years was 96.7% (95% confidence interval 91.5 to 98.7) with aseptic glenoid failure as the end point. . Radiologically, 63 shoulders (50.4%) showed no evidence of notching, 51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching and one (0.8%) had grade 4 notching. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere. Conclusion. The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969–75

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154). Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaulated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications. We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (. sd. ) as endpoints. The Constant score was found to improve from a mean of 26.8 (. sd. 10.3) pre-operatively to 57.6 (. sd. 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (. sd. 27.4) pre-operatively to 125° (. sd. 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (. sd. 6.5) pre-operatively to 30.3° (. sd. 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years. Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis. Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them

Aims. Radiostereometric analysis (RSA) allows an extremely accurate measurement of early micromotion of components following arthroplasty. . Patients and Methods. In this study, RSA was used to measure the migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent total shoulder arthroplasty using an improved surgical technique (seven men, four women, mean age 68). Patients were evaluated clinically using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores and by CT scans two years post-operatively. . Results. There were two patterns of migration, the first showing little, if any, migration and the second showing rotation by > 6° as early as three months post-operatively. At two years, these two groups could be confirmed on CT scans, one with osseointegration around the central peg, and the second with cystic changes. Patients with osteolysis around the central peg were those with early migration and those with osseointegration had minimal early migration. Both groups,however,had similar clinical results. . Conclusion. Rapid early migration associated with focal lucency and absence of osseointegration was observed in three of 11 glenoid components, suggesting that lack of initial stability leads to early movement and failure of osseointegration. Cite this article: Bone Joint J 2017;99-B:674–9

Glenoid replacement is technically challenging. Removal of a cemented glenoid component often results in a large osseous defect which makes the immediate introduction of a revision prosthesis almost impossible. We describe a two-stage revision procedure using a reversed shoulder prosthesis. Freeze-dried allograft with platelet-derived growth factor was used to fill the glenoid defect. Radiological incorporation of the allograft was seen and its consistency allowed the placement of a screwed glenoid component. There were no signs of new mature bone formation on histological examination. The addition of platelet-derived growth factor to the allograft seems to contribute to an increase in incorporation and hardness, but does not promote the growth of new bone

The incidence of loosening of a cemented glenoid componentin total shoulder arthroplasty, detected by means of radiolucent lines or positional shift of the component on true anteroposterior radiographs, has been reported to be between 0% and 44%. Radiolucent lines are, however, difficult to detect and to interpret because of the mobility of the shoulder girdle and the obliquity of the glenoid which hinder standardisation of radiographs. We examined radiolucencies around cemented glenoid components in 48 patients, with a mean follow-up of 5.3 years, and found progressive changes to be present predominantly at the inferior pole of the component. This may hold a clue for the mechanism of loosening of this implant. In five patients we performed an additional analysis of loosening of the glenoid component using digital roentgen stereophotogrammetric analysis (RSA). After three years, three of the five implants had loosened (migration 1.2 to 5.5 mm). In only one, with gross loosening, were the radiological signs consistent with the RSA findings. When traditional radiographs are used for assessment, the rate of early loosening is underestimated. We recommend that RSA be used for this

The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (> 5 mm), displaced (> 2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint. After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one. Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph

We studied the stability of cemented all-polyethylene keeled glenoid components by radiostereometric analysis (RSA) in 16 shoulders which had received a total shoulder replacement. There were 14 women (one bilateral) and one man with a mean age of 64 years. The diagnosis was osteoarthritis in eight and rheumatoid arthritis in seven. Two of the shoulders were excluded from the RSA study because of loosening of the tantalum markers. Three tantalum markers were inserted in the glenoid socket, two in the coracoid process and two in the acromion. The polyethylene keeled glenoid component was marked with three to five tantalum markers. Conventional radiological and RSA examinations were carried out at five to seven days, at four months and at one and two years after operation. Radiolucent lines were found in all except three shoulders. Migration was most pronounced in the distal direction and exceeded 1 mm in four shoulders. In ten shoulders rotation exceeded 2° in one or more axes with retroversion/anteversion being most common. No correlation was found between migration and the presence of radiolucencies on conventional radiographs

Fixation of the glenoid component is critical to the outcome of total shoulder arthroplasty. In an in vitro study, we analysed the effect of surface design and thickness of the cement mantle on the pull-out strength of the polyethylene pegs which are considered essential for fixation of cemented glenoid components. The macrostructure and surface of the pegs and the thickness of the cement mantle were studied in human glenoid bone. The lowest pull-out forces, 20 ± 5 N, were for cylindrical pegs with a smooth surface fixed in the glenoid with a thin cement mantle. The highest values, 425 ± 7 N, were for threaded pegs fixed with a thicker cement mantle. Increasing the diameter of the hole into which the peg is inserted from 5.2 to 6.2 mm thereby increasing the thickness of the cement mantle, improved the mean pull-out force for the pegs tested

Aims

The amount of glenoid bone loss is an important factor in deciding between soft-tissue and bony reconstruction when managing anterior shoulder instability. Accurate and reproducible measurement of glenoid bone loss is therefore vital in evaluation of shoulder instability and recommending specific treatment. The aim of this systematic review is to identify the range methods and measurement techniques employed in clinical studies treating glenoid bone loss.

1. Five cases of bilateral glenoid hypoplasia are described. Flattening of the humeral heads and sometimes other skeletal abnormalities coexisted. 2. The condition is considered to be congenital. 3. The differential diagnosis and etiology are discussed

We reviewed 12 patients with primary glenoid dysplasia. Ten were assessed clinically and two from case notes and radiographs. We identified two groups according to the age at onset of symptoms. The first (seven patients) consisted of boys and younger men, all of whom developed symptoms before the age of 40 years. All four children were free from pain, whereas the three adults in this group had varying degrees of this. Four patients had symptoms of instability. The second group consisted of older men (five patients) all of whom had noted the onset of symptoms, in the form of pain and stiffness, after the age of 40 years. All five had radiological evidence of osteoarthritis. Although the four children in our study had minimal symptoms, all eight adults had ongoing shoulder pain and dysfunction, despite a specific rehabilitation programme. Four patients required surgery; one had posterior stabilisation for instability and three arthroplasties of the shoulder for osteoarthritis

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection. At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus

Superior labral tears of the shoulder involve the biceps tendon and labrum complex which may be detached, displaced inferiorly, and interposed between the glenoid and the humeral head. We have treated ten young athletes with painful shoulders due to this lesion by arthroscopic stapling. Arthroscopy at the time of staple removal, after three to six months, showed that all the lesions had been stabilised. Clinical review at over 24 months showed an excellent or good result in 80%. The two relative failures were due in one to residual subacromial bursitis, and the other to multidirectional shoulder instability. Arthroscopic stapling can restore the shoulder anatomy, and it is recommended for active adolescent athletes with this lesion

We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both

In a 41-year-old man, right-sided infraspinatus muscle weakness was associated with compression of the suprascapular nerve caused by a spinoglenoid ganglion cyst. The lesion was confirmed using electromyography and MRI. In addition, arthroscopy showed an incomplete discoid labrum. The free inner edge of the labrum was removed as in a meniscectomy of a discoid meniscus in the knee joint. Arthroscopic decompression of the cyst was performed through a juxtaglenoid capsulotomy which was left open. Neurological function recovered completely.

Aims. The aim of this study was to compare the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) using small and standard baseplates in Asian patients, and to investigate the impact of a mismatch in the sizes of the glenoid and the baseplate on the outcomes. Methods. This was retrospective analysis of 50 and 33 RSAs using a standard (33.8 mm, ST group) and a small (29.5 mm, SM group) baseplate of the Equinoxe reverse shoulder system, which were undertaken between January 2017 and March 2021. Radiological evaluations included the size of the glenoid, the β-angle, the inclination of the glenoid component, inferior overhang, scapular notching, the location of the central cage in the baseplate within the vault and the mismatch in size between the glenoid and baseplate. Clinical evaluations included the range of motion (ROM) and functional scores. In subgroup analysis, comparisons were performed between those in whom the vault of the glenoid was perforated (VP group) and those in whom it was not perforated (VNP group). Results. Perforation of the vault of the glenoid (p = 0.018) and size mismatch in height (p < 0.001) and width (p = 0.013) were significantly more frequent in the ST group than in the SM group. There was no significant difference in the clinical scores and ROM in the two groups, two years postoperatively (all p > 0.05). In subgroup analysis, the VP group had significantly less inferior overhang (p = 0.009), more scapular notching (p = 0.018), and more size mismatch in height (p < 0.001) and width (p = 0.025) than the VNP group. Conclusion. In Asian patients with a small glenoid, using a 29.5 mm small baseplate at the time of RSA was more effective in reducing size mismatch between the glenoid and the baseplate, decreasing the incidence of perforation of the glenoid vault, and achieving optimal positioning of the baseplate compared with the use of a 33.8 mm standard baseplate. However, longer follow-up is required to assess the impact of these findings on the clinical outcomes. Cite this article: Bone Joint J 2023;105-B(11):1189–1195

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available. Cite this article: Bone Joint J 2024;106-B(10):1100–1110

Aims. The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids. Methods. Intact right cadaveric shoulders from donors aged between 50 and 65 years were assigned to a ceramic group (n = 8, four male cadavers) and a metal group (n = 9, four male cadavers). A dedicated shoulder wear simulator was used to simulate daily activity by replicating the relevant joint motion and loading profiles. During testing, the joint was kept lubricated with diluted calf serum at room temperature. Each test of wear was performed for 500,000 cycles at 1.2 Hz. At intervals of 125,000 cycles, micro-CT scans of each glenoid were taken to characterize and quantify glenoid wear by calculating the change in the thickness of its articular cartilage. Results. At the completion of the wear test, the total thickness of the cartilage had significantly decreased in both the ceramic and metal groups, by 27% (p = 0.019) and 29% (p = 0.008), respectively. However, the differences between the two were not significant (p = 0.606) and the patterns of wear in the specimens were unpredictable. No significant correlation was found between cartilage wear and various factors, including age, sex, the size of the humeral head, joint mismatch, the thickness of the native cartilage, and the surface roughness (all p > 0.05). Conclusion. Although ceramic has better tribological properties than metal, we did not find evidence that its use in hemiarthroplasty of the shoulder in patients with healthy cartilage is a better alternative than conventional metal humeral heads. Cite this article: Bone Joint J 2024;106-B(11):1273–1283

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. Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning. Methods. A case-based survey presented surgeons with a patient’s history, physical examination, and, sequentially, radiographs, select static CT images, and PSP with a 3D imaging program. For each imaging modality, the surgeons were asked to identify the Walch classification of the glenoid and to propose the surgical treatment. The participating surgeons were grouped according to the annual volume of shoulder arthroplasties that they undertook, and responses were compared with the recommendations of two experts. Results. A total of 59 surgeons completed the survey. For all surgeons, the use of the PSP significantly increased agreement with the experts in glenoid classification (x. 2. = 8.54; p = 0.014) and surgical planning (x. 2. = 37.91; p < 0.001). The additional information provided by the PSP also showed a significantly higher impact on surgical decision-making for surgeons who undertake fewer than ten shoulder arthroplasties annually (p = 0.017). Conclusions. The information provided by PSP has the greatest impact on the surgical decision-making of low volume surgeons (those who perform fewer than ten shoulder arthroplasties annually), and PSP brings all surgeons in to closer agreement with the recommendations of experts for glenoid classification and surgical planning. Cite this article: Bone Joint J 2020;102-B(3):365–370

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

Aims. The aim of this study was to 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. Controversy about the use of an anatomical total shoulder arthroplasty (aTSA) in young arthritic patients relates to which is the ideal form of fixation for the glenoid component: cemented or cementless. This study aimed to evaluate implant survival of aTSA when used in patients aged < 60 years with primary glenohumeral osteoarthritis (OA), and to compare the survival of cemented all-polyethylene and cementless metal-backed glenoid components. Materials and Methods. A total of 69 consecutive aTSAs were performed in 67 patients aged < 60 years with primary glenohumeral OA. Their mean age at the time of surgery was 54 years (35 to 60). Of these aTSAs, 46 were undertaken using a cemented polyethylene component and 23 were undertaken using a cementless metal-backed component. The age, gender, preoperative function, mobility, premorbid glenoid erosion, and length of follow-up were comparable in the two groups. The patients were reviewed clinically and radiographically at a mean of 10.3 years (5 to 12, . sd. 26) postoperatively. Kaplan–Meier survivorship analysis was performed with revision as the endpoint. Results. A total of 26 shoulders (38%) underwent revision surgery: ten (22%) in the polyethylene group and 16 (70%) in the metal-backed group (p < 0.0001). At 12 years’ follow-up, the rate of implant survival was 74% (. sd.  0.09) for polyethylene components and 24% (. sd.  0.10) for metal-backed components (p < 0.0002). Glenoid loosening or failure was the indication for revision in the polyethylene group, whereas polyethylene wear with metal-on-metal contact, instability, and insufficiency of the rotator cuff were the indications for revision in the metal-backed group. Preoperative posterior subluxation of the humeral head with a biconcave/retroverted glenoid (Walch B2) had an adverse effect on the survival of a metal-backed component. Conclusion. The survival of a cemented polyethylene glenoid component is three times higher than that of a cementless metal-backed glenoid component ten years after aTSA in patients aged < 60 years with primary glenohumeral OA. Patients with a biconcave (B2) glenoid have the highest risk of failure. Cite this article: Bone Joint J 2018;100-B:485–92

Aims. The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up. Methods. A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted. Results. The ROM (p < 0.001), CS (p < 0.001), and DASH score (p < 0.001) showed significant improvements after shoulder arthroplasty for both implants. There were no differences between the groups treated with stemmed or stemless shoulder prosthesis with respect to the mean CS (79.2 (35 to 118) vs 74.4 (31 to 99); p = 0.519) and DASH scores (11.4 (8 to 29) vs 13.2 (7 to 23); p = 0.210). The ten-year unadjusted cumulative survival rate was 95.3% for the stemmed anatomical shoulder prosthesis and 91.5% for the stemless shoulder prosthesis and did not differ between the treatment groups (p = 0.251). The radiological evaluation of the humeral components in both groups did not show loosening of the humeral implant. The main reason for revision for each type of arthroplasties were complications related to the glenoid. Conclusion. The use of anatomical stemless shoulder prosthesis yielded good and reliable results and did not differ from anatomical stemmed shoulder prosthesis over a mean period of ten years. The differences in periprosthetic humeral bone adaptations between both implants have no clinical impact during the follow-up. Cite this article: Bone Joint J 2021;103-B(7):1292–1300

The three-dimensional (3D) correction of glenoid erosion is critical to the long-term success of total shoulder replacement (TSR). In order to characterise the 3D morphology of eroded glenoid surfaces, we looked for a set of morphological parameters useful for TSR planning. We defined a scapular coordinates system based on non-eroded bony landmarks. The maximum glenoid version was measured and specified in 3D by its orientation angle. Medialisation was considered relative to the spino-glenoid notch. We analysed regular CT scans of 19 normal (N) and 86 osteoarthritic (OA) scapulae. When the maximum version of OA shoulders was higher than 10°, the orientation was not only posterior, but extended in postero-superior (35%), postero-inferior (6%) and anterior sectors (4%). The medialisation of the glenoid was higher in OA than normal shoulders. The orientation angle of maximum version appeared as a critical parameter to specify the glenoid shape in 3D. It will be very useful in planning the best position for the glenoid in TSR. Cite this article: Bone Joint J 2014;96-B:513–18

Aims. The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). Methods. This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. Results. At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. Conclusion. Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718–724

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff. When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present

In 100 patients the fulcrum axis which is the line connecting the anterior tip of the coracoid and the posterolateral angle of the acromion, was used to position true anteroposterior radiographs of the shoulder. This method was then compared with the conventional radiological technique in a further 100 patients. Three orthopaedic surgeons counted the number of images without overlap between the humeral head and glenoid and calculated the amount of the glenoid surface visible in each radiograph. The analysis was repeated for intraobserver reliability. The learning curves of both techniques were studied. The amount of free visible glenoid space was significantly higher using the fulcrum-axis method (64 vs 31) and the comparable glenoid size increased significantly (8.56 vs 6.47). Thus the accuracy of the anteroposterior radiographs of the shoulder is impaired by using this technique. The intra and interobserver reliability showed a high consistency. No learning curve was observed for either technique

Aims. Promising medium-term results from total shoulder arthroplasty (TSA) have been reported for the treatment of primary osteoarthritis in young and middle-aged patients. The aim of this study was to evaluate the long-term functional and radiological outcome of TSA in the middle-aged patient. Patients and Methods. The data of all patients from the previous medium-term study were available. At a mean follow-up of 13 years (8 to 17), we reviewed 21 patients (12 men, nine women, 21 shoulders) with a mean age of 55 years (37 to 60). The Constant-Murley score (CS) with its subgroups and subjective satisfaction were measured. Radiological signs of implant loosening were analysed. Results. Two shoulders (two patients) were revised and in two shoulders of two different patients, revision surgery was recommended. The mean CS increased from 23.3 (10 to 45) pre-operatively to 56.5 (26 to 81; p < 0.0001), but with a decrease in CS from 62.8 (38 to 93) to 56.5 (26 to 81) between medium- and long-term follow-up (p = 0.01). Without revision surgery, 18 patients (95%) rated their result as good or very good. The mean radiolucent line score for the glenoid components increased from 1.8 (0 to 6) to 8.2 (2 to 18) between medium- and long-term follow-up (p < 0.001). . Conclusion. TSA in young and middle-aged patients leads to improvement in clinical function and a relatively high satisfaction rate. However, clinical or radiological glenoid loosening worsens in the long term. Further studies are needed to optimise the treatment options in this patient population. Cite this article: Bone Joint J 2017;99-B:939–43

We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index). The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1° (26.8° to 38.6°) in the control group, 38.0° (29.5° to 43.5°) in the RCT group and 28.1° (18.6° to 35.8°) in the OA group. Of patients with a CSA > 35°, 84% were in the RCT group and of those with a CSA < 30°, 93% were in the OA group. We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders. Cite this article: Bone Joint J 2013;95-B:935–41

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

Aims. Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature. Materials and Methods. A systematic review using the search terms “reverse shoulder”, “reverse total shoulder”, or “inverted shoulder” was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design. Results. The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs. Conclusion. Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627–634

This study provides recommendations on the position of the implant in reverse shoulder replacement in order to minimise scapular notching and osteophyte formation. Radiographs from 151 patients who underwent primary reverse shoulder replacement with a single prosthesis were analysed at a mean follow-up of 28.3 months (24 to 44) for notching, osteophytes, the position of the glenoid baseplate, the overhang of the glenosphere, and the prosthesis scapular neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four Grade 2) and 47 (31.1%) had an osteophyte. In patients without either notching or an osteophyte the baseplate was found to be positioned lower on the glenoid, with greater overhang of the glenosphere and a lower PSNA than those with notching and an osteophyte. Female patients had a higher rate of notching than males (13.3% vs 13.0%) but a lower rate of osteophyte formation (22.9% vs 50.0%), even though the baseplate was positioned significantly lower on the glenoid in females (p = 0.009) and each had a similar mean overhang of the glenosphere. Based on these findings we make recommendations on the placement of the implant in both male and female patients to avoid notching and osteophyte formation. Cite this article: Bone Joint J 2013;95-B:530–5

Aims. Scapular notching is a frequently observed radiographic phenomenon in reverse shoulder arthroplasty (RSA), signifying impingement of components. The purposes of this study were to evaluate the effect of glenoid component size and glenosphere type on impingement-free range of movement (ROM) for extension and internal and external rotation in a virtual RSA model, and to determine the optimal configuration to reduce the incidence of friction-type scapular notching. Materials and Methods. Preoperative CT scans obtained in 21 patients (three male, 18 female) with primary osteoarthritis were analyzed using modelling software. Two concurrent factors were tested for impingement-free ROM and translation of the centre of rotation: glenosphere diameter (36 mm vs 39 mm) and type (centred, 2 mm inferior eccentric offset, 10° inferior tilt). Results. Glenosphere size was most predictive of increased extension and external rotation, whereas lateralization of the centre of rotation was the most predictive factor for internal rotation. A larger diameter of glenosphere combined with a 10° tilted configuration demonstrated superior values for extension and external rotation, whereas the eccentric component improved internal rotation by a mean 8.9° (standard deviation 2.7°) compared with a standard concentric glenosphere. Conclusion. Glenosphere configuration can be modified to increase range of movement in RSA. Friction-type scapular notching was most effectively reduced by use of a large-diameter glenosphere with 10° inferior tilt. Cite this article: Bone Joint J 2018;100-B:1182–6

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

Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p < 0.001), as was resorption of the greater (p < 0.001) and lesser tuberosities (p = 0.009)

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.

Aims

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.

There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs. Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65° in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24° in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis. Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency. Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4° and mean abduction improved by 35°. There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications. The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss

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.

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives

There are theoretical and practical advantages to modular rather than monoblock designs of prostheses for shoulder arthroplasty, but there are no reported studies which specifically compare the clinical and radiological results of their use. We have compared the results of unconstrained total shoulder arthroplasty for osteoarthritis using both types of implant. The monoblock design was used between 1992 and 1995 and the modular design after 1995. Both had cemented all-polyethylene glenoids, the monoblock with matched and the modular with mismatched radii of curvature. There were 34 consecutive shoulders in each group with a mean follow-up of 6.1 years in the first and 5.2 years in the second. There were no significant differences in improvement of pain scores, active elevation, external rotation, internal rotation, patient satisfaction, or the Neer ratings between the two groups. Two of 28 glenoid components in the first group and six of 30 in the second met the criteria for being radiologically at risk for loosening (p = 0.25). There were no significant differences in clinical outcome or radiological changes between the first- and second-generation designs of implant for shoulder arthroplasty

We studied serial CT scans of 45 arthritic shoulders (34 rheumatoid, 11 osteoarthritic) and 19 normal shoulders, making measurements at three levels on axial images. The maximum anteroposterior diameter of the glenoid was increased in rheumatoid glenoids at the upper and middle levels by 6 mm and in osteoarthritic glenoids at all levels by 5 to 8 mm as compared with normal. In rheumatoid cases, nearly half the available surface of the glenoid was of unsupported bone, mainly posteriorly at the upper and middle levels. In osteoarthritic glenoids, the best supported bone was anterior at the upper level and central at the middle and lower levels. The depth of the rheumatoid glenoid was reduced by a mean of 6 mm at the upper and middle levels and by 3 mm at the lower level. This inclined the surface of the glenoid superiorly. The depth at the middle level in osteoarthritis was reduced by a mean of 5 mm, suggesting central protrusion. Osteoarthritic glenoids were retroverted by a mean of 12.5 degrees, but of rheumatoid glenoids two-thirds were retroverted (mean 15.1 degrees) and one-third anteverted (mean 8.2 degrees). Our findings have important implications for the planning and placement of the glenoid component of total shoulder replacements; CT can provide useful information

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

Aims

The aims of this study were to validate the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds for Western Ontario Shoulder Instability Index (WOSI), Rowe score, American Shoulder and Elbow Surgeons (ASES), and visual analogue scale (VAS) scores following arthroscopic Bankart repair, and to identify preoperative threshold values of these scores that could predict the achievement of MCID and PASS.

Surgical treatment for traumatic, anterior glenohumeral instability requires repair of the anterior band of the inferior glenohumeral ligament, usually at the site of glenoid insertion, often combined with capsuloligamentous plication. In this study, we determined the mechanical properties of this ligament and the precise anatomy of its insertion into the glenoid in fresh-frozen glenohumeral joints of cadavers. Strength was measured by tensile testing of the glenoid-soft-tissue-humerus (G-ST-H) complex. Two other specimens of the complex were frozen in the position of apprehension, serially sectioned perpendicular to the plane containing the anterior and posterior rims of the glenoid, and stained with Toluidine Blue. On tensile testing, eight G-ST-H complexes failed at the site of the glenoid insertion, representing a Bankart lesion, two at the insertion into the humerus, and two at the midsubstance. For those which failed at the glenoid attachment the mean yield load was 491.0 N and the mean ultimate load, 585.0 N. At the glenoid region, stress at yield was 7.8 ± 1.3 MPa and stress at failure, 9.2 ± 1.5 MPa. The permanent deformation, defined as the difference between yield and ultimate deformation, was only 2.3 ± 0.8 mm. The strain at yield was 13.0 ± 0.7% and at failure, 15.4 ± 1.2%; therefore permanent strain was only 2.4 ± 1.1%. Histological examination showed that there were two attachments of the anterior band of the inferior glenohumeral ligament at the site of the glenoid insertion. In one, poorly organised collagen fibres inserted into the labrum. In the other, dense collagen fibres were attached to the front of the neck of the glenoid

Aims

We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients.

Aims

The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years.

Aims

Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients.

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor. Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid. All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001). Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery. A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy. Cite this article: 2015;97-B:1090–5

We performed a prospective study using MRI in 16 consecutive infants with a mean age of 5.2 months (2.7 to 8.7) who had shown inadequate recovery from an obstetric lesion of the brachial plexus in the first three months of life, in order to identify early secondary deformities of the shoulder. Shoulders were analysed according to a standardised MRI protocol. Measurements were made of the appearance of the glenoid, glenoid version and the position of the humeral head. The appearance of the glenoid on the affected side was normal in only seven shoulders. In the remainder it was convex in seven and bioconcave in three. The degree of subluxation of the humeral head was significantly greater (p = 0.01) in the affected shoulders than in normal shoulders (157° v 170°). The presence of an abnormal appearance of the glenoid, retroversion of the glenoid and subluxation of the humeral head increased with age. There was a statistical difference (p = 0.05) between infants younger than five months and those who were older

A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated:. 1. The pathology comprises two important elements: (a) anterior detachment of the glenoid labrum from the bone margin of the glenoid, associated with some degree of stripping of the anterior part of the capsule from the front of the neck of the scapula, found in 87 per cent. of cases examined adequately at operation; (b) defect or flattening of the posterolateral aspect of the articular surface of the head of the humerus which engages with the glenoid cavity when the arm is in external rotation and abduction; this defect is demonstrated most readily in antero-posterior radiographs taken with the humerus in 60 to 70 degrees of internal rotation and was shown to be present in 82 per cent. of cases which had been subjected to adequate radiographic examination. 2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small. 3. Either type of lesion alone may predispose to recurrence of the dislocation. 4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great. 5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin. 6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head. 7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability

Aims

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model.

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

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

Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

The glenopolar angle assesses the rotational alignment of the glenoid and may provide prognostic information and aid the management of scapula fractures. We have analysed the effect of the anteroposterior (AP) shoulder radiograph rotational offset on the glenopolar angle in a laboratory setting and used this to assess the accuracy of shoulder imaging employed in routine clinical practice. Fluoroscopic imaging was performed on 25 non-paired scapulae tagged with 2 mm steel spheres to determine the orientation of true AP views. The glenopolar angle was measured on all the bony specimens rotated at 10° increments. The mean glenopolar angle measured on the bone specimens in rotations between 0° and 20° and thereafter was found to be significantly different (p < 0.001). We also obtained the AP radiographs of the uninjured shoulder of 30 patients treated for fractures at our centre and found that none fitted the criteria of a true AP shoulder radiograph. The mean angular offset from the true AP view was 38° (10° to 65°) for this cohort. Radiological AP shoulder views may not fully project the normal anatomy of the scapular body and the measured glenopolar angle. The absence of a true AP view may compromise the clinical management of a scapular fracture. Cite this article: Bone Joint J 2013;95-B:1114–20

We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously. At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming

The floating shoulder is defined as ipsilateral fractures of the midshaft of the clavicle and the neck of the glenoid. This rare injury can be difficult to manage without a thorough understanding of the complex anatomy of the shoulder girdle. Surgical intervention needs to be considered for all of these injuries. While acceptable results can be expected with non-operative management of minimally-displaced fractures, displacement at one or both sites is best managed with surgical reduction and fixation

Aims

The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.

1 . The concept of the capsular mechanism of the shoulder joint with regard to recurrent anterior dislocation of the shoulder has been defined and a survey of the literature presented. 2. An anatomical, including an embryological, investigation of shoulder joints with special reference to the structure and function of the glenoid labrum and to the variations in the arrangement of the gleno-humeral ligaments and the synovial recesses of the anterior capsular mechanism is reported. The labrum, which is generally believed to be a consistent, fibrocartilaginous structure, is shown to be a redundant portion of capsular tissue and a continuation of the capsule as it attaches to the osseous glenoid rim. The fibrocartilaginous element is confined to a small transition zone at the capsular attachment in the great majority of cases. The great variability in the arrangement of the gleno-humeral ligaments and synovial recesses is stressed, and it is shown that an anterior pouch of variable size is present when the middle gleno-humeral ligament is attached to the scapular neck and not to the labrum. 3. The basic lesions of the anterior capsular mechanism found at operation for recurrent anterior dislocation of the shoulder in twenty-five consecutive cases using a modified Bankart procedure with a standard anterior approach to the joint are reported, and the findings are correlated with the results of the anatomical investigation. In most cases the lesions were found to be of the Bankart type with or without avulsion of the periosteum of the scapular neck. In four cases, however, the soft-tissue attachment to the anterior glenoid rim was intact; in those cases a large synovial pouch was present and the middle gleno-humeral ligament was either not discernible or it arose from the scapular neck. In all cases a postero-lateral notch on the humeral head was palpable and laxity of the subscapularis could be demonstrated. When measured, the joint capacity was always greatly augmented. 4. The present work shows, from a basic standpoint, that Bankart's original idea that the recurrent state was due to the failure of healing of the fractured fibrocartilaginous glenoid labrum is no longer tenable. 5. Finally, the anomalous attachment or the insufficient development of the middle gleno-humeral ligament in certain cases of recurrent anterior shoulder dislocation is shown to provide the anatomical basis for the recurrent state in these cases; this is the weak area in the antero-inferior part of the capsule which has been described in the literature for the past hundred years. Thus we have returned to the original view of Hippocrates

Metallosis after shoulder replacement has not previously been described in the literature. We report a patient who developed extensive metallosis after implantation of an uncemented Nottingham shoulder replacement. He underwent a revision procedure. Examination of the retrieved prosthesis showed that the titanium porous coating was separating from the humeral stem and becoming embedded in the ultra-high-molecular-weight polyethylene glenoid component, resulting in abrasive wear of the humeral component. There was metallosis despite exchange of the modular humeral head. Both components had to be exchanged to resolve the problem

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead