Die Implantation einer inversen Schulterendoprothese (TEP) stellt eine bewährte Methode zur Schmerzlinderung und Schulterfunktionsverbesserung dar. Die Ergebnisse variieren je nach Patientenalter, Krankheitsgrad und Erfahrung des Operateurs. Indikationen für eine inverse TEP sind vielfältig, von der Defektarthropathie bis hin zu Frakturen. Aktuelle Studien zeigen verbesserte Überlebensraten und reduzierte Komplikationen nach primärer Implantation. Die präoperative Planung mittels 3-D-CT oder MRT gilt als Goldstandard. Patientenspezifische Instrumente (PSI) wurden eingeführt, sind jedoch mit Kosten und Wartezeit verbunden. Die Navigation mit "Augmented Reality" (AR) bietet eine effizientere Alternative. Die intraoperative Übertragung der Planung auf den Patienten erfolgt über AR-Brillen und ermöglicht Echtzeitinformationen, wodurch der Chirurg den Blick vom Situs nicht abwenden muss. Dies optimiert den Workflow und bietet potenziell präzisere Implantationsresultate. Zusammenfassend bietet die Kombination von 3-D-Planung, Navigation und AR eine vielversprechende Methode für präzise und effiziente Implantationen von inversen Schulterendoprothesen. Allerdings steht der Nachweis verbesserter Standzeiten und Funktionsscores noch aus.

Safe and bone-sparing implantation of a stem- and cement-free reversed shoulder prosthesis.

Shoulder arthritis with rotator cuff degeneration, symptomatic rotator cuff arthropathy with no further therapy, posttraumatic arthritis, rheumatoid arthritis, humeral head necrosis, revision surgery after implantation of a surface prosthesis.

Infection, axillary nerve lesion, deltoid muscle insufficiency, insufficient central glenoid bone substance for glenoid screw fixation.

Implantation of the shoulder prosthesis via a standard deltopectoral approach. Dissection and resection of the humeral head. Glenoid preparation, soft tissue release, baseplate and glenosphere placement. Implantation of the humeral shell and inlay.

Short-term immobilization in a Gilchrist bandage. Followed by early functional rehabilitation.

The surgical technique has so far been used in 42 cases in the author's clinic. Both objectively and subjectively, good postoperative results and a significant reduction in pain were observed in the patients.

Background: In reverse shoulder arthroplasty (RSA), the neck-shaft angle (NSA) has trended downward from 155° to 135° to reduce scapular notching, but concerns about instability persist. To assess superior-lateral stability, we developed the intraoperative two-hand lever test (2HLT). The primary objective was to evaluate the effectiveness of the 2HLT, analyze the learning curve in this first study reporting on the new Perform stem, and compare the liner characteristics of 155° and 135° systems. Methods: In a single-surgeon learning curve study, 81 RSA procedures with the new Perform stem (Stryker) were included. The outcomes included the 2HLT test applied in 65 cases, early dislocations, stem alignment, stem length, liner type/thickness, and complications. The early dislocation rate was compared to 167 prior Ascend Flex RSA procedures (Stryker). The liner characteristics of three 135° systems (Perform/Stryker, Univers/Arthrex, and Altivate/Enovis) were compared to traditional 155° Grammont systems (Delta Xtend/DePuy, Affinis Metal/Mathys, SMR 150/Lima, and Aequalis Reversed/Stryker), focusing on jump height (JH) and the liner stability ratio (LSR). Results: In 63% (31/49) of the cases, the 2HLT detected superior-lateral instability, necessitating a retentive 135° liner. The early dislocation rate in the Perform cohort was 4.9% (0% for retentive liners, 8% for standard liners) versus 0% in the Ascend Flex cohort. The mean effective NSA was 133° (127-144°) for short Perform stems and 135° (129-143°) for long stems. Long Perform stems significantly reduced varus outlier density below 132° and 130° (p = 0.006, 0.002). The 36 mm Perform 135° standard liner has a JH of 8.1 mm and an LSR of 152%, markedly lower than the Altivate (10.0 mm/202%) and Univers (9.7 mm/193%) and similar to traditional 155° Grammont liners (8.1-8.9 mm/147-152%). Perform retentive liners have LSR values of 185-219%, comparable to the established 135° design standard liners (195-202%). In the Perform cohort, early complications included four superior-lateral dislocations (all standard liners, LSR 147-152%) requiring four revisions. Conclusions: Perform standard liners have a lower LSR than the established 135° designs. Retentive Perform liners (LSR > 184%) are comparable to standard liners of established 135° designs and effectively mitigate instability. We recommend discontinuing non-retentive Perform standard liners (NSA 135°, LSR < 158%) due to the 63% superior-lateral instability rate detected with the novel 2HLT, necessitating retentive liners, the documented LSR-NSA implant mismatch, and an early clinical dislocation rate of up to 8%.

Fractures of the acromion and spine can have a major impact on the outcome of reverse shoulder arthroplasty (RSA) with respect to pain, motion, and function. Reports on internal fixation for these fractures are isolated to small series or case reports with variable outcomes. The purpose of this study was to report on the outcome of open reduction and internal fixation (ORIF) of acromion or spine fractures encountered before or after RSA and describes our evolution of fixation techniques.

Between 2011 and 2023, 22 fractures or nonunions of the acromion or spine of the scapula underwent ORIF at a single institution and were followed for a minimum of 1 year. In 16 shoulders, fractures occurred after RSA, whereas 5 shoulders underwent ORIF prior to RSA. One shoulder had undergone prior failed ORIF elsewhere and revision ORIF was performed at our institution. There were 10 males and 12 females with a mean age of 67 (SD = 15.1) years. Fixation strategies included single (n = 11) and double plate fixation (n = 11). Kruskal-Wallis one-way analyses of variance were used to analyze continuous variables and Chi-square tests employed for categorical variables.

Of the 5 fractures treated with ORIF pre-RSA, 1 shoulder suffered an additional fracture medial to the hardware and 1 required additional bone grafting for incomplete union at the time of RSA. These 5 shoulders all underwent RSA uneventfully, but 1 fracture experienced late displacement of the scapular spine nonunion, leading to plate removal. Of the 16 post-RSA ORIF shoulders, radiographic union was confirmed in 14 and substantial residual inferior angulation identified in 3. New fractures occurred after ORIF in 5 shoulders. For patients who underwent ORIF after RSA, pain scores improved from a mean of 8 to 1.9 points, with more modest elevation gains (58.2°-91.3° pre and postoperatively, respectively).

ORIF of acromion and scapular spine fractures or nonunions in the setting of RSA have the potential to lead to union. When these fractures and nonunions are encountered prior to RSA, ORIF allows for uneventful RSA implantation, but secondary displacement may occur. ORIF seems to lead to improvements in pain, but more modest improvements in motion and function. Our fixation strategy has evolved to (1) dual plating, (2) spanning the whole length of the spine with 1 of the plates, (3) use of hook features under the acromion or os trigonum if possible, and (4) liberal use of bone graft.

Proximal humerus and shaft fractures are common, comprising 10-11 % of all fractures. Progress in their management includes refined surgical techniques and implants, coupled with a deeper understanding of fracture patterns.

This study examines the effect of surgical education on in-hospital outcomes for operatively treated proximal and humerus shaft fractures, aiming to enhance patient care and results.

This study analyzed cases from 1st of January 2010 until the 31st of December 2021 using data extracted from the Swiss working group for quality assurance in surgery, including patients with proximal humerus and shaft fractures who underwent surgical procedures like open reduction with internal fixation (ORIF), closed reduction with internal fixation (CRIF), external fixation, or prosthesis. Analysis included patient demographics, procedure details, and outcomes, comparing those with and without teaching of the surgical procedures. Binary logistic regression identified risk factors, with statistical significance set at p = 0.001.

A total of 6,654 patients were analyzed. Most were treated with ORIF (74 %) or CRIF (17 %). The average hospital stay was 6.5 days. Teaching surgeries, comprising 5.4 % of all procedures, were more common among patients with fewer comorbidities and with public insurance coverage. These surgeries took slightly longer to perform compared to non-teaching cases (120±65 min vs. 113±60 min, p= <0.001). Public insurance coverage, absence of comorbidities, and certain surgical procedures (CRIF and ORIF vs. prosthesis) were associated with surgery being a teaching case. Complications occurred in 8 % of patients, with no significant difference between teaching and non-teaching groups. Predictors of complications included higher American Society of Anesthesiologists-score, antibiotic use, anticoagulation therapy, fracture of shaft, higher age, and longer surgery duration.

Educational status did not affect in-hospital mortality and morbidity in patients with a operatively treated shaft or proximal humeral fracture. However, teaching was an independent predictor of a prolonged duration of surgery. Despite the significant differences, the clinical outcome was comparable in both groups, therefore substantiating the advantages of teaching operations for both patient safety and resident education. They combine the competence of experienced surgeons with the training of residents, whilst ensuring the safety through oversight and best practices. Not only does this environment improve patient outcomes, but also provides residents with hands-on experience, thus helping them make critical decisions, building confidence and developing essential skills.

Reverse shoulder arthroplasty (RSA) has witnessed a significant advancement with the introduction of lateralisation techniques, aiming to enhance shoulder function and implant durability. Traditional medialised designs, following Grammont's principles, have encountered challenges such as scapular notching, reduced rotational strength, and instability. In contrast, lateralisation methods, which reposition the joint center of rotation laterally on the glenoid, humerus, or both, seek to improve deltoid leverage, optimize the rotator cuff muscles' length-tension relationship, and enhance joint stability. Strategies for achieving lateralisation include bone grafts, lateralised glenosphere designs, and metallic augmented base plates. Clinical and biomechanical studies have shown that lateralised RSA designs decrease scapular notching, enhance range of motion, and promote stability. However, these advantages come with drawbacks like heightened shear forces, potential acromial stress fractures, and the risk of joint overstuffing. The future of RSA involves striking a balance between these aspects through tailored implant configurations and the utilization of cutting-edge technologies such as artificial intelligence, 3D modeling, and augmented reality to optimize surgical results. Further research is imperative to validate the long-term efficacy of lateralised RSA and refine these novel approaches to shoulder arthroplasty.

The aim of this study is to analyse the most cited articles in shoulder arthroplasty surgery and identify trends in topics by decade.

Journal Citation Index Web of Science (WoS) was searched to find articles using the search terms "shoulder arthroplasty", "shoulder hemiarthroplasty", "shoulder replacement" and "shoulder prosthesis". All articles were ranked according to most cited overall and most cited between 2022 and 2023, and then further analysed to find the most cited articles per decade. Articles were studies for topic, study type, evidence level and number of subjects. A second search was performed using Google Scholar (GS) with the same search terms.

All the most cited articles were published in 4 orthopaedic journals. Citation counts were higher for GS searches than WoS for every article, by an average of 1.92 times. Each decade's most cited articles seemed to fit into a few broad topics, showing trends in that decade. The highest cited papers were generally low-level evidence studies.

Shoulder arthroplasty literature appears to follow trends throughout the decade. High quality evidence is lacking in the highest cited papers, but this study highlights the importance and value of these lower-evidence breakthrough studies, which have shaped shoulder arthroplasty surgery.

Early reverse total shoulder arthroplasty (RTSA) designs demonstrated high glenoid baseplate complication and revision rates. Although contemporary designs have reduced the incidence of glenoid baseplate failures, there are reports of elevated failure risks in RTSA with glenoid bone grafting within the first 2 years. This study aims to evaluate the incidence and etiology of aseptic glenoid baseplate failure with a contemporary central screw baseplate. The null hypothesis is that majority of the baseplate failure occurs within the first 2 years and that use of glenoid bone grafting does not lead to a higher risk of baseplate failure.

In 2014-2019, a total of 753 consecutive patients who underwent primary RSA using the same inlay press-fit humeral stem and monoblock central screw baseplate were retrospectively reviewed. Fracture and septic arthropathy cases were excluded. All patients underwent preoperative radiographic and computed tomographic evaluation. If there was significant glenoid erosion (Walch A2, B2, B3, C1, C2, E2, E3, and/or E4 variants), patient-specific structural glenoid bone grafting was performed. All patients underwent standardized radiographic follow-up, and failure was strictly defined as any hardware breakage and/or shift in glenoid baseplate position. Failures were defined as "early" if occurring within 2 years and "late" if occurring >2 years after surgery. Comparative analysis was performed to evaluate demographics, glenoid graft use, and graft union rates between the cohorts.

There were 23 patients with baseplate failures (23 of 753, 3.0%) at a mean of 23 months. Twenty-two failures (96%) occurred in patients who received structural glenoid bone grafting. Only 1 failure (0.2%) occurred when bone grafting was not indicated (P < .001). The most common failure pattern was associated with the B2 glenoid (16 of 23, 70%). There were 5 early failures (22%) and 18 late failures (78%). There were no differences in any patient demographic characteristics between cohorts. All 5 early failures had graft nonunion, and 4 of them occurred without trauma. In the 18 late failures, 9 (50%) occurred without trauma (P = .135). Seventeen of these patients had glenoid grafting, among which 9 (53%) had graft nonunion.

Contemporary RTSA glenoid baseplate designs have an acceptably low incidence of failure. However, the addition of structural bone graft to correct glenoid wear leads to higher aseptic baseplate failure rate. The majority of these patients suffer failure after the 2-year postoperative mark, highlighting the necessity of longer follow-up. Further analysis is necessary to quantify glenoid characteristics (severity of glenoid erosion, critical size of graft) associated with failure.

Current options for reconstruction of large glenoid defects in reverse total shoulder arthroplasty (RTSA) include structural bone grafting, use of augmented components, or 3D-printed custom implants. Given the paucity in the literature on structural bone grafts in RTSA, this study reflects our experience on clinical and radiographic outcomes of structural bone grafts used for glenoid defects in RTSA.

We identified 33 consecutive patients who underwent RTSA using structural bone grafts for glenoid bone loss between 2008 and 2019. Twenty-six patients with a mean clinical follow-up of 4.4 ± 3.9 years and a mean radiographic follow-up of 2.7 ± 3.2 years were included. Patient demographic data, perioperative functional outcomes, radiographic outcomes, complications, and reoperation rates were determined.

Between 2008 and 2019, 26 RTSAs were performed using structural autograft or allograft for glenoid defects. There were 20 females (77%) and 6 males (23%), with a mean presenting age of 68 years (range 41-86), mean BMI of 29 (range 21-44), and mean Charlson Comorbidity Index of 3 (range 0-8). There were 19 cases of central glenoid defects, and 7 were combined central and peripheral defects. Structural grafts included humeral head autograft (7), proximal humerus autograft (7), iliac crest autograft (7), distal clavicle autograft (2), and femoral head allograft (3). All 18 revision RTSA cases had simultaneous humeral-sided revision. There was significant postoperative improvement in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (27.0 ± 12.6 preoperation vs. 59.8 ± 24.1 postoperation; P < .001) and visual analog scale scores (8.1 ± 3.6 preoperation vs. 3.0 ± 3.2 postoperation; P < .001). Range of motion improved significantly for active forward elevation (63° ± 36° preoperation vs. 104° ± 36° postoperation; P < .001) and external rotation (21° ± 20° preoperation vs. 32° ± 23° postoperation, P = .036). Eighty-eight percent of cases (23 of 26) had successful reconstruction of the glenoid, defined as no visible radiolucent lines nor glenoid component migration at final follow-up. The reoperation rate was 19% (5 of 26). Postoperative complications included 2 cases of acromial stress fractures that were treated nonoperatively, for a total complication rate (including reoperation) of 27% (7 of 26 cases).

The use of structural bone autografts and allografts in RTSA was associated with improved outcome scores and range of motion. A reoperation rate of 19% and total complication rate of 27% were reported for these challenging cases. However, 86% of these complications were not related to structural glenoid reconstruction failure. Structural grafts are a reasonable option for glenoid reconstruction in RTSA cases with glenoid bone loss.

Data on the 1-year postoperative revision, complication, and economic outcomes in a hospital setting after total shoulder arthroplasty (TSA) are sparse.

A retrospective cohort study using the Premier Healthcare Database, a hospital-billing data source, evaluated 1-year postoperative revision, complication, and economic outcomes of reverse (RTSA) and anatomic (ATSA) TSA for patients who underwent the procedure from 2015 until 2021. All-cause revisits, including revision-related events (categorized as either irrigation and débridement or revision procedures and device removals) and shoulder/nonshoulder complications were collected. The incidences and costs of these revisits were evaluated. Generalized linear models were used to evaluate the associations between patient characteristics and revision and complication occurrences and costs.

Among 51,478 RTSA and 34,623 ATSA patients (mean [standard deviation] ages RTSA 71.5 [8.1] years, ATSA 66.8 [9.0] years), 1-year adjusted incidences of all-cause revisits, irrigation/débridement, revision procedures/device removals, and shoulder/nonshoulder complications were RTSA: 45.0% (95% confidence interval (CI): 44.6%-45.5%), 0.1% (95% CI: 0.1%-0.2%), 2.1% (95% CI: 2.0%-2.2%), and 17.8% (95% CI: 17.5%-18.1%) and ATSA: 42.3% (95% CI: 41.8%-42.9%), 0.2% (95% CI: 0.1%-0.2%), 1.9% (95% CI: 1.8%-2.1%), and 14.4% (95% CI: 14.0%-14.8%), respectively; shoulder-related complications were RTSA: 12.4% (95% CI: 12.1%-12.7%) and ATSA: 9.9% (95% CI: 9.6%-10.3%). Significant factors associated with a high risk of revisions and complications included, but were not limited to, chronic comorbidities and noncommercial insurance. Per patient, the mean (standard deviations) total 1-year hospital cost was $25,225 ($15,911) and $21,520 ($13,531) for RTSA and ATSA, respectively. Revision procedures and device removals were most costly, averaging $22,920 ($18,652) and $26,911 ($18,619) per procedure for RTSA and ATSA, respectively. Patients with revision-related events with infections had higher total hospital costs than patients without this event (RTSA: $60,887 (95% CI: $56,951-$64,823) and ATSA: $59,478 (95% CI: $52,312-$66,644)), equating to a mean difference of $36,148 with RTSA and $38,426 with ATSA. Significant factors associated with higher costs of revision-related events and complications included age, race, chronic comorbidities, and noncommercial insurance.

Nearly 45% RTSA and 42% ATSA patients returned to the hospital, most often for shoulder/nonshoulder complications (overall 17.8% RTSA and 14.4% ATSA, and shoulder-related 12.4% RTSA and 9.9% ATSA). Revisions and device removals were most expensive ($22,920 RTSA and $26,911 ATSA). Infection complications requiring revision had the highest 1-year hospital costs (∼$60,000). This study highlights the need for technologies and surgical techniques that may help reduce TSA health care utilization and economic burden.

Navigated augmented reality (AR) through a head-mounted display (HMD) has led to accurate glenoid component placement in reverse shoulder arthroplasty (RSA) in an in-vitro setting. The purpose of this study is to evaluate the deviation between planned, intraoperative, and postoperative inclination, retroversion, entry point, and depth of the glenoid component placement during RSA, assisted by navigated AR through an HMD, in a surgical setting.

A prospective, multicenter study was conducted. All consecutive patients undergoing RSA in 2 institutions, between August 2021 and January 2023, were considered potentially eligible for inclusion in the study. Inclusion criteria were as follows: age >18 years, surgery assisted by AR through an HMD, and postoperative computed tomography (CT) scans at 6 weeks. All participants agreed to participate in the study and informed consent was provided in all cases. Preoperative CT scans were undertaken for all cases and used for 3-dimensional (3D) planning. Intraoperatively, glenoid preparation and component placement were assisted by a navigated AR system through an HMD in all patients. Intraoperative parameters were recorded by the system. A postoperative CT scan was undertaken at 6 weeks, and 3D reconstruction was performed to obtain postoperative parameters. The deviation between planned, intraoperative, and postoperative inclination, retroversion, entry point, and depth of the glenoid component placement was calculated. Outliers were defined as >5° for inclination and retroversion and >5 mm for entry point.

Seventeen patients (9 females, 12 right shoulders) with a mean age of 72.8 ± 9.1 years (range, 47.0-82.0) met inclusion criteria. The mean deviation between intra- and postoperative measurements was 1.5° ± 1.0° (range, 0.0°-3.0°) for inclination, 2.8° ± 1.5° (range, 1.0°-4.5°) for retroversion, 1.8 ± 1.0 mm (range, 0.7-3.0 mm) for entry point, and 1.9 ± 1.9 mm (range, 0.0-4.5 mm) for depth. The mean deviation between planned and postoperative values was 2.5° ± 3.2° (range, 0.0°-11.0°) for inclination, 3.4° ± 4.6° (range, 0.0°-18.0°) for retroversion, 2.0 ± 2.5 mm (range, 0.0°-9.7°) for entry point, and 1.3 ± 1.6 mm (range, 1.3-4.5 mm) for depth. There were no outliers between intra- and postoperative values and there were 3 outliers between planned and postoperative values. The mean time (minutes : seconds) for the tracker unit placement and the scapula registration was 03:02 (range, 01:48 to 04:26) and 08:16 (range, 02:09 to 17:58), respectively.

The use of a navigated AR system through an HMD in RSA led to low deviations between planned, intraoperative, and postoperative parameters for glenoid component placement.

Nerve injury is the most feared complication of upper limb surgery. In about 17% of cases, the injury is iatrogenic and the potential for recovery is poor. In this context, patients file for compensation in about a quarter of cases. Defective patient installation or locoregional anaesthesia are rarely the cause of nerve injury. Nerves may be injured during creation of the surgical approach, implantation of the material or reduction of a traumatic injury. The injury is usually related to nerve release, retractor positioning or inappropriate limb-segment lengthening. Stretching and/or compression of a nerve trunk or branch is thus often the main cause. Among diagnostic tools, imaging studies (ultrasonography, computed tomography, and magnetic resonance imaging) provide information on nerve structure but not on the potential for recovery. Electromyography combined with a neurological examination establishes the diagnosis, guides the management strategy, allows nerve-function monitoring, and indicates when nerve repair or palliative surgery is indicated. Electromyography also has prognostic value, both at diagnosis and during follow-up, by showing whether nerve regeneration is taking place. When creating the surgical approaches, thorough familiarity with anatomic safe zones and nerve trajectories is crucial to ensure full control of the zones at highest risk for nerve injury. LEVEL OF EVIDENCE: IV.

Acromial stress fractures can occur after reverse total shoulder arthroplasty (rTSA). We performed this study to assess the incidence, risk factors, characteristics, and outcome of acromial stress fractures and reactions after rTSA.

We determined the incidence of acromial stress fractures and reactions in a cohort of patients who underwent rTSA, and assessed risk factors using a case-control design. Each patient who developed an acromial stress fracture or reaction after rTSA (case) was matched by date of rTSA with 2 patients who did not develop acromial stress fractures/reactions after rTSA (control subjects); univariate and multivariable analyses were performed to identify risk factors. Characteristics of acromial stress fractures/reactions are described. Outcomes were compared between cases and control subjects.

The incidence of acromial stress fracture/reaction after rTSA was 11% (24/220 rTSAs). Acromial stress fractures/reactions occurred at a median time of 5.5 months after rTSA (range: 20 days-118 months) and most were fractures (18/24, 75%). Using a multivariable analysis, we found 2 factors to be independently associated with the occurrence of an acromial stress fracture/reaction after rTSA: corticosteroids use (adjusted OR: 9.6, 95% confidence interval: 1.1-86.1, P = .04) and previous shoulder surgery (adjusted OR: 7.2, 95% confidence interval: 1.4-36.6, P = .02). In this cohort, in which the management was exclusively conservative, the occurrence of post-rTSA acromial stress fracture/reaction was associated with a significantly worse functional outcome at last follow-up visit, as compared with control subjects. This was illustrated by significantly lower American Shoulder and Elbow Surgeons Shoulder score, higher Shoulder Pain and Disability Index and Disabilities of the Arm, Shoulder and Hand scores, and worse forward elevation and internal rotation as compared with control patients who did not develop acromial stress fracture/reaction after rTSA.

In our Australian cohort, acromial stress fractures/reactions were relatively common after rTSA, and independently associated with corticosteroids use and previous shoulder surgery. The occurrence of acromial stress fracture/reaction was associated with a significantly worse functional outcome, as compared with patients who do not develop this complication after rTSA.

To evaluate CT imaging findings in symptomatic patients with and without revision surgery (RS) after reverse shoulder arthroplasty (RSA).

In this retrospective study, two radiologists assessed CT imaging findings in symptomatic patients with RSA over 5 years, including material fracture and loosening of the peg, baseplate, screws, and humeral stem, screw positioning, prosthesis dislocation, glenoid notching, fractures, and deltoid muscle quality. The primary outcome parameter was RS. Patients were assigned Group 1 (RS) or Group 2 (No RS).

Ninety-nine patients (mean age 70.4 ± 10.3 years, 61 females) met the inclusion criteria. Fifty-two patients (29 females) received RS after 34.0 ± 38.3 months. The only CT imaging finding significantly associated with RS was prosthesis dislocation (P = .007, odds ratio (OR) 10.95, 95% CI 1.34-89.24). All other evaluated CT imaging findings were not associated with RS. Yet, loosening of the peg (30% vs. 16%), baseplate (15% vs. 6%), and superior screw (18% vs. 7%) and periprosthetic humeral fractures (29% vs. 13%)-as common reasons for RS-were more frequent in patients with RS than in those without, however not reaching significance (P ≥ .11). The large majority of patients had glenoid notching (79% vs. 94%), irrespective of RS.

In this cohort of symptomatic patients after RSA, prosthesis dislocation was the only CT imaging finding associated with RS. Besides, there was a trend with higher numbers of loosening of the peg, baseplate, and superior screw, as well as periprosthetic humeral fractures in patients with RS, though not reaching significance.

Background/Objectives: Classical reverse shoulder arthroplasty (RSA) with a high neck-shaft angle (NSA) of 155° has shown satisfactory outcomes. However, newer RSA designs aim to improve results by modifying the stem design. This study evaluates the 5-year outcomes of a stem design featuring a rectangular metadiaphyseal fixation and a 135° NSA. Methods: This prospective bicentric case series included and longitudinally followed up patients that were treated for cuff arthropathy, massive irreparable rotator cuff tears, or eccentric osteoarthritis using a non-cemented rectangular metadiaphyseal fixation stem with a 135° NSA (Univers Revers, Arthrex, Naples, FL, USA). Subjective and objective functional outcome scores (Constant-Murley Score (CS), Shoulder Pain and Disability Index (SPADI), and Subjective Shoulder Value (SSV)), range of motion (ROM), radiographic outcome, adverse events, complications, and quality of life were investigated. Results: This study enrolled 132 patients (59% female, mean age 75 years, SD 6). At the 5-year follow-up, subjective and objective outcomes significantly improved compared to baseline: CS (32.9 to 71.7, p < 0.001), SPADI (38.7 to 86.2, p < 0.001), and SSV (43.0 to 84.1, p < 0.001). ROM improved in flexion (80° to 142.4°, p < 0.001), abduction (71.5° to 130.2°, p < 0.001), internal rotation (p < 0.001), internal rotation at 90° abduction (12.7° to 45.0°, p < 0.001), and abduction strength (0.8 kg to 5.2 kg, p < 0.001). External rotation remained unchanged (32.1° to 32.0°, p = 0.125), but external rotation at 90° abduction improved (20.9° to 52.7°, p < 0.001). No signs of implant migration, subsidence, shift, tilt, alignment loss, or wear were observed, but scapular bone spur formation (11%), scapular notching grade 1 (10%), bone resorption (10%), and partial humeral radiolucent lines (1%) were reported. Conclusions: Rectangular stems with metadiaphyseal fixation and a 135° neck-shaft angle in RSA consistently improve shoulder function, showing no aseptic loosening and minimal radiological changes at 5 years.

As the incidence of reverse total shoulder arthroplasty (rTSA) continues to rise, better understanding of the long-term risks and complications is necessary to determine the best choice of implant. The majority (75%) of rTSAs performed in New Zealand use either SMR (Systema Multiplana Randelli; Lima-LTO) or Delta Xtend (DePuy Synthes). The aim of this registry-based study was to compare implant survival, risk of revision, and reasons for revision between the 2 most frequently used rTSA prostheses: SMR and Delta Xtend.

Using data from the New Zealand Joint Registry between 1999 and 2022, we identified 5891 patients who underwent rTSA using either SMR cementless (62.8%) or Delta Xtend prostheses (37.2%). Delta Xtend was subdivided into cementless (31.4% of total) and cemented humeral stem (5.8% of total) subgroups for analysis. Revision-free implant survival and functional outcomes (Oxford Shoulder Score [OSS] at 6 months, 5 years, and 10 years were adjusted by age, American Society of Anesthesiologists [ASA] grade, indication, sex, and surgeon volume for between-group comparisons.

Ten-year revision-free implant survival was 93.0%, 92.5%, and 95.8% for Delta Xtend cemented, Delta Xtend cementless, and SMR, respectively. The Delta Xtend cemented implant had a 2-fold higher adjusted revision risk compared with both the Delta Xtend cementless and the SMR cementless implants (hazard ratio [HR] = 2.04, P = .011; and HR = 2.59, P < .001, respectively). There was no significant difference between the Delta Xtend cementless and SMR cementless groups (HR = 1.28, P = .129). The Delta Xtend cemented group was significantly (P ≤ .01) older, had more comorbidities (ASA 3 or 4), female, and indicated for fracture compared with other groups. The most common reason(s) for revision was aseptic loosening and infection for Delta Xtend cementless; aseptic loosening, instability or dislocation, and infection for Delta Xtend cemented; and aseptic loosening alone for SMR cementless. Average OSS was significantly lower in Delta Xtend cemented compared with Delta Xtend cementless and SMR cementless at 6 months (30.8, 35.9 vs. 35.6, respectively, P < .01) and 5 years (37.4, 40.7 vs. 39.5, respectively, P < .01).

Overall, we found that the Delta Xtend cemented group had more than a 2-fold risk of revision compared with Delta Xtend cementless and SMR cementless groups, whereas there was no difference in revision risk between the Delta Xtend and SMR cementless prostheses. As the incidence of rTSA continues to rise, better understanding of the long-term risks and complications is necessary to determine the best choice of implant.

Inverted-bearing reverse shoulder arthroplasty (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner to minimize polyethylene wear and debris secondary to impingement between the humerus and glenoid neck. IB-RSA long-term survivorship, complication and revision rates, as well as clinical and radiographic outcomes have not been reported yet.

This is a monocentric retrospective study on a consecutive series of 151 patients who underwent primary IB-RSA from January 2009 to September 2015 and were evaluated clinically and radiologically at the minimum 8-year follow-up. All complications and reoperations were recorded. Survivorship analysis with any revision surgery as endpoint was done using Kaplan-Meier survival curves.

Seventy-eight patients (follow-up rate 51.7%) were reviewed at a mean follow-up of 10.1 ± 1.9 years. At 10 years, the revision-free survival was 98.7% (95% confidence interval: 94.8-99.7). Sixteen complications (10.6%) were observed: 2 axillary nerve injuries, 2 infections, 2 glenoid loosening (which stabilized within 1 year), 2 cases of otherwise unexplained painful stiffness, 4 acromial fractures, 1 post-traumatic scapular pillar fracture, and 3 post-traumatic humeral periprosthetic fractures. Two patients were revised due to infection. No cases of late glenoid loosening and humeral loosening were observed. The revision rate was 1.3%. All the clinical scores and range of motion significantly improved at the last follow-up compared with preoperative status: final Constant score was 66.1 ± 17.4, Subjective Shoulder Value 79.1 ± 20.9, and the American Shoulder and Elbow Surgeons 82.2 ± 17.7. Scapular notching was observed in 51.4% of patients: only 1 case of grade 3 notching was observed in an early glenoid subsidence case.

Primary IB-RSA appears to be a safe and effective procedure and does not present specific implant-associated complications at long-term follow-up. Radiographic analysis showed that inverting the biomaterials leads to a distinct kind of notching with mainly mechanical features.

Background The role of tranexamic acid (TXA) in primary elective hip, knee, and shoulder arthroplasty is well established. This is a retrospective study, which explores the efficacy of TXA in proximal humerus fractures (PHF) requiring shoulder arthroplasty. Design and methods Patients undergoing reverse total shoulder arthroplasty (RSA) for PHF between January 2022 and May 2024 in Queen Elizabeth Hospital (QEH), Birmingham, UK were identified. Patients were administered 1 g of intravenous TXA injection preoperatively during anesthetics induction. The parameters reviewed included changes in hemoglobin (Hb) levels from preoperative to postoperative, postoperative blood transfusion rates, and length of hospital stay. Results Out of 78 patients, 35 (45%) patients received TXA whereas 43 (55%) patients did not receive TXA preoperatively. No significant drop in Hb levels from preoperative to postoperative was observed (TXA: 1.7 ± 1.2 g/dL vs. non-TXA: 2.0 ± 1.3 g/dL, P = 0.30). Seven out of 78 (8.9%) patients required blood transfusion (3 (TXA) vs. 4 (non-TXA); 6 (86%) females vs. 1 (14%) males). In the blood transfusion cohort, patients from both groups required a longer length of hospital stay postoperatively (TXA: 20.3 + 16.0 days vs. non-TXA: 18.5 ± 14.8 days, P = 0.88). Conclusion Intravenous 1 g of TXA preoperatively was not associated with a significant decrease in postoperative Hb reduction in trauma patients undergoing RSA for PHF. Females undergoing RSA are at a greater risk of blood transfusion despite TXA administration. Future studies should consider investigating the dose-dependent efficacy of intravenous TXA on Hb drop postoperatively on trauma patients undergoing RSA.

While outcomes following reverse total shoulder arthroplasty (rTSA) have often been gauged through radiological assessments focusing on prosthesis position, there is increasing recognition of patient-reported outcomes, particularly satisfaction, as indicators of surgical success. The objective of this study was to correlate radiological findings with clinical outcomes, patient satisfaction, and health-related quality of life (HRQoL).

A retrospective evaluation was conducted on patients following rTSA at a minimum of 2 years postoperatively. Functional outcome (active range of motion [ROM], Constant Score [CS], American Shoulder and Elbow Surgeons score, and Simple Shoulder Test) and the Short Form-36 were evaluated. Strictly anteroposterior radiographs were used to determine preoperative and postoperative parameters. Preoperative measurements included acromiohumeral interval, reverse shoulder arthroplasty angle, center of rotation (COR), and deltoid length. Postoperatively, the lateralization angle, distalization angle, acromiohumeral distance, peg-glenoid rim distance, sphere-bone overhang distance, reverse shoulder arthroplasty, COR, and deltoid length were measured. Scapular notching was classified according to Sirveaux et al.

A total of 49 patients were evaluated at an average of 30.78 ± 7.15 months postoperatively at last follow-up. Active ROM, pain on the Visual Analog Scale, and CS showed significant improvement (P < .05). There was a high level of patient contentment, which correlated positively with the American Shoulder and Elbow Surgeons score and CS, and negatively with postoperative pain Visual Analog Scale. Postoperative HRQoL, measured by the Short Form-36, showed strong positive correlations with all clinical scores (P < .05). Distalization had a negative impact on external rotation (P = .001) and strength capacity (P = .031). Medialization of the COR showed a contrary relationship to external rotation (P < .001) and strength capacity (P < .001).

This study confirms rTSA's effectiveness in reducing pain and improving daily function, with a high readiness among patients to undergo the surgery again. Patient contentment and HRQoL showed a strong correlation with the clinical outcomes of the surgery. Radiological measurements may predict postoperative ROM and scapular notching yet fail to accurately reflect patient quality of life.

There is a paucity of literature on manufacturer mismatch in reverse shoulder arthroplasty (RSA). It is unclear if the use of different implant manufacturers for the glenoid side and the humeral side influences patient outcomes in primary RSA. We hypothesize that patients undergoing primary RSA with manufacturer mismatch such that humeral and glenoid components are from different manufacturers will not experience adverse outcomes when compared to a cohort of patients with humeral and glenoid components from the same manufacturer.

Between January 2016 and June 2020, all patients who had an RSA implanted by one fellowship-trained shoulder surgeon were considered potentially eligible for inclusion in this retrospective analysis of data prospectively collected during a multicenter study. The inclusion criteria were as follows: primary RSAs implanted through a deltopectoral approach with glenoid and humeral components from different manufacturers, and complete data available at 2 years follow-up. The cohort was divided into a mismatch group and a control group, with the latter comprising patients having undergone RSA with components from the same manufacturer.

From the initial cohort, 191 patients were available for the 2-year clinical and radiological evaluation. Among these individuals were 60 men and 131 women, with a mean age of 74. The mismatch group comprised 39 patients and the control group included 152 patients. Baseline outcome scores of the mismatch and matched cohorts were similar regarding visual analog score (P = .220), Subjective Shoulder Value (P = .518), American Shoulder and Elbow Surgeons (P = .670), and Constant (P = .477) scores. Two-year postoperative outcome scores of the mismatched and matched cohorts were also similar regarding visual analog score (P = .716), Subjective Shoulder Value (P = .125), American Shoulder and Elbow Surgeons (P = .673), and Constant (P = .607) scores. The complication rate and radiological complications were similar.

Mixing of glenoid and humeral components from different manufacturers does not appear to affect patient outcomes in primary RSA at 2 years follow-up. The results may provide valuable information for orthopedic surgeons when selecting the appropriate implant components for RSA and help guide clinical decision-making for better patient outcomes. It appears reasonable to have manufacturer mismatch when appropriate matching of implant material and curvature at a given diameter is used.

The purpose of this study was to examine the radiographic and clinical outcomes of stemless reverse total shoulder arthroplasty (RTSA) after a minimum 2-year follow-up.

Between July 2018 and March 2023, 50 patients underwent 50 stemless RTSA with the Lima component. Twenty-eight patients with a follow-up of more than 2 years were reviewed. The average age was 71.9 years (range, 61-85 years), and the average follow-up period was 2.2 years (range, 2.0-5.1 years). Bone marrow density of the proximal humerus was measured before RTSA. We evaluated preoperative and postoperative range of motion, clinical score, radiographic change, and postoperative complications.

Significant increases were observed postoperatively in forward flexion (112.0°-162.5°, P<0.01) and internal rotation (from L3 to T12 level, P<0.05). No changes were observed in external rotation (from 43.0° to 45.2°, P=0.762). The clinical scores improved for Korean Shoulder Scoring system (from 64 to 93, P<0.01) and American Shoulder and Elbow Surgeons score (from 17.5 to 27.3, P<0.01). Although radiolucent lines of less than 2 mm were observed in all cases, no osteolysis and loosening of the stemless humeral component was found. Scapular notching was observed in 18 cases (64.3%).

Stemless RTSA showed good radiographic and clinical results after a minimum 2-year follow-up. Level of evidence: IV.

The annual utilization of reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (ATSA) has grown exponentially, in part due to the expanded indications of RTSA. This evolution in shoulder arthroplasty prompts the need to evaluate outcomes between ATSA and RTSA. However, many other studies comparing outcomes between ATSA and RTSA lacked a large nationally-represented sample, a matched cohort analysis, or both. In this study, we compare outcomes between patients undergoing ATSA or RTSA in a large matched-cohort analysis.

Patients undergoing RTSA or ATSA from the National Inpatient Sample database between 2016 and 2019 were identified. Groups were propensity-matched based on demographics and comorbidities. We compared medical and surgical complications, length of stay, and total hospital charges. T-tests and chi-square tests were performed for continuous and categorical variables, respectively. Odds ratios were calculated as a ratio between RTSA and ATSA groups.

Following matching, there were 38,782 patients in the ATSA group and 35,461 patients in the RTSA group. The RTSA group had higher odds of acute renal failure (OR 1.35), blood loss anemia (OR 1.39), and pneumonia (OR 1.19). There were no differences for myocardial infarction, pulmonary embolism, deep venous thrombosis, mortality, periprosthetic fracture, or dislocation. The RTSA group had higher odds of periprosthetic mechanical complication (OR 1.92), but lower odds of periprosthetic joint infection (OR 0.65). The mean length of stay and total hospital charges were both higher in the RTSA group (p < 0.001).

We found patients undergoing RTSA are at higher odds of inpatient medical complications, including acute renal failure and acute blood loss anemia. RTSA is associated with higher odds of short-term periprosthetic mechanical complications.

Humeral loosening (HL) is an uncommon indication for revision shoulder arthroplasty. This systematic review describes patient characteristics (prosthetic type removed, reimplanted, and septic vs. aseptic loosening status), re-revision rate, and outcomes following revision surgery for a loose humeral stem.

An electronic database search of PubMed, Scopus, Embase, and Cochrane was conducted accordant to the Preferred Reporting Items for Systematic Reviews and Meta-analyses method. Studies that reported information on patients who had revision arthroplasty due to HL and reported their postrevision outcomes were included in this review.

Our review included 13 studies, from which 119 revision cases due to HL were extracted. The prostheses subtypes revised for HL were 48.7% (58/119) anatomic total shoulder arthroplasties (TSAs), 46.2% (55/119) reverse shoulder arthroplasties (RSAs), and 5.0% (6/119) hemiarthroplasties (HAs). The implants used to revise patients with HL were 52.2% (59/113) RSAs, 35.4% (40/113) HAs, and 12.4% (14/113) TSAs. Septic loosening occurred in 11.7% (14/119) of the cases. Ninety-seven cases provided details regarding subsequent revisions, of which 28.9% (28/97) were re-revised. The following outcome scores were available: mean satisfaction rate was 71.4% (n = 49), the mean total American Shoulder and Elbow Surgeons score was 52.5 (range 30-66) (n = 28), and the mean Constant score was 40.3 (range 34-41.3) (n = 14).

The most revised implants for HL were TSAs and RSAs. Reverse shoulder arthroplasties were the most common implants used for revision, followed by HAs. Aseptic loosening accounted for most cases, suggesting that infection is rarely the primary cause of HL. There is a pronounced risk of re-revision for recurrent HL. The irregular reporting of validated outcome scores makes it difficult to draw definitive conclusions regarding the treatments of these patients.

Avascular necrosis (AVN) of the humeral head is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely, total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty), is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies.

Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio because TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox proportional hazard modeling. χ2 analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness.

In total, 4825 patients undergoing TSA and 1969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = .017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = .148) and no difference in the observed etiologies for revision (P > .05 for all).

After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10 years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

The aim of this study was to observe the effects of changing humeral tray thickness on the resultant of intraoperative glenohumeral joint loads using a load-sensing system (LSS).

An rTSA was performed on fresh frozen full-body cadaver shoulders by using an internal proprietary LSS on the humeral side. The glenohumeral loads (Newtons) and the direction of the resultant force applied on the implant were recorded during four standard positions (External rotation, Extension, Abduction, Flexion) and three "complex" positions of Activity Daily Life ("behind back", "overhead reach" and "across chest"). For each position, the thickness was increased from 0 to 6 mm in a continuous fashion using the adjustment feature of the humeral system. Each manoeuvre was repeated three times.

All shoulder positions showed a high repeatability of the glenohumeral load magnitude measured with an intra-class correlation coefficient of over 0.9. For each position, we observed a strong but no linear correlation between humeral tray thickness and joint loads. It was a cubical correlation (rs = 0,91) with a short ascending phase, then a plateau phase, and finally a phase with an exponential growth of the loads on the humeral implant. In addition, an increase in trail-poly thickness led to a recentering of force application at the interface of the two glenohumeral implants.

This study provides further insight into the effects of humeral implant thickness on rTSA glenohumeral joint loads during different positions of the arm. Data obtained using this type of device could guide surgeons in finding the proper implant balance during rTSA.

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.

MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated.

The initial search elicited 3,166 results and, following removal of duplicates and screening, 13 studies with a total of 1,042 RSAs were identified. An increase in shoulder scores pre- to postoperatively was reported in all the studies. Following revision of a RSA to a further RSA, there was a significant increase in the American Shoulder and Elbow Surgeons Score (mean difference 20.78 (95% CI 8.16 to 33.40); p = 0.001). A re-revision rate at final follow-up ranging from 9% to 32%, a one-year re-revision rate of 14%, and a five-year re-revision rate of 23% were reported. The complication rate in all the studies was between 18.5% and 36%, with a total incidence of 29%.

This is the largest systematic review of the outcomes following revision of a RSA. We found an improvement in functional outcomes after revision surgery, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure.

In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes.

Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected.

A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups.

RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms.

There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition.

Reverse shoulder arthroplasty (RSA) has become a widely used procedure since its introduction in the 1980s, and is currently used to treat a wider range of conditions than its original indication. The original Grammont-style RSA revolutionized shoulder arthroplasty but had several limitations, including scapular notching and reduced rotational motion. This review discusses the evolution of RSA design, particularly the development of a lateralized center of rotation constructs, which aims to improve all the disadvantages associated with the Grammont-style design and more closely reproduce the native anatomy in order to improve patient outcomes in an expanded context of pathologies.

Reverse shoulder arthroplasty (RSA) designs include multiple options for glenoid component lateralization, and humeral component lateralization and distalization (inlay/onlay constructs). The influence of combined glenoid lateralization, and humeral distalization on acromial and deltoid stresses is not well understood. The purpose of this study was to evaluate changes in deltoid and acromial stresses with variations in glenoid lateralization, and with inlay versus onlay humeral components in RSA.

Finite element analysis was performed using a RSA system with both inlay and onlay configurations. Variations in total glenoid lateralization from 3 to 9 mm were evaluated. Deltoid and acromial stresses were determined following virtual implantation and with 50° of external rotation.

Increased glenoid lateralization resulted in greater stress of the deltoid and acromion. There was a modest increase in deltoid stress with glenoid lateralization alone (7% and 7.5% with progressive lateralization from 3 to 6 mm and 6 to 9 mm, respectively), but deltoid stress increased substantially with use of an onlay construct (60% at 9 mm of glenoid lateralization). Acromial stress correspondingly increased 37% with glenoid lateralization, and up to 117% with an onlay humeral construct.

Increased lateralization of the glenoid component resulted in increased levels of deltoid and acromial stress. For a given amount of glenoid lateralization, utilization of an inlay stem decreased acromial and deltoid stresses compared to onlay constructs. These data allow surgeons to better understand the interactions of glenoid and humeral lateralization and distalization in the setting of contemporary RSA systems.Level of Evidence: Basic Science Study: Computer Modeling.

Background: Proximal humeral bone deficiency in revision shoulder arthroplasty is an emerging and challenging problem as the use of reverse shoulder arthroplasty (RSA) increases. This paper presents a technical note discussing our detailed preoperative planning steps, surgical techniques, and their rationale in carrying out the use of an allograft prosthetic composite (APC) to address proximal humeral bone deficiency in revision RSA. The outcomes of this technique are also presented. This paper also presents a systematic review to further discuss the existing literature on RSA with APCs. Methods: The preoperative surgical planning and the surgical technique employed to execute proximal humeral reconstruction using APC during revision arthroplasty are discussed in the technical note. The preliminary clinical and radiological results of five patients who underwent revision shoulder arthroplasty with proximal humeral reconstruction using APCs are presented. The PRISMA guidelines were followed to perform the systematic review. A systematic search using PubMed, Embase, and Cochrane databases was conducted. All studies involving RSA and APCs were pooled, and the data were extracted and analyzed. Results: A total of 14 studies were eligible for inclusion in the systematic review, with a total of 255 patients and a mean follow-up of 57 months. All studies in the systematic review and the patients included in the author's case series showed improvements in the level of pain, range of motion, function, and satisfaction. Graft incorporation in the systematic review was 84%. Conclusions: Based on the available literature and the results of our case series, the use of an APC construct is a viable option for proximal humeral bone deficiency in revision shoulder arthroplasty.

Knowledge regarding differences in the order of frequency of complications after reverse total shoulder arthroplasty (rTSA) between Asian and Western populations is limited. We therefore asked for (1) what is the order of frequency of complications after primary rTSA in the Korean population? (2) What are the rates of complication, reoperation, and revision, and clinical outcomes after index surgery?

We retrospectively reviewed the 299 consecutive cases who underwent primary rTSA with more than 1 year of follow-up over a period of 12 years. The mean age of the patients was 73.4 years (range, 58-88 years) and the mean follow-up period was 3.8 years (range, 1-11.5 years). Evaluation of the clinical outcomes, complications, and reinterventions was performed at the final follow-up.

The mean visual analog scale pain score, University of California at Los Angeles score, American Shoulder and Elbow Surgeons score, and subjective shoulder value improved from 6.7, 10.2, 30.7, and 27.7% before rTSA to 1.4, 26.4, 80.5, 77.2% after rTSA, respectively (P < .001). Overall, 45 complications (15.1%) were observed in 44 patients. The order of frequency of complications was as follows: 16 cases of scapular stress fracture (5.4%), 9 intraoperative or postoperative periprosthetic fracture (3.0%), 6 brachial plexus injury (2.0%), 4 instability (1.3%), 2 glenoid loosening (0.7%), 2 glenoid disassembly (0.7%), 2 periprosthetic joint infection (0.7%), 1 glenoid fixation failure (0.3%), 1 humeral stem fixation failure (0.3%), 1 hematoma (0.3%), and 1 complex regional pain syndrome (0.3%). Reintervention was performed in 15 cases (5.0%) including reoperation (8 cases; 2.7%) and revision surgery (7 cases; 2.3%).

At a mean follow-up period of 3.8 years, primary rTSA showed satisfactory clinical outcomes with a complication rate of 15.1%, a reoperation rate of 2.7%, and a revision rate of 2.3%. Scapular stress fracture appears to be the most common complication after rTSA in the Korean population.

Humeral distalization is inherent to reverse total shoulder arthroplasty (rTSA) and is often produced with concomitant humeral lateralization via the level of the humeral head cut, implant positioning, implant neck shaft angle, and polymer insert thickness. Biomechanical data on the isolated effects of humeral distalization remain limited but could be important to consider when optimizing postoperative rTSA shoulder function. This study investigated the effects of isolated humeral distalization on shoulder biomechanics using a biorobotic shoulder simulator.

Eight fresh-frozen cadaveric shoulders were tested using custom polymer inserts that translated the bearing surface 0, +5, +10, and +15 mm along the humeral stem axis, producing isolated distalization without lateralization. Specimens underwent passive elevation in the scapular plane with a static scapula to assess glenohumeral range of motion. Scapular plane abduction motion trajectories were then performed, driven by previously collected scapulothoracic and glenohumeral kinematics from rTSA patients. The effect of isolated distalization on passive elevation was tested using mixed-effects linear regression and the effect on muscle force, joint reaction force, and muscle excursion during active scapular-plane abduction was tested using statistical parametric mapping random effects analysis.

Maximum passive scapular plane elevation increased with humeral distalization (4° per 5 mm distalization). During active elevation, deltoid and rotator cuff muscle forces, and joint reaction forces, increased up to 37% per 5 mm of distalization. Simulated deltoid muscle excursion was altered with increasing distalization but amounted to no more than 0.8 mm change from baseline per 5 mm of distalization. Rotator cuff muscles were consistently lengthened throughout abduction, up to 1.6 mm per 5 mm of distalization. These trends were observed across various patient motions.

Isolated humeral distalization caused dramatic increases in the muscle forces required to perform scapular-plane abduction. Joint reaction forces increased correspondingly. These results suggest that implant and surgical strategies to generate deltoid muscle tension without humeral distalization may promote better active range of motion and more durable long-term outcomes over approaches that rely on distalization.

The liner design is a key determinant of the constraint of a reverse total shoulder arthroplasty (rTSA). The aim of this study was to compare the degree of constraint of rTSA liners between different implant systems.

An implant company's independent 3D shoulder arthroplasty planning software (mediCAD 3D shoulder v. 7.0, module v. 2.1.84.173.43) was used to determine the jump height of standard and constrained liners of different sizes (radius of curvature) of all available companies. The obtained parameters were used to calculate the stability ratio (degree of constraint) and angle of coverage (degree of glenosphere coverage by liner) of the different systems. Measurements were independently performed by two raters, and intraclass correlation coefficients were calculated to perform a reliability analysis. Additionally, measurements were compared with parameters provided by the companies themselves, when available, to ensure validity of the software-derived measurements.

There were variations in jump height between rTSA systems at a given size, resulting in large differences in stability ratio between systems. Standard liners exhibited a stability ratio range from 126% to 214% (mean 158% (SD 23%)) and constrained liners a range from 151% to 479% (mean 245% (SD 76%)). The angle of coverage showed a range from 103° to 130° (mean 115° (SD 7°)) for standard and a range from 113° to 156° (mean 133° (SD 11°)) for constrained liners. Four arthroplasty systems kept the stability ratio of standard liners constant (within 5%) across different sizes, while one system showed slight inconsistencies (within 10%), and ten arthroplasty systems showed large inconsistencies (range 11% to 28%). The stability ratio of constrained liners was consistent across different sizes in two arthroplasty systems and inconsistent in seven systems (range 18% to 106%).

Large differences in jump height and resulting degree of constraint of rTSA liners were observed between different implant systems, and in many cases even within the same implant systems. While the immediate clinical effect remains unclear, in theory the degree of constraint of the liner plays an important role for the dislocation and notching risk of a rTSA system.

Since the original Grammont design of a reverse shoulder arthroplasty there has been a trend to decrease inclination angle from 155° to 145 or 135°. Furthermore, lateralization on the glenoid side has been advocated. These changes decrease the risk for impingement between humerus and the inferior part of the glenoid (notching). These changes were also made to improve restoration of rotation. However, there is very little evidence that rotation has improved due to these changes. A negative effect of lateralization is that it increases the risk for glenoid loosening. Furthermore, the stress on acromion increases which may lead to more acromion or scapula spine fractures. More randomized studies are needed to define optimal design of a reverse shoulder arthroplasty.

With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes.

A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means.

Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies.

Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.

Postoperative infection after the Latarjet procedure, ranging from 1% to 6%, can compromise the functional outcome of young athletes. Cutibacterium acnes is a main pathogen as a consequence of an intraoperative contamination.

To evaluate intraoperative contamination with C. acnes and the effectiveness of the local application of vancomycin during the Latarjet procedure.

Cohort study; Level of evidence, 2.

This was a single-center study including 75 patients (mean age, 26 years; range, 15-55 years) operated on for anterior shoulder instability with the primary open Latarjet procedure; they underwent the same protocol of skin preparation and preoperative prophylactic antibiotics. Three groups of 25 patients were created and divided sequentially, without the results of each group being known before the end of the study: group A (5 mg/mL of vancomycin), group B (20 mg/mL of vancomycin), and group C (control group with no vancomycin). Swab samples of the coracoid were taken before sectioning the coracoid process (time 1) and after its preparation (time 2). The coracoid was then wrapped in gauze impregnated with different concentrations of vancomycin, except for group C. A final sample (time 3) was taken before screwing the bone block onto the glenoid. All samples were cultured for 21 days, and patients underwent clinical and radiological follow-up for 6 months.

The C. acnes contamination rates at times 1, 2, and 3 were 25%, 44%, and 45%, respectively, without significant difference. There was no significant difference between groups A and B with respect to the number of positive cultures at each time point. Of 9 positive cultures at time 1, all were still positive at time 3 in group A, whereas 3 of 5 were negative in group B (P = .027). The rate of C. acnes at time 3 in the control group was higher than that in the 2 other groups (68% vs 44% for group A and 20% for group B; P = .003). Body mass index was the only prognostic factor for a C. acnes-positive culture (26.05 ± 3.39 vs 23.34 ± 2.33; P = .018). No clinical infection was reported at the 6-month postoperative follow-up.

The rate of C. acnes contamination ranged from 25% to 68% during the open Latarjet procedure in young athletes. Vancomycin reduced the bacterial contamination when it was used at high concentrations in a gauze wrap on the coracoid. The type of C. acnes detected and its clinical implications remain to be studied.

Several reconstruction methods exist for Malawer type I/V proximal humerus reconstruction after bone tumor resection; however, no consensus has been reached regarding the preferred methods.

We conducted a literature search on various types of proximal humerus oncologic reconstruction methods. We collected data on postoperative functional outcomes assessed based on Musculoskeletal Tumor Society (MSTS) scores, 5-year reconstruction survival rates, and complications. We calculated each reconstruction's weighted mean based on the sample size and standard errors. Complications were categorized based on the Henderson classification. Based on these integrated data, our primary objective is to propose an optimal strategy for proximal humerus reconstruction after bone tumor resection.

We examined various reconstruction techniques, including modular prosthesis (752 patients in 21 articles), osteoarticular allograft (142 patients in 6 articles), allograft prosthesis composites (APCs) (236 patients in 12 articles), reverse shoulder total arthroplasty (141 patients in 10 articles), composite reverse shoulder total arthroplasty (33 patients in 4 articles), claviculo-pro-humero (CPH) technique (51 patients in 6 articles), and cement spacer (207 patients in 4 articles). Weighted mean MSTS scores were: modular prosthesis (73.8%), osteoarticular allograft (74.4%), APCs (79.2%), reverse shoulder total arthroplasty (77.0%), composite reverse shoulder total arthroplasty (76.1%), CPH technique (75.1%), and cement spacer (69.1%). Weighted 5-year reconstruction survival rates were modular prosthesis (85.4%), osteoarticular allograft (67.6%), APCs (85.2%), reverse shoulder total arthroplasty (84.1%), and cement spacer (88.0%). Reconstruction survival data was unavailable for composite reverse shoulder total arthroplasty and CPH technique. Major complications included shoulder joint instability: modular prosthesis (26.2%), osteoarticular allograft (41.5%), APCs (33.9%), reverse shoulder total arthroplasty (17%), composite reverse shoulder total arthroplasty (6.1%), CPH technique (2.0%), and cement spacer (8.7%). Aseptic loosening of the prosthesis occurred: modular prosthesis (3.9%) and reverse shoulder total arthroplasty (5.7%). Allograft fracture was observed in 54.9% of patients with osteoarticular allograft.

The complication profiles differed among reconstruction methods. Weighted mean MSTS scores exceeded 70% in all methods except cement spacer, and the 5-year reconstruction survival rate surpassed 80% for all methods except osteoarticular allograft. Proximal humerus reconstruction after bone tumor resection should consider potential complications and patients' individual factors.

Total shoulder arthroplasty (TSA) in patients with rheumatoid arthritis (RA) can present unique challenges. The aim of this study was to compare both systemic and joint-related postoperative complications in patients undergoing primary TSA with RA versus those with primary osteoarthritis (OA).

Using the TriNetX database, Current Procedural Terminology and International Classification of Diseases, 10th edition codes were used to identify patients who underwent primary TSA. Patients were categorized into two cohorts: RA and OA. After 1:1 propensity score matching, postoperative systemic complications within 90 days following primary TSA and joint-related complications within 5 years following anatomic TSA (aTSA) and reverse shoulder arthroplasty (RSA) were compared.

After propensity score matching, the RA and OA cohorts each consisted of 8,523 patients. Within 90 days postoperation, RA patients had a significantly higher risk of total complications, deep surgical site infection, wound dehiscence, pneumonia, myocardial infarction, acute renal failure, urinary tract infection, mortality, and readmission compared to the OA cohort. RA patients had a significantly greater risk of periprosthetic joint infection and prosthetic dislocation within 5 years following aTSA and RSA, and a greater risk of scapular fractures following RSA. Among RA patients, RSA had a significantly higher risk of prosthetic dislocation, scapular fractures, and revision compared to aTSA.

Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. Knowledge of the risk profile of RA patients undergoing TSA is essential for appropriate patient counseling and education. Level of evidence: III.

Acromial stress fracture (ASF) is an uncommon but acknowledged complication of reverse total shoulder arthroplasty (RTSA). There is no standardised method to directly measure the bone mineral density of the acromion to allow a detailed analysis of the potential mechanism of ASF. The aim is to establish a reliable and reproducible technique for measurement of acromial density on computer tomography (CT).

A retrospective review on CT scans obtained for three groups of patients: those planned for RTSA (n = 26); age and gender-matched non-operative (n = 26); and young non-operative patients (n = 28) were performed. Standardised axial images of 1 mm thickness at 1 mm increments were created following horizontal straightening on the coronal and sagittal views. To assess inter-rater reliability, two senior CT radiographers performed density measurements using standard region of interest (ROI) tool on the CTs with the ROI placed on the mid (ROI 1) and posterior (ROI 2) acromion. ROIs were selected as the most common locations for acromion fracture post RTSA. Measurements were repeated at least 6 weeks apart. Intra-class coefficients (ICC) were used to determine intra- and inter-rater reliability.

ICCs demonstrated good to high intra-rater and inter-rater reliability for both ROI 1 and ROI 2 across all three groups. The lower margin of 95% confidence intervals was more than 0 for all intra-class coefficients.

This study demonstrates a reliable method of measuring acromion density on CT. This method can be used to assess bone mineral density in the clinical setting and in future studies investigating ASF following RTSA.

We aimed to report the survival of different reverse shoulder arthroplasty (RSA) designs and brands, and factors associated with revision. The secondary aim was to evaluate the reasons for revision.

We included 4,696 inlay and 798 onlay RSAs reported to the Norwegian Arthroplasty Register (NAR) 2007-2022. Kaplan-Meier estimates of survivorship and Cox models adjusted for age, sex, diagnosis, implant design, humeral fixation, and previous surgery were investigated to assess revision risks. The reasons for revision were compared using competing risk analysis.

Overall, the 10-year survival rate was 94% (confidence interval [CI] 93-95). At 5 years all brands exceeded 90%. Compared with Delta Xtend (n = 3,865), Aequalis Ascend Flex (HR 2.8, CI 1.7-4.6), Aequalis Reversed II (HR 2.2, CI 1.2-4.2), SMR (HR 2.5, CI 1.3-4.7), and Promos (HR 2.2, CI 1.0-4.9) had increased risk of revision. Onlay and inlay RSAs had similar risk of revision (HR 1.2, CI 0.8-1.8). Instability and deep infection were the most frequent revision causes. Male sex (HR 2.3, CI 1.7-3.1), fracture sequelae (HR 3.1, CI 2.1-5.0), and fractures operated on with uncemented humeral stems had increased risk of revision (HR 3.5, CI 1.6-7.3).

We found similar risk of revision with inlay and onlay designs. Some prosthesis brands had a higher rate of revision than the most common implant, but numbers were low.

The aim of the present study was to assess the effectiveness of balloon implantation in patients with irreparable supraspinatus tears alone or in combination with other rotator cuff (RC) tendon tears and the effect of several covariables, such as age, gender, status of the long head biceps, with or without tendon repair and regardless the number of tendon involved.

Patients enrolled from 'San Carlo' Hospital of Potenza (Italy, IT), from January 2012 to September 2014, underwent arthroscopic implantation of shoulder balloon by a single surgeon, and followed for 3 years. The American Shoulder and Elbow Surgeons (ASES) and Constant score (CS) were administered pre-, post-operatively at 12 months, and then annually. Patients were classified on the basis of the number of tendons involved in the tears and treatment performed, considering the reparability of the tendons themselves. Gleno-humeral joint osteoarthrosis (OA) was evaluated through shoulder radiographs and classified according to the Samilson-Prieto classification, at the first examination and at the final follow-up. Statistical improvements were evaluated using a variance model (least-squares means) and a T distribution test for the evaluation between different treatment groups.

A total of 61 procedures were performed, and eight patients were lost during follow-up. The mean baseline CS was 30.2 ± 15.4 with statistically significant improvement, respectively, at 1-, 2- and 3-year follow-up to 69.3 ± 4.2, 74.6 ± 3.6 and 69.7 ± 5.1 respectively. ASES score at baseline was 22.5 ± 10.9, with a statistically significant improvement to 69.7 ± 9.2, 68 ± 17.8 and 71.2 ± 16.6 at 1-, 2- and 3-year follow-up, respectively. Tenotomy or absence of long head biceps at presentation did not influence results (n.s.), with no difference according to gender and age. At final follow-up, 24 patients (43.9%) showed progression of glenohumeral OA. One patient required secondary surgery for shoulder replacement after 18 months for persistent pain and one patient required implant removal following post-operative laser treatment.

Arthroscopic rotator cuff tears repair with subacromial spacer balloon implantation showed statistically significant clinical and functional improvement at 3-year follow-up. Patients treated with combined partial repair and subacromial spacer balloon implantation experienced good results independent of gender, age, type of tear and long-head biceps tendon status. The risks related to this procedure appear to be minimal.

Level IV.

To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly.

Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported.

Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations.

In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws.

Level IV Retrospective Case Series.