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Year : 2016  |  Volume : 10  |  Issue : 2  |  Page : 57-58   


Arthroplasty of the shoulder joint

1 Cape Shoulder Institute, Cape Town, South Africa
2 Department of Orthopaedic Surgery, Seth GS Medical College, King Edward VII Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Deepak N Bhatia
Department of Orthopaedic Surgery, Seth GS Medical College, King Edward VII Memorial Hospital, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-6042.180716

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Date of Web Publication20-Apr-2016

How to cite this article:
de Beer J, Bhatia DN. Arthroplasty of the shoulder joint. Int J Shoulder Surg 2016;10:57-8

How to cite this URL:
de Beer J, Bhatia DN. Arthroplasty of the shoulder joint. Int J Shoulder Surg [serial online] 2016 [cited 2019 Aug 20];10:57-8. Available from:

In 2016, the shoulder community hails the forward thinking of Charles S. Neer, II who designed the first shoulder replacement system to deal with painful arthritic shoulders. The solution was clearly needed: shoulder replacement has increased, developed, and surged with leaps and bounds all over our planet (53,000 shoulder replacements are done annually in the USA only). The initial clinical problem catered for was degenerative joint disease of the shoulder joint, but the principle proved so successful that other pathologies of the shoulder that proved to be amenable to related procedures.

Before dealing with those "other" problems managed with shoulder arthroplasty, we should first reflect on the realities of glenohumeral arthroplasty. Although survivorship of the prosthetic replacement of the shoulder has been acceptable, it is not equal to the hip and knee. The failure/weak point is mainly the glenoid component which seldom gives more than 10-15 years of survival. [1] Significant attention has been paid to the glenoid component's longevity and latest developments include (a) Avoiding excessive reaming of the glenoid with respect to the subchondral bone as reaming into cancellous bone favors early loosening of the glenoid component. [2] (b) New glenoid component designs have different radii to fit the glenoid radius and thus avoiding to have to ream the glenoid to fit the back surface of the prosthesis - the prosthesis conforms to the glenoid. (c) In cases with glenoid erosion (B2 type), excessive reaming of the glenoid to achieve neutral version is not recommended, and use of posterior augmented components or even a reverse prosthesis may be considered. [2],[3],[4]

The concern about the survivorship of the glenoid prosthesis is most relevant when considering the common problem of degenerative joint disease in younger individuals (younger than 60 years). This has led to some of the following considerations: (a) Using only hemiprostheses in younger patients seemed to be a solution and is still practiced in many centers. The stark reality has been that in many of those patients, significant erosion of the glenoid has been observed and the opinion has swung against using metal hemiprostheses. [5],[6] (b) Glenoid resurfacing seemed to be a reasonable option for selected cases, and various forms of biological glenoid resurfacing procedures have been done (allograft material and human dermis). (c) Acceptable results have been published for these methods, but there have been constraints like availability, cost, and laws prohibiting the use of human tissue in many countries. [7],[8] (d) Simple arthroscopic debridement, capsulotomy, and removal of osteophytes have been suggested by some authors with varying degrees of success. [9] Admittedly, these less invasive procedures are intended to "play for time" to extend the actual date for prosthetic replacement. (e) A new development has been the pyrocarbon hemiprosthesis which seems to be "gentle" to the glenoid with decreased erosion of bone; this may offer a solution in the younger patients, and long-term outcome is awaited.

The brilliant concept of reverse geometry prosthesis was designed by Grammont and Baulot, and was intended for rotator cuff arthropathy (arthritic shoulder with an absent rotator cuff). [10] By medializing the center of rotation with the semi-constrained design, it offered an increase of strength to the deltoid. The reverse prosthesis became a most successful solution, and the indications for the prosthesis expanded are as follows:

  1. In severe bone loss, especially on the glenoid side, including the advanced B2 configurations and bone grafting, the reverse prosthesis was a good solution [5]
  2. In difficult cases of fracture sequelae with malunions and loss of the tuberosities, possibly the only solution is the reverse prosthesis [11]
  3. For revision cases where the glenoid is damaged significantly, bone grafting and reverse replacement are often the only solution (in some cases, particularly with noncontained bone lesions, requiring two-stage revision) [12]
  4. Loss of rotator cuff muscles with no arthritis: this needs special mention as there has been a tendency for surgeons to resort to reverse prosthetic replacements for cases with difficult and irrepairable rotator cuff lesions. Considering the potential complications that could be encountered in prosthetic replacement, attention should be given to all the available solutions for such difficult rotator cuff tears. With good arthroscopic technique s and fixation methods, 90% of rotator cuff tears are repairable. [13],[14] It is, therefore, not indicated to resort to reverse replacement in many such cases. Tendon transfer procedures have been shown to be most effective and carry a lower complication risk than prosthetic replacement:

    • Latissimus dorsi tendon (with or without teres major) transfer for posterosuperior cuff lesions [15]
    • Lower head of trapezius transfers for posterior cuff lesions [16]
    • Pectoralis major, pectoralis minor, and latissimus dorsi transfer for anterosuperior lesions [17]
    • Arthroscopic superior capsular reconstruction for lesions of the supraspinatus and infraspinatus [18]
  5. Tumor surgery: In cases where the proximal humerus has to be removed, the reverse prosthesis has been a valuable part of the treatment to afford the patients some acceptable function [19]
  6. Proximal humeral fractures: in elderly, osteoporotic patients with four part fractures, hemi fracture prostheses often led to poor results due to the nonunion of the tuberosities. Superior migration of the prosthesis and painful poor function were the common results. The advent of the reverse prosthesis circumvented those problems as function could remain acceptable without relying on the greater tuberosity and superior cuff. [20] Later versions of the reverse prosthesis have now become available which allows for ingrowth of the tuberosities with even better function.
In summary, shoulder arthroplasty has evolved since Charles S. Neer, II first designed his hemiprosthesis. Several options are available, and shoulder surgeons must consider all different possibilities (techniques and prosthetic choice) to treat their patients for their optimal results.

   References Top

Neer CS 2 nd . The classic: Articular replacement for the humeral head 1955. Clin Orthop Relat Res 2011;469:2409-21.  Back to cited text no. 1
Gazielly DF, Scarlat MM, Verborgt O. Long-term survival of the glenoid components in total shoulder replacement for arthritis. Int Orthop 2015;39:285-9.  Back to cited text no. 2
Kersten AD, Flores-Hernandez C, Hoenecke HR, D'Lima DD. Posterior augmented glenoid designs preserve more bone in biconcave glenoids. J Shoulder Elbow Surg 2015;24:1135-41.  Back to cited text no. 3
Gilot GJ. Addressing glenoid erosion in reverse total shoulder arthroplasty. Bull Hosp Jt Dis 2013;71 Suppl 2:S51-3.  Back to cited text no. 4
Denard PJ, Walch G. Current concepts in the surgical management of primary glenohumeral arthritis with a biconcave glenoid. J Shoulder Elbow Surg 2013;22:1589-98.  Back to cited text no. 5
Mercer DM, Gilmer BB, Saltzman MD, Bertelsen A, Warme WJ, Matsen FA 3 rd . A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: Preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming. J Shoulder Elbow Surg 2011;20:301-7.  Back to cited text no. 6
de Beer JF, Bhatia DN, van Rooyen KS, Du Toit DF. Arthroscopic debridement and biological resurfacing of the glenoid in glenohumeral arthritis. Knee Surg Sports Traumatol Arthrosc 2010;18:1767-73.  Back to cited text no. 7
Longo UG, Berton A, Alexander S, Maffulli N, Wallace AL, Denaro V. Biological resurfacing for early osteoarthritis of the shoulder. Sports Med Arthrosc 2011;19:380-94.  Back to cited text no. 8
Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic management (CAM) procedure: Clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis. Arthroscopy 2013;29:440-8.  Back to cited text no. 9
Grammont PM, Baulot E. The classic: Delta shoulder prosthesis for rotator cuff rupture 1993. Clin Orthop Relat Res 2011;469:2424.  Back to cited text no. 10
Mansat P, Bonnevialle N. Treatment of fracture sequelae of the proximal humerus: Anatomical vs reverse shoulder prosthesis. Int Orthop 2015;39:349-54.  Back to cited text no. 11
Valenti P, Kilinc AS, Sauzières P, Katz D. Results of 30 reverse shoulder prostheses for revision of failed hemi- or total shoulder arthroplasty. Eur J Orthop Surg Traumatol 2014;24:1375-82.  Back to cited text no. 12
Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: Results after five to fifteen years. J Shoulder Elbow Surg 2013;22:1199-208.  Back to cited text no. 13
Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy 2001;17:905-12.  Back to cited text no. 14
Gerber C, Rahm SA, Catanzaro S, Farshad M, Moor BK. Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years. J Bone Joint Surg Am 2013;95:1920-6.  Back to cited text no. 15
Hartzler RU, Barlow JD, An KN, Elhassan BT. Biomechanical effectiveness of different types of tendon transfers to the shoulder for external rotation. J Shoulder Elbow Surg 2012;21:1370-6.  Back to cited text no. 16
Valenti P, Boughebri O, Moraiti C, Dib C, Maqdes A, Amouyel T, et al. Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results. Int Orthop 2015;39:477-83.  Back to cited text no. 17
Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon. Am J Sports Med 2016. pii: 0363546516631751.  Back to cited text no. 18
King JJ, Nystrom LM, Reimer NB, Gibbs CP Jr., Scarborough MT, Wright TW. Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections. J Shoulder Elbow Surg 2016;25:45-54.  Back to cited text no. 19
Lopiz Y, García-Coiradas J, Serrano-Mateo L, García-Fernández C, Marco F. Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: Results, health-related quality of life and complication rates. Int Orthop 2016;40:771-81.  Back to cited text no. 20


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