| | Complications with the Reversed Prosthesis: Prevention and ManagementWhile the reverse prosthesis can provide dramatic, almost miraculous improvement in patients with debilitating shoulder dysfunction secondary to rotator cuff deficient arthritic shoulders, the reported complication rate is frightingly high. Some complications are by their very nature unavoidable. The purpose of this paper is to review the most common complications, give advice as to avoidance when possible and offer treatment alternatives should complications arise. The results of total shoulder arthroplasty are disease specific. The degree of involvement of the rotator cuff tendons, either from disease in the case of rheumatoid arthritis (RA) or degeneration in patients with rotator cuff tear arthropathy (RCTA), is the rate limiting factor in determining the results. Management of the rotator cuff–deficient arthritic shoulder has presented a vexing problem for orthopedic surgeons for years as evidenced by the creation of a whole new classification scheme referred to as limited goals.1 The development of superior migration of the humeral head, with the loss of the instant center of rotation effectively decreases the deltoid moment arm. This, along with the creation of superiorly oriented eccentric forces on the glenoid face, leads to painful pseudoparalysis in a number of older patients. Conventional total shoulder arthroplasty has had a disappointing track record in this disease category because of early loosening of cemented glenoid components and inconsistency in providing motion return and pain relief.2 Hemiarthroplasty has likewise provided limited goals–only benefits and even these limited degrees of improvement can deteriorate with time. The use of a bipolar device also provides similar limited goals function.3 Unfortunately, the joint may be overstuffed laterally, unstable, or just as, or more, painful after the surgery than before. Before the FDA’s approval of the reverse prosthesis, the senior author combined a hemiarthroplasty with a concomitant resurfacing of the glenoid, coracoacromial arch, and acromion using a tendo Achilles allograft in an effort to lower the instant center, contain the humeral head, and resurface the articulating surfaces of both the glenoid and the acromion.4 In 1985 Professor Paul Grammont resurrected an idea from the 1970s: a constrained total shoulder arthroplasty with a reversed ball and socket design (RBS).5 His hypothesis was that, by lowering and medializing the instant center of rotation, the deltoid would function more efficiently and allow the shoulder to be elevated above the horizontal with no rotator cuff. The medialization that occurred would put the instant center close to or on the glenoid face thus decreasing the stress on glenoid fixation, which was a major cause of failure of these laterally offset designs. The lowering of the instant center would theoretically make the deltoid more efficient by advancing it on a Blix curve. In the framework of Codman’s statement “Give me something different for it may be better,” The Shoulder Service at the W.B. Carrell Memorial Clinic began using an RBS design with a lateral offset in late 2002. Our experience with the Grammont style RBS began in May 2004 and continues to date. We are indebted to our colleagues from Europe who have promulgated this technology and studied its clinical application in a scientific fashion. Much of their work is summarized in this paper. Like others who have struggled to improve our results in this difficult group of patients, we have become intoxicated with the dramatic improvement in results provided by the reversed prosthesis in our patients with rotator cuff arthropathy, failed hemiarthroplasty, and failed total shoulder replacement. However these results come with a price. One could intuitively predict that implanting a complicated device in elderly patients with multiple comorbidities, prone to complications, oftentimes in a multiply operated surgically altered wound environment would result in an increased complication rate. The prediction that the complication rate would exceed that of conventional total shoulder arthroplasty has indeed held true, with complication rates in one series approaching 50%.6 Others have reported lower but not insignificant complication rates with RBS designs These rates range from 15 to 25.6% at a minimum of 2 year follow-up with correspondingly lower reoperation rates.7, 8, 9 The potential complications occurring after RBS are as follows: perioperative or postoperative fractures of the humerus or glenoid, blood vessel or nerve injury, acromial stress fractures, hematoma, scapular notching, infection, instability, humeral component dissociation, screw breakage, dislocation of polyethylene insert, humeral component loosening, and glenoid component loosening. The purpose of this paper is to make the surgeon aware of these potential complications, provide methods of preventing complications to the extent that they can be avoided, and provide treatment options for these complications should they occur. General Considerations  Many of the complications of the reversed prosthesis can be minimized by careful preoperative planning including not only high-quality radiographs but computed tomography (CT) scans as well (Fig. 1A and B). On the CT scan, the center starting point can be ascertained as well as whether the peg of the reverse will penetrate the cortex. Patients who have had previous surgery will need to be cultured and an assessment of their deltoid and axillary nerve status performed. A thorough medical history is required, including information on balance and tendency to fall. In this elderly population one must ascertain whether the patient will be able to remember and follow postoperative instructions. Before undertaking an RBS procedure the surgeon must be able to and prepared by way of training and preparation to deal with all of the aforementioned potential adverse events. Intraoperative Complications Intraoperative complications related to fracture of the humerus or glenoid have been reported from Walch and coworkers8 to occur in 8.5% of patients. Vascular injuries are rare (<1%). Nerve lesions occurring in conjunction with RBS surgery are usually brachial plexus traction injuries with spontaneous healing and can amount to about 5% of operations. The radial nerve is at risk during revision surgery with penetration or injury from cerclage wires. Humeral Fractures There is nothing inherent in the diaphyseal portion of the stem design of any of the currently available RBS prostheses that would increase the fracture rate; however, in the metaphyseal portion of all, the wide tray for the polyethylene humeral socket or the metal shell for the same can create hoop stresses that can fracture the proximal portion of the humerus. The spherical reamers used for this metaphyseal preparation will thin out the tuberosities and make fracture more likely. Fortunately, since the design is constrained and will work well with the deltoid alone, fractures above the deltoid insertion are of little consequence with regard to functionality with RBS. In a series of 457 implantations there were 15 diaphyseal fractures, 6 tuberosity fractures, and 7 cases of significant cortical perforations. It should be emphasized that most of these fractures occurred as a part of revision procedures during the cement removal process. In 16 cases osteosynthesis was utilized mostly with cerclage wiring. Twenty-two of 28 cases healed; however, 3 cases went on to complete loosening and another 3 had radiolucent lines greater than 2 mm in at least one zone.8 The complications can be lessened by more aggressive humeral head removal early in the case and avoidance of the aggressive humeral reamers until glenoid preparation is complete, ie, most metadiaphyseal fractures occur while levering back on the humeral head during glenoid exposure. Controlled osteotomies and windows will lessen the incidence of uncontrolled fracture propagation. Cementing in a smaller reversed stem into an intact cement mantle has also been used to avoid complete cement removal. The use of an ultrasonic device such as the Oscar (Biomet, Warsaw, IN) will also limit intraoperative fracture. Management intraoperative humeral fractures can generally be accomplished by cerclage wires, especially Luque wires (Fig. 2), which will help fix osteotomies and fractures when they occur. The use of tibial strut allografts appears to improve fixation and heal readily in revision shoulder arthroplasty (Fig. 3). Plates that utilize wires and screws can also be employed if extra stability is required and the bone available lends itself to plate fixation. Glenoid Fractures Glenoid fractures can occur during implantation of the glenoid baseplate at two different times with varying degrees of impact on the outcome of the surgery and an ability to proceed forward with the full implantation of the reversed. In the reaming phase the aggressive reamers of the Grammont type, which cut the groove for glenosphere taper seating, can catch the bone if applied too forcefully and fracture the rim of the glenoid. The frequency of this complication is 2% in a series of 457 cases.10 Small rim fractures that do not affect the integrity of the scapula can be reduced under the metaglenoid and fixation accomplished with the screws that fix the baseplate. Complete fractures of the scapula can occur. These usually occur during insertion of the 8 mm centrally pegged metaglenoid into the central hole. During impaction the scapula can be literally cleaved in half (Fig. 4). The balance between a tight press-fit and this complication must be weighed in individual cases. The complication can be minimized by applying the glenoid reamers slowly and gradually to the glenoid face. Fractures related to the post can be minimized by careful templating and measuring the glenoid vault on CT scanning and not pushing the envelope with regard to utilizing the reversed. If a more severe fracture of the scapula occurs, this author recommends conversion to hemiarthroplasty. Postoperative Complications Hematoma One of the most preventable complications after reversed shoulder arthroplasty is hematoma formation. Unlike conventional arthroplasty in which the glenoid, whose venous sinusoids can bleed profusely, is filled with and tamponaded by cement, current RBS designs rely on cementless fixation on the glenoid side. This cementless fixation and ingrowth technology with multiple screw holes with the reversed designs will result in more extensive bleeding postoperatively. Werner and coworkers6 reported an alarming number of hematomas that required reoperation. In contradistinction to the above-mentioned study, a series of 457 prosthesis from France, including revisions, reported the occurrence of only three hematomas. All of these surgeries involved implantation of a drain that was left in from 24 to 72 h. The large dead space, as well as the oozing from bone and muscle in revision cases, makes the use of a drain an attractive option. In the French series none of the hematomas were evacuated. The senior author’s experience has been that the superior approach bleeds much less. All reversed shoulders are drained until drainage is less than 30 mL per 8-h period or 48 h, whichever comes first. With the exception of one patient who restarted Plavix (Sanofi Aventis, Paris, France) immediately postoperatively, no hematomas have occurred in over 100 reversed shoulders. The one hematoma resolved spontaneously. Scapular Notching Erosion of the lateral border of the scapula is a complication unique to reversed shoulder arthroplasty and has been classified by Sirveaux and coworkers9 (Fig. 5). Pressure from the medialized humerus, humeral component, and/or the polyethylene spacer initiates the process oftentimes within the first several months of implantation. Factors that favor notch formation include the horizontal nature of the humeral tray (155° neck shaft angle as opposed to conventional arthroplasty between 125 and 140°) (Fig. 6) and the lack of a neck on the glenosphere. Subsequent increase in size of the notch is postulated to come from osteolysis secondary to macrophage stimulation by polyethylene wear debris.11 Sirveaux and coworkers9 have offered a classification of the notch as follows: Grade 1, pillar notching only; Grade 2, the defect contacts the lower screw of the base plate; Grade 3, the notch extends over the lower screw; and Grade 4, the notch extends under the baseplate. Obviously this classification scheme is dependent on the length and angle of insertion of the screw. Some debate continues regarding the degree of clinical significance and progression of the notch. Some, perhaps up to 79%, do not progress after 1 year.6 However, other notches do progress through varying stages and are associated with increased lucencies around the screws.12 Studies have shown poorer clinical results with Sirveaux Stage 3 and 4 notching.9 On the other hand, a recent review of 457 shoulders treated over a 10-year time frame showed notching in 60% of the cases with 22% graded 1 and 18% graded 2. Notching can be minimized by lowering the glenosphere on the face of the glenoid and by creating an inferior tilt of the base plate, thus narrowing the glenometaphyseal angle. More varus positioning of the stem will also accomplish this but is difficult with the Grammont design. Because of the importance of tilting the baseplate, the deltopectoral approach has a lower incidence of notching than the anterosuperior approach. An inferior tilt is possible through the superior approach simply by removing more humeral head and retracting it anteriorly or posteriorly to allow the surgeon to lower his hands. The use of a more lateralized design such as the Encore RSP TM (Encore Orthopedics, Austin, Texas) theoretically lowers the incidence of notching but increases the stress on glenoid fixation. Given the newness of this technology and the fact that our understanding of the human shoulders reaction to these implants is in an embryonic state it will probably be several years before we know what the optimal design or approach will be. In the absence of symptoms, notching itself requires no specific treatment. If the glenoid component fails, then conversion to hemiarthroplasty is this author’s choice of treatment. Infection Deep infection after reversed shoulder arthroplasty averages approximately 2% for primary arthroplasty and 7% for revision surgery.7 This is similar to the rate in anatomic prostheses but since the reversed prosthesis is used more frequently as a revision device it appears as a more frequent complication in nonstratified abstracts. Sperling and coworkers13 have offered a classification of infection after shoulder arthroplasty after surgery. Acute infections are diagnosed in the first 2 months. Subacute infections are diagnosed between 2 and 12 months postoperatively, and chronic infections are diagnosed after 12 months. The diagnosis of deep infection, the largest series to date, was made at an average of 17 months postimplantation. Acute phase reactants were elevated in 73% of the cases. Bone scanning was positive in three of three cases who had bone scans. Proprionibacterium acnes was responsible for 40% of the infections. With regard to the relationship between timing of infection and results, acute infections were treated by open debridement, washout, and partial exchange of polyethylene and were treated successfully. Subacute infections treated with open debridement only in three of three had persistent active infection. Chronic infection was treated by resection arthroplasty in all but one patient. Only one patient was reimplanted as a second-stage procedure. Deep infections, especially with Methicillin-resistant organisms, can be lowered by doing nasal cultures, identifying the offending organism, using Bactroban (GlaxoSmithKline, London, England) ointment in the nasal passages, Rifampin preoperatively, and Vancomycinas the drug of choice for intravenous prophylaxis. Patients should be given chlorhexadine scrubbing materials to use for 5 to 7 days on their shoulder area before surgery. In patients who have acne around the shoulder, an addition of a tetracycline type compound or clindamycin are usually effective against Proprionibacterium. In the revision category, many patients are infected preoperatively. Prophylactic antibiotics should be withheld in this group until cultures and, even more importantly, histologic evaluation for acute inflammation are made. If acute inflammation is seen at the time of revision surgeries, patients should be presumptively treated for infection with both an anti-Staph drug as well as a drug that covers anaerobic bacteria such as Proprionibacterium. It appears from the work of Jacquot and coworkers14 that simply washing out and debriding an infected reversed prosthesis is ineffective, even in acute infections. At the very least, the polyethylene and glenosphere should be exchanged. Resection arthroplasty is clearly the most reliable treatment of an infected reversed shoulder arthroplasty. Instability Despite the constrained nature of the reversed, postoperative instability can occur (Fig. 7). It is more catastrophic and more noticeable to the patient than after nonconstrained arthroplasty, in which subtle instability progressing to a dislocated component is sometimes not appreciated by the patient. The postoperative instability rate in one large series of reversed shoulder arthroplasty was 4.8%. It appears that the surgical approach utilized for reversed prostheses is an important factor in the instability rate. The superolateral approach had an instability rate of 0%, whereas the deltopectoral approach had an instability rate of 6%. Revision arthroplasty, because of the proximal bone and soft tissue loss and the requirement for a deltopectoral approach, is associated with a particularly high instability rate of 10.7%.15 Instability can present as an inferior chronic subluxation, recurrent subluxation, or frank dislocation. It can occur immediately in most cases but can occur greater than 1 month postoperatively. The main cause of instability after reversed shoulder arthroplasty is the anterior–inferior release required through a deltopectoral approach to allow inferior seating of the base plate and glenoid exposure. This requires careful deltoid tensioning and care should be utilized to repair any soft tissue takedown, especially the subscapularis. The other source of instability occurs from a cam or a levering out effect in which humeral bone contacts the scapula in varying positions, causing the component to level out. In this author’s experience, this has been seen in fracture sequelae cases in which heterotopic ossification sometimes quite distally on the humeral shaft can cause instability (Fig. 8A and B). Prevention Prevention of prosthetic instability following reversed shoulder arthroplasty involves careful approach selection. Our center prefers the superior approach for all primary reversed shoulder arthroplasties and has had no instability in a series of almost 200 cases. If a deltopectoral approach is utilized, it is extremely important to repair the subscapularis. Humeral tensioning during the trial reduction phase should give the surgeon valuable knowledge as to the proper humeral height. Rather than use a spacer, which adds to the expense of the surgery, if during the trial reduction phase of the surgery instability is noted, the humeral component can be cemented in a slightly proud position and then one of the standard, 6, 9, or 12 mm polyethylene components can be applied. The knowledge that not all instabilities are related to lack of deltoid tension is important in preventing dislocations. Before leaving the operating table, the patient’s arm should be placed in the extremes of adduction, extension, and external rotation to see if the component can be levered out. The shoulder should be placed through a full range of motion. Any tendency for the shoulder to dislocate during that range of motion should be investigated carefully. More often than not, simple removal of humeral bone, which is contacting the native scapula and causing the disarticulation of the reversed prosthesis will be curative. My personal preference is to immobilize all of these patients for 3 weeks in an Ultra sling (Smith and Nephew DonJoy, Carlsbad, CA) to allow soft tissue healing to occur and to protect these sometimes elderly patients with balance/mobility issues who could fall or perhaps forget and use their arm inappropriately during the early postoperative phase. Closed reduction under general anesthesia and immobilization for 4 to 6 weeks is the initial treatment in all dislocations. If the problem becomes recurrent, revision with a larger polyethylene spacer or a 9 mm metal spacer rehauser will be curative in most cases. Rarely conversion to a 2 mm implant is necessary. Given the medical conditions of many of these patients, unless something simple such as polyethylene lengthening is sufficient to control instability, consideration should be given to conversion to hemiarthroplasty. The treatment of chronic inferior subluxation, which is usually related to axillary nerve dysfunction, requires no specific treatment.15 Humeral Component Dissociation This is a rare complication seen with early Delta type designs (Depuy, International Limited) with porous coated noncemented stems. If ingrowth failed to occur or occurred selectively in one part of the component or another, the rotational forces could essentially unscrew the humeral component from itself. Disassembly was reported to occur in 3 of 399 cases of the reversed. The Tornier Aequalis design (Tornier, Grenoble, France) has a polyethylene bushing to prevent antirotation. To date there has been no reported case of disassembly of the humeral component with the Aequalis reversed shoulder.16 Hopefully this design change will eliminate this particular complication. A third-generation cementing technique including plugging the canal and pressurization with a glue gun is the author’s recommended cementing technique, which will hopefully prevent loosening for a number of years. We have yet to see this complication on our unit. Screw Breakage Fracture of the screws that fix the glenoid base plate has been reported. It was a relatively frequent complication of the early version of the lateralized offset design RSP prosthesis by Frankle.7 The peripheral screws would break followed by the central screw. The design flaw as been addressed by the addition of larger diameter locking screws. It is a rarer complication of Grammont-style implants whose 4.5 mm screws, especially those of a locking variety, have a greater ability to withstand stress. The 8 mm central post found in the Grammont style prosthesis also helps decrease stress on the screws. If a screw is going to fracture on the Grammont-style reversed, it will usually be the inferior locking screw, which is subjected to mechanical impingement from the humeral tray in cases of notching. Five cases of screw fracture, 1.1%, have been associated with Grammont-style prosthesis. The presence of screw fractures lowered the Constant scores for these shoulders significantly. The addition of variable angle locking screw holes allows the inferior most screw to be placed more horizontally, which will hopefully protect it from pillar notching and osteolysis with subsequent fracture. Dislocation of Polyethylene Insert This is an extremely rare complication of the Grammont-style reversed. It was seen in the early ideations of the lateralized offset reversed. A single set screw held the poly socket onto the male trunion on the RSP. The senior author had two cases in which this screw backed out and the polyethylene tray dissociated (Fig. 9). Since the taper lock for the Grammont design is centrally located, marked polyethylene wear would have to occur for the poly to dislocate. Humeral Component Loosening Because of the medialization of the instant center of rotation that decreases stress on the glenoid side, concern has been raised over the future of the humeral component as the stress will be transferred to the humeral side. In a series of 399 implants, subsidence with gross loosening occurred in 3 patients. There were 16 cases of radiographic humeral loosening as defined by radio lucent lines (RLL) in 3 or more contiguous zones. The Constant Score was lower in this group.16 RLL were higher in the noncemented group than in those implants done with cement. In the United States only cemented versions of the humeral component are available. Glenosphere Dissociation Glenosphere dissociation can be subtle (Fig. 10A) or gross (Fig. 10B). Gross dissociation usually occurs as a catastrophic event after trauma. A more subtle form of glenosphere dissociation can occur at any time during the postoperative period and must be looked for carefully as a cause of unexplained pain persisting for several months after surgery. Oftentimes it can be appreciated better on an axillary lateral radiograph. The initial design of the Delta prosthesis had a glenosphere that screwed into the base plate. Unfortunately, the glenosphere was unscrewed by the differential flexion to extension ratio in the right arm of a number of patients. Initial problems with glenosphere dissociation were felt to have been solved with a peripheral morse taper and a safety screw. The glenoid reamer for the Tornier reversed is designed to cut a groove into the surface of the glenoid for the glenosphere to allow full seating and engagement of the taper. Any eccentric reaming that is done or eccentric drilling of the oversized drill for the peg can result in a mismatch between the baseplate and the groove, which can lead to incomplete seating and, therefore, full engagement of the taper. Incomplete taper seating is manifest by an inability to fully engage the safety screw. If the safety screw does not fully seat, the glenosphere must be removed and the groove and its relation to the baseplate and any surrounding bony prominences must be ascertained. The use of a small dental burr to deepen the groove or remove any bony prominences is recommended with reseating of the glenosphere and full engagement of the safety screw. Another mode of dissociation has been seen by the senior author. In this mode the central plate of the glenosphere unscrews from the glenosphere itself. There has been one other case of this mode of failure in the United States.17 Both cases occurred after the patients were involved in motor vehicle accidents. Glenoid Baseplate Component Loosening Catastrophic early glenoid loosening in total shoulder arthoplasty in association with massive cuff tears led Matsen to coin the term rocking horse glenoid2 and led largely to the abandonment of total shoulder arthroplasty as a treatment for the rotator cuff deficient arthritic shoulder. The hope of lower glenoid failure rates with the reversed design of Grammont has been realized at least at the 2- to 5-year time frame. The overall rate at 2 years minimum follow-up is 1.5%.10 This should be a relatively rare late phenomenon in an ingrowth group of implants and indeed that is the case being diagnosed as an early phenomenon at an average of 20 months postoperatively. It’s quite likely that these cases represent failure of ingrowth.10 Glenoid fracture at implantation increases the rate of glenoid loosening to 22% versus <1% in cases when the glenoid is unfractured. Two cases of glenoid component loosening occurred because of fracture of the neck of the scapula. The surgical revision rate for glenoid complications is 1.8%. Glenoid loosening can be minimized by avoiding glenoid fracture and maintaining an inferior tilt on the glenoid component (Fig. 11A and B). An inferior tilt on the glenoid component will decrease shear forces and increase compressive forces, which should take stress off the screw fixation and enhance bony ingrowth. The author routinely makes a paste of the humeral head in primary reversed shoulders or uses a bone graft substitute of a gel variety in revision cases to promote bony growth onto or into the peg and baseplate of the glenoid component. In addition, nasal Calcitonin (Miacalcin Nasal Spray; Novartis, East Hanover, NJ) is used for 3 months and aggressive diagnosis and management of osteoporosis is employed as a long-term strategy. Glenoid base plate failure can be managed with revision to hemiarthroplasty plus or minus a tendo Achilles allograft resurfacing (Fig. 12). Acromial Fractures Acromial pathology is common pre- and postoperatively in the population of patients presenting and undergoing reversed prostheses.18 In a recent multicenter review, of the 41 patients who presented with acromial pathology preoperatively, 23 had an os acromiale meso-acromion and 17 had fragmentation or fracture of the acromion. A deltopectoral approach was used in 71% and a superolateral approach in 29%. There was no significant effect on range of motion, Constant score, or subjective results in the group of patients with preoperative os acromiale or fracture/fragmentation. Surprisingly, the surgical approach did not have a significant effect on the outcome despite the fact that 62% were displaced postoperatively by the added tension to the deltoid. On the other hand, a stress fracture of the scapular spine that occurs as a postoperative complication (Fig. 13) did have a negative effect on the Constant score. The authors routinely use the superior approach in primary rotator cuff arthropathy. The approach is made through the fracture site or os acromiale if it is a meso or pre os acromiale. Because the acromion of all patients with this condition are thinner than normal, fixation with screws and tension band wiring is oftentimes impossible. A simple technique, which restores the continuity of the deltoid, involves using a 1 mm Dacron tape (Deknatel, Fall River, MA) through drill holes on the posterior intact acromion, passing the sutures through the coraco acromial ligament and deltoid anteriorly. This suture configuration will lessen the tendency for the acromion to tilt downward. The fragment surfaces should be freshened with a curette and bone paste from the head or allograft bone matrix gel may be employed as well. The use of an abduction pillow for this subset of patients is recommended. Patients presenting with postoperative pain should be carefully palpated along the acromion and spine of the scapula; high-quality axillary lateral radiographs or CT scanning may be required to make the diagnosis radiographically. Patients with pain and/or radiographically diagnosable acromial fractures in the postoperative period are treated with immobilization in the abducted position, analgesics, and Miacalcin nasal spray. In summary, the Reverse prosthesis holds promise for restoration of function, diminished pain, and improved independence in elderly patients with painful pseudoparalytic rotator cuff–deficient arthritic shoulders. Complications are more prevalent. Because of the increased incidence of complications in patients undergoing revision of failed hemiarthroplasty and total shoulder arthroplasty, the surgeon and patient must think long and hard about the risk-to-benefit ratio before proceeding with revision surgery with a prosthesis of any kind, including the Reverse. The survivorship at 120 months for replacement (91%) and symptomatic glenoid loosening (84%) seems reasonable for patients with rotator cuff tear arthropathy.19 At this point the unanswered questions include the long-term survivorship of current Reverse designs and where exactly the center of rotation should be. Given the previous failures at treating this condition with other implant technologies at this time, we can only hope that what we have been given will indeed be better in an enduring sense. References 1. 1Neer CS, Watson KC, Stanton FJ. Recent experience in total shoulder arthroplasty. J Bone Joint Surg Am. 1982;64A:319–337. 2. 2Franklin JL, Barrett WP, Jackins S, et al. Glenoid loosening in total shoulder arthroplasty: association with cuff deficiency. J Arthroplasty. 1988;3:39–46. Abstract |
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3. 3Worland RL, Jessup, Arredondo J. Bipolar shoulder arthroplasty for rotator cuff arthropathy. J Shoulder Elbow Surg. 1997;85:245–256. 4. 4Krishnan SG, Burkhead WZ, Nowinski RJ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid and acromion for rotator cuff tear arthropathy. Tech Shoulder Elbow Surg. 2004;5:51–59. 5. 5Grammont P, Trouilloud P, Laffay JP, et al. Etude et realization d’une nouvelle prothese D’ePaule. Rhumatologie. 1987;10:407–418. 6. 6Werner CML, Steinmann PA, Gilbart M, et al. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball and socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87:1476–1486. MEDLINE 7. 7Frankle M, Siegal S, Pupello D, et al. The reversed shoulder prosthesis for glenohumeral arthritis with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005;87:1697–1705. MEDLINE 8. 8Walch G, Wall B, Mottier F. Complications and revisions of the reversed prosthesis: multicenter study of 457 cases. In: Walch G, Boileau P, Mole D, et al. editor. Reversed Shoulder Arthroplasty: Clinical results, complications, and revisions. Montpellier, France: Sauramps Medical; 2006;p. 303–313. 9. 9Sirveaux F, Favard L, Oudet D, et al. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff: results of a multi-center study of 80 shoulders. J Bone Joint Surg Br. 2004;86:388–395.
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10. 10Mole D, Navez G, Garaud P. Reversed shoulder replacement: problems related to the glenoid. In: Walch G, Boileau P, Mole D, et al. editor. Reversed Shoulder Arthroplasty: Clinical results, complications, and revisions. Montpellier, France: Sauramps Medical; 2006;p. 289–301. 11. 11Nyffeler RW, Werner CM, Simmen BR, et al. Analysis of a retrieved Delta III total shoulder prosthesis. J Bone Joint Surg Br. 2004;86:1187–1191.
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12. 12Levigne CH, Boileau P, Favard L, et al. Scapular notching. In: Walch G, Boileau P, Mole D, et al. editor. Reversed shoulder arthroplasty, in Reversed Shoulder Arthroplasty: Clinical results: Complications and Revisions: Nice Shoulder Course. Montepellier, France: Sauramps Medical; 2006;p. 353–369. 13. 13Sperling JW, Kozac TK, Hanson AD, et al. Infection after shoulder arthroplasty. Clin Orthop. 2001;382:206–216.
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14. 14Jacquot N, Chuinard CH, Boileau P. The results of deep infection after reversed shoulder arthroplasty. In: Walch G, Boileau P, Mole D editor. Reversed Shoulder Arthroplasty: Clinical Results, Complications, and Revisions. Montpellier, France: Sauramps Medical; 2006;p. 303–313. 15. 15Nove-Josserand L, Walch G, Wall B. Instability of the reversed prosthesis. In: Walch G, Boileau P, Mole D, et al. editor. Reversed Shoulder Arthroplasty: Clinical Results, Complications, and Revisions. Montpellier, France: Sauramps Medical; 2006;p. 247–259. 16. 16Chuinard C, Trojani C, Braassart N, et al. Humeral problems. In: Walch G, Boileau P, Mole D, et al. editor. Reversed arthroplasty, in Reversed Shoulder Arthroplasty: Clinical Results: Complications and Revisions: Nice Shoulder Course. Montpellier, France: Sauramps Medical; 2006;p. 275–279. 17. 17Norris T. Personal communication. 2006;. 18. 18Mottier F, Wall B, Leotard L, et al. Pathologic acromion in reversed shoulder arthroplasties. In: Walch G, Boileau P, Mole D, et al. editor. Reversed Shoulder Arthroplasty: Clinical Results, Complications, and Revisions. Montpellier, France: Sauramps Medical; 2006;p. 261–274. 19. 19Guery J, Favard L, Sirveaux F, et al. Reverse total shoulder arthroplasty survivorship analysis of 80 replacements followed for 5 to 10 years. J Bone Joint Surg Am. 2006;88:1742–1747. MEDLINE |
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The Shoulder Service, The Carrell Clinic, Dallas, TX.  Address reprint requests to Wayne Z. Burkhead, MD, Shoulder and Elbow Service, WB Carrell Memorial Clinic, 9301 N Central Expressway, Suite 400, Dallas, TX 75231.
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