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Home , Shoulder replacement, Shoulder surgery

Derek Plausinis, MASC, MD, FRCSC

What are the options for replacement today?

Anatomic total continues to provide excellent outcomes in cases of advanced osteoarthritis, while reverse total shoulder replacement is being used for some less common clinical scenarios.

ABSTRACT: Pain from osteoarthritis may have higher complication rates History or rheumatoid has tradi- and more long-term outcome stud- Shoulder was first de- tionally been the main indication for ies are needed to explore the risk scribed in 1953 for the treatment of shoulder replacement. Improved out- of complication with this proce- a fractured humeral head.1 Experi- comes for this procedure mean oth- dure. Absolute contraindications for ence with replacing the humeral head er conditions are now being treated shoulder replacement of any kind alone (a hemiarthroplasty) grew over with shoulder replacement as well. include a nonfunctional deltoid the years, and reports on several clin- These conditions include avascular muscle, active infection, and Char­ ical series were published in the early necrosis, tear arthrop- cot arthropathy.­ Possible complica- 1970s. athy, acute fracture, and posttrau- tions include infection, neurologi- During the 1970s and 1980s, clin- matic deformity. Surgical options cal injury, periprosthetic fracture, ical experience expanded to include for shoulder degeneration include and rotator cuff failure. Postopera- replacing the humeral head with a ball hemiarthroplasty (replacing the hu- tive protocols for rehabilitation vary component and implanting a socket meral head alone), anatomic total among surgeons, but most patients component in the glenoid cavity (an shoulder arthroplasty (replacing the gradually return to all activities over anatomic total shoulder replacement). humeral head with a ball component 4 to 6 months. In the long term, pa- Experience was also gained in revers- and the glenoid with a socket com- tients with a shoulder replacement ing the normal anatomy by replacing ponent), and reverse total shoulder are discouraged from engaging in the humeral head with a socket com- arthroplasty (replacing the humeral activities that involve strenuous lift- ponent and implanting a ball called a head with a socket component and ing or risk of falling. Like hip, knee, glenosphere in the glenoid cavity (a the glenoid with a ball component). and ankle replacements, shoulder reverse total shoulder replacement). Anatomic shoulder replacement for replacement has been evolving to Since the early decades of shoul- osteoarthritis provides excellent address pain caused by degen- der replacement, many different im- outcomes that match those of hip eration. Advances in surgical tech- plant designs have been developed replacement. Outcomes for hemiar- nique and implant design now allow and used. Currently, anatomic total throplasty are more unpredictable, us to treat patients with a variety of while reverse shoulder replacement problems. Dr Plausinis is an orthopaedic surgeon at Kelowna General Hospital and a clinical assistant professor in the Department of Orthopaedics at the University of British This article has been peer reviewed. Columbia.

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shoulder replacement is the standard longer able to provide a suitable load- arthritis, the outcomes for anatomic of care for advanced shoulder osteo- bearing surface to articulate with the total shoulder replacement are excel- arthritis, while reverse total shoulder glenoid. Glenoid problems are usu- lent and match those of hip and is used for many chal- ally secondary or coincident with the replacement. lenging clinical scenarios, and some humeral problems. Shoulder replace- situations still call for performing ment may also be considered in select Osteoarthritis hemiarthroplasty and replacing the cases of massive rotator cuff tendon Advanced osteoarthritis is the most humeral head alone. tears, or for uncommon tendon tears common diagnosis leading to shoul- or arthritis combined with instability. der replacement. As with hip and Indications and outcomes Although approximately one knee replacement, the procedure is an In keeping with the line of thought shoulder replacement is performed option for patients when nonoperative for other major joint replacements, for every thirty hip and knee replace- treatment has failed. Surgical candi- the primary indication for shoulder ments,2 this less commonly per- dates typically have pain and difficul- replacement is pain. Shoulder arthro- formed procedure has similar clinical ty with activities of daily living, pain plasty can be undertaken to treat the success rates. Some patients and phy- at rest, and/or pain at night. symptoms of advanced osteoarthritis, sicians wrongly believe that shoul- Historically, hemiarthroplasty inflammatory arthritis, postcapsulor- der replacement outcomes are mar- has been the surgical treatment of rhaphy arthropathy, avascular necro- ginal, a misconception based on the choice for osteoarthritis,4 but the re- sis, acute facture, or posttraumatic frequently poor functional outcome sults can be unpredictable when the deformity. In general, surgery is con- after hemiarthroplasty for fracture.3 humeral head alone is replaced.5 By sidered when the humeral head is no In fact, for routine advanced shoulder replacing the humeral head with a

Figure 1 Figure 2 Figure 3

Anatomic total shoulder replacement consisting Arthritic shoulder with a biconcave glenoid. Metal ingrowth portion of an uncemented of a typical uncemented stemmed humeral com- This axial view CT image reveals that the monoblock glenoid component. The longer ponent and a polyethylene glenoid component posterior glenoid is eroded (arrow) and the polyethylene portion of the glenoid component cemented in place. The glenoid component is humeral head subluxed posteriorly from the is radiolucent and not visible on the radiograph. radiolucent and not visible on the radiograph, anatomic position. Progressive degenerative but cement can be seen around the three gle- arthritis often leads to anterior capsular noid pegs, and a metallic marker embedded in contracture and eccentric posterior glenoid the central peg (arrow) can also be seen. wear.

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ball component and the glenoid with An anatomic total shoulder a socket component, anatomic total replacement requires intact shoulder arthroplasty ( Figure 1 ) has been found to relieve pain and sub- rotator cuff tendons or a stantially improve shoulder function and overall quality of life.6 repairable with An anatomic total shoulder re- good quality tendon tissue. placement requires intact rotator cuff tendons or a repairable rotator cuff tear with good quality tendon tissue. A full thickness rotator cuff tear in the presence of advanced osteoarthritis is uncommon but does occur in 8% of implants. While this has some theo- contrast, patients who undergo hemi- cases.7 When compared with hemiar- retical advantages for longevity,10 no arthroplasty are able to do most activ- throplasty, total shoulder replacement long-term studies have confirmed the ities of daily living but are not able has been shown to provide more reli- superiority of monoblock implants to do work above shoulder level.13 able and better pain relief, and greater and research is continuing. Rather than using a stemmed compo- improvements in motion. When con- For younger patients, covering the nent, hemiarthroplasty may be done sidering time to revision surgery as glenoid with a soft tissue graft (inter- with a resurfacing implant or a stem- treatment failure, total shoulder re- position arthroplasty) has been de- less implant ( Figure 4 ). These newer placement also has the best long-term scribed. However, recent studies have implants are designed to minimize survivorship (implant life span). In shown a high failure rate with this pro- loss on the humeral side, but a recent 20-year follow-up study of cedure and it has fallen out of favor since humeral loosening is an uncom- patients younger than 50 who under- over the last few years.11 In an effort mon problem, techniques designed to went shoulder arthroplasty, the 20- to conserve glenoid bone in a young- prevent humeral revision may be of year implant survivorship was 75.6% er patient, a hemiarthroplasty may be limited value. for hemiarthroplasty and 83.2% for performed and the glenoid alone may Although uncommon with osteo- total shoulder replacement.8 be reamed out rather than replacing it arthritis, large or massive chronic Many patients with osteoarthritis with a glenoid component. While this rotator cuff tears or significant rotator will have some degree of increased has the theoretical advantage of cor- cuff tendon and muscle atrophy can and asymmetrical posterior glenoid recting the glenoid deformity while wear that gives the appearance of a bi- preserving bone, there are few results concave glenoid ( Figure 2 ). Deciding from long-term studies and outcomes how to manage the glenoid deformity may be more unpredictable than those caused by eccentric wear is an impor- for traditional total shoulder replace- tant consideration in the treatment ment, regardless of whether there is a plan. In most cases, this can be ac- glenoid deformity or not.5,12 complished by reaming bone from the Patients formerly limited by the anterior side to correct the orientation effects of osteoarthritis can gain an (version) of the glenoid. The current average of 31 degrees of elevation standard of care requires cementing after hemiarthroplasty, as opposed to the glenoid component in place, since an average of 43 degrees after total previous experience with modular un- shoulder replacement.13 The function- cemented glenoids has been unfavor- al outcome of total shoulder replace- able.9 There is also now the option of ment is also superior to that of hemi- using an uncemented monoblock gle- arthroplasty. On average, patients noid ( Figure 3 ) that has the polyeth- who undergo total shoulder arthro- ylene molded into the metal implant plasty have only a slight restriction in rather than mechanically snapped activities and are reported to be able Figure 4 in place as is the case with modular to do work above shoulder level. In Hemiarthroplasty using a stemless component.

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ic shoulder replacement.15 Reverse Postcapsulorrhaphy arthropathy shoulder replacements tend to be Postcapsulorrhaphy arthropathy is a much more specialized, are much form of secondary arthritis that can more expensive, and have higher develop after a shoulder stabilization complication rates. They should only procedure for anterior instability with be performed by surgeons with sub- excessive anterior capsular tightness. stantial experience with this operation. Such procedures were typically used Overall, anatomic total shoulder in the remote past and are no lon- replacement with a glenoid com- ger performed. Postcapsulorrhaphy ponent appears to offer the best and arthropathy is unlikely to occur with most predictable pain relief, function, current operations for instability, but and long-term outcome for patients may occur following procedures that with osteoarthritis and an intact rota- have intentionally tightened the ante- tor cuff tendon. Newer options can be rior capsule and/or subscapularis ten- discussed with younger patients, and don excessively. This tightening can hemiarthroplasty can be considered in increase obligate posterior transla- select cases. If the glenoid is exces- tions on the glenoid and increase gle- sively worn or the rotator cuff ten- noid wear posteriorly. The pathologic dons are torn, reverse total shoulder process that follows is the same as in replacement can be considered. many routine osteoarthritis cases, and the treatment algorithm is also the Inflammatory arthritis same as for osteoarthritis. Figure 5 Rheumatoid arthritis is the most Scarring and retained hardware Reverse total shoulder replacement consisting common inflammatory arthritis lead- from previous surgery for postcap- of a glenosphere placed on a glenoid base ing to shoulder arthroplasty, but oth- sulorrhaphy arthropathy can increase plate and a humeral head component with a er inflammatory arthropathies and surgical complexity, and while concave polyethylene liner that is radiolucent and cannot be seen on the radiograph. As the crystal arthropathies can also lead patients can achieve improvements in deltoid muscle pulls up on the humerus, the to advanced joint destruction. The range of motion after shoulder arthro- humeral component can rotate around the gle- pattern of bone wear usually differs plasty, the degree of improvement is nosphere and the lack of rotator cuff function is not a problem. Unlike the humeral head in an from the wear seen with osteoarthri- not as great as in patients with routine anatomic shoulder replacement, which sublux- tis, however, and the bone tends to osteoarthritis. Patient-reported out- es superiorly, the humeral head in a reverse be more osteopenic. Still, the same comes, however, are comparable to shoulder replacement rotates along the axis of the glenosphere and allows shoulder elevation surgical decision-making strate- those in cases of total shoulder arthro- with the pull of the deltoid muscle. gies used for osteoarthritis can be plasty for osteoarthritis.18 employed, and similar outcomes can be expected.16 Avascular necrosis develop. If the rotator cuff will not The integrity of the rotator cuff Avascular necrosis of the shoulder function reliably to keep the humer- tendons is an important consider- differs from that of the hip in being al head centred in the glenoid, then ation with shoulder replacement sur- less likely to involve significant a traditional glenoid socket compo- gery, and patients with inflammatory symptoms and being responsive to nent should not be placed as it will arthropathies are more likely to have nonoperative treatment in many cases loosen prematurely.14 In such cases, torn rotator cuff tendons or thin and because of the non-weight-bearing either a hemiarthroplasty or a reverse atrophic tendons. Patients with defi- nature of the . When the total shoulder replacement ( Figure 5 ) cient or questionable rotator cuff ten- avascular necrosis involves a large should be considered. Reverse total dons are generally better candidates portion of the humeral head, there is shoulder replacement can also be for either hemiarthroplasty or reverse a higher chance of articular incongru- considered for cases where bone total shoulder replacement, depend- ity, collapse of the humeral head, and grafts may be needed to address gle- ing on preoperative function, age and pain. If avascular necrosis is recog- noid deformity, and where instability activity level, glenoid wear pattern, nized early in the disease process, it is more likely to occur after anatom- and patient expectations.17 can often be treated using hemiarthro-

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plasty alone with excellent short-term has traditionally been a hemiarthro- in revision procedures).26 However, and long-term results.19 However, if plasty. This can provide pain relief experience has been gained with this secondary degenerative changes have but does nothing to restore function, implant over time and a more recent already developed on the glenoid which requires rotator cuff sufficien- study reports lower complication side, then total shoulder replacement cy for proper shoulder elevation and rates of 7.0% overall (4.3% in prima- should be undertaken. Patients typi- external rotation.21 ry procedures and 19.0% in revision cally obtain excellent pain relief and Reverse total shoulder replace- procedures).27 functional improvement, but the clin- ment was initially developed to treat ical results of shoulder arthroplasty rotator cuff tear arthropathy in those Acute fractures for avascular necrosis may not be as patients with poor shoulder function Hemiarthroplasty has been used to good as for routine osteoarthritis.20 or pseudoparalysis. With the reverse treat some older patients with sig- shoulder replacement, rotator cuff nificant displacement in three- or Chronic rotator cuff tear with function is not required to keep the four-part proximal humerus fractures. secondary arthritis humeral head centred on the glenoid. Controversy remains regarding when Large and unrepaired or unrepairable The presence of a glenoid hemisphere to use arthroplasty for acute shoulder rotator cuff tears can lead to second- allows the humeral head, which is fractures and which arthroplasty op- ary arthritis. Surgeons will most com- replaced with a concave socket, to tion to use. Surgeons consider several monly use the diagnostic term rotator rotate around the hemispherical gle- factors when deciding whether arth- cuff tear arthropathy for this degener- noid component as the deltoid con- roplasty is a suitable option: fracture ative condition. Due to the loss of the tracts, thus obviating the need for a factors (type, comminution, associ- rotator cuff, which acts as a restraint functional rotator cuff. Pain relief ated dislocation, likelihood that a late to superior migration of the humer- is more predictable and superior to reconstruction will be successful) and al head, the humeral head gradually hemiarthroplasty alone.22 Despite patient factors (age, activity level, migrates superiorly and ultimately these advantages, reverse shoulder comorbidities, patient preferences forms an accessory articulation with replacement has several limitations. after consultation). the acromion, with superior sublux- Patients often lose some internal rota- The outcomes of hemiarthroplasty ation along the glenoid. Degenerative tion, and reaching behind the back for fractures can be quite variable. Al- changes occur first as the humeral for personal care may become impos- though approximately 79% of patients head articulates with the acromion. sible. External rotation typically does have no pain after hemiarthroplasty The greater tuberosity at the top of the not improve since the infraspinatus is for fracture, more than half have a humerus begins to round and degen- torn in many cases. If patients have poor functional outcome.3 Hemiar- erative changes progress. Eventually, less than functional active external throplasty remains a useful option in the superior glenoid also begins to rotation (external rotation to neutral), select cases. More commonly these wear because of the superior sublux- a latissimus dorsi tendon transfer can days, nonoperative care is being con- ation. Acromial degenerative chang- be considered, but this involves more sidered for elderly patients, and re- es also occur, and degenerative or surgical time and the need for postop- verse shoulder replacement is being stress fractures of the acromion can erative bracing.23,24 considered as an initial treatment28 for be seen occasionally. Advanced cas- Although the initial pain relief younger more active patients. Reverse es may present with large subdeltoid and functional improvements can shoulder replacement for fracture effusions, and the humeral head may be impressive with reverse shoulder should not be viewed as an emergen- show signs of collapse with avascu- arthroplasty for a chronic rotator cuff cy procedure that must be performed lar necrosis. Eventually, progressive tear, patients need to appreciate that immediately, and for best outcome the rotator cuff tear arthropathy will lead they will always perceive some weak- treating orthopaedic surgeon should to progressive poor shoulder func- ness in the shoulder. One multicentre refer to a tertiary care surgeon with tion,21 and in some cases can result in study found that functional outcomes expertise in the procedure. pseudoparalysis (active forward flex- declined gradually after 7 years,25 and ion less than 90 degrees with full pas- an early study of reverse shoulder Posttraumatic arthritis, sive motion). replacement reported a high compli- deformity, and nonunion The surgical care for more ad- cation rate of 19.0% overall (13.0% Posttraumatic arthritis with minimal vanced rotator cuff tear arthropathy in primary procedures and 37.0% deformity can be approached in the

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same manner as routine osteoarthritis. is involved. In younger patients, soft with a prolonged period of no walker When posttraumatic deformity is sig- tissue options may be considered for use (ideally 3 months in the author’s nificant, however, an anatomic recon- this challenging scenario, although opinion). struction may not be possible. In the the outcome can be unpredictable. In Patients who cannot comply with past, was combined with older patients, rotator cuff tears are postoperative recommendations be- implantation of a traditional stemmed often accompanied by some degree cause of dementia, uncontrolled psy- humeral component, but this has be- of arthritis, and healing of rotator cuff chiatric illness, alcohol or substance come less usual now that we know tendons tends to be poor. Reverse abuse, or walker dependence are at combining osteotomy with hemiarth- shoulder replacement is a more con- high risk for tendon failures, insta- roplasty or total shoulder replacement strained shoulder arthroplasty that bility, and poor functional outcomes. essentially converts the proximal hu- does not depend on the rotator cuff, These patients are typically strongly merus to a four-part fracture and the and is an attractive option in such discouraged from having a shoulder outcome is often poor.29 More often cases. replacement. currently, reverse shoulder replace- ment is used in older patients for a Contraindications Complications more predictable outcome when there A nonfunctional deltoid muscle is Infection is one of the more seri- is significant deformity of the prox- an absolute contraindication to all ous and challenging complications. imal humerus.30 shoulder arthroplasties. The deltoid Chronic indolent infections with When nonunion occurs following is the prime mover of the shoulder. propionibacteria are now recognized trauma, primary open reduction and If the deltoid is compromised due to more frequently, and were likely will be considered trauma, neuropathy, or myopathy, underrecognized previously. The risk if there is enough proximal humeral function cannot be restored and the of infection is likely higher for shoul- bone. However, many cases of proxi- chance of instability increases signifi- der replacement than for hip and knee mal humerus nonunion involve the cantly. Other absolute contraindica- replacement, and published studies shaft eroding into the humeral head tions include active infection, open have reported infection rates rang- and development of tuberosities over injuries, and Charcot arthropathy. ing from 0% to 4%.31,32 As with deep time. The humeral head may be thin Because the shoulder is a non- infection after hip and knee replace- and unrepairable. In such cases, either weight-bearing joint and does not ment, reoperation is required along hemiarthroplasty or reverse total shoul- directly affect a patient’s mobility or with prolonged IV antibiotics. Often der replacement will be considered.30 longevity, relative contraindications chronic infections are treated in two are also of significant importance. surgical stages. Propionibacteria have Instability Shoulder replacement is a major open emerged as the most common patho- In rare cases, older patients may procedure done under general anaes- gens in chronic shoulder arthroplasty present with a combination of prob- thetic. Careful weighing of anesthet- infections and can be challenging to lems, one of which is instability. With ic, medical, and surgical risks against diagnose. massive rotator cuff tears, especially potential quality of life improvements Neurological injury can be a dev- with previous rotator cuff surgery, the is needed for patients with significant astating complication. The incidence proximal humerus can often sublux medical comorbidities and patients of of injury to the brachial plexus or a anterosuperiorly (anterosuperior in- very advanced age. peripheral nerve is approximately stability). Patients may be unaware Shoulder implants are not de- 1.8%. Fortunately, most patients of the subluxation, or may complain signed for constant weight-bearing. recover from these injuries, but per- of shifting, but a fixed anterosuperi- Patients who use a walker for security manent deficits are seen in approxi- or dislocation is uncommon. If older and balance alone and can manage mately 1 in 10 cases of neurological patients with subluxation undergo a with a cane may be candidates for ar- injury.31 hemiarthroplasty, instability is likely throplasty. Patients who use a walker Periprosthetic fracture occurs in to persist and the outcome will be un- for significant weight-bearing support approximately 2.0% of cases.32 The satisfactory. are typically not candidates for shoul- incidence of anterior instability rang- Massive rotator cuff tears can der arthroplasty because they are at es from 0.9% to 1.8%, and posterior also lead to frank anterior shoulder high risk for prosthetic loosening and instability occurs in approximately dislocation when the subscapularis failure, and they cannot usually cope 1.0% of cases.

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Rotator cuff failure is another dis- After 4 weeks, the use of the sling tation vary, but most involve a grad- tinct problem that can present early or is discontinued and patients begin ual return to all activities over 4 to 6 late. Early failures may be related to using the affected arm for waist- months. avulsion of the subscapularis tendon level activities. After 6 weeks, patients repair or unrecognized injury to the are encouraged to use the affected Competing interests supraspinatus tendon. Because ana- arm for all light activities, including The author is involved in clinical research tomic total shoulder arthroplasties reaching. Structured physiotherapy supported by Zimmer, a medical technol- rely on a functional rotator cuff, and begins at this time, and patients are ogy company, but does not receive any fi- the rotator cuff is prone to degenera- informed that home exercise is criti- nancial remuneration from private industry. tion with age, a replaced shoulder is cal to achieving motion recovery. still vulnerable to rotator cuff strains A strengthening program can begin References and tears (both degenerative and trau- at 9 weeks. 1. Neer CS, Brown TH Jr, McLaughlin HL. matic). The rate of rotator cuff tearing After 4 to 6 months, patients grad- Fracture of the neck of the humerus with in shoulder arthroplasty ranges from ually return to all activities as their dislocation of the head fragment. Am J 1.3% to 7.8%.32 comfort level permits. In the long Surg 1953;85:252-258. Upper extremity thromboembolic term, patients are discouraged from 2. Hasan SS, Leith JM, Smith KL, Matsen FA events are rare, with an incidence rate strenuous lifting, heavy labor, and 3rd. The distribution of shoulder replace- of only 0.2%, while the incidence rate activities that put them at risk of a fall ment among surgeons and hospitals is for lower extremity deep vein throm- or injury. significantly different than that of hip or bosis is 0.5%.31 knee replacement. J Shoulder Elbow In one study, 4.6% of patients un- Summary Surg 2003;12:164-169. dergoing for osteoar- Since the first modern shoulder sur- 3. Maier D, Jaeger M, Izadpanah K, et al. thritis received a blood transfusion.33 geries were performed, total shoulder Proximal humeral fracture treatment in However, in the author’s experience, replacement has evolved to become an adults. J Bone Joint Surg Am 2014;96: transfusion is quite uncommon and is orthopaedic procedure with excellent 251-261. needed in less than 2.0% of uncom­ outcomes. For routine osteoarthritis, 4. Neer CS. Replacement arthroplasty for plicated cases. anatomic total shoulder replacement glenohumeral osteoarthritis. J Bone Joint offers patients clinical success rates Surg Am 1974;56:1-13. Postoperative protocols comparable to those of hip replace- 5. Levine WN, Fischer CR, Nguyen D, et al. Postoperative protocols for rehabi­ ment surgery.34 Hemiarthroplasty Long-term follow-up of shoulder hemiar- litation vary among surgeons and may be performed in select cases, but throplasty for glenohumeral osteoarthri- depend on the shoulder pathology and the outcomes are more unpredictable. tis. J Bone Joint Surg Am 2012;94:e164. surgical procedure used. The author’s The reverse total shoulder replace- 6. Carter MJ, Mikuls TR, Nayak S, et al. Im- pattern of practice for routine total ment is a newer procedure that has pact of total shoulder arthroplasty on ge- shoulder replacement begins with been successful in cases of poor rota- neric and shoulder-specific health-related a hospital stay of 1 or 2 nights and tor cuff function and in other chal- quality-of-life measures. J Bone Joint includes the following activities. lenging scenarios. However, reverse Surg Am 2012;94:e127. Patients are encouraged to walk total shoulder replacement may have 7. Edwards TB, Boulahia A, Kempf JF, et al. on the day of surgery and to go for a higher complication rate and fur- The influence of rotator cuff disease on daily walks thereafter. In the major- ther long-term outcome studies are the results of shoulder arthroplasty for pri- ity of cases, a routine sling is used for needed. Absolute contraindications to mary osteoarthritis: Results of a multi- comfort, but occasionally an external shoulder replacement include a non- center study. J Bone Joint Surg Am 2002; rotation brace may be required (e.g., functional deltoid muscle and active 84:2240-2248. in cases of concomitant tendon trans- infection, while relative contraindi- 8. Schoch B, Schleck C, Cofield R, Sperling fer or posterior instability). Patients cations include significant medical JW. Shoulder arthroplasty in patients do pendular exercises and passive comorbidities and very advanced younger than 50 years: Minimum 20-year rotation exercises immediately, and age. Possible complications that may follow-up. J Shoulder Elbow Surg 2015; 1 to 2 weeks after surgery they begin ensue are chronic infection with pro- 24:705-710. passive and assisted elevation exer- pionibacteria and rotator cuff failure. 9. Papadonikolakis A, Matsen FA. Metal- cises. Postoperative protocols for rehabili- backed glenoid components have a

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higher rate of failure and fail by different 19. Gadea F, Alami G, Pape G, et al. Shoulder A systematic review. J Orthop Trauma modes in comparison with all-polyethyl- hemiarthroplasty: Outcomes and long- 2015;29:60-68. ene components: A systematic review. J term survival analysis according to etiolo- 29. Boileau P, Trojani C, Walch G, et al. Shoul- Bone Joint Surg Am 2014;96:1041-1047. gy. Orthop Traumatol Surg Res 2012; der arthroplasty for the treatment of the 10 Galatz L. Trabecular metal technology in 98:659-665. sequelae of fractures of the proximal hu- shoulder arthroplasty. Orthop Proc 2012; 20. Orfaly RM, Rockwood CA, Esenyel CZ, merus. J Shoulder Elbow Surg 2001; 94-B(suppl 40):55. Wirth MA. Shoulder arthroplasty in cases 10:299-308. 11. Hammond LC, Lin EC, Harwood DP, et al. with avascular necrosis of the humeral 30. Walch G, Boileau P, Noël E. Shoulder ar- Clinical outcomes of hemiarthroplasty and head. J Shoulder Elbow Surg 2007; throplasty: Evolving techniques and indi- biological resurfacing in patients aged 16(suppl 3):S27-S32. cations. Joint Bone Spine 2010:77:501- younger than 50 years. J Shoulder 21. Ecklund KJ, Lee TQ, Tibone J, Gupta R. 505. Elbow Surg 2013:22:1345-1351. Rotator cuff tear arthropathy. J Am Acad 31. Gonzalez JF, Alami GB, Baque F, et al. 12. Gilmer BB, Comstock BA, Jette JL, et al. Orthop Surg 2007;15:340-349. Complications of unconstrained shoulder The prognosis for improvement in com- 22. Leung B, Horodyski M, Struk AM, Wright prostheses. J Shoulder Elbow Surg fort and function after the ream-and-run TW. Functional outcome of hemiarthro- 2011;20:666-682. arthroplasty for glenohumeral arthritis: plasty compared with reverse total shoul- 32. Sperling JW, Hawkins RJ, Walch G, Zuck- An analysis of 176 consecutive cases. J der arthroplasty in the treatment of rotator erman JD. Complications in total shoulder Bone Joint Surg Am 2012;94:e102. cuff tear arthropathy. J Shoulder Elbow arthroplasty. J Bone Joint Surg Am 2013; 13. Bryant D, Litchfield R, Sandow M, et al. A Surg 2012;21:319-323. 95:563-569. comparison of pain, strength, range of 23. Alami GB, Rumian A, Chuinard C, et al. 33. Sperling JW, Duncan SF, Cofield RH, et motion, and functional outcomes after Outcomes of reverse total shoulder ar- al. Incidence and risk factors for blood hemiarthroplasty and total shoulder ar- throplasty associated with the modified transfusion in shoulder arthroplasty. J throplasty in patients with osteoarthritis of L’Episcopo procedure for combined loss Shoulder Elbow Surg 2005;14:599-601. the shoulder. A systematic review and of active elevation and external rotation. 34. Boorman RS, Kopjar B, Fehringer E, et al. meta-analysis. J Bone Joint Surg Am Orthop Proc 2012;94-B(suppl 38):170- The effect of total shoulder arthroplasty on 2005;87:1947-1956. 170. self-assessed health status is comparable 14. Franklin JL, Barrett WP, Jackins SE, Mat- 24. Puskas GJ, Catanzaro S, Gerber C. Clinical to that of total hip arthroplasty and coro- sen FA 3rd. Glenoid loosening in total outcome of reverse total shoulder arthro- nary artery bypass grafting. J Shoulder shoulder arthroplasty. Association with plasty combined with latissimus dorsi Elbow Surg 2003;12:158-163. rotator cuff deficiency. J Arthroplasty transfer for the treatment of chronic com- 1988;3:39-46. bined pseudoparesis of elevation and ex- 15. Smith CD, Guyver P, Bunker TD. Indica- ternal rotation of the shoulder. J Shoulder tions for reverse shoulder replacement: A Elbow Surg 2014;23:49-57. systematic review. J Bone Joint Surg Br 25. Guery J, Favard L, Sirveaux F, et al. Re- 2012;94:577-583. verse total shoulder arthroplasty: Survi- 16. Barlow JD, Yuan BJ, Schleck CD, et al. vorship analysis of eighty replacements Shoulder arthroplasty for rheumatoid ar- followed for five to ten years. J Bone thritis: 303 consecutive cases with mini- Joint Surg Am 2006;88:1742-1747. mum 5-year follow-up. J Shoulder Elbow 26. Wall B, Nové-Josserand L, O’Connor DP, Surg 2014;23:791-799. et al. Reverse total shoulder arthroplasty: 17. Young AA, Smith MM, Bacle G, et al. Ear- A review of results according to etiology. ly results of reverse shoulder arthroplasty J Bone Joint Surg Am 2007;89:1476- in patients with rheumatoid arthritis. J 1485. Bone Joint Surg Am 2011;93:1915-1923. 27. Groh GI, Groh GM. Complications rates, 18. Cadet ER, Kok P, Greiwe RM, et al. Inter- reoperation rates, and the learning curve mediate and long-term follow-up of total in reverse shoulder arthroplasty. J Shoul- shoulder arthroplasty for the manage- der Elbow Surg 2014;23:388-394. ment of postcapsulorrhaphy arthropathy. 28. Ferrel JR, Trinh TQ, Fischer RA. Reverse J Shoulder Elbow Surg 2014;23:1301- total shoulder arthroplasty versus hemiar- 1308. throplasty for proximal humeral fractures:

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