Deltopectoral approach · High-complexity revision arthroplasty
- Instability is the most common indication (around 40 percent of revisions) — management rests on restoring soft-tissue tension (a thicker polyethylene liner first, a lateralised glenosphere second) and correcting component position, never simply reducing and hoping.
- Baseplate loosening demands bone-stock assessment on a metal-artefact CT and a reconstruction matched to the defect: a larger or augmented baseplate for minor peripheral loss, BIO-RSA (structural graft under the baseplate) for major central loss, and a custom implant for vault compromise.
- Always exclude infection before an aseptic revision — inflammatory markers, joint aspiration with an extended culture hold, and a labelled white-cell scan if equivocal.
- Nerve injury is more common in revision than primary; the axillary nerve is the most commonly injured nerve in shoulder arthroplasty and is vulnerable during subscapularis takedown.
- The Sirveaux and Nerot grade (1 to 4) describes scapular NOTCHING, not glenoid bone-loss volume — do not conflate the two in the viva.
- Outcomes are lower than primary reverse TSA: five-year survival 85 to 90 percent (versus 93 to 95 percent primary) and satisfaction 70 to 75 percent — set realistic expectations.
When & Why
Why revise a reverse TSA. A reverse total shoulder arthroplasty fails in a handful of recognisable ways, and each mode points to a different operation. The first task is therefore to make the diagnosis, then to decide what the revision must achieve — restore tension, reconstruct bone, or eradicate infection — before ever picking up a scalpel.
- Clinical features
- Subluxation or dislocation, often atraumatic, with a clicking sensation
- Key imaging
- Component position on the axillary view; subscapularis integrity on MRI
- Surgical strategy
- Soft-tissue tensioning, thicker polyethylene, with or without a lateralised glenosphere
- Clinical features
- Progressive pain, loss of function, a grinding sensation
- Key imaging
- Radiolucent lines greater than 2mm, baseplate migration, screw breakage on serial radiographs
- Surgical strategy
- Remove baseplate, assess bone loss, augment or graft, larger or custom baseplate
- Clinical features
- Acute loss of function, palpable hardware, pseudo-paralysis
- Key imaging
- Separated glenosphere on any view; baseplate may be intact
- Surgical strategy
- Assess the locking mechanism; replace the glenosphere, with the baseplate if damaged
- Clinical features
- Trauma history, pain, deformity (humeral more common than scapular)
- Key imaging
- Fracture pattern, implant stability, bone quality on CT
- Surgical strategy
- ORIF if implant stable; revision with a long stem if unstable; a scapular fracture may need plating
- Clinical features
- Pain, swelling, drainage, constitutional symptoms
- Key imaging
- Soft-tissue oedema, effusion, loosening on MRI, nuclear-medicine scan
- Surgical strategy
- Two-stage revision: explant and spacer, six weeks of antibiotics, reimplantation after clearance
Exclude infection first. Before any aseptic revision, screen for infection: CRP and ESR (a CRP greater than 10 is suggestive), joint aspiration with a culture hold of 48 to 72 hours minimum, and a labelled white-cell scan if aspiration is equivocal. Revision surgery carries a higher infection risk than primary (3 to 5 percent versus 1 to 2 percent), so the work-up is non-negotiable. Preoperative imaging. AP, scapular Y and axillary views show implant position, bone loss and subluxation. A CT scan with metal-artefact reduction is essential — it characterises glenoid bone loss as central (contained/cavitary), peripheral (uncontained/segmental) or combined (the Antuna pattern), and quantifies residual vault depth and version for screw-trajectory planning. Remember the viva trap: the Sirveaux and Nerot grade (1 to 4) describes scapular NOTCHING, not glenoid bone-loss volume — the two are classified differently and must not be conflated. Implant inventory. Obtain the previous operative notes (implant type, sizes, cementing) and have revision stems (long stem, metaphyseal-engaging), baseplate options (standard, augmented, custom), glenosphere options (various sizes and lateralisation offsets), bone graft (allograft versus iliac-crest autograft), and subscapularis-reconstruction materials available before starting. Neurovascular structures at risk. Revision dissection is scarred and the nerves are less predictable than in a primary. Know the five structures and their safe distances before you cut:
- Location
- Courses 5 to 7cm inferior to the acromion, anteroinferior to subscapularis, exiting the quadrangular space; vulnerable more than 5cm below the coracoid
- How to protect it
- Careful subscapularis mobilisation; palpate and protect it during inferior release; avoid dissection more than 5cm below the coracoid tip
- Location
- Enters the conjoint tendon 3 to 8cm distal to the coracoid tip (variable)
- How to protect it
- Keep medial retractor penetration under 2cm; avoid aggressive medial stripping; visualise the conjoint tendon
- Location
- Scapular notch (superiorly) and spinoglenoid notch (posterosuperiorly)
- How to protect it
- Avoid over-medialising baseplate screws; take care with the superior screw; limit posterosuperior dissection
- Location
- 2 to 3cm medial to the coracoid process and conjoint tendon
- How to protect it
- Controlled medial retraction; avoid overzealous medial soft-tissue release; identify landmarks
- Location
- Deltopectoral interval, with variable tributaries
- How to protect it
- Preserve or carefully ligate; retract laterally with the deltoid (disruption causes deltoid venous congestion)
Setup. Beach-chair position at 30 to 40 degrees, head in neutral, the entire scapula free to manipulate. Regional anaesthesia (interscalene block) gives 12 to 24 hours of analgesia. Ensure the arm can be extended off the side of the table for humeral work, and beware hypotension with a steep beach-chair angle.
The Operation
The goal is a stable, well-fixed reverse arthroplasty with restored soft-tissue tension and reconstructed glenoid bone, approached through the extensile deltopectoral interval. The exposure — identifying the coracoid, opening the deltopectoral interval, and mobilising a scarred subscapularis while protecting the axillary nerve — is the foundation of the whole case and is laid out as the first steps below.
Operative sequence
- Beach-chair position at 30 to 40 degrees, head supported in neutral, the entire scapula free to manipulate.
- Ensure the arm can be extended off the side of the table for humeral exposure — inadequate setup makes component extraction difficult and raises fracture risk.
- Beware hypotension with a steep beach-chair position; reduce the angle if the patient becomes unstable.
- Use the previous deltopectoral incision, extending proximally toward the clavicle or 1 to 2cm beyond the deltoid insertion as needed.
- If several previous incisions exist, use the most lateral one to preserve the medial skin-bridge blood supply — parallel incisions under 3cm apart risk skin necrosis.
- Handle thin, scarred skin gently with minimal undermining; if there is a previous-infection history, consider plastic-surgery input for flap cover.
- Identify the cephalic vein at the lateral border of pectoralis major and develop the internervous plane between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves).
- Preserve the cephalic vein, retracting it laterally with the deltoid (or ligate it if necessary), and divide the clavipectoral fascia.
- Dense scar obliterates the normal planes — identify the coracoid tip first as a landmark and work from known to unknown to protect the musculocutaneous nerve.
- The axillary nerve is vulnerable if dissection extends more than 5cm below the coracoid tip.
- Identify the subscapularis remnant or previous repair — it is often scarred to the anterior capsule and the humeral component.
- If quality is poor (under 50 percent thickness), consider leaving it detached and converting to a latissimus dorsi transfer at completion for external-rotation strength.
- The axillary nerve exits at the inferior border — palpate and protect it during inferior mobilisation; aggressive mobilisation can denervate the muscle even without transection.
- Release the anterior capsule from the glenoid rim and the inferior capsule from the humeral neck — an extensive circumferential release around the humeral component is essential, or extraction will cause an iatrogenic fracture.
- Inferior release beyond 5cm from the coracoid risks the axillary nerve; posterosuperior release risks the suprascapular nerve at the spinoglenoid notch.
- If the glenosphere is removable, dislocate first, then remove the sphere; if it is locked, remove the humeral tray first, then dislocate.
- Use external rotation and extension. If you cannot dislocate, STOP and remove the glenosphere rather than forcing it.
- Forced dislocation fractures the humeral shaft (especially in osteoporotic bone); levering against the glenosphere fractures the glenoid rim.
- Remove the polyethylene liner, then dislocate (or remove the glenosphere first), and use an extraction device on the taper — or on the cement, if cemented.
- For a well-fixed uncemented stem, create a humeral window with an oscillating saw to preserve bone stock for the revision stem (see the pearl below for the exact dimensions).
- Beware a humeral shaft fracture during extraction (3 to 5 percent in revision) and the radial nerve in the posterior spiral groove with any distal extension.
- Retract the humerus posteriorly and inferiorly, release soft-tissue adhesions around the baseplate, and expose its edge circumferentially.
- Use bent Hohmann retractors — one inferior, one posterior, one superior — to create the triangulated exposure essential for baseplate removal.
- The superior retractor risks the suprascapular nerve at the scapular notch; aggressive posterior retraction risks the spinoglenoid notch.
- Remove the glenosphere (if not already done), then the locking screws sequentially, and extract the baseplate with dedicated removal tools or osteotomes.
- Remove the peripheral screws first (superior, inferior, posterior) and the central compression screw last, maintaining some fixation during dissection to prevent the baseplate spinning.
- Screw breakage leaves retained hardware (drill it out, or leave it if well buried); levering the baseplate aggressively fractures the glenoid vault.
- Remove fibrous tissue and sclerotic bone, then assess the remaining stock against the CT and classify the defect: central (contained/cavitary), peripheral (uncontained/segmental) or combined (the Antuna pattern), plus residual vault depth and version.
- Test quality with a curette — if it penetrates easily, there is insufficient stock for screw purchase and you need grafting or augmentation.
- Avoid over-resecting sclerotic bone (unnecessary loss) and recognise the full defect extent, or the reconstruction will be inadequate.
Match the reconstruction to the defect pattern and the residual vault: - Minor peripheral defect (under 5mm). Use a larger-diameter baseplate that covers the defect, or an augmented baseplate with a built-in wedge. Place the augment on the defect side (typically inferior) to restore anatomy, structural support and version. Augment overhang risks impingement and instability; inadequate seating causes micromotion and early loosening.
- Major central defect (over 5mm) — BIO-RSA. Use a structural graft — iliac-crest autograft (best biology) or femoral-head allograft — greater than 10mm thick, shaped to fill the defect and fixed with screws through the baseplate into native bone. Expect incorporation over 6 to 12 months (delay full activity); around 20 percent volume resorption is acceptable, but inadequate compression causes baseplate subsidence.
- Severe loss with vault compromise — custom implant. A patient-specific baseplate engaging the scapular body (coracoid, spine and pillar) is required; it needs preoperative CT planning and 6 to 8 weeks to manufacture. An interim graft-compaction procedure with delayed reconstruction is an alternative.
- Position the baseplate with 10 to 15 degrees of inferior tilt, neutral or slight anteversion, flush with the inferior glenoid rim — avoid superior placement.
- Inferior tilt is critical to prevent scapular notching: use the glenoid vault as the reference (perpendicular to the vault is neutral, then tilt inferiorly).
- Superior tilt causes notching and accelerated loosening; excessive retroversion limits external rotation and causes posterior instability.
- Place the central compression screw first (into the vault), then the peripheral locking screws, aiming for bicortical purchase with divergent trajectories for maximum fixation.
- Direct the superior screw toward the coracoid base (strong bone), the inferior screws toward the scapular pillar, and the posterior screw toward the spine — avoid convergence.
- Anterior screws risk the brachial plexus (stay lateral to the coracoid base); superior-medial screws risk the suprascapular nerve; over-torquing breaks screws or fractures bone.
- Select the appropriate glenosphere (36mm standard, 42mm for lateralisation), ensure full locking-mechanism engagement, and check stability manually.
- A lateralised glenosphere (+10mm) improves the deltoid moment arm and reduces notching but increases shear on the baseplate — use it selectively for instability.
- Incomplete locking causes dissociation (check for a gap between sphere and baseplate); an oversized sphere limits motion and impinges on the acromion.
- If the humeral component is loose, remove the old stem and ream to fit a revision stem — at least 2mm larger in diameter or 20mm longer.
- Use a long-stem revision (120 to 150mm) that bypasses stress risers from previous screw holes and cement by two cortical diameters below any defect; cement it if bone quality is poor.
- Underfilling the canal risks subsidence and instability; over-sizing during reaming fractures the osteopenic revision bone.
- Insert trial components, reduce, and test stability through the full range — forward flexion, abduction, rotation; it should be stable to 90 degrees flexion and 30 degrees external rotation.
- Perform the shuck test: apply inferior traction; under 1cm of translation is acceptable, more than 1cm indicates inadequate tensioning — use a thicker polyethylene or a more lateralised glenosphere.
- Forced reduction during trialing causes an iatrogenic fracture; instability recognised but not addressed leads to early revision for dislocation.
- After a satisfactory trial, implant the final baseplate with glenosphere and the humeral stem with the chosen polyethylene thickness. Do not alter the plan at this stage — if there is an instability concern, return to trials and reassess every variable (glenosphere size and lateralisation, polyethylene thickness, humeral version).
- Manage the subscapularis: if quality is adequate, repair it to the lesser tuberosity with transosseous sutures or anchors; if deficient, leave it unrepaired or perform a tendon transfer. Because a reverse TSA is deltoid-dependent, subscapularis repair is less critical than in an anatomic TSA, and some surgeons leave it unrepaired intentionally in the revision setting.
- Test stability through the full passive range on the table — aim for 140-plus degrees flexion and 40-plus degrees external rotation without dislocation. If unstable, inadequate soft-tissue tensioning is the commonest error and a thicker polyethylene liner (8, 10 or 12mm options) solves most cases.
The axillary nerve exits the inferior border of subscapularis 5 to 7cm below the coracoid and is the most commonly injured nerve in shoulder arthroplasty. Palpate and protect it during subscapularis takedown and any inferior capsular release, and keep inferior dissection within 5cm of the coracoid tip. Most injuries are neurapraxia recovering over 3 to 6 months — obtain an EMG at six weeks if there is no clinical recovery.
For a well-fixed stem, make a rectangular cortical window about 2cm wide, beginning 2cm distal to the lesser tuberosity, with a length roughly twice the stem length, and secure it with cerclage wires at closure. A window that is too proximal weakens the metaphysis, and an incomplete osteotomy propagates into a fracture during extraction.
Ten to fifteen degrees of inferior tilt is the single most important baseplate decision: superior tilt drives scapular notching and early loosening. Use the glenoid vault as the perpendicular reference and tilt inferiorly from there.
If the shuck test shows more than 1cm of inferior translation, the joint is under-tensioned. Work up the ladder: a thicker polyethylene first (8, 10, 12mm), a lateralised glenosphere second (+4 or +10mm), and repair the subscapularis if tissue allows. Never implant finally on an unstable trial.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation & therapy | |-------|--------|---------------------------| | Immediate | 0 to 6 weeks | Sling in adduction and neutral rotation; six weeks if subscapularis repaired, gentle pendulums at two weeks if not. Sutures out at 14 days; radiographs at two weeks | | Early rehab | 6 to 12 weeks | Passive forward flexion to 90 and external rotation to neutral (weeks 6 to 8); flexion to 120 and external rotation to 20 (weeks 8 to 10); active-assisted ROM (weeks 10 to 12). No lifting over 1kg, no reaching behind the back, no driving until eight weeks | | Strengthening | 3 to 6 months | Active ROM with light resistance bands (months 3 to 4); progressive resistance 1 to 3kg (months 4 to 5); return to activities of daily living (months 5 to 6) | | Long term | 6-plus months | Annual radiographs for five years then biennial; no overhead sports, no heavy lifting over 10kg overhead; golf and swimming acceptable after six months; lifetime dental antibiotic prophylaxis | Expected outcomes are generally lower than after a primary reverse TSA: forward flexion 100 to 120 degrees (versus around 140 primary), abduction 90 to 110 degrees (versus around 130 primary), external rotation 0 to 30 degrees depending on subscapularis status, and internal rotation typically limited to hand-to-lateral-thigh. Around 70 to 80 percent of patients gain significant pain relief and 70 to 75 percent are satisfied or very satisfied — realistic preoperative counselling is essential. Complications
- Recognition
- Sudden loss of function, deformity, arm held in adduction; radiograph shows loss of articulation between humeral liner and glenosphere
- Prevention
- Adequate soft-tissue tensioning with trial reduction, thicker polyethylene, lateralised glenosphere if deltoid insufficient, correct inferior baseplate tilt
- Management
- Closed reduction under sedation if acute. If recurrent (more than two episodes), revise: thicker polyethylene, reassess component position, consider a constrained liner
- Recognition
- Progressive pain, grinding, weakness; serial radiographs show radiolucent lines over 2mm, screw breakage, baseplate migration
- Prevention
- Bone-stock assessment, grafting of defects over 5mm, bicortical divergent screws, avoid superior tilt
- Management
- Remove the loose baseplate, assess bone loss, BIO-RSA for major defects, custom implant for massive loss; graft incorporation 6 to 12 months
- Recognition
- Intraoperative: visible crack or change in bone feel. Postoperative: pain, deformity, radiographic fracture line; humeral shaft commonest
- Prevention
- Careful extraction (humeral window if well-fixed), avoid forced dislocation, gentle reaming, prophylactic cerclage if cortex thinned
- Management
- Intraoperative: cerclage if nondisplaced, long stem if unstable. Postoperative: ORIF with plate if implant stable, long-stem revision if implant loose
- Recognition
- Acute: wound drainage, erythema, fever, raised WCC or CRP. Chronic: persistent pain, raised ESR or CRP beyond six weeks, sinus tract; positive aspiration culture
- Prevention
- Preoperative infection screening, IV antibiotics one hour pre-incision, normothermia, minimise operative time, meticulous haemostasis
- Management
- Acute (under three weeks): irrigation and debridement with liner exchange plus suppressive antibiotics. Chronic: two-stage revision (explant, spacer, six weeks antibiotics, reimplant)
- Recognition
- Axillary: deltoid weakness, lateral shoulder numbness. Musculocutaneous: weak elbow flexion, lateral forearm numbness. Suprascapular: external-rotation weakness. May appear only in recovery
- Prevention
- Identify and protect the axillary nerve during subscapularis mobilisation, keep medial retractor depth under 2cm, avoid superior screw medialisation, gentle retraction
- Management
- Most neurapraxia recovers over 3 to 6 months; EMG at six weeks if no recovery. Persistent complete deficit: consider tendon transfers at 6 to 12 months
- Recognition
- Progressive erosion of the lateral scapular pillar inferior to the glenosphere on the AP radiograph; Sirveaux grade 1 (pillar only) to grade 4 (baseplate undersurface)
- Prevention
- Baseplate inferior tilt 10 to 15 degrees, glenosphere lateralisation or inferior eccentricity, avoid superior placement, appropriate glenosphere size
- Management
- Grades 1 to 2: observe (usually asymptomatic and stable). Grades 3 to 4: monitor with serial radiographs, revise if progressive pain or dysfunction
- Recognition
- Acute pain and ecchymosis over the acromion or scapula, palpable step-off; radiograph or CT shows a fracture line — acromial base or scapular spine commonest; often weeks after surgery with minor trauma
- Prevention
- Avoid excessive superior glenosphere placement, appropriate size, gentle screw insertion, optimise bone quality
- Management
- Most treated non-operatively: sling for six weeks, delayed therapy. ORIF if a displaced acromial fracture compromises deltoid function or baseplate screws are involved
Viva & Exam Focus
REVISEREVISE — indications for reverse TSA revision
GLENOIDGLENOID — bone-loss management strategy
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 72-year-old presents three years after a reverse TSA with three recurrent anterior dislocations. Radiographs show well-fixed components in a satisfactory position. How do you assess and manage this patient?”
“You review a 68-year-old two years after a reverse TSA with progressive pain and a grinding sensation. Radiographs show a 3mm radiolucent line around the baseplate with superior screw breakage. What is your diagnosis and management plan?”
“During a revision reverse TSA for instability you have trialed several polyethylene liner thicknesses and still have 1.5cm of inferior subluxation on arm traction. The baseplate and humeral component positions appear appropriate. What are your next steps?”
Indications
- Instability — the commonest indication (about 40 percent); assess tensioning and component position
- Baseplate loosening — radiolucent lines over 2mm, screw breakage, migration; assess bone stock
- Glenosphere dissociation — check the locking mechanism and baseplate integrity before revising
- Periprosthetic fracture — humeral (commoner) or scapular; management depends on implant stability
- Infection — two-stage revision only after full eradication
Exposure & danger zones
- Deltopectoral interval; identify the coracoid first in the scarred field; protect the cephalic vein
- Axillary nerve — exits 5 to 7cm below the coracoid; the most commonly injured nerve in shoulder arthroplasty
- Musculocutaneous nerve — enters the conjoint 3 to 8cm from the coracoid; keep medial retraction under 2cm
- Suprascapular nerve — scapular and spinoglenoid notches; avoid over-medial screw placement
Glenoid defect reconstruction
- Classify by pattern — central/contained, peripheral/uncontained, or combined — plus residual vault depth
- Minor peripheral loss — larger or augmented baseplate
- Major central loss — BIO-RSA: structural graft over 10mm under the baseplate, screws into native bone
- Severe vault compromise — custom implant engaging the coracoid, spine and pillar
Stability optimisation
- Thicker polyethylene liner is the first choice (8, 10, 12mm options)
- Lateralised glenosphere is the second choice (+4 or +10mm)
- Baseplate 10 to 15 degrees inferior tilt; divergent bicortical screws
- Repair the subscapularis if adequate — it improves anterior stability
Complications & outcomes
- Instability 10 to 15 percent; infection 3 to 5 percent; nerve injury 2 to 4 percent; periprosthetic fracture 5 to 8 percent
- Five-year survival 85 to 90 percent (versus 93 to 95 percent primary); satisfaction 70 to 75 percent
- Sirveaux and Nerot grades 1 to 4 describe NOTCHING, not bone-loss volume — do not conflate
- Re-revision rate 15 to 25 percent at five years; male sex worsens revision-RSA survival
Background & Evidence
Survivorship and epidemiology. Revision reverse TSA carries a materially higher failure burden than primary. Five-year implant survival is around 85 to 90 percent (compared with 93 to 95 percent for primary reverse TSA) and ten-year survival around 75 to 80 percent, with a re-revision rate of 15 to 25 percent at five years. The most common reasons to re-revise are instability (around 40 percent), infection (around 25 percent) and loosening (around 20 percent), and revisions performed for instability fare worse than an anatomic-to-reverse conversion. The multicentre series of Chelli and Boileau quantified this precisely (see the reference below): in 1611 reverse shoulder arthroplasties, ten-year revision-free survival was 80.9 percent for revision RSA versus 91.0 percent for primary RSA, with male sex and younger age additional risk factors. National joint registries (NJR UK, AJRR US, AOANJRR Australia, and the Nordic registries) consistently report the same message — revision arthroplasty has higher subsequent re-revision rates and lower survivorship than primary — and registry data should be read alongside the peer-reviewed series when counselling patients. Biomechanics and why revisions fail. The Grammont design medialises and distalises the centre of rotation, recruiting the deltoid to compensate for a deficient cuff and minimising glenoid torque to protect the baseplate. Restoring deltoid tension is therefore the dominant biomechanical goal of any revision: lost deltoid length and inadequate soft-tissue tension are the principal drivers of post-revision instability, while a medialised centre of rotation protects against early baseplate loosening. Outcomes are explicitly less predictable and complication rates higher in the revision setting. Classification — the viva trap. Glenoid bone loss and scapular notching are graded on DIFFERENT systems and must not be conflated. Bone loss is described by pattern — central (contained/cavitary), peripheral (uncontained/segmental) or combined (the Antuna pattern) — together with residual vault depth, and this pattern drives the reconstruction (larger or augmented baseplate, BIO-RSA, or custom implant). Scapular notching is graded separately by the Sirveaux and Nerot system, grade 1 (confined to the lateral pillar) through grade 4 (reaching the baseplate undersurface); grades 1 and 2 are usually stable and observed, grades 3 and 4 are concerning for progressive loosening. Prognostic factors.
Revision of a failed anatomic TSA (better than a failed primary reverse); preserved bone stock or successful grafting; a stable soft-tissue envelope; absence of infection; age under 75 years.
Three or more prior surgeries; severe uncontained or combined glenoid loss with vault compromise; subscapularis deficiency; active or incompletely eradicated infection; poor bone quality (osteoporosis, rheumatoid arthritis).
References
Survivorship of Reverse Shoulder Arthroplasty According to Indication, Age and Gender
- Multicentre series of 1611 RSAs (including 239 revision RSAs) with mean follow-up 5.6 years
- 10-year revision-free survival was 80.9% for revision RSA (failed arthroplasty) vs 91.0% for primary RSA (p less than 0.001)
- Revision RSA in males had significantly worse survival than females (72.3% vs 84.5% at 10 years)
- Most frequent complications overall were infection (3.8%), instability (2.8%) and humerus-related (2.8%)
Grammont Reverse Prosthesis: Design, Rationale, and Biomechanics
- Grammont design medialises and distalises the centre of rotation, recruiting deltoid to compensate for a deficient cuff
- Medialised centre of rotation minimises glenoid torque and protects against early baseplate loosening
- Failure to restore deltoid tension is a key cause of prosthetic instability
- Authors explicitly note results are less predictable and complication or revision rates higher in the revision setting
Effects of Acquired Glenoid Bone Defects on Surgical Technique and Clinical Outcomes in Reverse Shoulder Arthroplasty
- 216 shoulders with preoperative 3D CT; 56 had acquired glenoid bone defects requiring altered technique
- All defective glenoids used an alternative (scapular spine) central-screw centreline; bone-grafting used in 22 cases
- Defective glenoids required larger glenospheres (36 or 40mm) significantly more often (p less than 0.001)
- No graft failure or resorption; ASES scores improved equivalently to normal glenoids at 2 years
Bony Increased-Offset Reversed Shoulder Arthroplasty: Minimizing Scapular Impingement While Maximizing Glenoid Fixation
- Prospective series of 42 patients with autologous bone graft (BIO-RSA) under the baseplate, lengthened 25mm central peg plus four screws
- Graft incorporated completely in 98% (41/42); no graft resorption, glenoid loosening or instability at mean 28 months
- Inferior scapular notching in only 19%; Constant score improved from 31 to 67
- Bony lateralisation keeps the centre of rotation at the bone interface, minimising torque versus metallic lateralisation
Grammont Award 2018: Scapular Fractures in Reverse Shoulder Arthroplasty - Prevalence, Functional and Radiographic Results
- Multicentre review of 1953 Grammont-style RSAs; scapular (acromial base or spine) fracture prevalence 1.3%
- Most fractures occurred within the first 6 postoperative months and 68% were atraumatic
- Abduction-splint immobilisation frequently resulted in nonunion or malunion
- Final outcomes were poor regardless of acromial versus spine site (mean Constant 47, elevation 109 degrees)
Further reading 1. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S):147S-161S. doi:10.1016/j.jse.2004.10.006 2. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y 3. Neyton L, Erickson J, Ascione F, Bugelli G, Lunini E, Walch G. Grammont Award 2018: Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up. J Shoulder Elbow Surg. 2019;28(2):260-267. doi:10.1016/j.jse.2018.07.004 4. Levy JC, Virani N, Pupello D, Frankle M. Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency. J Bone Joint Surg Br. 2007;89(2):189-195. doi:10.1302/0301-620X.89B2.18161 5. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999;14(6):756-760. doi:10.1016/s0883-5403(99)90232-2 6. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86(3):388-395. doi:10.1302/0301-620x.86b3.14024 7. Flatow EL, Harrison AK. A history of reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2011;469(9):2432-2439. doi:10.1007/s11999-010-1733-6 8. Klein SM, Dunning P, Mulieri P, Pupello D, Downes K, Frankle MA. Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty. J Bone Joint Surg Am. 2010;92(5):1144-1154. doi:10.2106/JBJS.I.00778 9. Boileau P, Moineau G, Roussanne Y, O'Shea K. Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469(9):2558-2567. doi:10.1007/s11999-011-1775-4 10. Chelli M, Boileau P, Domos P, et al. Survivorship of reverse shoulder arthroplasty according to indication, age and gender. J Clin Med. 2022;11(10):2677. doi:10.3390/jcm11102677 11. National joint replacement registries reporting shoulder arthroplasty outcomes worldwide — including the National Joint Registry (NJR, UK), the American Joint Replacement Registry (AJRR, US), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Nordic registries — consistently report that revision arthroplasty has higher subsequent re-revision rates and lower implant survivorship than primary RSA. Registry data should be read together with the peer-reviewed series above when counselling patients.