Origins of Reverse Shoulder Arthroplasty and Common Misconceptions

Abstract

Reverse shoulder arthroplasty (RSA) has become a widely accepted procedure for patients with severe rotator cuff deficiency in the setting of glenohumeral arthritis. While the general acceptance of RSA is relatively recent, the concept of RSA is not new as several RSA devices were originally developed beginning in the 1970’s. Despite some of these reports showing few or no complications, none of these devices caught on as a viable option to treat patients with rotator cuff deficiency. The resurgence of RSA began with Paul Grammont’s work with his “Trompette” prosthesis which he designed in 1985 and later reported on in 1987. Two common misconceptions have emerged in the current RSA literature about the RSA devices from the 1970s. The first is that all RSA devices from the 1970s had high rates of failure and the second is that a lateral center of rotation caused those failures. This chapter shows the extent to which these misconceptions have been disseminated and presents evidence that counters both of these claims.

Appendix

			Type
			No error	Major error		Minor error
Lead author	Year	Title		Unrelated reference	Unsubstantiated assertion	Generalization	Specific quotation(s)	Description of error	Description of error
Ahir, S.P.	2004	Analysis of glenoid fixation for a reversed anatomy fixed-fulcrum shoulder replacement	1
Baulot E.	2011	Grammont’s idea: the story of Paul Grammont’s functional surgery concept and the development of the reverse principle			1		“The use of the first generation of reverse shoulder prosthesis was discontinued because of loosening and mechanical complications 18, 28”	Reference 18 is Gerard’s original report that contained 2 mechanical complications but no loosening [10], and reference 28 is Kölbel’s earliest report (in German) on the design rationale of his implant but does not report loosening or complications [14]
Boileau, P.	2005	Grammont reverse prosthesis: design, rationale, and biomechanics		1	1		“These previous constrained shoulder prostheses, other than the Grammont, tended to fail because their design resulted in excessive torque and shear forces at the glenoid component-bone interface.”	Major error 1: The authors are referring to 6 references cited earlier in the text: Bayley, Brostrom, Fenlin, Gerard, Kolbel, and Neer. The assertion is unsubstantiated by the references given as none of these articles determined that failure was caused by excessive torque and sheer forces nor were they designed to do so [27]. The authors’ assertion is also not supported by all of the references. For example, two of the references, Bayley [6] and Gerard et al. [10], report no aseptic baseplate loosening. Furthermore, the Fenlin reference is a design rationale paper that gives a brief summary of [5] cases with only one of the 5 patients experiencing glenoid loosening [9]. The case of loosening involved a Charcot shoulder which would be considered a contraindication to joint replacement surgery today	Major error 2: The Neer reference given is the classic article on cuff-tear arthropathy, and is not about an original RSA device
Boileau, P.	2006	Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty			1		“Furthermore none of these designs have been able to withstand the increased stresses that their fixed fulcrum imposed on the bone-prosthesis interface, leading to early failure and abandonment of these designs (8, 29, 31, 33, 39)”.	Only Refs. 8, 29 are RSA designs (Kessel [13] and Kölbel [14]), and the other 3 are anatomic fixed-fulcrum devices (the Stanmore [54], McElwain and English [55], and Michael Reese [56] devices). Neither of the two RSA studies came to the conclusion that increased stresses caused early failure. In fact, the Kölbel reference only reported one early loosening out of 14 patients and in that patient “the pin for cement fixation had to be shortened” due to a “tiny scapula”[57]
Boileau, P.	2008	Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis			1		“Moreover, lateralization of the center of rotation (outside the scapula) is mechanically risky because it increases the torque and shear forces at the glenoid and may lead to prosthetic loosening 8”	This is another example of a causal assertion that is unsubstantiated. Moreover, Ref. 8 is Boileau’s study in 2005 [25], which has an unsubstantiated assertion of causation
Boileau, P.	2011	Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation		1	1		“Historically, clinical experience (1970s and 1980s) with lateralized offset prostheses has been disastrous with a high rate of glenoid loosening witnessed, leading to abandonment of the design 5, 14, 35”	Major error 1: Reference 5 is Boileau et al. [25] from 2005 where the assertion of the causes of failure of the early reverse designs was not substantiated by the 6 references given (discussed in Boileau 2005)	Major error 2: References 14, 35 are unrelated to the topic in the assertion. Reference 14 is a comparison of subjective shoulder value to Constant score by Gilbart [58], and reference 35 is a technique paper for Delta reverse shoulder prosthesis by Valenti [59]
Boulahia, A.	2002	Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear			1		“Earlier attempts using a reverse shoulder prosthesis design were burdened by early loosening of the glenoid component caused by a laterally offset center of rotation resulting in a rocking horse phenomenon occurring at the glenoid bone component interface (Figure 4).” And figure 4’s caption: “the laterally located center of rotation of the early reverse design prostheses caused early loosening”	The assertion of causation is unsubstantiated as none of the original reverse design articles determined that failure was caused by a laterally located center of rotation nor were they designed to do so. Also, the “rocking horse” phenomenon is related to anatomical total shoulder replacements, not reverse designs [26]
Flatow, E.L.	2011	A history of reverse total shoulder arthroplasty	1
Frankle, M.A.	2005	The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients.				1	“Early designs of reversed shoulder implants, however, were plagued with difficulties related to glenoid failure and soon fell out of favor 17.”	While the assertion that early designs were plagued with difficulties related to glenoid failure is true for some devices, it is not true for all of them so I consider this an oversimplification/generalization. In fact, while the study referenced (Brostrom [21]) had a 13 % aseptic baseplate failure rate, another study by Bayley [6] on the same implant reported no aseptic cases of loosening
Gerber, C.	2009	Reverse total shoulder arthroplasty		1			“Early designs resulted in catastrophic failure of the glenoid implant, 8 and reverse total shoulder arthroplasty became virtually banned from orthopaedic practice.”	Reference [8] is an article by Melvin Post [60] about the Michael Reese constrained implant which is anatomic and not reversed. The post article does contain references several constrained implants, both anatomic and reversed in its intro, but the article is about the experience with Michael Reese implant
Grassi, F.A.	2009	Six-year experience with the Delta III reverse shoulder prosthesis			1		“The Delta III reverse prosthesis restores mobility around a stable centre of rotation and avoids early loosening noted with constrained implants 18–20”	The authors assert “The Delta III… avoids early loosening noted with constrained implants” and only reference [20] is a paper on RSA (Brostrom [21]). This assertion is not substantiated because in that particular reference only 3 out of 23 patients had aseptic baseplate loosening (13 %) compared to 2 out of 23 in the Grassi et al. paper (8.7 %). This difference is not statistically significant (p = 0.9958, chi-square test). Additionally, differences in the two studies further weaken the assertion. Namely, follow-up in the Brostrom article was a minimum of 62 months versus a minimum of 26 months in Grassi. Also, only one of Grassi’s patients had rheumatoid arthritis (RA), whereas all 23 in Brostrom’s paper had RA
Holcomb, J.O.	2009	Revision reverse shoulder arthroplasty for glenoid baseplate failure after primary reverse shoulder arthroplasty			1		“Historically, RSA designs have failed at the glenoid interface due to inadequate glenoid fixation 3, 5, 29”	Similar to other studies above, the assertion of causation of the glenoid interface failing because of inadequate fixation is unsubstantiated by the references given. Reference 3 is Boileau’s 2005 discussed above, and both Refs. [5, 29] are about the Kessel prosthesis. These studies were not designed to determine causality
Jacobs, R.	2001	Treatment of rotator cuff arthropathy with a reversed Delta shoulder prosthesis	1
Jazayeri, R.	2011	Evolution of the reverse total shoulder prosthesis			1		“This medialization of the center of rotation in a reverse shoulder prosthesis was a key step in overcoming implant loosening, which was the main cause of failure in previous designs”	The assertion that implant loosening was the main cause of failure in previous designs is unsubstantiated because of lack of studies in the literature designed to determine causality
Kalouche, I.	2009	Reverse shoulder arthroplasty: does reduced medialisation improve radiological and clinical results?			1		“Early reverse shoulder prostheses (Gerard and Lannelongue, Kolbel, Kessel, Fenlin) 10, 14, 19, 20 had a center of rotation outside the scapula: their functional results were poor, with high rates of failure due to glenoid loosening”	Unsubstantiated assertion. By focusing only on the center of rotation being outside the scapula, the reader is left to believe this was the cause of the poor results in these devices which, due to many factors including the patient populations therein, is likely a spurious association. The fact is there were other possible causes of poor outcome in these studies that have to be evaluated statistically before you can assert causation. As covered in previous examples, these studies were not designed to determine causation
Kontaxis, A.	2009	The biomechanics of reverse anatomy shoulder replacement—a modelling study	1
Middernacht, B.	2008	Glenosphere disengagement: a potentially serious default in reverse shoulder surgery			1		“Medialization of the COR as proposed by Grammont et al. 15, 16 seemingly reduces the risk of loosening of the glenoid component”	Unsubstantiated assertion. The logic asserted by the authors would lead you to believe that not medializing would increase the risk of loosening of the glenoid component. While Grammont reported no loosenings in his 1993 article medialization was not isolated as a causative factor for success [23]. It is just as likely that the press-fit design (eliminating cement) with transfixion screws reduced the risk of loosening
Nam, D.	2010	Observations on retrieved humeral polyethylene components from reverse total shoulder arthroplasty		1	1		“After its introduction in the 1970’s, reverse shoulder arthroplasty had minimal clinical success, as its constrained design and lateralized glenohumeral center of rotation led to excessive shear forces and failure of the glenoid component 1, 2”	Major error 1: The assertion of causation is unsubstantiated as none of the original reverse design articles determined that failure was caused by a lateralized glenohumeral center of rotation nor were they designed to do so	Major error 2: Both Refs. 1, 2 are unrelated in that neither is about the early RSA designs. Reference 1 is a book chapter on hemiarthroplasty by Carl Basamania [61], and Ref. [29] is an editorial by Charles Rockwood on overuse of current RSAs and makes no mention of the early RSAs from the 1970s [62]
Nam, D.	2010	Reverse total shoulder arthroplasty: current concepts, results, and component wear analysis		1	1		“When introduced in the 1970’s, reverse TSA found minimal clinical success because its constrained design combined with a lateralized glenohumeral center of rotation led to excessive shear forces transmitted though the glenoid component and failure 1, 29”	See discussion of Nam et al. (40) from JBJS above. The same two errors are made but in a different journal
Naveed, M.A.	2011	The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures				1	“The initial designs of constrained reverse shoulder replacements (Fenlin, Gerard, Kessel, Kölbel, Liverpool, Neer) had high failure rates and were withdrawn from the market.”	Oversimplification/generalization. While some of these had “high” rates of failure, this is debatable for the Fenlin, Gerard, Kessel, and Kölbel
Nicholson, G.P.	2010	Scapular notching: recognition and strategies to minimize clinical impact			1		“While early reverse designs were fraught with problems, including catastrophic failure of the glenoid secondary to excessive torque and shear forces 7 instability 7, and poor active shoulder motion 1, 7…”	Unsubstantiated claim that the catastrophic failure of the glenoid was caused by torque and shear forces. Furthermore, the two references cited are not the original studies of the early designs but recent reports (Boileau et al. [25] and Gerber et al. [32]), both with their own quotational errors as discussed above
Nyffeler, R.W.	2004	Analysis of a retrieved delta III total shoulder prosthesis			1		“Earlier types of reversed total shoulder prostheses were withdrawn from the market because of high rate of aseptic loosening of the glenoid component due to high eccentric loads 12”	The reference contradicts the assertion that high eccentric loads caused glenoid component failure. The reference listed is a study on the long-term follow-up of the Kessel prosthesis and does not conclude anything about eccentric loads, but rather high loads associated with constrained devices (anatomic and reversed). However, this study does note that “The screw of the scapular component was large in comparison with the bone available for fixation in the scapular neck, leaving little room for variations. Thus, individual bone quality and differences in neck size could account for variations in loosening.” [63]
Rittmeister, M.	2001	Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions	1
Roche, C.	2009	An evaluation of the relationships between reverse shoulder design parameters and range of motion, impingement, and stability	1
Sirveaux, F.	2004	Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff.				1	“In the 1970s, some surgeons believed that a constrained prosthesis (Table 1) was the appropriate solution… high rates of loosening and mechanical complications led them to discontinue the use of such implants”	This is similar to the oversimplification/generalization committed in the Frankle and Naveed studies discussed above.
Trappey, G.J.	2010	What are the instability and infection rates after reverse shoulder arthroplasty?			2		“These initial RSA designs had a laterally offset center of glenohumeral rotation that led to a high rate (26 %) of glenoid component loosening and failure 1.”	Major error 1: The assertion of causation is unsubstantiated as none of the original reverse design articles determined that failure was caused by a laterally offset center of glenohumeral rotation nor were they designed to do so	Major error 2: The authors are referring to the 26 % failure rate of the Kessel design in the 1992 paper by Brostrom [21]. However, the authors do not reference Brostrom directly, and they only reference Boileau’s paper from 2005 which states the re-operation rate in Brostrom’s paper was 26 % which is true. However, the aseptic baseplate loosening rate in the Brostrom paper is only 13 % and not 26 % as asserted by Trappey et al.
Valenti, P.	2011	Do less medialized reverse shoulder prostheses increase motion and reduce notching?			1		“Analysis of mark 1, 2, and 3 (3M Healthcare Ltd, Loughborough, UK) prostheses shows the fixed, most external center of rotation, at some distance from the glenoid bone, creates considerable tilt forces in the glenoid cavity. These forces cause loosening of the glenoid component and fracture of the implant”	The assertion of causation is unsubstantiated as none of the original reverse design articles including Neer’s [16] determined that failure was caused by a lateralized glenohumeral center of rotation nor were they designed to do so. It appears as though the authors may be citing a study in the UK of the Neer devices but do not provide a reference of that work
Vanhove, B.	2004	Grammont’s reverse shoulder prosthesis for rotator cuff arthropathy. A retrospective study of 32 cases	1
Wall, B.	2007	Reverse total shoulder arthroplasty: a review of results according to etiology			1		“These designs created excessive shear forces that led to rapid glenoid component loosening 2–9”	Major error: Unsubstantiated assertion by 2 of the references given. Specifically, the Fenlin and Gerard devices came to no such conclusion. It should be noted that six of the eight references listed here have to do with anatomic constrained devices. References [2, 5] are about the Stanmore total shoulder replacement [54, 64], and Refs. [6–9] are by Melvin Post who was primarily addressing the Michael Reese implant which is anatomic [56, 65–67]
Werner, C.M.	2005	Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket	1
Wiater, J.M.	2009	Shoulder arthroplasty: prosthetic options and indications		1			“Also popularized in the 1970s were fixed fulcrum constrained reverse ball-and-socket prostheses, designed for patients with pain and limited function resulting from arthritis and concomitant rotator cuff deficiency. 3–5”	Of the three references given, only Ref. [3] (Neer [20]) has to do with the preceding assertion. References [4, 5] are both modern studies on RSA [3, 51] and have nothing to do with the constrained reverse devices from the 1970s
Young, S.W.	2009	The SMR reverse shoulder prosthesis in the treatment of cuff-deficient shoulder conditions				1	“Early ‘constrained’ designs of reverse shoulder implants were complicated by early failure of the glenoid component 8.”	This is similar to the oversimplification/generalization committed in the Frankle, Naveed, and Sirveaux studies discussed above
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