Review Article: Stemless Reverse Shoulder Arthroplasty

Tyler A. Luthringer, MD, John G. Horneff III, MD, Joseph A. Abboud, MD
JAAOS®, January 15, 2024, Vol 32, No 2
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Reverse total shoulder replacement for patients with “weight-bearing” shoulders

Ofer Levy, Georgios Arealis, Oren Tsvieli, Paolo Consigliere, Omri Lubovsky
Clinics in Shoulder and Elbow (eISSN 2288-8721)
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Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty

S. Virani,  A. Leonidou,  G. Panagopoulos, N. Holmes, G. Sforza, J. Relwani,  O. Levy

MUSCULOSKELETAL SURGERY (2023) 107:239–252, Published online: 22 May 2022
/uploads/files/Virani_et_al_2022-_Management_of_glenoid_bone_loss_with_impaction_and_structural_bone.pdf

The influence of preoperative teres minor muscle fatty degeneration on active external rotation following reverse total shoulder arthroplasty

Paolo Consigliere, MD, Arunava Ray, MD, MBBS, MRCS, Caroline Witney-Lagen, MD, FRCS (Orth), Alessio Bernasconi, MD, PhD, FEBOT, Laura Mariani, MD,
Luigi Piscitelli, MD, Luis Natera, MD, PhD, Berta Buch, MD, Ehud Atoun, MD, Giuseppe Sforza, MD, MCh(Orth), and Ofer Levy, MD, MCh(Orth), FRCS

Acute Versus delayed reverse total shoulder arthroplasty for proximla humeral fractures: a consecutive cohort study

Georgios N. Panagopoulos, MD, Mattia Pugliese, MD, Andreas Leonidou, MD, FRCS (TR&Orth), Faisal Butt, MD, Monketh Jaibaji, MD,
Panayiotis D. Megaloikonomos, MD, Paolo Consigliere, MD, Giuseppe Sforza, MD, Ehud Atoun, MD, Ofer Levy, MD, MC(Orth), FRCS

Intermediate to long term results of stemless metaphyseal reverse shoulder arthroplasty: A five to nine year follow-up

Siddharth Virani, Natalie Holmes*, Mina Al-Janabi, Chris Watts, Chris Brooks, Jaikumar Relwani

Accelerated rehabilitation following reverse total shoulder arthroplasty 

Jonathan Lee, PT, Paolo Consigliere, MD, Ernest Fawzy, FRCS(Orth),Laura Mariani, MD, Caroline Witney-Lagen, FRCS(Orth), Luis Natera, MD, PhD,
Berta Buch, MD, Ehud Atoun, MD, Giuseppe Sforza, MD, MC(Orth), Eyal Amar, MD, Ofer Levy, MD, MC(Orth), FRCS

​Pioneers of a Stemless Reverse Shoulder - A Review of Design Concepts and Outcomes

​Outcome of a metaphyseal reverse total shoulder replacement in rheumatoid arthritis

Use of reverse stemless shoulder arthroplasty in a patient with multiple hereditary exostosis

Shoulder proprioception following reverse total shoulder arthroplasty.

Joint replacement affects the proprioception, as shown in knees, elbows, and shoulder studies.
Joanna Walecka1,2 · Przemysław Lubiatowski1,2 · Paolo Consigliere3 · Ehud Atoun3 · Ofer Levy3
Article in International Orthopaedics · August 2020

https://doi.org/10.1007/s00264-020-04756-x
 

Excellent Results with the Verso Stemless-Metaphyseal reverse TSA - from an Independent Centre.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral prosthesis without a stem: survivorship, early to mid‐term clinical and radiological outcomes in a prospective study from an independent centre
Andreas Leonidou1 · Siddharth Virani1 · Christopher Buckle1 · Clarence Yeoh2 · Jaikumar Relwani1
European Journal of Orthopaedic Surgery & Traumatology. Published: 20 August 2019
https://doi.org/10.1007/s00590-019-02531-2

Click Here for the full paper

Excellent results with the Verso TSA were published in Italy in 2019! 

A group of orthopaedic surgeons from northern Italy from Piacenza and Verona published their first few years experience with the stemless reverse TSA - The VERSO. 
They present Excellent clinical and radiologic results that mirror the results of the designing centre!
Cementless metaphyseal reverse shoulder arthroplasty: our preliminary experience
Gian Mario Micheloni1, Gianpaolo Salmaso1, Mattia Berti2, Sara Bortolato1, Gino Zecchinato1, Alberto Momoli1, Stefano Giaretta1
1 Orthopedic and Traumatology Unit, Ospedale San Bortolo, Vicenza, Italy; 2 Orthopedic and Traumatology Unit, AOUI Verona, Ospedale Civile Maggiore Borgo Trento, Verona, Italy
Summary. Reverse shoulder arthroplasty (rTSA) is a largely used procedure with a wide variety of indications.
The incidence of this surgery is increased in recent years and the literature expects similar trend for the
future. Metaphyseal stem rTSA seems to be a promising solution considering major objectives the preservation
of humeral bone stock and ease of revision. In our study we analyzed 19 patients treated with cementless
metaphyseal stem rTSA for osteoarthritis (group A) and acute fractures (group B). In group A (7 patients) the
average Constant score improved from 21,57 (16-29) to 56,85 (38-72), the average SST improved from 2,29
(1-4) to 9,43 (8-12) and the mean VAS score improved from 14,29 to 4,86. In group B (12 patients) the mean
Constant-Murlay score at last follow up was 42,17; the average SST was 7 and average pain score was 8,92.
Overall active range-of-motion (ROM) improved significantly. Surgical considerations, clinical (analyzing
Constant score and Simple Shoulder Test) and radiological short-term outcomes are encouraging, with low
rate of complications. Long term follow-up studies are necessary to confirm our findings and the potential
benefits related to these implants. (www.actabiomedica.it)

Key words: shoulder arthroplasty, reverse shoulder arthroplasty (rTSA), range-of-motion (ROM)

[Read more]

Excellent results with the Verso Stemless-Metaphyseal reverse TSA in patients with Severe Juvenile Rheumatoid Arthritis - from the German Centre for Rheumatoid Arthritis in Oberammergau. 

From Dr. Martin Arbogast, Clinic Oberammergau, Center for Rheumatology, Orthopedics and Pain Therapy 

The Verso rTSA should serve as the "first-line" arthroplasty for treatment of severe JRA that failed medical treatment and suffer from severe arthritis and deficient rotator cuff. 

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Stemless reverse shoulder arthroplasty: indications, technique
- 13 years of European experience  - Review Article

Ofer Levy, Georgios N. Panagopoulos, Andreas Leonidou, Ehud Atoun
Annals of Joint, 2018, http://dx.doi.org/10.21037/aoj.2018.12.02
Abstract: Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral
arthropathy with deficient rotator cuff such as: rotator cuff arthropathy, rheumatoid arthritis, proximal
humeral fractures sequela, irreparable rotator cuff tears, and failed shoulder replacement. Good midterm
and long-term results with restoration of active elevation have been reported. However, early studies
showed relatively high rates of complications (24–50%) and many of them require further surgery. Most of
the current designs of rTSA are with a humeral diaphyseal stem. A significant part of the reported intraoperative
and postoperative complications, as well as difficulties arising during revision surgery, are related
to the diaphyseal humeral component. Therefore, preservation of bone stock has become a major goal.
Metaphyseal cementless implants without a diaphyseal stem have been developed to preserve bone and resect
only minimal amount of bone. In 2005 the first stemless reverse TSAs were introduced for clinical use in
Europe, with the Verso shoulder [Innovative Design Orthopaedics, London, UK (formerly Biomet, UK)]
in UK and the TESS reverse shoulder (Biomet, France) in France. This review examines the European
experience with stemless metaphyseal reverse TSAs, the history, the design rationale, the indications and
the clinical and radiological outcome. The European experience with stemless metaphyseal reverse TSAs
now spans over 13 years, with results that are at least equal with the stemmed implants. Specific design
biomechanical considerations will be discussed.
Keywords: Shoulder; arthroplasty; reverse TSA; stemless, cementless; replacement; metaphyseal; bone graft
impaction; glenoid notching; rotation, no stem

[Read More] 

VERSO PAPER IN INTERNATIONAL ORTHOPAEDICS 2014:

Reverse shoulder arthroplasty with a short metaphyseal humeral stem

Ehud Atoun, Alexander Van Tongel, Nir Hous, Ali Narvani, Jai Relwani, Ruben Abraham, Ofer Levy
International Orthopaedics (SICOT), Published online 06 April 2014 

Excellent Verso® glenoid baseplate fixation

- in a study comparing 6 different reverse shoulder designs at the Imperial College London: 
Primary stability in reversed-anatomy glenoid components. 
A R Hopkins and U N Hansen
Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2009 223: 805

The Least complications with the Verso shoulder compared with other reverse shoulder systems

from the Royal National Orthopaedic Hospital, Birmingham, UK  
Complication rates from three commonly used reverse polarity total shoulder replacements: a minimum two year follow-up of 64 cases
S. Robati, M.K. Shahid, J. Allport, A. Ray and G. Sforza

Bone Joint J 2013 vol. 95-B no. SUPP 27 25

The Verso® total shoulder replacement design rationale and early results

Ofer Levy MD MCh(Orth) FRCS

Revised 2010 

The Verso total shoulder replacement was developed for use in severe rotator cuff deficient shoulders with arthritis.  Patients with cuff tear arthropathy or any other arthritic condition combined with severe cuff deficiency such as advanced rheumatoid arthritis, fracture sequelae and multiple failed surgery combined with severe rotator cuff deficiency.

Patients may suffer from antero-superior instability and antero-superior escape of the humeral head due to deficient rotator cuff and destructed coracoacromial arch.  These patients suffer from severe pain and limitation of movement and function.  They may have marked limitation in the function affecting even simple tasks of daily living such as taking care of their own hygiene, feeding themselves, getting dressed and undressed.  This lack of function can make the difference between a person being independent or needing 24/7 nursing. 

The treatment options for patients with this condition are very few.  Non-constraint conventional shoulder replacement; either resurfacing or stemmed hemiarthroplasty would provide them with pain relieve but no improvement of active motion and in cases of antero-superior escape will fail to improve their stability.  Bi-polar hemiarthroplasty will probably do the same.  The only option to improve these patients’ range of motion is by using a semi-constrained prosthesis with reversed geometry design, which allows the deltoid muscle to function better and improve the shoulder mobility.  All designs of reversed shoulder prosthesis in the 70’s have failed due to their excessive lateralisation of centre of rotation causing increased toque on the implant-bone interface of the glenoid component leading to glenoid loosening.  Professor Grammont’s idea of medialisation of centre of rotation towards the face of the glenoid and tensioning the glenoid muscle inferiorly has shown to be successful.

Reversed shoulder prostheses are gaining popularity in recent years.  Good mid-term results with restoration of active elevation have been reported.  However there is a high complication rate with a stemmed prostheses ranging between 24% to 50% in different series and many of them require further surgery.

Of major concerns are glenoid or humeral shaft fractures on preparation, dislocations and instability as well as high infection rate.  Glenoid notching is a serious complication that was noticed in over 70% cases with Grammont type of prosthesis  and seems to appear quite early at 2-3 months post operatively (Levigne et al., J Shoulder Elbow Surg 2008).  The amount of bone resected for the insertion of stemmed prosthesis make any further revision surgery very difficult and therefore the use is limited to the very elderly patients.

The Verso prosthesis – a novel different design of stemless, reversed geometry prosthesis with metaphyseal fixation and minimal bone resection, cementless and bone impaction fixation has been developed to overcome these concerns.  We have developed this prosthesis following extensive research since 1997 and it has been in clinical use since 2005.  The indications for the use of the Verso are in patients with glenohumeral arthritis and severe rotator cuff deficiency mainly;-

Patients with rotator cuff arthropathy
Fracture sequelae arthropathy with severe rotator cuff deficiency.
Severe rheumatoid arthritis with dysfunctional or torn rotator cuff
Severe cuff deficiency following multiple failed surgery with antero-superior escape
Patient who had surface replacement arthroplasty which had deteriorated due to severe cuff deficiency can be revised to revere shoulder replacement.
Patients with severe shoulder dysfunction following failed rotator cuff tear repair for massive cuff tears.
Patients with stemmed shoulder replacement with severe cuff deficiency can be revised to verso total shoulder replacement either primary stemless prosthesis or stemmed verso prosthesis.
Patients with facture nonunion of the proximal humerus with severe cuff deficiency can be treated with primary stemless verso or a stemmed verso prosthesis.
The rationale behind the design of the Verso was to create a simple yet sophisticated implant. When the implant and technique are simple, there are fewer places for errors.  Another principal is minimal bone resection and indeed the only bone that is resected in this procedure is the top end of the humeral head having a slice thickness of only 20mm. Even this bone is recycled and used for bone impaction.  Stemless, cementless fixation: there are only 3 thin fins which, combined with bone impaction technique gives immediate press fit fixation of the prosthesis to the humeral metaphysis and further biological fixation from the porous and hydroxyapatite coating. This design provides direct load transfer to the humeral metaphysis which greatly reduces stress shielding and proximal bone absorption.

To avoid the serious problem of glenoid notching the humeral shell liner was designed with a 10º angle ream which results in a low medial edge and available system to allow optimal position in each patient to avoid glenoid notching. 

The glenoid head is aimed slightly lower than the bottom edge of the glenoid bone and it is angled inferiorly at 5º thus reducing further to risk of glenoid notching. 

Rotational movements have been improved substantially compared with the other prostheses with the use of the dial-able 10º angle polyethylene liners and insertion of the humeral shell in 30º of retroversion. 

Revision and back up options were designed as well.  There is a revision-stemmed kit and a salvage kit, for cases where the glenoid has been fractured and the glenoid head cannot be implanted. This salvage kit comprises of a ‘mega head’, which is 2/3rds of a sphere that can be fitted on the humeral shell as “mega hemiarthroplasty”.  This will lateralise the centre of rotation and tension to deltoid muscle, and therefore, hopefully improve its function.  All options remain open for future surgery if deemed necessary as bone stock is preserved.  All the liners, glenoid heads, base plates and humeral shells are modular and interchangeable.