Bony Increased-offset Reversed Shoulder Arthroplasty: Minimizing Scapular Impingement While Maximizing Glenoid Fixation

Survival and long-term (minimum 10-year) outcomes of bony increased-offset-reverse shoulder arthroplasty.

Aim: To assess the survival and outcomes of BIO-RSA (Bony-increased-offsetreverse shoulder arthroplasty) at a minimum of 10 years follow-up.Background: Bony lateralization has been proposed to avoid the problems related to medialization with RSA (inferior scapular notching, decresed shoulder rotation, prosthetic instability, and poor shoulder contour).Although the BIO-RSA became a technique widespread worldwide, long-term results are lacking.Methods: Between 2006 and 2014, 192 patients (196 shoulders) underwent BIO-RSA with a Grammont-type prosthesis for the treatment of osteoarthritis with cuff deficiency.In all cases, an autologous cancellous bone graft was harvested from the humeral head.Patients with fracture sequelae, previous failed arthroplasty, and other types of graft (allograft, iliac crest) were excluded.At a minimum of 10 years, 55 patients died, 31 were lost to followup, 6 patients with dementia could not be evaluated, leaving 100 patients (104 shoulders) for clinical and radiological analysis.Among the 100 patients, 60 patients (63 shoulders) were evaluated by phone interview using auto-Constant, 40 patients accepted to come back for radiographic and CT-Scan analysis.Prosthesis survival was assessed in the 196 shoulders using Kaplan-Meier method with revision as endpoint.The mean follow-up was 12.7 years (10 to 18 years).Results: The 10-year overall prosthetic survival rate was 97% (95% CI: 94e99.1%).Revision surgery was performed in 2 % (4/196): 3 glenoid loosening and 1 postoperative periprosthetic fractures.The main complications were (out of 196): glenoid loosening with graft failure occurred in 2% (4/196), acromial/scapular spine fracture in 2%, and postoperative periprosthetic humeral fracture in 2%.At a mean of 12.7 years, 94% of the patients (98/104) were either satisfied or very satisfied; the mean Subjective Shoulder Value was 80% 18 and the mean VAS was 1.3 2 points.The mean absolute and adjusted Constant scores were 72 14 points and 112% 21, respectively.The mean Flexion, External rotation, and Internal rotation were 150.5 26.4 , 26.9 15 , and 6 2.2 points, respectively.The bone graft was visible on last radiograph and CT-scans in 95.1%.Scapular Notching was recorded in 73.2% of cases (41.4% stages 1 and 2) and signs of proximal humeral osteolysis was recorded in 41.5% of cases (29% in zones 1 and 2). Conclusion:This study is the first to report the long-term results of BIO-RSA, which has proven to be a safe procedure with a high implant survival rate.Satisfactory results in terms of clinical, subjective, and radiological outcomes were reported.

Clinical results of bony increased-offset reverse shoulder arthroplasty (BIO-RSA) associated with an onlay 145° curved stem in patients with cuff tear arthropathy: a comparative study

Bony increased-offset–reverse shoulder arthroplasty: 5 to 10 years' follow-up

Bony increased-offset reverse shoulder arthroplasty vs. metal augments in reverse shoulder arthroplasty: a prospective, randomized clinical trial with 2-year follow-up.

Reverse shoulder arthroplasty (RSA) is often employed to manage acute or chronic traumatic sequelae and rotator cuff arthroplasty, with lateralised designs increasing in popularity. Glenoid side lateralisation was initially popularised through the use of bony increased offset reverse shoulder arthroplasty (BIO-RSA). Novel implants use augmented metal glenoid baseplates to lateralise the implant, however little is known about how these patients compare to those with BIO-RSA.This systematic review and meta-analysis aimed to compare outcomes between bone increased offset (BIO-RSA) or metal increased offset (MIO-RSA) in patients with RSA.A detailed search of Pubmed, Cochrane, Medline and EMBASE was carried out, including all studies focusing on primary reverse total shoulder replacements with lateralised glenoid components using either bone graft (BIO-RSA) or metal augments (MIO-RSA). Collected data for included studies included demographics, method of lateralisation and complications.Two-thousand-one hunded-sixty (2160) patients were included in 28 studies, with a mean age of 72.6 (23- 93), with 57.7% being female. 964 patients underwent BIO-RSA and 1196 underwent MIO-RSA. After a mean follow-up of 32.7 months (3–126), there was no significant difference in range of movement post-operatively. There was a significantly lower pain score (p<0.01) and higher Constant (p=0.02), ASES (p=0.02) and UCLA (<0.01) scores in patients post MIO-RSA. Moreover, there was lower rates of revisions (1.3% v 3.0%, p<0.01), loosening (0.8% v 2.6%, p<0.01) and scapular notching (4.0% v 17.9%, p<0.01) in the MIO-RSA group.This systematic review and meta-analysis has shown favourable outcomes with MIO-RSA when compared with BIO-RSA. BIO-RSA and MIO-RSA outcomes are summarised, but contemporary literature is too heterogenous to allow direct comparison. Long term studies are required to ascertain if this effect is maintained.

Does bony increased-offset reverse shoulder arthroplasty decrease scapular notching?

BackgroundInferior scapular notching is a complication unique to reverse shoulder arthroplasty. The most efficient technique to avoid inferior scapular notching has been reported to be lateralization of the glenoid offset. This study aims to compare radiological and functional outcomes of the DELTA Xtend® Reverse Shoulder System Lateralized Glenosphere Line Extension (intervention group) with the Standard DELTA Xtend® Reverse Shoulder System (control group). We hypothesize that the lateralization improves the patient outcome by decreasing the risk of inferior scapular notching without increasing the risk of migration and loosening of glenoid component.MethodsIn this randomized controlled trial, all Danish citizens with rotator cuff arthropathy or degeneration of the glenohumeral joint with severe posterior wear and allocated for a reverse total shoulder arthroplasty at the department of orthopaedic surgery at Herlev and Gentofte Hospital, Copenhagen University Hospital, will be considered for participation. The exclusion criteria are as follows: below 50 years of age, cognitive or linguistic impairment, insufficient glenoid bone stock, previous fracture in the upper extremity and autoimmune-mediated inflammatory arthritis. There will be included a total of 122 patients of which 56 will participate in the radiostereometric analysis. This number of patients allows 20% to drop out. The co-primary outcomes are the pattern and magnitude of the migration of the glenoid component assessed by radiostereometric analysis and the Western Ontario Osteoarthritis of the Shoulder index. The secondary outcomes are inferior scapular notching, patient-reported and functional outcomes (Oxford shoulder score, Constant-Murley score and pain), side effects and complications, changes in bone mineral density and economy. The included patients will be examined before the surgery, within 1 week and 3, 6, 12 and 24 months after.DiscussionNo previous studies have compared the conventional reverse shoulder arthroplasty with the lateralized reverse shoulder arthroplasty in a randomized controlled trial regarding migration and functional outcome. Furthermore, radiostereometric analysis has not been used to evaluate the migration of reverse shoulder arthroplasty in a randomized controlled trial. This study intends to determine which treatment has the most optimal outcome for the benefit of future patients with an indication for reverse shoulder arthroplasty.Trial registrationThe study has been notified to Pactius and has approval number P-2021-231. Furthermore, the study will be registered on Clinicaltrials.gov before starting the inclusion.

Lateralisation in reverse shoulder arthroplasty can be achieved through bone graft (BIO-RSA) or metal augments (MIO-RSA). This systematic review and meta-analysis aimed to compare outcomes in both these methods. A systematic review of Pubmed, Cochrane, Medline and EMBASE was performed including all studies on primary reverse total shoulder replacements with lateralised glenoid components using either bone graft (BIO-RSA) or metal augments (MIO-RSA). Collected data for included studies included demographics, method of lateralisation and complications. 30 studies comprising 2364 shoulders in 2558 patients were included, with a mean age of 72.8 (23-93), and 59.7% being female. 1026 patients underwent BIO-RSA and 1328 underwent arthroplasty with metal augmented glenoid components. After 31.5months (3-126) follow-up, there was a significantly lower pain score (p < 0.05) and higher ASES (p < 0.05) and UCLA (p < 0.05) scores in patients post MIO-RSA, but no significant difference in range of movement post-operatively. Moreover, there was lower rates of revisions (1.3% v 3.0%, p < 0.01), loosening (0.8% v 2.4%, p < 0.01) and scapular notching (3.8% v 17.3%, p < 0.01) in the MIO-RSA group. BIO-RSA and MIO-RSA outcomes are summarised, suggesting preliminary evidence of some superiority of MIO-RSA, but heterogeneity in the selected studies limits the conclusions that can be drawn from results. Long term studies are required to ascertain if this effect is maintained.

Reverse shoulder arthroplasty (RSA) has revolutionized the management of many shoulder pathologies. Lateralization has become favourable to combat complications (e.g. notching, compromised external rotation), using a metallic, or autogenous bone-graft baseplates - bony increased-offset reverse shoulder arthroplasty (BIO-RSA). We systematically reviewed the literature to determine: Does BIO-RSA improve range of motion and outcome scores?Are notching rates decreased?Does the graft heal? All available prospective studies, trials and case series reporting on BIO-RSA were included. Outcomes were grouped into outcome scores, range of motion and radiographic outcomes. Data were pooled and statistical analysis performed. Eight studies reported on 385 RSA - 235 BIO-RSA and 150 standard-RSA (STD-RSA). Follow-up was 20-36 months; average age 74 years. Outcome scores: Constant-Murley and SSV scores showed statistically significant post-operative benefit of BIO-RSA (mean-difference 4.0 (95% confidence interval (CI): 0.79,7.1) and 6.8 (95% CI: 3.8, 9.9)). No Minimal Clinically Importance Difference was surpassed. Range of motion: No difference was found in any direction. Notching: Notching was less likely with BIO-RSA (odds ratio 0.19 (95% CI: 0.10, 0.38)). Healing and loosening: 92% grafts fully healed/incorporated. Loosening rate was 2.4%. Literature on BIO-RSA is limited with only one randomised controlled trial (RCT). Weak evidence exists for improved outcome scores. Range of motion is equivocal. Notching rates are significantly lower in BIO-RSA. The graft usually heals.

Bilateral bony increased-offset reverse shoulder arthroplasty in rheumatoid arthritis shoulder with severe glenoid bone defect: A case report

Bony Increased-Offset Reverse Shoulder Arthroplasty (BIO-RSA) for Cuff Tear Arthropathy

In glenohumeral osteoarthritis, progressive bone erosion often leads to posterior humeral head subluxation and increased glenoid retroversion. Correcting this deformity represents a major challenge in reverse shoulder arthroplasty (RSA), where surgical techniques commonly aim to restore neutral glenoid orientation (0°). Evidence regarding the influence of preoperative glenoid retroversion on postoperative outcomes remains limited. This study aimed to evaluate whether clinical and functional outcomes at a minimum 2-year follow-up differ according to preoperative glenoid retroversion in patients undergoing reverse total shoulder arthroplasty (RTSA) with systematic intraoperative correction to neutral. A total of 161 patients undergoing RTSA were retrospectively reviewed. Preoperative planning was performed using 3D software to restore neutral glenoid orientation via the bony-increased offset reverse shoulder arthroplasty technique. Glenoid retroversion was measured preoperatively on CT scans using the Friedman method, while postoperative glenoid version was assessed on axillary radiographs to confirm neutral orientation. Patients were stratified into two groups based on preoperative retroversion (<10° and ≥10°). Clinical outcomes and range of motion at a minimum follow-up of 24 months were compared between groups. Glenoid lateralization was assessed radiographically using the glenoid lateralization angle (GLA). Group comparisons were performed using the Mann-Whitney U test, and correlations were assessed using Spearman analysis. A p-value < 0.05 was considered statistically significant. After exclusion of four patients with postoperative complications, 157 patients were included in the final analysis. The mean postoperative glenoid version was 0.35° ± 0.8° (range, -1° to +2°). No significant differences were observed in any clinical outcome between patients with <10° and ≥10° of preoperative glenoid retroversion, and no significant correlations were found between preoperative retroversion and postoperative outcomes. Radiographic analysis confirmed restoration of near-neutral glenoid version in all patients and demonstrated comparable glenoid lateralization between groups, with no significant differences in the GLA. In glenohumeral osteoarthritis, the most common pattern of bone loss results in increased glenoid retroversion and posterior humeral head subluxation. It remains debated whether, when applying standard correction techniques aimed at restoring neutral glenoid version, the severity of preoperative glenoid retroversion influences postoperative outcomes. The findings of this study indicate that, when RSA is performed with restoration of neutral glenoid version, postoperative clinical and functional outcomes are independent of the degree of preoperative glenoid retroversion. Level III cohort study.

BackgroundBony increased-offset reverse shoulder arthroplasty (BIO-RSA) may address issues such as inferior scapular notching, prosthetic instability and limited postoperative shoulder rotation; all of which have been reported with the standard RSA and attributed to the medialized design. We hypothesised that this lateralization may increase the rate of scapular stress fractures.MethodsA retrospective review of prospectively collected data was performed on patients who had undergone a RSA between January 2013 and October 2016. A comparative cohort study was designed to compare patients with a standard Grammont-style RSA to those with a BIO-RSA using the same implant. Functional outcome was measured by the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the Subjective Shoulder Value (SSV), the Western Ontario Osteoarthritis of the Shoulder (WOOS) index and pain scores. Radiographs were obtained for all patients and examined for the presence of scapular fracture as well as scapular notching and graft incorporation.ResultsA total of forty patients (22 patients in the standard RSA cohort and 18 with BIO-RSA) were included in the study. Patient characteristics (including age, gender, length of follow-up, dominant side and osteoporosis) were similar in both groups (p > 0.05). The average postoperative follow-up was 20 months (range 12–48 months). There was bone graft incorporation in all BIO-RSA patients at the final radiological follow-up, with no evidence of graft resorption. The overall scapular stress fracture rate was 12.5% (9.1% in the standard RSA and 16.7% in the BIO-RSA). The rates were similar in both cohorts (p = 0.64). All fractures were managed conservatively. To determine whether the presence of a scapular stress fracture had an influence on outcomes, the cohort was divided into cases with and without fracture. Patients with a stress fracture had worse ASES (p = 0.028) and WOOS (p = 0.048) scores. Additionally, osteoporosis was present more commonly in the fracture group (80% vs 17%; p = 0.01). A statistically significant difference was identified when comparing the rates of scapular notching between standard RSA and BIO-RSA cohorts (68% vs 33%; p = 0.028). Furthermore, when notching was present, significantly worse outcome scores were present in all outcome measures (p < 0.001).ConclusionThe BIO-RSA technique was associated with an increase in scapular stress fracture rate when compared to the standard RSA; however, this was not found to be significant. Furthermore, both techniques resulted in similar improvements in the measured functional outcomes. BIO-RSA, however, was associated with a lower scapular notching rate, justifying further evaluation of this technique.Level of evidenceRetrospective cohort study, level III

Patient-specific BIO-RSA (bony increased-offset reverse shoulder arthroplasty) for glenoid dysplasia (type C) osteoarthritis.