Fig 2 - uploaded by Boileau Pascal
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A photograph shows the first prototype of the ''medializing'' prosthesis. This prototype was based on the drawing of Grammont but does not include the metaphyseal rotation system. The stem was screwed. This prototype was never implanted. Image from the personal archives of Emmanuel Baulot.
Source publication
The increased use of the reverse prosthesis over the last 10 years is due to a large series of publications using the reverse prosthesis developed by Paul Grammont. However, there is no article reporting the story of the concepts developed by Grammont.
The purposes of this review are to describe the principles developed by Grammont, the chronology...
Citations
... [9] Tasarım ve Biyomekanik Ters total omuz protezi, (TTOP) ilk olarak 1974 yılında Charles Neer tarafından tasarlanmış ve o zamandan beri önemli ölçüde geliştirilmiştir. [10][11][12] Ters omuz protezinin en büyük özelliği, yalnızca glenohumeral artrozu değil, aynı zamanda masif rotator manşet yırtığında da tedavi edebilmesidir. Bununla birlikte, 1974'te Charles Neer'in ilk tasarımı, oldukça kısıtlı tasarımlar ve rotasyon merkezinin lateralizasyonu nedeniyle glenoid bileşen gevşemesi ve implant kırılması gibi çeşitli sınırlamalara sahipti. ...
... 4) Yarı kısıtlı bir implant özelliği aracılığıyla hareket aralığını arttıran büyük bir glenosfer sağlamak. [10][11][12][13][14][15] İlk sonuçlardan memnun olmayan Paul Grammont ters omuz protezin ikinci neslinde, kayma kuvvetlerini ve implantlardaki mekanik torku azaltmak ve güçlü bir fiksasyon sağlamak için dönme merkezini glenoid yüzeyle doğrudan temas hâlinde yerleştirecek şekilde bir yarım küre şeklinde revize edilmiş bir glenosfer geliştirmiştir. ...
... [7] TERS OMUZ PROTEZ TARİHÇESİ Ters omuz protez kavramı, ilk olarak 1974 yılında Charles Neer tarafından ortaya atılmış ve o zamandan günümüze önemli gelişmeler göstermiştir. [8] Charles Neer'ın glenohumeral artritli hastalara uyguladığı küre ve yuva geometrisi ilk ters omuz protez tasarımı olan "Neer II" sonuçları tatmin edici olmamıştır. [9] Ters omuz protezindeki en büyük yenilik yalnızca glenohumeral artriti değil, aynı zamanda rotator manşet yetersizliğini de tedavi edebilmesiydi. ...
... BIO-RSA minimizes complications such as limited range of motion, scapular notching, and prosthetic instability. 1 970'li yıllarda Neer tarafından ortaya konulan ters omuz protezi (TOP); Grammont tarafından 1980'li yıllarda geliştirilmiş ve günümüzde sık uygulanan bir tedavi yöntemi hâline gelmiştir. [1] Modern TOP'nin öncüsü olarak kabul edilen Grammont, glenohumeral rotasyon merkezinin medializasyonu ve humerusun inferiora yer değiştirmesinden oluşan iki ana biyomekanik prensibi tarif etmiştir. Böylece glenoide binen yük azalacak ve deltoid moment kolu artacaktır. ...
... To address this concern, he further medialized the COR by changing the glenosphere component from two-thirds of a sphere to a hemisphere, placing it directly at the glenoid bone implant interface. Additionally, he substituted the cemented baseplate for a central press-fit peg baseplate with two 3.5 mm divergent screws [6,8,10]. These two modifications led to the Delta III prosthesis, which consists of a medialized COR at the glenoid-implant interface and a valgus, 155 • humeral neck shaft angle (NSA) (Figure 1). ...
... With that in mind, the "Trompette" prosthesis was introduced in 1985. It was composed of a cemented glenoid component that consisted of two-thirds of a 44 mm diameter sphere that placed the COR in a medialized position in comparison to the native humerus and a cemented humeral polyethylene cone [8]. The initial outcomes with this prosthesis were successful, as reported in his initial series with a 6 month follow-up [9], but he later reported an unacceptable rate of glenoid component loosening. ...
... To address this concern, he further medialized the COR by changing the glenosphere component from two-thirds of a sphere to a hemisphere, placing it directly at the glenoid bone implant interface. Additionally, he substituted the cemented baseplate for a central press-fit peg baseplate with two 3.5 mm divergent screws [6,8,10]. These two modifications led to the Delta III prosthesis, which consists of a medialized COR at the glenoid-implant interface and a valgus, 155° humeral neck shaft angle (NSA) (Figure 1). ...
Reverse shoulder arthroplasty (RSA) has become a widely used procedure since its introduction in the 1980s, and is currently used to treat a wider range of conditions than its original indication. The original Grammont-style RSA revolutionized shoulder arthroplasty but had several limitations, including scapular notching and reduced rotational motion. This review discusses the evolution of RSA design, particularly the development of a lateralized center of rotation constructs, which aims to improve all the disadvantages associated with the Grammont-style design and more closely reproduce the native anatomy in order to improve patient outcomes in an expanded context of pathologies.
... 32,36 The foundation for current RSA implants was established in 1985 by Paul Grammont, whose design emphasized an implant with a medial and distal center of rotation and an increased deltoid moment arm to compensate for rotator cuff injury and lack of function. 36,37 However, this design came with new concerns such as scapular notching and inherent loss of external rotation. For example, in a retrospective study of 461 shoulders that received Grammont-type RSA, 68% of cases were reported to have scapular notching. ...
Purpose of Review
This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions.
Recent Findings
The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA’s 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations.
Summary
Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.
... The clinical application of rTSA has been adopted for decades, with the first theoretical design developed in 1972 [2]. The primary concept was to reconstruct a stable medialized and distalized center of rotation that can achieve long-term survival of the glenoid components with decreased shear stress at the implant-glenoid interface [3]. The current objective of the rTSA is to create a functional shoulder, especially in cases with deteriorated rotator cuff structures. ...
Reverse total shoulder arthroplasty (rTSA) is increasingly being used as a reliable option for various shoulder disorders with deteriorated rotator cuff and glenohumeral joints. The stemless humerus component for shoulder arthroplasties is evolving with theoretical advantages, such as preservation of the humeral bone stock and decreased risk of periprosthetic fractures, as well as clinical research demonstrating less intraoperative blood loss, reduced surgical time, a lower rate of intraoperative fractures, and improved center of rotation restoration. In particular, for anatomical total shoulder arthroplasty (aTSA), the utilization of stemless humeral implants is gaining consensus in younger patients. The current systematic review of 14 clinical studies (637 shoulders) demonstrated the clinical outcomes of stemless rTSA. Regarding shoulder function, the mean Constant-Murley Score (CS) improved from 28.3 preoperatively to 62.8 postoperatively. The pooled overall complication and revision rates were 14.3% and 6.3%, respectively. In addition, recent studies have shown satisfactory outcomes with stemless rTSA relative to stemmed rTSA. Therefore, shoulder surgeons may consider adopting stemless rTSA, especially in patients with sufficient bone quality. However, further long-term studies comparing survivorship between stemless and stemmed rTSA are required to determine the gold standard for selecting stemless rTSA.
... The first RSA concept which became widely used for patients with CTA was presented by Paul Grammont. He used a medialized and distalized design to create a stable fulcrum around which the humerus could rotate and provided enough delta tension to enable very good elevation and abduction movements [3]. With the rising recognition of associated complications of this concept such as inferior scapular notching and unsatisfying outcomes in axial rotation, modified reversed arthroplasty designs were developed [2,[4][5][6][7]. ...
Background
The two major reverse shoulder arthroplasty (RSA) designs are the Grammont design and the lateralized design. Even if the lateralized design is biomechanically favored, the classic Grammont prosthesis continues to be used. Functional and subjective patient scores as well as implant survival described in the literature so far are comparable to the lateralized design. A pure comparison of how the RSA design influences outcome in patients has not yet been determined. The aim of this study was a comparison focused on patients with cuff tear arthropathy (CTA).
Methods
We analyzed registry data from 696 CTA patients prospectively collected between 2012 and 2020 in two specialized orthopedic centers up to 2 years post-RSA with the same follow-up time points (6,12 24 months). Complete teres minor tears were excluded. Three groups were defined: group 1 (inlay, 155° humeral inclination, 36 + 2 mm eccentric glenosphere (n = 50)), group 2 (inlay, 135° humeral inclination, 36 + 4 mm lateralized glenosphere (n = 141)) and group 3 (onlay, 145° humeral inclination, + 3 mm lateralized base plate, 36 + 2 mm eccentric glenosphere (n = 35)) We compared group differences in clinical outcomes (e.g., active and passive range of motion (ROM), abduction strength, Constant-Murley score (CS)), radiographic evaluations of prosthetic position, scapular anatomy and complications using mixed models adjusted for age and sex.
Results
The final analysis included 226 patients. The overall adjusted p-value of the CS for all time-points showed no significant difference (p = 0.466). Flexion of group 3 (mean, 155° (SD 13)) was higher than flexion of group 1 (mean, 142° (SD 18) and 2 (mean, 132° (SD 18) (p < 0.001). Values for abduction of group 3 (mean, 145° (SD 23)) were bigger than those of group 1 (mean, 130° (SD 22)) and group 2 (mean, 118° (SD 25)) (p < 0.001). Mean external rotation for group 3 (mean, 41° (SD 23)) and group 2 (mean, 38° (SD 17)) was larger than external rotation of group 1 (mean, 24° (SD 16)) (p < 0.001); a greater proportion of group 2 (78%) and 3 (69%) patients reached L3 level on internal rotation compared to group 1 (44%) (p = 0.003). Prosthesis position measurements were similar, but group 3 had significantly less scapular notching (14%) versus 24% (group 2) and 50% (group 1) (p = 0.001).
Conclusions
Outcome scores of different RSA designs for CTA revealed comparable results. However, CTA patients with a lateralized and distalized RSA configuration were associated with achieving better flexion and abduction with less scapular notching. A better rotation was associated with either of the lateralized RSA designs in comparison with the classic Grammont prosthesis.
Level of Evidence
Therapeutic study, Level III.
... The latter was initially introduced to treat glenohumeral arthritis with rotator cuff arthropathy; however, it is widely used for other indications such as rotator cuff deficiency, chronic dislocations, or proximal humeral fractures [11][12][13]. ...
Background: Proximal humeral fractures with severe comminution and poor bone quality are among the most common injuries in the elderly population. Reverse shoulder arthroplasty (RSA) has been widely used to manage complex three- and four-part humeral head fractures. The purpose of the present study was to report the result of this technique in the demanding population of octogenarians.
Materials and methods: Twenty-six patients above the age of 80 years were included in the study and followed for a minimum of one-year follow-up. To assess the functional outcomes the postoperative range of motion (ROM), the Constant score, the visual analog scale for pain, and the disability of the arm and shoulder score (DASH) were measured at 6 and 12 months. Radiological assessment and potential complications were also recorded.
Results: The mean age of the study population was 81.9 years (81-86) at the time of surgery. There was a statistically significant improvement in all outcomes over the follow-up intervals. Shoulder ROM was 125.7o for flexion, 98.2o for abduction, 42.2o for internal rotation, and 43.2o for external rotation at 12 months. The mean Constant, DASH, and VAS scores at the last follow-up were 61.3, 31.9, and 0.5, respectively. Reported complications include one superficial surgical site infection.
Conclusion: RSA is a safe and reliable surgical option with satisfactory outcomes to manage complex three- and four-part fractures of the humeral head as it can provide prompt pain relief and function in octogenarians.
... The Grammont-style rTSA originally defined many of the goals that continue to guide implant design and surgery, 3,7,9 including a medialized joint center of rotation and lengthened humerus, which increases the deltoid abduction moment arm, resulting in glenohumeral stability and a mechanical advantage of the deltoid. However, the traditional 155 neck-shaft angle (NSA) humeral inlay prosthesis combined with a medialized glenosphere resulted in high rates of scapular notching, limited internal-rotation range of motion (ROM), and a mid-to long-term decline in function potentially as a result of deltoid fatigue with reduced ROM and strength. ...
... A goal of rTSA is to improve abduction ROM via the deltoid's mechanical advantage to offset rotator cuff deficiencies. 3,7,9 However, in our study, only inlay humeral implants reduced deltoid forces compared with the native shoulders whereas onlay implants did not, supporting the theory that inlay implants improve deltoid efficiency. Additionally, the required rotator cuff forces increased in both systems by 4-9 times vs. the native shoulders, which may be why some patients experience postoperative rotational deficit after rTSA. ...
... Although reverse total shoulder arthroplasty (RTSA) was originally designed for rotator cuff tear arthropathy in elderly patients, indications have been widened from osteoarthritis to irreparable rotator cuff tears and three or four-part proximal humeral fractures in recent years [1,2]. Improvement of the prosthesis design has let the surgeons to use RTSA more often in different kinds of indications but as the number of operations increased, a number of complications also followed this increase meanwhile [3]. ...
Introduction
The evolution of prosthesis design has increased the frequency of RTSA procedures across various indications. This rise in surgeries has also led to a growing number of associated complications. This case report highlights an unusual occurrence: a mechanical failure of a RTSA at the humeral stem tray.
Case Report
A 55-year-old male patient was admitted to our hospital with a sharp pain after 2 years of his initial reverse total shoulder arthroplasty (RTSA) surgery. A broken humeral stem of the RTSA was diagnosed on the plain radiography and the patient underwent a one-stage revision. Further complications have not arisen during his follow-up to date and the patient has a nearly full range of motion.
Conclusion
Although a humeral stem tray failure is a rarely seen complication for shoulder arthroplasty, surgeons who have used this model prosthesis should be aware that they may encounter such a complication.
