Fig 5 - uploaded by Boileau Pascal
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The ''Trompette'' reverse prosthesis is shown. This is the modern version of the ''medializing'' reverse prosthesis as Grammont had imagined. The prototype dates from 1985 and the first implantation was in 1986. This prosthesis included a polyethylene humeral component and an alumina ceramic glenoid component with a volume equivalent to 2/3 of a sphere of 44 mm. 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
... Historically, the idea of RSA was to restore mobility and function in shoulders with cuff tear arthropathy [4,42]. In this situation, the deltoid muscle is able to replace the rotator cuff to a large extent [6]. ...
Introduction
One current trend in the field of shoulder arthroplasty is a design shift to shorter and metaphyseal fixed humeral stem components. The aim of this investigation is to analyze complications resulting in revision surgery after anatomic (ASA) and reverse (RSA) short stem arthroplasty. We hypothesize that complications are influenced by the type of prosthesis and indication for arthroplasty.
Materials and methods
A total of 279 short stem shoulder prostheses were implanted by the same surgeon (162 ASA; 117 RSA), and 223 of these prostheses were implanted as primary procedures; in 54 cases, arthroplasty was performed secondary to prior open surgery. Main indications were osteoarthritis (OA) (n = 134), cuff tear arthropathy (CTA) (n = 74) and posttraumatic deformities (PTr) (n = 59). Patients were evaluated at 6 weeks (follow-up 1; FU1), 2 years (FU2) and the time span of the last follow-up defined as FU3 with a minimum FU of 2 years. Complications were categorized into early complications (within FU1), intermediate complications (within FU2) and late complications (> 2 years; FU3).
Results
In total, 268 prostheses (96.1%) were available for FU1; 267 prostheses (95.7%) were available for FU2 and 218 prostheses (77.8%) were available for FU3. The average time for FU3 was 53.0 months (range 24–95). A complication leading to revision occurred in 21 prostheses (7.8%), 6 (3.7%) in the ASA group and 15 (12.7%) in the RSA group (p < 0.005). The most frequent cause for revision was infection (n = 9; 42.9%). After primary implantation, 3 complications (2.2%) occurred in the ASA and 10 complications (11.0%) in the RSA group (p < 0.005). The complication rate was 2.2% in patients with OA, 13.5% in CTA and 11.9% in PTr.
Conclusions
Primary reverse shoulder arthroplasty had a significantly higher rate of complications and revisions than primary and secondary anatomic shoulder arthroplasty, respectively. Therefore, indications for reverse shoulder arthroplasty should be critically questioned in each individual case.
... From its introduction in 1985 by Dr. Paul Grammont the use of reverse total shoulder arthroplasty (RTSA) has increased steadily [1][2][3]. Alongside with its use, also the indications of this type of prosthesis have expanded [4]. Developed to tackle rotator cuff deficiencies, RTSA finds practical use in cuff tear arthropathy, massive rotator cuff tears, primary osteoarthritis, proximal humerus fractures, failed anatomical total shoulder arthroplasty or hemiarthroplasty and orthopedic oncologic pathologies [4][5][6][7]. ...
Purpose
The use of reverse total shoulder arthroplasty has increased over the last decade. Like any other implant it is associated with complications sometimes leading to revision. We carried out a registry-based study in order to find possible risk factors associated with the need of revision surgery.
Methods
The RIPO registry was analyzed from July 2008 to December 2018 collecting available data. Two groups (degenerative or fracture) were formed and compared to determine possible risk factors difference in revision surgery.
Results
A total of 7,966 shoulder prosthesis were implanted. There was a 1.5% intra or peri-operative complication rate. The revision rate was 4.0% at a mean follow-up of 4.4 years. A total of 3,073 reverse total shoulder prosthesis were implanted and available for follow-up. An increase of revision rate (the most frequent causes being aseptic loosening, infection and instability) was found in patients younger than 65 years and in male patients. Two groups were then formed on the basis of the primary diagnosis: osteoarthritis and proximal humerus fracture. Comparison between the two groups showed an increase in instability requiring revision in the fracture group.
Conclusion
Reverse shoulder prosthesis is a valid treatment option both in the elective and in the trauma settings, but young and male patients should be informed of the inherently increased risk of revision and prosthesis used in the fracture setting should be evaluated more thoroughly to prevent instability.
... However, these constrained prostheses had high rates of failure, primarily due to glenoid component loosening in response to powerful forces directed on the glenoid implant and insufficient anchoring capacity of the scapula [15] . In 1985, Paul Grammont published a paradigm-shifting system for total shoulder arthroplasty that shifted the center of glenohumeral joint rotation medially and distally with respect to previous shoulder implant designs, allowing the deltoid to provide elevation and stability at the glenohumeral joint without the need for an intact rotator cuff [22,23] . Grammont's design was further refined and released in 1991 as the Delta III shoulder implant, composed of a half-sphere implant at the glenoid (glenosphere) fixed by a central peg and two screws, a polyethylene cup, and a humeral stem [22] . ...
... In 1985, Paul Grammont published a paradigm-shifting system for total shoulder arthroplasty that shifted the center of glenohumeral joint rotation medially and distally with respect to previous shoulder implant designs, allowing the deltoid to provide elevation and stability at the glenohumeral joint without the need for an intact rotator cuff [22,23] . Grammont's design was further refined and released in 1991 as the Delta III shoulder implant, composed of a half-sphere implant at the glenoid (glenosphere) fixed by a central peg and two screws, a polyethylene cup, and a humeral stem [22] . This "reversal" of the native ball and socket locations on the humerus and glenoid led to Grammont's implant becoming known as the reverse total shoulder arthroplasty. ...
... It is useless to search for an anatomic solution, as this very anatomic system led to failure". [3] In 1985, he developed the "Trompette" prosthesis, and later reported promising functional results. By moving the center of rotation medially and inferiorly, he was successful in providing a longer lever-arm for deltoid function, allowing it to compensate for a de cient rotator cuff. ...
... Even early prosthetics placed in the 1990s showed a roughly 90 percent 10-year survival, and that appears to be improving with more modern implant designs. [3,24,25] As rotator cuff tear arthropathy was the original indication for rTSA, the outcomes in this population are, expectedly, ver y favorable. Several retrospective studies have consistently demonstrated excellent patient satisfaction in terms of pain reduction and improvement in functional motion. ...
... Surgical treatment with reverse total shoulder arthroplasty (rTSA) has increased significantly in the past few years, as indications for rTSA in particular have expanded to include not only cuff arthropathy [2,15] but also other diagnoses such as advanced glenohumeral osteoarthritis with biconcave glenoid [30], massive rotator cuff tears [16] and proximal humerus fractures [27]. The rTSA is characterized by a high survival rate and high patient satisfaction [37]. ...
Introduction
While the incidence of reverse total shoulder arthroplasty (rTSA) is increasing constantly, newer implants with designs other than the classic Grammont geometry are gaining importance. More anatomic inclination angles and lateralization are supposed to have a positive impact on clinical results and complication rates. Presentation of midterm results therefore is important to support these assumptions. The aim of this study was to report the midterm clinical outcome of primary rTSA with an uncemented humeral short-stem prosthesis (USSP) with a humeral inclination angle of 145° and the analysis of different variables on the outcome.
Methods
This is a retrospective study of all patients with primary rTSA using an USSP and a combined humeral inclination angle of 145° (Ascend™ flex, Stryker) with a minimum clinical follow-up of 2 years. The implant combines a 132.5° inclination for the humeral stem with an additional 12.5° for the polyethylene inlay. Primary outcomes were patient-reported outcome measures: ASES score, simple shoulder test (SST) and subjective shoulder value (SSV). Secondary outcomes were complication and revision rates.
We analyzed different variables: preoperatively gender, age, indication for surgery and status of rotator cuff. Also, the glenoid morphology was classified according to Walch and a proximal humerus cortical bone thickness measurement (CBT avg) of 6 mm was used as a threshold for osteoporosis. Postoperatively, we analyzed different radiologic parameters: filling ratio, distalization and lateralization angles according to Boutsiadis.
Results
A total of 84 out of 99 (85%) patients with a mean FU of 46.7 months (range 24–80 months) could be included: 62 women and 22 men with a mean age of 74.7 years. Mean ASES score significantly increased from 47 preoperatively to 85.8 at the last follow-up (p = 0.001). The postoperative SST reached an average of 65.3 and the mean SSV was 83%. None of the variable parameters analyzed could be identified as a risk factor for a lower outcome defined as a SSV < 70. Three patients (3.6%) had a complication: one incomplete lower plexus lesion, one dislocation and one major hematoma. Surgical revision was needed in two cases (2.4%).
Conclusion
The midterm clinical outcome of primary reverse total shoulder arthroplasty (rTSA) with an uncemented humeral short stem and a humeral inclination angle of 145° showed good-to-excellent results with a low complication and revision rate independent from a wide range of pre- and postoperative variables. PROMs are comparable to those reported for anatomic TSA with a low complication rate, different to historical studies especially with the Grammont design.
Level of evidence
Treatment study, Level IV.
... This procedure was described and validated by Paul Grammont in 1985 [15], consisting of an inverted ball and socket joint transplant, where the concavity of the glenoid fossa is replaced with a glenosphere, complementary to a humeral cup [16]. This concept was based on an inversion of the anatomy, enhancing the role of the deltoid muscle in cases of massive rotator cuff tear (MRCT) and cuff tear arthropathy (CTA) [17][18][19]. ...
The aim of this study was to have updated scrutiny of the influence of the humeral neck-shaft angle (HNSA) in patients who underwent reverse shoulder arthroplasty (RSA). A PRISMA-guided literature search was conducted from May to September 2021. Clinical outcome scores, functional parameters, and any complications were reviewed. Eleven papers were identified for inclusion in this systematic review. A total of 971 shoulders were evaluated at a minimum-follow up of 12 months, and a maximum of 120 months. The sample size for the “HNSA 155°” group is 449 patients, the “HNSA 145°” group involves 140 patients, and the “HSNA 135°” group comprises 291 patients. The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. Positive outcomes are described for all the 155°, 145°, and 135° HSNA groups. Among the different implant designs, the 155° group show a better SST score, but also the highest rate of revisions and scapular notching; the 145° cohort achieve the best values in terms of active forward flexion, abduction, ASES score, and CMS, but also the highest rate of infections; while the 135° design obtains the best results in the external rotation with arm at side, but also the highest rate of fractures. High-quality studies are required to obtain valid results regarding the best prosthesis implant.
... The idea of reverse total shoulder arthroplasty (RTSA) was first introduced in 1974 by Charles Neer and has considerably progressed ever since [1][2][3]. The great novelty of RTSA was its ability to treat not only glenohumeral arthrosis, but also rotator cuff deficiency. ...
... In 1985, Paul Grammont introduced the novel "ball-and-socket" design, which was based on four key principles: (1) shifting the center of rotation medially to decrease the 2 of 15 mechanical torque at the glenoid component, thus avoiding glenoid loosening; (2) lowering the humerus to tension the deltoid muscle, which increases muscle fiber recruitment of the anterior and posterior deltoid in order to compensate a deficient rotator cuff; (3) a fixed center of rotation distalized and medialized to the glenoid joint line, leading to an inherently stable implant; (4) a large glenosphere increasing the range of motion through a semi-constrained implant feature [1,6]. In 1987, the first series of eight cases reported preliminary functional outcomes: all patients were pain-free, however the postoperative range of motion varied widely among patients [2,7]. ...
... In 1985, Paul Grammont introduced the novel "ball-and-socket" design, which was based on four key principles: (1) shifting the center of rotation medially to decrease the 2 of 15 mechanical torque at the glenoid component, thus avoiding glenoid loosening; (2) lowering the humerus to tension the deltoid muscle, which increases muscle fiber recruitment of the anterior and posterior deltoid in order to compensate a deficient rotator cuff; (3) a fixed center of rotation distalized and medialized to the glenoid joint line, leading to an inherently stable implant; (4) a large glenosphere increasing the range of motion through a semi-constrained implant feature [1,6]. In 1987, the first series of eight cases reported preliminary functional outcomes: all patients were pain-free, however the postoperative range of motion varied widely among patients [2,7]. ...
Purpose of review: The purpose of this review is to summarize recent literature regarding the latest design modifications and biomechanical evolutions of reverse total shoulder arthroplasty and their impact on postoperative outcomes. Recent findings: Over the past decade, worldwide implantation rates of reverse total shoulder arthroplasty have drastically increased for various shoulder pathologies. While Paul Grammont's design principles first published in 1985 for reverse total shoulder arthroplasty remained unchanged, several adjustments were made to address postoperative clinical and biomechanical challenges such as implant glenoid loosening, scapular notching, or limited range of motion in order to maximize functional outcomes and increase the longevity of reverse total shoulder arthroplasty. However, the adequate and stable fixation of prosthetic components can be challenging, especially in massive osteoarthritis with concomitant bone loss. To overcome such issues, surgical navigation and patient-specific instruments may be a viable tool to improve accurate prosthetic component positioning. Nevertheless, larger clinical series on the accuracy and possible complications of this novel technique are still missing. Keywords: reverse total shoulder arthroplasty; biomechanics; implant design; patient-specific instruments; computer navigation
... Historically, reverse total shoulder arthroplasty (RTSA) was designed for the treatment of pseudoparalysis with cuff tear arthropathy in elderly low-demand patients [2,6,17]. Over the past decades, indications have expanded comprising irreparable rotator cuff tears without osteoarthritis, primary osteoarthritis, acute proximal humerus fractures, fracture sequelae, and failed anatomic shoulder arthroplasty [5,20,22,27]. ...
Background
The purpose of the present study was to compare the functional and radiographic outcomes following reverse total shoulder arthroplasty (RTSA) in a senior athletic and non-athletic population.
Material and methods
In this retrospective cohort study, patients who underwent RTSA between 06/2013 and 04/2018 at a single institution were included. Minimum follow-up was 2 years. A standardized questionnaire was utilized for assessment of patients’ pre- and postoperative physical fitness and sportive activity. Patients who resumed at least one sport were assigned to the athletic group, while patients who ceased participating in sports were assigned to the non-athletic group. Postoperative clinical outcome measures included the Constant score (CS), American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and visual analog scale (VAS) for pain. Active shoulder range of motion (ROM) and abduction strength were assessed. Radiographic evaluation was based on a standardized core set of parameters for radiographic monitoring of patients following shoulder arthroplasty.
Results
Sixty-one of 71 patients (85.9%; mean age: 72.1 ± 6.6 years) were available for clinical and radiographic follow-up at a mean of 47.1 ± 18.1 months. Thirty-four patients (55.7%) were assigned to the athletic group and 27 patients (44.3%) to the non-athletic group. The athletic group demonstrated significantly better results for CS ( P = 0.002), ASES score ( P = 0.001), SST ( P = 0.001), VAS ( P = 0.022), active external rotation ( P = 0.045) and abduction strength ( P = 0.016) compared to the non-athletic group. The overall rate of return to sport was 78.0% at an average of 5.3 ± 3.6 months postoperatively. Incomplete radiolucent lines (RLL) around the humeral component were found significantly more frequently in the athletic group compared to the non-athletic group ( P = 0.019), whereas the occurrence of complete RLLs around the implant components was similar ( P = 0.382). Scapular notching was observed in 18 patients (52.9%) of the athletic group and 12 patients (44.9%) of the non-athletic group ( P = 0.51). The overall rate for revision surgery was 8.2%, while postoperative complications were encountered in 3.3% of cases.
Conclusion
At mid-term follow-up, the athletic population demonstrated significantly better clinical results following RTSA without a higher rate of implant loosening and scapular notching when compared to non-athletic patients. However, incomplete radiolucency around the humeral component was observed significantly more often in the athletic group.
Level of evidence
III.
... Reverse shoulder arthroplasty (RSA) was developed in 1985 by Grammont et al. 1 It is based on medialization and inferiorization of the rotational center of the glenohumeral joint, a mechanism that increases the lever arm and the deltoid force moment to compensate a rotator cuff (RC) defficiency. 1,2 In addition to rotator cuff arthropathy (RCA), [3][4][5] RSA is currently indicated in extensive RC injuries, 3,5,6 fracture sequelae, 3,7 inflammatory arthropathies, 3 severe fractures of the proximal humerus, 3,5 primary arthroplasties revision, 3,5 and posttumor resection reconstruction. ...
... Reverse shoulder arthroplasty (RSA) was developed in 1985 by Grammont et al. 1 It is based on medialization and inferiorization of the rotational center of the glenohumeral joint, a mechanism that increases the lever arm and the deltoid force moment to compensate a rotator cuff (RC) defficiency. 1,2 In addition to rotator cuff arthropathy (RCA), [3][4][5] RSA is currently indicated in extensive RC injuries, 3,5,6 fracture sequelae, 3,7 inflammatory arthropathies, 3 severe fractures of the proximal humerus, 3,5 primary arthroplasties revision, 3,5 and posttumor resection reconstruction. 3,5 Reverse shoulder arthroplasty is indicated mainly for elderly patients with decreased shoulder function and active anterior elevation lower than 90°; 3 it is contraindicated in subjects with severe impairment or no deltoid contraction. ...
Resumo
Objetivo Avaliar os resultados clínicos da artroplastia reversa do ombro no tratamento de suas diversas indicações.
Métodos Estudo longitudinal retrospectivo que analisou os resultados dos escores Constant, UCLA e amplitudes de movimentos dos pacientes submetidos à artroplastia reversa do ombro.
Resultados Foram analisados 28 pacientes, a média de idade foi de 75.6 anos, com seguimento médio de 45 meses. No geral, obtivemos uma variação significativa (p < 0,0001) entre o escore UCLA pré-operatório (10,2 pontos) e o escore UCLA pós-operatório (29,6 pontos), o que corresponde a um aumento relativo de aproximadamente 200%. Além disso, obtivemos pontuação média do escore Constant de 67,8 e uma taxa de complicações de 17,8%. Quanto aos resultados funcionais segundo as indicações, os casos de sequela de fratura apresentaram as melhores médias de elevação (165°), escore Constant (79 pontos), escore UCLA pós-operatório (32,5 pontos) e aumento absoluto na variação do escore UCLA (22 pontos), sem significância estatística. Porém, identificou-se que os casos operados por sequela de fratura apresentaram elevação (p = 0,027) e pontuação no escore Constant (p = 0,047) significativamente maiores em relação aos casos de artropatia do manguito rotador. Além disso, observamos que as menores médias dos escores Constant e UCLA pós-operatórios foram obtidos nas seguintes etiologias: artrose primária, fratura aguda e revisão de artroplastia.
Conclusão A artroplastia reversa de ombro apresentou resultados funcionais satisfatórios, podendo ser uma opção de tratamento não somente nos casos de artropatia do manguito rotador, mas também em várias outras patologias.
... The performance of reverse total shoulder replacement (RTSA) for several indications has been steadily increasing over a number of years [1][2][3][4][5][6][7][8]. Since the advent of the Grammont-style prostheses in the 1980s [9], the evolution of RTSA implants has been well-documented, particularly with respect to the glenoid component, with the progressive lateralisation and inferior shift of the glenosphere aiming to reduce scapula notching and component loosening while increasing range of motion (ROM) [10]. In conjunction with these changes, design modifications to the humeral component have also been enacted; for example, the articulating humeral tray was changed from the Grammont-style inlay configuration to an onlay-tray system resulting in increased humeral off-set with the aim of further improving range of motion and reducing implant impingement and scapula notching [11]. ...
Background:
Prosthesis selection, design, and placement in reverse total shoulder arthroplasty (RTSA) affect post-operative results. The aim of this systematic review was to evaluate the influence of the humeral stem version and prosthesis design (inlay vs. onlay) on shoulder function following RTSA.
Methods:
A systematic review of the literature on post-operative range of motion (ROM) and functional scores following RTSA with specifically known humeral stem implantations was performed using MEDLINE, Pubmed, and Embase databases, and the Cochrane Library. Functional scores included were Constant scores (CSs) and/or American Shoulder and Elbow Surgeons (ASES) scores. The patients were organised into three separate groups based on the implanted version of their humeral stem: (1) less than 20° of retroversion, (2) 20° of retroversion, and (3) greater than 20° of retroversion.
Results:
Data from 14 studies and a total of 1221 shoulders were eligible for analysis. Patients with a humeral stem implanted at 20° of retroversion had similar post-operative mean ASES (75.8 points) and absolute CS (68.1 points) compared to the group with humeral stems implanted at less than 20° of retroversion (76 points and 62.5 points; p = 0.956 and p = 0.153) and those implanted at more than 20° of retroversion (73.3 points; p = 0.682). Subjects with humeral stem retroversion at greater than 20° tended towards greater active forward elevation and external rotation compared with the group at 20° of retroversion (p = 0.462) and those with less than 20° of retroversion (p = 0.192). Patients with an onlay-type RTSA showed statistically significantly higher mean post-operative internal rotation compared to patients with inlay-type RTSA designs (p = 0.048). Other functional scores and forward elevation results favoured the onlay-types, but greater external rotation was seen in inlay-type RTSA designs (p = 0.382).
Conclusions:
Humeral stem implantation in RTSA at 20° of retroversion and greater appears to be associated with higher post-operative outcome scores and a greater range of motion when compared with a retroversion of less than 20°. Within these studies, onlay-type RTSA designs were associated with greater forward elevation but less external rotation when compared to inlay-type designs. However, none of the differences in outcome scores and range of motion between the humeral version groups were statistically significant.
