Evolution of Stemless Reverse Shoulder Arthroplasty: Current Indications, Outcomes, and Future Prospects

Abstract

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.

Full text

Citation: Hatta, T.; Mashiko, R.;
Kawakami, J.; Matsuzawa, G.; Ogata,
Y.; Hatta, W. Evolution of Stemless
Reverse Shoulder Arthroplasty:
Current Indications, Outcomes, and
Future Prospects. J. Clin. Med. 2024,
13, 3813. https://doi.org/10.3390/
jcm13133813
Academic Editor: Emmanuel
Andrès
Received: 6 May 2024
Revised: 16 June 2024
Accepted: 27 June 2024
Published: 28 June 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Journal of
Clinical Medicine
Review
Evolution of Stemless Reverse Shoulder Arthroplasty: Current
Indications, Outcomes, and Future Prospects
Taku Hatta 1,2 ,*, Ryosuke Mashiko 1, Jun Kawakami 2, Gaku Matsuzawa 3, Yohei Ogata 4and Waku Hatta 4
1Department of Orthopedic Surgery, Joint Surgery, Sports Clinic Ishinomaki, Ishinomaki 986-0850, Japan;
r-mashiko@jss-clinic.com
2Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai 980-8547, Japan;
jun_gene@yahoo.co.jp
3Department of Orthopedic Surgery, Iwaki Medical Center, Iwaki 973-8402, Japan; gaku1019@gmail.com
4Division of Gastroenterology, Tohoku University School of Medicine, Sendai 980-8574, Japan;
gmaps177@gmail.com (Y.O.); waku-style@festa.ocn.ne.jp (W.H.)
*Correspondence: t-hatta@jss-clinic.com; Tel./Fax: +81-225-98-9901
Abstract: 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.
Keywords: stemless; reverse shoulder arthroplasty; complication; revision surgery
1. Introduction
Reverse total shoulder arthroplasty (rTSA) is increasingly being used as a reliable
surgical option for rotator-cuff-deficient glenohumeral arthropathies, glenoid deformity
due to primary osteoarthritis, proximal humerus fractures, rheumatoid arthritis, chronic
glenohumeral dislocation, and failed hemiarthroplasty (HA) or anatomic total shoulder
arthroplasty (aTSA) [
1
]. 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. From 2000 to 2010, the nationally adjusted population
rate of shoulder arthroplasties increased 5.0-fold in the United States [
4
]. The efficacy of
rTSA has recently been recognized, with reliable pain relief and excellent functional out-
comes. However, there are concerns regarding long-term survivorship and the occurrence
of rTSA-related complications. In particular, the long-term outcomes of rTSA in specific
populations, such as younger, more active, more obese, and/or more porotic populations,
require further investigation [5–7].
J. Clin. Med. 2024,13, 3813. https://doi.org/10.3390/jcm13133813 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2024,13, 3813 2 of 15
Traditionally, the humeral component for shoulder arthroplasties has been composed
of a long stem that has been utilized to stabilize the humerus. Although a short stem
has recently been adopted in some prostheses, the majority of clinical studies assessing
the usefulness of rTSA have investigated the outcomes of long-stemmed implants [
8
–
10
].
The advantages of stemmed implants include augmentation with cement, particularly
in patients with poor bone quality [
11
]. While the survivorship of stemmed rTSAs has
been shown to be satisfactory at 10–15 years, cases that require revision surgery are still
common [8,10,12–16].
Stemless humeral components for aTSA are being increasingly utilized in the United
States and have been compared with traditional stemmed implants in radiographic and
patient-reported outcome measure (PROM)-based studies. According to clinical reports,
stemless shoulder arthroplasties have similar implant longevity and PROMs to stemmed
arthroplasties [
17
–
22
]. Recent studies have demonstrated that stemless implants have been
shown to result in less intraoperative blood loss [
23
], reduced surgical time [
23
,
24
], a lower
rate of intraoperative fractures [25], and improved center of rotation restoration [26].
On the other hand, recent biomechanical and radiological studies indicated a potent
influence of the technical gap for implantation on the durability of stemless rTSA. Of these,
the neck–shaft angle at the osteotomy of the proximal humerus may affect the primary
fixation of stemless rTSA [
27
]. Using specific surgical devices, however, surgeons should
note the deviation in performing osteotomy or implantation in terms of resection height,
inclination, or retroversion angle [28].
Whether stemless rTSA could become equivalent to or even superior to the gold
standard of stemmed rTSA remains controversial [
29
]. Future studies should focus on
specific populations in which stemless rTSA should be used instead of stemmed rTSA.
This review aimed to discuss the evolution, current indications, and reported outcomes of
stemless rTSAs, especially with a focus on the pooled incidence of overall complications
and revision surgery following stemless rTSA.
2. Methods
2.1. Literature Search and Data Extraction
A systematic review of the clinical application of stemless rTSA in patients with
shoulder disorders was conducted. The MEDLINE/PubMed, Cochrane, and Google
Scholar databases were searched in April 2024, according to our methodology, which
adhered to the PRISMA guidelines for identifying and evaluating relevant studies (Figure 1).
The search strategy employed a combination of the following keywords: (stemless OR
non-stemmed) AND (reverse) AND (shoulder arthroplasty OR shoulder replacement).
Additional articles were identified by examining the reference lists of articles selected for
full-text review. Two independent researchers (T.H. and R.M.) determined that each article
was eligible for inclusion by carefully reviewing its contents. In the case of disagreement,
a third researcher (J.K.) was consulted to reach a consensus. Finally, 18 studies were
included in this review to identify the clinical and radiologic outcomes of stemless rTSA.
Furthermore, 14 studies were included for a quantitative analysis to investigate functional
improvement, as well as complication and revision rates.
However, the total number of articles reporting outcomes in patients who underwent
stemless rTSA was insufficient for some focus in this review. Therefore, relevant articles,
including data from stemless aTSA, were also utilized after consensus among the three
researchers was obtained.

J. Clin. Med. 2024,13, 3813 3 of 15
J.Clin.Med.2024,13,38133of16



Figure1.PRISMAflowchart[30–32].
However,thetotalnumberofarticlesreportingoutcomesinpatientswhounderwent
stemlessrTSAwasinsufficientforsomefocusinthisreview.Therefore,relevantarticles,
includingdatafromstemlessaTSA,werealsoutilizedafterconsensusamongthethree
researcherswasobtained.
2.2.QualityAssessment
Twoindependentresearchers(T.H.andR.M.)assessedtheriskofbiasusingtheJo-
annaBriggsInstitute(JBI)CriticalAppraisalToolsforuseinJBISystematicReviewsfor
prevalencestudies[33].Theriskofbiaswascategorizedaslow(≥70%),moderate(50–
69%),andhigh(≤49%),basedonthepercentageof“yes”responsesto9questions.All
discrepancieswerediscussedandresolvedbyconsensusinconsultationwithathirdre-
searcher(J.K.).

Figure 1. PRISMA flowchart [30–32].
2.2. Quality Assessment
Two independent researchers (T.H. and R.M.) assessed the risk of bias using the
Joanna Briggs Institute (JBI) Critical Appraisal Tools for use in JBI Systematic Reviews
for prevalence studies [
33
]. The risk of bias was categorized as low (
≥
70%), moderate
(50–69%), and high (
≤
49%), based on the percentage of “yes” responses to 9 questions.
All discrepancies were discussed and resolved by consensus in consultation with a third
researcher (J.K.).
2.3. Statistical Analyses
Clinical studies demonstrating the incidence of complications and revision surgery
were included in the current meta-analysis. The Freeman–Tukey double arcsine method
and inverse variance method were utilized for calculating the pooled proportion and
corresponding 95% confidence interval (CI) of prevalence. A random-effects model was
used to pool the data, and statistical heterogeneity among studies was evaluated using
Cochran’s Q test (significant at p< 0.10) with quantifying via the I2 statistics [
34
]. I2
statistics values were categorized as low (<30%), moderate (30–59%), substantial (60–75%),
and considerable (>75%) heterogeneity. Publication bias was assessed qualitatively using
funnel plots and quantitatively using Egger’s test (significant at p
≤
0.10) [
35
]. Statistical
analyses were conducted using R version 4.2.1 (R Foundation).

J. Clin. Med. 2024,13, 3813 4 of 15
3. Evolution of Stemless rTSA
The first design for the “canal-sparing” stemless shoulder arthroplasty system was de-
veloped in 2003, but it did not draw much attention until the middle of 2010 when stemless
implants received attention based on the following theoretical advantages: preservation
of humeral bone stock, reduced periprosthetic fracture risk, higher adaptability during
implantation, easier implantation in cases of altered anatomy such as post-traumatic malu-
nion, and less complex revision surgery in case of failure of the stemless device [
4
,
36
–
38
].
Over the decades, alterations in implant material, design, and geometry, in addition to
supporting evidence, have been carried out to improve the overall function and long-term
durability of stemless shoulder prostheses.
3.1. Implant Design
The design of stemless humeral prostheses has also changed. The initial model of the
Total Evolution Shoulder System (TESS; Zimmer Biomet, Warsaw, IN, USA) was introduced
in 2003 as a first-generation stemless shoulder prosthesis. This is composed of six-branched
anchors like a “corolla,” which enable it to impact into the humeral metaphysis. However,
with this configuration, there is a risk of contact with the lateral cortex of the humerus
during impaction, which may result in intraoperative fractures. The structure of the
implant assembly between the anchor and the surface portion is disadvantageous, causing
metallosis [
39
]. The modified TESS model was subsequently developed in 2005, and the
stemless rTSA system included a one-piece cup-configured corolla to increase the contact
area of the humerus [
39
]. Kadum et al. (2011) first reported the clinical outcomes of stemless
TESS prostheses in 17 rTSA patients, with short-term follow-up (range 9–24 months).
Although specific outcomes specific to TESS rTSA were not described, complications
included instability secondary to malpositioned glenosphere in one patient and dislocation
secondary to migrated humeral component in one patient [
30
]. A clinical study by Ballas
and Beguin (2013) focused on the outcomes of stemless TESS rTSA and demonstrated
an implant revision rate of 7.1% (4 of 56 shoulders) with an average follow-up period
of 4.8 years. Among these, there were no cases of periprosthetic humeral radiolucency,
migration, or loosening of the stemless component. Functionally, the mean Constant-
Murley Score (CS) improved from 28 (standard deviation (SD): 8) preoperatively to 62 (SD:
12) postoperatively [
40
]. There have been five additional studies with a specific focus on
stemless TESS rTSA; at an average of 17.5–101.6 months of follow-up of 189 shoulders in
184 patients, the implant survival rate of stemless TESS rTSA was reported to reach 94.7%.
Notably, no patient was found to have humeral-implant-associated complications in the
modified corolla [23,41–44].
As another stemless metaphyseal rTSA implant released around the same period, the
Vesro Shoulder System (Innovative Design Orthopedics, Theale, UK) has been clinically
utilized since 2005. It is composed of a short, non-stemmed metaphyseal implant with
three tapered fins to achieve immediate metaphyseal press-fit stabilization. Atoun et al.
(2014) first reported the clinical outcomes of 31 patients who underwent Verso rTSA with
an average follow-up of 3 years. The mean CS improved from 12.7 preoperatively to
56.2 postoperatively. Regarding postoperative complications, one patient had an acromion
stress fracture, and five patients sustained traumatic periprosthetic fractures after falls [
31
].
Several clinical studies have also reported satisfactory outcomes, with a 6.1–13.0% revision
rate at an average of 36–50 months of follow-up [
32
,
45
]. Most recently, Virani et al. (2021)
reported the clinical outcomes of 22 shoulders in 21 patients who underwent Verso rTSA
with an average follow-up period of 78 months (range 60–114 months). The mean CS
improved from 18 preoperatively to 72 postoperatively, and postoperative complications
included a 0 periprosthetic infection in one patient and periprosthetic fractures after falls in
two patients [46].
With the prospect of promoting minimally invasive TSA, several companies have
commercialized stemless rTSA as next-generation implants. EasyTech (FX Solutions, Viriat,
France) was developed in 2011 and has an impacted cage with peripheral serrated pegs.

J. Clin. Med. 2024,13, 3813 5 of 15
The onlay component was originally used to demonstrate that the entire concave articular
part is located above the resection plane. A clinical study demonstrated an implant revision
rate of 7.0% (8/115 cases) after 24 months of follow-up. Regarding stemless-implant-
associated complications, five patients showed humeral loosening. Functionally, the mean
CS improved from 32.5 (SD: 10.3) preoperatively to 61.8 (SD: 15.6) at the 24-month follow-
up [
47
]. The Comprehensive Nano Reverse system (Zimmer Biomet) was developed in 2012
and has an onlay tray system with six thick and short fins. However, for rTSA, this onlay
tray system turned out to be insufficient for fixation, with a potential risk of varus seesaw
motion; consequently, this system was withdrawn from the market. To date, a clinical
study has reported the outcomes of Nano rTSA in 15 patients, with an average follow-up
of 27 months (range 9–24 months). Functional improvement was obtained, with the mean
CS ranging from 30 (SD: 18) preoperatively to 60 (SD: 18) postoperatively. However, 4
of 15 cases required revision surgeries, including postoperative migration of the humeral
component in two patients, instability secondary to an episode of cerebrovascular stroke in
one patient, and traumatic periprosthetic fracture in one patient [48].
In 2015, SMR Reverse (Lima Corporate, Villanova, Italy) was designed using a proxi-
mal peripheral ring and three fins. This inlay system uses a polyethylene (PE) glenosphere
and metal humeral insert to prevent the occurrence of PE wear debris. Schoch et al. (2021)
reported the clinical outcomes of 52 patients who underwent stemless SMR rTSA, with a
minimal follow-up of 24 months (range 24–41 months). Functionally, the mean CS improved
from 24.9 (SD: 9.8) preoperatively to 72.4 (SD: 8.7) at 2 years of follow-up. Radiologically,
gross loosening of the humeral component was observed in one case. Postoperative com-
plications included deep infection in one patient and periprosthetic fracture in one patient
who required revision surgery [
49
]. To date, there have been three studies with a specific
focus on stemless SMR rTSA. In 111 shoulders in 110 patients, the revision-free rate of
stemless SMR rTSA was reported to reach 96.4% with an average follow-up period of
35.8 months. Radiologically, a radiolucent line around the stemless implant was observed
in 25 of 107 shoulders (23.4%). Nevertheless, it was notable that no implant-associated
complications requiring revision were observed in patients with SMR rTSA [49–51].
3.2. Implant Material
Currently available humerus components are made of cobalt–chrome or titanium alloy
with a full hydroxyapatite coating and a titanium plasma spray.
Hydroxyapatite coating was adopted to improve fixation strength, with the initial
introduction to hip and knee arthroplasties in the 1980s [
52
]. This coating has been shown
to accelerate bone ingrowth via its inherent osteoconductive properties [
53
], with a number
of studies supporting minimized micromotion at the implant–bone interface [54–56].
Porous plasma spray, which is adopted in most cementless arthroplasties, has been rec-
ognized as a major evolution. A randomized controlled study clarified the efficacy of these
properties in preventing subsidence in patients who underwent total knee arthroplasty [
57
].
3.3. Biomechanical Properties
Traditionally, the presence of a stem component has been considered essential for
achieving rigid stability in the humeral canal. However, biomechanical advancement may
enable sufficient fixation strength within the humeral metaphysis.
Ryan et al. (2023) biomechanically investigated the differences in initial strength
against torsional load among long-, short-, and stemless implants [
58
]. They found that
the force required to cause failure in synthetic humerus implanted with stemless compo-
nents was significantly decreased compared with those with long or short stems. They
emphasized the importance of metaphyseal cancellous bone quality for stable fixation
with stemless implants. Cunningham et al. (2024) investigated the effect of the neck–shaft
angle on the primary fixation of stemless rTSA using finite element analysis. They found
that lower neck–shaft angles with more varus placement may increase bone-implant dis-
traction in simulated activities of daily living. Therefore, appropriate osteotomy of the

J. Clin. Med. 2024,13, 3813 6 of 15
humeral head with a higher neck–shaft angle and cancellous bone quality can be considered
important for achieving stable fixation in stemless rTSA [27].
4. Indication Considerations
With the advancement of modern design, the findings of several studies have encour-
aged surgeons to use stemless shoulder prostheses. In particular, the stemless shoulder
prosthesis may have advantages in younger patients since bone stock preservation is
preferred. However, the use of stemless shoulder prostheses in patients with decreased
bone quality due to conditions such as osteoporosis or rheumatoid arthritis remains a
concern. However, for such patients, there might be a great need for a less invasive stemless
shoulder prosthesis.
4.1. Young Age
Colasanti et al. (2023) investigated the treatment options for which consensus was
gained among international shoulder surgeons for the treatment of osteoarthritis in shoul-
ders under 50 years of age [
59
]. Notably, 79% of surgeons selected stemless humeral
components for HA or aTSA as the proposed surgical procedure. Recent studies have
demonstrated that a growing number of young patients are required to undergo rTSA.
A clinical investigation utilizing the New Zealand Joint Registry records reported that
younger patients undergoing reverse shoulder arthroplasty demonstrated higher implant
retention rates than older patients [
5
]. Moreover, the Australian Orthopaedic Association
National Joint Replacement Registry demonstrated that among patients aged <55 years, the
revision rate did not differ between aTSA and rTSA. In contrast, patients aged 55–64 years
of age had a relatively low revision rate after rTSA [
60
]. Regarding other risk factors,
younger age at the time of surgery may be associated with the periprosthetic infection
rate [61].
4.2. Obesity
The potential impact of obesity on patients who require TSA should be noted. In
contrast to hip or knee arthroplasties, in which increased weight-dependent micromotion
could be present, shoulder arthroplasty may have less impact on the occurrence of compli-
cations in obese patients. Hatta et al. (2017) demonstrated that increased body mass index
(BMI) had no significant impact on postoperative complications in patients who underwent
shoulder arthroplasty [
61
]. In contrast, Gruson et al. (2023) reported that morbid obesity
(BMI > 40 kg/m
2
) may not be associated with increased operative time, intraoperative
total blood volume loss, or perioperative medical or surgical complications after aTSA.
However, it was predictive of increased length of hospital stay [
62
]. Moreover, Theodoulou
et al. (2019) reported greater risks of dislocation, fracture, and revision with increasing
BMI in shoulder arthroplasties [
63
]. Regarding the surgical procedure, Phillips et al. (2023)
investigated the effect of morbid obesity on the healing rates of lesser tuberosity osteotomy
for stemless and stemmed aTSA [
64
]. Although there were no differences in the healing
rates between stemless and stemmed aTSA, significantly increased BMI was found in
patients with a lack of healing compared with those with a healed lesser tuberosity, with a
failure rate of 9.4% for BMI 30–40, 12.5% for BMI 40–50, and 28.6% for BMI > 50. Although
lesser tuberosity osteotomy is less common in patients who undergo rTSA, morbid obesity
is a potential risk factor for nonunion when lesser tuberosity osteotomy is performed.
4.3. Osteoporosis
Osteoporosis is frequently observed in patients who undergo aTSA or rTSA. Although
there has been a lack of detailed investigation, regional osteopenia was noted to be a
relative contraindication to stemless shoulder prostheses due to an association with early
humeral component loosening [
65
,
66
]. Primary and secondary stability are important
factors in implant stability, and patients with osteoporosis may have concerns regarding
both. For primary stability, surgeons must carefully assess bone quality at the humeral

J. Clin. Med. 2024,13, 3813 7 of 15
metaphysis, in which the stemless TSA is embedded. Although preoperative assessment
tools, including plain radiography, CT, BMD, and/or MRI, are examined, no objective tests
are available to determine the bone quality of a stemless prosthesis [67,68]. For secondary
stability, stemless shoulder implants mainly rely on osseointegration for rigid fixation
of the metaphyseal components. The quality of the bone for this response has been a
concern in patients with osteoporosis or osteopenia. A biomechanical study investigated
the micromotion of a single stemless humerus component using finite element analysis
and demonstrated that increased micromotion was significantly dependent on decreased
cancellous bone density [
69
,
70
]. Accordingly, surgeons should note the importance of
preoperative or intraoperative assessments to ensure adequate bone quality when selecting
a stemless implant.
5. Outcomes from Quantitative Analysis
A total of 14 clinical studies (637 shoulders in 629 patients) were included in the
quantitative analysis to clarify the current outcomes of stemless rTSA [
23
,
40
–
51
,
71
]. The
analysis included six TESS studies (272 shoulders of 266 patients), three Verso studies
(127 shoulders of 126 patients), three SMR studies (108 shoulders of 107 patients), one
EasyTech study (115 shoulders of 115 patients), and one Nano study (15 shoulders of
15 patients). The mean age at the time of surgery was 71.1 years, and the mean follow-up
period after surgery was 40.6 months (Table 1).
Table 1. Patients’ characteristics in clinical studies with stemless rTSA.
Study Year Mean Age Year
(SD) Sex (Male %) Final Number of
rTSA in Analysis
Implant Mean Follow-Up
Months (SD)
A’Court et al. [51] 2024 64.3 (11.4) 40 30 SMR 37.5 (14.0)
Rosso et al. [50] 2024 70.1 54 26 SMR 46.8
Nabergoj et al. [47] 2023 68.7 47 115 EasyTech 24
Galhoum et al. [48] 2022 70 (7) NS 15 Nano 27 (6)
Schoch et al. [49] 2021 61.2 62 52 SMR 29.3
Micheloni et al. [71] 2019 73.1 (8.0) 29 7 Verso 6.4 (1.3)
Virani et al. [46] 2021 76 NS 22 Verso 78
Beck et al. [41] 2019 72.4 (6.7) 19 29 TESS 101.6
Levy et al. [45] 2016 74.4 20 98 Verso 50
Moroder et al. [23] 2016 75.6 (4.6) 29 24 TESS 35.2 (14.6)
von Engelhardt et al. [44] 2015 73.2 (7.8) NS 56 TESS 17.5 (10.2)
Teissier et al. [43] 2015 73 70 91 TESS 41
Kadum et al. [42] 2014 69 63 16 TESS 35
Ballas et al. [40] 2013 74 29 56 TESS 56
SMR (Lima Corporates), EasyTech (FX Solutions), Nano (Zimmer Biomet), Verso (Innovative Design Orthopedics),
TESS (Zimmer Biomet). rTSA: reverse total shoulder arthroplasty, SD: standard deviation. NS: not stratified.
Regarding PROMs to assess shoulder function, CS was the most frequently used
among the studies: 10 studies for preoperative assessment and 11 studies for postoperative
assessment. According to quantitative analysis, the mean CS in patients who underwent
stemless rTSA improved from 28.3 preoperatively to 62.8 postoperatively (Table 2).

J. Clin. Med. 2024,13, 3813 8 of 15
Table 2. Functional improvement and complications in clinical studies with stemless rTSA.
Study Year Preop. CS
(Mean, SD)
Postop. CS
(Mean, SD)
Incidence of
Complications (%, n)
Incidence of
Revision (%, n)
A’Court et al. [51] 2024 NR NR 23.3 (7) 9.0 (3)
Rosso et al. [50] 2024 44.1 (18.7) 83.1 (10.1) 34.6 (9) 3.8 (1)
Nabergoj et al. [47] 2023 32.5 (10.3) 61.8 (15.6) 17.4 (20) 7.0 (8)
Galhoum et al. [48] 2022 30 (18) 60 (18) 26.7 (4) 26.7 (4)
Schoch et al. [49] 2021 34.9 (9.8) 72.4 (8.7) 3.8 (2) 3.8 (2)
Micheloni et al. [71] 2019 21.6 56.9 0 (0) 0 (0)
Virani et al. [46] 2021 18 72 13.6 (3) 4.5 (1)
Beck et al. [41] 2019 13 60.5 6.9 (2) 6.9 (2)
Levy et al. [45] 2016 14 59 12.2 (12) 3.1 (3)
Moroder et al. [23] 2016 NR 65.4 (12.9) 25 (6) 4.2 (1)
von Engelhardt et al. [44] 2015 NS NS 3.6 (2) 1.8 (1)
Teissier et al. [43] 2015 40 (24) 68 (12) 3.3 (3) 1.1 (1)
Kadum et al. [42] 2014 NR NR 25 (4) 12.5 (2)
Ballas et al. [40] 2013 29 (8) 62 (12) 14.3 (8) 7.1 (4)
CS: Constant-Murley Score, rTSA: reverse total shoulder arthroplasty, SD: standard deviation, NR: not recorded,
NS: not stratified.
Incidence of Complications and Revision Surgery from Meta-Analysis
Among 637 shoulders from 14 studies, complications were reported in 82 cases, with
the incidence ranging from 0% [
71
] to 34.6% [
50
]. Regarding the quality assessment of
14 studies based on the JBI Critical Appraisal Tools, 10 studies were categorized as being at
low risk, and 4 studies were at moderate risk (Supplementary Table S1).
The pooled incidence of overall complications following stemless rTSA was 14.3%
(95% CI, 9.9%–20.2%), with substantial heterogeneity across studies (I
2
= 61%) (Figure 2A).
Common postoperative complications included instability/displacement (n = 16), peripros-
thetic fracture at the humerus (n = 12), and displacement/malpositioning/migration of the
humeral implant (n = 11, Table 3). The pooled incidence of revision surgery after stemless
rTSA was 6.3% (95% CI, 4.1%–9.5%), with low heterogeneity (I
2
= 27%) (Figure 3A). No
potential publication bias for the incidence of overall complications or revision surgery
was confirmed by Egger’s test (p= 0.19, 0.20, respectively). The funnel plots are shown in
Figures 2B and 3B.
Table 3. Incidence of postoperative complications in 637 patients who underwent stemless rTSA.
Shoulders Incidence (%) Incidence of All
Complications (%)
Instability and/or dislocation 16 2.5 19.5
Humeral implant displacement/malpositioning/migration 11 1.7 13.4
Superficial infection 1 0.2 1.2
Deep infection 4 * 0.6 4.9
Hematoma 4 0.6 4.9
Periprosthetic fracture (humerus) 12 1.9 14.6
Periprosthetic fracture (glenoid) 2 0.3 2.4
Periprosthetic fracture (unspecified) 2 0.3 2.4
Acromion fracture 6 0.9 7.3
Scapular spine fracture 1 0.2 1.2
Clavicle fracture 1 0.2 1.2
Glenosphere disassembly from baseplate 8 1.3 9.8

J. Clin. Med. 2024,13, 3813 9 of 15
Table 3. Cont.
Shoulders Incidence (%) Incidence of All
Complications (%)
Dysesthesia in the hand 3 0.5 3.7
Postoperative stiffness 3 0.5 3.7
Subscapularis rupture 2 0.3 2.4
Symptomatic mesacromion 1 0.2 1.2
Chronic scapulothoracic conflict 1 0.2 1.2
Glenoid ossification 1 0.2 1.2
Glenoid and humeral loosening 1 0.2 1.2
Asymmetrical polyethylene 1 0.2 1.2
Incorrectly positioned humeral base plate 1 0.2 1.2
Overall complications 82 12.9 100.0
This table represents updated data from the study by Ajibade et al. [
29
]. * It is unclear whether deep infection
occurred in the shoulder of a stemless or stemmed patient [41]. rTSA: reverse total shoulder arthroplasty.
J.Clin.Med.2024,13,38139of16



Figure2.Forestplot(A)andfunnelplot(B)intheanalysisoftheoverallcomplicationratefollowing
stemlessrTSA[23,40–51,71].
Tab le3.Incidenceofpostoperativecomplicationsin637patientswhounderwentstemlessrTSA.
ShouldersIncidence(%)IncidenceofAllComplications
(%)
Instabilityand/ordislocation16 2.5 19.5
Humeralimplantdisplacement/malpositioning/migration11 1.7 13.4
Superficialinfection10.2 1.2
Deepinfection4*0.6 4.9
Hematoma40.6 4.9
Periprostheticfracture(humerus)12 1.9 14.6
Periprostheticfracture(glenoid)20.3 2.4
Periprostheticfracture(unspecified)20.3 2.4
Acromionfracture60.9 7.3
Scapularspinefracture10.2 1.2
Claviclefracture10.2 1.2
Glenospheredisassemblyfrombaseplate81.3 9.8
Dysesthesiainthehand30.5 3.7
Postoperativestiffness30.5 3.7
Subscapularisrupture20.3 2.4
Symptomaticmesacromion10.2 1.2
Chronicscapulothoracicconflict10.2 1.2
Glenoidossification10.2 1.2
Glenoidandhumeralloosening10.2 1.2
Asymmetricalpolyethylene10.2 1.2
Incorrectlypositionedhumeralbaseplate10.2 1.2
Overallcomplications82 12.9 100.0
ThistablerepresentsupdateddatafromthestudybyAjibadeetal.[29].*Itisunclearwhetherdeep
infectionoccurredintheshoulderofastemlessorstemmedpatient[41].rTSA:reversetotalshoulder
arthroplasty.
Figure 2. Forest plot (A) and funnel plot (B) in the analysis of the overall complication rate following
stemless rTSA [23,40–51,71].
J.Clin.Med.2024,13,381310of16



Figure3.Forestplot(A)andfunnelplot(B)intheanalysisoftherevisionsurgeryratefollowing
stemlessrTSA[23,40–51,71].
6.ComparativeAnalysisofStemmedandStemlessrTSA
Withrecentlyreportedoutcomes,ithasbeenrecognizedthatbothstemmedand
stemlessshoulderarthroplastiesachievesatisfactoryoutcomesintermsofpainrelief,
functionalrecovery,andimplantsurvivorship.Recently,thefocushasbeenoncomparing
theseimplantdesigns.AsseeninTable s4and5,clinicalstudiescomparingstemmedand
stemlessshoulderarthroplastiesdemonstratedthattheseimplanttypesshowednosignif-
icantassociationwithanypatientcharacteristic.
Tab le4.ComparativestudiesofstemmedandstemlessrTSA.
StudyYear
Mean
AgeYear
(SD)
Sex
(Male
%)
MeanBMI
kg/m2(SD)
FinalNum‐
berofrTSA
inAnalysis
Implant
MeanFol‐
low‐Up
Months
(SD)
MainFindings
A’Courtet
al.[51]2024
76.5(6.3)
vs.64.3
(11.4)
53vs.
40
29.2(5.7)vs.
28.5(4.5)30vs.30SMR(Lima
Corporate)
31.3(8.7)vs.
37.5(14.0)
- Nosignificantdifferencesin
PROMs,ROM
- Fourstemmedandseven
stemlesscausedcomplica-
tions
- Threestemlessrequiredrevi-
sion
Moroder
etal.[23]2016
74.3(4.6)
vs.75.6
(4.6)
29vs.
29NR24vs.24
Delta
XTEND
(Depuy)
TESS(Zim-
merBiomet)
34.2(10.5)
vs.35.2
(14.6)
- Nosignificantdifferencesin
PROMs,ROM
- Fourstemmedandsixstem-
lesscausedcomplications
- Threestemmedandtwo
stemlessre
q
uiredrevision
Kadumet
al.[42]201472vs.6927vs.
63NR15vs.16TESS(Zim-
merBiomet)35vs.35
- Bothgroupsimprovedin
PROMs,ROM
- Twostemlessrequiredrevi-
sion
rTSA:reversetotalshoulderarthroplasty,SD:standarddeviation,BMI:bodymassindex,PROMs:
patient-reportedoutcomemeasures,ROM:rangeofmotion,NR:notreported.Eachcolumnrepre-
sentsstemmedvs.stemless.
Figure 3. Forest plot (A) and funnel plot (B) in the analysis of the revision surgery rate following
stemless rTSA [23,40–51,71].
6. Comparative Analysis of Stemmed and Stemless rTSA
With recently reported outcomes, it has been recognized that both stemmed and
stemless shoulder arthroplasties achieve satisfactory outcomes in terms of pain relief,
functional recovery, and implant survivorship. Recently, the focus has been on comparing

J. Clin. Med. 2024,13, 3813 10 of 15
these implant designs. As seen in Tables 4and 5, clinical studies comparing stemmed
and stemless shoulder arthroplasties demonstrated that these implant types showed no
significant association with any patient characteristic.
Table 4. Comparative studies of stemmed and stemless rTSA.
Study Year Mean Age
Year (SD)
Sex
(Male %)
Mean BMI
kg/m2(SD)
Final Number of
rTSA in
Analysis
Implant
Mean
Follow-Up
Months (SD)
Main Findings
A’Court
et al. [51]2024 76.5 (6.3) vs.
64.3 (11.4) 53 vs. 40 29.2 (5.7) vs.
28.5 (4.5) 30 vs. 30 SMR (Lima
Corporate)
31.3 (8.7) vs.
37.5 (14.0)
- No significant differences
in PROMs, ROM
- Four stemmed and seven
stemless caused
complications
- Three stemless required
revision
Moroder
et al. [23]2016 74.3 (4.6) vs.
75.6 (4.6) 29 vs. 29 NR 24 vs. 24
Delta XTEND
(Depuy)
TESS (Zimmer
Biomet)
34.2 (10.5) vs.
35.2 (14.6)
- No significant differences
in PROMs, ROM
- Four stemmed and six
stemless caused
complications
- Three stemmed and two
stemless required revision
Kadum
et al. [42]2014 72 vs. 69 27 vs. 63 NR 15 vs. 16 TESS (Zimmer
Biomet) 35 vs. 35
- Both groups improved in
PROMs, ROM
- Two stemless required
revision
rTSA: reverse total shoulder arthroplasty, SD: standard deviation, BMI: body mass index, PROMs: patient-reported
outcome measures, ROM: range of motion, NR: not reported. Each column represents stemmed vs. stemless.
Table 5. Randomized controlled trials comparing stemmed and stemless aTSA.
Study
Year
Mean Age
Year (SD)
Sex
(Male %)
Mean BMI
kg/m2(SD)
Final Number of
aTSA in Analysis Implant Follow-Up Main Findings
Romeo
et al. [72]
2020
66.0 (median)
vs. 66.0
(median)
73 vs. 69
31.8 (median)
vs. 30.3
(median)
68 vs. 143
Univers II
(Arthrex)
Eclipse (Arthrex)
2 years
- No significant
differences in PROMs
- 3.8% of stemmed and
3.2% of stemless
required revision
Wiater
et al. [73]
2020
62.1 (9.6) vs.
63.1 (9.0) 65 vs. 67 30.1 (5.3) vs.
30.6 (5.8) 123 vs. 116
Comprehensive
(Zimmer Biomet)
Nano (Zimmer
Biomet)
2 years
- No significant
differences in PROMs,
ROM
- Nine stemmed and
nine stemless caused
failure
Uschok
et al. [22]
2017
69 vs. 65 35 vs. 50 NR 18 vs. 15 (2 years)
15 vs. 14 (5 years)
Univers II
(Arthrex)
Eclipse (Arthrex)
2 and 5 years
- No significant
differences in PROMs,
ROM
- One stemmed caused
greater tuberosity
fracture
- 6.7% of stemmed and
7.1% of stemless
required revision
Mariotti
et al. [74]
2014
NS NR NR 10 vs. 9
Aequalis (Stryker
Tornier) 2 years
- No significant
differences in PROMs,
ROM
- No complications in
either group
aTSA: anatomical total shoulder arthroplasty, SD: standard deviation, BMI: body mass index, PROMs: patient-
reported outcome measures, ROM: range of motion, NR: not reported, NS: not stratified. Each column represents
stemmed vs. stemless.
6.1. Clinical Outcomes
Three studies compared the short-term clinical and radiological outcomes between
stemmed and stemless rTSA [
23
,
42
,
51
]. In a study with approximately 3 years of follow-
up, Moroder et al. (2016) showed no differences in the postoperative Constant Score,
American Shoulder and Elbow Surgeons (ASES) score, muscle strength, and range of

J. Clin. Med. 2024,13, 3813 11 of 15
shoulder motions. Radiologically, nine cases (38%) of stemmed and two cases (26%) of
stemless rTSA demonstrated grade 1 or 2 scapular notching [
23
]. More recently, A’Court
et al. (2024) compared stemmed and stemless rTSA with a minimal follow-up of 2 years.
There were no differences in the postoperative range of shoulder motion, Oxford Shoulder
Score, or ASES score. Radiologically, the stemless group included osteolysis around the
greater tuberosity in three cases (10%) and periprosthetic radiolucent lines in six cases
(20%) [51].
However, several studies evaluated outcomes in comparison with stemmed aTSA.
Looney et al. (2022) performed a systematic review and meta-analysis comparing the out-
comes of stemmed and stemless aTSA [
75
]. They utilized four randomized controlled trials,
including 229 stemmed and 358 stemless aTSA cases [
22
,
72
–
74
]. They demonstrated no
differences in the postoperative forward flexion, abduction, or external rotation. Moreover,
no differences were found between the stemmed and stemless designs in the occurrence
of humeral fractures or the risk of revision surgeries. Further comparative studies on
long-term outcomes are required to validate the selection of stemless rTSAs.
6.2. Complications
Complications after rTSA have been reported. Several investigations have attempted
to reduce the incidence of complications using advanced biomechanical and kinematic
approaches [
76
,
77
]. However, knowledge of complications after stemless rTSA is insuffi-
cient. Moroder et al. (2016) investigated the incidence of postoperative complications after
stemmed and stemless rTSA [
23
]. Four cases (17%) of stemmed rTSA and six cases (25%)
of stemless rTSA had complications; however, stemless-component-related complications
were not observed. A’Court et al. also reported three cases (10%) of stemmed and stemless
rTSA in which revision surgery was required [51].
The incidence of humeral periprosthetic fractures has been reported to be lower in
stemless prostheses (0.89%) than in stemmed prostheses (1.6–19.4%) [
78
,
79
]. A multicenter
study analyzed eight patients (four rTSA and four aTSA) who had sustained a postoper-
ative periprosthetic fracture following stemless shoulder arthroplasty and reported that
conservative treatment seemed to be appropriate in patients with low or non-displaced
fractures without implant loosening. One of the four stemless rTSA patients had fibrous
nonunion at the greater tuberosity. However, the functional outcomes after conservative
treatment were maintained in all patients, and no implant loosening was observed [80].
7. Conclusions
As designs and techniques have improved over time, stemless rTSAs are evolving and
gaining popularity, with recent studies showing satisfactory outcomes. The current review
has demonstrated the evolution of and currently available evidence for stemless rTSA
and indicates that shoulder surgeons may consider adopting stemless rTSA, especially for
patients with sufficient bone quality:
•
The current meta-analysis demonstrated that the pooled overall complication and
revision rates were 14.3% and 6.3%, respectively;
•
Comparative studies may indicate equivalent functional recovery and incidence of
complications between stemmed and stemless prostheses;
•
Further long-term studies comparing the survivorship between stemless and stemmed
rTSAs are required to determine the gold standard for selecting stemless rTSA.
Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/jcm13133813/s1, Table S1. Quality assessment of included studies
using the JBI Critical Appraisal Tools for JBI Systematic Reviews.
Author Contributions: Conceptualization, T.H.; methodology, T.H.; investigation, T.H., R.M., J.K.,
Y.O. and W.H.; writing—original draft preparation, T.H.; writing—review and editing, R.M., J.K.,
G.M. and W.H.; visualization, T.H.; supervision, T.H. and G.M.; project administration, T.H. All
authors have read and agreed to the published version of the manuscript.

J. Clin. Med. 2024,13, 3813 12 of 15
Funding: The research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: Taku Hatta: Zimmer Biomet, consultant.
References
1.
Walch, G.; Mesiha, M.; Boileau, P.; Edwards, T.B.; Levigne, C.; Moineau, G.; Young, A. Three-dimensional assessment of the
dimensions of the osteoarthritic glenoid. Bone Jt. J. 2013,95-B, 1377–1382. [CrossRef] [PubMed]
2.
Grammont, P.M.; Baulot, E. The classic: Delta shoulder prosthesis for rotator cuff rupture. 1993. Clin. Orthop. Relat. Res. 2011,469,
2424. [CrossRef] [PubMed]
3.
Baulot, E.; Sirveaux, F.; Boileau, P. Grammont’s idea: The story of Paul Grammont’s functional surgery concept and the
development of the reverse principle. Clin. Orthop. Relat. Res. 2011,469, 2425–2431. [CrossRef] [PubMed]
4.
Trofa, D.; Rajaee, S.S.; Smith, E.L. Nationwide trends in total shoulder arthroplasty and hemiarthroplasty for osteoarthritis. Am. J.
Orthop. 2014,43, 166–172.
5.
Gao, R.; van der Merwe, M.; Coleman, B.; Boyle, M.J.; Frampton, C.M.; Hirner, M. Outcomes of reverse shoulder arthroplasty in
patients under 55 years old: Results from the New Zealand joint registry. Shoulder Elb. 2023,15, 69–74. [CrossRef] [PubMed]
6.
Kim, H.G.; Kim, S.H.; Kim, S.C.; Park, J.H.; Kim, J.S.; Kim, B.T.; Lee, S.M.; Yoo, J.C. Return to Sports Activity After Reverse Total
Shoulder Arthroplasty. Orthop. J. Sports Med. 2023,11, 23259671231208959. [CrossRef]
7.
Su, F.; Kucirek, N.; Goldberg, D.; Feeley, B.T.; Ma, C.B.; Lansdown, D.A. Incidence, risk factors, and complications of acromial
stress fractures after reverse total shoulder arthroplasty. J. Shoulder Elb. Surg. 2024,33, 65–72. [CrossRef]
8.
Bacle, G.; Nove-Josserand, L.; Garaud, P.; Walch, G. Long-Term Outcomes of Reverse Total Shoulder Arthroplasty: A Follow-up
of a Previous Study. J. Bone Jt. Surg. 2017,99, 454–461. [CrossRef] [PubMed]
9.
Cuff, D.J.; Pupello, D.R.; Santoni, B.G.; Clark, R.E.; Frankle, M.A. Reverse Shoulder Arthroplasty for the Treatment of Rotator Cuff
Deficiency: A Concise Follow-up, at a Minimum of 10 Years, of Previous Reports. J. Bone Jt. Surg. 2017,99, 1895–1899. [CrossRef]
10.
Favard, L.; Levigne, C.; Nerot, C.; Gerber, C.; De Wilde, L.; Mole, D. Reverse prostheses in arthropathies with cuff tear: Are
survivorship and function maintained over time? Clin. Orthop. Relat. Res. 2011,469, 2469–2475. [CrossRef]
11.
Mazaleyrat, M.; Favard, L.; Boileau, P.; Berhouet, J. Humeral osteolysis after reverse shoulder arthroplasty using cemented or
cementless stems comparative retrospective study with a mean follow-up of 9 years. Orthop. Traumatol. Surg. Res. 2021,107,
102916. [CrossRef] [PubMed]
12.
Ek, E.T.; Neukom, L.; Catanzaro, S.; Gerber, C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears
in patients younger than 65 years old: Results after five to fifteen years. J. Shoulder Elb. Surg. 2013,22, 1199–1208. [CrossRef]
[PubMed]
13.
Guery, J.; Favard, L.; Sirveaux, F.; Oudet, D.; Mole, D.; Walch, G. Reverse total shoulder arthroplasty. Survivorship analysis of
eighty replacements followed for five to ten years. J. Bone Jt. Surg. 2006,88, 1742–1747. [CrossRef]
14. Cuff, D.; Clark, R.; Pupello, D.; Frankle, M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency: A concise
follow-up, at a minimum of five years, of a previous report. J. Bone Jt. Surg. 2012,94, 1996–2000. [CrossRef] [PubMed]
15.
Chelli, M.; Boileau, P.; Domos, P.; Clavert, P.; Berhouet, J.; Collin, P.; Walch, G.; Favard, L. Survivorship of Reverse Shoulder
Arthroplasty According to Indication, Age and Gender. J. Clin. Med. 2022,11, 2677. [CrossRef] [PubMed]
16.
Porcellini, G.; Combi, A.; Merolla, G.; Bordini, B.; Stea, S.; Zanoli, G.; Paladini, P. The experience of the RIPO, a shoulder prosthesis
registry with 6-year follow-up. Musculoskelet. Surg. 2018,102, 273–282. [CrossRef] [PubMed]
17.
Berth, A.; Pap, G. Stemless shoulder prosthesis versus conventional anatomic shoulder prosthesis in patients with osteoarthritis:
A comparison of the functional outcome after a minimum of two years follow-up. J. Orthop. Traumatol. 2013,14, 31–37. [CrossRef]
[PubMed]
18.
Magosch, P.; Lichtenberg, S.; Habermeyer, P. Survival of stemless humeral head replacement in anatomic shoulder arthroplasty:
A prospective study. J. Shoulder Elb. Surg. 2021,30, e343–e355. [CrossRef]
19.
Maier, M.W.; Lauer, S.; Klotz, M.C.; Bulhoff, M.; Spranz, D.; Zeifang, F. Are there differences between stemless and conventional
stemmed shoulder prostheses in the treatment of glenohumeral osteoarthritis? BMC Musculoskelet. Disord. 2015,16, 275.
[CrossRef]
20.
Simon, M.J.K.; Coghlan, J.A.; Hughes, J.; Wright, W.; Dallalana, R.J.; Bell, S.N. Mid-term outcomes of a stemless ceramic head
anatomic total shoulder replacement. BMC Musculoskelet. Disord. 2022,23, 50. [CrossRef] [PubMed]
21.
Spranz, D.M.; Bruttel, H.; Wolf, S.I.; Zeifang, F.; Maier, M.W. Functional midterm follow-up comparison of stemless total shoulder
prostheses versus conventional stemmed anatomic shoulder prostheses using a 3D-motion-analysis. BMC Musculoskelet. Disord.
2017,18, 478. [CrossRef] [PubMed]
22.
Uschok, S.; Magosch, P.; Moe, M.; Lichtenberg, S.; Habermeyer, P. Is the stemless humeral head replacement clinically and
radiographically a secure equivalent to standard stem humeral head replacement in the long-term follow-up? A prospective
randomized trial. J. Shoulder Elb. Surg. 2017,26, 225–232. [CrossRef] [PubMed]

J. Clin. Med. 2024,13, 3813 13 of 15
23.
Moroder, P.; Ernstbrunner, L.; Zweiger, C.; Schatz, M.; Seitlinger, G.; Skursky, R.; Becker, J.; Resch, H.; Krifter, R.M. Short to
mid-term results of stemless reverse shoulder arthroplasty in a selected patient population compared to a matched control group
with stem. Int. Orthop. 2016,40, 2115–2120. [CrossRef] [PubMed]
24.
Liu, E.Y.; Kord, D.; Horner, N.S.; Leroux, T.; Alolabi, B.; Khan, M. Stemless anatomic total shoulder arthroplasty: A systematic
review and meta-analysis. J. Shoulder Elb. Surg. 2020,29, 1928–1937. [CrossRef] [PubMed]
25.
Willems, J.I.P.; Hoffmann, J.; Sierevelt, I.N.; van den Bekerom, M.P.J.; Alta, T.D.W.; van Noort, A. Results of stemless shoulder
arthroplasty: A systematic review and meta-analysis. EFORT Open Rev. 2021,6, 35–49. [CrossRef]
26.
Sears, B.W.; Creighton, R.A.; Denard, P.J.; Griffin, J.W.; Lichtenberg, S.; Lederman, E.S.; Werner, B.C. Stemless components lead
to improved radiographic restoration of humeral head anatomy compared with short-stemmed components in total shoulder
arthroplasty. J. Shoulder Elb. Surg. 2023,32, 240–246. [CrossRef] [PubMed]
27.
Cunningham, D.E.; Spangenberg, G.W.; Langohr, G.D.G.; Athwal, G.S.; Johnson, J.A. Stemless reverse humeral component
neck-shaft angle has an influence on initial fixation. J. Shoulder Elb. Surg. 2024,33, 164–171. [CrossRef] [PubMed]
28.
Rojas, J.T.; Jost, B.; Hertel, R.; Zipeto, C.; Van Rooij, F.; Zumstein, M.A. Patient-specific instrumentation reduces deviations
between planned and postosteotomy humeral retrotorsion and height in shoulder arthroplasty. J. Shoulder Elb. Surg. 2022,31,
1929–1937. [CrossRef] [PubMed]
29.
Ajibade, D.A.; Yin, C.X.; Hamid, H.S.; Wiater, B.P.; Martusiewicz, A.; Wiater, J.M. Stemless reverse total shoulder arthroplasty: A
systematic review. J. Shoulder Elb. Surg. 2022,31, 1083–1095. [CrossRef]
30.
Kadum, B.; Mafi, N.; Norberg, S.; Sayed-Noor, A.S. Results of the Total Evolutive Shoulder System (TESS): A single-centre study
of 56 consecutive patients. Arch. Orthop. Trauma Surg. 2011,131, 1623–1629. [CrossRef]
31.
Atoun, E.; Van Tongel, A.; Hous, N.; Narvani, A.; Relwani, J.; Abraham, R.; Levy, O. Reverse shoulder arthroplasty with a short
metaphyseal humeral stem. Int. Orthop. 2014,38, 1213–1218. [CrossRef]
32.
Leonidou, A.; Virani, S.; Buckle, C.; Yeoh, C.; Relwani, J. 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. Eur. J. Orthop. Surg. Traumatol. 2020,30, 89–96. [CrossRef]
33.
Munn, Z.; Moola, S.; Lisy, K.; Riitano, D.; Tufanaru, C. Methodological guidance for systematic reviews of observational
epidemiological studies reporting prevalence and cumulative incidence data. Int. J. Evid. Based Healthc. 2015,13, 147–153.
[CrossRef]
34.
Higgins, J.P.; Thompson, S.G.; Deeks, J.J.; Altman, D.G. Measuring inconsistency in meta-analyses. BMJ 2003,327, 557–560.
[CrossRef]
35.
Egger, M.; Smith, G.D.; Phillips, A.N. Meta-analysis: Principles and procedures. BMJ 1997,315, 1533–1537. [CrossRef] [PubMed]
36.
Churchill, R.S.; Athwal, G.S. Stemless shoulder arthroplasty-current results and designs. Curr. Rev. Musculoskelet. Med. 2016,9,
10–16. [CrossRef] [PubMed]
37.
Churchill, R.S.; Chuinard, C.; Wiater, J.M.; Friedman, R.; Freehill, M.; Jacobson, S.; Spencer, E., Jr.; Holloway, G.B.; Wittstein,
J.; Lassiter, T.; et al. Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A
Prospective Two-Year Multicenter Study. J. Bone Jt. Surg. 2016,98, 552–560. [CrossRef] [PubMed]
38.
Harmer, L.; Throckmorton, T.; Sperling, J.W. Total shoulder arthroplasty: Are the humeral components getting shorter? Curr. Rev.
Musculoskelet. Med. 2016,9, 17–22. [CrossRef]
39. Teissier, J.; Teissier, P. Stemless shoulder arthroplasty. Orthop. Traumatol. Surg. Res. 2023,109, 103460. [CrossRef]
40.
Ballas, R.; Béguin, L. Results of a stemless reverse shoulder prosthesis at more than 58 months mean without loosening. J. Shoulder
Elb. Surg. 2013,22, e1–e6. [CrossRef]
41.
Beck, S.; Patsalis, T.; Busch, A.; Dittrich, F.; Dudda, M.; Jager, M.; Wegner, A. Long-term results of the reverse Total Evolutive
Shoulder System (TESS). Arch. Orthop. Trauma Surg. 2019,139, 1039–1044. [CrossRef] [PubMed]
42.
Kadum, B.; Mukka, S.; Englund, E.; Sayed-Noor, A.; Sjoden, G. Clinical and radiological outcome of the Total Evolutive Shoulder
System (TESS(R)) reverse shoulder arthroplasty: A prospective comparative non-randomised study. Int. Orthop. 2014,38,
1001–1006. [CrossRef] [PubMed]
43.
Teissier, P.; Teissier, J.; Kouyoumdjian, P.; Asencio, G. The TESS reverse shoulder arthroplasty without a stem in the treatment of
cuff-deficient shoulder conditions: Clinical and radiographic results. J. Shoulder Elb. Surg. 2015,24, 45–51. [CrossRef] [PubMed]
44.
von Engelhardt, L.V.; Manzke, M.; Filler, T.J.; Jerosch, J. Short-term results of the reverse Total Evolutive Shoulder System (TESS)
in cuff tear arthropathy and revision arthroplasty cases. Arch. Orthop. Trauma Surg. 2015,135, 897–904. [CrossRef] [PubMed]
45.
Levy, O.; Narvani, A.; Hous, N.; Abraham, R.; Relwani, J.; Pradhan, R.; Bruguera, J.; Sforza, G.; Atoun, E. Reverse shoulder
arthroplasty with a cementless short metaphyseal humeral implant without a stem: Clinical and radiologic outcomes in
prospective 2- to 7-year follow-up study. J. Shoulder Elb. Surg. 2016,25, 1362–1370. [CrossRef]
46.
Virani, S.; Holmes, N.; Al-Janabi, M.; Watts, C.; Brooks, C.; Relwani, J. Intermediate to long term results of stemless metaphyseal
reverse shoulder arthroplasty: A five to nine year follow-up. J. Clin. Orthop. Trauma 2021,23, 101611. [CrossRef]
47.
Nabergoj, M.; Ladermann, A.; Authom, T.; Beaudouin, E.; Azar, M.; Wahab, H.; Leger, O.; Haight, H.; Harris, H.; Collin, P.
Stemless reverse shoulder arthroplasty: Clinical and radiologic outcomes with minimum 2 years’ follow-up. J. Shoulder Elb. Surg.
2023,32, e464–e474. [CrossRef] [PubMed]
48.
Galhoum, M.S.; Elsheikh, A.A.; Wood, A.; Yin, Q.; Frostick, S.P. Anatomic and Reverse Stemless Shoulder Arthroplasty: Functional
and Radiological Evaluation. J. Shoulder Elb. Arthroplast. 2022,6, 24715492221118765. [CrossRef]

J. Clin. Med. 2024,13, 3813 14 of 15
49.
Schoch, C.; Plath, J.E.; Ambros, L.; Geyer, M.; Dittrich, M. Clinical and radiological outcomes of a stemless reverse shoulder
implant: A two-year follow-up in 56 patients. JSES Int. 2021,5, 1042–1048. [CrossRef]
50.
Rosso, C.; Kränzle, J.; Delaney, R.; Grezda, K. Radiologic, clinical, and patient-reported outcomes in stemless reverse shoulder
arthroplasty at a mean of 46 months. J. Shoulder Elb. Surg. 2024,33, 1324–1330. [CrossRef]
51.
A’Court, J.J.; Chatindiara, I.; Fisher, R.; Poon, P.C. Stemless reverse arthroplasty: Does the stemless compare to a conventional
stemmed implant? Clinical and radiographic evaluation 2 years minimum follow up. J. Shoulder Elb. Surg. 2024, online ahead of
print. [CrossRef] [PubMed]
52.
Schwabe, M.T.; Hannon, C.P. The Evolution, Current Indications and Outcomes of Cementless Total Knee Arthroplasty. J. Clin.
Med. 2022,11, 6608. [CrossRef] [PubMed]
53.
Furlong, R.J.; Osborn, J.F. Fixation of hip prostheses by hydroxyapatite ceramic coatings. J. Bone Jt. Surg. Br. 1991,73, 741–745.
[CrossRef]
54.
Toksvig-Larsen, S.; Jorn, L.P.; Ryd, L.; Lindstrand, A. Hydroxyapatite-enhanced tibial prosthetic fixation. Clin. Orthop. Relat. Res.
2000,370, 192–200. [CrossRef] [PubMed]
55.
Dumbleton, J.; Manley, M.T. Hydroxyapatite-coated prostheses in total hip and knee arthroplasty. J. Bone Jt. Surg. 2004,86,
2526–2540. [CrossRef] [PubMed]
56.
Carlsson, A.; Bjorkman, A.; Besjakov, J.; Onsten, I. Cemented tibial component fixation performs better than cementless fixation:
A randomized radiostereometric study comparing porous-coated, hydroxyapatite-coated and cemented tibial components over 5
years. Acta Orthop. 2005,76, 362–369. [CrossRef] [PubMed]
57.
Winther, N.S.; Jensen, C.L.; Jensen, C.M.; Lind, T.; Schroder, H.M.; Flivik, G.; Petersen, M.M. Comparison of a novel porous
titanium construct (Regenerex(R)) to a well proven porous coated tibial surface in cementless total knee arthroplasty—A
prospective randomized RSA study with two-year follow-up. Knee 2016,23, 1002–1011. [CrossRef] [PubMed]
58.
Ryan, W.K.; Vander Voort, W.D.; Saad, M.A.; Wu, E.; Garcia-Nolen, T.C.; Bayne, C.O.; Szabo, R.M. The effect of shoulder prosthesis
stem length on failure due to torsional loading. A biomechanical study in composite humeri. JSES Int. 2023,7, 819–826. [CrossRef]
59.
Colasanti, C.A.; Lin, C.C.; Simovitch, R.W.; Virk, M.S.; Zuckerman, J.D. International consensus statement on the management of
glenohumeral arthritis in patients ≤50 years old. J. Shoulder Elb. Surg. 2023,32, e329–e342. [CrossRef]
60.
McBride, A.P.; Ross, M.; Duke, P.; Hoy, G.; Page, R.; Dyer, C.; Taylor, F. Shoulder joint arthroplasty in young patients: Analysis of
8742 patients from the Australian Orthopaedic Association National Joint Replacement Registry. Shoulder Elb. 2023,15, 41–52.
[CrossRef]
61.
Hatta, T.; Werthel, J.D.; Wagner, E.R.; Itoi, E.; Steinmann, S.P.; Cofield, R.H.; Sperling, J.W. Effect of smoking on complications
following primary shoulder arthroplasty. J. Shoulder Elb. Surg. 2017,26, 1–6. [CrossRef]
62.
Gruson, K.I.; Lo, Y.; Rothchild, E.; Shah, P.; Tabeayo, E.; Qawasmi, F. Does Morbid Obesity (BMI >/=40 kg/m
2
) Impact Operative
Time, Blood Loss, Length of Stay, or Complications Following Anatomic Total Shoulder Arthroplasty? Arch. Bone Jt. Surg. 2023,
11, 389–397. [CrossRef]
63.
Theodoulou, A.; Krishnan, J.; Aromataris, E. Risk of poor outcomes in patients who are obese following total shoulder arthroplasty
and reverse total shoulder arthroplasty: A systematic review and meta-analysis. J. Shoulder Elb. Surg. 2019,28, e359–e376.
[CrossRef] [PubMed]
64.
Phillips, C.; Pasqualini, I.; Barros, H.; Menendez, M.E.; Horinek, J.L.; Ardebol, J.; Denard, P.J. Lesser Tuberosity Osteotomy
Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by
Body Mass Index and Tobacco Use. J. Clin. Med. 2023,12, 834. [CrossRef]
65.
Zdravkovic, V.; Kaufmann, R.; Neels, A.; Dommann, A.; Hofmann, J.; Jost, B. Bone mineral density, mechanical properties, and
trabecular orientation of cancellous bone within humeral heads affected by advanced shoulder arthropathy. J. Orthop. Res. 2020,
38, 1914–1919. [CrossRef]
66. Leafblad, N.; Asghar, E.; Tashjian, R.Z. Innovations in Shoulder Arthroplasty. J. Clin. Med. 2022,11, 2799. [CrossRef] [PubMed]
67.
Hatta, T.; Shinagawa, K.; Kawakami, J.; Kanazawa, K.; Hayakawa, T.; Yamamoto, N.; Yamakado, K. A survey and biomechanical
analysis of the feasibility of the thumb test for determining the cancellous bone quality for stemless shoulder prosthesis. J. Orthop.
Surg. 2023,31, 10225536231218869. [CrossRef]
68.
Athwal, G.S. Spare the Canal: Stemless Shoulder Arthroplasty Is Finally Here: Commentary on an article by R. Sean Churchill,
MD; et al.: “Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System. A Prospective
Two-Year Multicenter Study”. J. Bone Jt. Surg. 2016,98, e28. [CrossRef]
69.
Favre, P.; Henderson, A.D. Prediction of stemless humeral implant micromotion during upper limb activities. Clin. Biomech 2016,
36, 46–51. [CrossRef]
70.
Favre, P.; Seebeck, J.; Thistlethwaite, P.A.; Obrist, M.; Steffens, J.G.; Hopkins, A.R.; Hulme, P.A.
In vitro
initial stability of a
stemless humeral implant. Clin. Biomech 2016,32, 113–117. [CrossRef]
71.
Micheloni, G.M.; Salmaso, G.; Berti, M.; Bortolato, S.; Zecchinato, G.; Momoli, A.; Giaretta, S. Cementless metaphyseal reverse
shoulder arthroplasty: Our preliminary experience. Acta Biomed. 2019,90, 47–53. [CrossRef] [PubMed]
72.
Romeo, A.A.; Erickson, B.J.; Costouros, J.; Long, N.; Klassen, J.; Araghi, A.; Brown, J.; Setter, K.; Port, J.; Tyndall, W.; et al.
Eclipse stemless shoulder prosthesis vs. Univers II shoulder prosthesis: A multicenter, prospective randomized controlled trial. J.
Shoulder Elb. Surg. 2020,29, 2200–2212. [CrossRef] [PubMed]

J. Clin. Med. 2024,13, 3813 15 of 15
73.
Wiater, J.M.; Levy, J.C.; Wright, S.A.; Brockmeier, S.F.; Duquin, T.R.; Wright, J.O.; Codd, T.P. Prospective, Blinded, Randomized
Controlled Trial of Stemless Versus Stemmed Humeral Components in Anatomic Total Shoulder Arthroplasty: Results at
Short-Term Follow-up. J. Bone Jt. Surg. 2020,102, 1974–1984. [CrossRef]
74.
Mariotti, U.; Motta, P.; Stucchi, A.; Ponti di Sant’Angelo, F. Stemmed versus stemless total shoulder arthroplasty: A preliminary
report and short-term results. Musculoskelet. Surg. 2014,98, 195–200. [CrossRef] [PubMed]
75.
Looney, A.M.; Day, J.; Johnson, J.L.; Johnston, P.S. Outcomes Between Stemmed and Stemless Total Shoulder Arthroplasty: A
Systematic Review and Meta-analysis of Randomized Controlled Trials. J. Am. Acad. Orthop. Surg. Glob. Res. Rev. 2022,6,
e22.00077. [CrossRef]
76.
Parada, S.A.; Flurin, P.H.; Wright, T.W.; Zuckerman, J.D.; Elwell, J.A.; Roche, C.P.; Friedman, R.J. Comparison of complication
types and rates associated with anatomic and reverse total shoulder arthroplasty. J. Shoulder Elb. Surg. 2021,30, 811–818.
[CrossRef] [PubMed]
77.
Rajabzadeh-Oghaz, H.; Kumar, V.; Berry, D.B.; Singh, A.; Schoch, B.S.; Aibinder, W.R.; Gobbato, B.; Polakovic, S.; Elwell, J.; Roche,
C.P. Impact of Deltoid Computer Tomography Image Data on the Accuracy of Machine Learning Predictions of Clinical Outcomes
after Anatomic and Reverse Total Shoulder Arthroplasty. J. Clin. Med. 2024,13, 1273. [CrossRef] [PubMed]
78.
Habermeyer, P.; Lichtenberg, S.; Tauber, M.; Magosch, P. Midterm results of stemless shoulder arthroplasty: A prospective study.
J. Shoulder Elb. Surg. 2015,24, 1463–1472. [CrossRef] [PubMed]
79. Fram, B.; Elder, A.; Namdari, S. Periprosthetic Humeral Fractures in Shoulder Arthroplasty. JBJS Rev. 2019,7, e6. [CrossRef]
80.
Dukan, R.; Juvenspan, M.; Scheibel, M.; Moroder, P.; Teissier, P.; Werthel, J.D. Non-operative management of humeral peripros-
thetic fracture after stemless shoulder arthroplasty. Int. Orthop. 2024,48, 253–259. [CrossRef]
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