ORTHOPAEDIC SURGERY

Functional and clinical outcome of total shoulderarthroplasty with oversized glenoid

Hans-Christian Jeske • Markus Wambacher • Christian Dallapozza •

Clemens Hengg • Rebecca Schoepf • Juergen Oberladstaetter • Franz Kralinger

Received: 27 October 2011 / Published online: 9 March 2012

� Springer-Verlag 2012

Abstract

Background The Epoca-Reconstruction-(Reco)�-Glenoid

has been developed to treat patients with cuff-tear-

arthropathy. The glenoid component of this system has a

hemispheric shape that canopies the humeral head. This

design is believed to provide a stable fulcrum and restore

normal deltoid function. The purpose of this study was to

analyse strengths and disadvantages of the Epoca-Reco�-

Glenoid in cuff-tear-arthropathy patients. Changes in

functional outcome using Constant-Murley-Scoring(CMS),

CMS sub-scoring parameters and radiological outcome

were analysed. For this purpose, a classification for

radiologic lucency was proposed. Diverging results, influ-

encing factors and alternative treatment options have been

discussed to analyse weaknesses and enhance future

development of this arthroplastic model.

Materials and methods 23 patients aged 68 ± 8.4 years

with irreparable cuff-tear-arthropathy refractory to physio-

therapeutic treatment were treated with Reco-Glenoid Total-

Shoulder-Arthroplasty (TSA). Pre-operative standardized

evaluations included history, physical examination, radio-

graphs, computer tomography and clinical scorings. The

post-operative controls included physical examination with

CMS, video documentation and radiological evaluation.

Results After a median follow-up time of 38 ± 18

months, the CMS had been significantly improved (p \0.001) from (17.4 ± 5.8) to (43.2 ± 19.2) points. Signifi-

cant improvement in pain, activities of daily life, range of

motion (p \ 0.001) and power (p = 0.006) was achieved.

Significantly, inferior results in functional outcome and

higher lucency rates were observed in female patients and

in patients treated with small glenoid components. The

follow-up rate was 100 %.

Conclusion The semi-constraint reconstruction glenoid

prosthesis model in cuff-tear-arthropathy patients signifi-

cantly improves shoulder function, however, it yields

controversial results, with satisfactory results in male and

poor results in female patients. Revision rate of the female

cohort and loosening of the glenoid component in this

short-term follow-up is of concern. Further investigations

taking BMD, osteopenic conditions and influence of sur-

face area in smaller individuals into consideration are

recommended, to determine whether this is the underlying

cause of the inferior results in females.

Keywords Total shoulder arthroplasty � Loosening �Cuff-tear-arthropathy � Semi-constraint � Oversized glenoid

Introduction

Patients with painful cuff-tear arthropathy (CTA) are

extensively inhibited in their activities of daily life. In

elderly patients, this impairment of shoulder function may

even compromise their independence [33]. When physio-

therapeutic conservative treatment and debridement [6, 7]

does not achieve satisfactory functional outcome and the

rotator cuff tear [18] is irreparable, arthroplasty (and in

exceptional cases, arthrodesis) is the remaining viable

treatment option. In young patients and in older patients

with higher functional demand, treatment with hemi

shoulder arthroplasty (HSA) [37], total anatomical shoul-

der arthroplasty (TSA) [8, 12, 27, 29, 35] or reversed total

shoulder arthroplasty (RTSA) [3, 4, 19, 20] have been

H.-C. Jeske � M. Wambacher � C. Dallapozza (&) �C. Hengg � R. Schoepf � J. Oberladstaetter � F. Kralinger

Department of Traumatology and Sports Medicine, Innsbruck

Medical University, Anichstrasse 35, 6020 Innsbruck, Austria

e-mail: swede.publish@yahoo.com

123

Arch Orthop Trauma Surg (2012) 132:927–936

DOI 10.1007/s00402-012-1496-5

described. Generally TSA is believed to give good pain

relief and restore functional movement [1, 5], but in

advanced CTA results were less favourable [41]. The HSA

yields favourable results for the compensated CTA, but

there is no solution for patients with pseudoparalysis due to

anterior–superior escape [37].

In recent years, RTSA models have gained popularity

and seem to currently boast the best functional outcome

[18, 21, 38, 39], since this prosthetic design enables a

distalisation and medialisation of the prosthetic centre of

rotation [10, 19, 20]. However, notching with consecutive

glenoid loosening, instability and infection are still com-

mon problems in this prosthetic design [4, 15, 30, 36, 40].

The Reco Glenoid (RG) (Fig. 1) is thought to provide a

stable fulcrum, due to a semi-constraint design. Because

the RG canopies the humeral head, it is believed to inhibit

an anterior–superior escape. The RG shows in its canopy-

ing construction resemblance with the acetabular roof cup

design of the revision hip prosthesis designed by R. Ganz

[16, 22]. The humeral head component is thereby reduced

from its upward migrated position into a centered position,

restoring the normal deltoid lever arm. The solid tripod

fixation of the glenoid is further believed to contribute to

the reduced loosening rate of this model.

In current literature, there is no pre-existent classifica-

tion evaluating loosening rates on glenoid prosthetic types

with a tripod fixation (e.g. acromial, coracoid and glenoid

fixation). We therefore developed a radiological classifi-

cation (Fig. 2), that assessed radiolucency of this prosthetic

model based on radiolucency classifications of Franklin

et al. [14] and Lazerus et al. [28] (Table 1). The proposed

classification is a scientific classification, to enable an exact

evaluation of the prosthetic loosening. Since for this pur-

pose exact differentiations are necessary, the classification

is divided into eight different degrees of lucency. For

practicability in a clinical setting, we suggest a ‘‘simplified

lucency classification’’ on the basis of the scientific clas-

sification, where Grade 0 is identical. In the simplified

classification ‘‘Grade 1’’ expresses an ‘‘incomplete

lucency’’, corresponding to Grades 1–4 in the original

classification. ‘‘Grade 2’’; ‘‘complete lucency without gross

loosening’’ corresponds to Grades 5 and 6 and finally

‘‘Grade 3’’; ‘‘gross loosening’’ is identical to Grade 7 in the

original classification (Table 1).

In this study, we wanted to evaluate the functional and

radiological outcome of patients with CTA (Hamada [23],

Loew [31]) after treatment with a semi-constraint TSA

prosthetic model (Epoca� Shoulder Prosthesis, Synthes

GmbH, Solothurn, Switzerland) combined with an over-

sized glenoid component (Epoca Reco� Glenoid, Synthes

GmbH, Solothurn, Switzerland). Further influencing fac-

tors on outcome parameters, such as gender, pathology and

prosthesis component sizes were also analysed.

Materials and methods

This study is a consecutive clinical level IV study [2, 34]

approved by a local ethics committee (No. UN3850-284/

4.7).

23 patients (15 women and 8 men (35 %)) with CTA

(Hamada types II–V, Loew types I–III) (Tables 2, 3, 4, 5, 6)

and a mean age of 68 ± 8.4 years, with chronic irreparable

CTA and biomechanically decompensated (pseudoparalyt-

ic) shoulder function refractory to physiotherapeutic treat-

ment, were treated with RG-TSA. 12 patients were treated

after primary CTA and 11 patients were treated after sec-

ondary CTA (post-infection, post-trauma, post-failed rotator

cuff reconstruction or HSA treatment) (Tables 2, 3).

Deltoid muscle impairment was considered contraindi-

cated for this procedure. The operations were performed

between 2003 and 2008. The mean follow-up time post-

surgery was 37.5 (±18) months and the follow-up rate was

100 %.

Pre-operative assessment

Pre-operative assessment included X-rays in three planes

(a.p., axial and outlet view), CT scans and functional

scoring. The pre-operative shoulder function was evaluated

using the absolute Constant Murley score (CMS) and ‘Age-

and Gender-Related’ CMS [9]. The patients’ pre-operativeFig. 1 Screw positioning as recommended by the manufacturer

(Synthes GmbH, Solothurn, Switzerland)

928 Arch Orthop Trauma Surg (2012) 132:927–936

123

diagnoses, and Hamada and Loew classifications, are listed

in Tables 2 and 3.

Surgical technique

The patient was placed in a ‘‘beach-chair position’’ and a

delto-pectoral surgical approach was used. The remnants of

the subscapularis tendon were secured with stay sutures

before surgical release. Soft tissue tenodesis of the biceps

tendon, if present, to the pectoralis major tendon was

performed routinely. Full subperiostal humeral release and

consecutive instrumentation of the humeral component

were followed by capsular release for the necessary sur-

gical exposure. It is essential that the glenoid, acromion

and coracoid process are accessible. The reaming was

performed using a standard Epoca� Glenoid reamer. With

a motorized burr, the superior unreamed glenoid was pre-

pared until flush full-contact bony fit of the largest RG

Fig. 2 A radiological lucency

classification to evaluate

loosening of prosthetic glenoid

components with tripod fixation

(e.g. Reco Glenoid�)

Arch Orthop Trauma Surg (2012) 132:927–936 929

123

metalback component to the acromion, glenoid and cora-

coid was established. At least six 3.5 mm screws (Fig. 3)

secured the component. A centre hole for the glenoid inlay

was drilled. The RG provides a tripod anchorage with

divergent screws placed in the coracoid, the acromion and

the glenoid. The osseous contact surface of the metalback

is coated with a hydroxyapatite layer. At this point of the

surgery, reduction with trial inlays could be performed.

The definite inlay was cemented (Fig. 4) and the remnants

of the detached subscapularis were meticulously reinserted

after implantation of the definite humeral component.

Post-operative treatment

Passive and active assisted range of motion (ROM) was

commenced following drain removal on the second post-

operative day. Shoulder sling-free active ROM was started

from the seventh post-operative week. Full load bearing

was restricted for 3-month post-surgery.

Post-operative assessment

Shoulder function was assessed by CMS and ‘‘Age- and

Gender-Related’’ CMS. Power was measured with a Not-

tingham Mecmesin� (Slinfold, West Sussex, UK) myom-

eter. X-ray examinations in three plains (anterior-posterior,

outlet and axial views) were performed to assess prosthetic

loosening, in accordance with the proposed classification.

These examinations were performed 6- and 12-month post-

surgery, and at final follow-up.

Since there is no existing protocol evaluating the osse-

ous component loosening of a prosthetic component such

as the RG, we adapted a protocol designed by Franklin

et al. [14] (Table 1) for the keeled glenoid prosthetic

components, and from Lazarus et al. [28] developed for

pegged prosthetic glenoid components (Table 1). The

degree of loosening was estimated by the radiological

lucency. For scientific evaluations, the lucency was repre-

sented in 8� (Fig. 2; Table 1). This classification was

simplified for clinical practice. In the simplified classifi-

cation, the lucency was represented in 4� (Fig. 2; Table 1).

Statistical analysis

Distribution of data was determined by Kolmogorov–

Smirnov analysis. Our null hypothesis (H0) was that there

would be no differences in functional shoulder outcome

scores pre- and post-operatively, and no correlation

between functional outcome scores and glenoid size,

functional outcome scores and gender or primary pathology

(primary or secondary CTA). The independent samples

T test was used for normally distributed data, and the Mann–

Whitney U test was used to access non-normally distributed

data to assess level of significance. The Pearson Correlation

Table 1 Comparison of radiological lucency classifications to evaluate prosthetic loosening

Grade Findings

Franklin et al. Lazarus et al. Jeske et al. Simplified

Jeske, et al.

0 No radiolucency

1 Radiolucency at superior or

inferior flange

Incomplete radiolucency around one or

two pegs

Incomplete radiolucency line of

acromial and coracoid screw fixation

without glenoid loosening

Incomplete

radiolucency

2 Incomplete radiolucency at keel Complete radiolucency (B2 mm wide)

around one peg only, with or without

incomplete radiolucency around

another peg

Complete radiolucency line around

the screws of the acromial and

coracoid fixation without glenoid

loosening

Complete

radiolucency

without gross

loosening

3 Complete radiolucency (B2 mm

wide) around the keel

Complete radiolucency (B2 mm wide)

around two or more pegs

Incomplete radiolucency around

acromial, coracoid and glenoid

components

Gross

loosening

4 Complete radiolucency ([2 mm

wide) around the keel

Complete radiolucency ([2 mm wide)

around two or more pegs

Complete radiolucency around

acromial and coracoid fixation and

incomplete radiolucency around

glenoid components

5 Gross loosening Gross loosening Complete radiolucency around

acromial and coracoid fixation and

glenoid components (B2 mm wide)

6 – – Complete radiolucency around

acromial and coracoid fixation and

glenoid components ([2 mm wide)

7 – – Gross loosening

930 Arch Orthop Trauma Surg (2012) 132:927–936

123

Coefficient was used to test correlation of variables for

normally distributed data. Unless otherwise noted, data are

presented as mean ± SD. Statistical significance was set at

a 5 % level. IBM SPSS statistics 20.0 software (IBM

Armonk, NY, USA) was used for all analyses.

Results

Clinical outcome

Post-surgery, the mean overall CMS of patients in this

study improved from (17.4 ± 5.8) to (43.2 ± 19.2) points

Table 2 All patients separately represented with age, gender, follow-

up time, pre- and post-operative absolute CMS, CTA according to

Hamada- and Loew-classification, lucency classification according to

Jeske, Reco Glenoid sizes, primary (p) and (s) secondary CTA as

indications for surgery and post-operative complications with the

post-operative time marked for the revision surgeries (M months)

ID Age Sex FU CS pre CS post Hamada Loew Jeske RG size Indication Complication/revision

1 74 # 25 14 33 2 2 2 50 p

2 56 $ 60 16 47 4 3 4 42 s

3 72 # 69 29 79 3 2 2 50 p

4 77 # 26 23 45 5 2 0 52 s

5 69 $ 32 12 29 5 3 3 42 s

6 62 $ 11 18 36 5 3 4 46 p

7 71 $ 39 19 20 5 3 4 42 p

8 79 $ 48 21 48 5 3 3 42 s

9 49 # 12 16 52 3 2 1 50 s

10 75 $ 27 16 21 4 3 6 42 p Loosening 11 M

11 73 $ 8 12 37 4 3 4 42 p

12 76 $ 29 12 30 3 3 6 44 s

13 68 $ 14 8 33 5 2 6 42 s Loosening 18 M

14 61 # 31 19 63 4 2 1 48 p

15 77 $ 54 19 41 3 3 3 42 s

16 71 $ 36 16 43 4 3 6 42 p Loosening 36 M

17 56 $ 25 25 87 5 3 2 50 p

18 67 # 23 21 70 4 3 1 48 s

19 75 # 22 7 57 2 3 1 54 s

20 71 $ 65 10 30 5 3 1 42 s

21 58 $ 54 27 14 5 3 6 42 p Loosening 42 M

22 56 # 45 23 58 4 3 3 46 p

23 72 $ 60 16 21 4 3 5 42 p Trauma 12 M

Table 5 Radiological evaluations of CTA according to Hamada et al.

[22]

Hamada classification

Grade I AHD [ 6 mm

Grade II AHD \ 6 mm

Grade III Grade II ? acetabulization

Grade VI Grade III ? narrowing of the GH joint

Grade V Grade IV ? collapse of the humeral head

AHD acromiohumeral distance, GH gleno-humeral

Table 4 Pre-, post-operative CMS and CMS improvement after

RECO-Glenoid arthroplasty in patients with primary and secondary

CTA

Significance

(p)

Parameters Primary

CTA

Secondary

CTA

n.s. Pre-operative CMS 19.5 ± 5.4 15.0 ± 5.6

n.s. Post-operative CMS 42.7 ± 24.1 43.8 ± 12.7

n.s. Constant score

improvement

23.2 ± 22.0 28.8 ± 11.7

Table 3 Pre-operative assessment of CTA pathology and classifica-

tion according to Hamada- and Loew, described as number of patients

(a total of 23 patients)

Grade Hamada Loew CTA pathology n

I – – Primary CTA 12

II 2 6 Status post-rotator cuff repair 4

III 4 17 Post-traumatic (post-osteosynthesis) 5

IV 8 Status post-infection 1

V 9 Status post-HSA 1

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(p \ 0.001). The CMS of the injured side was pre-opera-

tively on average 27 % of the contralateral side. This score

increased significantly (p \ 0.001) to an average of 72 %

at the latest follow-up. The mean ‘Age- and Gender-

Related’ CMS more than doubled from the pre-operative

evaluation (20.4 (±6.7) points) to the evaluation made at

the final follow-up (50.8(±21.9)) (p \ 0.001).

CMS sub-scoring parameters

Pain was significantly reduced (p \ 0.001), as the mean

CMS improved from 2.4 (±3.7) to 10.9 (±3.9) points

(maximum 15 points, for total pain relief).

Activities of daily life also significantly improved

(p \ 0.001)—the mean CMS increased from 6.0 (±1.7) to

12.7(±4.8) (maximum 20 points).

ROM increased significantly (p \ 0.001), with a mean

CMS increase from 9.1 (±3.3) to 17.0 (±9.4) (maximum

40 points).

Power in abduction increased from an average of 0.7

(±1.6) to 2.7 (±3.3) points measured by CMS (p = 0.006)

(maximum 25 points).

Abduction increased significantly (p \ 0.001) from 47

(±25) to 75 (±41) degrees.

Flexion increased significantly (p = 0.007) from 52

(±25) to 75 (±42) degrees. External rotation at 0� and 90�

Table 6 Symptom-based classification of CTA according to Loew et al. [30]

Loew classification

Type Morphology Character Symptomatic Radiological pathology

I Arthritic Stable Pain under load and motion and on

ADLs

Cranial migration of humeral head, acetabulisation,

joint space narrowing, arthritic deformities

(osteophytes), joint incongruence

II Non-reactive Unstable Highly limited ROM, temporary or

permanent glenohumeral

dislocation

Cranial migration and decentration of humeral head,

wide joint space, no or only minimal arthritic

deformities, joint congruency, insufficient joint

stability

III Necrotic Destructive Permanent rest pain, extremely

limited ROM

Cranial migration and collapse of humeral head,

glenoid erosion, joint incongruence

ADLs activities of daily life

Fig. 3 Intraoperative view after fixation of the Reco Glenoid� base

plate

Fig. 4 Intraoperative view after cementing the inlay

932 Arch Orthop Trauma Surg (2012) 132:927–936

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abduction (p \ 0.001 and p = 0.041, respectively)

increased significantly (Table 7).

Primary and secondary CTA

We did not see any differences in pre-operative CMS, post-

operative CMS or post-operative functional CMS

improvement between these two groups (Table 4).

Prosthetic size

Component size correlated with functional outcome. Lar-

ger glenoid components showed significantly higher CMS

(p = 0.001) and had significantly lower lucency rates

(p \ 0.001) according to the Jeske classification (Table 8).

Gender

Pre-operative CMS, or sub-scoring parameters of CMS and

age, was not significantly different between genders. Post-

operatively, male patients had significantly better outcomes

in activities of daily life, ROM, power, flexion, abduction

and absolute CMS (Table 9). Glenoid loosening and

polyethylene wear required surgical revision in 33 % of

female patients (n = 5), whereas no revisions were needed

in male patients. One female patient was revised to an

RTSA elsewhere (Delta III). Two patients required

removal of the loose prosthesis with suspicion of low-grade

infection, without proof of bacterial contamination. In one

patient arthroscopic tissue was harvested for culturing and

mechanical stability of the glenoid component was asses-

sed confirming loosening. Also in this case no bacterial

proof of contamination was gained. One patient required

reimplantation of the glenoid component due to traumatic

pull-out.

Radiological outcome

Radiolucency lines were observed in all but one of the

operated patients, however, 12 of these patients showed

lucency lines around the acromial and/or coracoid fixation

without glenoid loosening (Grades I–III), and 10 patients

Table 7 Pre-operative and post-operative outcome after treatment

with Epoca TSA in combination with RG

Significance

(p)

Parameters Pre-

operative

Post-

operative

\0.001 Constant score 17.4 ± 5.8 43.2 ± 19.2

\0.001 Age- and gender-related

constant score

20.4 ± 6.7 50.8 ± 21.9

\0.001 Pain 2.4 ± 3.7 10.9 ± 3.9

\0.001 ROM 9.1 ± 3.3 17.0 ± 9.4

\0.001 Activities of daily life 6.0 ± 1.7 12.7 ± 4.8

0.006 Power 0.7 ± 1.6 2.7 ± 3.3

0.007 Flexion 52.2 ± 24.6 75.0 ± 41.8

\0.001 Abduction 47.2 ± 24.7 75.4 ± 40.5

\0.001 ER at 0� abduction 3.5 ± 10.7 24.4 ± 21.4

0.041 ER at 90� abduction 24.4 ± 21.4 14.6 ± 29.7

Constant score points, flexion, abduction and external rotation are

represented in degrees

Maximum score for pain, 15; activities of daily life, 20; range of

motion (ROM), 40; power, 25

Table 8 Correlations of post-operative outcomes with RG sizes and

lucency rates. Improved functional outcomes were observed in larger-

sized glenoids

Parameters Correlation

of RG sizes

(p)

Correlation to

lucency rate by

Jeske (p)

Differences in

outcome between

genders (p)

Constant score 0.001 0.002 0.008

Pain n.s. 0.025 n.s.

Activities of

daily life

0.007 \0.001 0.004

ROM 0.002 0.024 0.017

Power \0.001 0.001 0.002

Abduction 0.002 0.016 0.011

Flexion 0.001 0.031 0.008

ER at 0�abduction

n.s. n.s. n.s.

ER at 90�abduction

0.008 0.016 n.s

Lucency rate

(Jeske)

\0.001

Arithmetic mean comparisons of radiological and clinical outcomes

between genders found better clinical outcomes in male patients

Significance is represented as p

Table 9 Differences in post-operative outcomes between male and

female patients

Significance

(p)

Parameters Female post-

operative

Male post-

operative

0.011 Constant score

improvement

19.3 ± 16.8 38.1 ± 12.4

n.s. Pain 10.0 ± 3.8 12.5 ± 3.8

0.004 Activities of daily

life

10.6 ± 3.8 16.5 ± 4.1

0.017 ROM 13.7 ± 8.8 23.3 ± 7.4

0.002 Power 1.6 ± 3.3 4.9 ± 1.9

0.008 Flexion 59.0 ± 36.2 105.0 ± 35.9

0.011 Abduction 60.3 ± 32.9 103.8 ± 39.9

Constant score points, flexion and abduction are represented in

degrees

Maximum score for pain, 15; activities of daily life, 20; range of

motion (ROM), 40; power, 25

Arch Orthop Trauma Surg (2012) 132:927–936 933

123

showed loosening of the glenoid components (Grades V–

VII). In one case, the loosening was due to direct trauma.

The radiologic lucency rates are presented in Table 2. The

functional outcome in terms of increased post-operative

CMS showed a negative correlation with the lucency rate

(p = 0.002). The lucency rate correlated with glenoid size

(p \ 0.001). Smaller sized prostheses showed higher rates

of lucency. Female patients had significantly higher

lucency rates p \ 0.001.

No neurovascular complications were observed.

Discussion

The RG-TSA Epoca� Shoulder Prosthesis System (Synthes

GmbH, Solothurn, Switzerland) represents a new semi-

constraint TSA system. Searching the ‘Medline’ literature

database via the ‘National Library of Medicine’ through

‘PubMed’, only one article presenting results using this

prosthesis system is evident [13].

In this study, we evaluated the clinical and radiological

outcome of patients with CTA treated with RG. This sys-

tem provides a stable centre of rotation (COR) due to the

semi-constraint construction, which canopies the humeral

head (Fig. 1).

Grammont et al. [19] found that a distalisation of 10 mm

would increase the deltoid momentum of 30 %, which was

one of the key precognitions that inspired him to develop

the RTSA. Due to this lengthening of the deltoid muscle,

the muscular momentum increases [10]. Further, the me-

dialisation of the COR increases the deltoid momentum

another 20 % [18, 20].

The RTSA provides a stable COR, medialising the COR

and distalising the humeral head [11]. In comparison, the

RG provides a stable COR due to a canopying construction

of the humeral head, which inhibits an anterior–superior

escape. Deltoid muscle length is restored to normal length.

Considering the therapeutic regimen of chronic CTA,

we must consider the available treatment options for our

patients. CTA should initially be conservatively treated

[24, 25], but when shoulder function becomes painfully

impaired, surgical treatment is indicated [17, 18, 38].

Arthroscopic debridement has achieved good results in

irreparable massive rotator cuff ruptures [6, 7], but not in

patients with CTA.

Generally speaking, patients with decompensated

chronic CTA are treated with arthroplasty. There are

unconstrained and constrained TSA, HSA and RTSA sys-

tems available. One major drawback of the unconstrained

TSA, especially in earlier studies, was post-operative gle-

noid loosening [1, 4, 14, 41]. Several authors have, there-

fore, considered the HSA to be the preferred therapeutic

option [42, 43]. However, Sanchez-Sotelo et al. [37]

demonstrated that the main benefit reported by patients at a

5-year follow-up post-HSA was pain relief—ROM

improved, but only modestly.

Analysis of the available literature on chronic CTA

therapy to date suggests that the best results are achieved

by RTSA models [3, 4, 18, 20, 21, 36, 38, 40]. However,

one major drawback of this prosthetic system is the inferior

notching caused by an impingement of the humeral com-

ponents against the scapular notch, which has been postu-

lated to be the main cause of glenoid loosening [18, 30, 38,

39]. According to De Wilde et al. [10], the inferior

notching can already occur at less than 16� of abduction

when using a 36-mm glenosphere. However, the fact

remains that even if the RTSA today can be considered the

best therapeutic option in the treatment of decompensated

chronic CTA, it remains associated with markedly high

complication rates such as infection, notching, polyethyl-

ene wear and loosening. In other words, this therapeutic

option provides the most optimal functional results, but is

associated with complication rates up to three times as high

as conventional TSA treatments, including deterioration of

radiologic results after approximately 6 years [32], and

deterioration of functional results after 6–8 years [4, 21,

30, 32].

The use of the RG in patients with CTA has improved

functional outcome significantly in all CMS and in all CMS

sub-scoring parameters. In contrast to RSA systems, sta-

bility seems to be a further benefit of this system, since no

case of instability has been observed in this series. How-

ever, the use of the RG yields controversial results. Female

gender and small-sized glenoid components showed infe-

rior functional results and higher lucency rates (Tables 7,

8), whereas male patients showed satisfactory post-opera-

tive functional results (Fig. 5). Consequently, female

patients were associated with high revision rates (33 %)

and male patients did not require any revisions in this

study.

The inferior results in smaller glenoids might be

explained by relatively higher eccentric loads in smaller

components. Smaller sized prosthetic components have

smaller surfaces, which might be a disadvantage, since less

prosthetic [22] surface is available for a sufficient

ingrowth, consecutively this might in the end lead to higher

loosening rates and inferior functional outcomes. Since

woman had smaller sized prosthetic components

(p \ 0.001), this might be an explanation for the inferior

results in the female patients.

Unfortunately, a linear regression statistic model to

analyze predictive factors (size or gender) cannot be

applied, since the study group is too small, and because

gender affects glenoid component size.

Because primary fixation strength is influenced by local

bone mineral density (BMD) [26], we speculated that

934 Arch Orthop Trauma Surg (2012) 132:927–936

123

decreased bone quality due to osteoporosis might be the

foremost influencing factor to explain our findings.

Enhanced primary fixation of RG (with, for example,

angular screw fixation) may perhaps solve this problem.

Limitations of this study include the small study population

and short follow-up time.

Conclusions

Revision rate of the female cohort and loosening of the

glenoid component in this short-term follow-up is of con-

cern. Further investigations taking BMD, osteopenic con-

ditions and influence of surface area in smaller individuals

into consideration are recommended, to determine whether

this is the underlying cause of the inferior results in

females.

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