Acta Biomed 2019; Vol. 90, Supplement 12: 54-63 DOI: 10.23750/abm.v90i12-S.

8983 © Mattioli 1885

Original article

Onlay versus Inlay humeral steam in Reverse Shoulder

Arthroplasty (RSA): clinical and biomechanical study
Alessandro Beltrame1, Paolo Di Benedetto1, Chiara Cicuto1, Vanni Cainero1, Renato Gisonni1,
Araldo Causero1
1
Clinic of Orthopaedics, University Hospital of Udine, Italy

Summary. Background and aim of the work: Reverse shoulder arthroplasty (RSA) is becoming treatment of
choice in glenohumeral arthropathies with massive lesion of the rotator cuff, due to a gradual extension of
indications and new designs that provide better outcome. In this study we compared two different reverse
shoulder prosthesis designs, defined as Inlay (or typical Grammont type) and a relatively new model defined
as Onlay (that preserves tuberosity bone stock). We analyzed clinical, biomechanical and radiological out-
comes, as well as complications of RSA in these two groups. Methods: We performed a prospective study on a
population of 42 patients undergoing Reverse Shoulder Replacement by a single expert surgeon. We consider
21 patients (group A) who underwent to reverse shoulder replacement with a curved onlay steam with 145°
inclination (Ascend Flex group, Wright medical, Memphis, TN, USA) and 21 patients who underwent to
reverse shoulder replacement with a traditional Inlay Grammont steam (Modular Shoulder System SMR,
Systema Multiplana Randelli; Lima-LTO, San Daniele del Friuli, Italy) between August 2010 and October
2018. We studied the following items: active range of motion (AROM), radiological parameters (lateraliza-
tion shoulder angle LSA, Distalization Shoulder Angle DSA), functional scale (Constant-Murley Score),
post-operative complications (infection, aseptical implant mobilitazion, residual pain, scapular notching, frac-
tures, tuberosity reabsorbtion, dislocation, bleedings, nerve palsy, pulmonary embolus). Results: A significant
improvement in ROM and functional score (Constant Shoulder Score) were observed in both groups. Group
A (Onlay design 145°, medial tray) provides improvement in adduction, extension and external rotation
compared to group B. No significant differences were found in abduction, external rotation and forward
flexion. At 6 months follow-up, pain relief was detected in all patients. Although complications occur in a
high percentage of patients in literature, no postoperative complications were observed in our cases series.
Conclusions: Our results showed how RSA is a real solution to improve quality of life and to restore pain-free
shoulder ROM in patients where cuff tear arthropathy occurs. Onlay design 145° may provides better active
external rotation, extension, adduction: it is necessary to continue follow up and include more cases to prove
these data. (www.actabiomedica.it)

Key words: reverse shoulder arthroplasty, inlay, onlay, cuff tear arthropathy, outcomes, ROM, Constant Mur-
ley Score, SMR, Aequalis Ascend Flex, scapular notching, LSA, DSA

Introduction thies with massive lesion of the rotator cuff due to a

gradual extension of indications and new designs that
Background and aim of the work provide better outcome. In this study we compare two
different reverse shoulder prosthesis designs, defined
Reverse shoulder arthroplasty (RSA) is becom- as Inlay (or typical Grammont type) and a relatively
ing treatment of choice in glenohumeral arthropa- new model defined as Onlay (that preserves tuberos-
Onlay versus Inlay humeral steam in RSA 55

ity bone stock). We analyzed clinical, biomechanical diagnosis in identifying chondral, fibrocartilaginous,
and radiological outcomes, as well as complications of and intraarticular ligamentous lesions in patients who
RSA in these two groups. cannot be evaluated by MRI; Arthro-MDCT should
Massive cuff tears determinate gradual biome- be useful also after replacement surgery because it of-
chanical joint alterations: forces and motion vectors are fers less artifacts generated by metal materials com-
modified resulting in an antero-superior migration of pared to post-operative MRI (10).
the humeral head, and subsequent alteration of rotation Computed Tomography (TC) study is indispen-
fulcrum of the gleno-humeral joint: in motion, humeral sable for pre-operative planning (8). Currently we
head center showed a medial shift at the late phase of also have software to process TC images and elabo-
scapular plane full abduction and anterior shift at the rate a complete pre-operative planning: it is possible
internal rotation position during full axial rotation (1, to choose different size of prosthesis components and
11, 21). Articular cartilage surface undergo to struc- perform a movement simulation in intra and extraro-
tural alterations and gradually a new joint is created tation, abduction/adduction, elevation/forward flexion
between upper humeral head and acromial arch. Ec- to find out any possible notching point (es. Tornier
centric osteoarthrosis is the final progression of these Blue Print 3D Planning – Wright Engineered with IM-
alterations, characterized by severe pain (in particular ASCAP Tecnology ) (9) (fig. 2).
night pain) and gradual restriction of active range of The original indication for RSA was CTA, but
motion that could evolve to a condition defined “pseu- the success of this implant has led to extend the in-
doparalytic arm”, in which patients can’t move the af- dications. The procedure now is widely executed and
fected arm independently (1, 11). Neer, in 1983, called RSA is indicated in patients with functioning deltoid
this disorder “cuff tear arthropathy” (CTA) character- muscle and with a unrepairable lesion of the rotator
ized by the association of gleno-humeral joint arthritis cuff, in the event of: rheumatoid arthritis, pseudopar-
and a massive rotator cuff tear (1) (fig. 1). alitic shoulder, avascular humeral head necrosis, severe
The incidence of cuff tear arthropathy is about proximal humeral fractures (Neer score 4) and frac-
2% in patients over 80 years of age (2). Conservative tures sequelae, correction of functional deformities,
treatment should be tried in early cuff tear arthropa- chronic shoulder instability, post infections arthrosis
thy (5, 6) but lesion dimensions and tendon’s quality and revision after failure of previous shoulder arthro-
must be carefully evaluatued to give the best chance of plasty or hemirthroplasty (11, 15-19, 24).
success: pre-operative MRI evaluation is mandatory to The Grammont prosthetic model is characterized
analyze residual tendons integrity and grade of retrac- by non-anatomical design (Fig. 3), that medializes the
tion and fatty infiltration (7, 12). In selected patients rotational center, refining the deltoid muscle lever arm
with absolute or relative contraindications to MRI, and intrinsic stability of the implant in the absence of
Multidetector Computed Tomography Arthrography a functioning rotator cuff: this design increases deltoid
(Arthro-MDCT) of the shoulder provides accurate efficiency and reduces mechanical torque at the gle-

Figure 1. “Cuff tear arthropathy” (CTA) characterized by a

massive rotator cuff tear that gradually leads to Eccentric Os- Figure 2. Pre-operative planning. The red spot on inferior scap-
teoarthrosis ular neck shows the Notching point
56 A. Beltrame, P. Di Benedetto, C. Cicuto, et al.

SMR system is a modular implant that consists of

inlay humeral stem, reverse humeral body and reverse
liner. Due to its modularity, different combinations are
allowed: it is possible to adjust reverse liner dimen-
sion, diameter of glenosphere (30, 36, 44 mm), angle
of retroversion, implant height and glenospheres ec-
centricity.
Lädermann et al. (25) showed effectively in Fig.
4 the design of traditional Inlay Grammont straight
stem (inclination 155°) compared to Onlay curved
stem (inclination 145°) and Onlay humeral tray. The
red line passes through the center of the stem. Inlay
steam causes humeral distalization but Onlay steam
causes less humeral distalization and more lateraliza-
tion (red arrow); moreover, the center of the Liner is
medialized with the Inlay curved stem which results in
more humeral lateralization (Fig. 4).
Onlay curved steam design also preserve tuberos-
ity bone stock for eventually future prosthetic inter-
vention, both proximally and distally: unlike tradition-
al steams, curved design preserves greater tuberosity
bone stock; short steam preserves distal canal bone
stock (Fig 5).

Methods

We performed a prospective study on a population

Figure 3. Reverse Shoulder Arthoplasty (P.Grammont, 1991,
of 42 patients undergoing Reverse Shoulder Replace-
Delta III, DePuy)
ment. We considered 21 patients (group A) who un-
noid component (decreasing glenoid loosening) (13, derwent to reverse shoulder replacement with a curved
14). onlay steam with 145° inclination (Ascend Flex group,

Figure 4. a. Inlay steam; b. Onlay curved steam

Onlay versus Inlay humeral steam in RSA 57

range [55-88]. Median age in group A was 77 years, in

group B was 75 years.
Both Group A and group B included 6 male
(29%) and 15 female (71%).
Operated arm is dominant arm in 12/21 cases
(57%) in group A and in 14/21 cases (67%) in group B.
Both Group A and group B included 3 patient
(14%) who previously underwent to an arthroscopic
repair of rotator cuff in the same shoulder.
Mean follow up was 12 months.
Deltopectoral approach was performed in all pa-
tients, in beach-chair position.
In post-operative time, all shoulders were im-
mobilized by simple brace for 2 weeks. Early passive
mobilization was started in 1° post-operative day (ex-
cept for forcing external rotation to allow subscapularis
tendon repair). After 2 weeks patients started active
Figure 5. Onlay Aequalis Ascend Flex curved steam: bone stock assisted rehabilitation program.
preservation zones Physical and radiographic assessments were per-
formed pre-operative and during post-operative fol-
low-up at 1, 3, 6 and 12 months after surgery. Dur-
Wright medical, Memphis, TN, USA) and 21 patients
ing physical evaluation, Active Range Of Motion
who underwent to reverse shoulder replacement with
(AROM) was evaluated in abduction-adduction, for-
a traditional Inlay Grammont steam with 155° inclina-
ward flexion-extension, external rotation (with elbow
tion (Modular Shoulder System SMR, Systema Mul-
in anatomic position and 90° of flexion) and internal
tiplana Randelli; Lima-LTO, San Daniele del Friuli,
rotation; according to the International Society of Bi-
Italy) between August 2010 and October 2018. For
omechanics, abduction, flexion were noted positively
the 145° implant a 3,5 mm eccentric humeral tray was
while adduction, extension, external rotation were not-
positioned in supero-lateral position, to minimize lat-
ed negatively (20, 21). We found difficulties in stand-
eralization. All prosthesis were implanted by the same
ardized internal rotation measurements: most patients
expert surgeon.
were unable to perform active internal rotation in su-
Exclusion criteria were: recent glenoid, scapular
pine position mantaining shoulder at 90° abduction,
or humeral fractures, fractures sequelae, chronic or
which is the way suggested to take goniometric param-
acute shoulder instability, previous shoulder surgery
eters: according to the International Society of Biome-
(except for arthroscopic rotator cuff repair), brachiora-
chanics, internal rotation must be noticed in positive
dial plexus deficiency.
degrees values (20). In this study, to asses Internal ro-
Inclusion criteria were: cuff tear arthropathy, ec-
tation, Vertebral levels were converted to points using
centric arthrosis, eccentric or concentric arthrosis in
the method showed by Triplets et Al (22, 23) (fig. 6).
patients who underwent to previous arthroscopic rota-
Pain relief was included in functional outcomes
tor cuff repair.
and measured using Constant-Murley Shoulder Score
We included all the patients operated with Onlay
(Fig. 7).
implant that respected inclusion criteria and the last
We studied the following radiographic param-
(temporary criterium) 21 patients operated with Inlay
eters: lateralization shoulder angle (LSA), Distaliza-
implant that respected inclusion criteria.
tion Shoulder Angle (DSA), acromion-humeral dis-
Mean age at surgical time in group A was 77
tance (AHD), post-surgery humeral offset, scapular
years±3.8, range [68-85] and in group B was 73±8,2,
notching, tuberosity reabsorption. LSA and DSA were
58 A. Beltrame, P. Di Benedetto, C. Cicuto, et al.

Figure 6. Active Internal Rotation: each image has a cor-

responding vertebral range. Vertebral levels are converted to
points for analysis purposes (Triplets et al. (22)

Figure 8. DSA and LSA angle in Inlay RSA (28)

Figure 9. DSA and LSA angle in Onlay RSA (28)

All measurements were calculated using O3 Re-

porting Workstation (ORWS Insiel FVG Version
3.2.2) with an accuracy up to 0,01 mm. Scapular Notch-
ing and Tuberosity Reabsorption were evaluated in sub-
sequent radiographs taken during post-operative follow
up at 1, 3, 6 months and 1 year. Scapular Notching was
evaluated on AP view in external and internal rotation
and classified using Sirveaux Classification (26, 27).
We also reserched any complication during 1 year
follow up: infection, aseptical implant mobilization,
residual pain, scapular notching, fractures, tuberosity
reabsorbtion, dislocation, bleedings, nerve palsy, pul-
monary embolus.
Categorical variables were reported as frequencies
Figure 7. Constant-Murley Score and percentages. The Student’s t test or the Mann-
Whitney U test was used to compare continuous vari-
measured on standard anteroposterior radiographs by ables between the two groups. Statistical significance
a single orthopaedist, blinded to surgical outcome, us- for all tests was set at a p-value of <0.05. All statistical
ing the method illustrated by Boutsiadis et al. (28) (fig. analysis were performed by Stata/IC 13.0 (StataCorp
8, 9). LP, College Station, USA).
Onlay versus Inlay humeral steam in RSA 59

Results underwent to arthroscopic repair of rotator cuff in the

same shoulder.
Group A (Onlay steam) and B (Inlay steam) were Maximum improvement in ROM was obtained
omogeneus in median age at surgical time, gender at 6 months and it was maintained at 1 year after re-
composition, surgery related to dominant arm, previ- placement in both groups.
ous arthroscopic surgery. Median age in group A was At 1 year follow up, in group A (Onlay) mean
77 years [68-85], in group B was 75 years [55-88]. AROM was: Abduction +142 °[100-170], Adduction
Both groups included 29% male and 71% female. Op- -35° [20-45], Forward flexion +153°[120-180], Exten-
erated arm is dominant arm in 57% of group A pa- sion -29° [20-40], extrarotation -42°[30-60]; active in-
tients and in 67% of group B patients. Both Group A ternal rotation was 4,6 points (reported as mean score,
and group B included 3 patients (14%) who previously as show in fig. 6). (Table 1)

Table 1. Postoperative improvement in active ROM: mean abduction/adduction, forward flexion/extension, extra/intrarotation. De-
grees are noted as absolute values; internal rotation was reported as mean score
60 A. Beltrame, P. Di Benedetto, C. Cicuto, et al.

At 1 year follow up, in group B (Inlay) mean on-humeral distance AHD (r=0.62, P<0.001): higher
AROM was: Abduction +144°[100°-180°], Adduction DSA values where found in more distalizated RSA.
-24° [15-40], Forward flexion +158°[120-180], Exten- LSA and DSA angles showed negative linear cor-
sion -20°[10-30], extrarotation -37°[20-40]; internal relation (r=-0,42, P<0.001): more distally the implant
rotation was 4,8 (reported as mean score, as show in is placed, less lateralization is achieved. Mean LSA in
fig. 6) (Table 1). group A was 92°±8.1, higher than in group B 81±5.4.
Constant Shoulder Score was submitted to pa- Mean DSA in group A was 47°±6.9, lower than in
tients before surgery, at 1, 3, 6 and 12 months follow- group B 49±9.
up (Table 2). Group A (Onlay steam) and B (Inlay We did not find significant positive correlation
steam) were omogeneus in mean pre-operative Con- between LSA and Active External Rotation (R²=0,15)
stant-Murley Score: Group A 39 points; Group B 41 and between DSA and Active Forward flexion
points. There was no significant difference between (R²=0,04) as demonstraded by Boutsiadis et Al (28).
two groups in Constant-Murley score at 1, 3, 6 and 12 Six months after RSA, inferior Scapular Notch-
months post-surgery, with a rapid restoration of pain- ing was detected in 3 patients (24%) in group B. These
free AROM of the shoulder (Table 2). patients developed a low grade of scapular notching
At 3 months pain relief was detected in all pa- (<5mm) which did not reach the lower screw (26, 27).
tients except of 3 patients in Group A, who declared The radiographic finding of inferior Scapular Notch-
mild pain that was correlated to delayed phisioterapy: ing did not correlates with worst functional outcomes
these 3 patients started active exercises 40 days post- in our series.
surgery and gradually regained AROM in the fol-
lowing 3 months. At 6 months follow-up, pain relief
was detected in all patients (parameter included in
Constant-Murley Score). One patient declared that he
was not satisfied for a distal humerus fracture with a
complete lesion of radial nerve occurred 1 year after
shoulder replacement but this fracture couldn’t be con-
sidered as a implant complication (Fig. 10).
Regarding radiological findings, we discovered a
linear correlation between LSA values and prosthe-
sis offset (r=0.64, P<0.001): higher LSA values where
found in more lateralized RSA (group A); we detected
a Linear Correlation between DSA values and acromi-
Figure 10. Distal humerus fracture with complete lesion of ra-
dial nerve occurred 1 year after shoulder replacement

Table 2. The variation of Constant Shoulder Score showed no

significant difference between group A and B

Figure 11. Scapular Notching, grade 1, at six month follow up

Onlay versus Inlay humeral steam in RSA 61

During follow up no other patients developed tray configuration that minimize total Onlay humerus
specific complications as: local and systemic infections, lateralization; they also described a dramatic improve-
aseptical implant components mobilization, residual ment in extension and external rotation but in their
pain, fractures, tuberosity reabsorbtion, dislocation, study forward flexion remains unchanged (25).
bleedings, nerve palsy, pulmonary embolus. Regarding radiological findings, we discovered a
linear correlation between LSA values and prosthe-
sis offset (r=0.64, P<0.001): higher LSA values where
Conclusions found in more lateralized RSA (group A); we detected
a Linear Correlation between DSA values and acromi-
Reverse shoulder arthroplasty (RSA) is an ex- on-humeral distance AHD (r=0.62, P<0.001): higher
cellent surgical treatment to restore pain-free ROM, DSA values where found in more distalizated RSA.
function and strength of the shoulder affected by LSA angle is a reproducible measurement to es-
massive irreparable rotator cuff tears and cuff tear ar- timate implant lateralization, DSA is a reproducible
thropaty (3, 4, 32). measurement to estimate implant distalization. LSA
Group A (Onlay steam) and B (Inlay steam) were and DSA angles showed negative linear correlation
omogeneus in median age at surgical time, gender (r=-0,42, P<0.001): more distally the implant is placed,
composition, surgery related to dominant arm, previ- less lateralization is achieved. Mean LSA in group A
ous arthroscopic surgery. These parameters offered a was 92°±8.1, higher than in group B 81±5.4. Mean
good starting point for comparison. Outcomes of all DSA in group A was 47°±6.9, lower than in group
RSA showed the capacity to restore pain-free ROM, B 49±9. So, Inlay steam causes humeral distalization
function and strength, improving the quality of life. but Onlay steam causes less humeral distalization and
Constant-Murley functional score increased signifi- more lateralization.
cantly after surgery in both groups. These values express how, biomechanically, Onlay
In particular, compared to literature data, in our prosthesis with its short stem, with curved metafisary
study, prosthesis reached a more satisfactory mean ac- grip, is able to lateralize the humerus more than Gram-
tive range of motion. mont traditional steam. This evidence is found in our
It is now how loss of the external rotation is a study, on implants where the tray was placed medially
serious problem, disclosed by several authors; also el- (supero-lateral position): therefore it is evident that
evation recovery may not be enough to bring up this the design of the model itself gives greater lateraliza-
deficit; external rotation in these shoulders depends by tion in comparison with the traditional stem. Läder-
teres minor muscle conditions: particularly in older pa- mann et al. (25) stated that eccentric tray position had
tients, this muscle is often retracted, atrophied or fatty a little influence with humeral offset only increasing by
infiltrated (11, 33). 1.8 mm when moving from “supero-lateral position” to
Group A (Onlay 145° inclination steam, with tray “infero-medial position” and concluded that humeral
placed medially) showed at 1 year follow up an im- offset is more affected by curved onlay steam design
provement in mean adduction (-35° vs -24°), exten- that by inclination (155° -145°) or tray position.
sion (-29° vs -20°) and external rotation (-42° vs -37°) Inlay RSA provided in our study higher DSA val-
compared to Group B (Inlay traditional 155° inclina- ues, that correlated with higer distalization (higer ac-
tion steam), while mean abduction (+142° vs +144°) romion-humeral distance): this arm lengthening didn’t
and mean forward flexion (+153° vs +158°) slightly affect functional outcome.
decrease. Internal rotation didn’t show significant dif- In comparison to Boutsiadis et Al. study, we did
ference in the two groups. These data partially confirm not find significant positive correlation between LSA
Lädermann et Al. study (25): they found that there and Active External Rotation (R²=0,15) and between
was 9° decrease in abduction and 5° increase in adduc- DSA and Active Forward flexion (R²=0,04) (28). In
tion between an Inlay Grammont design and an On- their study LSA and DSA measurements were cor-
lay 145° design with tray placed medially, which is the related with post-operative AROM outcomes: LSA
62 A. Beltrame, P. Di Benedetto, C. Cicuto, et al.

angles between 75° and 95° were correlated to better follow-up to obtain more data, above all about com-
active external rotation and DSA angles between 40° plications, in order to be able to extend safely surgical
and 65° resulted in better active forward flexion. indications to younger selected patients in the future.
Onlay curved steam design also preserve tuberos- In addition, all patients in this series were oper-
ity bone stock for eventually future prosthetic inter- ated by the same arthroplasty shoulder surgeon (se-
vention, both proximally and distally; unlike tradition- lection bias). We initially found some difficulty in
al steams, curved design preserves greater tuberosity comparing our data with those provided in literature
bone stock and short steam preserves distal canal bone by similar studies because we had found different and
stock: these features could be useful to plan RSA in not always specified measurement methods for Active
patients younger than 65 years old, who are more likely Range of Motion. To facilitate bigger metaanalysis, we
to undergo to implants revisions (24, 29-31). suggest to follow the ISB recommendation on defini-
Although in literature intraoperative and periop- tions of joint coordinate systems (20) and Green and
erative complications occur in a high percentage of pa- Triplet measure for internal rotation (22, 23).
tients and long term outcomes are difficult to predict,
during 1 year follow up none of the patients included Conflict of interest: Each author declares that he or she has no
commercial associations (e.g. consultancies, stock ownership, equity
in study developed specific complications as: local and interest, patent/licensing arrangement etc.) that might pose a con-
systemic infections, aseptical implant components flict of interest in connection with the submitted article
mobilization, residual pain, fractures, tuberosity reab-
sorbtion, dislocation, bleedings, nerve palsy, pulmo-
nary embolus. A heparin prophylaxis was gave to all Reference
patients for 35 post-operative days.
1. Neer CS, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone
In our study 3 patients in group B (14%) showed
Joint Surg 1983;65(9):1232-1244.
a low grade (grade 1 of the Sirveaux classification) of 2. Smith CD, Guyver P, Bunker TD. Indications for reverse
scapular notching six months after surgery but radio- shoulder replacement: a systematic review. J Bone Joint Surg
graphic finding of inferior Scapular Notching did not Br 2012; 94:577-83.
correlates with worst functional outcomes in our series 3. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer
Award 2005: The Grammont reverse shoulder prosthesis: re-
(26, 27). sults in cuff tear arthritis, fracture sequalae, and revision ar-
Scapular notching has been attributed to a me- throplasty. J Shoulder Elbow Surg 2009;15:527-540.
chanical impingement of the humeral liner against 4. Ackland DC, Roshan-Zamir S, Richardson M, Pandy M. G.
the scapular neck when the arm is fully adducted. It Moment arms of the shoulder musculature after reverse total
shoulder arthroplasty. J Bone Joint Surg Am 2010;92:1221-
can developed an osteolytic process as a result of wear
30.
debris of the polyethylene liner; the radiographic inci- 5. Parsons IM, Weldon EJ, Titelman RM, Smith KL. Gleno-
dence increase with time and concerns between 49% humeral arthritis and its management. Phys Med Rehabil
and 70% of patients. It is now unknow if Scapular Clin N Am 2004; 15: 447-74.
6. Schmidt CC, Jarrett CD, Brown B T. Management of rotator
Notching really affects the function or lead to prosthe-
cuff tears. J Hand Surg 2015;40:399-408.
sis mobilization (3, 11, 26, 27). 7. Di Benedetto P, Beltrame A, Cicuto C, Battistella C, Gisonni
We concluded that our experience with SMR and R, Cainero V, Causero A. Rotator cuff tears reparability index
Aequalis Ascend Flex RSA shows two safe and effec- based on pre-operative MRI: our experience. Acta Biomed.
tive surgical options to resolve pain and restore the ca- 2019Jan10;90(1-S):36-46.
8. De Filippo M, Castagna A, Steinbach SL,Silva M,Concari
pacity to perform daily activities. G, Pedrazzi G, Pogliacomi F, Sverzellati N, Petriccioli D,
The major limitation of our analysis was repre- Vitale M, Ceccarelli F, Zompatori M, Rossi C. Reproduc-
sented by the small population evaluated in the pre- ible Non invasive Method for Evaluation of Glenoid Bone
sent study (42 RSA). An another important limitation Loss by Multiplanar Reconstruction Curved Computed To-
mographic Imaging Using a Cadaveric Model. Arthroscopy
was represented by the short follow-up in the context
2013Mar;29(3):471-7.
of arthroplasty surgery. In particular Group A includ- 9. Werner BS, Hudek R, Burkhart KJ, Gohlke F. The influ-
ed more recents implants and we need to contiunue ence of three-dimensional planning on decision-making
Onlay versus Inlay humeral steam in RSA 63

in total shoulder arthroplasty. J Shoulder Elbow Surg. ized protocol for measurement of range of movement of the
2017Aug;26(8):1477-1483. shoulder using the Plurimeter-V inclinometer and assess-
10. De Filippo M, Bertellini A, Sverzellati N, Pogliacomi F, ment of its intrarater and interrater reliability. Arthritis Care
Costantino C, Vitale M, Zappia M, Corradi D, Garlaschi Res. 1998;11:43–52.
G, Zompatori M. Multidetector computed tomography ar- 24. Ek ET, Neukom L, Catanzaro S, Geber C. Reverse total
thrography of the shoulder: diagnostic accuracy and indica- shoulder arthroplasty for massive irreparable rotator cuff
tions. Acta Radiol. 2008Jun;49(5):540-9. teatrs in patient younger than 65 years old: results after 5
11. Beltrame A, Di Benedetto P, Salviato D, Niccoli G, Gi- to fifteen years. J Shoulder Elbow Surg 2013;22:1199-208.
sonni R, Cainero V, Causero A.The SMR reverse shoulder 25. Lädermann A, Denard PJ, Boilau P, Farron A, Deransart P,
arthroplasty in rotator cuff arthropathy management. Acta Terrier A, Ston J, Walch G. Effect of humeral steam design
Biomed. 2017Oct18;88(4S):81-89. on humeral position and range of motion in reverse shoul-
12. Di Benedetto ED, Di Benedetto P, Fiocchi A, Beltrame der arthroplasty. Int Orthop. 2015Nov;39(11):2205-13.
A, Causero A. Partial repair in irreparabile rotator cuff 26. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole
tear: our experience in long-term follow-up. Acta Biomed. D: Grammont inverted total shoulder arthroplasty in the
2017;Suppl4:69-74. treatment of glenohumeral osteoarthritis with massive rup-
13. Berliner JL, Regalado-Magdos A, Ma CB, Feeley BT. Bio- ture of the cuff: Results of a multicentre study of 80 shoul-
mechanics of reverse total shoulder arthroplasty. J. Shoulder ders. J Bone Joint Surg Br 2004;86:388-395.
Elbow Surg 2015;24:150-60. 27. Friedman RJ, Barcel DA; Eichinger, Josef Karl MD. Scap-
14. Neer CS. Replacement arthroplasty for glenohumeral os- ular Notching in Reverse Total Shoulder Arthroplasty.
teoarthritis. J Bone Joint Surg Am 1974;56:1-13. JAAOS2019;27(6):200-209.
15. Boulahia A, Edwards TB, Walch G, Baratta RV. Early re- 28. Boutsiadis A, Lenoir H, Denard PJ, Panisset JC, Brossard
sults of a reverse design prosthesis in the treatment of ar- P, Delsol P, Guichard F, Barth J. The lateralization and dis-
thritis of the shoulder in elderly patients with a large rotator talization shoulder angles are important determinants of
cuff tear. Orthopedics 2002; 25:129-33. clinical outcomes in reverse shoulder arthroplasty. J Shoul-
16. Frankle M, et al. The Reverse Shoulder Prosthesis for der Elbow Surg. 2018Jul;27(7):1226-1234.
glenohumeral arthritis associated with severe rotator cuff 29. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L,
deficiency. A minimum two-year follow-up study of sixty Mole D. Reverse prostheses in arthropathies with cuff tear:
patients. J Bone Joint Surg Am 2005;87:1697-705. are survivorship and functional maintained over time? Clin
17. Grammont PM, Baulot E. Delta shoulder prosthesis for Orthop Rel Res 2011;469:2469-75.
rotator cuff rupture. Orthopedics1993;16:65-8. 30. Sershon RA, Van Thiel GS, Lin EC et Al. Clinical outcomes
18. Grammont P, Trouilloud P, Laffay JP, Deries X. Etude et of reverse total shoulder arthroplasty in patient aged young-
réalisation d’une nouvelle prothèse d’épaule. Rhumatolo- er than 60 years. J Shoulder Elbow Surg. 2014;23:395-400.
gie1987;39:407-18. 31. Muh SJ, Streit JJ, Wanner JP, et Al. Early follow-up of re-
19. Walch G, Bacle G, Lädermann A, Nové-Josserand L, verse total shoulder arthroplasty in patients sixty years of
Smithers CJ. Do the indications, results, and complications age OR younger. J Bone Joint Surg Am 2013;95:1877-83.
of reverse shoulder arthroplasty change with surgeon’s expe- 32. Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder
rience? J Shoulder Elbow Surg 2012;21:1470-7. arthroplasty improves function in cuff tear arthropathy. Clin
20. Wu G, Van der Helm FCT, Veeger HEJ (DirkJan), Makh- Orthop 2011;469:2476-82.
sous M, Van Roy P, Anglin C, Nagels J, Karduna AR, Mc 33. Simovitch RW, Helmy N, Zumstein MA, Gerber C. Im-
Quade K, Wang X, Werner FW, Buchholz B. ISB recom- pact of fatty infiltration of the teres minor muscle on the
mendation on definitions of joint coordinate systems of vari- outcome of reverse total shoulder arthroplasty. J Bone Joint
ous joints for the reporting of human joint motion—Part II: Surg Am 2007;89:934-9.
shoulder, elbow, wrist and hand. J Biomech 2005;38(5):981-
992.
21. Naoya K, Takamitsu O,Naohide T, Satoshi H, Hidehiko Received: 1 October 2019
H, Takeshi S, Satoru I, Hirotaka G, Yoshitaka N, Takahiro Accepted: 3 November 2019
S, Yasuharu N. Dynamic kinematics of the glenohumeral Correspondence:
joint in shoulders with rotator cuff tears. J Orthop Surg Res. Paolo Di Benedetto, MD, PhD
2018;13: 9. Clinica Ortopedica
22. Triplet JJ, Everding NG, Levy JC, Moor MA. Functional Azienda Sanitaria Universitaria Integrata di Udine
internal rotation after shoulder arthroplasty: a comparison P.le S.Maria della Misericordia, 15 - 33100 Udine
of anatomic and reverse shoulder arthroplasty. J Shoulder Tel. +39 0432 559464
Elbow Surg. 2015Jun;24(6):867-74. Fax +39 0432 559298
23. Green S, Buchbinder R, Forbes A, Bellamy N. A standard- E-mail: paolo.dibenedetto@asuiud.sanita.fvg.it