Review Article

Stemless Reverse Shoulder Arthroplasty

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Tyler A. Luthringer, MD
John G. Horneff III, MD
Joseph A. Abboud, MD
ABSTRACT
Since the Food and Drug Administration (FDA) approval nearly two
decades ago, the indications for and utilization of reverse shoulder
arthroplasty (RSA) have expanded considerably. Stemless RSA
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designs have been used in Europe since 2005, but have only recently
been introduced in domestic Investigational Device Exemption trials.
Potential advantages of stemless RSA are similar to those of stemless
anatomic total shoulder arthroplasty, which may include fewer shaft-
related complications, avoidance of stress shielding, bone
preservation, and easier revision surgery. European data support
similar outcomes between certain stemless RSA prostheses
compared with that of stemmed RSA implants at early and mid-term
follow-up. However, long-term outcomes remain to be seen and
differences exist between the stemless RSA designs used in Europe
and those being studied in domestic clinical trials. An understanding
of the potential advantages and disadvantages of stemless RSA,
differences between existing designs, and reported clinical outcomes
is prudent for the safe and meaningful implementation of this new
technology in the United States.
From the Rothman Orthopaedic Institute,
Philadelphia, PA (Luthringer and Abboud), the

T
Carolina Orthopaedic and Neurosurgical he emerging availability of stemless humeral implants for reverse
Associates, Greenville-Spartanburg, SC
(Luthringer), and the University of Pennsylvania,
shoulder arthroplasty (RSA) in the United States warrants an overview
Philadelpha, PA (Horneff). of this new technology and a discussion of the available literature for
Abboud or an immediate family member has surgeons considering its use. Over the past few decades, the evolution of the
received royalties from Djo Global, Zimmer- humeral stem design in RSA has paralleled that seen previously in anatomic
Biomet, Smith and Nephew, Stryker, and Globus
Medical, Inc; has received research or total shoulder arthroplasty (aTSA).1,2 Similar to the first generation of fixed-
institutional support from Lima Corporation— geometry humeral implants introduced by Neer 1951, the Grammont
Italy, Orthofix, Arthrex, and Oref; and serves as a
board member, owner, officer, or committee original reverse prototype used a monoblock humeral implant.3,4 Implant
member of the American Shoulder and Elbow modularity and variable geometry became the hallmarks of second and third-
Society and Pacira. Neither of the following
authors nor any immediate family member has
generation aTSA implants, respectively, which permitted modifications to
received anything of value from or has stock or better match native humeral anatomy.2 In RSA, subsequent iterations of
stock options held in a commercial company or
humeral implants have come to permit modifications of tray and insert
institution related directly or indirectly to the
subject of this article: Luthringer and Horneff thickness, offset, humeral inclination, and constraint to maximize muscle
J Am Acad Orthop Surg 2024;32:e63-e72 moment arms, avoid impingement, and optimize shoulder function. Fixation
DOI: 10.5435/JAAOS-D-23-00075 techniques have also changed over time from cemented to press-fit designs.
Copyright 2023 by the American Academy of
The latest generation of humeral implants is stemless designs. Introduced
Orthopaedic Surgeons. for aTSA in Europe in 2004 and approved by the Food and Drug

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 Stemless Reverse Shoulder Arthroplasty

Administration (FDA) in 2016 for use in the United revision surgery. Modifications of the RSA implant
States, stemless designs are projected to outpace that of design and alterations in the surgical technique were
conventional stemmed implants in European markets by popularized in response to the nearly ubiquitous and
2024.5-7 While stemless humeral implants have also previously unseen phenomenon of scapular notching
been used for RSA in Europe since 2005, they are only associated with the MGMH design. The concept of lat-
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recently being evaluated in the United States through eralization and a shift toward a more anatomic NSA
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FDA Investigational Device Exemption (IDE) trials.8,9 (135
) of the humeral implant were two such mod-
Early and mid-term outcomes from European studies ifications. Lateralization (or offset) of RSA involved
have shown similar results between certain stemless shifting the center of rotation (COR) laterally from the
designs and conventional, stemmed RSA.7 Although a face of the glenoid, compared with the MG design, and
paucity of data is available on the systems currently can be achieved on the glenoid side, humeral side, or
being investigated for use in the United States, knowl- both. The classification by Routman et al12 categorized
edge and understanding of this emerging technology is existing implant designs based on the amount of later-
necessary as it becomes available to orthopaedic alization (or global offset) between the COR and the
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surgeons. humerus and whether the implant lateralizes through

the glenoid or humeral implant. The combination of
these two variables results in four possible designs, with
the Grammont-style prosthesis being the construct of
Modifications of Contemporary Humeral reference: MGMH, lateralized glenoid and medialized
Stem Design in Reverse Shoulder humerus, MGLH (medialized glenoid and lateralized
Arthroplasty humerus), and lateralized glenoid and lateralized
In 1985, the Grammont original ‘trompette’ reverse humerus. The introduction of lateralized humerus
prototype consisted of a cemented glenosphere and all- prostheses brought about humeral onlay designs, which
polyethene, monoblock humeral implant.10 Early loos- use a flat, modular metaphyseal humeral tray that at-
ening and failure of the glenoid implant led to several taches to the stem on top of the humeral head cut sur-
design modifications seen in the second iteration of the face. In contrast to the inlay designs characteristic of
Grammont design, the Delta III (DePuy International MGMH and lateralized glenoid and medialized
Ltd). Initially released in France in 1991, the Delta III humerus constructs, onlay humeral implants offer
implant would become the first FDA-approved reverse greater capacity to increase lateralization using the
prosthesis for use in the United States. Compared with humeral tray and polyethylene insert and may allow
earlier RSA designs, the breakthrough success of the adjustment of anteroposterior eccentricity of the hum-
Delta III implant is attributed to improvements in gle- eral tray relative to the stem.
noid implant design and fixation.4,10 However, notable Various strategies have been implemented to improve
changes to the humeral implant were made as well, humeral-sided fixation for noncemented, press-fit de-
which laid the foundation for many modern-day RSA signs. Stem surface roughening, grit-blasting, plasma
designs used today. The three-part humeral implant of spray, and hydroxyapatite coating as well as porous
the Delta III consisted of a conical diaphyseal humeral scaffolds have been used to promote bony ongrowth and
stem, a modular metaphyseal inlay block, and the ingrowth, respectively. Changes in stem geometry have
polyethylene humeral insert. Initially, the diaphyseal also been implemented to enhance stability against
stem and metaphyseal block were polished for cemen- rotational torque forces, including the addition of prox-
tation and later became available with hydroxyapatite imal fins, distal flutes, and grooves. These advancements
coating for noncemented fixation. This classic me- have allowed for the popularization of noncemented
dialized glenoid-medialized humerus (MGMH) ‘Gram- designs and the opportunity to achieve more proximal,
mont’ design used a nonanatomic, varus neck-shaft bone-sparing fixation with shorter humeral stems. The
angle (NSA) of 155
to increase the acromiohumeral latest generation of RSA implants focuses on bone pres-
interval and deltoid tension.11 ervation strategies to minimize potential challenges of
Subsequent changes in RSA humeral implant design revision surgery. One such example includes the advent
have been rooted in efforts to optimize function and of convertible systems that allows one to retain the
impingement-free range of motion (ROM), to avoid humeral stem while replacing the modular anatomic
scapular notching, and to improve bone-preserving fix- humeral head for a reverse prosthesis humeral tray.
ation, to minimize future challenges associated with Convertibility has previously been touted an advantage

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 Tyler A. Luthringer, MD, et al

Review Article
of humeral onlay designs; however, several inlay stems gration. Favre and Henderson18 demonstrated that
now afford the same capability. Although convertible 99% of a stemless aTSA implant (Sidus Stem-Free
systems provide a relatively noninvasive, bone-sparing Shoulder, Zimmer GmbH) surface experienced sub-
option for conversion of anatomic to RSA, the optimum threshold micromotion in a finite-element (FE) model of
stem position may be different for each construct. simulated physiologic activity. The percentage of
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The use of stemless humeral implants in aTSA has been implant surface area that experienced micromotion
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another preparedness strategy to facilitate implant removal between 100 and 150 mm did, however, increase con-
with minimal bone loss and allow for reinsertion and siderably when loaded (2 kg) in forward elevation and
optimal positioning of an RSA humeral implant when abduction. This may be relevant in RSA as forward
necessary. The success of stemless humeral implants in elevation and abduction are the primary motions
aTSA has since led to the application of similar designs for restored, which may have implications for early mobi-
RSA. These canal-sparing designs rely solely on meta- lization in overweight individuals if a stemless humeral
physeal or epiphyseal noncemented fixation and bony implant is used. Micromotion of stemless humeral im-
ingrowth or ongrowth properties for implant stability.7 plants in RSA has not yet been specifically studied and
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While stemless RSA has been used effectively in Europe should be prioritized as a topic of future biomechanical
for nearly two decades, differences exist between those research.
prostheses and the implants being investigated in FDA Fixation of stemless implants is heavily dependent on
trials. Furthermore, the potential effect of biomechanical the quality of bone density of the proximal humeral
differences between anatomic and RSAs should be con- metaphysis. Spatial mapping of the bone density in this
sidered with the adoption of this new technology for RSA. region has found stronger bone located in the periphery
and medial calcar regions.19 Although various designs
exist, there is little evidence to determine how much this
Biomechanical Considerations with variability in bone density can affect fixation of stemless
Stemless Reverse Shoulder Arthroplasty implant designs. Furthermore, different stemless designs
To date, most of the biomechanical research on stemless use a variety of fixation features to improve implant
humeral implants has investigated aTSA constructs. stability.20 Reeves et al21 predicted how these design
When considering the implications of this research in the features affect bone stress and strain responses using
setting of RSA, it should be recognized that the loads aTSA FE model and found a trade-off between implant
experienced by the humerus in RSA are different from types. Stemless implants with central peg fixation were
aTSA because of fundamental differences in construct found to have the lowest potential for peri-implant bone
philosophy and design. Notable differences include resorption, which may optimize osseointegration,
increased constraint of the reverse articulation, increased whereas implants with peripheral fixation had the
deltoid lever arm, and the presence of torsional stress on greatest bone-implant contact area to enhance primary
humeral implant as it rotates as a fulcrum about a fixed implant stability. Bachmaier et al22 noted that in
COR.13-15 Anatomic TSA recreates the native COR and stemless RSA where the medialization of the gleno-
maintains normal deltoid and rotator cuff force vectors humeral COR induces higher postoperative shear forces
that contribute to stabilizing compressive forces at the and tilting effects on the humeral implant, the effect can
glenohumeral articulation. In RSA, nonanatomic be notable for implant loosening. Those authors
reconstruction alters the force vectors of the deltoid and compared a peripheral fixation with a central impaction
remaining rotator cuff about a medialized COR to fixation design in 25 cadaveric specimens and found
optimize function in a pathologic shoulder. While RSA that the peripheral fixation design provided higher peri-
reduces the muscle forces required during shoulder implant bone mineral density and bone volume fraction,
function, it produces greater shear force and less com- which led to improved primary fixation.
pression at the implant articulation.16,17 Owing to the A major impetus for the development of stemless
increased shear forces produced in RSA compared with humeral designs has been to minimize the risk of stress
aTSA, available biomechanical data on stemless aTSA shielding. Standard-length diaphyseal fitting stems con-
constructs cannot be extrapolated and reliably applied tribute to proximal bone resorption through stress
to stemless RSA. shielding by redistributing load from native proximal
Reliable fixation of noncemented humeral implants is humerus subcortical bone to distal regions of contact
dependent on primary implant stability to limit micro- between the implant and the endosteum. FE analysis has
motion below the threshold of 150 mm for osseointe- shown stemless implants to more closely match the intact

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 Stemless Reverse Shoulder Arthroplasty

stresses of proximal cortical bone at the expense of higher healing and have been successfully managed with sling
trabecular bone stress in an aTSA model.23 Provided immobilization without additional surgery.9,31,33-35 In
adequate fixation can be achieved, the more normal cases of altered anatomy, such as posttraumatic mal-
stress profiles of stemless implants should decrease risk union, stemless RSA offers higher adaptability during
of proximal stress shielding over traditional stemmed implantation because the implant can be inserted
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implants, which has been corroborated in clinical independent of neck-shaft deformities and within a
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radiographic study.24-26 Still, rates of stress shielding greater range of humeral osteotomy inclination
range between 0 and 40% with different stemless angles.7,8,31,32,36
implants in aTSA clinical studies, in part, because of Stemless humeral implants can be used for many of the
heterogeneity in reported definitions and length of fol- same diagnoses as traditional, stemmed RSA, including
low-up.24,25,27-29 FE modeling has also predicted how rotator cuff tear arthropathy; irreparable rotator cuff
different stemless designs influence the location and tears; osteoarthritis with at-risk rotator cuff, severe gle-
concentration of stress experienced by surrounding noid deformity; and posttraumatic arthritis.9 Ideal in-
bone.21 This may affect not only the overall likelihood dications include primary RSA with favorable
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of stress shielding but the regions of the proximal metaphyseal bone stock and cases of posttraumatic
humerus where stress shielding is most likely to occur. malunion with metadiaphyseal deformity that cannot
Medial calcar and greater tuberosity resorptive changes accept a stemmed implant.9
have predominated with anchor fin and hollow screw-
type stemless aTSA designs, respectively.26,28-30 While
neither of these implants are available for use in RSA,
the development, location, and effect of stress shielding Disadvantages and Contraindications
with stemless RSA designs should be monitored going A notable disadvantage of current stemless RSA designs
forward. Resorption of greater tuberosity and proximal is the limited modularity to increase humeral offset and
humeral bone in RSA could lead to compromised deltoid tension. The addition of notable humeral offset
external rotation function and instability due to loss of through thicker humeral trays and polyethylene inserts
protective deltoid wrapping. In addition, stress shielding likely imparts additional torque onto the bone-implant
of the medial calcar could be potentiated by impinge- interface; however, the effect this has on primary implant
ment and scapular notching. stability has not yet been extensively studied. When
adequate soft-tissue balance and stability cannot be
achieved intraoperatively, implant removal and arthro-
plasty with a stemmed implant may be necessary. The
Advantages and Indications same disadvantage may be of concern should postoper-
There have been several proposed advantages of stemless ative instability require revision surgery.
humeral implants in RSA similar to their use in aTSA. Safe use of stemless humeral implants in RSA is
Press-fit, noncemented fixation within the epiphyseal predicated on the presence of adequate bone stock and
and metaphyseal bone avoids instrumentation of the in- ability to achieve stable press-fit metaphyseal fixation to
tramedullary canal and may allow for shorter operating avoid early aseptic loosening before osseointegra-
time and lower intraoperative blood loss.7,31 Preserva- tion.32,37,38 This may limit their utility in certain patient
tion of humeral bone and potential reduction of meta- populations and the revision setting. In addition, secure
physeal stress shielding relative to traditional diaphyseal fixation of lesser tuberosity osteotomy may be more
fitting stems may also facilitate implant extraction and challenging with the use of a stemless implant, and a
simplify revision surgery when necessary.7,8,32 Stemless large lesser tuberosity osteotomy harvest has the
implants may lower the risk of intraoperative humeral potential to affect primary implant stability. Perhaps the
shaft periprosthetic fracture, but still risk fracture of largest disadvantage of stemless RSA is the scarcity of
more proximal metaphyseal bone.8,32,33 If intra- long-term clinical data and a lack of published outcomes
operative proximal fracture occurs and compromises on the subset of stemless implants being investigated by
stemless implant fixation, bypassing with a short or FDA IDE trials.8,32,33,38
standard-length stem may obviate the need for extensile Relative contraindications for stemless RSA may
exposure. Postoperative periprosthetic fractures that include many patients with severe osteoporosis, large
occur in metaphyseal bone around or just below well- metaphyseal subchondral cysts, deficient metaphyseal
fixed stemless implants may have a higher propensity for bone stock, osteonecrosis, acute proximal humerus

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 Tyler A. Luthringer, MD, et al

Review Article
fractures, pseudarthrosis, and metabolic bone dis- Humeral Inclination
ease.8,9,39 Special consideration should be given before The humeral inclination of stemmed implants is pre-
using a stemless RSA implant in the revision setting.37 determined by the NSA of the implant design, which
guides accurate restoration of the desired inclination
angle even if the humeral osteotomy is slightly off. Cox
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et al40 examined stemless, short, and standard-stem

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Technical Considerations aTSA implants and demonstrated that stemless implants

Unlike traditional stemmed implants that are guided by were markedly more likely to be inserted in varus. At the
the orientation of the intramedullary canal and allow for time, these stemless implants were relatively new, but it
modularity of the tray/insert in relation to the stem, illustrated the point that stemmed implants can aid
placement of a stemless humeral implant can be much less surgeons in accurately restoring patient anatomy. In
forgiving. For example, if a surgeon is attempting to stemless RSA, valgus placement of humeral implants
properly balance the soft tissues when trialing a stemmed can lead to an increased risk of scapular notching as seen
RSA, the distalization and lateralization of the humerus with the varus 155
NSA of the Grammont design.
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with respect to the glenoid can be altered by using an Because the placement of stemless humeral implants is
offset tray that can ‘dial in’ appropriate soft-tissue bal- so dependent on the angle and version of the humeral
ance even if the tray is not perfectly centered over the osteotomy, careful and accurate humeral resection is
longitudinal axis of the canal. Similarly, if increased paramount. The use of preoperative planning software
tension is desired, the thickness of the tray and poly- in shoulder arthroplasty has focused mostly on place-
ethylene can be increased to a substantial degree with ment of glenoid implants because of limited bone stock
the security of the stem helping to reduce concerns for of the glenoid vault; with the advent of stemless humeral
excessive stress at the bone-implant interface. This is implants, it will be equally important for the treating
particularly useful in settings of bone loss such as severe surgeon to carefully examine and measure the humerus
deformity, revision surgery, or fracture scenarios. This as well.
modularity is unavailable with current stemless designs, Postoperatively, it can be difficult to assess the humeral
and the limits of sizing can be affected by relatively less inclination of an implanted stemless implant if the radio-
contact between the stemless implant and the host bone graph projection is not parallel to the base of the humeral
with increased concern for loosening. implant. Beck et al41 investigated this concern using a
sawbone model and various angles of radiographic pro-
Humeral Head Resection Height jections. The authors found that by measuring the radii of
When performing a humeral head resection, the goal is to the minor (a) and major (b) axes of the ellipse as well as
remove as little bone as possible to permit sufficient access the observed inclination angle (f) on a postoperative
for glenoid instrumentation and properly restore soft- qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
tissue balance once all implants are placed. In the setting of radiograph, the formula arccosð 12ðbaÞ2 · cosðfÞÞ
severe cuff tear arthropathy, a patient’s soft tissues could correctly determine the real inclination angle within
(ie, triceps, deltoid, and conjoint tendon) may be mark- 1.5
.
edly tight because of years of proximal humeral migra-
tion. This can often make glenoid exposure difficult even Placement of the Stemless Humeral Implant
after proper soft-tissue releases are performed. A larger Unlike stemmed implants that are seated within the canal
humeral head resection is one solution to improve access and require greater preparation of proximal cancellous
in this scenario. With traditional stemmed implants, this bone, stemless implants rely heavily on the press-fit
resected bone can be ‘built up’ by increasing the humeral impaction of the humeral anchor into the metaphysis.
trays and polyethylene insert thickness that can add Owing to thinner cortices in this region of the humerus,
upwards of 20 mm of height to the humeral construct. the quality of the cancellous bone is much more impor-
This is counterintuitive if using a stemless implant where tant to the stability of the implant. Surgeons often
preservation of proximal humerus cancellous bone is describe the ‘thumb test’ in which the tactile feel of
paramount to the support and stability of the humeral cancellous bone is determined to be of adequate quality
anchor. As such, one must carefully assess the amount of for initial fixation of a stemless humeral implant.
bone taken during humeral resection and understand the Conversely, sclerotic bone (ie, in the setting of osteo-
limitations of the implant design being used to ensure that necrosis) can also cause difficulty in gaining good initial
proper stability can be achieved. fixation at the time of impaction. Levy et al34 reported

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 Stemless Reverse Shoulder Arthroplasty

on two patients who sustained a nondisplaced fracture data have been published regarding their use. Compared
of proximal metaphyseal bone during impaction of a with the Verso and TESS, the Easytech and SMR pros-
Verso stemless press-fit RSA; unlike the other stemless theses are more consistent with lateralized RSA designs.
RSA implants discussed in the following section, this Easytech is the only available onlay humeral design and is
implant is more consistent with a short or mini-stem intended for placement at a 145o NSA. Of the current
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design. These were managed conservatively with suc- stemless implants on the market, Easytech is also the
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cess, but the concern for potential early loosening was only implant with a completely peripheral fixation
noted by the authors. The force vector of stemless design. The SMR Stemless Reverse system is an inlay
implant impaction is slightly more lateral than the axial- humeral design inserted at an anatomic 135o NSA; a
directed force applied when inserting a stemmed implant unique characteristic of this implant is the inverse
into thicker cortical bone; surgeons must be aware of bearing polyethylene glenosphere and metallic humeral
this potential hazard and appreciate bone quality when insert.
impacting stemless RSA implants.
In any of these technical considerations, careful pre-
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operative planning and scrutinization of humeral anat-

omy on preoperative CT scan can be helpful when Clinical Outcomes Based on Implant
placing stemless implants. Furthermore, intraoperative Design
fluoroscopy can offer real-time feedback regarding Given the relatively new concept of stemless RSA, there
osteotomy measurements and provide surveillance for are little long-term clinical data compared with tradi-
any intraoperative fractures if desired by an adopting tional RSA designs. The Verso and TESS stemless systems
surgeon. have been in use the longest, and much of the published
literature is focused on these two implants.44 Because of
the variability in implant design, it is important to
critically evaluate the literature based on the implant
Stemless Reverse Shoulder Arthroplasty being studied and not assume that clinical outcomes can
Implant Designs be broadly applied across all stemless RSA designs.
There is considerable variability among the stemless RSA Published data on early clinical outcomes have been
implants on the market. Differences in implant geometry favorable across most stemless implant designs. Two
and design features also exist between the stemless RSA studies have examined the Verso implant at early follow-
implants that have been most extensively studied in Eu- up within 3 years.9,35 Both studies demonstrated
rope and those being investigated in FDA trials (Table improvement in patient forward elevation and abduction,
1).33,37,42,43 The Verso Prosthesis (Innovative Design with Atoun et al showing a statistically significant
Orthopaedics, London, UK) and the Total Evolutive improvement in Constant scores (mean, 12.7 preopera-
Shoulder System (TESS) (Zimmer-Biomet) are the two tively to 56.2 postoperatively).9,35 Neither study
stemless designs with the longest track record in Euro- demonstrated any humeral radiolucency, early signs of
pean markets. Both implants use a nonanatomic 150o to loosening, or subsidence, with only as high as Grade 2
155o NSA and an inlay humeral design that is most scapular notching noted in a minority of patients
consistent with a traditional Grammont-style prosthesis. (9/68).9,35 These good outcomes have been noted to
In addition, the Verso prosthesis is advertised as a continue into mid-term follow-up. Levy et al34 found
stemless implant but has a design more consistent with a continued patient satisfaction, better postoperative
short or mini stem. Both the Verso system and TESS ROM, and markedly improved Constant scores at an
have standard stem length options, where the Verso average of 4 years (range, 2 to 7 years). Radiographically,
stemmed option is a different implant and the TESS can there remained no signs of humeral stress shielding or
accommodate a modular stemmed attachment. Neither radiolucency, implant loosening, or subsidence. Virani
of these implants is currently being investigated for use et al33 continued their follow-up to an average of 6.5
in the United States. years and found that the results maintained notable
The Easytech Reversed Stemless (FX Solutions) and improvement in postoperative functional scores with no
Shoulder Modular Replacement (SMR) Stemless Reverse signs of humeral or glenoid implant loosening. Humeral
(LimaCorporate) systems are currently in the final stages radiolucencies were noted in two patients after successful
of FDA IDE clinical trials. Although these implants have conservative management of metaphyseal periprosthetic
already been available for use in Europe, limited clinical fracture; otherwise no evidence of stress shielding was

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 Tyler A. Luthringer, MD, et al

Review Article
Table 1. Current Stemless Reverse Shoulder Arthroplasty Prostheses and Associated Design Features
Implant Design Features
Verso (Innovative Design Orthopaedics, London, UK)
• Advertised as a stemless implant.
• Design more consistent with a short stem.
2PryfeE6jbxt1znn6ZGWZ8yfwYq5Q36JtzF2bye5XZkWkaLEtL9TOhyIXzBEDmTN1JfaPQt7ndLyq2DiUgc01oQmd7zxU9ffAsWg

• Humeral implant has three hydroxyapatite-coated tapered

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fins for noncemented press-fit fixation.37

• Designed with a 155o NSA
• Uses an inclined 10o polyethylene liner to help reduce
medial impingement.
phVakq9CkzoQie4QBRFU= on 01/03/2024

Total Evolutive Shoulder System (TESS) (Zimmer-Biomet,

Warsaw, IN, USA)
• Short reverse corolla noncemented metaphyseal-
epiphyseal inlay CoCr implant
• Six wings are designed to provide rotational stability
• Ti plasma spray and hydroxyapatite coating.35
• Designed for 150-155o NSA
• Stemmed option available

Easytech Reversed Stemless (FX Solutions, Viriat, France)

• Anchor base design for peripheral fixation within the cortical
rim.
• ’Christmas tree’ like peripheral pegs are plasma-sprayed Ti
with hydroxyapatite coating to support the onlay design tray.
• Designed for 145o NSA, more consistent with lateralized
reverse TSA designs.40
• Only stemless RSA with a completely peripheral fixation
design.41

Shoulder Modular Replacement (SMR) Stemless Reverse

(LimaCorporate, San Daniele del Friuli, Italy)
• Trabecular Ti humeral core implant with a proximal ring and
two radiating fins to central peg, available in 8 sizes.
• Impacted directly into the metaphysis with an inlay design
placed at a 135o NSA.
• 5o CoCr humeral liner available in 40 mm or 44 mm to match
the respectively sized polyethylene glenosphere.41

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 Stemless Reverse Shoulder Arthroplasty

noted. The authors, however, did note an increase in the results (mean follow-up 44 months) demonstrating
incidence of scapular notching at 23.5%. notable improvements in ROM and functional scores;
The TESS implant has also demonstrated early success, no evidence of humeral loosening; and complication and
with short-term evidence showing notable improvement in revision rates of 12% and 5%, respectively. Kostretzis
patient satisfaction, functional outcomes, and postopera- et al49 echoed these findings in their systematic review of
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tive ROM.36,37,44,45 Early scapular notching was slightly 517 patients from 13 studies with mean follow-up
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higher in the TESS implant, ranging from 13 to 30% of ranging between six and 102 months, citing complica-
cases; the incidence of humeral radiolucent lines was not tion and revision rates both of 7%. Of those revisions,
reported in these studies.36,37,45 More noteworthy was only 1.4% were related to humeral implant issues. The
early glenoid loosening noted in two of the studies (seven authors concluded that at mid-term follow up, stemless
of 72 patients in total) and one study showing early reverse implants resulted in clinical and radiological
humeral loosening in a patient who underwent stemless outcomes equivalent to their stemmed counterparts.
reverse arthroplasty as a revision procedure.37,45 Despite Ajibade et al44 evaluated 10 studies with a total of 437
these findings, mid and long-term follow-up studies have stemless RSAs followed for a range of six to 102 months
phVakq9CkzoQie4QBRFU= on 01/03/2024

been promising; Beck et al reported favorable long-term and demonstrated similar findings of functional
survivorship of 93% at 8.5 years comparable with con- improvement with a relatively low rate of complica-
ventional stemmed implants.38,46 The incidence of scap- tions. It should be noted that the participants in all of
ular notching was noted to increase with this longer these systematic reviews had only TESS and Verso im-
duration of follow-up, and many authors have proposed plants because of limited published data on other
continued evaluation of a more anatomical NSA to reduce implant designs.
these occurrences.36,37,45
Schoch et al8 reported the only published data on the
SMR Stemless Reverse implant with 2-year clinical and
radiological outcomes comparable with stemmed im- Complications
plants. Constant scores showed notable improvement The complications seen with stemless RSA are similar to
(from 35 to 74). Radiographically, the authors did note those seen with traditional RSA implants, regardless of
radiolucency around the humeral implant in nearly a humeral implant fixation. Scapular notching is a com-
quarter of the cases with complete loosening of one mon radiographic finding in RSA, particularly in
humeral implant. Interestingly, the authors stated that Grammont-style designs with varus 155o NSA compared
the patient with evidence of complete humeral loosening with lateralized designs with a more anatomic NSA.
did well with no need for revision. Because many of the early stemless reverse designs have
The only available data on the Easytech Reversed embraced the 155o NSA, there is a correlating rate of
Stemless implant was recently published by Nabergoj scapular notching between 0 and 96%.8,45 This wide
et al47 who reported on 115 patients with a minimum range is likely because of the greater variability in the
2-year follow-up from a prospective multicenter trial. placement of stemless implants opposed to stemmed
Constant scores and subjective shoulder values showed designs bound by the limits of implant within the
notable improvement from 33 to 62 and 27 to 78, canal.50 Scapular notching, however, does not always
respectively. Radiographically, scapular notching was have a clinical effect, and although its rates can be high,
observed in 24% patients, humeral loosening in 4% its effects on revisions are markedly lower.
(5 patients), and glenoid loosening in 4% (4 patients); Overall rates of complications in stemless RSA have
humeral radiolucency was not independently reported. remained fairly consistent across studies. Pooled analyses
Concerningly, the authors reported a complication rate have described complication rates between 6.5% and
over 17% with eight implant revisions. Indications for 13.7%.7,44,48,49 The TESS implant, which remains the
implant revision included three dislocations, three most studied design, has an overall complication rate
humeral implant displacements (two secondary to fall), ranging from 1% to 13%.36,37,45 Variation in compli-
one case of combined glenoid and humeral loosening, cation rates reported can be because of variation in
and one periprosthetic humerus fracture. surgical indications. This is especially true when it comes
When pooling the available data across all designs, to the most common complication: instability. Instability
stemless RSA has performed favorably compared with with dislocation is the most commonly reported com-
traditional implants. Liu et al48 pooled 324 stemless RSA plication in RSA overall, with rates ranging from 1.5% to
patients from seven studies with early and mid-term 31%.51 Not surprisingly, it is also the most frequently

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 Tyler A. Luthringer, MD, et al

Review Article
reported complication in stemless RSA.44,48,49 Many of design of existing stemless prosthesis, and limited data
these dislocations occur in stemless RSAs performed for are currently available on the implants being investigated
fracture or other indications with humeral bone loss that for use in the United States. Use of stemless implants in
can result in loss of proper deltoid tension.8,44,45 Because RSA requires unique technical considerations and careful
of limitations in humeral implant height positioning and humeral head resection to ensure accurate implant
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the need for adequate fixation in the metaphyseal bone, placement and adequate construct stability because of
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instability may be more likely to occur.44 the limited modularity of these implants. As more studies
Another complication of concern is periprosthetic with longer follow-up are conducted, appropriate in-
fractures. As mentioned before, impaction of the humeral dications and differences between various implant de-
implant into metaphyseal bone with thinner cortices can signs will continue to become clearer.
result in intraoperative fractures. Fortunately, such
fractures described in the literature have done well with
nonsurgical treatment after implantation.34,46 Postop- References
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 Stemless Reverse Shoulder Arthroplasty

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