Analysis of a retrieved Delta III total

shoulder prosthesis

R. W. Nyffeler, A reversed Delta III total shoulder prosthesis was retrieved post-mortem, eight months
C. M. L. Werner, after implantation. A significant notch was evident at the inferior pole of the scapular neck
B. R. Simmen, which extended beyond the inferior fixation screw. This bone loss was associated with a
C. Gerber corresponding, erosive defect of the polyethylene cup. Histological examination revealed a
chronic foreign-body reaction in the joint capsule. There were, however, no histological
From the University signs of loosening of the glenoid base plate and the stability of the prosthetic articulation
of Zurich, Zurich, was only slightly reduced by the eroded rim of the cup.
Switzerland

R. W. Nyffeler, MD Dipl.
Ing, ETH
Orthopaedic Hospital,
University Lausanne, Av.
Pierre-Decker 4, CH-1005
Lausanne, Switzerland.

C. M. L. Werner, MD

C. Gerber, MD
Department of Orthopaedic
Surgery, University of
Zurich, Balgrist, Forchstrasse
340, CH-8008 Zurich,
Switzerland.

B. R. Simmen, MD
Schulthess Clinic,
Lengghalde 2, CH-8008
Zurich, Switzerland.
Correspondence should be
sent to Dr R. W. Nyffeler.
©2004 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.86B8.
15228 $2.00
J Bone Joint Surg [Br]
2004;86-B:1187-91.
Received 16 December 2003;
Accepted 17 February 2004
The Delta III total shoulder (DePuy Interna-
tional Ltd, Leeds, England) is a reversed, semi-
constrained prosthesis, which is recommended
for the treatment of painful glenohumeral
arthritis associated with an irreparable rotator
cuff tear. This prosthesis transposes the shapes
of the scapular and humeral joint surfaces in
order to medialise the centre of rotation of the
joint. The aim is to increase the length of the
lever arm of the deltoid muscle and to improve
the stability of the implant.1 The glenoid com-
ponent consists of a convex metallic hemi-
sphere (glenosphere) with a diameter of 36 or
42 mm fixed on a hydroxyapatite-coated base
plate (metaglene) which is anchored to the gle-
noid by a central plug and four diverging
screws. The modular humeral component has
a conical stem with a metaphyseal component
which accommodates a concave polyethylene
bearing-surface (epiphysis).
Good short- and mid-term results for pain
relief, active elevation and patient satisfaction
have been reported.2-4 There is, however, con-
cern about the rate of complications and the
durability of the fixation of this prosthesis. The
presence of a bony defect or notch at the in-
ferior part of the scapular neck is a common
radiographic finding at early follow-up.5-7
Component loosening, component dissocia-
tion, instability and fatigue fractures of the
acromion have also been described.6,8 It is not
clear if the bone loss at the inferior scapular
neck is progressive or whether it is necessarily
associated with loosening of either the glenoid
or humeral components due to polyethylene
particulate disease. The purpose of the current
report is to present the post-mortem and histo-
logical findings regarding notching, fixation
and stability of a reversed Delta III total shoul-
der prosthesis (DePuy International Ltd) re-
trieved eight months after implantation.
Materials
A fresh frozen left shoulder specimen of a 91-
year-old man, who died following a severe
brain injury after a fall was examined post-
mortem. The glenohumeral joint had been
replaced by a Delta III shoulder prosthesis
(DePuy International Ltd) eight months before
death. The operation was performed beause of
a painful, pseudoparalytic shoulder with an
irreparable rotator cuff tear. Pre-operative
radiographs showed superior subluxation of
the humeral head and mild degenerative
changes with osteopenia of the glenoid (Fig.
1a). A Delta III prosthesis (humeral epiphysis
size 1, lateralised humeral cup and glenosphere
of 36 mm diameter) was inserted using the
standard technique.9 Radiographs six weeks
post-operatively showed a small notch at the
lateral border of the scapula and a radiolucent
line on the posterior aspect of the glenoid com-
ponent (Fig. 1b). At the latest follow-up three
and a half months post-operatively the patient
was almost pain free. Both active forward ele-
vation and abduction of the arm were to 90˚
but with only little abduction strength.
Results
Gross inspection. Macroscopic examination
revealed an intact deltoid muscle. The supra-
spinatus tendon was replaced by thick scar
tissue firmly adherent to the acromion and the
muscle, which was atrophic. The subscapularis

VOL. 86-B, No. 8, NOVEMBER 2004 1187

1188 R. W. NYFFELER, C. M. L. WERNER, B. R. SIMMEN, C. GERBER

Fig. 1a Fig. 1b Fig. 1c

Radiographs of the shoulder of a 91-year-old man. Figure 1a – Pre-operative image shows pronounced proximal migration of the humeral head and
mild degenerative changes with osteopenia of the glenoid. Figure 1b – There is a small notch on the lateral border of the scapula six weeks after
insertion of a reversed Delta III prosthesis. Separation of the upper part of the humeral component from the glenosphere is a sign of abutment of
the inferior part of the cup against the scapular neck in adduction. Figure 1c – There is a large radiolucent zone around the inferior screw and a
radiolucent line between the glenoid component and scapula eight months post-operatively.

Fig. 2 Fig. 3

Photomicrograph showing inflammation of the joint capsule with multi- Photograph showing the erosion around the inferior pole of the glenoid
nucleate giant cells, macrophages, polyethylene fragments and a small and the scapular neck. The inferior screw and the inferior part of the gle-
piece of bone (haematoxylin and eosin, x 50). noid base plate are denuded of bone. The polyethylene liner is worn.

tendon was attached to the lesser tuberosity with non-
resorbable sutures, and the muscle was of normal appear-
ance. The infraspinatus tendon was thin but in continuity;
the muscle was atrophic. The teres minor was normal.
Radiographic findings. True anteroposterior radiographs
were taken under fluoroscopic control with the proximal
humerus in adduction and neutral rotation and revealed a
small radiolucent line of less than 1 mm between cement
and bone of the humeral shaft. On the scapular side a 1 mm
thick radiolucent line was evident behind the fixation plate
of the glenoid component. There was also a large inferior
scapular notch with erosion of the bone beyond the inferior
fixation screw, corresponding to a grade 4 notching on the
radiographic scoring system proposed by Valenti et al7 (Fig.
1c). This classification system has five grades: grade 0, no
notch; grade 1, small notch; grade 2, notch with condensa-
tion; grade 3, erosion up to the inferior screw; grade 4, ero-
sion over the inferior screw with extension under the base
plate.
Intra-articular findings. The synovium was of a normal
colour and the capsule was thick and hard, especially
posteroinferiorly and superiorly. A biopsy of the capsule

THE JOURNAL OF BONE AND JOINT SURGERY

 ANALYSIS OF A RETRIEVED DELTA III TOTAL SHOULDER PROSTHESIS
Fig. 4
Photograph of the posterior aspect of the shoulder showing that the
superior and posterior fixation screws have perforated the cortex of the
scapular neck. A posterior screw may damage the suprascapular nerve at
the base of the scapular spine.
was fixed in 10% buffered formalin before embedding, sec-
tioning and staining with haematoxylin and eosin. Light
microscopy showed granulomatous tissue containing
multinucleate giant cells, macrophages, bone debris and
polyethylene fragments (Fig. 2).
The inferior pole of the glenoid and the scapular neck
were eroded, corresponding to the radiographic notch on
the lateral border of the scapula. The posteroinferior part
of the glenoid component was denuded of bone as was the
inferior fixation screw, except at its tip. The inferior rim of
the lateralised polyethylene cup was worn down to the
metal epiphysis of the prosthesis (Fig. 3). The defect
enclosed an arc of 120˚ of the circumference of the cup.
Examination with low-power magnification revealed a very
rough surface with deep scratches on the defect but no fur-
ther damage to the articular surface. The metallic rim of the
epiphysis and the inferior screw were not damaged.
After excision of all soft tissues, it was evident that the
superior screw was orientated towards the supraspinatus
fossa and had perforated the cortex of the scapular neck.
The posterior screw had perforated the cortex close to the
base of the scapular spine (Fig. 4). The anterior screw was
completely covered by bone.
Range of movement. The range of movement was tested
after venting the joint and releasing the soft tissues. Maxi-
mum abduction in the scapular plane was 70˚ with respect
to the plane of the glenoid component. Abduction was lim-
ited by abutment of the greater tuberosity against the sub-
acrominal scar tissue. In neutral rotation, adduction was
limited by direct contact of the abraded polyethylene cup
with the inferior fixation screw. In this position the proxi-
mal humerus formed an angle of 5˚ of abduction with
respect to the plane of the base plate. The inferior rim of the
VOL. 86-B, No. 8, NOVEMBER 2004
1189
Fig. 5
Photomicrograph of a section in the frontal plane through the glenoid and
the centre of the glenoid base plate showing incomplete seating of the
component with a thin layer of connective tissue on the upper part and a
thin layer of cartilage on the inferior part. The inferior pole of the glenoid
is eroded, the corresponding part of the prosthesis is not supported by
bone. Thin trabeculae adhere to the hydroxyapatite coated central peg.
The fixation screws have been removed before sectioning (toluidine blue,
scale in mm).
cup rubbed on the denuded screw during flexion, extension
and rotational movements in adduction, explaining the ero-
sion of the polyethylene retrieved in this specimen.
Prosthesis-bone interface. The scapula was divided in the
frontal plane through the centre of the glenoid component
in order to assess the quality of bony ingrowth on its
hydroxyapatite coated base. The cuts were stained with
toluidine blue and examined under light microscopy.
Incomplete seating of the base plate with good fixation of
the central peg in the glenoid bone were found (Fig. 5).
There was a small layer of connective tissue superiorly and
a thin layer of cartilage inferiorly between the base plate
and the glenoid, as a sign of incomplete reaming during
preparation of the glenoid bone. The inferior parts of the
glenoid and scapular neck were eroded and the correspond-
ing portion of the prosthesis was not supported by bone.
The glenoid bone was osteopenic with thin trabeculae
adhering to the hydroxyapatite coating of the central fixa-
tion peg. The component was stable without signs of
trabecular fracture. The humeral component was firmly
attached to the humeral shaft and could not be removed
without destruction of bone.
Stability of the prosthesis. The eroded polyethylene cup was
removed and subjected to stability tests. A glenosphere with
a diameter of 36 mm was attached to the cross head of a
1190 R. W. NYFFELER, C. M. L. WERNER, B. R. SIMMEN, C. GERBER
90
80
lateral displacement x 10 (mm)
Subluxation force (N) and
70
60
50
40
30
20
Subluxation force
10 Lateral displacement
10
-20 -15 -10 -5 0 5 10 15
Distance from centre of PE cup (mm)
< Intact rim I Defect rim >
Fig. 6
Diagram depicting the lateral displacement multiplied by ten, and the sub-
luxation force vs the translation towards the intact (left) and the defective
rim (right). The compressive load was 50 N.
universal testing machine (Instron, High Wycombe, UK),
with the equator oriented in a vertical position. The cup
was aligned in front of the glenosphere and fixed to a fric-
tionless loading frame mounted on the platform of the test-
ing machine. A load of 50 N was applied to the loading
frame using a pulley and a hanging weight to press the cup
onto the glenosphere. The effective depth of the cup was
determined by measuring the lateral displacement of the
cup as the glenosphere was translated with a speed of 50
mm per minute from the intact rim through the deepest
point of the cup towards the defective rim. The dislocation
force was also recorded with a frequency of 10 Hz during
this manoeuvre. The depth of the cup was 8 mm with
respect to the intact rim and 4.1 mm with respect to the
defective rim (Fig. 6). The stability ratio, which is defined as
the relationship between dislocation force and compressive
load, was found to be 1.69 in the direction of the intact rim
and 1.51 in the direction of the defective rim (difference
10.7%).10 The value of 1.69 corresponded well to the
theoretical value of 1.67, calculated using the formula pub-
lished by Anglin, Wyss and Pichora11 for a rigid ball and
socket joint with a radius of curvature of 18 mm for the
sphere, a cup diameter of 30 mm and a coefficient of fric-
tion of 0.05.
Discussion
The Delta III reversed shoulder prosthesis is recommended
for use in older patients with irreparable rotator cuff tears
and osteoarthritis. Earlier types of reversed total shoulder
prostheses were withdrawn from the market because of a
high rate of aseptic loosening of the glenoid component due
to high eccentric loads.12 In the Delta III prosthesis the
centre of rotation lies in the plane between the glenoid com-
ponent and glenoid bone and theoretically there should be
no eccentric loads. However, medialisation of the centre of
rotation brings the humeral component closer to the scap-
ula with the risk of impingement between the polyethylene
cup and the inferior scapular neck. Repetitive contact
between polyethylene and bone may result in polyethylene
wear, chronic inflammation, osteolysis and loosening of the
glenoid implant.
An inferior notch very often develops within the first
months after the operation but may not progress thereafter.
In this case, mechanical impingement between epiphyseal
polyethylene and the inferior screw was present but it had
not led to loosening of the glenoid component. Despite the
20 lack of bony support and poor reaming of the glenoid bone,
the component was not loose. We hypothesised that stabil-
ity of the glenoid component depends mainly on the central
peg and the two monoaxial screws placed in the frontal
plane.
Perforation of the posterior cortex by the drill or the pos-
terior screw may damage the suprascapular nerve at the
base of the scapular spine (Fig. 4). A lesion of this nerve is
only harmless if the infraspinatus tendon is torn or if the
muscle is degenerated. If the infraspinatus is intact pre-
operatively, the nerve should be protected during surgery in
order to preserve external rotation of the arm.
The lesion of the rim of the cup reduced its effective
depth by 49%. The stability ratio, however was only
reduced by 11% under a compressive load of 50 N. The dif-
ference between these two values can be explained by the
form of the defect and the degree of constraint of the design
of the prosthesis. The intact portion of the rim enclosed the
glenoid component like an open ring and provided good
resistance against dislocation in the direction of the defect.
This seems to be confirmed in clinical practice. To our
knowledge a large inferior notch and wear of the poly-
ethylene cup have not been reported to be associated with
instability of the humeral component. Therefore, the risk of
impingement of the polyethylene cup on the inferior
glenoid may be reduced by using, either a polyethylene cup
with an asymmentric rim or a humeral component with a
smaller neck-shaft angle. Positioning the glenoid compo-
nent more inferiorly on the glenoid could also reduce the
risk of inferior glenoid impingement. Further biomechani-
cal studies are necessary to verify these hypotheses.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
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