J Shoulder Elbow Surg (2014) 23, 1662-1668

www.elsevier.com/locate/ymse

Reverse shoulder arthroplasty in 41 patients

with cuff tear arthropathy with a mean follow-up
period of 5 years
Nawfal Al-Hadithy, MRCS*, Peter Domos, MRCS, Mathew D. Sewell, FRCS,
Ravi Pandit, FRCS

Luton and Dunstable Hospital, Luton, UK

Background: Reverse shoulder arthroplasty (RSA) is an accepted treatment for patients with pseudopar-
alysis due to cuff tear arthropathy. There have been limited studies with midterm clinical and radiologic
results. We present our results for a single surgeon from a district general hospital.
Methods: Forty-one consecutive Delta III RSAs were performed by an anterosuperior approach in 37 pa-
tients (29 women and 8 men) with pseudoparalysis due to cuff tear arthropathy. The patients’ mean age was
79 years (range, 68-91 years). The mean follow-up period was 5 years. All patients were available for final
review, and none were lost to follow-up.
Results: The mean age-adjusted Constant and Oxford scores improved from 34.2 points to 71.0 points and
15 points to 33 points, respectively. Mean abduction and forward flexion improved from 64
to 100
and
55
to 110
, respectively. Scapular notching was seen in 68% of patients, but there was no deterioration in
function or satisfaction scores. Stress shielding of the proximal humerus was seen in 10% of patients. One
patient underwent revision to a hemiarthroplasty because of glenoid component failure after a fall. There
were no early postoperative dislocations in our series.
Conclusion: RSA for pseudoparalysis due to cuff tear arthropathy provides good functional results at 5 years;
however, there is a high rate of scapular notching, which does not seem to affect overall functional outcomes.
Level of evidence: Level IV, Case Series, Treatment Study.
Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Reverse shoulder arthroplasty; cuff tear arthropathy; Delta

Successful surgical management of cuff tear arthropathy
is challenging, and the excellent results of unconstrained
arthroplasty in primary glenohumeral arthritis have not
been replicated in cuff tear arthropathy.12 The early failures
of total shoulder arthroplasty due to eccentric loading of the
glenoid component meant that hemiarthroplasty remained
No institutional review board/ethical approval was required for this study.
*Reprint requests: Nawfal Al-Hadithy, MRCS, Luton and Dunstable
Hospital, Luton, UK.
E-mail address: Nawfal@Yahoo.com (N. Al-Hadithy).
the surgical option of choice for most surgeons, despite
inconsistent relief of pain and poor function.10,29,30
The Delta III reverse shoulder arthroplasty has been
used more recently and provides better functional outcomes
than hemiarthroplasty because of a medialized center of
rotation, which reduces torque on the glenoid component
and increases the mechanical advantage of the deltoid.1
Despite concerns about scapular notching and failure
rates, indications and implantations have been increasing.
There have been numerous studies reporting the outcome of
the Delta III prosthesis; however, they are limited by short

1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.03.001
Reverse shoulder arthroplasty to cuff arthropathy
Table I Sirveaux classification of scapular notching
Grade 1: Defect confined to pillar
Grade 2: Defect reaches lower screw
Grade 3: Defect crosses lower screw
Grade 4: Defect extends under baseplate
follow-up periods and by varying indications for implan-
tation, including revision, fracture, and nonunion, making it
difficult to reliably compare results.13,15,27,31,32 Other arti-
cles have reported on multicenter studies involving
different surgeons, with variations in surgical techniques
and postoperative rehabilitation leading to confounding
factors, making interpretation of results difficult.13,33
We present the midterm clinical and radiologic results of
primary Delta III prostheses for cuff tear arthropathy per-
formed by a single surgeon in a district general hospital, in
patients with no previous surgical procedures, with a mean
follow-up period of 5 years.
Materials and methods
Between 2002 and 2010, 41 consecutive Delta III reverse shoulder
arthroplasties were performed in 37 patients (29 women and 8 men)
with symptomatic cuff tear arthropathy. The mean age of the pa-
tients was 79 years (range, 68-91 years). A total of 4 patients un-
derwent bilateral procedures. Surgery was performed on the right
shoulder in 31 cases and on the left shoulder in 10 cases. The main
indication for implantation was severe pain with functional
impairment and pseudoparalysis, with radiologic signs of gleno-
humeral arthritis and proximal migration of the humeral head. Pa-
tients with active sepsis, avascular necrosis, rheumatoid arthritis,
post-traumatic arthritis, and symptomatic acromioclavicular joint
arthritis were not included in the study. All patients were deemed to
have an intact subscapularis tendon by clinical examination.
Preoperative and postoperative clinical and functional out-
comes were measured with the Oxford5 and Constant2 shoulder
scores by 2 independent surgeons who were not involved with the
original operation. The Oxford score is a validated 12-question
patient-reported scoring system evaluating pain, function, and
range of motion. It ranges from 0 points (worse) to 48 points
(best). The Constant score is a 100-point validated scoring system
that is patient reported and clinician assessed and covers pain,
function, range of motion, and strength.
Anteroposterior, lateral, and axillary radiographs were ob-
tained in all patients at 6 weeks and 6 months, as well as yearly
thereafter.
Serial radiographs were evaluated for component malposition,
periprosthetic radiolucency, scapular notching, stress shielding,
heterotrophic ossification, and prosthesis failure by 2 independent
assessors. Scapular notching was graded according to the classi-
fication of Sirveaux et al34 (Table I). Radiolucent lines were
assessed according to the criteria of Sperling et al.35
All operations were performed by the senior author (R.P.) with
patients under a general anesthetic, supplemented with an inter-
scalene block. The anterosuperior McKenzie approach was used.
The subscapularis tendon was inspected and confirmed to be
intact in all cases. The humeral neck was resected by use of the
1663
Follow-up in months
120
100
80
60
40
20
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Figure 1 Follow-up duration in months.
appropriate jig. All components (glenoid baseplates and humeral
stems) were uncemented and hydroxyapatite coated. The gleno-
sphere was implanted in a neutral position as inferiorly as possible,
in an effort to achieve an inferior overhang as described by Nyffeler
et al.28 The glenoid baseplate was held in place with 4-mm pe-
ripheral locking screws. The size of the glenosphere was determined
by the size that helped achieve the best soft-tissue tension and sta-
bility. Humeral stems were implanted in 10
of retroversion.
The postoperative antibiotic protocol consisted of 1 intrave-
nous dose of 1.5g cefuroxime. The arm was placed in a sling to
immobilise the shoulder joint. Physiotherapy was started on day 1
and included full unrestricted passive-assisted mobilization, pro-
gressing to gradually increase function by 4 to 6 weeks.
Concentric strengthening was increased at 6 weeks post-
operatively, after which use of the sling was discontinued.
Statistical analysis
The Constant and Oxford scores were normally distributed. The
paired t test was therefore used to compare the preoperative and
postoperative scores. All analyses were performed with SPSS
software program (version 9.0; SPSS, Chicago, IL, USA). P < .05
was considered significant.
Results
All patients were available for follow-up at a mean of
60 months (range, 20-101 months) (Fig. 1). Patients were
split into 2 groups depending on whether they had more or
less than 48 months’ follow-up. There were 9 shoulders
(group 1) with less than 48 months’ follow-up and 32
shoulders (group 2) with more than 48 months’ follow-up.
Functional outcome
On subjective assessment, 20 patients (49%) felt that their
shoulder was much better, 11 (27%) thought it was better, 6
(15%) were unsure, and 3 (7%) thought it was worse. The
preoperative and postoperative Constant and Oxford scores
are reported in Table II and range of motion in Table III.
There were significant gains (P < .05) between preopera-
tive and postoperative scores (24 months and final follow-
1664 N. Al-Hadithy et al.

Table II Mean constant, age-adjusted constant, and Oxford scores preoperatively and postoperatively
Constant score (points) Age-adjusted constant Oxford score (points)
score (points)
Group 1: Shoulders with <48 mo of follow-up (n ¼ 9)
Preoperatively 26 32 16
24 mo postoperatively 54 66 31
Final follow-up 53 65 29
Group 2: Shoulders with >48 mo of follow-up (n ¼ 32)
Preoperatively 23 32 14
24 mo postoperatively 65 74 36
Final follow-up 64 73 33
All shoulders
Preoperatively 24 34 15
24 months postoperatively 63 73 35
Final follow-up 60 71 32

Table III Mean range of motion preoperatively and postoperatively

Time of scoring Flexion (
) Abduction (
) ER (
) IR
Group 1: Shoulders with <48 mo of follow-up (n ¼ 9)
Preoperatively 56 63 13 Buttock
24 mo postoperatively 98 97 23 Waist
Last postoperative visit 101 101 17 SI joint
Group 2: Shoulders with >48 mo of follow-up
(n ¼ 32)
Preoperatively 54 64 13 Buttock
24 mo postoperatively 124 99 24 Waist
Last postoperative visit 111 102 21 SI joint
All shoulders
Preoperatively 55 64 13 Buttock
24 mo postoperatively 118 98 23 Waist
Last postoperative visit 108 101 19 SI joint
ER, external rotation; IR, internal rotation; SI, Sacro-iliac

up); however, there was no significant difference between
the 24-month and final follow-up scores, although there was
a trend toward reduction in function.
Radiographic outcome
Radiographs were obtained preoperatively, immediately
postoperatively, and at most recent follow-up and were
available for review.
Scapular notching was noted in 28 shoulders (68%) and
was assessed by the Sirveaux classification33; 22 shoulders
(54%) had grade 1 or 2 notching, and 6 patients (15%) had
grade 3 or 4 notching (Fig. 2). In all cases, notching was
visible on radiographs at 12 months, but only 3 progressed
with time, from grade 2 to 3 in 2 patients and from grade
2 to 4 in 1 patient. There was no observed association
between progression of scapular notching and deteriora-
tion of Constant or Oxford scores at 24 months and final
follow-up.
Two patients had malpositioned screws (1 inferior and 1
posterior) on initial radiographs (Fig. 3) However, both had
an uneventful postoperative course, with no evidence of
further loosening or screw cutout. Five patients (12%) had
radiolucent lines, with 3 (7%) around the glenoid compo-
nent in zones 1 and 2; all were less than 2 mm in width and
non-progressive. Two patients had humeral radiolucent
lines in zones 7, 8, and 9, but they were less than 1 mm and
non-progressive.
The presence of stress shielding was defined as thinning
of either medial or lateral cortical bone with osteopenia as
classified by Melis et al.24 Four patients had medial prox-
imal humeral stress shielding. In all cases, it was non-
progressive and confined to the metaphysis without any
signs of aseptic loosening. Three of these patients had
scapular notching as well. Periprosthetic heterotrophic
ossification was present in 42% of patients.
Complications
Of the patients, 4 (10%) had complications, with 1 under-
going revision surgery. Two patients had post-traumatic
glenoid component failure. One patient fell 6 weeks
Reverse shoulder arthroplasty to cuff arthropathy
Figure 2 Anteroposterior radiograph of left shoulder showing
scapular notching due to mechanical impingement by medial rim
of humeral cup.
postoperatively, causing the glenoid component to migrate
superiorly (Fig. 4, A and B). At 2 months, he underwent
revision to a hemiarthroplasty (Fig. 4, C); although he was
pain free, he had limited abduction of 40
. The other
glenoid component failure occurred in an 88-year-old
low-demand patient from a nursing home, whodafter a
falldhad minimal superior migration of the glenoid
component in her nondominant hand. Because she was able
to abduct her shoulder to 50
and had minimal pain, she
declined further intervention.
One patient fell 5 months after surgery and sustained a
minimally displaced fracture of the acromion. The shoulder
was treated nonoperatively with a period of immobilization
and healed uneventfully.
One patient had a broken superior glenoid screw (Fig. 5)
at 18 months after initial surgery without any history of
trauma. He had the lowest functional scores with some
occasional pain but preferred nonoperative management.
He was monitored regularly with radiographs, but no gle-
noid loosening or other complications occurred.
Of the 9 patients (22%) who were either unsure or un-
happy about the outcome of their procedures, 4 were the
patients who had complications. Of the remaining 5 pa-
tients, all complained of persistent pain; however, despite
serial review including inflammatory markers and radio-
logic evaluation, no cause was identified, and these patients
were managed expectantly. Of the 5 patients, 1 did not have
scapular notching; the remaining 4 had grade 1 or 2
notching and the notching was non-progressive.
1665
Figure 3 Malpositioned glenoid screw penetrating through the
cortex of the scapula.
There were no cases of superficial or deep infection,
loosening, dislocations, periprosthetic fractures, or axillary
nerve injuries. Thus far, no patients in our series have un-
dergone revision for loosening or scapular notching.
Discussion
Over the past decade, reverse shoulder arthroplasty has
increasingly been used for cuff tear arthropathy. With
increasing surgical confidence, the indications have also
extended to now include rheumatoid arthritis, massive
cuff tears, fracture sequelae, and revision after hemi-
arthroplasty.19 Our study has shown that the Delta III pros-
thesis can improve pain and function in patients with cuff tear
arthropathy, with a low complication rate; however, move-
ment and function seems to deteriorate over time.
There were significant gains in Oxford scores (15 points
to 32 points) and Constant scores (24 points to 60 points) in
both patient groups of patients; however, we found lower
increases in range of motion compared with other studies
that evaluated cuff tear arthropathy.7,13,18 This may be
partly explained by our longer follow-up period of
60 months compared with a mean of 29 months. We noted
general deteriorations in functional scores and range of
motion after 24 months to final follow-up. Favard et al9
performed a survivorship analysis of 527 reverse shoulder
arthroplasties and found that although revision rates at
10 years were relatively low (11%), functional scores
deteriorated with time. Although they suggested that the
reason for this is unknown, others have hypothesized that
over-tensioning the deltoid muscle and periscapular muscle
fatigue may be responsible.21,23
In a series of 60 patients, Frankle et al11 found a glenoid
baseplate failure rate of 12% at 21.4 months’ follow-up and
1666 N. Al-Hadithy et al.

Figure 4 (A) Postoperative radiograph after reverse shoulder arthroplasty. (B) At 2 months after a fall, the glenoid component failed with
superior migration. (C) Revision to a hemiarthroplasty was performed, and although function was limited, the patient was pain free.

Figure 5 Anteroposterior radiograph of left shoulder postoperatively (A), with subsequently broken superior screw (B). A radiolucent
area is seen around the central peg (B), showing that the implant is toggling.

attributed it to the use of 3.5-mm peripheral screws for
fixation. Harman et al18 found that using peripheral screws
of 5 mm reduced micromotion at the baseplate-bone
interface to less than 150 mm, which is generally the
accepted threshold for bony ingrowth.20 In their follow-up
study, Cuff et al4 secured the baseplate with 5-mm screws
and found no cases of loosening at 27.5 months. A further
study evaluated 96 shoulders, in which the baseplate was
secured with locking screws, and no failures were noted at
2 years’ follow-up.3 Frankle et al found that their 8 failures
occurred because of metal fatigue of the glenoid baseplate
screws at a mean of 21.4 months, and they suggested that
the first 2 years was a critical period because failure of bony
ingrowth could result in early failure. We elected to use 4-
mm peripheral locking screws and had 2 instances of
baseplate failure and 1 case of screw breakage, all of which
occurred within 24 months from surgery. The use of lock-
ing screws may contribute to malpositioning of the screw
due to a lack of adequate tactile feedback.
Several studies have suggested that an inferior tilt of the
glenoid baseplate reduces scapular notching by reducing it
reduces inferomedial impingement of the humerus against
the pillar of the scapula. However, these are based mostly
on retrospective observations.2,14,18 More recently, biome-
chanical studies have suggested that inferior translation of
the glenosphere allowing overlap of the inferior glenoid rim
may be more important than inferior tilt alone.6,16,28 In a
prospective randomized study, Edwards et al7 found that a
computer-navigated inferior tilt of 10
did not reduce the
incidence or severity of scapular notching. Although their
follow-up period was limited, at 21 months, other authors
have shown that notching appears within 2 years and tends
not to progress past that time point.14 Grassi et al14 found
that an inferior overhang did not prevent progression of
scapular notching. Although we aimed to position the
glenoid baseplate in the neutral position, with an inferior
overhang of 3 to 4 mm, Levigne et al22 found that there was
a tendency to position the glenosphere with a superior tilt
and superior placement with the superolateral approach
when compared with the deltopectoral approach. Melis
et al24 found notching to be more prevalent with the
superolateral approach (23 of 35 cases) than with the del-
topectoral approach (9 of 30 cases); however, they did not
assess for glenoid implant positioning and noted that many
surgeons did not aim for inferior positioning of the base-
plate on the glenoid. Gutierrez et al17 found that an infe-
riorly tilted glenoid had the most uniform compressive
forces and less tensile force and micromotion compared
with a superiorly tilted baseplate and found that a superior
tilt predisposed patients to early failure.
Reverse shoulder arthroplasty to cuff arthropathy
Our findings are consistent with those of Edwards et al,7
and our notching rate of 68% was consistent with other
studies with rates ranging from 50% to 96%.2,22,33,36 It
therefore appears that inferior glenosphere tilt does not
reduce the incidence of scapular notching. In line with other
studies, we found no relation between scapular notching and
function or pain at 24 months or final follow-up. Recently,
several authors have attempted to reduce scapular notching
rates by increasing the offset of reverse shoulder arthroplasty.
Frankle et al11 reported successful clinical outcomes with the
Reverse Shoulder Prosthesis (DJO Surgical, Austin, TX,
USA), which has a center of rotation closer to its anatomic
location. In a further study evaluating the Reverse Shoulder
Prosthesis, Cuff et al3 found no instances of scapular notch-
ing in their series of 96 shoulders.
Like Melis et al,24 we found a high incidence (10%) of
proximal humeral bone resorption due to stress shielding.
In their series, Melis et al noted significantly higher rates of
bone resorption in uncemented humeral stems as compared
with cemented prostheses; this is in keeping with other
research on bone resorption due to stress shielding.26
However, in contrast to Melis et al, our results were in
line with those of Sirveaux et al,34 where we found that 3 of
our 4 patients with proximal humeral bone resorption had
associated scapular notching. We noticed that proximal
humeral resorption occurred predominantly on the medial
cortex, and this may be due to direct impingement on the
inferior scapula, therefore causing both scapular notching
and proximal humeral resorption.
Our complication and revision rates of 10% and 2%,
respectively, are lower than those in other series. Zumstein
et al37 reviewed 21 studies and found complication, reop-
eration, and revision rates of 24%, 3.5%, and 10%,
respectively, with reoperations being defined as in-
terventions requiring return to the operating theater without
altering or replacing the components and revisions defined
as total or partial exchange of the components. We attribute
our low complication rate to a combination of factors-
surgical approach, implant development, preferential im-
plantation of the prosthesis in the neutral position with an
inferior overhang, and an elderly population (79 years) with
low demands. The most common and serious complication
is dislocation, with an incidence of up to 9%.2,7,18,32
Zumstein et al found that 97.3% of dislocated shoulders
requiring reoperations in those that were performed using
the deltopectoral approach, and this was the most common
cause of reoperation. Mole et al25 reviewed 527 reverse
shoulder arthroplasties and found significantly lower
instability rates with the anterosuperior approach (0.8%)
compared with the deltopectoral approach (5.1%). In our
series, we used the anterosuperior approach exclusively and
had no dislocations; in addition, surgery was only per-
formed in shoulders with an intact subscapularis tendon,
which has been shown to halve the incidence of disloca-
tion.8 Several studies also used the first Grammont pros-
thesis, where glenoid disassembly was a problem. This has
1667
since been resolved by introducing a modified Morse taper
fixation for the glenosphere on the metaglene.1
We acknowledge the limitations of this study being retro-
spective. Scapular notching is difficult to assess if the X-ray
beam is not aligned and perpendicular to the baseplate.
Furthermore, although we aimed for an inferior tilt, radio-
graphic assessment was abandoned because we found inter-
observer variability to be unacceptable, which we attributed to
the variability in positioning of the radiographs and the lack of
accuracy of plain radiographs. We minimized assessment bias
by having 2 independent assessors who were not involved with
the index operation perform the evaluations.
Conclusion
Our experience with Delta reverse shoulder replacement
for cuff tear arthropathy performed by a single surgeon
from a district general hospital has been encouraging.
Patients with cuff tear arthropathy can expect significant
improvements in function and pain, with an acceptable
complication rate at 5 years. There is a high incidence of
scapular notching; however, no association was seen
with functional outcome. We continue to use the Delta
III reverse shoulder prosthesis for cuff tear arthropathy
and are encouraged by the outcomes and low compli-
cation rates in this elderly population.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
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