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1. The Evolution of Materials
& Techniques in Total Shoulder
Arthroplasty
Manos Antonogiannakis
Director
3rd
Orthopaedic Department Ygeia
Hospital - Center for Shoulder
Arthroscopy

2. 1893 Jules E. Pean
1st successful shoulder replacement
-26 years before the first hip replacement
-tuberculosis infected shoulder of a 32-year-old Parisian
-2 years later implant removed because of sepsis
2 platinum loops connecting the scapula to a
paraffin-hardened rubber ball

3. Themistocles Gluck
had already designed an ivory shoulder
hemiarthroplasty

4. 1951 Baron and Senn
acrylic prosthesis to replace the proximal humerus
1953 de Anquin
performed 11 acrylic shoulder replacements for fracture allows
tendinous reattachment around the prosthesis
BUT
poor wear characteristics
anchorage difficulty
component breakage

5. Semiconstrained devices
English McNab prosthesis
Mazas nonretentive prosthesis
Hooked DANA prosthesis by Amstutz
DANA total shoulder system
was the first system with multiple head and glenoid sizes

6. Constrained Bickel prosthesis
(1970)
By Mayo Clinic
Cement stem & small metallic ball
Polyethylene socket within the glenoid
vault
Bone removal from the scapula
High complication rates & revision

7. Constrained Stanmore prosthesis
by Lettin and Scales
Standard ball-and-socket
Increased constraint
Glenoid 3 long pegs cemented
Range of motion inconsistent and disappointing
High revision rates

8. Bipolar designs
Smooth, concentric contact
Decreased contact stress & friction
Increased moment arm
Bateman developed
2 bipolar designs

9. 1953 Charles S. Neer II - The original Neer I
Vitallium (cobalt-chrome alloy)
One stem size & 44mm radius head
Hole in the lateral neck
Top of the head slightly flattened

10. 1953, the Neer I prosthesis available in three stem
sizes
1955, that number increased to five,
four fins, multiple fenestrations for bone ingrowth
1955 Neer’s clinical series was first published in
the Journal of Bone and Joint Surgery and consisted
of using his shoulder prosthesis in 12 cases with
excellent and satisfactory results.

11. Development of the Neer II in 1970
& 1st
generation prosthesis
Monoblock humeral stem and
cemented, all-polyethlene
keeled component
flute for cement egress
2 holes for suture fixation
standard stem lengths
with 3 diameters
& 2 head lengths

12. Modular or 2nd
generation prosthesis in 1980
Biomet, Cofield, Global
Did not achieve Neer’s aim of mimicking the normal anatomy
restoring the center of rotation
Two major problems were encountered:
1.the prosthetic head was often malpositioned
2.the head was frequently oversized.

13. Modular & Adaptable 3rd
generation
prosthesis in 1990
Modularity = different sizes
Adaptability = restoration of the COR
anatomical unconstrained
recreate normal anatomy
variable inclination and offset
The Aequalis prosthesis adopted
these criteria and became the first
third-generation shoulder replacement
Gilles Walch , Pascal Boilleau , Christian Gerber

14. Glenoid resurfacing prosthesis
The first glenoid component
introduced by Neer in 1972
all-polyethylene
oval-shaped
curved back
triangular keel designed for cementation
Major concern
radiolucencies at cement-bone interface
and loosening

15. What surface geometry?
Anatomic versus oval
Flat or Convex back
keeled or pegged designs
What material?
All-polyethylene
Metalbacked (1984 Neer )
Hydroxyapatite-coated
Plasma-sprayed
Tantalum (Zimmer)
Trabecular Titanium
(Lima)

16. Convex or flat back?
The convex-back glenoid component outperformed the
flat-back
What is the optimal mismatch between
components?
radial mismatch appears to be optimised at greater than
5.5 mm
Cemented or uncemented glenoid?
cementless metal-backed components inferior to
cemented all-polyethylene implants

18. The Reverse TSA
• Although very good results were obtained
with the Anatomic TSA it required a
functioning rotator cuff
• Reverse shoulder arthroplasty became the
solution for that problem

19. 1970-1973 The Neer Mark Ι,ΙΙ,III by Neer &
Averill
1st
fixed fulcrum prosthesis
reverse ball-and-socket
glenoid keeled & cemented
Mark I : larger ball
allow more motion
Mark II : small ball
& cuff reattach
but limited ROM
Mark III: axial rotation in the humeral stem
Due to failures Neer abandoned constrained designs

20. 1972 Reeves
spiked glenoid component
cemented
1972 Gerard
component screwed into the
glenoid without cement
vs Mark & Reeves implants

21. But..
none of these reverse devices caught on as a
viable option

22. The resurgence of RSA
1985 Trompette prosthesis
1. 2/3 of a sphere
2. PE humeral stem
3. Cemented glenosphere
The prototype dates from 1985
The first implantation was in 1986
LATERALIZED COR

23. 1991 Delta III ( the first reverse
that survived the test of time)
2 innovations
glenoid large ball
humerus inclination of 155˚( non anatomic)
1. Half of sphere
2. Polyethylene cup
3. Modular
4. Baseplate fixed with two diverging
polar screws & two equatorial screws
In 1995 glenoid fixed with a porus coating
central peg
COR AT THE LEVEL OF THE GLENOID
MEDIALIZATION & DISTALIZATION OF THE

24. A paradigm shift
Instead of trying to restore the
anatomy
To change the natural anatomy in
order to have better functional
results
Instead of mimicking Nature
Improve Nature

25. DELTA III - GOLD STANDARD - MEDIALIZATION
Lever arm of deltoid & tension of deltoid fibers
AA Elevation 130˚
but…
slackening of the remaining cuff (IS, Tm, SSC )
scapular impigment : notching & bone loos & PE wear
proper deltoid tension: instability 3-6% (no deltoid wrapping)
acromion stress fracture

26. Solutions
• Increasing the diameter of the
glenosphere (36-44mm)
• Eccentric glenosphere
• Inferior and with a downward inclination,
implantation of the glenosphere
• Polyethylene glenospere
• Lateralization of the glenosphere

27. LATERALIZATION OF THE GLENOSPHERE
1.Metallic offset lateralization
2/3 of a sphere (DJO) &
glenosphere over the baseplate
2.Bony increased offset
BIO RSA (P.Boileau)

28. LATERALIZATION IN HUMERUS
Humeral cut 155˚ vs 135˚
PE inlay distalization
PE onlay lateralization & distalization

29. The Swedish Registry from 1999

30. Resurfacing (Paralel line of development)
In 1970s Bateman developed resurfacing device
replaces only the humeral head
& Jonsson
similarly developed cup arthroplasty
used in placed of fusion
in rheumatoid arthritis

31. Resurfacing Evolution
Advantage no stem
Drawback glenoid erosion
PyroCarbon’s
Low surface friction
Nonadhesive properties
Contribute to preserving cartilage

32. Short stem & Stemless Humeral
Bone preserving
Avoidance of stress risers
Recreated the anatomy
Hydroxyapatite (HA) coating
A need of good metaphyseal bone stock

33. CONVERTIBILITY
Revise hemi & total-shoulder arthroplasties to a
reverse shoulder
Anatomical Shoulder
Inverse/Reverse System, Zimmer The Aequalis Ascend Flex
convertible shoulder system

34. Affinis Inverse -Mathysmedical
Vitamys & Ceramys
(an effort to improve on wear
characteristics)
oxidation resistance
excellent wear and aging behaviour
5,4 times lower wear rate compared to
CoCr - UHMWPE
Vitamys Glenospheres
highly cross-linked polyethylene
addition of 0,1% atocopherol (vit E)
Ceramys inlay
nano-crystalline dispersion of 80% zirconium
oxide& 20% aluminum oxide
free of Co Cr & Nickel
high resilience and durability

35. Zimmer Trabecular Tantalum
• Exceptional initial fixation
• High coefficient of friction
between Trabecular Metal Material
& cancellous bone
• Enables vascularization
• Maximizes bone and soft-tissue ingrowth
• More normal bone remodeling

36. Lima Trabecular Titanium
an effort to increase fixation strength
to the sceleton
a biomaterial that
imitates trabecular bone morphology
light weight
corrosion resistance
excellent biocompatibility
high mechanical performance
High open porosity & adequate pore size
enhance cell migration
vascularization
transport of oxygen & nutrients
ions & bone inducing factors
osteoconduction & osteoinduction

37. Electron Beam Melting technology
creation of any three-dimensional design
either dense or porous parts
produce exclusive implants
reconstruct 3D patient anatomy
through 3D printing
( CT scans and MRI data)
PROMADE
focused on implants designed
specifically for the sole use
of particular patient.
SMR AXIOMA TT
METAL BACK

38. It was a long road traveled
• Today we can succed results of a
magnitude unimaginable 20 gears ago
Reverse TSA 3 months post-op Anatomic TSA 4 months post-op

39. And the evolution continues
as ingenious surgeons strive
to lessen human suffering and
improve the quality of life of
our patients
The main issue being the
longevity of the results

40. THANK YOU FOR
YOUR
ATTENTION !!!

42. The shoulder arthroplasty “family tree” by R.Micael Gross

44. 1950 Frederick Krueger
Vitallium mold prosthesis
Egg-shaped head, rounded corners
Cementless implantation
Fenestrated stem for bone ingrowth

45. 1973 Interposition Arthroplasty
by Swanson
using Silastic
In 1970s all polyethylene glenoid components
used in the Neer & St.George prostheses, like
Kenmore design

46. 1972 R. Kölbel prosthesis
1973 Kessel RSA
cementless glenoid component
with a single large self-tapping
lag screw

47. 1975 Fenlin
designed a 2-pieces
glenoid component
with 2 extensions
1978 Gristina
Trispherical Prosthesis
metal glenoid, two metal &
two polyethylene hemispheres

48. Grammont’s first idea
varus position of the humeral head
The Ovoide prosthesis
Introduced in 1980
Break the link with anatomy
This prosthesis has theoretically two CORs.
Abandoned because of problems of instability

50. LATERALIZATION GLENOSPHERE + HUMERUS
Increase deltoid lever arm
Increase tension ISS/Tm/SSc
Increase compressive forces
Increase stability
Decrese medial impigment
LATERALIZATION BOTH + INFERIOR TILT
DISTALIZATION OF THE HUMERUS
Increase deltoid tension but the same deltoid lever arm

51. Keeled versus pegged?
The peg-shaped provides
greater theoretic stability
against shear forces
Offset keel versus centered keel?
Anterior offset demonstrates
better resistance to bending
compared with the centered
keel