Short Stems and Stemless Shoulder Arthroplasty: Current Concepts Review



1 1 Hospital General de Granollers, Avinguda Francesc Ribas s/n, postcode: 08402, Granollers, Barcelona, Spain 2 Universitat Autònoma de Barcelona, Campus Bellaterra, Cerdanyola del Vallès, Barcelona, Spain

2 Reading Shoulder Unit, Berkshire Independent Hospital, Reading, United Kingdom

3 Hospital General de Granollers, Avinguda Francesc Ribas s/n, postcode: 08402, Granollers, Barcelona, Spain


Historically, the shoulder arthroplasty humeral component has been designed for the management of infections, 
tumours and fractures. In all these cases the stem was needed as a scaffold. Original humeral components were not 
developed for use in shoulder arthritis, so these designs and derivates had a long stem. The newest humeral implants 
innovations consist in shortening of the implant, or even removing the whole stem, to rely on stemless fixation at the 
level of the metaphysis. This implies the advantages of preserved bone stock, less stress shielding, eliminating the 
diaphyseal stress riser, easier implant removal at revision, and humeral component placement independent from the 
humeral diaphyseal axis. Nowadays, surgeons try to balance the need for a stable fixation of the humeral component 
with the potential need for revision surgery. Complications of revision shoulder arthroplasty are related to the need for 
removing a well-fixed humeral stem, the length of the procedure, and the need to treat severe bone loss. 
Level of evidence: V


  1. NEER CS. Articular replacement for the humeral head. 
    J Bone Joint Surg Am. 1955;37-A(2):215–28.
    2. Levy O, Copeland SA. Cementless surface replacement 
    arthroplasty of the shoulder. 5- to 10-year results with 
    the Copeland mark-2 prosthesis. J Bone Joint Surg Br. 
    2001; 83(2):213-21.
    3. Werner BC, Dines JS, Dines DM. Platform systems in 
    shoulder arthroplasty. Curr Rev Musculoskelet Med. 
    4. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz 
    SM. Prevalence and projections of total shoulder and 
    elbow arthroplasty in the United States to 2015. J 
    Shoulder Elb Surg. 2010; 19(8):1115-20.
    5. Hollatz MF, Stang A. Nationwide shoulder arthroplasty 
    rates and revision burden in Germany: analysis of the 
    national hospitalization data 2005 to 2006. J Shoulder 
    Elb Surg. 2014;23(11):e267-74. 
    6. Matsen FA 3rd, Li N, Gao H, Yuan S, Russ SM, Sampson 
    PD. Factors Affecting Length of Stay, Readmission, 
    and Revision After Shoulder Arthroplasty: A 
    Population-Based Study. J Bone Joint Surg Am. 
    7. Chacon A, Virani N, Shannon R, Levy JC, Pupello D, 
    Frankle M. Revision arthroplasty with use of a reverse 
    shoulder prosthesis-allograft composite. J Bone Joint 
    Surg Am. 2009;91(1):119–27. 
    8. Flury MP, Frey P, Goldhahn J, Schwyzer H-K, 
    Simmen BR. Reverse shoulder arthroplasty as a 
    salvage procedure for failed conventional shoulder 
    replacement due to cuff failure--midterm results. Int 
    Orthop. 2011;35(1):53–60. 
    9. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, 
    complications, reoperations, and revisions in reverse 
    total shoulder arthroplasty: a systematic review. J 
    Shoulder Elb Surg. 2011;20(1):146–57. 
    10.Sperling JW, Cofield RH. Humeral windows in 
    revision shoulder arthroplasty. J Shoulder Elb Surg. 
    11.Levy O, Narvani A, Hous N, Abraham R, Relwani J, 
    Pradhan R et al. Reverse shoulder arthroplasty with 
    a cementless short metaphyseal humeral implant 
    without a stem: clinical and radiologic outcomes in 
    prospective 2- to 7-year follow-up study. J Shoulder 
    Elb Surg. 2016;25(8):1362–70. 
    12.Levy O, Tsvieli O, Merchant J, Young L, Trimarchi A, 
    Dattani R et al. Surface replacement arthroplasty for 
    glenohumeral arthropathy in patients aged younger 
    than fifty years: results after a minimum ten-year 
    follow-up. J Shoulder Elb Surg. 2015;24(7):1049–60. 
    13.Cisneros LGN, Atoun E, Abraham R, Tsvieli O, 
    Bruguera J, Levy O. Revision shoulder arthroplasty: 
    does the stem really matter? J Shoulder Elb Surg. 
    14.Neer CS. Replacement arthroplasty for glenohumeral 
    osteoarthritis. J Bone Joint Surg Am. 1974;56(1):1–13.
    15.Raiss P, Edwards TB, Deutsch A, Shah A, Bruckner T, 
    Loew M et al. Radiographic changes around humeral 
    components in shoulder arthroplasty. J Bone Joint 
    Surg Am. 2014;96(7):e54.
    16.Cil A, Veillette CJH, Sanchez-Sotelo J, Sperling JW, 
    Schleck C, Cofield RH. Revision of the humeral 
    component for aseptic loosening in arthroplasty of 
    the shoulder. J Bone Joint Surg Br. 2009;91(1):75–81. 
    17.Matsen FA, Iannotti JP, Rockwood CA. Humeral 
    fixation by press-fitting of a tapered metaphyseal 
    stem: a prospective radiographic study. J Bone Joint 
    Surg Am. 2003;85(2):304–8.
    18.Levy O, Copeland SA. Cementless surface replacement 
    arthroplasty (Copeland CSRA) for osteoarthritis of the 
    shoulder. J Shoulder Elb Surg. 2004;13(3):266–71. 
    19.Levy O, Funk L, Sforza G, Copeland SA. Copeland 
    surface replacement arthroplasty of the shoulder 
    in rheumatoid arthritis. J Bone Joint Surg Am. 
    20.Mullett H, Levy O, Raj D, Even T, Abraham R, Copeland 
    SA. Copeland surface replacement of the shoulder. 
    Results of an hydroxyapatite-coated cementless 
    implant in patients over 80 years of age. J Bone Joint 
    Surg Br. 2007;89(11):1466–9. 
    21.Thomas SR, Wilson AJ, Chambler A, Harding I, Thomas 
    M. Outcome of Copeland surface replacement shoulder 
    arthroplasty. J Shoulder Elb Surg. 2005;14(5):485–91. 
    22.Collin P, Matsukawa T, Boileau P, Brunner U, Walch G. 
    Is the humeral stem useful in anatomic total shoulder 
    arthroplasty? Int Orthop. 2017;41(5):1035–9. 
    23.Berth A, Pap G. Stemless shoulder prosthesis versus 
    conventional anatomic shoulder prosthesis in patients 
    with osteoarthritis: a comparison of the functional 
    outcome after a minimum of two years follow-up. J 
    Orthop Traumatol. 2013;14(1):31–7.
  2. 24.Uschok S, Magosch P, Moe M, Lichtenberg S, Habermeyer 
    P. Is the stemless humeral head replacement clinically 
    and radiographically a secure equivalent to standard 
    stem humeral head replacement in the long-term 
    follow-up? A prospective randomized trial. J Shoulder 
    Elb Surg. 2017;26(2):225–32. 
    25.Mariotti U, Motta P, Stucchi A, Sant’Angelo FP di. 
    Stemmed versus stemless total shoulder arthroplasty: 
    a preliminary report and short-term results. 
    Musculoskelet Surg. 2014;98(3):195–200. 
    26.Habermeyer P, Lichtenberg S, Tauber M, Magosch 
    P, Barvencik F, Gebauer M et al. Midterm results of 
    stemless shoulder arthroplasty: a prospective study. 
    J Shoulder Elb Surg. 2010;24(9):1463–72. 
    27.Sahota S, Sperling JWJW, Cofield RHRHRH, Brems 
    JJ, Carroll RM, Izquierdo R et al. Humeral windows 
    and longitudinal splits for component removal in 
    revision shoulder arthroplasty. J Shoulder Elb Surg. 
    28.Nagels J, Stokdijk M, Rozing PM, Bauer T, Schils J, 
    Dujovne A et al. Stress shielding and bone resorption 
    in shoulder arthroplasty. J Shoulder Elb Surg. 
    29.Lee M, Chebli C, Mounce D, Bertelsen A, Richardson 
    M, Matsen F et al. Intramedullary reaming for 
    press-fit fixation of a humeral component removes 
    cortical bone asymmetrically. J Shoulder Elb Surg. 
    30. Singh JA, Sperling J, Schleck C, Harmsen W, Cofield R. 
    Periprosthetic Fractures Associated with Primary Total 
    Shoulder Arthroplasty and Primary Humeral Head 
    Replacement. J Bone Jt Surg. 2012;94(19):1777–85. 
    31.Verborgt O, El-Abiad R, Gazielly DF, Amstutz HC, 
    Thomas J, Kabo JM et al. Long-term results of 
    uncemented humeral components in shoulder 
    arthroplasty. J Shoulder Elb Surg. 2007;16(3 
    32.Ballmer FT, Sidles JA, Lippitt SB, Matsen FA. Humeral 
    head prosthetic arthroplasty: Surgically relevant 
    geometric considerations. J Shoulder Elb Surg. 
    33.Boileau P, Walch G. The three-dimensional geometry 
    of the proximal humerus. Implications for surgical 
    technique and prosthetic design. J Bone Joint Surg Br. 
    34.Roberts SN, Foley AP, Swallow HM, Wallace WA, 
    Coughlan DP. The geometry of the humeral head 
    and the design of prostheses. J Bone Joint Surg Br. 
    35.Geurts GF, van Riet RP, Jansen N, Declercq G. Placement 
    of the Stemless Humeral Component in the Total 
    Evolutive Shoulder System (TESS). Tech Hand Up 
    Extrem Surg. 2010;14(4):214–7. 
    36.Keener JD, Chalmers PN, Yamaguchi K. The Humeral 
    Implant in Shoulder Arthroplasty. J Am Acad Orthop 
    Surg. 2017;25(6):427–38. 
    37.Ballas R, Béguin L. Results of a stemless reverse shoulder 
    prosthesis at more than 58 months mean without 
    loosening. J Shoulder Elb Surg. 2013;22(9):e1-6. 
    38.Kadum B, Mukka S, Englund E, Sayed-Noor A, Sjödén 
    G. Clinical and radiological outcome of the Total 
    Evolutive Shoulder System (TESS®) reverse shoulder 
    arthroplasty: a prospective comparative nonrandomised study. Int Orthop. 2014;38(5):1001–6. 
    39.Teissier P, Teissier J, Kouyoumdjian P, Asencio G. The 
    TESS reverse shoulder arthroplasty without a stem in 
    the treatment of cuff-deficient shoulder conditions: 
    clinical and radiographic results. J Shoulder Elb Surg. 
    40.Jónsson E, Egund N, Kelly I, Rydholm U, Lidgren L. Cup 
    arthroplasty of the rheumatoid shoulder. Acta Orthop 
    Scand. 1986;57(6):542–6. 
    41.Pearl ML. Proximal humeral anatomy in shoulder 
    arthroplasty: Implications for prosthetic design and 
    surgical technique. J Shoulder Elb Surg. 2005;14(1 
    Suppl S):99S-104S. 
    42.Pearl ML, Volk AG. Retroversion of the proximal 
    humerus in relationship to prosthetic replacement 
    arthroplasty. J Shoulder Elb Surg. 1995;4(4):286-9. 
    43. Mackenzie DB. The antero-superior exposure for total 
    shoulder replacement. Orthop Traumatol. 1993;2:71–7. 
    44.Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. 
    Grammont reverse prosthesis: design, rationale, and 
    biomechanics. J Shoulder Elb Surg. 2005;14(1 Suppl 
    45.Atoun E, Van Tongel A, Hous N, Narvani A, Relwani 
    J, Abraham R et al. Reverse shoulder arthroplasty 
    with a short metaphyseal humeral stem. Int Orthop. 
    46.Throckmorton TW, Zarkadas PC, Sperling JW, Cofield 
    RH. Radiographic stability of ingrowth humeral stems 
    in total shoulder arthroplasty. Clin Orthop Relat Res. 
    47.Schnetzke M, Coda S, Walch G, Loew M. Clinical 
    and radiological results of a cementless short stem 
    shoulder prosthesis at minimum follow-up of two 
    years. Int Orthop. 2015;39(7):1351–7.
    48.Hudek R, Werner B, Abdelkawi AF, Schmitt R, Gohlke 
    F. Radiolucency in stemless shoulder arthroplasty is 
    associated with an imaging phenomenon. J Orthop 
    Res. 2017;35(9):2040-2050. 
    49.Melis B, DeFranco M, Lädermann A, Molé D, Favard L, 
    Nérot C et al. An evaluation of the radiological changes 
    around the Grammont reverse geometry shoulder 
    arthroplasty after eight to 12 years. J Bone Joint Surg 
    Br. 2011;93(9):1240–6. 
    50.Hayes PR, Flatow EL. Total shoulder arthroplasty in 
    the young patient. Instr Course Lect. 2001;50:73–88.
    51.Sperling JW, Cofield RH, Rowland CM. Minimum 
    fifteen-year follow-up of Neer hemiarthroplasty and 
    total shoulder arthroplasty in patients aged fifty years 
    or younger. J Shoulder Elb Surg. 2004;13(6):604–13. 
    52.Levy O, Walecka J, Arealis G, Tsvieli O, Della Rotonda 
    G, Abraham R et al. Bilateral reverse total shoulder 
    arthroplasty—functional outcome and activities of 
    daily living. J Shoulder Elb Surg. 2017;26(4):e85–96. 
    53.Mollon B, Mahure SA, Roche CP, Zuckerman JD. Impact 
    of scapular notching on clinical outcomes after 
    reverse total shoulder arthroplasty: an analysis of 476 
    shoulders. J Shoulder Elb Surg. 2017;26(7):1253–61. 
    54.Kempton LB, Balasubramaniam M, Ankerson E, 
    Wiater JM. A radiographic analysis of the effects of  glenosphere position on scapular notching following 
    reverse total shoulder arthroplasty. J Shoulder Elb 
    Surg. 2011;20(6):968–74. 
    55.Holschen M, Franetzki B, Witt K-A, Liem D, Steinbeck 
    J. Is reverse total shoulder arthroplasty a feasible 
    treatment option for failed shoulder arthroplasty? 
    A retrospective study of 44 cases with special 
    regards to stemless and stemmed primary implants. 
    Musculoskelet Surg. 2017;101(2):173-180. 
    56.Litchfield RB, McKee MD, Balyk R, Mandel S, Holtby 
    R, Hollinshead R et al. Cemented versus uncemented 
    fixation of humeral components in total shoulder 
    arthroplasty for osteoarthritis of the shoulder: 
    a prospective, randomized, double-blind clinical 
    trial—A JOINTs Canada Project. J Shoulder Elb Surg. 
    57.Court-Brown CM, Garg A, McQueen MM. The 
    epidemiology of proximal humeral fractures. Acta 
    Orthop Scand. 2001;72(4):365–71. 
    58.Andersen JR, Williams CD, Cain R, Mighell M, Frankle 
    M. Surgically Treated Humeral Shaft Fractures 
    Following Shoulder Arthroplasty. J Bone Jt SurgeryAmerican Vol. 2013;95(1):9–18. 
    59.Boyd AD, Thornhill TS, Barnes CL. Fractures adjacent 
    to humeral prostheses. J Bone Joint Surg Am.