Place of the stemless shoulder implant in 2023

Background: Traditional shoulder arthroplasty relies on intramedullary stems for humeral fixation. While effective, these designs present challenges regarding bone preservation, potential diaphyseal complications, and complexity during revision surgery. The development of stemless implants, initiated approximately 20 years ago with the TESS system, sought to address these issues by utilizing epiphysometaphyseal fixation.

Objective: This article reviews the 20-year evolution of stemless shoulder technology, evaluates current clinical indications for anatomical and reverse designs, and analyzes the advantages and limitations of these fourth-generation implants.

Key Points: Stemless implants utilize various fixation methods, including central posts, wings, or boxes, to achieve primary press-fit in the high-density bone of the proximal humerus. Clinical data indicate that anatomical stemless total shoulder arthroplasty (TSAa) provides functional outcomes and complication rates comparable to stemmed designs. Ideal indications include concentric osteoarthritis and post-instability arthropathy in patients with sufficient bone stock. For reverse total shoulder arthroplasty (TSAr), stemless options are more limited due to higher mechanical constraints, with inlay designs showing more consistent stability than early onlay models. Primary advantages include significant bone sparing, reduced intraoperative blood loss, shorter operative times, and simplified revision procedures. Conversely, poor bone quality, trauma, and severe osteoporosis remain primary contraindications.

Conclusion: Stemless implants have become a standard component of the shoulder arthroplasty armamentarium. They are highly reliable for anatomical procedures in patients with adequate bone stock. While stemless reverse designs are feasible, they require precise surgical technique and careful patient selection to ensure long-term stability.