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Reverse shoulder arthroplasty

Surgeon-side topic for reverse shoulder arthroplasty. Backed by 399 articles from the corpus, retrieved via combined MeSH + title-text matching.

Overview

Reverse total shoulder arthroplasty (rTSA) is a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation [14]. While rTSA provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [7], it does not appear to offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [1]. Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change [18], with at least a 23-point improvement representing a substantial clinical benefit [18].

The procedure is increasingly utilized in younger demographics, with use increasing among patients younger than 60 years of age [3]. However, patients younger than 60 years of age undergoing rTSA experience significantly higher rates of 90-day surgical complications compared to older patients [3]. In patients below the age of 55, rTSA and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. Revision rTSA demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [2], though the outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [24].

Patients undergoing revision of a failed anatomic total shoulder arthroplasty to rTSA have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction [6]. These revision cases also carry higher complication and revision rates compared with primary rTSA [6]. Conversely, patients with good outcomes after first rTSA can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [5]. Treatment with rTSA for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization [15].

Anatomy & Pathophysiology

Osseous and Ligamentous Architecture

The glenoid is suspended from the scapular body by the neck and fixed to the clavicle via the acromioclavicular and coracoclavicular ligaments [25]. As the glenoid face transitions into the neck, the vault narrows [25]. The scapular spine is subcutaneous posteriorly and widens gradually toward the acromion base laterally [25]. The acromion curves anteriorly to meet the clavicle at the acromioclavicular joint and connects to the coracoid via the coracoacromial ligament, which originates under the anterior acromial margin [25]. In rotator cuff-tear arthropathy, acromial thinning and eventual fragmentation occur at the final stages of disease [40].

Neural Anatomy and Surgical Landmarks

The suprascapular nerve arises from C4–C5 nerve roots off the supraclavicular brachial plexus at "Erb's point" [25]. It runs medial to the coracoid base, under the transverse scapular ligament within the suprascapular notch [25]. Branches to the supraspinatus arise within 1 cm of the notch [25]. The nerve continues through the supraspinatus fossa laterally and distally on the supraspinatus undersurface [25]. It passes under the ill-defined spinoglenoid ligament around the lateral scapular base within the spinoglenoid notch [25]. Termination occurs via posterior capsular sensory branches heading laterally and an infraspinatus motor branch heading medially within 1 cm of the scapular spine lateral margin [25]. Cadaver studies locate the nerve 29 mm (23 to 35 mm) from the glenoid superior rim at the suprascapular notch and 18 mm (14 to 24 mm) from the posterior rim at the spinoglenoid notch [25]. Injury causes pain and denervation of the supraspinatus and infraspinatus [25].

Reverse Shoulder Arthroplasty Design Principles

The traditional Grammont reverse prosthesis features a glenoid component shaped as a third of a sphere [26]. Its center of rotation is medial to the glenoid component–bone interface [26]. The humeral component is inset, resting almost completely inside the proximal humeral metaphysis [26]. The polyethylene opening angle is relatively horizontal at 155 degrees [26]. Once articulated, the humerus sits more medial and distal than preoperatively [26]. The Grammont prosthesis is recommended for implantation in more anteversion (0 to 10 degrees of retroversion) than conventional arthroplasty [26]. Subsequent designs modified features to place the center of rotation more lateral than the Grammont prosthesis [26]. Later designs introduced a 135-degree opening angle for the humeral component [26]. Other designs utilized an onlay humeral bearing to lateralize the humerus without altering the center of rotation [26]. A 145-degree opening angle was selected for some later bearing designs [26].

Biomechanics and Kinematics

Reverse shoulder arthroplasty (RSA) does not require the rotator cuff for function but depends on an intact deltoid neuromuscular unit [40]. Grammont principles mandate that the prosthesis be inherently stable and perfectly concentric [40]. The weight-bearing part must be convex and the supported part concave (reversed) [40]. The center of the sphere must be at or within the glenoid neck (medialized) [40]. The center of rotation must be medialized and distalized [40]. Medialization decreases shear forces on the glenoid and lowers baseplate failure risk [40]. Distalization doubles the deltoid lever arm and optimizes sarcomere length–tension curves [40]. Distalization increases deltoid efficiency by 30% at the cost of rotational strength [40]. Lateralized glenosphere and humerus designs aim to improve rotational profile, deltoid function, implant stability, and decrease impingement (scapular notching) [40]. Early designs had high failure rates due to profound lever arms on the glenoid and baseplate bone [40]. Recent designs have increased forces seen by the scapula and acromion [40]. RSA restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics [32]. There is an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation compared to asymptomatic shoulders [41]. The scapulothoracic contribution to overall movement is significantly increased in RSA patients compared with healthy shoulders [36]. Scapular kinematics during rehabilitation exercises differ depending on the plane and modality of the exercise [38]. Isolated humeral distalization caused dramatic increases in muscle forces required for scapular-plane abduction, with joint reaction forces increasing correspondingly [39]. A 135° neck-shaft angle with a 42mm glenosphere maximized range of motion for most motions [46]. A 155° neck-shaft angle with a 36mm glenosphere optimized abduction and forward elevation [46]. The isolated effect of increasing glenosphere eccentricity on shoulder stability appears negligible in the position of instability [55]. Joint stability and abduction capability were compromised by more extensive rotator cuff tears in lateralized RSA [49]. Subscapularis repair might be essential to enhancing biomechanical effectiveness in lateralized RSA [49]. There remains little knowledge regarding the optimal glenoid version in reverse shoulder arthroplasty [31]. Significant changes from preoperative to postoperative conditions were not demonstrated for other kinematic parameters aside from those already noted [44].

Complications: Scapular Fractures

Periprosthetic scapular fractures are universally associated with stable glenoid implants [19]. They can result in new glenohumeral instability due to changes in glenosphere orientation and loss of deltoid tension [19]. This fracture is a unique complication of RSA that occurs more commonly than periprosthetic humeral fractures [40]. Postoperative rates range from 0.9% to 11.2% [40]. Female gender is a risk factor, accounting for up to 100% of some series [40]. Fractures typically occur in patients 70 to 80 years old [40]. One study of patients under age 65 showed a 0% postoperative fracture rate [40]. Osteoporosis is a significant risk factor, with 30.8% of fracture patients having osteoporosis compared to 18.4% of controls [40]. Fatigue fractures can occur through weakened acromia or those with preexisting lesions [40]. Preoperative planning using supine CT may inaccurately pose bones, affecting the surgical plan, biomechanics, and outcomes [34]. Adjusting patient-specific scapula posture significantly impacts predicted impingement-free motion amplitudes and range of motion [42].

Classification

Indication by Pathology: Reverse total shoulder arthroplasty (RTSA) does not appear to offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [1]. The ongoing Reverse or Anatomical replacement for Painful Shoulder Osteoarthritis, Differences between Interventions trial aims to definitively answer the question of anatomic versus reverse shoulder arthroplasty for cuff intact glenohumeral osteoarthritis [16]. Conversely, RTSA provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [7]. Significant differences exist between RTSA performed for fractures versus arthropathy regarding patient characteristics, surgical complexity, and hospital resource utilization [15].

Age and Revision Risk: RTSA use has increased among patients younger than 60 years of age [3]. Patients younger than 60 years undergoing RTSA experience significantly higher rates of 90-day surgical complications compared to older patients [3]. In patients below the age of 55, RTSA has a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. In the predominantly male patient population below the age of 55, stemless anatomic total shoulder arthroplasty has a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. Revision RTSA demonstrates an implant survival rate of 85% at ten years [2].

Surgical Modality and Outcomes: Concomitant subscapularis repair in lateralized RTSA decreased glenohumeral abduction but increased internal rotation [9]. RTSA was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization [10]. Active external rotation after RTSA is complex and not governed by a single muscle-tendon unit [12]. Total impingement-free range-of-motion in RTSA decreases with combined component version greater than 30 degrees of retroversion [61].

Infection and Versatility: RTSA is a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation [14]. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis in staged revision with antibiotic spacers for shoulder prosthetic joint infections [17]. Functional improvement was not seen after hemiarthroplasty and cement spacer in staged revision with antibiotic spacers for shoulder prosthetic joint infections [17].

Other Considerations: Deep learning-based models can accurately and efficiently identify commonly used reverse shoulder arthroplasty implants [58].

Clinical Presentation

Primary Osteoarthritis: Reverse total shoulder arthroplasty (rTSA) does not appear to offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [1]. However, rTSA may be a reliable treatment option in patients at risk for developing rotator cuff failure, demonstrating similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty in patients with restricted preoperative forward elevation [22]. Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, while an improvement of at least 23 points indicates a substantial clinical benefit [18].

Acute Injury vs. Chronic Arthropathy: Treatment with rTSA provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [7]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to rTSA have worse clinical outcomes compared with those undergoing primary rTSA, including all patient-reported outcome measures (PROMs), abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates [6]. Revision rTSA demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [2]. Patients with good outcomes after first rTSA can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [5].

Age and Complication Profiles: rTSA use has increased among patients younger than 60 years of age, but this population experiences significantly higher rates of 90-day surgical complications compared to older patients [3]. In patients below the age of 55, rTSA and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. Patients with periprosthetic scapular fractures typically present around their 8th decade of life after a sudden increase in pain or loss of function in an otherwise smooth postoperative course [19]. These fractures generally occur within 1 year but up to 2 years from surgery, and patients who go on to have periprosthetic scapular fractures initially outperform those who do not [19].

Inspection and Palpation: Diagnosis of periprosthetic scapular fractures is often subtle and requires a high index of suspicion [19]. New pain at the base of the acromion may be the only finding in a stress reaction and should raise suspicion for fracture [19]. Tenderness along the acromion or scapular spine raises suspicion for fracture [19]. Deformity on physical examination is concerning for dislocation, hematoma, or displaced fracture [19]. Stress fractures can be more painful than after they propagate into a displaced fracture [19].

Range of Motion and Stability: Patients achieve maximum medical improvement at 1 postoperative year following rTSA for rotator cuff deficiency [8]. Concomitant subscapularis repair in lateralized rTSA decreased glenohumeral abduction and increased internal rotation [9]. Fracture can result in motion limited by pain, new weakness, or loss of function [19]. Periprosthetic scapular fractures can result in new glenohumeral instability due to the change of the orientation of the glenosphere and loss of deltoid tension [19]. Periprosthetic scapular fractures are universally associated with stable glenoid implants [19].

Red-Flag Patterns: A sudden loss of function or increase in pain is consistent with both scapular fracture and infection [19]. Risk factors for periprosthetic scapular fractures include a history of steroid use, osteoporosis, subacromial decompression, or rotator cuff tear arthropathy [19]. Radiographic measurements are generally valid for evaluating postoperative parameters in rTSA [30].

Return to Activity: Return to sports after rTSA is possible and highly frequent [13]. Patients undergoing rTSA return to sporting activities at varying rates depending on age and prior surgery, with walking and swimming being the most common activities postoperatively [27]. Reverse shoulder arthroplasty for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization [15]. The outcome for rTSA can be measured with the treatment effect method; the 2 years treatment effects vary from 1 to 0.09 [23]. The report demonstrates the clinical and radiological success of near-simultaneous rTSA for bilateral displaced proximal humerus fractures in a geriatric patient with early range of motion [20].

Investigations

Plain radiography: Standard evaluation for periprosthetic scapular fractures must include AP, scapular Y, and axillary views [53]. The scapular Y view identifies displaced scapular spine or body fractures, while the axillary view is particularly helpful for locating fractures at the acromial base [53]. Radiographic signs of displaced acromial fracture include progressive downsloping of the acromion relative to the scapular spine or narrowing of the acromial–tuberosity interval [53]. Independent reviewers accurately diagnosed 78.8% of periprosthetic scapular fractures with good inter-rater reliability (k = 0.782) and excellent intra-rater reliability (k = 0.862) [53]. Patients with these fractures demonstrate significantly greater changes in acromial–tuberosity distance (p < 0.001) and acromial tilt (p < 0.001) from initial postoperative radiographs to final images [53]. Routine evaluation of acromial–tuberosity distance and acromial tilt is recommended to improve detection [53]. However, plain radiographs can miss subtle fractures; in one series, 32.1% of fractures presented with pain and negative plain films, and 39% required CT to diagnose nondisplaced fractures [53].

CT: New pain along the scapula in the setting of normal radiographs should trigger a CT scan to diagnose nondisplaced fractures [53]. A negative CT scan may occur in the setting of a stress reaction, which may be better elicited on a bone scan [53]. Preoperative CT with three-dimensional reconstruction is extremely useful for planning reverse shoulder arthroplasty for fracture, including assessment of glenoid component positioning, version, inclination, rotation, and anticipated screw length [28]. Radiographs of both humeri with magnifier markers may be used to determine stem positioning relative to the fracture line on the humeral shaft [28].

Bone scan: A bone scan is indicated when a stress reaction is suspected despite a negative CT scan [53].

Other Considerations: Diagnosis of periprosthetic scapular fractures often requires a high index of suspicion as identification can be subtle [19]. New pain at the base of the acromion may be the only finding in a stress reaction associated with periprosthetic scapular fractures [19]. Tenderness along the acromion or scapular spine raises suspicion and should be confirmed with imaging [19]. A sudden loss of function or increase in pain is consistent with both scapular fracture and infection and should trigger further workup [19]. Periprosthetic scapular fractures are universally associated with stable glenoid implants but can result in new glenohumeral instability due to changes in glenosphere orientation and loss of deltoid tension [19]. Patients with these fractures typically present in their 8th decade after a sudden increase in pain or loss of function, generally occurring within 1 year but up to 2 years from surgery [19]. Risk factors include a history of steroid use, osteoporosis, subacromial decompression, or rotator cuff tear arthropathy [19]. Interestingly, patients who go on to have periprosthetic scapular fractures initially outperform those who do not [19].

Preoperative planning for reverse shoulder arthroplasty requires careful assessment of radiographs and CT with three-dimensional reconstruction [28]. If a fractured glenoid rim is large enough to interfere with baseplate stability, fixation with small fragment screws may be performed [28]. Surgeons are recommended to limit superior screw length to ≤25 mm and posterior screws to ≤15 mm to reduce the risk for nerve injury and postoperative scapular fracture [25]. The suprascapular nerve is located 29 mm (23 to 35 mm) from the superior rim of the glenoid at the suprascapular notch and 18 mm (14 to 24 mm) from the posterior rim at the spinoglenoid notch [25]. Injury to this nerve can cause pain and denervation of the supraspinatus and infraspinatus [25]. Reverse shoulder arthroplasty is best performed in the beach chair position with the trunk at approximately 70 degrees (barber chair position) [28]. The preferred surgical approach for fracture is a deltopectoral approach, though management and reduction of the greater tuberosity is easier from a superior deltoid-splitting approach [28].

Functional outcomes and implant survival are critical considerations for patient counseling. Reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [1]. Revision reverse shoulder arthroplasty demonstrates an implant survival rate of 85% at ten years [2]. Patients younger than 60 years of age undergoing reverse total shoulder arthroplasty experience significantly higher rates of 90-day surgical complications compared to older patients [3]. In patients under 55 years of age with primary glenohumeral osteoarthritis, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. Patients with good outcomes after a first reverse total shoulder arthroplasty can be counseled on contralateral total shoulder arthroplasty as early as 3 months postoperatively with confidence of a similar result on the contralateral side [5]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary reverse total shoulder arthroplasty, including all patient-reported outcome measures, abduction, elevation, pain relief, and patient satisfaction [6]. Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [7]. Patients achieve maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty for rotator cuff deficiency [8]. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis in staged revision with antibiotic spacers for shoulder prosthetic joint infections, but was not seen after hemiarthroplasty and cement spacer [17]. Two-day staged bilateral reverse shoulder arthroplasty for traumatic proximal humerus fractures in a geriatric patient demonstrated clinical and radiological success with early range of motion [20]. Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty [22]. The outcome for reverse shoulder arthroplasty can be measured with the treatment effect method, where 2-year treatment effects vary from 1 to 0.09 [23]. Radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty [30]. Superior augmented baseplates in reverse shoulder arthroplasty with minimal superior glenoid erosion are associated with similar range of motion and adverse events but somewhat improved postoperative patient-reported outcomes compared with nonaugmented baseplates at 3-year follow-up [68].

Surgical technique and specific outcomes also inform the clinical picture. Concomitant subscapularis repair in lateralized reverse total shoulder arthroplasty decreased glenohumeral abduction and increased internal rotation [9]. Reverse total shoulder arthroplasty was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization [10]. Active external rotation after reverse shoulder arthroplasty is complex and not governed by a single muscle-tendon unit [12]. Return to sports after reverse shoulder arthroplasty is possible and highly frequent [13]. The Reverse or Anatomical replacement for Painful Shoulder Osteoarthritis, Differences between Interventions trial aims to definitively answer the question of anatomic versus reverse replacement for cuff-intact glenohumeral osteoarthritis [16].

Treatment

Non-Operative

Patients with severe shoulder pain who are candidates for arthroplasty should exhaust other pain-reducing options before utilizing opioid medications [65]. While conservative management is an option, reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [7].

Operative

Indications: Reverse shoulder arthroplasty is the replacement procedure of choice when arthroplasty is considered for proximal humeral fractures [26] and is advocated for complex proximal humerus fractures in elderly patients due to more consistent and predictable results compared with hemiarthroplasty or plate osteosynthesis [60]. It serves as a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation [14]. In patients below the age of 55 with primary glenohumeral osteoarthritis, reverse shoulder arthroplasty demonstrates a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [4]. However, in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity, reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty [1]. Patients with good outcomes after a first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [5].

Surgical Approach / Technique: Rehabilitation guidelines for reverse total shoulder replacement aim to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery [21]. Concomitant subscapularis repair in lateralized reverse total shoulder arthroplasty decreased glenohumeral abduction and increased internal rotation [9]. Active external rotation after reverse shoulder arthroplasty is complex and not governed by a single muscle-tendon unit [12]. Healing of at least the greater tuberosity in good position provides a higher chance of restoration of active external rotation in reverse shoulder arthroplasty for proximal humeral fractures [26]. Not performing a tuberosity repair at the time of reverse arthroplasty for proximal humeral nonunion has been correlated with a higher rate of dislocation [26]. Shoulder arthroplasty is considered for proximal humeral nonunion in the presence of severe cavitation and bone loss at the humeral head and metaphysis or collapse and degenerative change of the humeral articular surface [29]. Severe tuberosity malunion in a proximal humeral nonunion is more reliably compensated for with reverse arthroplasty than with osteotomy and internal fixation [29].

Implant Selection: The semiconstrained nature of the reverse prosthesis provides a stable fulcrum that allows the deltoid to elevate the shoulder even in the absence of a functional rotator cuff [26]. In the Grammont reverse prosthesis, the center of rotation is medial to the glenoid component–bone interface to decrease shear stress and provide compressive stress [26]. In the Grammont reverse prosthesis, the humeral component is inset and the opening angle of the polyethylene is relatively horizontal (155 degrees) [26]. Once the implants are articulated in a Grammont reverse prosthesis, the humerus is more medial and more distal than preoperatively, providing a mechanical advantage to the deltoid for active elevation [26]. A more horizontal opening angle was selected in the Grammont reverse prosthesis to decrease the chances of dislocation [26]. The humeral component in a Grammont reverse prosthesis is recommended to be implanted in more anteversion (0 to 10 degrees of retroversion) than conventional arthroplasty [26]. Subsequent reverse designs have modified features including a larger portion of a sphere, placing the center of rotation more lateral than Grammont's prosthesis [26]. Later reverse designs introduced humeral components with an onlay humeral bearing to lateralize the position of the humerus without changing the center of rotation, with a selected 145-degree opening angle [26]. Reverse total shoulder arthroplasty was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization [10]. Patient-specific implants have emerged as an innovative approach to addressing complex glenoid bone loss cases in reverse shoulder arthroplasty by restoring the native joint line, minimizing bone removal, and providing customized fixation [62].

Adjuncts: Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure, demonstrating similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty in patients with restricted preoperative forward elevation [22].

Revision: Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [2]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates [6]. Functional improvement was obtained after reimplantation of a reverse total prosthesis but was not seen after hemiarthroplasty and cement spacer in staged revision with antibiotic spacers for shoulder prosthetic joint infections [17]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [24]. Hemiarthroplasty is less commonly considered than reverse arthroplasty for proximal humeral nonunion [29]. The functional outcome of hemiarthroplasty for nonunion is particularly concerning when tuberosity osteotomies need to be added [29]. Most studies on hemiarthroplasty for nonunion suggest the procedure may be effective in reducing or eliminating pain but there is a high rate of complications that often require further surgery and are associated with disappointing functional recovery [29].

Other Considerations: Reverse total shoulder arthroplasty use has increased among patients younger than 60 years of age, but this population experiences significantly higher rates of 90-day surgical complications compared to older patients [3]. Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty for rotator cuff deficiency [8].

Complications

Infection (PJI): Functional improvement is achievable following staged revision with antibiotic spacers and reimplantation of a reverse total shoulder prosthesis [17], whereas outcomes are not observed after hemiarthroplasty and cement spacer [17]. Reverse total shoulder arthroplasty presents good results after failed shoulder arthroplasty, including the infected shoulder [74].

Aseptic loosening: Revision reverse shoulder arthroplasty demonstrates an implant survival rate of 85% at ten years [2]. Although a low rate of humeral component loosening was observed in cement-within-cement revision reverse total shoulder arthroplasty, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening [63]. Glenoid erosion was the predominant cause of revision for humeral resurfacing and hemiarthroplasty in patients under 55 years of age [66].

Instability: In patients under 55 years of age, instability was the main cause of revision for stemmed anatomic and reverse total shoulder arthroplasty [66]. Although a low rate of humeral component loosening was observed in cement-within-cement revision reverse total shoulder arthroplasty, higher rates of complications and re-revision surgery were observed over time secondary to instability [63].

Periprosthetic fracture: The incidence of intraoperative greater tuberosity fractures is more than double when revising an arthroplasty to rTSA compared to primary rTSA [73]. This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in reverse total shoulder arthroplasty for proximal humerus fractures [70].

Thromboembolism: Complications and reoperation rates for revision reverse shoulder arthroplasty are higher than those for primary RSA [64].

Wound complications: Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls [69]. Patients younger than 60 years of age undergoing reverse total shoulder arthroplasty experience significantly higher rates of 90-day surgical complications compared to older patients [3].

Other Considerations: Reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [1]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction [6]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have higher complication and revision rates compared with those undergoing primary rTSA [6]. Outcomes for revision reverse shoulder arthroplasty are comparable to primary RSA specifically for the revision of failed anatomic shoulder arthroplasty [64]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [24]. Reverse total shoulder arthroplasty is a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation [14]. Return to sports after reverse shoulder arthroplasty is possible and highly frequent [13]. Thirteen studies reported one or more return to sport criteria following shoulder arthroplasty, with time after surgery being the most common return to sport criterion used [72].

Recovery

Light activity (weeks): Return to driving is recommended between 6 and 12 weeks postoperatively [52]. Patients may resume light activities and desk work within this timeframe, though specific timelines for light ADLs are not explicitly defined in the provided evidence beyond the general scope of early rehabilitation.

Full activity (months): Patients can return to sporting activities at varying rates depending on age and prior surgery, with walking and swimming being the most common activities postoperatively [27]. Return to sport is possible and highly frequent following reverse shoulder arthroplasty [13], and a high return to sport can be expected after total shoulder arthroplasty [59].

Complete recovery / outcome plateau (months): Patients achieve maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [8]. Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks [67]. Acute recovery can be assessed via maximum elevation [71], while chronic recovery is assessed via time spent above 90 degrees of elevation [71].

Rehabilitation protocol: Rehabilitation guidelines aim to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery [21]. Early, active rehabilitation is safe and effective, and may offer early clinical benefits over a conservative, delayed mobilisation programme [33]. Self-directed home therapy following reverse shoulder arthroplasty may be a viable alternative to formal supervised physical therapy, showing no significant differences in outcomes across multiple measures [37].

Functional milestones: Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change [18]. Those with at least a 23-point improvement in their ASES score experience a substantial clinical benefit [18]. Reverse total shoulder arthroplasty was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization [10], whereas active external rotation is complex and not governed by a single muscle-tendon unit [12].

Other Considerations: Revision reverse shoulder arthroplasty demonstrates an implant survival rate of 85% at ten years [2]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary reverse total shoulder arthroplasty, including all patient-reported outcome measures, abduction, elevation, pain relief, and patient satisfaction [6]. These revision patients also have higher complication and revision rates compared with those undergoing primary reverse total shoulder arthroplasty [6]. Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral total shoulder arthroplasty as early as 3 months postoperatively [5]. Timely interventions, such as pectoralis major tendon transfer, may provide meaningful functional recovery in cases of subscapularis retear after reverse total shoulder arthroplasty [45]. The report demonstrates the clinical and radiological success of near-simultaneous reverse shoulder arthroplasty for bilateral displaced proximal humerus fractures in a geriatric patient with early range of motion [20].

Key Evidence

  • [L3] Reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty in this population. (10.1016/j.jse.2025.01.038)
  • [L3] Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years. (10.1302/0301-620x.107b11.bjj-2025-0436.r1)
  • [L3] Reverse total shoulder arthroplasty use has increased among patients younger than 60 years of age, but this population experiences significantly higher rates of 90-day surgical complications compared to older patients. (10.1016/j.jseint.2025.05.020)
  • [L3] In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty. (10.1016/j.jse.2024.07.032)
  • [L4] Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. (10.1016/j.jse.2023.10.007)
  • [L3] Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates. (10.1016/j.jse.2024.09.019)
  • [L1] Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. (10.1016/j.jse.2024.02.023)
  • [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. (10.1016/j.jse.2018.05.029)
  • [L5] Concomitant subscapularis repair in lateralized reverse total shoulder arthroplasty decreased glenohumeral abduction and increased internal rotation. (10.5397/cise.2025.00675)
  • [L3] Reverse total shoulder arthroplasty was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization. (10.1016/j.jseint.2026.101636)
  • [L4] Active external rotation after reverse total shoulder arthroplasty is complex and not governed by a single muscle-tendon unit. (10.1016/j.jse.2023.08.031)
  • [L4] Return to sports after reverse shoulder arthroplasty is possible and highly frequent. (10.1136/jisakos-2020-000581)
  • [L5] Reverse shoulder arthroplasty is a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation, with a large body of literature demonstrating its success. (10.1016/j.jseint.2025.02.019)
  • [L3] Reverse shoulder arthroplasty for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization. (10.1016/j.jse.2024.08.037)
  • [L4] The Reverse or Anatomical replacement for Painful Shoulder Osteoarthritis, Differences between Interventions trial aims to definitively answer this question. (10.1177/17585732251319977)
  • [L3] Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after hemiarthroplasty and cement spacer. (10.1007/s11999.0000000000000049)
  • [L3] Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. (10.1007/s11999-016-4968-z)
  • [Case_report] The report demonstrates the clinical and radiological success of near-simultaneous reverse shoulder arthroplasty for bilateral displaced proximal humerus fractures in a geriatric patient with early range of motion. (10.1016/j.xrrt.2022.09.003)
  • [L5] The review outlines rehabilitation guidelines developed to manage patients who have undergone reverse total shoulder replacement, aiming to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery. (10.1111/j.1758-5740.2011.00138.x)
  • [L3] Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure. (10.1016/j.jse.2024.03.003)
  • [L3] The outcome for reverse shoulder arthroplasty can be measured with the treatment effect method; the 2 years TE's vary from 1 to 0.09. (10.1186/s12891-020-03427-7)
  • [L3] Patients undergoing reverse total shoulder arthroplasty return to sporting activities at varying rates depending on age and prior surgery, with walking and swimming being the most common activities postoperatively. (10.1177/2325967115s00167)
  • [L3] The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty. (10.1016/j.jse.2024.10.016)
  • [L5] There remains little knowledge regarding the optimal glenoid version. (10.1016/j.xrrt.2025.06.019)
  • [L1] rTSA restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics. (10.1016/j.jse.2026.03.002)
  • [L1] Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. (10.1177/1758573220937394)
  • [L4] Thus, preoperative planning using supine CT may inaccurately pose bones, with consequent effects on the surgical plan, the resultant shoulder biomechanics, and clinical outcomes. (10.1016/j.xrrt.2025.08.006)
  • [L4] The ST contribution to overall shoulder movement is significantly increased in patients with an rTSA compared with a healthy shoulder. (10.1016/j.jse.2024.12.018)
  • [L2] This study suggests that self-directed home therapy following reverse shoulder arthroplasty may be a viable alternative to formal supervised physical therapy, showing no significant differences in outcomes across multiple measures. (10.1016/j.jseint.2025.02.012)
  • [L4] Scapular kinematics during rehabilitation exercises after rTSA differ, depending on the plane and modality of the exercise. (10.1016/j.jse.2024.11.027)
  • [L5] Isolated humeral distalization caused dramatic increases in the muscle forces required to perform scapular-plane abduction, with joint reaction forces increasing correspondingly. (10.1016/j.jse.2024.07.055)
  • [L1] There is an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation following TSA compared to asymptomatic shoulders. (10.1016/j.jse.2025.08.010)
  • [L4] Adjusting patient-specific scapula posture significantly impacts predicted impingement-free motion amplitudes and range of motion in reverse total shoulder arthroplasty. (10.1016/j.xrrt.2025.05.022)
  • [L4] However, significant changes from the preoperative to postoperative conditions were not demonstrated for other kinematic parameters. (10.1016/j.jseint.2025.04.025)
  • [Case_report] Timely interventions, such as pectoralis major tendon transfer, may provide meaningful functional recovery in cases of subscapularis retear after reverse total shoulder arthroplasty. (10.1016/j.xrrt.2026.100673)
  • [L5] A 135° neck-shaft angle with a 42mm glenosphere maximized ROM for most motions, while a 155° neck-shaft angle with a 36mm glenosphere optimized abduction and forward elevation. (10.1016/j.jse.2024.12.049)
  • [L5] Joint stability and abduction capability were compromised by more extensive rotator cuff tears, and subscapularis repair might be essential to enhancing biomechanical effectiveness, even in l-rTSA. (10.1016/j.jse.2025.03.027)
  • [L4] The review highlights significant variability in return-to-driving timelines across different procedures and immobilization devices, with recommendations ranging from immediate return for minor hand surgery to 6-12 weeks for shoulder arthroplasty, emphasizing the need for standardized guidelines. (10.1530/EOR-23-0117)
  • [L5] The isolated effect of increasing glenosphere eccentricity on shoulder stability following rTSA appears negligible in the position of instability. (10.1016/j.jse.2025.03.007)
  • [L5] Deep learning-based models can accurately and efficiently identify commonly used reverse shoulder arthroplasty implants. (10.1016/j.jse.2025.10.011)
  • [L1] A high return to sport can be expected after total shoulder arthroplasty. (10.1016/j.jseint.2025.05.028)
  • [L5] Reverse shoulder arthroplasty is advocated for complex proximal humerus fractures in elderly patients because it provides more consistent and predictable results compared with hemiarthroplasty or plate osteosynthesis. (10.5435/jaaos-d-24-00890)
  • [L5] Total impingement-free range-of-motion in reverse total shoulder arthroplasty decreases with combined component version greater than 30 degrees of retroversion. (10.1016/j.jseint.2025.101414)
  • [L5] Patient-specific implants have emerged as an innovative approach to addressing complex glenoid bone loss cases in reverse shoulder arthroplasty by restoring the native joint line, minimizing bone removal, and providing customized fixation. (10.1016/j.jseint.2024.12.007)
  • [L4] Although a low rate of humeral component loosening was observed, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability. (10.1016/j.xrrt.2024.08.006)
  • [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. (10.1016/j.jse.2023.06.039)
  • [L3] Patients with severe shoulder pain who are possible candidates for shoulder arthroplasty should exhaust other pain-reducing options before using opioid pain medications. (10.5435/jaaos-d-18-00112)
  • [L3] The study analyzed cumulative percent revision rates in patients under 55, finding that glenoid erosion was the predominant cause of revision for humeral resurfacing and hemiarthroplasty, while instability was the main cause for stemmed anatomic and reverse total shoulder arthroplasty. (10.1016/j.jisako.2025.100747)
  • [L2] Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks. (10.1016/j.jse.2025.06.016)
  • [L3] Superior augmented baseplates in reverse shoulder arthroplasty with minimal superior glenoid erosion are associated with similar range of motion and adverse events but somewhat improved postoperative patient-reported outcomes compared with nonaugmented baseplates at 3-year follow-up. (10.1016/j.jse.2024.01.047)
  • [L3] Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls. (10.1016/j.jse.2019.11.029)
  • [L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
  • [L4] This study demonstrates that acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively. (10.1016/j.jse.2019.01.003)
  • [L4] Thirteen studies reported one or more RTS criteria following shoulder arthroplasty, with time after surgery being the most common RTS criterion used. (10.1016/j.jisako.2023.06.004)
  • [L3] IGTFs are infrequent during primary rTSA, but the incidence is more than double when revising an arthroplasty to rTSA. (10.1016/j.jse.2025.06.014)
  • [L3] rTSA is a viable option for revision cases and presents good results after failed shoulder arthroplasty, including the infected shoulder. (10.1016/j.jseint.2024.10.014)

See Also

References

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1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.