Progression of arthritic glenoid bone loss as revealed by the axillary "truth" view.

 Natural history of glenoid bone loss in primary glenohumeral osteoarthritis: how does bone loss progress over a decade?

These authors sought to determine how glenohumeral subluxation and glenoid bone loss changed over time in 48 shoulders that underwent arthroplasty and had been evaluated with standardized high-quality axillary radiographs 

at 1 or more time points over the 5-15 years before arthroplasty. The mean interval time between the oldest and most recent radiographs was 8.9 years (range 5-15 years). 

Below is an example of how glenoid morphology progressed over roughly an 8-year period of time from an A1 glenoid to a B3 glenoid. Note the standardization of the axillary "truth" views that enabled comparisons of the glenohumeral pathoanatomy over time. The patient was a 43-year-old male (body mass index 26.6) at initial presentation for symptomatic right shoulder osteoarthritis and went onto an anatomic total shoulder arthroplasty. From presentation to year 5, the glenoid morphology remained A1 with 3 intervening radiographs documented. At year 6, the patient was noted to have a B1 glenoid (top right), a B2 glenoid at year 7 (bottom left), and a B3 glenoid at year 8 before proceeding with surgery (bottom right).

On each axillary view, the glenoid type

and the degree of posterior humeral decentering on the face of the glenoid

were documented.

Glenoid morphology on the earliest radiograph was classified as A1 in 22, A2 in 13, B1 in 1, B2 in 9, B3 in 1, and D in 2 shoulders. 

Walch A patterns identified on early radiographs most commonly maintained an A pattern over time, but 20% developed eccentric wear with 5 of 35 becoming B type and 2 of 35 becoming a D type before arthroplasty. 

All B-type glenoids remained B type. 

Classic progression of bone loss along the same concentric or eccentric ‘‘track’’ occurred 41% of the time, with , the only B1 glenoid becoming a B2 glenoid, and 56% (5/9) of B2 glenoids becoming B3 glenoids before arthroplasty. 

Only 15% (2/13) of A2 glenoids developed eccentric wear compared with 32% (7/22) of A1 glenoids.

Comment: This study demonstrates that glenohumeral pathoanatomy can be well characterized using the axillary "truth" view without the additional expense and radiation dosage of a CT scan.

This study also demonstrates that the description of glenoid pathoanatomy cannot be constrained to discrete static "types", but rather the amount of bone loss, change in version, and humeral decentering each exist on a continuum from "none" to "a lot" with progressive transitions from one type to another.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

The power of the "truth" view in the detection of early shoulder arthritis

 A young man presented with pain and stiffness after prior procedures on his clavicle, biceps, and subscapularis.

His examination confirmed mild-moderate stiffness of his glenohumeral joint.

His Grashey view was not remarkable

However, his axillary "truth" view revealed decentering of the humeral head on the glenoid and moderate glenohumeral osteoarthritis.

Our thoughts on how to get the most information out of three simple plain films is shown in this link.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

The arthritic shoulder: version, biconcavity and humeral head decentering

A good understanding of arthritic shoulder arthroplasty can be gained from standard plain x-ray views without the need for CT scans or 3D planning software.

Here is the anteroposterior view of the right shoulder of a former baseball pitcher in his early 30's several years after a posterior labral repair. The film shows loss of radiographic joint space and osteophytes.

His axillary "truth" view, taken with the arm in a functional position of elevation, shows the humeral head sitting in the posterior concavity of a biconcave glenoid

With a usual amount of glenoid retroversion

And substantial posterior decentering of the humeral head on the face of the glenoid

The amount of decentering can be measured in terms of the amount of posterior displacement of the center of the humeral head in reference to the perpendicular bisector of a line segment connecting the anterior and posterior edges of the glenoid.

This is all the information needed to plan his reconstructive surgery which will be a ream and run.

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To see a YouTube video on how the ream and run is done, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Not Becoming a Robot with the Industrialization of Medicine

Not Becoming a Robot with the Industrialization of Medicine

This venerable author points out the risk of using technology rather than basic clinical skills when evaluating and managing patients.

A couple of sentences were eye catching. 

"Examinations such as MRI and CT may cost 4 to 5 times more than ordinary radiographs. In many cases, however, much less expensive radiographs—preceded by a detailed careful history and physical examination—may suffice for making the diagnosis and treatment".

"We also must remember that not all diagnostic tests are harmless. Take, for instance, a CT scan. The amount of radiation exposure to one’s body from a CT scan is 50 to 100 times more millisieverts than that of an ordinary chest radiograph. The effects of this radiation stay in the body permanently and are additive. Cumulative radiation to surgeons from radiographs over 15 to 20 years increases the risk of cancer by 3 to 5 times "

These thoughts surely apply to the evaluation of the arthritic shoulder. See our approach to the cost effective imaging of shoulder arthritis in this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Glenoid version before and after arthroplasty.

Determining glenoid component version after total shoulder arthroplasty

These authors examined the issue of measuring postoperative glenoid version, pointing out that postoperative CT scans add cost and radiation exposure (of course preoperative CT scans also add cost and radiation exposure as well).

They present a method for assessing glenoid component version after TSA using preoperative CT and postoperative plain radiographs.

Preoperative glenoid version was measured using established methods with an axillary x-ray, 2-dimensional CT, and Glenosys software. 

Postoperative glenoid component version and inclination were measured using Mimics software with preoperative CT and postoperative x-rays. 

It is interesting to see how closely the values for retroversion obtained with axillary x-rays correlated with those obtained using various CT-based methods

Similarly the preoperative to postoperative change in glenoid version was similar with the different methods of preoperative measurement.

The authors point out that the Mimics protocol requires purchase of specialized software, becoming proficient in software 3D modeling, and approximately 30 minutes spent on each patient’s evaluation and analysis due to a lack of specific programming to automate the protocol.

Comment: In an effort to carry out side-by-side comparison of preoperative and and postoperative glenoid version in a practical manner without the added cost and radiation of CT scans, it seems to make the most sense to use standardized axillary views taken in a functional position of elevation in the plane of the scapula

Here are two preop-post op comparisons. Note the standardization of portion and projection.

As for "correcting" preoperative glenoid version, it may not be as important as once thought, click on this reference:

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

CT scans and their radiation risk

There is currently great enthusiasm for using computer tomographic (CT) scans to create detailed images of the arthritic shoulder. While CT scans may be necessary in unusually complex cases, we find that for the great majority of patients having surgery for shoulder arthritis a standard set of x-rays including the axillary "truth" view provides all the needed information as pointed out in this link.

Here are some examples of the preoperative anatomy of some arthritic shoulders as seen on standardized axillary views

and some preoperative and postoperative comparisons of standardized axillary views, showing the restoration of the desired anatomic relationships in a shoulder with severe arthritis.

Two recent articles that have discussed the potential risks associated with radiation prompted this blog post:

An Estimation of Lifetime Fatal Carcinogenesis Risk Attributable to Radiation Exposure in the First Year Following Polytrauma A Major Trauma Center’s Experience Over 10 Years

These authors point out that the utilization of medical imaging continues to rise, including routine use in major trauma centers. Their aims  were to estimate the amount of radiation exposure from radiographic imaging and the associated fatal carcinogenesis risk among patients treated for polytrauma at 1 institution. 2,394 patients, with a mean injury severity score of 29 were included in their analysis. The mean total radiation dose received was 30.45 mSv and the median dose was 18.46 mSv. One hundred and fifteen patients received >100 mSv of radiation. The total patient group had a 3.56% mean risk of fatal carcinogenesis of any type that related solely to medical exposure of radiation as a result of their injuries. In their lifetime, 85 patients would be expected to develop cancer as a result of medical imaging that they had undergone in the year following their accident. They caution that this study does not provide an actuarial analysis: it is unknown how many patients in the study actually went on to develop cancer.

and How Can We Reduce Cancer Risk Due to Medical Imaging?

We also note a quote from the well-known book The Gene: An Intimate History: In 1926 Herman Muller "exposed a cohort of flies to an even lower dose of radiation...Even a cursory look confirmed a striking result: the newly born flies had accumulated mutations -- dozens of them, perhaps hundreds." (page 115). 

In Radiation Exposure from Musculoskeletal Computerized Tomographic Scans the authors point out that the radiation dose from a shoulder CT scan exceeds that of 25 chest x-rays.

Where does all this leave shoulder patients and shoulder surgeons? First we need to recognize that x-rays and particularly CT scans subject the body to ionizing radiation which can increase the risk of mutations and cancer. Second, each CT scan subjects the patient to 26 times the radiation of a standardized axillary view. Third, it has yet to be demonstrated that patients with preoperative CT scans realize better clinical outcomes from shoulder arthroplasty than those having only the standard preoperative x-rays. Fourth, we suggest that it is reasonable to reserve the use of CT scans for the special cases of glenohumeral arthritis in which the needed information cannot be gained from standard x-rays.

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Do CT scans add value to the preoperative evaluation of the arthritic shoulder?

Intraobserver and interobserver reliability of the modified Walch classification using radiographs and computed tomography 

These authors sought to evaluate the intraobserver and interobserver agreement of the modified Walch classification system using both plain radiographs and computed tomography (CT). 

Three fellowship-trained shoulder surgeons blindly and independently evaluated radiographs and CT scans of 100 consecutive shoulders (98 patients) and classified all shoulders according to the modified Walch classification in 4 separate sessions, each 4 weeks apart.

They included patients who had a diagnosis of primary osteoarthritis and who then underwent shoulder arthroplasty of some type. All patients had preoperative CT scans and axillary radiographs obtained routinely prior to surgery. There were 50 men (51%) and 48 women (49%).

The first reading by the most senior observer on the basis of CT scans was used as the gold standard (distribution: A1, 18; A2, 12; B1, 20; B2, 25; B3, 22; C, 1; and D, 2). 

The average intraobserver agreement for radiographs and CT scans was 0.73 (substantial; 0.72, 0.74, and 0.72) and 0.73 (substantial; 0.77, 0.69, and 0.72), respectively. 

The average interobserver agreement was 0.55 (moderate; 0.61, 0.51, and 0.53) for radiographs and 0.52 (moderate; 0.63, 0.50, and 0.43) for CT scans.

There was a high degree of agreement between the CT scan and the axillary views for each of the three reviewers:

This study showed that the modified classification can be applied to both CT images and axillary radiographs. It found that both axillary radiographs and CT scans can be used reliably with the modified Walch classification to deliver a reproducible assessment of glenoid morphology, as well as to broadly subcategorize the presence or absence of bone loss and eccentric wear or subluxation.This is useful for surgeons who do not, or cannot, routinely obtain CT images prior to shoulder replacement.

Comment:  This study is reassuring to those surgeons (including us) who find that an axillary view provides sufficient information to characterize the pathoanatomy and plan the surgical procedure for the great majority of patients coming to shoulder arthroplasty.

We note that CT scans expose the patient to 26 times the radiation of a standard set of plain radiographs and cost approximately $1000 more. Standardization of the axillary technique can yield highly reproducible views that can be easily analyzed for glenoid type, version, and the degree of decentering as demonstrated below

The use of standardized preoperative and postoperative axillary views provides a practical method for determining the effectiveness of surgical reconstruction.

While it can be argued that CT scans with 3D reconstructions in the plane of the scapula are more precise than an axillary view, it has not been show that patients having this more complex imaging protocol obtain the better functional outcomes necessary to justify its substantial added expense and radiation exposure.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Glenoid version measurement - does CT add value?

Determining glenoid component version after total shoulder arthroplasty

These authors present a method to assess glenoid component version after TSA using only routine preoperative CT and postoperative radiographs (x-rays).

Preoperative glenoid version was measured using established methods with an axillary x-ray, 2-dimensional CT, and Glenosys software. Postoperative glenoid component version and inclination were measured for 61 TSA patients using Mimics software with preoperative CT and postoperative x-rays. Four patients also had postoperative CTs. Glenoid implantation and imaging were performed on 14 cadavers, allowing validation of results against postoperative CT glenoid retroversion measurement.

The average preoperative glenoid version measurements by axillary view were virtually identical to that for the CT and Glenosys software:

The average amount of change in glenoid version from preoperative to postoperative were virtually identical for the axillary views and the different CT measurements and the Gleosys software:

Comment: We have found that preoperative and postoperative glenoid version can be reproducibly measured using standardized axillary views as shown in the examples below. Note the presence of the "eye" of the spinoglenoid notch on each film (arrows). 

We do not find that CT scans add value in assessing preoperative or postoperative glenoid version in the routine case of shoulder arthroplasty.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Glenoid version - measurement and importance in shoulder arthroplasty

Determining glenoid component version after total shoulder arthroplasty

These authors point out that the use of computed tomography (CT) to measure glenoid version adds cost and radiation exposure in comparison to standard radiographs.

They present a method for assessing glenoid component version after TSA using routine preoperative CT and postoperative radiographs.

They measured preoperative glenoid version using established methods with an axillary x-ray, 2-dimensional CT, and patented commercial Glenosys software. 

They measured postoperative glenoid component version and inclination for 61 TSA patients using patented commercial Mimics software for  preoperative CT and postoperative x-rays.  Glenoid implantation and imaging were performed on 14 cadavers, allowing validation of results against the gold standard postoperative CT glenoid retroversion measurement.

Compared with the gold standard, retroversion and inclination measurement error was 2° ± 1°and 2° ± 1°, respectively. Average postoperative version correction was 6° ± 7°, with 35 of 61 patients (57%) corrected to <10° of retroversion. Correlation between preoperative version measurement methods was
good to very good, except on the axillary x-ray. Patients not corrected to <10° of retroversion had significantly higher preoperative retroversion (14° ± 6°) than those corrected to <10° (6° ± 7°; P < .00001).

Comment: As pointed out by the authors, it is important to minimize cost and radiation exposure by avoiding CT scans that do not affect the clinical outcome of the patient. It is also important to avoid expenditures on patented commercial software, again unless it can be shown to improve the clinical outcome of surgery.

In the assessment of glenoid version, we have found that a standardized plain axillary view provides the  information necessary to plan and conduct shoulder arthroplasty without the need for CT scans. However, the view needs to be standardized as shown in the figure below (see this link)

 rather than a 'random' axillary view as shown below.

The value of the standardized axially view is detailed in the article, "Axillary view: arthritic glenohumeral anatomy and changes after ream and run." This article concluded that "The axillary view provides a practical method of characterizing glenohumeral anatomy before and after surgery that is less costly and exposes the patient to less radiation than a CT scan."


While the authors express concern that "Glenoid component loosening after total shoulder arthroplasty (TSA) may occur if retroversion is not corrected to <10°", this concern was not validated in a recent publication "Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty? which analyzed the clinical outcomes of 71 TSAs performed using a standard all-polyethylene pegged glenoid component inserted without effort to change glenoid version. This study compared the outcomes in the 21 in which the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°) with the 50 in which it was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°). At the 2-year followup the mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The mean difference in improvement between the two groups was 0.9 (95% CI, - 2.5 to 0.7; p = 0.412). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%). The mean difference between the two groups was 3% (95% CI, - 18% to 12%; p = 0.857). The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. With the numbers available, the radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). With the numbers available, the percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

This suggests that it may be possible to effectively manage arthritic glenohumeral joints without specific attempts to modify glenoid version. 

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Handball and the ream and run @ 6 years

Six years ago we met a dentist who had pain in his left shoulder. Even though he had 10/12 functions of his SST

he desired to proceed with a ream and run because he could not enjoy his sport of handball.

His preoperative films are shown below

His axillary "truth" view showed joint space narrowing that was not evident on the AP view.

He has returned to full action on the the handball court. His 6 year post operative films are shown here, showing a well-fixed thin impaction grafted smooth stem (no ingrowth surface) 

 and a stable regenerated joint surface on the axillary with no evidence of glenoid bone wear.

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The reader may also be interested in these posts:

Healing through joint replacement

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Glenohumeral pathoanatomy - are we making its evaluation too complicated?

Interest in the glenoid hull method for analyzing humeral subluxation in primary glenohumeral osteoarthritis

These authors opine that "humeral subluxation is the main cause of failure of total shoulder arthroplasty". They set out to compare humeral head subluxation in various reference planes and to search for a correlation with retroversion, inclination, and glenoid wear using reconstructions of 109 computed tomography scans of primary glenohumeral osteoarthritis and 97 of shoulder problems unrelated to shoulder osteoarthritis (controls) in (a) the scapular plane and (b) the glenoid hull plane
(a line perpendicular to the line joining the center of the glenoid and the tip of the hull (where the anterior and posterior cortical regions meet)).

They concluded that posterior subluxation of the humeral head may be defined in terms of the  glenohumeral offset or the scapulohumeral offset. They prefer measuring subluxation in the glenoid hull plane because it is less affected by the shape of the scapular body.

Comment: It is of interest that many new and increasingly complex methods for assessing glenohumeral pathoanatomy continue to surface monthly. To reduce the resulting confusion, we need to consider several points:

(1) As stated in this link, we need to ask "what information is needed" before a shoulder arthroplasty is performed. Do we need CT scans at all (see this link and this link) in most cases?

(3) While the term "static posterior subluxation of the humeral head" is in common use, the anteroposterior position of the humeral head on the glenoid is not 'static', but rather changes from when the arm is at the side to when the arm is flexed - a phenomenon known as functional decentering. Of course what is most important is not the preoperative posterior subluxation, but rather that noted at surgery as reported recently (see this link).

(3) We need to be clear on the definition of 'subluxation' (see this link). Some authors use the term subluxation to refer to the position of the humeral head in relation to all or part of the the body of the scapula. However, "subluxation" actually means separation of the joint surfaces as in incomplete or partial dislocation of the joint.

Basically, there are three important pieces of information we can obtain from preoperative imaging, each of which can be assessed by an axillary view taken with the arm in the functional position of elevation in the plane of the scapula (rather than with the arm adducted as is the case for CT scans).

First is the shape of the glenoid face. This film shows that the posterior 25% of the glenoid has a pathological concavity.

Second is the retroversion of the glenoid face as shown by the angle between G and S (S is a line drawn along the 'hull' as the authors of this article describe.

Third is the amount of posterior decentering of the head on the face of the glenoid when the arm is elevated in the plane of the scapua, which can be characterized as the ratio of C (the distance from the anterior lip of the glenoid) to G (the distance from the anterior to the posterior lip of the glenoid). 

In over 98% of our cases, these key elements of glenohumeral pathoanatomy can be gained from a single axillary view, avoiding the expense and radiation of a CT scan.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, reverse total shoulder patient information,  CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.