Background/Objectives: The terrible triad (TT) of the elbow combines elbow dislocation with radial-head and coronoid fractures. Existing systems classify either the individual osseous components or the broader spectrum of elbow fracture-dislocations, requiring multiple labels to describe the combined TT morphology. We propose a novel combined alphanumeric CT-based classification that integrates radial-head and coronoid morphology into one TT-specific code. The rationale is not merely terminological: the two axes correspond to osseous features routinely considered during preoperative planning and may therefore provide a compact, clinically oriented description in addition to standardising communication and research stratification. Methods: Radial-head morphology was coded 1–3 using CT-derived displacement, comminution and radial-neck involvement, while coronoid morphology was coded A–C using tip-fragment height and basal extension. Among 167 consecutive TT patients treated between 2012 and 2023, 63 had a qualifying post-reduction CT and met all eligibility criteria. Three observers with different levels of expertise independently classified anonymised CT datasets twice, three weeks apart, with randomised case order at T2. Interobserver agreement among all three raters was assessed with Fleiss’ κ; pairwise Cohen’s κ and exact percentage agreement were secondary analyses, and intra-observer agreement was assessed with Cohen’s κ. Results: For the combined alphanumeric code, Fleiss’ κ increased from 0.708 (95% CI 0.584–0.815) at T1 to 0.817 (0.702–0.913) at T2, with exact three-rater agreement of 71.4% and 84.1%, respectively. Radial-head Fleiss’ κ was 0.761 (0.615–0.888) at T1 and 0.821 (0.682–0.940) at T2; coronoid κ was 0.746 (0.602–0.864) and 0.807 (0.676–0.912). Intra-observer κ for the combined code ranged from 0.753 to 0.886. The final descriptive distribution was 1B 2/63 (3.2%), 2A 5/63 (7.9%), 2B 8/63 (12.7%), 3A 19/63 (30.2%), 3B 27/63 (42.9%) and 3C 2/63 (3.2%); no 1A, 1C or 2C cases were present. Conclusions: The novel combined CT-based alphanumeric system offers a compact, reproducible descriptor of paired osseous morphology. Its added value lies in integrating established fracture concepts into one TT-specific code with prespecified CT rules. In addition to standardising communication and research stratification, the paired descriptor may provide a clinically intuitive framework for treatment planning by simultaneously conveying radial-head complexity and coronoid morphology. It is not intended to replace assessment of ligamentous injury, dynamic stability or intraoperative findings, and treatment-guiding and prognostic validity require dedicated outcome-based studies. Level of evidence: IV (reliability study).

Background: Structural bone grafting to address glenoid bone defects in reverse shoulder arthroplasty (RSA) has become increasingly common, allowing restoration of lateralization, tilt, and version. Despite its advantages, graft-related radiographic alterations are frequently reported, while mechanical failure remains relatively uncommon. Interpretation of these findings is limited by the absence of standardized methods for postoperative graft evaluation. Methods: This systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and Google Scholar were searched up to February 8, 2026. Studies evaluating structural glenoid bone grafting in RSA with postoperative radiographic assessment of graft incorporation or failure were included. Two reviewers independently screened studies and extracted data regarding patient characteristics, graft features, imaging modalities, radiographic criteria, and graft-related complications. Methodological quality was assessed using the Newcastle–Ottawa Scale and RoB 2 tool. Results: Nineteen studies including 962 shoulders were analyzed. Radiographic assessment was reported at the latest available follow-up, with a mean of 40 months but ranging widely across studies (7 to 152 months). Standard radiographs were the most used imaging modality, followed by CT. Radiographic evaluation criteria were heterogeneous, most frequently based on radiolucent lines, graft thickness changes, or graft lysis. Radiographic signs suggestive of graft resorption were observed in 6.3% of shoulders, whereas graft failure associated with mechanical loosening occurred in 1.9%. Scapular notching was reported in 32.8% of cases. Discussion: Postoperative graft evaluation remains highly variable across studies, relying predominantly on qualitative radiographic parameters without standardized definitions. Importantly, radiographic signs suggestive of graft resorption were observed in 6.3% of cases, whereas true mechanical failure occurred in only 1.9%, indicating that many radiographic changes may reflect biological remodeling rather than clinically significant compromise.

Introduction: In glenohumeral osteoarthritis, progressive bone erosion often leads to posterior humeral head subluxation and increased glenoid retroversion. Correcting this deformity represents a major challenge in reverse shoulder arthroplasty (RSA), where surgical techniques commonly aim to restore neutral glenoid orientation (0°). Evidence regarding the influence of preoperative glenoid retroversion on postoperative outcomes remains limited. This study aimed to evaluate whether clinical and functional outcomes at a minimum 2-year follow-up differ according to preoperative glenoid retroversion in patients undergoing reverse total shoulder arthroplasty (RTSA) with systematic intraoperative correction to neutral. Methods: A total of 161 patients undergoing RTSA were retrospectively reviewed. Preoperative planning was performed using 3D software to restore neutral glenoid orientation via the bony-increased offset reverse shoulder arthroplasty technique. Glenoid retroversion was measured preoperatively on CT scans using the Friedman method, while postoperative glenoid version was assessed on axillary radiographs to confirm neutral orientation. Patients were stratified into two groups based on preoperative retroversion (<10° and ≥10°). Clinical outcomes and range of motion at a minimum follow-up of 24 months were compared between groups. Glenoid lateralization was assessed radiographically using the glenoid lateralization angle (GLA). Group comparisons were performed using the Mann–Whitney U test, and correlations were assessed using Spearman analysis. A p-value < 0.05 was considered statistically significant. Results: After exclusion of four patients with postoperative complications, 157 patients were included in the final analysis. The mean postoperative glenoid version was 0.35° ± 0.8° (range, −1° to +2°). No significant differences were observed in any clinical outcome between patients with <10° and ≥10° of preoperative glenoid retroversion, and no significant correlations were found between preoperative retroversion and postoperative outcomes. Radiographic analysis confirmed restoration of near-neutral glenoid version in all patients and demonstrated comparable glenoid lateralization between groups, with no significant differences in the GLA. Conclusion: In glenohumeral osteoarthritis, the most common pattern of bone loss results in increased glenoid retroversion and posterior humeral head subluxation. It remains debated whether, when applying standard correction techniques aimed at restoring neutral glenoid version, the severity of preoperative glenoid retroversion influences postoperative outcomes. The findings of this study indicate that, when RSA is performed with restoration of neutral glenoid version, postoperative clinical and functional outcomes are independent of the degree of preoperative glenoid retroversion. Level of evidence: Level III cohort study

Background: Reverse shoulder arthroplasty (RSA) has evolved through different humeral stem designs to optimize biomechanics and minimize complications. Although inlay and onlay configurations differ in geometry and bone preservation, their clinical outcomes often appear similar. This study aimed to compare clinical, functional, and radiographic outcomes between onlay and semi-inlay humeral stems, hypothesizing that comparable results may be achieved through distinct glenoid and humeral lateralization and distalization patterns. Methods: A retrospective analysis was conducted on 199 patients who underwent primary RSA between January 2021 and January 2024. Radiographic parameters lateralization shoulder angle (LSA), distalization shoulder angle (DSA), glenoid and humeral lateralization angles (GLA and HLA), and glenoid and humeral distalization angles (GDA and HDA) were measured on standardized anteroposterior radiographs. Clinical evaluation included Constant–Murley Score, Simple Shoulder Test, Visual Analog Scale, and range of motion. Statistical comparisons were performed using non-parametric or parametric tests according to data distribution (α = 0.05). Results: At a mean follow-up of 28 ± 8 months, 164 patients met the inclusion criteria (41 semi-inlay; 123 onlay); the groups showed no significant difference in clinical outcomes. Radiographically, semi-inlay stems demonstrated higher glenoid lateralization (GLA 53.31 ± 4.43 vs. 50.26 ± 6.92, p = 0.001) and lower humeral lateralization (HLA 34.52 ± 6.49 vs. 35.62 ± 9.11, p > 0.05), while onlay stems showed greater glenoid distalization (GDA 76.84 ± 12.03 vs. 70.01 ± 8.05, p = 0.001) and lower humeral distalization (HDA 22.04 ± 8.40 vs. 29.95 ± 6.53, p < 0.001). No significant differences were found for global LSA or DSA ( p > 0.05). Scapular notching incidence was comparable in the groups. Interobserver reliability for angular measurements was excellent ( κ = 0.82). Conclusion: Onlay and semi-inlay RSA designs achieved equivalent clinical outcomes through different biomechanical adaptations. Semi-inlay stems appear to compensate for their intrinsic lower humeral lateralization with increased glenoid lateralization, whereas onlay stems may balance their humeral geometry through greater glenoid distalization. These complementary strategies highlight that, rather than the selection of a specific stem design, it is the achievement of the desired lateralization and distalization obtained through different approaches that is key to successful RSA outcomes.

Background: Reverse shoulder arthroplasty (RSA) alters the glenohumeral center of rotation (CoR), but the relevance of preoperative-to-prosthetic CoR shift remains unclear. This study evaluated its association with postoperative outcomes after bony increased-offset RSA (BIO-RSA). Methods: We retrospectively reviewed 120 patients undergoing BIO-RSA with a 145° onlay humeral stem and a minimum 24-month follow-up; 97 met inclusion criteria. CoR positions were quantified using angular measurements based on reproducible scapular landmarks. Preoperative measurements were obtained from scapular-plane computed tomography reconstructions and postoperative measurements from 2-year true anteroposterior radiographs. ΔCoR was defined as Pre-CoR angle minus Post-CoR angle. Outcomes included visual analog scale pain, Constant–Murley score, Simple Shoulder Test, and active range of motion; associations were assessed using linear-regression and Spearman correlation analyses. Results: Each 1° increase in ΔCoR was associated with lower postoperative abduction (−1.13°, p = .028, R ² = .055) and forward flexion (−0.82°, p = .037, R ² = .050). Spearman analysis showed a significant association only with abduction (ρ = −0.255, p = .016). No significant associations were observed with pain or functional scores. Conclusion: A smaller preoperative-to-prosthetic CoR shift may be associated with greater elevation after BIO-RSA. Given the weak associations, ΔCoR should be interpreted cautiously as a radiographic parameter rather than an independent predictor.