Skip to content

Implants & Materials

Shoulder arthroplasty implant designs and materials, focusing on aTSA vs RSA selection and the role of porous tantalum and polyethylene in optimizing fixation.

Overview

Reverse shoulder arthroplasty designs for primary osteoarthritis demonstrate no implant-related complications across all three evaluated groups [1]. While patient and diagnostic factors significantly influence implant survival, the specific implant type and method of fixation appear less critical to outcomes [2]. In anatomic total shoulder arthroplasty, Trabecular Metal–backed glenoid components require cautious application with close patient follow-up [3]. For trapeziometacarpal arthritis, MAÏA® prostheses achieved an 88% survival rate at a final follow-up of 12 years [4].

Stemless reverse shoulder arthroplasty warrants caution until longer-term follow-up data become available, as rates of implant-associated complications and revision for stemless nano-reverse designs are high compared with literature reports [15, 16]. Conversely, the Stryker Ascend Flex uncemented metaphyseal bearing stem has demonstrated reassuring outcomes at a mean of 52 months [8]. Regarding platform systems, no indication exists that a platform system is superior to a standard prosthesis, with results remaining equivalent regarding revision rates [22].

Inset glenoid implants can be used safely and effectively to reconstruct deficient bone where standard implants are contraindicated [24]. For bioabsorbable anchors in glenohumeral shoulder surgery, careful attention to proper insertion techniques limits potential complications, while newer materials may address concerns regarding biocompatibility and strength [39]. Further long-term data collection is encouraged to establish a survival curve for the pyrocarbon humeral head resurfacing implant [14].

Anatomy & Pathophysiology

Kinematics and Muscle Mechanics

Reverse total shoulder arthroplasty (RTSA) shoulders maintain anterior and posterior deltoid moment-arm patterns similar to healthy shoulders, yet exhibit significantly larger moment-arm magnitudes and much greater intersubject variation [37]. Impingement in RTSA is determined by scapular motion, necessitating its inclusion in all shoulder models [34]. While lateralized RTSA designs decrease impingement and scapular notching, nonlateralized designs minimize shear forces [53]. Shear forces are significantly higher when the glenoid component is positioned at the medial center of rotation compared with the inferior center of rotation, a difference most pronounced during early abduction [50]. Increasing the diameter of the glenosphere alone does not alter the deltoid moment arm in RTSA [46].

Osseous and Implant Geometry

Anatomically shaped prosthetic heads may lead to better shoulder function and implant survivorship compared to spherical heads [38]. Custom non-spherical prosthetic heads more accurately replicate native humeral head shape, rotational range of motion, and glenohumeral joint kinematics than commercially available spherical prosthetic heads [41]. Extra-short humeral heads significantly reduce the incidence of glenohumeral joint overstuffing compared with short heads in anatomic total shoulder arthroplasty [36]. Mathematical formulae relating various humeral head dimensional measurements are presented for the design of future prosthetic shoulder systems [57]. Simulated humeral bone response after stemless anatomic shoulder replacement depends on fixation feature geometry [56].

Glenoid Positioning and Biomechanics

Anatomical reconstruction of the glenohumeral surfaces is important for the success rate of anatomical total shoulder arthroplasty [42]. Downward inclination of the glenoid component restores glenohumeral kinematics in total shoulder arthroplasty with supraspinatus deficiency but significantly increases cement stress due to subchondral bone resection [55]. Inferiorly tilting the glenosphere does not reduce inferior scapular neck impingement or subsequent scapular notching at 1-year follow-up [35]. Glenoid version as traditionally defined may have limited relevance when positioning the glenoid component during total shoulder arthroplasty, as the glenoid and scapular body development are controlled by independent genetic and biomechanical factors [47].

Resurfacing and Fracture Considerations

Resurfacing shoulder arthroplasty reproduces normal anatomy and compensates for glenohumeral wear, though there is a tendency to position these prostheses in varus due to technical imperfections [43]. Contralateral preoperative templating provides an algorithmic framework for reproducible outcomes in fracture reverse total shoulder arthroplasty [49].

Soft Tissue Interface

Anatomic total shoulder arthroplasty results in tendon-metal contact at the tendon-implant interface and produces higher tendon contact pressures compared to the native shoulder [61]. Successful application of suture anchors and tacks in shoulder surgery requires understanding the biology and biomechanics affecting their use, as well as knowledge of factors that can affect subsequent clinical outcomes [54].

Classification

Implant Design & Fixation: No implant-related complications were noted in all three groups of reverse shoulder arthroplasty designs for primary osteoarthritis [1]. Patient and diagnostic factors play a role in implant survival, while implant type and method of fixation are less important [2]. Patients with anatomic total shoulder arthroplasty using a short-stemmed humeral implant and hybrid glenoid had comparable long-term clinical results regarding survivorship to other implant systems [7]. Native anatomy was accurately reproduced in the majority of cases using a stemless humeral component, with no implant loosening observed at 2 to 6 years' follow-up [9]. Most postoperative complications and reoperations in the management of proximal humerus bone loss with allograft prosthetic composite technique are related to implant instability [10]. Rates of implant-associated complications and revision for stemless nano-reverse shoulder arthroplasty are high compared with those reported in the literature [16].

Glenoid & Scapular Morphology: The proposed classification system for glenoid bone loss is a helpful guide to the degree of bone loss when embarking on revision shoulder arthroplasty [45]. Scapular notching in reverse shoulder arthroplasty may be caused by different morphology of the polyethylene component and/or differences in glenosphere offset between prosthetic systems [58].

Material Properties & Surface Characteristics: Biocomposite anchors have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone [27]. The type of antibiotic selected has an important impact on cement properties [60]. Surface properties create higher frictional resistance, thereby providing better inherent stability for implants featuring novel surface morphology [67]. Pyrocarbon humeral head resurfacing implant material is too fragile to be used as a resurfacing implant and cannot achieve fixation of the implant to bone [68].

Other Considerations: Evidence regarding metal hypersensitivity to implants is primarily level IV and V [17]. Many cleared modern shoulder arthroplasty devices claim predicates based on subsequently recalled prostheses [26]. Results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods regarding stress shielding [63].

Clinical Presentation

Primary Osteoarthritis: No implant-related complications were noted across all three reverse shoulder arthroplasty designs [1]. Patients with anatomic total shoulder arthroplasty using the Zimmer Biomet Comprehensive® Shoulder System demonstrated long-term clinical results comparable to current longitudinal literature regarding survivorship of other implant systems [7]. Patient and diagnostic factors play a role in implant survival, while implant type and method of fixation are less important [2]. A history of prior implant complication was the most important patient feature for XGBoost performance in predicting complications and unplanned readmission following primary anatomic total shoulder replacements [13].

Component-Specific Outcomes: Trabecular Metal–backed glenoid components in anatomic total shoulder arthroplasty should be used with caution and patients followed closely [3]. The survival rate of MAÏA® prostheses for trapeziometacarpal arthritis at a 12-year follow-up was 88% [4]. Reassuring outcomes were demonstrated for the Stryker Ascend Flex uncemented metaphyseal bearing stem at a mean of 52 months [8]. Both humeral head resurfacing implants had only little migration and good clinical results at two years [18].

Stemless and Custom Designs: Radiologic evidence of maintained implant stability and good primary fixation was observed at 3 years of follow-up for a new stemless shoulder prosthesis [6]. The native anatomy was accurately reproduced in the majority of cases with no implant loosening at 2 to 6 years' follow-up using the Arthrex Eclipse stemless humeral component [9]. Prolonged time greater than 6 months from CT scan to device implantation for custom glenoid components resulted in bone loss that rendered the implants unusable [5]. Clinical and radiographic outcomes at 2 years for eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and PSI were promising, highlighting significant patient functional recovery and good implant stability [12].

Allograft and Specialized Materials: Most postoperative complications and reoperations related to proximal humerus bone loss managed with allograft prosthetic composite technique are related to implant instability [10]. The Trabecular Metal Monoblock Acetabular Cup System showed excellent early clinical and radiographic behavior [11]. Pyrocarbon interposition shoulder arthroplasty should remain to be tested in a few specialized shoulder centers until long-term results are available [29].

Failure Analysis and Hypersensitivity: Correlation of 3-dimensional measurements of glenoid and humeral component position with clinical outcome, anatomic factors, prosthetic design, and surgical factors will allow for better understanding of the causes of implant failure [19]. Evidence regarding metal hypersensitivity to implants is primarily level IV and V, reflecting the rare and incompletely understood nature of this entity [17]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [20].

Investigations

Plain radiography: Standard X-rays demonstrate osseous integration of Spongy Hydroxyapatite after 6 weeks in all patients, with active bone remodeling persisting for several years [65]. Radiographic evidence of maintained implant stability and good primary fixation exists at 3 years for a new stemless shoulder prosthesis [6]. Native anatomy was accurately reproduced in the majority of cases using the Arthrex Eclipse stemless humeral component, with no implant loosening observed at 2 to 6 years' follow-up [9]. Radiographic evolution of proximal humeral bony adaptations with a short uncemented stem was satisfactory at mid-term follow-up [28]. Patterns of proximal humeral bone resorption after total shoulder arthroplasty with an uncemented rectangular stem are a radiographic phenomenon without significant impairment of function or need for revision within 5 years [71]. At an intermediate follow-up of approximately 4 years, there were no significant differences in radiographic or clinical performance between pegged and keeled glenoid components [70]. Radiolucent lines were seen most commonly around the inferior pegs of an all-polyethylene pegged bone-ingrowth glenoid component, which may represent an incipient mode of failure [66]. The presence of radiolucent lines in Eclipse total shoulder arthroplasty requires long-term observation but does not impact clinical results [62]. Bone presence between the central peg's radial fins of a partially cemented pegged all poly glenoid component suggests fewer overall component radiolucencies [64]. High pore count and porosity in neat and composite bone cement mantles were not visible on standard clinical radiographs [69]. No implant-related complications were noted in all three groups of reverse shoulder arthroplasty designs for primary osteoarthritis [1].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [59].

CT: Prolonged time greater than 6 months from CT scan to device implantation for custom glenoid components in reverse total shoulder arthroplasty resulted in bone loss that rendered the implants unusable [5].

Other Considerations: Patient and diagnostic factors play a role in humeral component survival in shoulder arthroplasty, while implant type and method of fixation are less important [2]. Trabecular Metal–backed glenoid components in anatomic total shoulder arthroplasty should be used with caution and patients followed closely [3]. Clinical and radiographic outcomes at 2 years for eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and PSI were promising, highlighting significant patient functional recovery and good implant stability [12]. Mid-term clinical and radiological results of converting an anatomical total shoulder arthroplasty to a reverse shoulder arthroplasty using a modular system are promising [48]. The Trabecular Metal Monoblock Acetabular Cup System showed excellent early clinical and radiographic behavior [11]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [20].

Treatment

Operative

Implant Selection: Evidence supports the use of trabecular metal–backed glenoid components in anatomic total shoulder arthroplasty with caution and close patient follow-up [3]. The Zimmer Biomet Comprehensive® Shoulder System demonstrates comparable long-term survivorship to other implant systems [7], while the Stryker Ascend Flex uncemented metaphyseal bearing stem shows reassuring outcomes at a mean of 52 months [8]. For trapeziometacarpal arthritis, MAÏA® prostheses achieved an 88% survival rate at 12-year final follow-up [4]. Humeral head resurfacing implants exhibit little migration and good clinical results at two years [18], and no platform system has been shown superior to a standard prosthesis regarding revision rates at the implant component level [22]. Conversely, metal-backed implants may reduce the load carried by the bone, potentially detrimental to long-term total shoulder arthroplasty survival [30].

Fixation and Design: Radiologic evidence confirms maintained implant stability and good primary fixation for a new stemless shoulder prosthesis at 3 years [6]. A straight short stem validates efficacy for acceptable clinical outcomes and implant stability in reverse shoulder arthroplasty [32]. Inset glenoid implants can be safely and effectively used to reconstruct deficient bone where standard implants are contraindicated [24]. However, prolonged time greater than 6 months from CT scan to device implantation results in bone loss that renders custom glenoid implants unusable [5]. Nonanatomic reconstruction may influence the long-term survival of the Affinis Short stemless shoulder arthroplasty system [25], and surgeons should proceed with caution when using stemless reverse shoulder arthroplasty until longer-term follow-up data are available [15]. Further research is required to investigate the long-term durability of stemless anatomic total shoulder arthroplasty implants [23].

Outcomes and Patient Factors: Patient and diagnostic factors play a role in implant survival, while implant type and method of fixation are less important [2]. No implant-related complications were noted in all three groups of reverse shoulder arthroplasty designs for primary osteoarthritis [1]. Clinical and radiographic outcomes at 2 years for eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and patient-specific instrumentation were promising, highlighting significant patient functional recovery and good implant stability [12]. Despite radiographic subsidence, clinical outcomes remained unaffected in the Easytech stemless rTSA, suggesting mild early subsidence may represent a benign self-stabilization process [73]. Spontaneous seating of a glenosphere component with non-operative management occurred within one-year follow-up in an elderly patient with low demand [72]. The degree of arthritis should not affect the choice of prosthetic material for hemiarthroplasties, though this suggestion needs further investigation [51]. Knowledge of the array of shoulder prostheses currently available, their indications, and the use of treatment algorithms can lead to optimized patient outcomes [44].

Complications

Instability: Implant instability represents a primary driver of postoperative complications and reoperations, particularly in complex cases involving proximal humerus bone loss managed with allograft prosthetic composite techniques [10]. High rates of implant-associated complications and revision are specifically noted for stemless nano-reverse shoulder arthroplasty compared with literature reports [16]. Conversely, no implant-related complications were observed across all three reverse shoulder arthroplasty designs used for primary osteoarthritis [1].

Aseptic Loosening: Radiologic evidence of maintained implant stability and good primary fixation was observed at 3 years for a new stemless shoulder prosthesis [6], and no loosening was detected at 2 to 6 years for the Arthrex Eclipse stemless humeral component [9]. However, prolonged time greater than 6 months from CT scan to device implantation for custom glenoid components in reverse total shoulder arthroplasty resulted in bone loss that rendered the implants unusable [5]. Further follow-up is necessary to compare the long-term performance of stemless shoulder prostheses against conventional stemmed prostheses [21].

Polyethylene Wear / Component Failure: Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, Judet's bipolar prosthesis for radial head arthroplasty achieved mainly good clinical results [75]. Augmented polyethylene glenoid components demonstrated improved clinical outcomes without implant failure or complications during short-term follow-up in the presence of posterior glenoid bone loss [31]. The survival rate of MAÏA® prostheses for trapeziometacarpal arthritis was 88% at 12 years of follow-up [4].

Other Considerations: Surgeons should proceed with caution when using stemless reverse shoulder arthroplasty until longer-term follow-up data are available [15]. Trabecular Metal–backed glenoid components in anatomic total shoulder arthroplasty should be used with caution, and patients must be followed closely [3]. Patients with anatomic total shoulder arthroplasty using the Zimmer Biomet Comprehensive® Shoulder System had comparable long-term clinical results regarding survivorship to other implant systems [7]. History of prior implant complication was the most important patient feature for XGBoost performance in predicting complications and unplanned readmission following primary anatomic total shoulder replacements [13]. Authors encourage further long-term data collection to establish a survival curve for the pyrocarbon humeral head resurfacing implant [14]. Correlation of 3-dimensional measurements of glenoid and humeral component position with clinical outcome, anatomic factors, prosthetic design, and surgical factors will allow for better understanding of the causes of implant failure [19]. Many cleared modern shoulder arthroplasty devices claim predicates based on subsequently recalled prostheses [26].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or driving; however, mid-term radiographic evolution of proximal humeral bony adaptations with a short uncemented stem was satisfactory [28], and early clinical behavior for the Trabecular Metal Monoblock Acetabular Cup System was excellent [11].

Full activity (months): The Stryker Ascend Flex uncemented metaphyseal bearing stem demonstrated reassuring outcomes at a mean of 52 months [8], while radiologic evidence of maintained implant stability and good primary fixation for a new stemless shoulder prosthesis was observed at 3 years [6]. Patients with anatomic total shoulder arthroplasty using the Zimmer Biomet Comprehensive® Shoulder System had comparable long-term clinical results regarding survivorship to other implant systems [7].

Complete recovery / outcome plateau (months): The survival rate of MAÏA® prostheses for trapeziometacarpal arthritis at a final follow-up of 12 years was 88% [4]. Mid- to long-term follow-up indicates a low revision rate and good clinical survivorship for cemented, all-polyethylene pegged glenoid components in anatomic total shoulder arthroplasty [40]. Nonanatomic reconstruction may influence survival over the long term for the Affinis Short stemless shoulder arthroplasty system [25].

Rehabilitation protocol: Prolonged time greater than 6 months from CT scan to device implantation resulted in bone loss that rendered custom glenoid components unusable [5]. Not all biocomposite anchors are the same; they have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone [27].

Functional milestones: History of prior implant complication was the most important patient feature for XGBoost performance in predicting complications and unplanned readmission following primary anatomic total shoulder replacements [13].

Other Considerations: Authors encourage further long-term data collection to establish a survival curve for the pyrocarbon humeral head resurfacing implant [14]. Further follow-up is necessary regarding the long-term performance of stemless and conventional stemmed shoulder prostheses in the treatment of glenohumeral osteoarthritis [21]. Further research is required to investigate the long-term durability of stemless anatomic total shoulder arthroplasty implants [23]. Further studies with long-term follow-up are needed to determine whether the grafted area in Autologous Matrix-Induced Chondrogenesis will maintain structural and functional integrity over time [33].

Key Evidence

  • [L3] In all three groups, no implant related complications were noted. (10.1186/s12891-025-08749-y)
  • [L4] Patient and diagnostic factors play a role in implant survival; implant type and method of fixation are less important. (10.1016/j.jse.2009.04.011)
  • [L4] This implant should be used with caution, and patients followed closely. (10.1016/j.jse.2017.09.036)
  • [L4] The survival rate of the implants at the final follow-up of 12 years was 88%. (10.1177/17531934221136442)
  • [L3] Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. (10.5397/cise.2023.00563)
  • [L4] At 3 years of follow-up, there is radiologic evidence of maintained implant stability and good primary fixation. (10.1016/j.jse.2009.12.009)
  • [L4] Patients had comparable long-term clinical results to the current longitudinal literature regarding survivorship of other implant systems. (10.1016/j.jse.2024.11.018)
  • [L4] These findings demonstrate reassuring outcomes for this implant at a mean of 52 months. (10.1177/17585732231220358)
  • [L4] We were able to accurately reproduce the native anatomy in the majority of cases, with no implant loosening, at 2 to 6 years' follow-up. (10.1016/j.jse.2018.05.039)
  • [L4] Most of the postoperative complications and reoperations are related to implant instability. (10.1016/j.jse.2023.09.038)
  • [L4] The implant showed excellent early clinical and radiographic behavior. (10.1016/j.arth.2008.09.027)
  • [L4] Clinical and radiographic outcomes at 2 years were promising, highlighting significant patient functional recovery and good implant stability. (10.1016/j.jse.2022.01.010)
  • [L3] History of prior implant complication was the most important patient feature for XGBoost performance, a novel patient feature that surgeons should consider when counseling patients. (10.1177/24715492221075444)
  • [Letter] The authors encourage further long-term data collection to establish a survival curve for this implant. (10.1016/j.jse.2020.11.005)
  • [L4] Surgeons should proceed with caution when using this implant until longer-term follow-up data are available. (10.1016/j.jse.2023.01.042)
  • [L4] However, the rates of implant-associated complications and revision are high compared with those reported in the literature. (10.1186/s12891-025-09386-1)
  • [L5] The evidence regarding metal hypersensitivity to implants is primarily level IV and V, reflecting the rare and incompletely understood nature of this entity. (10.1016/j.jhsa.2017.06.009)
  • [L2] Both implants had only little migration and good clinical results. (10.1016/j.jse.2014.05.012)
  • [L5] Ultimately, correlation of these measurements with clinical outcome, anatomic factors, prosthetic design, and surgical factors will allow for better understanding of the causes of implant failure. (10.1016/j.jse.2013.01.005)
  • [L3] Further follow-up is necessary regarding the long-term performance of this prosthesis. (10.1186/s12891-015-0723-y)
  • [L3] No indication that platform system is better than standard prosthesis was found, and the results were equivalent. (10.1016/j.jse.2023.02.107)
  • [L1] Further research is required to investigate the long-term durability of the stemless implant. (10.1016/j.jse.2019.12.022)
  • [L4] This study documents for the first time the possibility of safely and effectively using inset glenoid implants to reconstruct deficient bone for which standard implants are contraindicated. (10.1016/j.jse.2011.03.023)
  • [L3] Nonanatomic reconstruction may influence survival over the long term. (10.1016/j.jse.2024.01.051)
  • [L4] Many of the cleared modern devices claim predicates based on subsequently recalled prostheses. (10.1016/j.jse.2022.09.017)
  • [L5] Not all biocomposite anchors are the same; they have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone. (10.1016/j.arthro.2019.08.023)
  • [L4] The radiographic evolution was satisfactory at mid-term follow-up. (10.1016/j.jses.2019.09.011)
  • [L4] Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers. (10.1016/j.jse.2017.01.002)
  • [L5] The use of a metal-backed implant reduces the load carried by the bone, which may be detrimental to long-term TSA survival. (10.1016/j.jse.2014.01.038)
  • [L4] Augmented polyethylene glenoid components demonstrated improved clinical outcome, without implant failure or complications, during short-term follow-up. (10.1016/j.jse.2016.09.053)
  • [L4] This study validates the efficacy of a straight short stem for acceptable clinical outcomes and implant stability in RSA. (10.1016/j.jse.2024.07.035)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L5] In addition, impingement is determined by scapular motion, which should be included in all shoulder models. (10.1016/j.jse.2015.06.011)
  • [L3] Despite previous biomechanical studies' predictions that inferiorly tilting the glenosphere might reduce inferior scapular neck impingement and subsequent scapular notching, our data showed no difference at 1-year follow-up. (10.1016/j.jse.2010.11.026)
  • [L3] Extra-short humeral heads significantly reduce the incidence of glenohumeral joint overstuf fi ng compared with short heads, maintaining more normal shoulder biomechanics. (10.1016/j.jseint.2021.11.013)
  • [L5] RTSA shoulders maintain the same anterior and posterior deltoid muscle moment-arm patterns as healthy shoulders but show much greater intersubject variation and larger moment-arm magnitudes. (10.1016/j.jse.2015.09.015)
  • [L5] The findings may have important clinical and economic implications given evidence that anatomically shaped heads might lead to better shoulder function and implant survivorship. (10.1016/j.jse.2018.03.002)
  • [L4] Careful attention to proper anchor insertion techniques can limit the potential for complications, and newer materials may address concerns of biocompatibility and material strength. (10.1016/j.arthro.2008.08.018)
  • [L4] Mid- to long-term follow-up indicates a low revision rate and good clinical survivorship for cemented, all-polyethylene glenoid components. (10.1016/j.jse.2022.08.007)
  • [L5] The custom, non-spherical prosthetic head more accurately replicated the head shape, rotational range of motion, and glenohumeral joint kinematics than the commercially available, spherical prosthetic head compared with the native humeral head. (10.1016/j.jse.2013.01.002)
  • [L5] This numerical study highlights the importance of an anatomical reconstruction of the glenohumeral surfaces for the success rate of anatomical total shoulder arthroplasty. (10.1016/j.jse.2010.06.006)
  • [L4] The resurfacing shoulder arthroplasty reproduces the normal anatomy and compensates glenohumeral wear, although there was a tendency to position the prosthesis in varus due to technical imperfections. (10.1016/j.jse.2012.07.014)
  • [L5] Knowledge of the array of shoulder prostheses currently available and the indications for each, as well as the use of treatment algorithms, can lead to optimized patient outcomes. (10.5435/00124635-200907000-00002)
  • [L4] The proposed classification system is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. (10.1302/0301-620x.98b3.36664)
  • [L5] Increasing the diameter of the glenosphere alone did not alter the deltoid moment arm. (10.1302/0301-620x.98b2.35912)
  • [L5] Glenoid version as traditionally defined may have limited relevance when positioning the glenoid component during total shoulder arthroplasty because the glenoid and scapular body development are controlled by independent genetic and biomechanical factors. (10.1016/j.jse.2008.11.012)
  • [L4] The mid-term clinical and radiological results of this technique are promising. (10.1302/0301-620x.97b12.35176)
  • [L4] The information obtained from the template provides an algorithmic framework that provides reproducible outcomes for a highly functional and stable shoulder unique to each patient. (10.1016/j.xrrt.2023.05.004)
  • [L5] Shear forces are significantly higher when the glenoid component is positioned in the MCP compared with the ICP, and this is more pronounced in early abduction. (10.1016/j.jse.2014.12.017)
  • [L5] Although the degree of arthritis should not affect the choice of prosthetic material, this suggestion needs to be further investigated. (10.1016/j.jse.2019.09.041)
  • [L4] The review summarizes biomechanical concepts and clinical outcomes, noting that nonlateralized designs minimize shear forces while lateralized designs decrease impingement and scapular notching. (10.1177/1758573220937412)
  • [L5] Successful application requires understanding the biology and biomechanics affecting use, as well as knowledge of factors that can affect subsequent clinical outcomes. (10.1177/0363546505282621)
  • [L5] The downward inclination of the glenoid restored glenohumeral kinematics but significantly increased cement stress due to subchondral bone resection. (10.1016/j.jse.2008.11.008)
  • [L5] Simulated humeral bone response after stemless anatomic shoulder replacement depends on fixation feature geometry. (10.1016/j.jse.2018.06.002)
  • [L5] Mathematical formulae relating various humeral head dimensional measurements are presented and may be useful for the design of future prosthetic shoulder systems. (10.1016/j.jse.2016.01.032)
  • [L3] These findings may be because of the different morphology of the polyethylene component and/or differences in glenosphere offset between the prosthetic systems. (10.1016/j.jse.2011.08.051)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] Anatomic total shoulder arthroplasty results in tendon-metal contact and higher tendon contact pressures compared to the native shoulder. (10.1016/j.jse.2018.04.017)
  • [L4] The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. (10.1302/0301-620x.104b1.bjj-2021-0869.r2)
  • [L4] These results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods. (10.1016/j.jse.2019.03.016)
  • [L4] More bone imparted fewer overall component radiolucencies. (10.1016/j.jse.2010.05.025)
  • [L4] Standard X-rays showed osseous integration after 6 weeks in all patients, with active bone remodeling still occurring after several years. (10.1054/jhsb.2001.0686)
  • [L4] Radiolucent lines were seen most commonly around the inferior pegs of the prosthesis, and this may represent an incipient mode of failure. (10.2106/jbjs.15.00475)
  • [Case_report] The material seems to be too fragile to be used as a resurfacing implant and cannot achieve fixation of the implant to bone. (10.1016/j.jse.2020.02.028)
  • [L5] The high pore count and porosity were not visible on standard clinical radiographs. (10.1016/j.arth.2007.03.040)
  • [L3] At an intermediate follow-up period of approximately 4 years, there were no significant differences in either radiographic or clinical performance between the pegged and keeled designs. (10.1016/j.jse.2009.10.018)
  • [L2] This is a radiographic phenomenon without significant impairment of function or need for revision within 5 years after surgery. (10.1016/j.jse.2014.02.024)
  • [L5] This case demonstrates spontaneous seating of the glenosphere component with non-operative management within one-year follow-up in an elderly patient with low demand for the affected joint. (10.1177/2471549220949147)
  • [L3] Despite radiographic subsidence, clinical outcomes remained unaffected, suggesting mild early subsidence may represent a benign self-stabilization process. (10.1016/j.jse.2025.09.003)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)

See Also

References

[1] Clinical and radiological comparison of three different reverse shoulder arthroplasty designs for patients with primary osteoarthritis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08749-y

[2] Survivorship of the humeral component in shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.04.011

[3] Outcomes of Trabecular Metal–backed glenoid components in anatomic total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.09.036

[4] Long-term survival analysis of 191 MAÏA® prostheses for trapeziometacarpal arthritis. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221136442

[5] Use of custom glenoid components for reverse total shoulder arthroplasty. Clinics in Shoulder and Elbow. 2023. DOI: 10.5397/cise.2023.00563

[6] Results of a new stemless shoulder prosthesis: Radiologic proof of maintained fixation and stability after a minimum of three years' follow-up. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.12.009

[7] Ten-year implant survivorship and performance of anatomic total shoulder arthroplasty patients with the Zimmer Biomet Comprehensive® Shoulder System: a short stemmed humeral implant and hybrid glenoid. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.018

[8] Survivorship of the Stryker Ascend Flex uncemented metaphyseal bearing stem at a minimum 2- and 5-year follow-up. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231220358

[9] Clinical and radiologic outcomes following total shoulder arthroplasty using Arthrex Eclipse stemless humeral component with minimum 2 years' follow-up. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.039

[10] Management of proximal humerus bone loss with allograft prosthetic composite technique in shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.09.038

[11] Migration of the Trabecular Metal Monoblock Acetabular Cup System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.09.027

[12] Clinical And Radiographic Results Of Eccentric Glenoid Reaming In Anatomical Total Shoulder Arthroplasty Using 3D Planning And PSI. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.010

[13] Development of a Machine Learning Algorithm for Prediction of Complications and Unplanned Readmission Following Primary Anatomic Total Shoulder Replacements. Journal of Shoulder and Elbow Arthroplasty. 2022. DOI: 10.1177/24715492221075444

[14] Response to Letter to the Editor regarding: “Fracture of pyrocarbon humeral head resurfacing implant: a case report”. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.11.005

[15] Stemless reverse shoulder arthroplasty: clinical and radiologic outcomes with minimum 2 years’ follow-up. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.042

[16] Long-term clinical and radiological outcomes of a stemless reverse shoulder implant that is fallen out of favor - stemless nano-reverse shoulder arthroplasty. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09386-1

[17] Making Sense of Metal Allergy and Hypersensitivity to Metallic Implants in Relation to Hand Surgery. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.009

[18] Evaluation of periprosthetic bone mineral density and postoperative migration of humeral head resurfacing implants: two-year results of a randomized controlled clinical trial. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.05.012

[19] Development and validation of a new method of 3-dimensional assessment of glenoid and humeral component position after total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.005

[20] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[21] Are there differences between stemless and conventional stemmed shoulder prostheses in the treatment of glenohumeral osteoarthritis?. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0723-y

[22] Revision Rate Of Shoulder Arthroplasty On Implant Component Level In Platform System Compared To Standard Design. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.107

[23] Stemless anatomic total shoulder arthroplasty: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.022

[24] Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.03.023

[25] Influence of humeral position of the Affinis Short stemless shoulder arthroplasty system on long-term survival and clinical outcome. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.051

[26] Shoulder arthroplasty device clearance: an ancestral network analysis. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.017

[27] Editorial Commentary: Fill It up: The Fate of “Absorbable” Implants. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.08.023

[28] Proximal humeral bony adaptations with a short uncemented stem for shoulder arthroplasty: a quantitative analysis. JSES Open Access. 2019. DOI: 10.1016/j.jses.2019.09.011

[29] Pyrocarbon interposition shoulder arthroplasty: preliminary results from a prospective multicenter study at 2 years of follow-up. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.01.002

[30] Load transfer after cemented total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.01.038

[31] Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.09.053

[32] Assessing the efficacy: mid-term clinical and radiological outcomes of the comprehensive short stem system in reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.035

[33] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[34] Mechanical tradeoffs associated with glenosphere lateralization in reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.06.011

[35] A radiographic analysis of the effects of glenosphere position on scapular notching following reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.026

[36] Extra-short humeral heads reduce glenohumeral joint overstuffing compared with short heads in anatomic total shoulder arthroplasty. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.013

[37] How do deltoid muscle moment arms change after reverse total shoulder arthroplasty?. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.09.015

[38] Spherical versus elliptical prosthetic humeral heads: a comparison of anatomic fit. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.002

[39] Bioabsorbable Anchors in Glenohumeral Shoulder Surgery. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2008.08.018

[40] Mid- to long-term outcomes of a cemented, all-polyethylene pegged glenoid component in anatomic total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.08.007

[41] The effects of prosthetic humeral head shape on glenohumeral joint kinematics: a comparison of non-spherical and spherical prosthetic heads to the native humeral head. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.002

[42] Biomechanical consequences of humeral component malpositioning after anatomical total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.06.006

[43] Resurfacing humeral prosthesis: do we really reconstruct the anatomy?. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.07.014

[44] Shoulder Arthroplasty: Prosthetic Options and Indications. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200907000-00002

[45] A new classification of glenoid bone loss to help plan the implantation of a glenoid component before revision arthroplasty of the shoulder. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b3.36664

[46] The effect of glenosphere diameter and eccentricity on deltoid power in reverse shoulder arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b2.35912

[47] Genetic and biomechanical determinants of glenoid version: Implications for glenoid implant placement in shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.11.012

[48] The use of a modular system to convert an anatomical total shoulder arthroplasty to a reverse shoulder arthroplasty. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b12.35176

[49] Contralateral preoperative templating for fracture reverse total shoulder arthroplasty: technique article and case series. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.05.004

[50] Rocking-horse phenomenon of the glenoid component: the importance of inclination. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.017

[51] Hemiarthroplasties: the choice of prosthetic material causes different levels of damage in the articular cartilage. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.09.041

[53] Lateralized versus nonlateralized reverse total shoulder arthroplasty. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220937412

[54] Suture Anchors and Tacks for Shoulder Surgery, Part 1. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546505282621

[55] Total shoulder arthroplasty: Downward inclination of the glenoid component to balance supraspinatus deficiency. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.11.008

[56] The effect of stemless humeral component fixation feature design on bone stress and strain response: a finite element analysis. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.06.002

[57] An anthropometric analysis to derive formulae for calculating the dimensions of anatomically shaped humeral heads. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.01.032

[58] The relationship between scapular notching and reverse shoulder arthroplasty prosthesis design. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.08.051

[59] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[60] Evaluation_of_Elution_and_Mechanical_Properties_of_High-Dose_Antibiotic-Loaded_B_S0883540315001643. n.d..

[61] Rotator cuff contact pressures at the tendon-implant interface after anatomic total shoulder arthroplasty using a metal-backed glenoid component. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.04.017

[62] Mid-term results of Eclipse total shoulder arthroplasty. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b1.bjj-2021-0869.r2

[63] Radiographic outcomes of impaction-grafted standard-length humeral components in total shoulder and ream-and-run arthroplasty: is stress shielding an issue?. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.016

[64] Bone presence between the central peg's radial fins of a partially cemented pegged all poly glenoid component suggest few radiolucencies. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.05.025

[65] Spongy Hydroxyapatite in Hand Surgery – A Five Year Follow-Up. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2001.0686

[66] Clinical and Radiographic Results of an All-Polyethylene Pegged Bone-Ingrowth Glenoid Component. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00475

[67] The_Effect_of_Surface_Morphology_on_the_Primary_Fixation_Strength_of_Uncemented_S0883540314007396. n.d..

[68] Fracture of pyrocarbon humeral head resurfacing implant: a case report. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.02.028

[69] Porosity of Neat and Composite Bone Cement Mantles. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.03.040

[70] Pegged versus keeled glenoid components in total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.10.018

[71] Patterns of proximal humeral bone resorption after total shoulder arthroplasty with an uncemented rectangular stem. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.02.024

[72] Case Report: Watching and Waiting? A Case of Incomplete Glenosphere Seating With Spontaneous Reversal in Reverse Shoulder Arthroplasty. Journal of Shoulder and Elbow Arthroplasty. 2020. DOI: 10.1177/2471549220949147

[73] Risk of humeral implant subsidence in Easytech stemless rTSA is mainly associated with surgical technique and patient activity. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.09.003

[75] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

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.