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Joint Replacement

Total shoulder arthroplasty (TSA) for osteoarthritis with intact cuff vs reverse TSA (rTSA) for cuff arthropathy, complex fractures, and revision.

Overview

Final recommendations derived from literature and expert consensus provide a resource for guiding decision-making for stakeholders in the clinical introduction of artificial joint arthroplasty devices [1]. Surgeons must examine existing literature on outcomes for different arthroplasty options to maximize clinical outcomes and revision-free implant survival [4]. Total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients [19].

Shoulder arthroplasty procedures continue to be the predominant surgical management for osteonecrosis of the humeral head [10]. Utilization of joint-preserving procedures for osteonecrosis of the humeral head is growing over time, notably in patients under 50 years of age [10]. Reverse arthroplasty can achieve highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff [14]. Age 70 years or older does not appear to be a contraindication to stemless anatomic total shoulder arthroplasty [58]. Postoperative improvements in patient-determined outcome scores and range of motion were similar between patients aged under 70 years and those aged 70 years or older undergoing stemless anatomic total shoulder arthroplasty [58].

With proper indications, unicompartmental and bicompartmental arthroplasty with a finned metal tibial-plateau implant has a place in reconstructive surgery of the arthritic knee joint [6]. Arthrodesis (AD) is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty [65]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for proximal interphalangeal joint prosthetic arthroplasty [20].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Native Joint Mimicry: Biomechanical evidence indicates that an elliptical implant yields glenohumeral kinematics that mimic the native joint [33]. In contrast, the spherical head shape does not show significant glenohumeral translation during humeral axial rotation, regardless of glenoid conformity [73].

Prosthetic Kinematic Alterations: In vivo, glenohumeral joint contact after total shoulder arthroplasty is not centered on the glenoid surface [67]. This lack of centering suggests that kinematics after shoulder arthroplasty may not be governed by ball-in-socket mechanics as traditionally thought [67]. Placement of a distal humeral hemiarthroplasty implant causes a small but significant alteration in elbow joint kinematics, regardless of implant size [80].

Component Positioning and Fit: Malpositioning of both the humeral and glenoid components adversely affects the range of motion, kinematics, and stability of the shoulder [42]. An anatomical reconstruction of the glenohumeral surfaces is important for the success rate of anatomical total shoulder arthroplasty [79]. Optimal glenohumeral mismatch in cemented pegged glenoid implants is multifactorial and has not been definitively established [81].

Implant Design Impacts: Extra-short humeral heads significantly reduce the incidence of glenohumeral joint overstuffing compared with short heads, maintaining more normal shoulder biomechanics [60]. The radiocapitellar prosthetic arthroplasty procedure largely preserves elbow kinematics and stability [55].

Reverse Total Shoulder Arthroplasty (RTSA)

Indications and Biomechanics: Reverse shoulder arthroplasty is a useful tool for treating older patients with B2 glenoid deformities, offering favorable biomechanics [52]. Most reverse prostheses impingements can be avoided by scapular compensation or by a glenosphere lateralization [66].

Instability Management: Assessment of patient, biomechanical, and surgical factors is critical in determining the best course of treatment for instability in reverse total shoulder arthroplasty [53].

Wear Testing Standards

Testing Protocols: Additional combined kinematics are an indispensable part of wear tests on anatomic shoulder replacements [30].

Classification

Post-Treatment Glenoid: This system addresses the surgical management of the glenoid during total shoulder arthroplasty, allowing for direct follow-up comparison of similarly treated glenoid replacements [24].

Glenoid Morphology Clustering: Patterns in glenoid defect types identified through clustering based on glenoid morphology highlight a need to further investigate a three-dimensional classification system [32].

Topographic PJI: A new perspective on prosthetic joint infection (PJI) classifications proposes introducing a topographic principle as a key factor affecting treatment strategy [43]. Identifying the exact location of bacterial colonization, such as the joint space versus the bone-prosthetic interface, guides this strategy [43]. Implant retention is potentially allowed where the bone-prosthetic interface is not invaded [43]. Radical intervention is necessitated where the bone-prosthetic interface is invaded [43].

Walch: The Walch classification has prognostic value for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff [71]. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses than the Walch classification [71].

Clinical Presentation

Joint arthroplasty provides dramatic relief of pain and maintenance of variable degrees of improved function [8]. Elective shoulder arthroplasty in patients 90 years of age and older provides excellent pain relief, improved functional outcome, and enhanced general health status [39]. Shoulder arthroplasty in patients 50 years old or less provides marked long-term relief of pain and improvement in motion, but nearly half of these young patients have an unsatisfactory result according to a rating system [40]. Early clinical and radiographic results for stemless shoulder arthroplasty are promising, but well-designed clinical studies and midterm results are lacking [15]. Two revisions were performed in the mid-term to long term for uncemented resurfacing shoulder hemiarthroplasty due to increased functional outcome scores and the absence of signs of loosening [16].

A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty [9]. Diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear [37]. Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty [35].

Prosthetic Joint Infection: The 2018 International Consensus Meeting criteria for prosthetic joint infection of the shoulder have strengthened validation, but many studies have not adopted them, affecting reported sensitivities and specificities [27]. Aseptic Loosening: Single-photon emission computed tomography/computed tomography has good clinical application value and should be a primary choice in the diagnosis of aseptic loosening after joint replacement [12]. Prosthesis loosening was not detected in the use of a cemented surface replacement prosthesis in the basal thumb joint [7]. Mechanical Complications: Dislocation of the polyethylene insert is a rare complication that should be included in the differential diagnosis for patients with sudden onset of mechanical symptoms, effusion, or unexplained pain after total knee arthroplasty [34]. Soft-Tissue Masses: Tumoral calcinosis complicating total joint replacement is rare and should be included in the differential diagnosis for a periprosthetic soft-tissue mass in the setting of chronic hemodialysis [36].

Investigations

A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty [9].

Plain radiography: Radiographic osteolysis after total shoulder arthroplasty may lead to clinically important complications such as aseptic loosening [108]. Xerograms can confirm the diagnosis of a prosthesis fracture and help localize the positions of fragments within the joint to facilitate surgical removal [99].

CT: Single-photon emission computed tomography/computed tomography has good clinical application value and should be a primary choice in the diagnosis of aseptic loosening after joint replacement [12].

Bone scan: Bone scan uptake after trapeziometacarpal joint arthroplasty progressively decreases over time, with normalization of tracer uptake expected between 14 and 25.5 months after surgery [106].

Treatment

Non-Operative

Non-operative treatments for post-dislocation shoulder osteoarthritis show similar osteoarthritis proportions at any point of follow-up compared to operative management [83]. For hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint, treatment options range from non-operative measures to surgical procedures including cheilectomy, arthroplasty, and arthrodesis [90]. Selection of treatment for hallux rigidus depends on disease stage and patient factors [90]. In rheumatoid arthritis, fully two-thirds of patients respond satisfactorily to non-surgical measures, though surgical treatment has an increasing role in the correction and prevention of deformities [97].

Operative

Indications: Joint replacement is indicated for pain relief and restoration of mobility [25]. Utilization of joint-preserving procedures for osteonecrosis of the humeral head is growing, notably in patients under 50 years of age [10]. For glenohumeral osteoarthritis with an intact rotator cuff, reverse arthroplasty can achieve highly favorable outcomes [14]. There is increasing interest in constrained or reverse total shoulder arthroplasty to treat cuff tear arthropathy, with promising early results [28]. Biologic resurfacing of the glenoid may have a minimal and undefined role in managing glenohumeral arthritis in young active patients compared to hemiarthroplasty or total shoulder arthroplasty [96]. Management of glenohumeral osteoarthritis remains controversial, and scientific evidence on this topic can be significantly improved [101]. Specific indications for the variety of glenoid implants available in anatomic total shoulder arthroplasty are still being studied [41].

Surgical Approach / Technique: Total shoulder arthroplasty using a stemless humeral component accurately reproduced native anatomy in the majority of cases with no implant loosening at 2 to 6 years' follow-up [68]. At 3 years of follow-up, a new stemless shoulder prosthesis showed radiologic evidence of maintained implant stability and good primary fixation [46]. Unicompartmental and bicompartmental arthroplasty of the knee with a finned metal tibial-plateau implant has a place in reconstructive surgery of the arthritic knee joint with proper indications [6]. Conversion of a fused knee to total knee arthroplasty resulted in good long-term fixation and high patient satisfaction [61]. Resection arthroplasty is effective in relieving pain after failed shoulder arthroplasty, but patients have poor postoperative function [76]. When a silastic radial-head prosthesis fractures, authors recommend removal of loose fragments and avoiding a second replacement attempt [51].

Implant Selection: In nearly 95% of knees for which total arthroplasty is indicated, a non-constrained cruciate-preserving prosthesis can provide adequate relief of pain, satisfactory axial alignment of the limb, and stability [103]. Prosthesis loosening was not detected in a cemented surface replacement prosthesis in the basal thumb joint [7]. A total of 13% of proximal interphalangeal joints treated with pyrocarbon implants required a secondary surgical procedure [29]. There is no evidence that one surgical approach for proximal interphalangeal joint arthroplasty is superior to another [26]. Additive manufacturing for metal applications in orthopaedic surgery offers improved biomechanical properties and fixation systems [44]. Additive manufacturing enables the use of implants in areas where current implants are not well suited [44].

Pain Management: Patients managed with a total joint regional anesthesia protocol emphasizing peripheral nerve blockade demonstrated better pain control, earlier walking ability, and earlier discharge from the hospital compared to historical controls [95]. Enhanced recovery after surgery protocols can be associated with decreased length of stay even in the absence of neuraxial anesthesia in some surgical settings [63]. Randomized, multicenter, prospective trials are needed regarding modern general anesthesia versus neuraxial anesthesia for primary total joint arthroplasty [63]. Collaborative guidelines between orthopaedics and rheumatology present a useful set of guidelines for perioperative medication management in rheumatic patient populations undergoing total hip or total knee arthroplasty [13].

Adjuncts: A novel process to reduce the cost of admission for treatment of infected shoulder arthroplasty has broad implications for managing periprosthetic joint replacement and reducing healthcare costs [5].

Setting of Care: Joint replacement is a successful and cost-effective procedure that decreases pain and restores mobility [25]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty [18].

Revision: Over 80% of revision shoulder replacements last 5 years [3]. Over 70% of revision shoulder replacements last 10 years [3].

Other Considerations: Final recommendations based on literature and expert consensus provide a resource for guiding decision-making for stakeholders in the clinical introduction of artificial joint arthroplasty devices [1]. Experts propose using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty [2]. Surgeons must examine existing literature on outcomes for different arthroplasty options to maximize clinical outcomes and revision-free implant survival [4]. Implant arthroplasty has been dramatically successful in terms of relief of pain and maintenance of variable degrees of improved function [8]. To make arthroplasty affordable globally, device manufacturers must design devices that are usable and affordable in emerging markets by addressing regional anatomic diversity and economic needs [11]. Device manufacturers should focus on simpler, novel solutions that prioritize affordability without sacrificing clinical success [11]. Patients with high preoperative pain scores undergoing proximal interphalangeal joint arthroplasty for osteoarthritis are at risk for postoperative pain reduction that will not be clinically relevant [93]. Improvements in pain, range of motion, and functionality can be achieved with shoulder replacement in humeral head avascular necrosis with a low risk of complications or need for additional procedures [98].

Complications

Infection (PJI): Periprosthetic joint infection (PJI) remains a formidable challenge, with incidence rates of 0.4% to 2% after primary total knee replacement [107]. Late deep wound infection secondary to hematogenous spread is an infrequent but devastating complication of total joint replacement [126]. Patients with multiple joint arthroplasties and a history of PJI are at higher risk for developing a second PJI, with metachronous rates ranging from 3% to 19% and synchronous rates from 1.3% to 6% [111]. Prior hip or knee prosthetic joint infection in another joint increases the risk three-fold of prosthetic joint infection after primary total knee arthroplasty [129]. The risk of PJI is 15-fold higher in patients on chronic antibiotic suppression [129]. Prior nonshoulder periprosthetic joint infection (PJI) of any joint increases rates of 90-day surgical site infection, sepsis, and hospital readmission, as well as 2-year all-cause revision after total shoulder arthroplasty [122].

Thromboembolism: The prevalence of venous thromboembolism (VTE) after total shoulder arthroplasty is low [123].

Other Considerations: Primary shoulder arthroplasty is associated with low 90-day reoperation and complication rates [127]. Over 80% of revision shoulder replacements last 5 years and over 70% last 10 years [3]. Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications [23]. Complication, reoperation, and revision rates for primary reverse total shoulder arthroplasty in patients younger than 65 years are similar to those seen in older patient cohorts, without an increase in revisions owing to aseptic loosening [112]. After 1 year, there is no increased risk of complications, revision, or inferior outcomes for reverse total shoulder arthroplasty in patients younger than 65 years compared to patients older than 65 years [133]. Patients 80 years and older have higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia, than patients younger than 80 years undergoing reverse total shoulder arthroplasty [132]. The overall rate of subsequent procedures for Ream-and-Run shoulder arthroplasty is 19%, and the rate of prosthetic revision is 12% at a mean of 10 years [117]. The calculated probability of polycentric total knee arthroplasty remaining successful ten years postoperatively is 66% [22]. Ninety-two percent of patients who had primary arthroplasty and 81% of those who had surgical revision had a good or excellent result using the kinematic stabilizer prosthesis [21]. Primary total elbow arthroplasty with the Nexel implant was associated with an unacceptably high rate of early implant loosening, periprosthetic fracture, and reoperation [113]. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty for pyrolytic carbon proximal interphalangeal joint arthroplasty [118]. The rate of early aseptic failure for an uncemented thumb carpometacarpal joint ceramic prosthesis was unacceptably high [128]. Clinical outcomes for surface replacement trapeziometacarpal joint prosthesis deteriorated clearly in case of loosening, while remaining excellent in the long-term for patients with a stable implant [124]. Cement-within-cement technique in revision reverse total shoulder arthroplasty is associated with higher rates of complications and re-revision surgery over time secondary to aseptic glenoid component loosening and instability [110]. Hemiarthroplasty and total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years have a similarly high complication rate [136]. There are no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in reverse shoulder arthroplasty for proximal humerus fractures [138]. Implant breakage incidence after shoulder arthroplasty is similar in clinical studies to data from worldwide arthroplasty registries [135].

Recovery

Light activity (weeks): Patients are interested in the timeline of recovery, ability to perform specific activities after surgery, and short-term and long-term restrictions following reverse total shoulder arthroplasty [119]. Total shoulder arthroplasty restores function in the shoulder with significant improvements in function [88]. Implant arthroplasty provides dramatic relief of pain [8] and maintains variable degrees of improved function [8]. Shoulder hemiarthroplasty provides sustained good-to-excellent pain relief and functional improvement at five to ten years postoperatively in carefully selected patients with osteoarthritis [139, 140].

Full activity (months): Higher return to work rates were seen in patients who were not on sick leave preoperatively after reverse total shoulder arthroplasty [75]. The literature reports that rates of return for total shoulder arthroplasty are slightly higher than those reported for reverse total shoulder arthroplasty and hemiarthroplasty [64]. Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prosthesis increases active elevation [130]. Early reported results suggest that average functional outcomes for reverse shoulder arthroplasty for proximal humeral fractures may be better than hemiarthroplasty in certain patients and specific clinical scenarios [116]. Functional results for reverse shoulder arthroplasty for proximal humeral fractures are reached more quickly than with hemiarthroplasty [116].

Complete recovery / outcome plateau (months): Recovery plateaus between 6 to 12 months after reverse shoulder arthroplasty [125]. Over 80% of revision shoulder replacements last 5 years [3]. Over 70% of revision shoulder replacements last 10 years [3]. Ninety-two percent of patients who had primary knee arthroplasty had a good or excellent result [21]. 81% of patients who had surgical revision of knee arthroplasty had a good or excellent result [21]. The calculated probability of polycentric total knee arthroplasty remaining successful ten years postoperatively was 66% [22]. Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival [23].

Rehabilitation protocol: Functional results for reverse shoulder arthroplasty for proximal humeral fractures have less dependence on rehabilitation than hemiarthroplasty [116]. Patients with a history of anterior shoulder instability undergoing total shoulder arthroplasty can expect continued improvement in function compared with preoperative values at mid-term follow-up [120]. Total shoulder arthroplasty performed after a coracoid transfer demonstrates similar results to total shoulder arthroplasty performed for primary osteoarthritis at early- to mid-term follow-up [69].

Functional milestones: B2 and B3 glenoid osteoarthritis treated with corrective and concentric reaming of the glenoid combined with pyrocarbon hemiarthroplasty shows high prosthesis survivorship at midterm follow-up [114]. Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prosthesis gives good relief of pain [130]. The overall results of revision using a reverse design prosthesis for unstable hemiarthroplasty are inferior to the outcome following the use of reverse arthroplasty in patients with cuff-tear arthropathy [130].

Other Considerations: Smoking increases the risk for revision, reoperation, and complications in patients undergoing primary reverse shoulder arthroplasty aged 65 years or younger [23]. Reverse total shoulder arthroplasty is associated with moderate complications [88]. Patient expectations for functional improvements after revision of failed reverse total shoulder arthroplasty with reverse should be tempered [74]. A high reoperation rate should be expected after revision of failed reverse total shoulder arthroplasty with reverse [74]. Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment [70].

Key Evidence

  • [L5] Final recommendations based on literature and expert consensus provide a first, useful resource for helping to guide decision-making for stakeholders in the clinical introduction of artificial joint arthroplasty devices. (10.1530/eor-23-0054)
  • [L5] The authors propose a World Expert Meeting to decipher evidence from eminence by having experts perform thorough literature reviews using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty. (10.1016/j.arth.2024.03.031)
  • [L1] Over 80% of revision replacements last 5 years and over 70% last 10 years. (10.1177/24715492221095991)
  • [L4] Surgeons must examine existing literature on outcomes for different arthroplasty options to maximize clinical outcomes and revision-free implant survival. (10.1016/j.csm.2018.05.008)
  • [L3] This has broad implications across orthopedics for the management of periprosthetic joint replacement and potential for tremendous impact of reducing healthcare costs. (10.1016/j.jse.2025.02.028)
  • [L4] The results suggest that with the proper indications this arthroplasty has a place in reconstructive surgery of the arthritic knee joint. (10.2106/00004623-198567080-00005)
  • [L4] Prosthesis loosening was not detected. (10.1016/j.jhsa.2009.12.026)
  • [L5] A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty. (10.1016/j.arth.2022.01.063)
  • [L4] These procedures continue to be predominantly shoulder arthroplasty; however, the utilization of joint preserving procedures seem to be growing over time, notably in patients <50 years of age. (10.1016/j.jse.2024.12.009)
  • [L5] To make arthroplasty affordable globally, device manufacturers must design devices that are usable and affordable in emerging markets by addressing regional anatomic diversity and economic needs, focusing on simpler, novel solutions that prioritize affordability without sacrificing clinical success. (10.5435/jaaos-d-15-00350)
  • [L1] It has good clinical application value and should be a primary choice in the diagnosis of AL after joint replacement. (10.1016/j.arth.2021.06.018)
  • [L5] This timely collaborative effort between experts in orthopaedics and rheumatology presents an extremely useful set of guidelines for perioperative medication management in rheumatic patient populations undergoing TKAs or THAs. (10.1016/j.arth.2017.07.022)
  • [L4] The findings suggest that reverse arthroplasty can achieve highly favorable outcomes for this indication. (10.1016/j.jse.2021.06.010)
  • [L4] Early clinical and radiographic results for stemless shoulder arthroplasty are promising, but well-designed clinical studies and midterm results are lacking. (10.1016/j.jse.2014.05.005)
  • [L4] Two revisions have been performed in the mid-term to long term because of increased functional outcome scores and the absence of signs of loosening. (10.1016/j.jse.2021.08.021)
  • [L3] Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty. (10.1016/j.jse.2025.02.055)
  • [L4] Total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients. (10.1016/j.arth.2013.03.029)
  • [L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. (10.1016/j.jhsa.2010.04.005)
  • [L4] Ninety-two per cent of the patients who had had primary arthroplasty and 81 per cent of those who had had surgical revision had a good or excellent result. (10.2106/00004623-198870040-00003)
  • [L3] The calculated probability of the arthroplasty remaining successful ten years postoperatively was 66 per cent. (10.2106/00004623-198466080-00008)
  • [L3] Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications. (10.1016/j.jse.2016.05.026)
  • [L5] The proposed classification system addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements. (10.1016/j.jse.2011.01.035)
  • [L5] This article is an editorial introducing a Special Issue of the Journal of Orthopaedic Research entitled 'Recent Advances in Total Joint Replacement.' It highlights that joint replacement is a successful and cost-effective procedure that decreases pain and restores mobility. (10.1002/jor.24734)
  • [L5] There is no evidence that one surgical approach for proximal interphalangeal joint arthroplasty is superior to another. (10.1302/0301-620x.104b12.bjj-2022-0946)
  • [L4] The article reviews current approaches to diagnosing and treating prosthetic joint infection of the shoulder, noting that while the 2018 International Consensus Meeting criteria have strengthened validation, many studies have not adopted them, affecting reported sensitivities and specificities. (10.5435/jaaos-d-24-00720)
  • [L5] There is increasing interest in the use of a constrained or reverse total shoulder arthroplasty to treat this complex process, with promising early results. (10.1016/j.jse.2008.11.003)
  • [L4] A total of 13% of the joints required a secondary surgical procedure. (10.1016/j.jhsa.2009.08.010)
  • [L5] The results obtained indicate that additional combined kinematics are an indispensable part of wear tests on anatomic shoulder replacements. (10.1016/j.jse.2018.02.063)
  • [L4] The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs. (10.1016/j.jse.2026.04.002)
  • [L4] Biomechanical evidence suggests that an elliptical implant yields glenohumeral kinematics that mimic the native joint, and early clinical results are promising. (10.5435/jaaos-d-22-01084)
  • [L4] Dislocation of the polyethylene insert is a rare complication that should be included in the differential diagnosis for patients with sudden onset of mechanical symptoms, effusion, or unexplained pain after total knee arthroplasty. (10.1016/j.arth.2009.11.014)
  • [L5] Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty. (10.5435/jaaos-20-09-604)
  • [Case_report] TC complicating total joint replacement is rare and should be included in the differential diagnosis for a periprosthetic soft-tissue mass in the setting of chronic hemodialysis. (10.1016/j.xrrt.2021.09.005)
  • [L4] Diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear. (10.1016/j.jse.2007.02.131)
  • [L4] Elective shoulder arthroplasty can be performed in patients 90 years of age and older, providing excellent pain relief, improved functional outcome, and enhanced general health status. (10.1016/j.jse.2007.09.005)
  • [L3] Shoulder arthroplasty provides marked long-term relief of pain and improvement in motion; however, nearly half of all young patients who have a shoulder arthroplasty have an unsatisfactory result according to a rating system. (10.2106/00004623-199804000-00002)
  • [L5] Specific indications for the variety of glenoid implants available today are still being studied. (10.5435/jaaos-d-23-00257)
  • [L5] Malpositioning of both the humeral and glenoid components will adversely affect the range of motion, kinematics, and stability of the shoulder. (10.1016/j.jse.2004.09.026)
  • [L5] The authors propose introducing a topographic principle into PJI classification, suggesting that identifying the exact location of bacterial colonization (e.g., joint space vs. bone-prosthetic interface) can guide treatment strategy, potentially allowing implant retention in cases where the interface is not invaded and necessitating radical intervention otherwise. (10.1007/s00402-018-3058-y)
  • [L5] This technology offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited. (10.5435/jaaos-d-19-00420)
  • [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)
  • [Case_report] When a prosthesis fractures, the authors recommend removal of loose fragments and avoiding a second replacement attempt. (10.2106/00004623-198163030-00022)
  • [L5] Reverse shoulder arthroplasty is a useful tool for treating older patients with B2 glenoid deformities, offering favorable biomechanics and proven success. (10.1177/2471549219897661)
  • [L4] Assessment of the patient and biomechanical and surgical factors is critical in determining the best course of treatment for instability in reverse total shoulder arthroplasty. (10.5435/jaaos-d-16-00408)
  • [L4] The procedure largely preserves elbow kinematics and stability. (10.1016/j.jse.2014.01.042)
  • [L3] Age 70 years or older does not appear to be a contraindication to stemless anatomic total shoulder arthroplasty, as postoperative improvements in patient-determined outcome scores and range of motion were similar between patients aged <70 years and those aged 70 years or older. (10.1016/j.jse.2022.08.003)
  • [L3] Shoulder arthroplasty after undergoing prior shoulder surgery results in overall clinically improved outcomes, however these results are inferior compared to patients without a history of prior shoulder surgery. (10.1177/2325967115s00168)
  • [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)
  • [L4] Conversion of a fused knee to total knee arthroplasty resulted in good long-term fixation and high patient satisfaction. (10.2106/jbjs.25.00149)
  • [L5] The authors endorse the need for randomized, multicenter, prospective trials regarding modern general anesthesia vs neuraxial anesthesia for primary total joint arthroplasty and state that enhanced recovery after surgery protocols can be associated with decreased length of stay even in the absence of neuraxial anesthesia in some surgical settings. (10.1016/j.arth.2020.01.059)
  • [L4] The literature reports that rates of return for total shoulder arthroplasty are slightly higher than those reported for reverse total shoulder arthroplasty and hemiarthroplasty. (10.1016/j.csm.2018.06.002)
  • [L1] AD is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty. (10.1016/j.arthro.2014.11.012)
  • [L5] Most reverse prostheses impingements reported in clinical and biomechanical studies can be avoided, either by scapular compensation or by a glenosphere lateralization. (10.1016/j.jse.2012.09.014)
  • [L4] In vivo, glenohumeral joint contact after total shoulder arthroplasty is not centered on the glenoid surface, suggesting that kinematics after shoulder arthroplasty may not be governed by ball-in-socket mechanics as traditionally thought. (10.2106/jbjs.h.01610)
  • [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)
  • [L3] At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. (10.1016/j.jse.2019.12.009)
  • [L4] Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment. (10.1016/j.jse.2006.10.016)
  • [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. (10.1016/j.jse.2023.08.029)
  • [L5] However, the spherical head shape does not show significant glenohumeral translation during humeral axial rotation, regardless of glenoid conformity. (10.1016/j.jse.2015.11.058)
  • [L4] However, patient expectations for functional improvements should be tempered, and a high reoperation rate should be expected. (10.1016/j.jse.2023.07.030)
  • [L3] Higher return to work rates were seen in patients who were not on sick leave preoperatively. (10.1302/0301-620x.107b9.bjj-2024-1587.r2)
  • [L4] Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. (10.1016/j.jse.2012.05.025)
  • [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)
  • [L5] This study showed a small but significant alteration in elbow joint kinematics with placement of a distal humeral hemiarthroplasty implant, regardless of implant size. (10.1016/j.jse.2014.02.011)
  • [L5] In a biomechanical model, optimal glenohumeral mismatch in cemented pegged glenoid implants is multifactorial and has not been definitively established. (10.1016/j.jse.2014.10.004)
  • [L1] Non-operative and operative treatments show similar OA proportions at any point of follow-up. (10.1007/s00167-020-06263-3)
  • [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. (10.1177/1758573220977184)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L4] Patients with high preoperative pain scores are at risk for postoperative pain reduction that will not be clinically relevant. (10.1016/j.jhsa.2022.03.026)
  • [L3] Patients managed with the Total Joint Regional Anesthesia protocol demonstrated better pain control, earlier walking ability, and earlier discharge from the hospital compared to historical controls. (10.2106/jbjs.e.00491)
  • [L4] Our results suggest that biologic resurfacing of the glenoid may have a minimal and as yet undefined role in the management of glenohumeral arthritis in the young active patient over more traditional methods of hemiarthroplasty or total shoulder arthroplasty. (10.1016/j.jse.2013.06.001)
  • [L5] Surgical treatment seems destined to have an increasing role in the correction and prevention of deformities caused by rheumatoid arthritis, with fully two-thirds of patients responding satisfactorily to non-surgical measures. (10.2106/00004623-196850030-00019)
  • [L3] Improvements in pain, ROM, and functionality can be achieved with low risk of complications or need for additional procedures. (10.1016/j.jse.2018.06.031)
  • [L1] Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved. (10.5435/00124635-201006000-00010)
  • [L4] Based on the findings in this study, in nearly 95 per cent of knees for which total arthroplasty is indicated a non-constrained cruciate-preserving prosthesis can provide adequate relief of pain, satisfactory axial alignment of the limb, and stability. (10.2106/00004623-198365070-00005)
  • [L4] Bone scan uptake after trapeziometacarpal joint arthroplasty progressively decreases over time, with normalization of tracer uptake expected between 14 and 25.5 months after surgery. (10.1177/17531934251345359)
  • [L5] Radiographic osteolysis after total shoulder arthroplasty may lead to clinically important complications such as aseptic loosening. (10.5397/cise.2021.00738)
  • [L4] Although a low rate of humeral component loosening was observed, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability. (10.1016/j.xrrt.2024.08.006)
  • [L4] Patients with multiple joint arthroplasties and a history of PJI are at higher risk for developing a second PJI, with metachronous rates ranging from 3% to 19% and synchronous rates from 1.3% to 6%. (10.5435/jaaos-d-23-00120)
  • [L4] Complication, reoperation, and revision rates were similar to those seen in older patient cohorts, without an increase in revisions owing to aseptic loosening. (10.1016/j.jse.2020.02.004)
  • [L4] Primary TEA with implantation of this implant was associated with an unacceptably high rate of early implant loosening, periprosthetic fracture, and reoperation. (10.1016/j.jseint.2022.04.001)
  • [L4] The study reports functional outcomes and high prosthesis survivorship at midterm follow-up. (10.1016/j.jse.2024.06.028)
  • [L5] Early reported results suggest that the average functional outcome may be better than hemiarthroplasty in certain patients and specific clinical scenarios, with results reached more quickly and with less dependence on rehabilitation. (10.1016/j.jse.2013.10.003)
  • [L3] The overall rate of subsequent procedures was 19%, and the rate of prosthetic revision was 12% at a mean of 10 years. (10.2106/jbjs.17.00201)
  • [L4] Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. (10.1016/j.jhsa.2006.10.017)
  • [L4] Patients are interested in the timeline of recovery, ability to perform specific activities after surgery, and short-term and long-term restrictions following rTSA. (10.1016/j.xrrt.2024.09.005)
  • [L3] At mid-term follow-up, patients with a history of anterior shoulder instability undergoing total shoulder arthroplasty can expect continued improvement in function compared with preoperative values. (10.1016/j.jse.2023.07.005)
  • [L3] Prior nonshoulder PJI of any joint increases rates of 90-day surgical site infection, sepsis, and hospital readmission, as well as 2-year all-cause revision after TSA. (10.5435/jaaos-d-21-00745)
  • [L3] The prevalence of VTE after TSA is low. (10.5435/jaaos-d-22-00352)
  • [L4] However, clinical outcomes improved significantly in the short-term and remained excellent in the long-term in those patients with a stable implant, but deteriorated clearly in case of loosening. (10.1186/s12891-021-03957-8)
  • [L5] It highlights that recovery plateaus between 6 to 12 months and emphasizes the need for future prospective studies to control for preoperative status and validate outcome measures across genders. (10.1097/01.blo.0000533613.25243.1c)
  • [L4] Late deep wound infection secondary to hematogenous spread is an infrequent but devastating complication of total joint replacement. (10.2106/00004623-198062080-00015)
  • [L4] Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. (10.1016/j.jse.2019.12.008)
  • [L4] The rate of early aseptic failure was unacceptably high. (10.1177/1753193416688427)
  • [L3] The risk of PJI was 15-fold higher in patients on chronic antibiotic suppression. (10.1302/0301-620x.101b7.bjj-2018-1189.r1)
  • [L4] The successful restoration of stability gives good relief of pain and increases active elevation, although the overall results are inferior to the outcome following the use of reverse arthroplasty in patients with cuff-tear arthropathy. (10.1302/0301-620x.95b5.30964)
  • [L3] Patients 80 years and older had higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia than patients <80 years of age. (10.1016/j.jse.2022.01.146)
  • [L3] After 1 year, we found no increased risk of complications, revision, or inferior outcomes compared to patients older than 65 years of age. (10.1186/s42836-021-00086-4)
  • [L2] Clinical studies revealed a similar incidence of implant failure compared to data of worldwide arthroplasty registries. (10.1186/s12891-023-06922-9)
  • [L1] This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. (10.1302/0301-620x.104b5.bjj-2021-1207.r2)
  • [L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
  • [L4] Shoulder hemiarthroplasty provides sustained good-to-excellent pain relief and functional improvement at five to ten years postoperatively in carefully selected patients with osteoarthritis. (10.2106/jbjs.f.00980)

See Also

References

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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.