*Article* **Inverted-Bearing Reverse Shoulder Arthroplasty: Consequences on Scapular Notching and Clinical Results at Mid-Term Follow-Up**

**Alessandro Castagna 1,2, Mario Borroni 2, Luigi Dubini 1, Stefano Gumina 3,4, Giacomo Delle Rose 2 and Riccardo Ranieri 1,\***


**Abstract:** Background: Scapular notching following reverse shoulder arthroplasty (RSA) is caused by both biological and mechanical mechanisms. Some authors postulated that osteolysis that extends over the inferior screw is caused mainly by biological notching. Inverted-bearing RSA (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner, decreasing the poly debris formation and potentially reducing high grades of notching. This study aims to report the results of IB-RSA on a consecutive series of patients at mid-term follow-up, focusing on the incidence of Sirveaux grade 3 and 4 scapular notching. Methods: A retrospective study on 78 consecutive patients who underwent primary IB-RSA between 2015–2017 was performed. At a 4 years minimum follow-up, 49 patients were evaluated clinically with Constant score (CS), Subjective shoulder value (SSV), American Shoulder and Elbow score (ASES), pain and range of motion, and with an X-ray assessing baseplate position (high, low), implant loosening, and scapular notching. Results: At a mean follow-up of 5.0 ± 0.9, all the clinical parameters improved (*p* < 0.05). One patient was revised for an infection and was excluded from the evaluation, two patients had an acromial fracture, and one had an axillary neuropraxia. Scapular notching was present in 13 (27%) patients (six grade 1, seven grade 2) and no cases of grade 3 and 4 were observed. Scapular nothing was significantly associated with high glenoid position (*p* < 0.001) and with lower CS (70 ± 15 vs. 58 ± 20; *p* = 0.046), SSV (81 ± 14 vs. 68 ± 20; *p* = 0.027), ASES (86 ± 14 vs. 70 ± 22; *p* = 0.031), and anterior elevation (148 ± 23 vs. 115 ± 37; *p* = 0.006). A 44 mm- compared to 40 mm-glenosphere was associate with better CS (63 ± 17 vs. 78 ± 11; *p* = 0.006), external (23 ± 17 vs. 36 ± 17; *p* = 0.036), and internal rotation (4.8 ± 2.7 vs. 7.8 ± 2.2; *p* = 0.011). Conclusions: IB-RSA is a safe and effective procedure for mid-term follow-up. Inverting biomaterials leads to a distinct kind of notching with mainly mechanical features. Scapular notching is associated with a high baseplate position and has a negative influence on range of motion and clinical outcome.

**Keywords:** reverse shoulder arthroplasty; cuff tear arthropathy; polyethylene; scapular notching; range of motion; larger glenosphere
