Revision Total Shoulder Arthroplasty: Epidemiology and Causes

  • Eloy Tabeayo
  • Konrad I. Gruson
  • James M. SaucedoEmail author


Total shoulder arthroplasty has gained remarkable popularity in the last few decades. Critical review of outcomes and large registries in different countries have led to newer designs and expanding indications, which have resulted in rapid growth around the world. Despite numerous advances in surgical techniques and implant designs, however, complications still occur, and with an active aging population and increasing popularity among upper extremity surgeons, we can expect those complications to increase both in volume and complexity. Recognition and timely diagnosis of adverse outcomes can help surgeons not only correct and salvage a poor outcome but understanding what leads to common complications may also help us to anticipate and avoid them altogether. Infection, component loosening, periprosthetic fracture, and instability are the major reasons for revision surgery. Though the diagnosis may be difficult, as many signs and symptoms may be subtle and nonspecific, a careful history and physical examination, critical review of radiographs, and a healthy level of suspicion may offer clues and guide the surgeon toward advanced imaging, laboratory studies, and other diagnostic measures. This chapter aims to provide the reader with the tools to successfully identify those patients who may need further surgical treatment in the setting of a total shoulder arthroplasty as well as to help avoid common pitfalls implicated in certain complications.


Total shoulder arthroplasty Reverse shoulder arthroplasty Infection Periprosthetic Fracture Instability Loosening Radiolucency Cutibacterium acnes 


  1. 1.
    Flatow EL, Harrison AK. A history of reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2011;469:2432–9.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Neer CS II. Articular replacement for the humeral head. J Bone Joint Surg Am. 1955;37-A:215–28.PubMedCrossRefGoogle Scholar
  3. 3.
    Neer CS. Replacement arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 1974;56-A:1–13.CrossRefGoogle Scholar
  4. 4.
    Australian Orthopaedic Association National Joint Replacement Registry. Hip, knee & shoulder arthroplasty. Annual reports. Adelaide, SA: AOANJRR; 2018.Google Scholar
  5. 5.
    Lübbeke A, Rees JL, Barea C, Combescure C, Carr AJ, Silman AJ. International variation in shoulder arthroplasty: incidence, indication, type of procedure, and outcomes evaluation in 9 countries. Acta Orthop. 2017;88:592–9.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    NJR. 15th Annual report 2018. Hemel Hempstead: NJR; 2018. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.Google Scholar
  7. 7.
    Bergen H. Norwegian National Advisory Unit on Arthroplasty and Hip Fractures Norwegian Arthroplasty Register Norwegian Cruciate Ligament Register Norwegian Hip Fracture Register Norwegian Paediatric Hip Register. Trondheim: Norwegian National Advisory Unit; 2018.Google Scholar
  8. 8.
    Lehtimäki K, Rasmussen JV, Mokka J, Salomonsson B, Hole R, Jensen SL, Äärimaa V. Risk and risk factors for revision after primary reverse shoulder arthroplasty for cuff tear arthropathy and osteoarthritis: a Nordic Arthroplasty Register Association study. J Shoulder Elbow Surg. 2018;27:1596–601.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Somerson JS, Hsu JE, Neradilek MB, Matsen FA. Analysis of 4063 complications of shoulder arthroplasty reported to the US Food and Drug Administration from 2012 to 2016. J Shoulder Elbow Surg. 2018;27:1978–86.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Gonzalez J-F, Alami GB, Baque F, Walch G, Boileau P. Complications of unconstrained shoulder prostheses. J Shoulder Elbow Surg. 2011;20:666–82.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88-A:2279–92.Google Scholar
  12. 12.
    Richards J, Inacio MCS, Beckett M, Navarro RA, Singh A, Dillon MT, Sodl JF, Yian EH. Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty. Clin Orthop Relat Res. 2014;472:2809–15.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Gerber C, Pennington SD, Nyffeler RW. Reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2009;17:284–95.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Werner CML, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87:1476–86.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20:146–57.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Walch G, Bacle G, Lädermann A, Nové-Josserand L, Smithers CJ. Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon’s experience? J Shoulder Elbow Surg. 2012;21:1470–7.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006;14:544–51.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Luessenhop CP, Higgins LD, Brause BD, Ranawat CS. Multiple prosthetic infections after total joint arthroplasty: risk factor analysis. J Arthroplasty. 1996;11:862–8.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Bala A, Penrose CT, Visgauss JD, Seyler TM, Randell TR, Bolognesi MP, Garrigues GE. Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elbow Surg. 2016;25:1971–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Hatta T, Werthel JD, Wagner ER, Itoi E, Steinmann SP, Cofield RH, Sperling JW. Effect of smoking on complications following primary shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26:1–6.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Everhart JS, Bishop JY, Barlow JD. Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26:1922–30.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Werthel JD, Hatta T, Schoch B, Cofield R, Sperling JW, Elhassan BT. Is previous nonarthroplasty surgery a risk factor for periprosthetic infection in primary shoulder arthroplasty? J Shoulder Elbow Surg. 2017;26:635–40.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Torrens C, Marí R, Alier A, Puig L, Santana F, Corvec S. Cutibacterium acnes in primary reverse shoulder arthroplasty: from skin to deep layers. J Shoulder Elbow Surg. 2019;28:839–46.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012;94:2075–83.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Peri-prosthetic infections after shoulder hemiarthroplasty. J Shoulder Elbow Surg. 2012;21:1304–9.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Weber P, Utzschneider S, Sadoghi P, Andress HJ, Jansson V, Müller PE. Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature. Int Orthop. 2011;35:365–73.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Topolski MS, Chin PYK, Sperling JW, Cofield RH. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg. 2006;15:402–6.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Alesi D, Roberti di Sarsina T, Zaffagnini S, Marcheggiani Muccioli G, Lullini G, Rotini R, Cammisa E, Fratini S, Rinaldi V, Guerra E. Diagnosis and treatment of infected shoulder arthroplasty: current concepts review. Joints. 2018;6:173–6.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Fink B, Sevelda F. Periprosthetic joint infection of shoulder arthroplasties: diagnostic and treatment options. Biomed Res Int. 2017;2017:1–10.CrossRefGoogle Scholar
  30. 30.
    Gómez-Ochoa SA, Espín-Chico BB, García-Rueda NA, Vega-Vera A, Osma-Rueda JL. Risk of surgical site infection in patients with asymptomatic bacteriuria or abnormal urinalysis before joint arthroplasty: systematic review and meta-analysis. Surg Infect (Larchmt). 2019;20:159–66.CrossRefGoogle Scholar
  31. 31.
    McElvany MD, Chan PH, Prentice HA, Paxton EW, Dillon MT, Navarro RA. Diabetes disease severity was not associated with risk of deep infection or revision after shoulder arthroplasty. Clin Orthop Relat Res. 2019;477:1358. Scholar
  32. 32.
    Wagner ER, Houdek MT, Schleck C, Harmsen WS, Sanchez-Sotelo J, Cofield R, Sperling JW, Elhassan BT. Increasing body mass index is associated with worse outcomes after shoulder arthroplasty. J Bone Joint Surg Am. 2017;99:929–37.PubMedCrossRefGoogle Scholar
  33. 33.
    Bohsali KI, Bois AJ, Wirth MA. Complications of shoulder arthroplasty. J Bone Joint Surg Am. 2017;99:256–69.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Sanchez-Sotelo J, Sperling JW, Rowland CM, Cofield RH. Instability after shoulder arthroplasty: results of surgical treatment. J Bone Joint Surg Am. 2003;85:622–31.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Moeckel B, Altchek DW, Warren RF, Wickiewicz TL, Dines DM. Instability of the shoulder after arthroplasty. J Bone Joint Surg Am. 1993;75:492–7.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Wirth MA, Rockwood CA. Current concepts review - complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am. 2016;78:603–16.CrossRefGoogle Scholar
  37. 37.
    Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ. Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome. J Shoulder Elbow Surg. 2005;14:492–6.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Jackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19:1085–90.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Van den Berghe GR, Nguyen B, Patil S, D’Lima DD, Mahar A, Pedowitz R, Hoenecke HR. A biomechanical evaluation of three surgical techniques for subscapularis repair. J Shoulder Elbow Surg. 2008;17:156–61.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJP, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am. 2005;87:1–8.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009;18:193–6.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Warren RF, Coleman SH, Dines JS. Instability after arthroplasty: the shoulder. J Arthroplasty. 2002;17:28–31.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Pearl ML, Volk AG. Retroversion of the proximal humerus in relationship to prosthetic replacement arthroplasty. J Shoulder Elbow Surg. 1995;4:286–9.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Young AA, Walch G, Pape G, Gohlke F, Favard L. Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am. 2012;94:685–93.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Haines JF, Trail IA, Nuttall D, Birch A, Barrow A. The results of arthroplasty in osteoarthritis of the shoulder. J Bone Joint Surg Br. 2006;88-B:496–501.CrossRefGoogle Scholar
  46. 46.
    Trappey GJ, O’Connor DP, Edwards TB. What are the instability and infection rates after reverse shoulder arthroplasty? Clin Orthop Relat Res. 2011;469:2505–11.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Boileau P. Complications and revision of reverse total shoulder arthroplasty. Orthop Traumatol Surg Res. 2016;102:S33–43.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Abdelfattah A, Otto RJ, Simon P, Christmas KN, Tanner G, LaMartina J, Levy JC, Cuff DJ, Mighell MA, Frankle MA. Classification of instability after reverse shoulder arthroplasty guides surgical management and outcomes. J Shoulder Elbow Surg. 2018;27:e107–18.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev. 2016;1:72–80.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Matthewson G, Kooner S, Kwapisz A, Leiter J, Old J, MacDonald P. The effect of subscapularis repair on dislocation rates in reverse shoulder arthroplasty: a meta-analysis and systematic review. J Shoulder Elbow Surg. 2019;28:989–97.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Mole D, Favard L. Excentered scapulohumeral osteoarthritis [article in French]. Rev Chir Orthop Reparatrice Appar Mot. 2007;93:37–94.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Clark JC, Ritchie J, Song FS, Kissenberth MJ, Tolan SJ, Hart ND, Hawkins RJ. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21:36–41.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Lazarus MD, Jensen KL, Southworth C, Matsen FA 3rd. The radiographic evaluation of keeled and pegged glenoid component insertion. J Bone Joint Surg Am. 2002;84:1174–82.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Hsu JE, Hackett DJJ, Vo KV, Matsen FA 3rd. What can be learned from an analysis of 215 glenoid component failures? J Shoulder Elbow Surg. 2018;27:478–86.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Franklin JL, Barrett WP, Jackins SE, Matsen FA. Glenoid loosening in total shoulder arthroplasty. J Arthroplasty. 1988;3:39–46.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Kocsis G, Payne CJ, Wallace A, McNally D. Wear analysis of explanted conventional metal back polyethylene glenoid liners. Med Eng Phys. 2018;59:1–7.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty. J Bone Joint Surg Am. 2013;95:2205–12.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Walch G, Moraga C, Young A, Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid. J Shoulder Elbow Surg. 2012;21:1526–33.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Sperling JW, Cofield RH, O’Driscoll SW, Torchia ME, Rowland CM. Radiographic assessment of ingrowth total shoulder arthroplasty. J Shoulder Elbow Surg. 2000;9:507–13.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Sanchez-Sotelo J, O’Driscoll SW, Torchia ME, Cofield RH, Rowland CM. Radiographic assessment of cemented humeral components in shoulder arthroplasty. J Shoulder Elbow Surg. 2001;10:526–31.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Gilot G, Alvarez-Pinzon AM, Wright TW, Flurin PH, Krill M, Routman HD, Zuckerman JD. The incidence of radiographic aseptic loosening of the humeral component in reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24:1555–9.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Cuff D, Levy JC, Gutiérrez S, Frankle MA. Torsional stability of modular and non-modular reverse shoulder humeral components in a proximal humeral bone loss model. J Shoulder Elbow Surg. 2011;20:646–51.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Boileau P, Melis B, Duperron D, Moineau G, Rumian AP, Han Y. Revision surgery of reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22:1359–70.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Lévigne C, Boileau P, Favard L, Garaud P, Molé D, Sirveaux F, Walch G. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17:925–35.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Vanhove B, Beugnies A. Grammont’s reverse shoulder prosthesis for rotator cuff arthropathy. A retrospective study of 32 cases. Acta Orthop Belg. 2004;70:219–25.PubMedPubMedCentralGoogle Scholar
  66. 66.
    Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89:1476–85.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Melis B, DeFranco M, Lädermann A, Molé D, Favard L, Nérot C, Maynou C, Walch G. An evaluation of the radiological changes around the Grammont reverse geometry shoulder arthroplasty after eight to 12 years. J Bone Joint Surg Br. 2011;93-B:1240–6.CrossRefGoogle Scholar
  68. 68.
    Cusick MC, Hussey MM, Steen BM, Hartzler RU, Clark RE, Cuff DJ, Cabezas AF, Santoni BG, Frankle MA. Glenosphere dissociation after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24:1061–8.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Wagner ER, Houdek MT, Elhassan BT, Sanchez-Sotelo J, Cofield RH. Sperling JW (2015) What are risk factors for intraoperative humerus fractures during revision reverse shoulder arthroplasty and do they influence outcomes? Clin Orthop Relat Res. 2015;473:3228–34.PubMedPubMedCentralCrossRefGoogle Scholar
  70. 70.
    Campbell JT, Moore RS, Iannotti JP, Norris TR, Williams GR. Periprosthetic humeral fractures: mechanisms of fracture and treatment options. J Shoulder Elbow Surg. 1998;7:406–13.PubMedCrossRefGoogle Scholar
  71. 71.
    García-Fernández C, Lópiz-Morales Y, Rodríguez A, López-Durán L, Martínez FM. Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management. Int Orthop. 2015;39:1965–9.PubMedCrossRefGoogle Scholar
  72. 72.
    Williams GRJ, Iannotti JP. Management of periprosthetic fractures: the shoulder. J Arthroplasty. 2002;17:14–6.PubMedCrossRefGoogle Scholar
  73. 73.
    Wright TW, Cofield RH. Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am. 1995;77:1340–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Eloy Tabeayo
    • 1
  • Konrad I. Gruson
    • 1
  • James M. Saucedo
    • 2
    Email author
  1. 1.Department of Orthopedic SurgeryMontefiore HospitalThe BronxUSA
  2. 2.Houston Methodist Orthopedics and Sports Medicine in HoustonHoustonUSA

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