Revision Total Shoulder Arthroplasty: Surgical Technique

  • Raul Barco
  • Alfonso Vaquero-Picado
  • Samuel Antuña


As shoulder arthroplasty is increasing, the expected amount of revisions is expected to increase accordingly. Revision shoulder arthroplasty is a complex procedure that requires precise planning and adequate strategy for effective treatment. The cause of revision in itself is essential as it may dictate the strategy of the procedure. Many aspects including patient expectations, prior procedures, physical examination and imaging, and laboratory findings will influence some of the decisions. The index arthroplasty may have become stiff, unstable, or loose, and the looming presence of infection can condition the procedure. Precise and careful handling of the soft tissues right from the skin incision is necessary in revision cases. While platform systems have facilitated revision, in many cases the humeral stem has to be revised, sometimes with the need of osteotomies. Bone loss may be augmented by strut grafting, impaction grafting, or allograft-prosthetic composite grafting. However, it is glenoid loosening the main problem after anatomic total shoulder arthroplasty, which can be revised to an anatomical implant or more typically to a reverse shoulder configuration. Glenoid bone loss can be peripheral or central, contained, or uncontained and this will guide decision-making regarding the reconstructive procedure.


Revision Total shoulder Arthroplasty Loosening Glenoid bone loss 


  1. 1.
    Wagner ER, Chang MJ, Welp KM, Solberg MJ, Hunt TJ, Woodmass JM, et al. The impact of the reverse prosthesis on revision shoulder arthroplasty: analysis of a high-volume shoulder practice. J Shoulder Elbow Surg. 2019;28(2):e49–56.CrossRefGoogle Scholar
  2. 2.
    Walch G, Bacle G, Ladermann A, Nove-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(11):1470–7.CrossRefGoogle Scholar
  3. 3.
    Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev. 2016;1(3):72–80.CrossRefGoogle Scholar
  4. 4.
    Foruria AM, Oh LS, Sperling JW, Cofield RH. Anteromedial approach for shoulder arthroplasty: current indications, complications, and results. J Shoulder Elbow Surg. 2010;19(5):734–8.CrossRefGoogle Scholar
  5. 5.
    Antuna SA, Sperling JW, Cofield RH, Rowland CM. Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg. 2001;10(3):217–24.CrossRefGoogle Scholar
  6. 6.
    Wagner E, Houdek MT, Griffith T, Elhassan BT, Sanchez-Sotelo J, Sperling JW, et al. Glenoid bone-grafting in revision to a reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2015;97(20):1653–60.CrossRefGoogle Scholar
  7. 7.
    Norris TR. Glenoid bone loss in reverse shoulder arthroplasty treated with bone graft techniques. Am J Orthop. 2018;47:3.CrossRefGoogle Scholar
  8. 8.
    Cil A, Veillette CJ, Sanchez-Sotelo J, Sperling JW, Schleck C, Cofield RH. Revision of the humeral component for aseptic loosening in arthroplasty of the shoulder. J Bone Joint Surg. 2009;91(1):75–81.CrossRefGoogle Scholar
  9. 9.
    Sahota S, Sperling JW, Cofield RH. Humeral windows and longitudinal splits for component removal in revision shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(10):1485–91.CrossRefGoogle Scholar
  10. 10.
    Sperling JW, Cofield RH. Humeral windows in revision shoulder arthroplasty. J Shoulder Elbow Surg. 2005;14(3):258–63.CrossRefGoogle Scholar
  11. 11.
    Wagner ER, Houdek MT, Hernandez NM, Cofield RH, Sanchez-Sotelo J, Sperling JW. Cement-within-cement technique in revision reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(8):1448–53.CrossRefGoogle Scholar
  12. 12.
    Budge MD, Moravek JE, Zimel MN, Nolan EM, Wiater JM. Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary? J Shoulder Elbow Surg. 2013;22(6):739–44.CrossRefGoogle Scholar
  13. 13.
    Stephens SP, Paisley KC, Giveans MR, Wirth MA. The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):1519–26.CrossRefGoogle Scholar
  14. 14.
    Abdeen A, Hoang BH, Athanasian EA, Morris CD, Boland PJ, Healey JH. Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am. 2009;91(10):2406–15.CrossRefGoogle Scholar
  15. 15.
    Cox JL, McLendon PB, Christmas KN, Simon P, Mighell MA, Frankle MA. Clinical outcomes following reverse shoulder arthroplasty-allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up. J Shoulder Elbow Surg. 2019;28(5):900–7.CrossRefGoogle Scholar
  16. 16.
    McLendon PB, Cox JL, Frankle MA. Humeral bone loss in revision shoulder arthroplasty. Am J Orthop. 2018;47:2.CrossRefGoogle Scholar
  17. 17.
    Sanchez-Sotelo J, Wagner ER, Sim FH, Houdek MT. Allograft-prosthetic composite reconstruction for massive proximal humeral bone loss in reverse shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(24):2069–76.CrossRefGoogle Scholar
  18. 18.
    Meijer ST, Paulino Pereira NR, Nota S, Ferrone ML, Schwab JH, Lozano Calderon SA. Factors associated with infection after reconstructive shoulder surgery for proximal humerus tumors. J Shoulder Elbow Surg. 2017;26(6):931–8.CrossRefGoogle Scholar
  19. 19.
    Parvizi J, Jacovides C, Zmistowski B, Jung KA. Definition of periprosthetic joint infection: is there a consensus? Clin Orthop Relat Res. 2011;469(11):3022–30.CrossRefGoogle Scholar
  20. 20.
    Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, et al. 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(22):2075–83.CrossRefGoogle Scholar
  21. 21.
    Richards J, Inacio MC, Beckett M, Navarro RA, Singh A, Dillon MT, et al. Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty. Clin Orthop Relat Res. 2014;472(9):2809–15.CrossRefGoogle Scholar
  22. 22.
    Moroder P, Trampuz A, Scheibel M. Propionibacterium: we found it, now we have to deal with it: commentary on an article by Jason E. Hsu, MD, et al.: “Single-stage revision is effective for failed shoulder arthroplasty with positive cultures for propionibacterium”. J Bone Joint Surg Am. 2016;98(24):e112.CrossRefGoogle Scholar
  23. 23.
    Frangiamore SJ, Saleh A, Grosso MJ, Kovac MF, Higuera CA, Iannotti JP, et al. alpha-Defensin as a predictor of periprosthetic shoulder infection. J Shoulder Elbow Surg. 2015;24(7):1021–7.CrossRefGoogle Scholar
  24. 24.
    Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am. 2014;96(23):1952–8.CrossRefGoogle Scholar
  25. 25.
    Zimmerli W, Sendi P. Role of rifampin against staphylococcal biofilm infections in vitro, in animal models, and in orthopedic-device-related infections. Antimicrob Agents Chemother. 2019;63(2):e01746-18.CrossRefGoogle Scholar
  26. 26.
    Klatte TO, Sabihi R, Guenther D, Kamath AF, Rueger JM, Gehrke T, et al. High rates of occult infection after shoulder fracture fixation: considerations for conversion shoulder arthroplasty. HSS J. 2015;11(3):198–203.CrossRefGoogle Scholar
  27. 27.
    Grosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg. 2012;21(6):754–8.CrossRefGoogle Scholar
  28. 28.
    Beekman PD, Katusic D, Berghs BM, Karelse A, De Wilde L. One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg. 2010;92(6):817–22.CrossRefGoogle Scholar
  29. 29.
    Ince A, Seemann K, Frommelt L, Katzer A, Loehr JF. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg. 2005;87(6):814–8.CrossRefGoogle Scholar
  30. 30.
    Cuff DJ, Virani NA, Levy J, Frankle MA, Derasari A, Hines B, et al. The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics. J Bone Joint Surg. 2008;90(3):336–42.CrossRefGoogle Scholar
  31. 31.
    Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau P. The management of infection in arthroplasty of the shoulder. J Bone Joint Surg. 2004;86(1):65–9.CrossRefGoogle Scholar
  32. 32.
    Jacquot A, Sirveaux F, Roche O, Favard L, Clavert P, Mole D. Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients. J Shoulder Elbow Surg. 2015;24(11):1713–22.CrossRefGoogle Scholar
  33. 33.
    Strickland JP, Sperling JW, Cofield RH. The results of two-stage re-implantation for infected shoulder replacement. J Bone Joint Surg. 2008;90(4):460–5.CrossRefGoogle Scholar
  34. 34.
    Romano CL, Borens O, Monti L, Meani E, Stuyck J. What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series. Int Orthop. 2012;36(5):1011–7.CrossRefGoogle Scholar
  35. 35.
    Sabesan VJ, Ho JC, Kovacevic D, Iannotti JP. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res. 2011;469(9):2538–43.CrossRefGoogle Scholar
  36. 36.
    Ortmaier R, Resch H, Hitzl W, Mayer M, Stundner O, Tauber M. Treatment strategies for infection after reverse shoulder arthroplasty. Eur J Orthop Surg Traumatol Orthop Traumatol. 2014;24(5):723–31.CrossRefGoogle Scholar
  37. 37.
    Klatte TO, Schneider MM, Citak M, Oloughlin P, Gebauer M, Rueger M, et al. Infection rates in patients undergoing primary knee arthroplasty with pre-existing orthopaedic fixation-devices. Knee. 2013;20(3):177–80.CrossRefGoogle Scholar
  38. 38.
    Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res. 2001;382:206–16.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Raul Barco
    • 1
    • 2
  • Alfonso Vaquero-Picado
    • 1
  • Samuel Antuña
    • 1
  1. 1.Department of Orthopedic Surgery“La Paz” University HospitalMadridSpain
  2. 2.Upper Limb Unit“La Paz” University HospitalMadridSpain

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