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Total shoulder arthroplasty
Surgeon-side topic for total shoulder arthroplasty. Backed by 412 articles from the corpus, retrieved via combined MeSH + title-text matching.
For patients: a plain-language version of this topic is available. See the patient guide.
Overview¶
Total shoulder arthroplasty is an effective and safe treatment option, demonstrating a safety profile comparable to other major joint arthroplasties [5, 16]. In early to midterm follow-up, the procedure yields good to excellent clinical results in greater than 90% of shoulders [2], with pain relief achieved in approximately 90% to 95% of patients [2]. Outcomes following anatomic total shoulder arthroplasty are durable and reproducible [199], providing substantial and durable improvement in shoulder function [8]. Long-term data confirm excellent survivorship with significant improvements in both pain and function [42].
Indications for the procedure continue to broaden, particularly for reverse shoulder arthroplasty, which has been highly successful in cuff-deficient shoulders [38]. However, reverse total shoulder arthroplasty does not offer functional benefits over anatomic total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and no glenoid deformity [210]. Age 70 years or older is not a contraindication to stemless anatomic total shoulder arthroplasty, as postoperative improvements in patient-determined outcome scores and range of motion are similar between patients aged <70 years and those aged 70 years or older [201]. Patients who have undergone prior ipsilateral shoulder surgery derive benefit from the procedure, although their magnitude of improvement and final scores are significantly lower than those of patients without prior surgery [27, 209].
Surgical planning requires knowledge of the array of available prostheses and the specific indications for each, as well as the use of treatment algorithms to optimize patient outcomes [44]. The AAOS has developed appropriate use criteria to determine the appropriateness of various humeral component designs during primary anatomic total shoulder arthroplasty based on evidence-based information and clinical expertise [6]. Outpatient shoulder arthroplasty is a safe and cost-effective alternative for appropriately selected patients, resulting in similar outcomes and complications compared to inpatient cohorts [39, 195, 202]. In a cohort of 640 patients undergoing shoulder arthroplasty for all indications, reported mortality rates were 0% at 30 days, 0.16% at 90 days, and 2% at 1 year [41]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost [35], while consensus recommendations on long-term follow-up and surveillance can contribute to guidelines in this area [1].
Anatomy & Pathophysiology¶
Bony Anatomy¶
The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [62]. The articular head of the humerus is spherical with a diameter of 37 to 57 mm [62]. The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [62]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [62]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [62]. The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [62]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [62]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [62]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [62].
The glenoid is a convex structure of shallow depth shaped like an inverted pear [62]. The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [63]. The neck-shaft angle measures an average of 135 degrees [63]. The humeral head is retroverted an average of 30 degrees [63]. The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [64]. The glenoid is connected with the flat body of the scapula by the scapular neck [64]. The coracoid process curves forwards from the superior surface of the scapular neck [64]. The scapular spine ends in a flattened bony process, the acromion, which curves forwards [64]. The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck, and the lateral border of the scapular body [64]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar and the spinal pillar [64]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [64]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [64]. The weakest bone in the scapula is located primarily in the central part of the infraspinous fossa [64]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [64].
The clavicle is the only long bone to ossify by intramembranous ossification [65, 71]. The medial epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [65]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [65, 71]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [65]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [65]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [65]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [65]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [65]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [65]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination [65]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [77]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [77]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [77].
The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [74]. The radius of curvature of the humeral head is approximately 25 mm [74]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [74]. The average neck-shaft angle is 45 degrees, with a range of 30 to 50 degrees [74]. Arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [74]. The normal position of the glenoid surface in relation to the axis of the scapular body ranges from 2 degrees of anteversion to 7 degrees of retroversion [74]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [74]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [74]. Humeral articular malposition of more than 4 mm leads to increased subacromial contact [74]. An offset of 8 mm in any direction significantly decreases passive range of motion [74]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [74]. The glenoid diameter ranges from 18 to 30 mm superiorly and 21 to 35 mm inferiorly [74]. The glenoid superoinferior height ranges from 30 to 48 mm [74]. The glenoid inclination averages 4.2 degrees, with a range of -7 to 20 degrees [74]. The humeral head inclination ranges from 30 to 55 degrees [74]. The glenoid version averages 1.5 degrees of retroversion, with a range of 10.5 degrees anteversion to 9.5 degrees retroversion [74]. The glenoid surface area ranges from 4 to 6 mm [74]. The humeral head surface area ranges from 11 to 19 mm [74]. The glenoid cartilage thickness is 2.16 mm [74]. The humeral head cartilage thickness is 1.44 mm [74]. The glenoid radius of curvature ranges from 22 to 28 mm [74]. The humeral head radius of curvature ranges from 23 to 28 mm [74]. The medial humeral offset ranges from 4 to 14 mm [74]. The posterior humeral offset ranges from -2 to 10 mm [74].
The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [77]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [77]. The coracoid process serves as an attachment for the coracoacromial ligament, coracoclavicular ligaments, conjoined tendon, and pectoralis minor [77]. The humeral head ossification center is usually present at birth [69]. The greater tuberosity ossification center appears by 1 to 3 years of age [69]. The lesser tuberosity ossification center appears by 5 years of age [69]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [69]. Humeral retroversion averages 65 degrees in infants and young children, approaching adult values by 11 years of age [69]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [69].
Vascular Supply¶
The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [62]. The posterior humeral circumflex artery travels with the axillary nerve and enters the quadrilateral space posteriorly [62]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [62]. The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch, the artery of Laing [62]. The ascending branch of the anterior humeral circumflex artery enters the humeral head at the interface of the bicipital groove and greater tuberosity [62]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [62]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [62]. The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [63]. Fractures of the anatomic neck have a poor prognosis because of complete disruption of the blood supply to the head [63]. Surgical neck fractures are common, and with these, the blood supply to the head is preserved [63]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [65]. The terminal intraosseous portion of the artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [65]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [69]. The anterior and posterior humeral circumflex arteries provide a rich blood supply to the proximal humerus [69].
Joints and Ligaments¶
The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [75]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [65]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [65]. The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [65]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [65]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [65, 71]. The conoid ligament is medial and the trapezoid ligament is lateral [65, 71]. The glenohumeral joint depends on static and dynamic stabilizers for movement and stability [74]. The rotator cuff stabilizes the glenohumeral joint via joint compression [65]. Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [65]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [65]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [65]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [65]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [65]. Contracture of the rotator interval is seen with adhesive capsulitis [65]. The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [65]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [65]. The superior glenohumeral ligament and coracohumeral ligament form a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [65]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [65]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation in 90 degrees of abduction and external rotation [65]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [65].
The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [65]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to it [65]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and infraspinatus [65]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [65]. Entrapment, traction, or compression at the spinoglenoid notch causes denervation of the infraspinatus [65]. The bony anatomy contributes little to stability of the glenohumeral joint [75]. The glenoid is encircled by the labrum, which increases the depth of the socket by 50% around the humeral head [75]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [75]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [75]. The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [75]. The superior glenohumeral ligament is the primary stabilizer to anterior and posterior stress in 0 degrees of abduction [75]. Tightening of the rotator interval decreases posterior and inferior translation [75]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction [75]. The middle glenohumeral ligament has little effect when the arm is in 90 degrees of abduction [75]. The inferior glenohumeral ligament is composed of an anterior band, a posterior band, and a thinner intervening axillary pouch [75]. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out [75]. With internal rotation, the opposite occurs in the inferior glenohumeral ligament complex [75]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [75].
The sternoclavicular joint rotates 30 degrees with shoulder motion [77]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability [77]. The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [77]. The posterior and superior acromioclavicular ligaments are considered the strongest [77]. The trapezoid ligament is approximately 25 mm from the acromioclavicular joint [77]. The conoid ligament is approximately 45 mm from the acromioclavicular joint [77]. The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [65]. The superior shoulder suspensory complex is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [65]. The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [65]. The inferior strut of the superior shoulder suspensory complex comprises the lateral scapular border and spine of the scapula [65].
Muscles and Nerves¶
The rotator cuff consists of four muscles: subscapularis, supraspinatus, infraspinatus, and teres minor [63]. The teres major is not a rotator cuff.
Classification¶
Complication Classification¶
A system of three complication categories was introduced to standardize the presentation of complications in shoulder arthroplasty [15]. In a study of 485 cases, the overall complication rate for shoulder arthroplasty was 11.6% [15]. However, a clear standardised set of shoulder arthroplasty complication definitions is lacking [187].
Glenoid Classification¶
Samilson-Prieto: This is the most widely adopted classification to determine the extent of osteoarthritis of the glenohumeral joint [57]. Grade 0 is normal, grade 1 is mild with osteophytes less than 3 mm on the humeral head, grade 2 is moderate with osteophytes between 3 and 7 mm on the humeral head or glenoid rim, and grade 3 is severe with osteophytes of more than 7 mm with or without articular incongruity [57].
Walch: This classification is used to grade glenoid wear patterns preoperatively [271].
Post-treatment Glenoid: A post-treatment glenoid classification system addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements [81].
Other Considerations: Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal [169]. Patient-specific planning brings surgeons into closer agreement with the recommendations of experts for glenoid classification and surgical planning [200].
Rotator Cuff Classification¶
Hamada-Fukuda: This is a radiographic morphological description of the natural course of massive rotator cuff tear assessing the height of the acromiohumeral space [57]. Type 1 represents normal joint morphology and an acromiohumeral distance of more than 6 mm [57].
Heterotopic Ossification Classification¶
Kjaersgard-Andersen: This classification is used to categorize heterotopic ossification after shoulder arthroplasty [17].
Custom Classifications: Custom classifications for heterotopic ossification include the Ko et al. classification (Type I and Type II) and the Verhofste et al. classification (Grade Ia, Ib, Ic, and II) [17].
Bone Loss and Defect Classification¶
PHAROS: The Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) classification system may be useful to anticipate the complexity of humeral reconstruction in revision total shoulder arthroplasty [131].
Bone Quality: Preoperative 3-dimensional CT bone density measures provide objective classifications of bone quality for stemless anatomic total shoulder arthroplasty [49].
Etiology and Pathology Classification¶
Larsen: This classification is used to grade shoulder disease in rheumatoid arthritis, with grade I representing medium destructive abnormality with erosions and joint space narrowing, grade IV including severe destructive abnormality with bone deformation, and grade V including mutilating abnormality where the original articular surface has disappeared [310].
Proximal Humerus Fracture Sequelae: Four basic pathophysiologic types of lesions were distinguished to categorize the sequelae of fractures of the proximal humerus [59].
Sirveaux: This classification is used to detect and grade inferior scapular notching after reverse shoulder arthroplasty [300].
Imaging and Radiographic Classification¶
Radiographic Osteoarthritis: Various radiographic classifications have been established to determine the extent of osteoarthritis of the glenohumeral joint [57].
Deep Learning: A deep learning algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time [43].
Clinical Presentation¶
General Outcomes and Pain¶
Pain relief is achieved in approximately 90% to 95% of all patients following total shoulder arthroplasty [2]. Elective shoulder arthroplasty remains a viable option for patients aged 90 years and older, providing excellent pain relief, improved functional outcome, and enhanced general health status [32]. In younger populations, prosthetic shoulder arthroplasty provides substantial improvement in active range of motion irrespective of diagnosis and glenoid management [99]; however, residual shoulder pain is common in these patients [99]. Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty [111]. Reverse total shoulder arthroplasty provides reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement [163]. Furthermore, shoulder arthroplasty represents a safe and reliable option for the management of symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable satisfaction following surgery [144].
Evaluation of Painful or Failed Arthroplasty¶
A thorough and systematic approach including history, physical examination, and appropriate diagnostic studies is necessary to evaluate failed shoulder arthroplasty, as the cause of pain and disability is often multifactorial [109]. An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival [124]. The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes in shoulder arthroplasty [94]. Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology [28]. Common causes of pain after shoulder arthroplasty include instability, periprosthetic joint infection (PPJI), component loosening or malposition, acromioclavicular joint osteoarthritis, subacromial impingement, rotator cuff tear, adhesive capsulitis, and synovitis [136]. The case of metastatic carcinoma to the acromion in a patient after total shoulder arthroplasty underscores the need to entertain a broad differential when evaluating a painful shoulder, even after total shoulder arthroplasty [164].
Diagnostic Arthroscopy¶
Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations [13]. When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty [14]. 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 [22]. Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies [95]. Arthroscopy after shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients but can be technically challenging [159].
Infection Diagnosis and Presentation¶
Periprosthetic joint infection (PPJI) occurs in up to 3.9% of total shoulder arthroplasty (TSA) cases and 18% of reverse total shoulder arthroplasty (rTSA) cases [136]. The clinical presentation of periprosthetic joint infection (PJI) of the shoulder can vary widely, from obvious infection with gross purulence and sinus tract formation to insidious presentations of stiffness and pain without overt signs of infection [141]. Patients with acute PJI may have more obvious symptoms including pain, erythema, drainage, and fever [148]. In contrast, patients with indolent PJI due to C. acnes or other similar organisms do not typically have such acute symptoms and instead present later after surgery with more subtle symptoms [148]. The most principal difference in shoulder arthroplasty infection compared to hip and knee is the more common occurrence of indolent infections caused by low virulent organisms such as P. acnes [25]. Patients with P. Acnes-infected shoulders do not typically present with the telltale signs and symptoms characteristic of a septic joint: severe pain, limited motion, large effusion, warmth, induration, erythema, or drainage [25]. Due to the varied presentation of PJI at the shoulder, the diagnosis in the setting of a potentially low-virulence bacterium such as Cutibacterium can be difficult to establish prior to revision surgery [141].
PPJI is difficult to diagnose because of high rates of false-negative culture findings [136]. Joint aspiration and culture findings are unreliable, with only a 16.7% sensitivity in the evaluation of painful shoulder arthroplasty [136]. Shoulder aspirations for cultures are not reliable and require at least 2 weeks of incubation in the appropriate growth media to detect the presence of P. Acnes [25]. A single aspiration will never answer the question as to whether the result is a false positive or a false negative for P. Acnes [25]. Frequently used serologic markers such as the erythrocyte sedimentation rate and C-reactive protein level can yield negative findings or can be only modestly elevated even in the presence of PPJI, especially with Cutibacterium acnes [136]. Diagnostic tools such as WBC, ESR, and CRP may not be helpful in diagnosing P. Acnes infection because they often remain within normal limits [25]. In patients with indolent PJI, ESR, CRP, CBC, and aspiration tests are often normal or nearly normal due to the poor sensitivity and specificity in this scenario [148]. Specific clinical symptoms including pain at rest, systemic symptoms including fevers, chills, or sweats, and WBC bone scan are poorly associated with the presence of infection in revision shoulder arthroplasty [110]. Radiographs, computed tomography (CT), and magnetic resonance imaging are all imperfect methods of evaluating patients with painful shoulder arthroplasty [136]. Radiographic findings of loosening, shift in position, or bone erosion are suggestive of infection in the shoulder [25]. Progressive lucency/loosening on X-ray can develop over time with C. acnes and raises the suspicion for PJI [148].
Diagnosis of periprosthetic shoulder infection should be based on clinical suspicion, patient factors, and intraoperative findings when perioperative testing is equivocal, particularly due to the indolent nature of organisms like P. acnes [137]. Determining the presence of infection in revision shoulder arthroplasty can be difficult, and a standardized approach is needed to determine the best course of treatment in this particular clinical setting [100]. About 45% of patients with no clinical signs of infection and a history of prior ipsilateral shoulder surgery undergoing primary shoulder arthroplasty grew positive intraoperative cultures [20]. Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology [162]. An infected shoulder arthroplasty can have a devastating effect on the function of the shoulder, but so can its treatment [25].
Osteolysis and Component Loosening¶
Radiographic osteolysis after total shoulder arthroplasty (TSA) remains a challenging clinical entity, as it may not initially manifest clinically apparent symptoms but can lead to clinically important complications, such as aseptic loosening [3]. A thorough consideration of medical history and physical examination is essential to rule out other causes of symptomatic TSA—namely, periprosthetic joint infection—as symptoms often progress to vague pain or discomfort due to subtle component loosening [3]. Early results of total shoulder arthroplasty in young patients show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients [7].
Soft Tissue and Rotator Cuff Findings¶
Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs [11]. Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%) in patients greater than 70 years of age [23].
Imaging and Surveillance¶
A monitoring tool developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty includes a structured core set of radiographic parameters [18]. Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients [26]. Preoperative clinical examination and radiological assessment is fundamental to anticipating specific difficulties in glenoid exposure [31]. Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty [140].
Complications and Risk Factors¶
Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage [19]. A preoperative diagnosis of a stroke in patients undergoing primary shoulder arthroplasty is associated with higher rates of perioperative complications and mortality when compared to a matched cohort [132]. The most common complications after anatomic total shoulder arthroplasty (aTSA) are, in order of decreasing frequency: component loosening, glenoid wear, instability, rotator cuff tear, periprosthetic fracture, neural injury, infection, hematoma, deltoid injury, and venous thromboembolism [146]. Comparing it with other arthroplasties such as total hip or total knee arthroplasty, anatomic total shoulder arthroplasty (aTSA) has a relatively short survival rate with an average of 10 years [146].
Investigations¶
Plain radiography: Standardized plain films are almost always sufficient for shoulder arthroplasty planning and provide information that cannot be obtained from CT scans [10]. Radiographs are the first imaging modality used to evaluate the presence and degree of glenohumeral arthritis [57]. The standard shoulder series should include orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [154]. The Neer trauma series consists of an AP view, a lateral view in the scapular plane (tangential Y-view), and a Velpeau modified axillary view, allowing evaluation of the joint in three separate perpendicular planes [119].
The first key view is the AP view in the plane of the scapula, taken so the beam passes through the glenohumeral joint [10]. This view shows the superoinferior position of the humeral head, osteophytes, joint space narrowing, medial humeral displacement, bone quality, loose bodies, and humeral head collapse or deformity [10]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [154]. An AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [154].
The second key view is the axillary view, taken with the arm in the functional position of elevation in the plane of the scapula [10]. Referred to as the “truth view,” it demonstrates glenohumeral relationships in elevation, a position where CT scans (taken with the arm adducted) cannot replicate [10]. This view shows humeral anatomy, glenoid bone amount, glenoid shape, version relative to the scapular plane, and the relationship of the humeral head to the glenoid fossa [10]. Joint space narrowing is most evident on this view compared to images with the arm at the side [10]. It can also show posterior subluxation or “functional decentering” not evident in adducted views [10]. The degree of posterior subluxation is measured by the position of the humeral head center relative to the scapular plane, the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [10]. This point of contact reflects the centering of the net humeral joint reaction force; malcentering leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [10]. The axillary view is necessary for evaluating glenohumeral instability, determining humeral head position, and detecting occult locked posterior dislocations in patients with limited passive external rotation [154]. It is also important for evaluating the glenoid articular surface and anterior-posterior humeral head relationship [119].
The scapular Y view provides visualization of the coracoacromial arch, revealing coracoacromial spurs associated with rotator cuff pathology, and serves as a reliable alternative for evaluating glenohumeral subluxation and dislocation [154]. The Grashey view, obtained by a 30° lateral oblique projection tangential to the glenohumeral joint, allows inference of rotator cuff status [57]. Normal acromiohumeral distance is 7 to 14 mm, and the glenohumeral joint space width should be symmetric superiorly and inferiorly [154]. The coracoclavicular distance is normally 1.1 to 1.3 cm [154]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked); type III morphology correlates with rotator cuff disease, though no direct causal relationship has been demonstrated [154]. In the Hamada-Fukuda classification, Type 1 indicates normal joint morphology and an acromiohumeral distance of more than 6 mm [57].
The Samilson-Prietro classification is the most widely adopted system for determining the extent of glenohumeral osteoarthritis: grade 0 is normal; grade 1 is mild with osteophytes less than 3 mm on the humeral head; grade 2 is moderate with osteophytes between 3 and 7 mm on the humeral head or glenoid rim; and grade 3 is severe with osteophytes of more than 7 mm with or without articular incongruity [57]. Patients with mild radiographic signs of arthritis have about sevenfold higher odds of failing to achieve the minimum clinically important difference (MCID) after anatomic total shoulder replacement compared to patients with severe arthritis [334]. Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible [298]. In 68 of 100 total shoulder arthroplasties, clinically useful information was identified on fluoroscopically positioned localized views that was not visualized on standard radiographic examination [299].
CT: CT scans may offer a few degrees of increased precision in measuring glenoid version, but this precision does not necessarily improve surgical quality or clinical outcome [10]. Three-dimensional reconstructions reveal fine anatomical details, but this additional information rarely changes arthroplasty planning or conduct [10]. CT is helpful for planning fracture surgery and shoulder joint replacement [96]. It is frequently used to evaluate shoulder fractures, assess bony lesions in recurrent instability, or for preoperative templating for shoulder arthritis [142]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in shoulder instability [154]. The use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for osteoarthritis has increased dramatically, with computed tomography use increasing the most [208]. Advanced 3-dimensional CT software can improve the accuracy of bony measurements and provide detailed planning specifications for anatomic total shoulder arthroplasty [330]. Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture [324]. A deep learning algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries [43].
MRI: Magnetic resonance imaging (MRI) is useful to identify osteonecrosis of the humeral head or a bone tumour [96]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [142]. It can identify labral tears and rotator cuff tears, although accuracy is enhanced by combining the scan with arthrography [96]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of joint surfaces [142]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [142]. MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty [203]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [268].
Traditional MRI is a diagnostic tool to complement physical examination and standard radiographs in managing anterior shoulder instability [125]. MRI evaluates soft tissues with high contrast and spatial resolution [125]. MR accuracy in identifying labral and rotator cuff tears ranges from 70% to 100% [125]. Multi-planar imaging allows detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff in different planes [125]. Magnetic resonance (MR) arthrography (MRA) refers to MRI of a joint injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [125]. The contrast material is injected prior to MRI by fluoroscopic or ultrasound guidance under strict aseptic technique [125]. By distending the joint capsule, the cartilage, ligaments, and labrum are outlined with contrast, increasing sensitivity for detecting tears and other lesions [125]. In the acute dislocation setting, a joint effusion with distension of the joint may outline these structures similarly, making the arthrogram unnecessary [125]. MRA has proven utility by increasing both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [125]. In a meta-analysis of diagnostic test accuracy for glenoid labral injuries, MRA sensitivity was 88% and specificity 93% vs. MRI sensitivity 76% and specificity 87% [125].
With standard MRI or MRA, the shoulder is routinely positioned in neutral or partial external rotation, but other alternative positions can be used to increase sensitivity for detecting labroligamentous injuries [125]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [125]. Limited ROM or pain may prohibit patients from performing the ABER provocative maneuver [125]. Full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [125]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position and more effective in identifying Perthes lesions [125]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [125]. MRAs can be helpful in evaluating lesions of the rotator interval and other associated findings that may ultimately affect the eventual surgical plan [125]. The presence of glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion have all been found to be associated with increased posterior labral tears and symptomatic instability [125]. Glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, but there was no significant association between instability and increased humeral head subluxation [125]. The diagnosis of multidirectional instability is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [125].
Arthrography involves injection of contrast agent in conjunction with either an MRI or CT scan, enhancing imaging of the joint to enable better identification of normal structures and pathology involving the joint surfaces [142]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [142]. When MRI or MR arthrography is contraindicated (eg, pacemaker, vascular clips), CT arthrography is indicated [142]. Assessment of painful total shoulder arthroplasty using computed tomography arthrography (CTA) was performed, and arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty [311].
Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [96].
Other Considerations: Successful postoperative radiologic evaluation of shoulder reconstructions requires an understanding of their fundamental hardware design, physiologic objective, preoperative imaging assessment, normal postoperative radiologic appearance, and findings and types of complication [50]. Knowledge of the normal biomechanics of the glenohumeral joint—particularly the function of the rotator cuff and the unique relationship of the humeral head to the glenoid—is essential for understanding the need for shoulder replacement and its subsequent complications [12]. Unique radiographic outcomes and complications exist for both surgical approaches and should factor into the decision-making process regarding the appropriate surgical approach for reverse total shoulder arthroplasty [24]. A core set of radiographic parameters has been developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty [18]. The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty [331]. Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings [333].
Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care [328]. Elimination of immediate postoperative radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care [328]. Radiographic changes at the periprosthetic interface are significantly more common in total shoulder arthroplasties compared to hemiarthroplasties [270]. In a study of primary total shoulder arthroplasty using a cementless metal-backed pegged polyethylene glenoid, 54 (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up [301]. Radiolucencies were noted around the glenoid component and/or screws in 45% of shoulders in a study of total shoulder arthroplasty with an uncemented glenoid component [316]. The radiographic changes seen at the implant-bone interfaces are much less frequent than those seen following cementing of the glenoid component in a study of ingrowth total shoulder arthroplasty [318]. Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients [7]. Radiographic osteolysis after total shoulder arthroplasty may not initially manifest clinically apparent symptoms but can lead to clinically important complications, such as aseptic loosening [3].
The clinical and radiologic results of the short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty [322]. The functional and radiographic outcomes of Eclipse total shoulder replacement are excellent [325]. Imaging did not show any complications like raised height of prosthesis or loosening signs during the follow-up period in a study of reversed shoulder arthroplasty for the treatment of proximal humerus fracture in the elderly [327]. The functional and radiologic results of the stemless shoulder arthroplasty are comparable to the third and fourth generation of standard stem arthroplasty [51]. Early clinical and radiographic results for stemless shoulder arthroplasty are promising, but well-designed clinical studies and midterm results are lacking [34]. The clinical and radiologic evaluation of an uncemented all-polyethylene glenoid is promising, with good clinical results and with no signs of loosening in 88% of the patients on computed tomography scans [336].
Treatment¶
Non-Operative¶
The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or NSAIDs for total shoulder arthroplasty candidates. However, nonoperative treatment of osteolysis should be pursued first to avoid surgery-associated risks [3].
Operative¶
Indications: Shoulder arthroplasty is an effective and safe treatment option [16], considered as safe as more commonly performed major joint arthroplasties [5]. Appropriate patient selection is crucial for successful outcomes, particularly in subscapularis-sparing techniques where the integrity of the supraspinatus and subscapularis tendons must be preserved [55]. Younger patients are likely to experience implant failure in their lifetime; therefore, alternative treatments focus on avoiding prosthetic glenoid implants, preserving glenoid bone stock, and using humeral implants that facilitate revision surgery [282]. A collaborative and comprehensive approach to pre-operative medical evaluation is critical for patients with diabetes mellitus [133]. Previous lower extremity periprosthetic joint infection and axillary lymph node dissection are not contraindications to shoulder arthroplasty [30, 157].
Surgical Approach / Technique: The long deltopectoral approach is the standard surgical exposure for shoulder arthroplasty in osteoarthritis and rheumatoid arthritis [306]. During anatomic total shoulder arthroplasty, careful dissection and meticulous soft tissue management ensure adequate visualization of articular and bony surfaces, allowing proper instrumentation use and accurate component placement [128]. The first and most important step in reconstructive glenoid surgery is exposure via a deltopectoral approach with circumferential tissue release, avoiding iatrogenic damage to the rotator cuff and neurovascular structures [307]. The anteromedial approach is a reliable technique to improve exposure in difficult cases [84]. The authors do not recommend the posterior approach for shoulder arthroplasty at this time, suggesting it should only be performed in prospective research trials after sufficient training [127]. For reverse shoulder arthroplasty, the deltopectoral approach is generally preferred for accessing the glenohumeral joint [314] and allows adequate access to fracture fragments for suture fixation and excellent glenoid exposure after mobilization in proximal humeral fractures [315]. A modified lateral deltoid-splitting approach is used when arthroplasty is clearly indicated preoperatively for acute fractures, offering better visualization and easier manipulation of the greater tuberosity [292]. Technical refinements allow exposure of both the proximal humerus and the glenoid through the rotator interval in shoulders with an intact rotator cuff [150]. A combined minimally invasive approach that preserves most of the subscapularis decreases the risk of devastating complications while allowing full access for replacement [302].
Subscapularis Management: The optimal management of the subscapularis tendon during total shoulder arthroplasty remains controversial [283]. Standard exposure uses the deltopectoral interval and necessitates takedown of the subscapularis tendon [309]. The most commonly used techniques for subscapularis management include tenotomy, peel, and lesser tuberosity osteotomy [309]. Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%) [23]. A subscapularis-sparing approach is becoming increasingly popularized because it obviates the need for takedown and allows for accelerated postoperative rehabilitation [309]. Total shoulder arthroplasty performed entirely through the rotator interval has been used to potentially reduce postoperative subscapularis failure [55]. Specialized instrumentation allows this technique to be performed more efficiently and reproducibly [55]. Special attention should be directed to humeral neck resection, inferior humeral neck osteophytes removal, and appropriate humeral head size selection as common pitfalls of the subscapularis-sparing approach [55]. If optimal visualization cannot be obtained during a subscapularis-sparing approach, the procedure can be converted to the standard technique by releasing the subscapularis tendon through tenotomy, peel, or lesser-tuberosity osteotomy [55]. The subscapularis-sparing approach allows rapid and complete rehabilitation compared with all other subscapularis takedown procedures [302]. Preoperative planning and patient selection remain keys to successfully performing minimally invasive subscapularis-retaining shoulder replacement [302]. The use of a novel technique for subscapularis repair has led to improved patient outcomes with regard to range of motion postoperatively following anatomic total shoulder arthroplasty [91]. Limitations of subscapularis repair prior to takedown include potential for fracture if buttons are placed too close together and limited utility with stemmed total shoulder arthroplasty implants [272]. Pectoralis major tendon transfer is a technique for management of subscapularis failure after anatomic total shoulder arthroplasty [312].
Implant Selection: The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual [225]. The materials used in total shoulder arthroplasty implants have been carefully chosen to minimize hardware-related complications [244]. Total shoulder arthroplasty with an all-polyethylene pegged glenoid component, utilizing hybrid fixation, demonstrated excellent clinical and radiographic results at early follow-up [276]. The semiconstrained total shoulder arthroplasty is an effective means of treatment for arthritis of the glenohumeral joint [278]. Until long-term results are available, pyrocarbon interposition shoulder arthroplasty should remain to be tested in a few specialized shoulder centers [279]. Although much attention has been directed to the development of humeral components, the major unsolved challenge lies on the glenoid side of the articulation [253]. The purpose of a report on press-fit fixation of the humeral component is to review the current literature and propose minimum requirements for radiographic descriptions of stress shielding [258]. The future of shoulder arthroplasty has the potential to integrate multiple advanced technologies that could improve preoperative planning, intraoperative execution, and patient outcomes [101].
Glenoid Management and Bone Loss: Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis [149]. The literature provides a cogent approach to the evaluation and treatment of surgical dilemmas associated with marked glenoid deficiency or deformity in total shoulder arthroplasty [120]. Distal clavicle autograft augmentation is a technique for managing glenoid bone loss in revision shoulder arthroplasty [304]. 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 [265]. The overall results of nonconstrained total shoulder replacements have been very satisfactory, with an average of 90% of patients having significant relief of pain regardless of their preoperative diagnosis [247].
Pain Management: Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist [190]. A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively [206]. Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen [213]. Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty [228]. A non-opioid multimodal pain protocol achieves equivalent pain control compared to a standard opioid protocol after total shoulder arthroplasty while significantly reducing opioid consumption [239]. There was a dose-dependent increase in the risk of surgical and medical complications with increasing totals of perioperative opioid consumption following total shoulder arthroplasty [240]. With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets [246]. An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids [249]. Anatomic total shoulder arthroplasty provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively [255]. Approximately 42% of patients undergoing total shoulder arthroplasty received an interscalene nerve block, while less than 1% were performed purely under regional anesthesia [224]. Local infiltration analgesia and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty [250]. Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement [233]. These findings highlight the need for further research and consensus to establish evidence-based perioperative protocols in elective shoulder replacement surgery [242].
Setting of Care: Total shoulder arthroplasty may be performed on an outpatient basis using perineural local anesthetic infusion [261]. Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty [248]. Under optimal circumstances simultaneous shoulder arthroplasty is feasible [153]. Operative time for total shoulder arthroplasty has decreased from 2008 to 2018 [151]. Prolonged length of stay after shoulder arthroplasty is multifactorial, with non-modifiable demographic factors compounded by modifiable social and structural elements [287]. Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty [274].
Revision: A thorough consideration of medical history and physical examination is essential to rule out other causes of symptomatic total shoulder arthroplasty, namely periprosthetic joint infection [3]. Current surgical options for osteolysis after total shoulder arthroplasty include glenoid polyethylene revision and conversion to reverse shoulder arthroplasty [3]. Complications of shoulder arthroplasty depend on the prosthesis type used [36]. With advances in implant design and techniques, the complication profile after anatomic shoulder arthroplasty is changing and outcomes are improving [285]. In the presence of previous non-arthroplasty operative interventions there is a significantly higher risk for infection in shoulders undergoing reverse total shoulder arthroplasty [264]. Patients with P. acnes-infected shoulders do not typically present with severe pain, limited motion, large effusion, warmth, induration, erythema, or drainage [25]. Diagnostic tools such as WBC, ESR, and CRP may not be helpful for P. acnes infection because they often remain within normal limits [25]. Shoulder aspirations for cultures are not reliable and require at least 2 weeks of incubation in the appropriate growth media to detect P. acnes [25]. The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [267]. Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with scapular fractures after reverse shoulder arthroplasty are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture [251]. Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent [143]. 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 [273]. Arthroscopic removal of a loose glenoid component in anatomic total shoulder arthroplasty is a described surgical technique [61]. Shoulder arthroscopy after anatomic total shoulder arthroplasty should include an intra-articular, subacromial, and subdeltoid evaluation of all relevant structures [61]. Intraoperative biopsies for culture are obtained from the anterior and posterior compartments, from behind the loose glenoid and from the subacromial space during arthroscopic removal of a loose glenoid component [61]. Suture cerclage may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty [275]. Allograft-prosthetic composite reconstruction is a technique for massive proximal humeral bone loss in reverse shoulder arthroplasty [286]. The hypothesis is that operative treatment with reversed total shoulder arthroplasty produces better functional outcomes and less pain compared with non-operative treatment at 2 years in patients 65 years of age and older with a displaced proximal humerus fracture [281].
Other Considerations: A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented [29]. Recommendations from a real-time Delphi technique can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1]. Controversial management areas in reverse shoulder arthroplasty have been highlighted and require exploration by further clinical studies [254].
Complications¶
Overall Complication Rates and Safety: The overall complication rate in a study of 485 shoulder arthroplasty cases was 11.6% [15]. Primary shoulder arthroplasty is associated with low 90-day reoperation and complication rates [52], and short-term reoperation after shoulder arthroplasty was infrequent [97]. Shoulder arthroplasty is considered as safe as the more commonly performed major joint arthroplasties [5]. The overall complication rate of total shoulder arthroplasty has decreased dramatically over time, with a striking diminution of component loosening [351]. In a series of 38 consecutive reverse total shoulder arthroplasties during the early learning curve, the complication rate was 15.7% [102]. In a cohort of 60 patients undergoing press-fit short stem reverse shoulder arthroplasty, 11 (18%) had complications, of which 9 (15%) were treated conservatively and 2 (3%) required reoperations without implant removal [106]. The risk of clinically noted complications in a systematic review of stemless reverse total shoulder arthroplasty was 6.5% in 418 shoulders [288]. In a study of anatomic short-stem humeral components, the overall complication rate during follow-up was 13.7%, which was significantly higher in the nonanatomic positioning group (35%) than in the anatomic positioning group (6%) [259]. Complications and reoperation rates for revision reverse shoulder arthroplasty were higher than those for primary reverse shoulder arthroplasty [355]. Shoulder arthroplasty in the management of native shoulder joint infections has a high complication rate [326]. The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 compared to a primary arthroplasty for fracture [349]. Complication and reoperation rates are higher for shoulder arthroplasty addressing the sequelae of anterior instability arthropathy compared to shoulder arthroplasty for primary glenohumeral joint arthritis, though the difference is not statistically significant [383].
Infection (PJI): The incidence of prosthetic joint infection of the shoulder ranges from 0.4% to 3% for primary anatomic total shoulder arthroplasty, 1% to 10% for primary reverse shoulder arthroplasty, and up to 15.4% for revision shoulder arthroplasty [340]. Infection is widely regarded as the most devastating cause of failure in shoulder arthroplasty [256]. The incidence of infection is reportedly as much as 4% in primary unconstrained arthroplasty and 15% in revision arthroplasty [256]. Intraoperative cultures taken at revision surgery for presumed aseptic loosening are positive in as much as 11% of cases [256]. The risk of infection after primary shoulder arthroplasty is significantly higher in patients with a history of prior nonarthroplasty-related surgery [335]. Infection is more likely to develop in shoulders undergoing primary reverse total shoulder arthroplasty that have had one or more nonarthroplasty operative procedures [386]. Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty [338]. When vancomycin is the primary prophylactic agent used at the time of primary shoulder arthroplasty, incomplete administration (infusion to incision time under 30 min) is associated with increased rates of infectious complications and periprosthetic joint infection [305]. Complete administration of vancomycin as the primary prophylactic agent does not adversely increase the rates of infectious complications and periprosthetic joint infection compared to cefazolin [363]. Managing complex and late presentation shoulder periprosthetic joint infection with two-stage revision is associated with high rates of infection eradication (80%) [284]. Single-stage revision demonstrated infection control and complication rates comparable with 2-stage revision for shoulder periprosthetic joint infection [293]. Aseptic reoperation within 90 days of primary total or reverse shoulder arthroplasty was associated with a notably increased risk of subsequent periprosthetic joint infection [387]. Prior nonshoulder periprosthetic joint infection 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 [388]. Shoulder arthroplasty for the treatment of the sequelae of an infected shoulder can be performed with a low risk of reinfection [389]. Fifty-two percent of revision shoulder arthroplasty cases with humeral loosening were aseptic [337].
Thromboembolic Events: The prevalence of deep vein thrombosis after reconstructive shoulder arthroplasty was 13.0% [220, 295]. Venous thromboembolism rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty [232]. Although the absolute rates of thromboembolic complications were less in patients who had shoulder arthroplasties compared with those of patients who had lower extremity procedures, a larger percentage of these complications were pulmonary embolisms [262]. Venous thromboembolism occurred infrequently following shoulder arthroplasty, with an incidence of 0.61% after anatomic total shoulder arthroplasty and 0.82% after reverse total shoulder arthroplasty [294]. The risk of venous thromboembolism following shoulder arthroplasty is low, and routine use of pharmacologic venous thromboembolism prophylaxis may not be necessary [321]. Routine use of low-dose aspirin results in a very low risk of venous thromboembolism and medication-associated complications following primary shoulder arthroplasty [339]. Long-term corticosteroid users are at a heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism, following total shoulder arthroplasty [359]. Tranexamic acid use during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events [345]. In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative tranexamic acid was not associated with a decrease in the 5-year probability of revision for deep infection [369].
Mechanical and Implant-Related Complications: Heterotopic ossification developed in 113 of 434 shoulders (26%) after total shoulder arthroplasty [17]. Heterotopic ossification developed in 28 of 41 shoulders (68%) after revision shoulder arthroplasty [17]. The most common postoperative complications reported in a systematic review of return to work after shoulder arthroplasty were postoperative stiffness/pain (n = 47), anterior dislocation or shoulder instability (n = 16), and progressive arthritis requiring revision (n = 7) [37]. Periprosthetic fracture was reported in 3 cases and infection in 1 case in a systematic review of return to work after shoulder arthroplasty [37]. In a study of 485 shoulder arthroplasty cases, survival without category 1 complication was 95.6%, survival without category 2 complication was 98.5%, and survival without category 3 complication was 97.7% [15]. In a series of 612 revision shoulder arthroplasties, 13 (16.3%) intraoperative complications were reported, including cement extrusion, distal cortical perforation of the stem, nonunions, and deep infections [257]. Nerve palsy is a rare complication but can occur while implanting humeral stems, with 18 patients (4.3%) reporting nerve palsy after primary stem implantation in a series of 417 total shoulder arthroplasties [257]. In a study of reverse total shoulder arthroplasty for acute fractures, tuberosities remained intact in 17 of 40 patients (42.5%) available for radiologic review [252]. A complication rate of 28% was reported in a study of reverse arthroplasty for acute proximal humeral fractures, including one perioperative glenoid fracture, five transient neurologic complications, three cases of reflex sympathetic dystrophy, one secondary deltoid rupture, one acromion fracture, and one dislocation [252]. In a study of reverse arthroplasty for fracture sequelae, the most common complication was postoperative deep infection (9.3%) [252]. In a study of small-stature patients undergoing reverse shoulder arthroplasty, complications included periprosthetic humeral fractures (4), humeral loosening (1), acromial stress fracture (1), glenoid loosening (1), dislocation (1), postoperative scapular body fracture (1), and nondermatomal arm numbness (1) [266]. In a study of average-stature patients undergoing reverse shoulder arthroplasty, complications included glenoid loosening (5), periprosthetic humeral fracture (4), humeral loosening (1), infection (3), implant failure (2), scapular body fracture (2), acromial stress fracture (1), dislocation (1), stiffness (1), and pulmonary embolism (1) [266]. In a study of anatomic short-stem humeral components, 2 patients were revised for aseptic glenoid component loosening and 3 patients developed secondary rotator cuff insufficiency requiring revision to a reverse shoulder arthroplasty [259]. Periprosthetic joint infection was observed in 2 patients in a study of anatomic short-stem humeral components, requiring a 2-stage revision surgery to a reverse shoulder arthroplasty [259]. In a study of cement-within-cement technique in revision reverse total shoulder arthroplasty, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability [320]. In a study of 11 patients with late glenoid component failure, none of the shoulders had infections and none of the humeral components were loose [104]. In a study of 176 shoulders undergoing arthroplasty for primary osteoarthritis, 2 shoulders had the humeral component revised [78]. In a study of 78 hemiarthroplasties in patients 50 years old or less, 15 (19%) were revised [297]. In a study of 60 patients undergoing press-fit short stem reverse shoulder arthroplasty, 2 (3%) had revision for infection with the removal of all components and 3 (5%) had revision of the glenoid component for dislocation [106]. In a prospective cohort study of the Delta Xtend reverse total shoulder arthroplasty, implant survival without reoperation for any complication was 88.2% after 11 years [112]. Patients who had undergone previous shoulder surgery showed a significantly lower survival rate (80.1%) compared to patients who had no prior surgery (97%) in a study of the Delta Xtend reverse total shoulder arthroplasty [112]. In a study of 383 screened patients, anatomic total shoulder arthroplasty was performed equally often as reverse total shoulder arthroplasty [114].
Medical and Systemic Complications: Cardiac and thromboembolic complications are uncommon after primary shoulder arthroplasty [222]. Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients, with a 1% incidence of never events [357]. Male patients had significantly higher odds of adverse events, death, myocardial infarction, and sepsis following shoulder arthroplasty [371]. In a study of 60 patients undergoing press-fit short stem reverse shoulder arthroplasty, 9 (15%) died of causes unrelated to the procedure [106]. In a study of 176 shoulders undergoing arthroplasty for primary osteoarthritis, 6 in 4 patients were lost as a result of death within 24 months after surgery [78]. In a study of 78 hemiarthroplasties in patients 50 years old or less, a postoperative complication that did not necessitate a revision procedure developed in four shoulders, including an immediate postoperative hematoma, subacromial bursitis, brachial plexus neuropathy, and an infection [297]. In a study of 38 consecutive reverse total shoulder arthroplasties, 2 out of 6 complications occurred intraoperatively in the first 20 shoulders and 4 occurred after at least 2 months postoperatively [102]. In a study of anatomic short-stem humeral components, a temporary incomplete brachial plexus neuropathy was observed postoperatively in 1 patient and a local hematoma in 1 patient that resolved after aspiration [259]. In a study of 485 shoulder arthroplasty cases, most complications were intraoperative findings or events that were treated during the index surgery or did not require revision (7%; category 1) [15].
Other Considerations: In a study of 383 screened patients, the majority of subjects were female (75.5%) and the mean age was 69.7 years [114]. In a study of 207 patients, the final patient population was determined following inclusion/exclusion criteria [86]. In a study of 38 consecutive reverse total shoulder arthroplasties, operation time decreased significantly after the 15th case [102]. In a study of 485 shoulder arthroplasty cases, the median follow-up for the fracture implant was one year and the survival rate for all complications was 94.2% [15]. In a study of 485 shoulder arthroplasty cases, 24 (34.3%) cases had a very satisfying result, 30 (42.9%) a satisfying result, 12 (17.1%) a somewhat disappointing result, and four (5.7%) a very disappointing result [15]. In a study of 176 shoulders undergoing arthroplasty for primary osteoarthritis, active total elevation improved from a preoperative mean of 102° to 138° postoperatively [78]. In a study of 176 shoulders undergoing arthroplasty for primary osteoarthritis, external rotation increased from a mean of 14° to 45° [78]. In a study of 38 consecutive reverse total shoulder arthroplasties, the UCLA score improved from a preoperative mean of 16.0 to a postoperative mean of 27.9 [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, the Constant score improved from a preoperative mean of 41.4 to a postoperative mean of 78.9 [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, the VAS score decreased from a preoperative mean of 4.0 to a postoperative mean of 2.8 [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, forward flexion range of motion improved from a preoperative mean of 99.9° to a postoperative mean of 135.4° [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, abduction range of motion improved from a preoperative mean of 69.2° to a postoperative mean of 124.8° [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, internal rotation at 90° abduction improved from a preoperative mean of L5 to a postoperative mean of L3 [102]. In a study of 38 consecutive reverse total shoulder arthroplasties, external rotation at 90° abduction remained statistically unchanged from a preoperative mean of 32.4° to a postoperative mean of 34.0° [102]. In a study of 60 patients undergoing press-fit short stem reverse shoulder arthroplasty, net improvements in functional outcomes were 34.7 for the absolute Constant score and 54% for the age-/sex-adjusted Constant score [106]. In a study of 11 patients with late glenoid component failure, the mean Simple Shoulder Test score dropped by 6.7 to a mean of 4.6 at a mean of 7.4 years after the index arthroplasty [104].
Recovery¶
Light activity (weeks): Driving performance returns to preoperative levels at 6 weeks after shoulder arthroplasty [115]. By 12 weeks postoperatively, patients demonstrate improved driving performance, with a significant decrease in collisions in simulated driving courses compared to preoperative and 2-week post-operative trials [204].
Full activity (months): Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively [362]. Patients with active sports participation before surgery are successfully able to return to sports activities, whereas those not participating before surgery are unlikely to resume sports [366]. Most patients being active prior to reverse shoulder arthroplasty are successfully able to return to their activity afterwards [381].
Complete recovery / outcome plateau (months): Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications [367]. Patients achieve maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [385]. After shoulder joint replacement, the range of shoulder motion shows substantial changes during the first year only [241]. Shoulder arthroplasty is generally associated with meaningful improvement in sleep quality between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter [390].
Rehabilitation protocol: A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty [182]. Rehabilitation should be tailored to the biomechanical principles and soft-tissue considerations unique to each form of total shoulder arthroplasty [230]. Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme [217]. There is insufficient literature to support the use of formal physical therapy over a physician-directed program, and no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty [229]. Acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively [394]. Preoperative baseline scores serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to counsel patients on surgery and tailor postoperative protocols [396].
Functional milestones: Within a group of patients with primary glenohumeral degenerative joint disease, shoulder arthroplasty is effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status [238]. 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 [352]. Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications [392]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [393]. Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications [391]. New glenoid components demonstrate significant improvement in patient-reported outcomes at 1 and 2 years post-surgery across a large multicenter cohort [379].
Other Considerations: Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks postoperatively [40]. The most common postoperative complications were postoperative stiffness/pain (n = 47), anterior dislocation or shoulder instability (n = 16) and progressive arthritis requiring revision (n = 7), periprosthetic fracture (n = 3), and infection (n = 1) [37]. In total, 14 patients were reported to have returned to the operating room for revision [37]. Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates [52]. Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation [234]. Although significant strength improvement from baseline was observed at 2 years after shoulder arthroplasty, subscapularis strength returned to normal in only a minority of patients [397]. 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 [56]. Although both workers' compensation and non-workers' compensation patients experienced significant clinical improvements after shoulder arthroplasty, workers' compensation patients had a higher reoperation rate, inferior patient-reported outcomes, and a higher rate of persistent pain [212]. Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively [237]. We anticipate that these recommendations, in addition to the limited applicable published evidence available, can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1]. Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment [223]. Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries [226]. Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [395]. Sixty-seven percent of patients successfully returned to work after shoulder arthroplasty [194]. Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return [235]. A high return to sport can be expected after total shoulder arthroplasty [243]. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty [216]. In patients aged 65 years and younger, anatomic total shoulder arthroplasty on the nondominant shoulder was associated with a significantly higher rate of return to sport [376].
Key Evidence¶
- [L4] We anticipate that these recommendations, in addition to the limited applicable published evidence available, can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty. [1] (10.1177/17585732251356963)
- [L5] Total shoulder arthroplasty yields good to excellent clinical results in greater than 90% of shoulders in early to midterm follow-up studies, with pain relieved in approximately 90% to 95% of all patients. [2] (10.1016/s0030-5898(05)70025-0)
- [L5] [3] (10.5397/cise.2021.00738)
- [L2] The authors believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties. [5] (10.1097/01.blo.0000238839.26423.8d)
- [L5] The AAOS developed appropriate use criteria to determine the appropriateness of various humeral component designs during primary anatomic total shoulder arthroplasty based on evidence-based information and clinical expertise. [6] (10.5435/jaaos-d-23-00758)
- [L4] Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients. [7] (10.1016/j.jse.2007.11.004)
- [L3] Total shoulder arthroplasty can provide substantial and durable improvement in shoulder function. [8] (10.1067/mse.2001.117122)
- [L4] Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs. [11] (10.1016/j.jse.2010.04.001)
- [L5] Knowledge of the normal biomechanics of the glenohumial joint-particularly the function of the rotator cuff and the unique relationship of the humeral head to the glenoid-is essential for understanding the need for shoulder replacement and its subsequent complications. [12] (10.1148/rg.2016150055)
- [L4] Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations. [13] (10.1016/j.jse.2026.07.016)
- [L4] When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty. [14] (10.1007/s12178-016-9318-y)
- [Paper] [15] (10.1007/s00264-009-0780-7)
- [L5] Shoulder arthroplasty is now an effective and safe treatment option. [16] (10.1016/j.jbspin.2010.09.004)
- [L3] [17] (10.5435/jaaos-d-24-00063)
- [L4] Our work presents a monitoring tool developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty and including a structured core set of radiographic parameters. [18] (10.2106/jbjs.oa.19.00025)
- [L5] Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage. [19] (10.1007/s12178-014-9249-4)
- [L3] About 45% of patients with no clinical signs of infection and a history of prior ipsilateral shoulder surgery undergoing primary shoulder arthroplasty grew positive intraoperative cultures. [20] (10.1016/j.jseint.2019.12.011)
- [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. [22] (10.1016/j.jse.2007.02.131)
- [L4] Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%). [23] (10.1177/17585732261441853)
- [L5] Unique radiographic outcomes and complications exist for both surgical approaches and should factor into the decision-making process regarding the appropriate surgical approach for reverse total shoulder arthroplasty. [24] (10.1016/j.ocl.2014.09.015)
- [L3] Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. [26] (10.5397/cise.2023.00836)
- [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. [27] (10.1177/2325967115s00168)
- [L3] Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. [28] (10.1016/j.otsr.2012.04.003)
- [L5] A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented. [29] (10.2519/jospt.2005.35.12.821)
- [L4] Thus, previous lower extremity PJI should not be considered a relative contraindication to shoulder arthroplasty. [30] (10.1016/j.jse.2016.05.024)
- [Paper] [31] (10.1016/j.otsr.2017.10.008)
- [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. [32] (10.1016/j.jse.2007.09.005)
- [Abstract] At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty. [33] (10.1016/j.jse.2022.01.004)
- [L4] Early clinical and radiographic results for stemless shoulder arthroplasty are promising, but well-designed clinical studies and midterm results are lacking. [34] (10.1016/j.jse.2014.05.005)
- [L3] Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty. [35] (10.1016/j.jse.2025.02.055)
- [L5] Complications of shoulder arthroplasty depend on the prosthesis type used. [36] (10.1007/s00330-008-1093-8)
- [L1] [37] (10.1016/j.jse.2018.12.011)
- [L4] The reverse shoulder arthroplasty has been highly successful in cuff deficient shoulders, with indications continuing to broaden. [38] (10.1007/s12178-011-9097-4)
- [L4] Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. [39] (10.1016/j.jse.2019.04.006)
- [L2] Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks. [40] (10.1016/j.jse.2025.06.016)
- [L4] This study reports 30-day, 90-day and 1-year mortality of 0%, 0.16% and 2% in 640 patients undergoing shoulder arthroplasty for all indications. [41] (10.1016/j.jor.2020.04.005)
- [L3] Total shoulder arthroplasty demonstrates excellent long-term survivorship with significant improvements in pain and function. [42] (10.1016/j.jse.2005.02.009)
- [L5] This algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries. [43] (10.1016/j.jse.2023.09.021)
- [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. [44] (10.5435/00124635-200907000-00002)
- [L5] Although clinical results of revision shoulder arthroplasty are, in general, inferior to primary shoulder arthroplasty, careful patient selection and adherence to surgical principles can lead to satisfactory results. [45] (10.1016/s1048-6666(03)00084-3)
- [L4] Preoperative 3-dimensional CT bone density measures provide objective classifications of bone quality for stemless anatomic total shoulder arthroplasty. [49] (10.1016/j.jse.2023.11.005)
- [L5] Successful postoperative radiologic evaluation of shoulder reconstructions requires an understanding of their fundamental hardware design, physiologic objective, preoperative imaging assessment, normal postoperative radiologic appearance, and findings and types of complication. [50] (10.1055/s-0034-1384833)
- [L4] The functional and radiologic results of the stemless shoulder arthroplasty are comparable to the third and fourth generation of standard stem arthroplasty. [51] (10.1016/j.jse.2015.02.023)
- [L4] Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. [52] (10.1016/j.jse.2019.12.008)
- [L5] [55] (10.1016/j.ocl.2020.02.003)
- [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. [56] (10.1016/j.jse.2016.05.026)
- [L5] [57] (10.1007/s00256-019-03183-3)
- [L4] [59] (10.1067/mse.2001.115985)
- [L5] [61] (10.1016/j.eats.2024.102987)
- [L2] [78] (10.1067/mse.2002.121146)
- [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. [81] (10.1016/j.jse.2011.01.035)
- [L4] The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases. [84] (10.1016/j.jse.2009.10.016)
- [L3] [86] (10.1016/j.jse.2019.04.041)
- [L4] The use of our technique has led to improved patient outcomes with regard to range of motion postoperatively following anatomic total shoulder arthroplasty and we recommend its adoption into practice. [91] (10.1016/j.xrrt.2023.01.004)
- [L2] The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes. [94] (10.1080/03009740600759720)
- [L4] Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies. [95] (10.1016/j.jse.2015.09.013)
- [L4] Short-term reoperation after shoulder arthroplasty was infrequent. [97] (10.2106/jbjs.m.00127)
- [L4] Prosthetic shoulder arthroplasty in young patients provides substantial improvement in active range of motion, irrespective of diagnosis and glenoid management, though residual shoulder pain is common. [99] (10.1016/j.arthro.2017.08.204)
- [L5] Determining the presence of infection in revision shoulder arthroplasty can be difficult, and a standardized approach is needed to determine the best course of treatment in this particular clinical setting. [100] (10.1016/j.jse.2014.10.005)
- [L5] The future of shoulder arthroplasty is exciting, with the potential to integrate multiple advanced technologies that could improve preoperative planning, intraoperative execution, and, ultimately, patient outcomes. [101] (10.1016/j.jseint.2024.04.007)
- [L4] [102] (10.1186/s13018-019-1077-1)
- [L4] [104] (10.1016/j.jse.2004.10.008)
- [L4] [106] (10.1016/j.jseint.2022.08.004)
- [L5] A thorough and systematic approach including history, physical examination, and appropriate diagnostic studies is necessary to evaluate failed shoulder arthroplasty, as the cause of pain and disability is often multifactorial. [109] (10.1016/j.jse.2013.12.003)
- [L4] Specific clinical symptoms including pain at rest, systemic symptoms including fevers, chills, or sweats, and WBC bone scan are poorly associated with the presence of infection in revision shoulder arthroplasty. [110] (10.1016/j.jseint.2025.02.005)
- [L3] Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. [111] (10.2106/jbjs.16.00541)
- [L4] [112] (10.1016/j.jse.2025.02.038)
- [L3] [114] (10.1016/j.jsea.2026.100034)
- [L4] Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty, with improved performance compared with preoperative levels by 12 weeks postoperatively. [115] (10.2106/jbjs.15.00162)
- [L5] The article reviews the literature and provides a cogent approach to the evaluation and treatment of surgical dilemmas associated with marked glenoid deficiency or deformity in total shoulder arthroplasty. [120] (10.1067/mse.2000.103656)
- [L5] An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival. [124] (10.5435/jaaos-21-01-23)
- [L5] The authors do not recommend the posterior approach for shoulder arthroplasty at this time and suggest it should only be performed in prospective research trials after sufficient training. [127] (10.1097/corr.0000000000001779)
- [L5] During anatomic total shoulder arthroplasty, careful dissection and meticulous soft tissue management ensure adequate visualization of the articular and bony surfaces, allowing the proper use of surgical instrumentation and ensuring accurate placement of prosthetic components. [128] (10.1016/j.eats.2023.07.007)
- [L5] The paper describes the major steps in total shoulder arthroplasty (TSA) including preoperative planning, surgical exposure, and component insertion. [129] (10.2106/jbjs.st.19.00011)
- [L3] This classification system may be useful to anticipate the complexity of humeral reconstruction. [131] (10.1097/corr.0000000000000590)
- [L3] A preoperative diagnosis of a stroke in patients undergoing primary shoulder arthroplasty is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. [132] (10.1016/j.jse.2022.10.014)
- [L4] A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with DM is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with DM. [133] (10.1007/s00264-018-3874-2)
- [L4] [136] (10.1016/j.arthro.2020.01.045)
- [L4] Diagnosis of periprosthetic shoulder infection should be based on clinical suspicion, patient factors, and intraoperative findings when perioperative testing is equivocal, particularly due to the indolent nature of organisms like P. acnes. [137] (10.2106/jbjs.rvw.m.00055)
- [L5] Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty. [140] (10.5435/jaaos-20-09-604)
- [L3] [141] (10.1016/j.jse.2026.04.036)
- [L4] Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent. [143] (10.1016/j.jse.2008.09.006)
- [L4] Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic GD, offering improved clinical outcomes and favorable satisfaction following surgery. [144] (10.1016/j.xrrt.2025.03.001)
- [L5] [146] (10.1016/j.xrrt.2025.06.011)
- [L5] This article describes a stepwise approach to glenoid exposure and preparation for anatomic total shoulder arthroplasty in the context of a prior Latarjet procedure. [147] (10.1016/j.eats.2025.103942)
- [L4] [148] (10.1007/s12178-020-09670-8)
- [L4] Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis. [149] (10.2106/00004623-198870080-00006)
- [L5] These technical refinements allow exposure of both the proximal humerus and the glenoid through the rotator interval in shoulders with an intact rotator cuff undergoing shoulder arthroplasty. [150] (10.1016/j.xrrt.2026.100738)
- [L3] Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. [151] (10.1177/17585732211008900)
- [L5] Under optimal circumstances simultaneous shoulder arthroplasty is feasible. [153] (10.1016/s1058-2746(96)80400-9)
- [L4] Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. [157] (10.1177/1758573218780519)
- [L4] Arthroscopy after shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients but can be technically challenging. [159] (10.1067/mse.2002.122257)
- [L3] Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology. [162] (10.1302/0301-620x.99b11.bjj-2017-0469.r1)
- [L4] Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. [163] (10.1016/j.jse.2020.10.003)
- [L5] The case underscores the need to entertain a broad differential when evaluating a painful shoulder, even after total shoulder arthroplasty. [164] (10.1067/mse.2002.126762)
- [Paper] Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal. [169] (10.1016/j.jseint.2024.08.170)
- [L5] A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty. [182] (10.1016/j.csm.2018.05.007)
- [L1] A clear standardised set of shoulder arthroplasty complication definitions is lacking. [187] (10.1007/s00402-017-2635-9)
- [L5] Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist. [190] (10.1016/j.ocl.2017.08.010)
- [L4] Sixty-seven percent of patients successfully returned to work after shoulder arthroplasty. [194] (10.1016/j.jsea.2026.100058)
- [L4] Outpatient total shoulder arthroplasty in appropriately selected patients is a safe and cost-effective alternative to inpatient total shoulder arthroplasty. [195] (10.5435/jaaos-d-21-00562)
- [Abstract] When the glenoid component revision is the indication for revision total shoulder replacement, these patients tend to achieve good to excellent results. [196] (10.1016/j.jse.2007.02.098)
- [L5] Outcomes following anatomic total shoulder arthroplasty have proven to be durable and reproducible. [199] (10.1097/bte.0000000000000075)
- [L4] The information provided by PSP has the greatest impact on the surgical decision-making of low volume surgeons (those who perform fewer than ten shoulder arthroplasties annually), and PSP brings all surgeons in to closer agreement with the recommendations of experts for glenoid classification and surgical planning. [200] (10.1302/0301-620x.102b3.bjj-2019-1153.r1)
- [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. [201] (10.1016/j.jse.2022.08.003)
- [L3] Transitioning appropriate patients to outpatient total shoulder arthroplasty results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up. [202] (10.1016/j.jse.2024.05.012)
- [L4] MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty. [203] (10.1007/s11420-014-9399-3)
- [Abstract] At 12 weeks status post anatomic or reverse total shoulder arthroplasty, patients showed improved driving performance, with a significant decrease in the number of collisions in the simulated driving course compared to preoperative and 2-week post-operative trials. [204] (10.1016/j.jse.2014.06.005)
- [L1] A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively. [206] (10.1016/j.jse.2021.12.015)
- [L3] The use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis has increased dramatically, with the use of computed tomography increasing the most. [208] (10.1177/1758573220908865)
- [L3] While patients who have undergone prior ipsilateral shoulder surgery derive benefit from shoulder arthroplasty, these patients are significantly younger, and their magnitude of improvement and final scores are significantly lower than patients without prior surgery. [209] (10.1016/j.arthro.2017.04.086)
- [L3] Reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty in this population. [210] (10.1016/j.jse.2025.01.038)
- [L3] Although both workers' compensation and non-workers' compensation patients experienced significant clinical improvements after shoulder arthroplasty, workers' compensation patients had a higher reoperation rate, inferior patient-reported outcomes, and a higher rate of persistent pain. [212] (10.1016/j.jse.2018.10.007)
- [L2] Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen. [213] (10.1016/j.jse.2017.11.015)
- [L4] Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty. [216] (10.1177/23259671251326076)
- [L1] Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. [217] (10.1177/1758573220937394)
- [Abstract] This is the first study to report the prevalence of DVT following reconstructive shoulder arthroplasty surgery (13.0%). [220] (10.1016/j.jse.2007.02.097)
- [L3] Cardiac and thromboembolic complications are uncommon after primary shoulder arthroplasty. [222] (10.1016/j.semarthrit.2011.09.003)
- [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. [223] (10.1016/j.jse.2006.10.016)
- [L4] Approximately 42% of patients undergoing total shoulder arthroplasty received an interscalene nerve block, while less than 1% were performed purely under regional anesthesia. [224] (10.1213/ane.0000000000001472)
- [L5] The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual. [225] (10.5435/jaaos-d-23-00257)
- [L4] Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries. [226] (10.5435/jaaosglobal-d-17-00073)
- [L2] Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty. [228] (10.1016/j.jse.2026.01.026)
- [L4] There is insufficient literature to support the use of formal physical therapy over a physician-directed program, and no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty. [229] (10.2106/jbjs.rvw.19.00129)
- [L5] Rehabilitation after total shoulder arthroplasty should be tailored to the biomechanical principles and soft-tissue considerations unique to each form of total shoulder arthroplasty. [230] (10.1002/arj.70509)
- [L3] VTE rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty. [232] (10.1016/j.jse.2014.09.025)
- [L1] Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement. [233] (10.1007/s00590-015-1678-2)
- [L4] Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation. [234] (10.1016/j.jse.2005.02.013)
- [L1] Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return. [235] (10.1007/s00167-017-4547-1)
- [L3] Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. [237] (10.1016/j.jse.2023.03.035)
- [L4] The data presented indicate that within a group of patients with primary glenohumeral degenerative joint disease, shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status. [238] (10.1016/s1058-2746(95)80203-7)
- [L1] A non-opioid multimodal pain protocol achieves equivalent pain control compared to a standard opioid protocol after total shoulder arthroplasty while significantly reducing opioid consumption. [239] (10.1016/j.jse.2026.04.063)
- [L3] There was a dose-dependent increase in the risk of surgical and medical complications with increasing totals of perioperative opioid consumption following total shoulder arthroplasty. [240] (10.1016/j.jse.2024.10.029)
- [L4] After shoulder joint replacement, the range of shoulder motion showed substantial changes during the first year only. [241] (10.1007/s00590-016-1795-6)
- [L5] These findings highlight the need for further research and consensus to establish evidence-based perioperative protocols in elective shoulder replacement surgery. [242] (10.1016/j.jseint.2026.101758)
- [L1] A high return to sport can be expected after total shoulder arthroplasty. [243] (10.1016/j.jseint.2025.05.028)
- [L4] The materials that are used in total shoulder arthroplasty (TSA) implants have been carefully chosen in an attempt to minimize hardware-related complications. [244] (10.2106/jbjs.rvw.19.00212)
- [L2] With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets. [246] (10.1016/j.jseint.2021.02.005)
- [L4] The overall results of nonconstrained total shoulder replacements have been very satisfactory, with an average of 90% of patients having significant relief of pain regardless of their preoperative diagnosis. [247] (10.1016/s1058-2746(05)80013-8)
- [L4] Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty. [248] (10.1016/j.ocl.2017.08.011)
- [L4] An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. [249] (10.1016/j.jse.2019.01.013)
- [L1] LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. [250] (10.2106/jbjs.22.00034)
- [L2] Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with fractures are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture. [251] (10.5435/jaaos-d-20-01205)
- [L4] [252] (10.1016/j.ocl.2008.06.006)
- [L5] Although much attention has been directed to the development of the humeral components used in shoulder arthroplasty, the major unsolved challenge lies on the glenoid side of the articulation. [253] (10.1016/j.jse.2007.02.112)
- [L5] Controversial management areas in reverse shoulder arthroplasty have been highlighted and require exploration by further clinical studies. [254] (10.5604/15093492.1119621)
- [L4] Anatomic total shoulder arthroplasty provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively. [255] (10.1016/j.jses.2019.11.005)
- [L4] [256] (10.1007/s11999-009-0875-x)
- [L2] [257] (10.1530/eor-2024-0053)
- [L5] The purpose of this report is to review the current literature on press-fit fixation of the humeral component during total shoulder arthroplasty and propose minimum requirements for radiographic descriptions of stress shielding. [258] (10.1016/j.jse.2017.12.020)
- [L3] [259] (10.1016/j.jse.2024.01.051)
- [L4] Total shoulder arthroplasty may be performed on an outpatient basis using perineural local anesthetic infusion. [261] (10.1213/01.ane.0000180199.52383.ce)
- [L2] Although the absolute rates of thromboembolic complications were less in patients who had shoulder arthroplasties compared with those of patients who had lower extremity procedures, a larger percentage of these complications were pulmonary embolisms. [262] (10.1097/01.blo.0000194679.87258.6e)
- [L3] In the presence of previous non-arthroplasty operative interventions there is a significantly higher risk for infection in shoulders undergoing rTSA. [264] (10.1016/j.jse.2014.11.008)
- [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. [265] (10.1016/j.jse.2013.06.001)
- [L3] [266] (10.1016/j.jse.2017.11.011)
- [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [267] (10.1177/1758573217702333)
- [L4] The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term. [268] (10.1016/j.jse.2020.07.037)
- [L4] Radiographic changes at the periprosthetic interface are significantly more common in total shoulder arthroplasties compared to hemiarthroplasties. [270] (10.1067/mse.2001.118482)
- [L4] [271] (10.1177/1758573220909981)
- [L4] Limitations include potential for fracture if buttons are placed too close together and limited utility with stemmed total shoulder arthroplasty implants. [272] (10.1016/j.eats.2021.11.025)
- [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. [273] (10.1177/2471549220949147)
- [L3] Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty. [274] (10.1177/17585732241269174)
- [L4] This technique may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty. [275] (10.1016/j.jseint.2020.03.002)
- [L4] Total shoulder arthroplasty with an all-polyethylene pegged glenoid component, utilizing hybrid fixation, demonstrated excellent clinical and radiographic results at the time of early follow-up. [276] (10.2106/jbjs.15.00475)
- [L4] The semiconstrained total shoulder arthroplasty is an effective means of treatment for arthritis of the glenohumeral joint. [278] (10.2106/00004623-197961040-00014)
- [L4] Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers. [279] (10.1016/j.jse.2017.01.002)
- [L2] The hypothesis is that operative treatment with reversed total shoulder arthroplasty produces better functional outcomes and less pain compared with non-operative treatment at 2 years, measured primarily with the QuickDASH score. [281] (10.1136/bmjopen-2018-024916)
- [L5] Younger patients with shoulder arthroplasty are likely to experience implant failure in their lifetime; therefore, the primary focus of alternative treatment has been to avoid the use of prosthetic glenoid implants, to preserve glenoid bone stock, and to use humeral implants that facilitate revision surgery. [282] (10.1016/j.jse.2014.09.029)
- [Paper] The optimal management of the subscapularis tendon during total shoulder arthroplasty remains controversial. [283] (10.1097/bte.0000000000000076)
- [L4] Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). [284] (10.1177/1758573219841057)
- [L4] With advances in implant design and techniques, the complication profile after anatomic shoulder arthroplasty is changing and outcomes are improving. [285] (10.1016/j.ocl.2021.03.002)
- [L4] [286] (10.2106/jbjs.st.17.00051)
- [L3] Prolonged LOS after shoulder arthroplasty is multifactorial, with non-modifiable demographic factors compounded by modifiable social and structural elements. [287] (10.1016/j.xrrt.2026.100856)
- [L2] [288] (10.1007/s12306-021-00710-1)
- [L4] [292] (10.1097/bte.0b013e3181a61de8)
- [L3] Single-stage revision demonstrated infection control and complication rates comparable with 2-stage revision for shoulder PJI. [293] (10.2106/jbjs.rvw.26.00055)
- [L3] VTE occurred infrequently following shoulder arthroplasty, with an incidence of 0.61% after aTSA and 0.82% after rTSA. [294] (10.1016/j.jsea.2026.100061)
- [L2] The prevalence of DVT after reconstructive shoulder arthroplasty was 13.0%, a rate comparable to that after hip arthroplasty but lower than that after knee arthroplasty. [295] (10.1016/j.jse.2008.07.011)
- [L3] [297] (10.2106/00004623-199804000-00002)
- [L3] Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible. [298] (10.1016/j.jseint.2026.101648)
- [L4] In 68 of 100 total shoulder arthroplasties evaluated, clinically useful information was identified on fluoroscopically positioned localized views that was not visualized on standard radiographic examination. [299] (10.1016/s1058-2746(09)80057-8)
- [Paper] [300] (10.1007/s00402-013-1688-7)
- [L4] Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. [301] (10.1177/1758573218789339)
- [L4] [302] (10.1016/j.csm.2018.05.006)
- [L4] [304] (10.1016/j.jse.2020.05.009)
- [L3] When vancomycin is the primary prophylactic agent used at the time of primary shoulder arthroplasty, incomplete administration (infusion to incision time under 30 min) seems to adversely increase the rates of infectious complications and PJI. [305] (10.1016/j.jse.2022.10.012)
- [L4] [306] (10.1016/j.cuor.2007.11.002)
- [L5] [307] (10.1097/00132589-200112000-00005)
- [L5] [309] (10.5435/jaaos-d-22-00222)
- [L2] [310] (10.1016/s1058-2746(96)80030-9)
- [L1] Arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty. [311] (10.1016/j.jse.2015.06.027)
- [L4] [312] (10.1016/j.xrrt.2022.05.001)
- [L5] [314] (10.1016/j.jisako.2023.05.007)
- [L5] [315] (10.1016/j.jse.2013.10.003)
- [L4] Radiolucencies were noted around the glenoid component and/or screws in 45% of shoulders. [316] (10.1097/00132589-200412000-00002)
- [L4] The radiographic changes seen at the implant-bone interfaces are much less frequent than those seen following cementing of the glenoid component. [318] (10.1016/s1058-2746(98)90096-9)
- [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. [320] (10.1016/j.xrrt.2024.08.006)
- [L4] The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. [321] (10.2106/jbjs.18.01200)
- [L4] The clinical and radiologic results of the short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty. [322] (10.1016/j.jse.2015.08.044)
- [L3] Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture. [324] (10.2106/jbjs.k.01516)
- [L4] The functional and radiographic outcomes of Eclipse total shoulder replacement are excellent. [325] (10.1016/j.jse.2018.05.039)
- [L2] Shoulder arthroplasty in the management of either primary or secondary native shoulder infections has a high complication rate and low functional outcome but low re-infection rates at short-term follow-up. [326] (10.1177/17585732241231758)
- [L4] Imaging did not show any complications like raised height of prosthesis or loosening signs during the follow-up period. [327] (10.1016/j.jor.2019.08.029)
- [L3] Elimination of these radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care. [328] (10.1007/s11999-012-2551-9)
- [Paper] Advanced 3-dimensional computed tomography imaging software can be used to improve the accuracy of bony measurements and provide detailed planning specifications in patients undergoing anatomic total shoulder arthroplasty. [330] (10.1097/bte.0b013e318256022c)
- [L3] The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty. [331] (10.1016/j.jse.2024.10.016)
- [L2] Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings. [333] (10.1016/j.jse.2019.04.005)
- [Paper] Patients with mild radiographic signs of arthritis have about sevenfold higher odds of failing to achieve the minimum clinically important difference (MCID) after anatomic total shoulder replacement compared to patients with severe arthritis. [334] (10.1097/corr.0000000000002747)
- [L2] The risk of infection after primary shoulder arthroplasty is significantly higher in patients with a history of prior nonarthroplasty-related surgery. [335] (10.1016/j.jse.2016.10.020)
- [L4] The clinical and radiologic evaluation of an uncemented all-polyethylene glenoid is promising, with good clinical results and with no signs of loosening in 88% of the patients on computed tomography scans. [336] (10.1016/j.jse.2013.01.036)
- [L4] Fifty-two percent of revision shoulder arthroplasty cases with humeral loosening were aseptic. [337] (10.1016/j.jse.2024.03.004)
- [L2] Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. [338] (10.1007/s11999-014-3696-5)
- [L3] Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. [339] (10.1016/j.jse.2020.09.030)
- [L2] The incidence of prosthetic joint infection of the shoulder ranges from 0.4% to 3% for primary aTSA, 1% to 10% for primary RSA, and up to 15.4% for revision shoulder arthroplasty. [340] (10.5435/jaaos-d-24-00719)
- [L3] Among shoulder arthroplasty patients, TXA use was not associated with increased complication odds, independent of a history of thrombotic events. [345] (10.1016/j.jse.2020.04.050)
- [L3] The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. [349] (10.1080/17453674.2018.1450207)
- [L4] The overall complication rate of total shoulder arthroplasty has decreased dramatically over time, with a striking diminution of component loosening. [351] (10.1016/j.jse.2005.05.005)
- [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. [352] (10.1016/j.jse.2023.07.005)
- [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. [355] (10.1016/j.jse.2023.06.039)
- [L3] Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients, with a 1% incidence of never events. [357] (10.1016/j.jse.2013.08.007)
- [L3] Long-term corticosteroid users are at a heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism following total shoulder arthroplasty. [359] (10.1177/17585732261460807)
- [L4] Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively. [362] (10.1016/j.csm.2018.06.002)
- [L3] Complete administration of vancomycin as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI compared to cefazolin. [363] (10.1016/j.jse.2024.03.059)
- [L4] Patients with active sports participation before total shoulder arthroplasty are successfully able to return to sports activities after surgery, whereas those not participating before surgery are unlikely to resume sports. [366] (10.1177/0363546514557940)
- [L3] Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications. [367] (10.1177/1758573220922845)
- [L3] In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection. [369] (10.1016/j.jse.2022.09.002)
- [L3] Male patients had significantly higher odds of adverse events, death, MI, and sepsis following shoulder arthroplasty. [371] (10.1007/s00264-017-3547-6)
- [L3] In patients aged 65 years and younger, anatomic total shoulder arthroplasty on the nondominant shoulder was associated with a significantly higher rate of return to sport. [376] (10.1177/03635465261423899)
- [L4] The study establishes a benchmark for early clinical value of new glenoid components by demonstrating significant improvement in patient-reported outcomes at 1 and 2 years post-surgery across a large multicenter cohort. [379] (10.1007/s00264-018-4213-3)
- [L4] Most patients being active prior to reverse shoulder arthroplasty surgery are successfully able to return to their activity afterwards. [381] (10.1007/s00402-016-2494-9)
- [L1] Complication and reoperation rates are higher compared to shoulder arthroplasty for primary glenohumeral joint arthritis; however, the difference is not statistically significant. [383] (10.1007/s00402-020-03400-y)
- [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. [385] (10.1016/j.jse.2018.05.029)
- [L3] Infection is more likely to develop in shoulders undergoing primary rTSA that have had one or more nonarthroplasty operative procedures. [386] (10.1016/j.jse.2014.12.036)
- [L3] Aseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI. [387] (10.1016/j.jseint.2021.06.002)
- [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. [388] (10.5435/jaaos-d-21-00745)
- [L4] Shoulder arthroplasty for the treatment of the sequelae of an infected shoulder can be performed with a low risk of reinfection. [389] (10.1016/j.jse.2013.12.011)
- [L4] Shoulder arthroplasty is generally associated with meaningful improvement in sleep quality between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter. [390] (10.1177/17585732261450975)
- [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. [391] (10.1177/1758573220977184)
- [L3] Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications. [392] (10.1177/17585732221097415)
- [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. [393] (10.1016/j.jse.2018.05.030)
- [L4] This study demonstrates that acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively. [394] (10.1016/j.jse.2019.01.003)
- [L4] Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. [395] (10.1016/j.jse.2023.10.007)
- [L3] Preoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols. [396] (10.1016/j.jse.2021.03.033)
- [L4] Although significant strength improvement from baseline was observed at 2 years after shoulder arthroplasty, subscapularis strength returned to normal in only a minority of patients. [397] (10.1016/j.jse.2014.06.042)
See Also¶
- Shoulder Arthroplasty
- Reverse Shoulder Arthroplasty
- Rotator Cuff
- Fractures
- Proximal Humerus Fracture
- Shoulder Arthroscopy
- Shoulder Arthritis
- Shoulder Instability
- Calcific Tendinitis
References¶
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