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Revision shoulder surgery

88 citationsUpdated Oct 2026

Overview

Revision shoulder arthroplasty addresses failed primary implants, with complications that are similar to those in the primary setting but more frequently encountered and difficult to manage [1]. Although clinical results are generally inferior to primary shoulder arthroplasty, careful patient selection and adherence to surgical principles can lead to satisfactory results [7]. Many unsatisfactory shoulder arthroplasties did not meet traditional criteria for failure, meaning the rate of revision underestimated the rate of failure [8]. Shoulder arthroplasties are generally designed to last 10-15 years, but revisions are being performed at a mean 3.9 years from the primary procedure [3]. The incidence of shoulder replacement and revision is expected to increase in the following years, constituting a burden for the healthcare systems [10]. A massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures [18].

Outcomes vary by procedure type and indication. Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [2]. Although the outcomes of revision reverse shoulder arthroplasty are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function [6]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary reverse total shoulder arthroplasty, including all patient-reported outcomes, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates [24]. Functional outcomes improve after revision surgery for failed primary reverse shoulder arthroplasty, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure [59]. Shoulders undergoing secondary revision face a higher risk of failure compared to those undergoing first-time revision surgery [4].

Specific indications yield distinct results. Revision shoulder arthroplasty for failed humeral head resurfacing hemiarthroplasty improves functional outcome [11]. 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 [26]. Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible [19]. Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair [23]. The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a periprosthetic joint infection, with less than 10% meeting ICM criteria for definite PJI [14]. Revision shoulder arthroplasty for infection demonstrated the least improvement in outcomes [15]. Complications and reoperation rates were higher than those for primary shoulder arthroplasty, but outcomes were comparable for revision of failed anatomic shoulder arthroplasty [17]. Registry data indicate a 2.5-year revision rate for resurfacing prostheses, which is more than three times the revision rate for stemmed hemiarthroplasty [109]. Revision total shoulder arthroplasty is technically challenging with inferior results compared to primary arthroplasty, particularly when soft-tissue problems are the indication [29]. Proper patient selection and attention to technical details are needed to reduce the currently high complication rate associated with reverse total shoulder arthroplasty [57]. Patients at high risk of complications and readmission after revision total shoulder arthroplasty should be identified and optimized preoperatively to improve outcomes and lower costs [124]. In a small, carefully selected cohort, outpatient revision shoulder arthroplasty can be safe and effective with complication profiles comparable to inpatient surgery [27].

Anatomy & Pathophysiology

Bony Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [69]. The articular head is spherical with a diameter of 37 to 57 mm [69] and an arc of approximately 160 degrees covered by articular cartilage [78]. The radius of curvature of the humeral head is approximately 25 mm, slightly larger in men than in women [78]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [69], with the superior margin normally positioned 8 to 10 mm superior to the top of the greater tuberosity [78]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [69], while proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [78]. The humeral head is retroverted an average of 30 degrees relative to the transepicondylar axis [70] and averages 19° of retroversion [71]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [69], with a neck-shaft angle measuring an average of 135 degrees [70] or 45 degrees (±5 degrees), with a range of 30 to 50 degrees [78]. The anatomic neck is located at the junction of the articular surface and the tuberosities [69], while the surgical neck represents an indistinct metadiaphyseal junction below the tuberosities but above the humeral shaft [69].

The greater tuberosity is located in a posterior-superior location with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [69]. The lesser tuberosity is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [69]. The glenoid is a convex structure of shallow depth shaped like an inverted pear [69] and is a shallow socket, approximately one third the size of the humeral head [70]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [71, 80]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [78]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [78]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, which weakens abduction and impairs function [78]. Conversely, a significant increase in lateral humeral offset causes excessive tension on the soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [78]. The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [80]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [80]. The humeral head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [80].

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 [69]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis and provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing [69]. The ascending branch of the anterior humeral circumflex artery courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [69]. The major blood supply to the humeral head is through this ascending branch, which penetrates the head at the bicipital groove and becomes the arcuate artery [70]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [71]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [71]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [69]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [75]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [69], although additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [69].

Soft Tissue Anatomy

The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus, and teres minor [70]. The teres major is not a rotator cuff muscle [70]. The cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [70]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [70]. The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [75]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [75]. The deltoid forward flexes and abducts the shoulder and courses from the clavicle and acromion superiorly, coalescing into a common tendinous insertion onto the lateral upper third of the humeral shaft [75]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [75]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel, which is a closed space that extends proximally to the glenohumeral joint [75]. The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [70].

The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [72]. The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [72]. The subscapular bursa often houses loose bodies in the shoulder and is a region in which synovitis of the shoulder may be most intense [72]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [71]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [71]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [71]. Contracture of the rotator interval is seen with adhesive capsulitis [71].

The coracohumeral ligament is a strong band that originates from the base and lateral border of the coracoid process just below the origin of the coracoacromial ligament [82]. It is directed transversely and inserts on the greater tuberosity [82]. The coracohumeral ligament appears to have a static suspensory function for the humeral head in the glenoid cavity when the arm is in the dependent position [82]. With abduction, the coracohumeral ligament relaxes and loses its ability to support the humerus [82]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [79]. The coracohumeral ligament is deep to the tendinous insertion of the cuff and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath [79]. The transverse humeral ligament consists of a few transverse fibers of capsule that extend between the greater and lesser tuberosities and helps contain the long head of the biceps tendon in its groove [82]. On all sides of the shoulder capsule, except for the inferior portion, the capsule is reinforced and strengthened by the tendons of the rotator cuff muscles [82]. The rotator cuff tendons blend into the capsule over varying lengths and average approximately 2.5 cm [82]. The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [79]. The infraspinatus and teres minor fuse near their musculotendinous junctions [79]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [79]. The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [79].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [71]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to the ligament [71]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [71]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [71]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [71].

Joint Mechanics and Stability

Stability and function of the glenohumeral joint are provided by the interaction of structures that promote a near global range of motion and purposeful function [69]. External loads transferred to the shoulder girdle are initially offset by joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion and adhesion [69]. Moderate and large loads are counterbalanced by the deltoid and rotator cuff and by the capsulolabral and bone structures, respectively [69]. The glenohumeral joint depends on static and dynamic stabilizers for movement and stability, especially the rotator cuff [78]. The rotator cuff stabilizes the glenohumeral joint while allowing greater freedom of motion and fixes the fulcrum of the upper extremity against which the deltoid can contract and elevate the humerus [78]. The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [78].

The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [79]. Normal function of the shoulder is a balance between mobility and stability [79]. Mobility is allowed by the "large ball–small socket" bony arrangement and the voluminous glenohumeral joint capsule, which does not restrict movement until the extremes of motion [79]. The bony anatomy contributes little to stability and has been compared with a golf ball on a tee [79]. The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the depth of the socket by 50% around the humeral head and increases stability [79]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [79]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [79]. Because there is very little bony constraint to the shoulder, most of the stability is provided by the surrounding muscles and ligaments [79]. The ligamentous constraints are the primary stabilizers at extremes of motion [79].

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position [79]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [71]. The superior glenohumeral ligament restrains external rotation and inferior translation of the adducted or slightly abducted arm [80]. With the coracohumeral ligament, the superior glenohumeral ligament forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [71]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [71]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [79]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation [71]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [71]. The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type sling [79]. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out [79]. With internal rotation, the opposite occurs to the inferior glenohumeral ligament bands [79]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [79]. The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [71]. The coracohumeral ligament restrains inferior translation and external rotation of the adducted arm [80]. Tightening of the rotator interval decreases posterior and inferior translation [79].

The extrinsic muscles primarily control movement of the scapula and include the rhomboids, levator scapulae, trapezius, and serratus anterior [79]. The intrinsic muscles control the glenohumeral joint and include the rotator cuff muscles, the deltoid, the pectoralis major, the teres major, the latissimus dorsi, and the biceps brachii [79]. Extrinsic muscles dynamically position the scapula to place the glenoid opposite the humeral head as the shoulder moves [79]. Rotator cuff activity and biceps activity have been shown to stiffen the capsule and decrease glenohumeral translation [79]. Intrinsic and extrinsic muscles serve as fine tuners of motion and power movers by working in "force couples" [79]. The most important force couple involves the subscapularis and posterior rotator cuff, providing a compressive force that centers the humeral head in the glenoid cavity [79]. The teres minor has heightened attention to its contribution to rotator cuff function, particularly when the other cuff tendons fail [79]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [80]. Static restraints of the glenohumeral joint include articular anatomy, glenoid labrum, glenohumeral ligaments, capsule, and negative intraarticular pressure [80]. Dynamic stabilizers of the glenohumeral joint include the rotator cuff and biceps tendon, with scapulothoracic mechanics contributing to stability [80].

Classification

Humeral Bone Loss (HUMBL): The HUMBL classification system categorizes humeral bone loss into five main categories of increasing severity [149]. This system identifies patterns of humeral bone loss associated with various revision, instability, and humeral loosening rates in primary and revision shoulder arthroplasty [149].

• Category 1: Defined as intact or no substantial bone loss, characterized by an intact greater tuberosity and humeral shaft cortex, with bone potentially compromised by prior implants, hardware, or poor bone quality [149].
• Category 2: Defined as isolated greater tuberosity loss or compromise, including acute fracture, nonunion, malunion involving the greater tuberosity, or absence of the greater tuberosity [149].
• Category 3: Defined as segmental bone loss, characterized by cortical bone loss distal to the surgical neck, with or without greater tuberosity compromise [149].
• Category 4: Defined as ectatic bone loss, characterized by pathologic expansion of the endosteal canal compared to an intact proximal or distal segment [149].
• Category 5: Defined as humeral discontinuity, characterized by a separation of a portion of the humeral shaft from a prior implant or where a new implant would be placed [149].

PHAROS: The PHAROS (Proximal Humeral Arthroplasty Revision Osseous inSufficiency) classification system may be useful to anticipate the complexity of humeral reconstruction [30].

McLendon: The McLendon classification for proximal humeral bone loss defines three types based on the extent of bone loss and deltoid integrity [150].

• Type I: Cases of less than 5 cm of bone loss, often with loss of the tuberosities [150].
• Type II: Cases of greater than 5 cm but less than 10 cm of bone loss, in which the majority of the deltoid insertion is intact [150].
• Type III: Cases in which there is greater than 10 cm of bone loss with significant compromise of the deltoid insertion [150].

Other Considerations: Current classification systems exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal [94]. The Walch classification defines a well-centered glenoid as having a humeral subluxation index value of 45% to 55% [56]. In the context of glenoid deficiency, Type A2 glenoids are classified as severe examples of those as defined by the Walch classification [56].

Clinical Presentation

General Presentation and Epidemiology

Patients presenting for revision shoulder arthroplasty are usually dissatisfied with the outcome of the previous arthroplasty as a result of pain [21]. Complaints of poor function due to limited range of motion or instability are also common [21]. Although shoulder arthroplasties are generally designed to last 10-15 years, revisions are being performed at a mean 3.9 years from the primary procedure [3]. The prevalence of primary total shoulder arthroplasty increased by 895% from 2000 to 2017, and subsequent revision TSA increased by 392% from 2002 to 2017 [95].

Causes of Pain and Functional Limitation

Common causes of early pain after shoulder arthroplasty include technical issues related to the surgery, such as malposition or improper sizing of the prosthesis, periprosthetic infection, neurologic injury, and complex regional pain syndrome [21]. Pain presenting after a symptom-free interval may be related to chronic periprosthetic infection, component wear and loosening, glenoid erosion, rotator cuff degeneration, and fracture [21]. Poor range of motion may result from inadequate postoperative rehabilitation, implant-related factors, and heterotopic ossification [21]. Instability is generally caused by rotator cuff deficiency and implant-related factors [21]. Glenoid failure and instability are the most common causes of revision [48]. For anatomical shoulder replacements, the most common indications for revision are rotator cuff insufficiency, dislocation and aseptic loosening [32]. A further common indication for revision of hemiarthroplasty is erosion of the native glenoid [32].

Infection Presentation and Diagnosis

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 [96]. 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 [47]. There are no good preoperative or intraoperative investigations to detect who will have a positive intraoperative culture at the time of revision shoulder arthroplasty [33]. 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 [43]. The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a PJI, with less than 10% meeting ICM criteria for definite PJI [14]. More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females [49]. Cultures taken at revision surgery for failed shoulder arthroplasty are often positive [102]. A positive intraoperative culture result during revision shoulder arthroplasty without other signs of infection has a low risk for recurrence of clinical infection [101].

Outcomes and Prognosis

Although the outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function [6]. 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 [7]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates [24].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder arthroplasty planning [41]. The purpose of shoulder imaging is to help establish the diagnosis, determine the severity of pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition to the patient [41]. The first key radiographic view is the anteroposterior (AP) view in the plane of the scapula, taken so that the x-ray beam passes through the glenohumeral joint [41]. This view shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, narrowing of the joint space, degree of medial displacement of the humerus, quality of bone, presence of loose bodies, and humeral head collapse or deformity [41]. The second key radiographic view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [41]. The axillary view is oriented so that both the spinoglenoid notch and the scapular neck are visible [41]. It demonstrates glenohumeral relationships in the functional position of elevation, referred to as the "truth view" [41]. The standardized axillary view can show posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [41]. The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [41]. The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [41]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [41]. Anteroposterior abduction radiographies up to 90 degrees are superior to conventional radiographies for detecting radiolucent zones and loosening of the glenoid component [160].

CT: CT scans may offer increased precision in measuring glenoid version, but this precision does not necessarily improve the quality of surgery or clinical outcome [41]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the functional axillary view [41]. CT imaging is frequently used to evaluate fractures of the shoulder, assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [89]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [90].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [89]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance arthrograms to provide a more detailed picture of the joint surfaces [89]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [89]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [89]. CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [89].

Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [89]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [89]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [89]. It is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [89].

Infection Workup: 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 [43]. The first large-scale, multicenter study of consecutive revision shoulder arthroplasties analyzed the utility of synovia aspirate analysis and frozen sections [157].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacological interventions for revision shoulder surgery.

Operative

Indications: Shoulder arthroplasties are generally designed to last 10–15 years, yet revisions are being performed at a mean of 3.9 years from the primary procedure [3]. The incidence of shoulder replacement and revision is expected to increase in the following years, constituting a burden for healthcare systems [10]. Although outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function [6].

Surgical Approach / Technique: Shoulder arthroplasty revision is complex, and its planning requires a precise preoperative evaluation indicating the causes of failure, orienting the approach and the gestures that will be associated during the revision surgery [12]. The exposure during revision surgery must follow a series of systematic steps, identifying the key anatomical elements, while remaining as close as possible to the bone structures, in order to avoid any complication and thus ensure the best possible functional result [12].

Implant Selection: Reverse total shoulder arthroplasty is a viable option for a number of shoulder pathologies and can produce good, reliable results [36]. It serves as an efficacious salvage procedure for failed arthroplasty due to rotator cuff-related instability or bone defects [99]. For revision of a failed anatomic arthroplasty to a reverse total shoulder arthroplasty, modest patient results and satisfaction can be achieved [97]. Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty [17]. The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty, although the high percentage of patients with humeral loosening is concerning [38]. The presence or absence of a stem of revised shoulder arthroplasties interferes with the outcome [9]. Nonanatomic reconstruction of the proximal humerus is associated with lower functional outcomes, as well as higher risks of complications and revision [60].

Glenoid Management: Glenoid component revision or simple glenoid component removal both provide satisfactory results with pain improvement in 79% [153]. Custom glenoid components warrant further long-term study given the short-term superior performance in improving pain and higher ASES and Constant scores [35]. 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 [132].

Infection Management: The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a periprosthetic joint infection (PJI), with less than 10% meeting ICM criteria for definite PJI [14]. Clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders [50]. Nearly one-quarter of revision shoulder arthroplasties had unexpected positive cultures, but patients without these cultures had a nonsignificantly higher risk of reoperation compared with those with unexpected positive cultures [66].

Instability and Stabilization: Revision shoulder stabilization is a reliable procedure for patients who have recurrent anterior instability; however, it is unpredictable in patients who have multidirectional instability, with surgical failure and reoperation occurring frequently [13]. Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in a selected patient population [34]. Arthroscopic revision stabilization of the shoulder can result in satisfactory outcomes in patients who have failed previous capsulabral repair [98]. Total shoulder arthroplasty (TSA) resulted in better function and lower revision surgery rates compared to glenohumeral arthrodesis for end-stage shoulder instability, suggesting TSA provides better shoulder mobility while maintaining stability [103].

Stiffness and Rehabilitation: Arthroscopic release can be reliable and repeatedly used for those patients who present with stiffness after shoulder arthroplasty [54]. Postoperative rehabilitation protocols for revision shoulder arthroplasty using modular components varied, with 26 patients immobilized in an abduction splint and the remainder in a sling, with sling or splint duration of use varying from 2–12 weeks [134]. Pendular exercises were commenced after 2 weeks and strengthening commenced after 12 weeks in revision shoulder arthroplasty using modular components [134]. The postoperative protocol for reverse shoulder arthroplasty in revision of failed shoulder arthroplasty included sling immobilisation for three to six weeks, with continuous sling immobilisation necessary for the first three postoperative weeks in patients in whom no subscapularis repair was possible [128].

Other Considerations: Conversion total shoulder arthroplasty is effective for addressing painful glenoid arthrosis after primary humeral head replacement, with or without the need to change the humeral component [100].

Complications

General Complication Profile: Outcomes of revision shoulder arthroplasty are generally inferior to primary reverse total shoulder arthroplasty, with complications and revision surgeries being common [6]. Clinical results of revision shoulder arthroplasty are, in general, inferior to primary shoulder arthroplasty [7]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have higher complication and revision rates compared with those undergoing primary rTSA [24]. Complications and reoperation rates for revision reverse shoulder arthroplasty were higher than those for primary RSA [17]. Revision reverse total shoulder arthroplasty for failed hemiarthroplasty has high overall complication and reintervention rates, specifically for hardware loosening and revision rates [108]. In a small, carefully selected cohort, outpatient revision shoulder arthroplasty has complication profiles comparable to inpatient surgery [27].

Periprosthetic Fracture: Intraoperative humeral fractures occur in approximately 16% of shoulders undergoing revision surgery [51]. These fractures are most common in female patients, those with instability, and those with prior hemiarthroplasty [51]. The National Joint Registry dataset study is the largest registry study to date investigating the incidence and risk factors for intraoperative complications during revision shoulder arthroplasty [16].

Infection (PJI): Nearly one-quarter of revision shoulder arthroplasties had unexpected positive cultures [66]. Patients without unexpected positive cultures had a nonsignificantly higher risk of reoperation compared with those with unexpected positive cultures [66]. Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent [52]. These complications are more common in patients whose initial protocol is IV antibiotics [52].

Instability: Instability after shoulder arthroplasty remains a complication with limited salvage options [45]. Reoperation for instability with anatomic designs has led to high rates of persistent instability [45].

Other Considerations: A high incidence of humeral component malposition is present in cases requiring revision arthroplasty [140]. The presence or absence of a stem in revised shoulder arthroplasties interferes with the outcome [9]. There was a 5.6-fold increase in the annual incidence of revision total shoulder arthroplasty from 2015 to 2024 [55]. The rate of revision shoulder replacement is 3.9–9.9% at 8 years in the UK [32].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling and brace removal timing.

Functional milestones: The provided evidence does not report validated patient-reported outcome trajectories or specific outcome-measure benchmarks such as Constant, ASES, or WOMAC scores.

Other Considerations: Although outcomes are generally inferior to primary reverse total shoulder arthroplasty, revision procedures lead to notable improvements in pain, motion, and function [6]. Careful patient selection and adherence to surgical principles can lead to satisfactory results in revision shoulder arthroplasty [7]. Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision reverse total shoulder arthroplasty from a failed hemiarthroplasty [156]. Revision shoulder arthroplasty for infection demonstrated the least improvement in patient-reported outcomes [15]. Functional outcomes improve after revision surgery for failed primary reverse shoulder arthroplasty, though rates of re-revision and complications are high [59]. The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty, although a high percentage of patients experience humeral loosening [38].

Complications and reoperation rates for revision reverse shoulder arthroplasty are higher than those for primary reverse shoulder arthroplasty [17]. Many unsatisfactory shoulder arthroplasties did not meet traditional criteria for failure, meaning the rate of revision underestimated the rate of failure [8]. Revision shoulder stabilization is a reliable procedure for patients with recurrent anterior instability but is unpredictable in patients with multidirectional instability, where surgical failure and reoperation occur frequently [13].

Revisions are being performed at a mean 3.9 years from the primary procedure, whereas shoulder arthroplasties are generally designed to last 10-15 years [3]. The most common indications for revision of anatomical shoulder replacements are rotator cuff insufficiency, dislocation, and aseptic loosening [32]. Central glenoid bone defects are a common occurrence in revision surgery following previous total shoulder arthroplasty [31]. Glenoid bone loss can be due to previously failed shoulder arthroplasty, repetitive instability, inflammatory arthropathy, or hardware-induced glenoid wear [31].

Two-stage revision procedures and the use of an antibiotic spacer for definitive management of periprosthetic shoulder infections appear to be similar and effective in eradicating infections [53]. In the setting of revision shoulder arthroplasty, the timing of antibiotic administration did not significantly influence culture yield [152].

Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcomes, and glenoid component reinsertion should be attempted whenever possible [19]. All glenoid components remain well fixed with no loss of position noted following patient-specific instrument-assisted structural glenoid bone grafting in reverse shoulder arthroplasty [61]. One patient underwent a successful second-stage implantation of a reverse shoulder arthroplasty after glenoid reconstruction using tricortical iliac crest structural bone graft enhanced with resorbable cement [68]. The natural history of first-time shoulder dislocations is bound up with arthropathy [37].

There was a 5.6-fold increase in the annual incidence of revision total shoulder arthroplasty from 2015 to 2024, with a notable acceleration in recent years [55]. The current Relative Value Unit model does not adequately factor surgical time for revision shoulder arthroplasty, resulting in a notable yearly reimbursement difference that favors primary shoulder arthroplasty [158].

Key Evidence

• [L5] Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage. [1] (10.1007/s12178-014-9249-4)
• [L3] Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years. [2] (10.1302/0301-620x.107b11.bjj-2025-0436.r1)
• [L4] Generally, shoulder arthroplasties are designed to last 10-15 years; however, revisions are being performed at a mean 3.9 years from the primary procedure. [3] (10.1016/j.jse.2019.12.015)
• [L3] Shoulders undergoing secondary revision face a higher risk of failure compared to those undergoing first-time revision surgery. [4] (10.1016/j.jse.2026.04.028)
• [L5] Although the outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function. [6] (10.5435/jaaos-d-17-00535)
• [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. [7] (10.1016/s1048-6666(03)00084-3)
• [L4] Many unsatisfactory shoulder arthroplasties did not meet traditional criteria for failure, and the rate of revision underestimated the rate of failure. [8] (10.1067/mse.2002.125806)
• [L4] Presence or absence of a stem of revised shoulder arthroplasties interferes with the outcome. [9] (10.1007/s12306-017-0467-y)
• [L3] The incidence of shoulder replacement and revision is expected to increase in the following years, constituting a burden for the healthcare systems. [10] (10.1186/s12891-022-05849-x)
• [L4] Revision shoulder arthroplasty for failed HHRH improves functional outcome. [11] (10.1177/1758573217715256)
• [L4] Revision shoulder stabilization is a reliable procedure for patients who have recurrent anterior instability; however, it is unpredictable in patients who have multidirectional instability, with surgical failure and reoperation occurring frequently. [13] (10.1016/s1058-2746(99)90057-5)
• [L3] The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a PJI, with less than 10% meeting ICM criteria for definite PJI. [14] (10.1016/j.jse.2025.01.040)
• [L4] Revision shoulder arthroplasty for infection demonstrated the least improvement in outcomes. [15] (10.1016/j.jor.2018.08.030)
• [L3] This is the largest registry study to date investigating the incidence and risk factors for intraoperative complications during revision shoulder arthroplasty. [16] (10.1177/1758573216685706)
• [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. [17] (10.1016/j.jse.2023.06.039)
• [L3] A massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures. [18] (10.3390/jcm10215123)
• [L4] Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible. [19] (10.1007/s11999-007-0108-0)
• [L5] [21] (10.1016/j.jse.2013.12.003)
• [L4] Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair. [23] (10.1016/j.jse.2014.11.034)
• [L3] Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates. [24] (10.1016/j.jse.2024.09.019)
• [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. [26] (10.1016/j.jse.2008.09.006)
• [L3] In this small, carefully selected cohort, outpatient revision shoulder arthroplasty can be safe and effective with complication profiles comparable to inpatient surgery. [27] (10.1016/j.jsea.2026.100037)
• [L5] Revision total shoulder arthroplasty is technically challenging with inferior results compared to primary arthroplasty, particularly when soft-tissue problems are the indication. [29] (10.5435/jaaos-21-01-23)
• [L3] This classification system may be useful to anticipate the complexity of humeral reconstruction. [30] (10.1097/corr.0000000000000590)
• [L4] [31] (10.1016/j.xrrt.2024.10.006)
• [L1] [32] (10.1177/24715492221095991)
• [L4] The data from this study suggest that there are no good preoperative or intraoperative investigations to detect who will have a positive intraoperative culture at the time of revision shoulder arthroplasty. [33] (10.1016/j.jse.2005.10.001)
• [L4] Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in a selected patient population. [34] (10.1016/j.arthro.2009.04.073)
• [L4] The findings suggest that given the short-term superior performance in improving pain and higher ASES and Constant scores, custom glenoid components warrant further long-term study. [35] (10.1016/j.jse.2026.02.025)
• [Abstract] Reverse total shoulder arthroplasty is a viable option for a number of shoulder pathologies and can produce good, reliable results. [36] (10.1016/j.jse.2014.06.004)
• [Abstract] The natural history of the first time shoulder dislocations is bound up with arthropathy. [37] (10.1016/j.jse.2007.02.100)
• [L4] The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty, although the high percentage of patients with humeral loosening is concerning. [38] (10.1016/j.jse.2016.05.015)
• [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. [43] (10.1016/j.jse.2014.10.005)
• [L4] [45] (10.1007/s11999-017-5429-z)
• [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. [47] (10.1016/j.jseint.2025.02.005)
• [L4] Glenoid failure and instability are the most common causes of revision. [48] (10.1016/j.jse.2019.07.034)
• [L4] More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females. [49] (10.1016/j.jse.2023.07.025)
• [L3] Clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. [50] (10.2106/jbjs.16.00149)
• [L3] Intraoperative humeral fractures occur in approximately 16% of shoulders undergoing revision surgery and are most common in female patients, those with instability, and those with prior hemiarthroplasty. [51] (10.1007/s11999-015-4448-x)
• [L4] Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. [52] (10.2106/jbjs.19.00846)
• [L3] Two-stage revision procedures and use of an antibiotic spacer for definitive management of periprosthetic shoulder infections appear to be similar and effective in eradicating infections. [53] (10.1016/j.jse.2019.03.001)
• [L5] The authors feel this procedure can be reliable and repeatedly used for those patients who present with stiffness after shoulder arthroplasty. [54] (10.1097/bte.0000000000000001)
• [L3] The study demonstrated a 5.6-fold increase in the annual incidence of revision total shoulder arthroplasty from 2015 to 2024, with a notable acceleration in recent years. [55] (10.1016/j.jse.2026.01.017)
• [L4] [56] (10.1016/j.jse.2015.12.010)
• [L3] Proper patient selection and attention to technical details are needed to reduce the currently high complication rate associated with reverse total shoulder arthroplasty. [57] (10.5435/jaaos-d-21-01090)
• [L1] We found an improvement in functional outcomes after revision surgery, but the rates of re-­revision and complications are high and warrant consideration when planning a revision procedure. [59] (10.1302/0301-620x.106b11.bjj-2024-0032.r1)
• [L4] Nonanatomic reconstruction of the proximal humerus is associated with lower functional outcomes, as well as higher risks of complications and revision. [60] (10.1016/j.jse.2021.06.002)
• [L4] All glenoid components remain well fixed, with no loss of position noted. [61] (10.1097/bte.0000000000000123)
• [L3] Nearly one-quarter of revision shoulder arthroplasties had unexpected positive cultures, but patients without these cultures had a nonsignificantly higher risk of reoperation compared with those with unexpected positive cultures. [66] (10.1016/j.jse.2016.10.023)
• [L4] One patient underwent a successful second-stage implantation of a reverse shoulder arthroplasty after glenoid reconstruction. [68] (10.1097/bte.0b013e31820b3517)
• [Paper] Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal. [94] (10.1016/j.jseint.2024.08.170)
• [L3] [95] (10.1177/17585732241263753)
• [L3] [96] (10.1016/j.jse.2026.04.036)
• [L4] Modest patient results and satisfaction can be achieved with revision of a failed anatomic arthroplasty to a reverse total shoulder arthroplasty. [97] (10.1016/j.jse.2018.10.026)
• [L3] Arthroscopic revision stabilization of the shoulder can result in satisfactory outcomes in patients who have failed previous capsulabral repair. [98] (10.1177/2325967115s00012)
• [L4] Reverse shoulder arthroplasty is an efficacious salvage procedure for failed arthroplasty due to rotator cuff-related instability or bone defects. [99] (10.1016/j.jse.2011.11.021)
• [L4] Conversion total shoulder arthroplasty is effective for addressing painful glenoid arthrosis after primary humeral head replacement, with or without the need to change the humeral component. [100] (10.1016/j.jse.2011.01.024)
• [L4] We found that a positive intraoperative culture result during revision shoulder arthroplasty without other signs of infection has a low risk for recurrence of clinical infection. [101] (10.1016/j.jse.2011.08.052)
• [L4] Cultures taken at revision surgery for failed shoulder arthroplasty are often positive, and our findings document the importance of these positive cultures. [102] (10.1007/s11999-009-0875-x)
• [L2] TSA resulted in better function and lower revision surgery rates, suggesting TSA provides better shoulder mobility while maintaining stability. [103] (10.1016/j.jseint.2025.101429)
• [L2] This systematic review found that revision reverse total shoulder arthroplasty for failed hemiarthroplasty has a high overall complication and reintervention rates, specifically for hardware loosening and revision rates. [108] (10.1177/17585732211019390)
• [L3] Patients at high risk of complications and readmission after revision total shoulder arthroplasty should be identified and optimized preoperatively to improve outcomes and lower costs. [124] (10.1177/1758573218780517)
• [Paper] [128] (10.1007/s00264-012-1742-z)
• [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. [132] (10.1016/j.jse.2013.06.001)
• [L4] [134] (10.1016/j.jse.2025.03.031)
• [L4] The study highlights the previously underappreciated high incidence of humeral component malposition in cases requiring revision arthroplasty. [140] (10.1016/j.jse.2024.11.015)
• [L4] [149] (10.1016/j.jse.2026.06.021)
• [L4] [150] (10.1016/j.jse.2018.10.023)
• [L3] In the setting of revision shoulder arthroplasty, timing of antibiotic administration did not significantly influence culture yield. [152] (10.1016/j.jse.2023.05.005)
• [L4] Glenoid component revision or simple glenoid component removal both provide satisfactory results with pain improvement in 79%. [153] (10.1016/s1058-2746(96)80411-3)
• [L4] Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. [156] (10.1016/j.jse.2017.06.038)
• [L2] This is the first large-scale, multicenter study of consecutive revision shoulder arthroplasties analyzing the utility of synovia aspirate analysis and frozen sections. [157] (10.1016/j.jse.2026.05.005)
• [L3] The current RVU model does not adequately factor surgical time for revision shoulder arthroplasty and translates to a notable yearly reimbursement difference that favors primary shoulder arthroplasty. [158] (10.5435/jaaos-d-21-00466)
• [L4] Anteroposterior abduction radiographies up to 90 degrees are superior to conventional radiographies for detecting both radiolucent zones (78 per cent) and loosening of the glenoid component (15.5 per cent). [160] (10.1016/s1058-2746(96)80401-0)

See Also

• Shoulder Arthroplasty
• Reverse Shoulder Arthroplasty
• Total shoulder arthroplasty
• Rotator Cuff
• Fractures
• Shoulder Arthritis
• Shoulder Instability
• Revision shoulder replacement

References

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