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Shoulder Arthroplasty

Reverse total shoulder arthroplasty for cuff tear arthropathy, complex fractures, and arthritis — comparing stemmed vs stemless humeral components.

239 citationsUpdated Nov 2026

Overview

Shoulder arthroplasty is an effective and safe treatment option, with safety profiles comparable to more commonly performed major joint arthroplasties [25, 7]. For degenerative joint disease, total shoulder arthroplasty provides substantial and durable functional improvement [52], while outcomes following anatomic total shoulder arthroplasty have proven durable and reproducible [209]. The procedure also represents a safe and reliable option for symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable satisfaction [33]. In cuff-deficient shoulders, reverse shoulder arthroplasty has been highly successful, with indications continuing to broaden [48]. Outpatient shoulder arthroplasty is a safe option for appropriately selected patients [44], and outpatient total shoulder arthroplasty serves as a safe and cost-effective alternative to inpatient care in this population [208].

Clinical outcomes vary based on surgical history and revision status. Shoulder arthroplasty performed after prior shoulder surgery results in overall clinically improved outcomes, although these results are inferior compared to patients without a history of prior shoulder surgery [39]. While clinical results of revision shoulder arthroplasty are generally inferior to primary shoulder arthroplasty, careful patient selection and adherence to surgical principles can lead to satisfactory results [55]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [179]. Specifically, when glenoid component revision is the indication for revision total shoulder replacement, patients tend to achieve good to excellent results [210]. At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty [43], and there was no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications [207].

Optimized patient outcomes depend on knowledge of the array of shoulder prostheses currently available, their specific indications, and the use of treatment algorithms [53]. 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 [54]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty [203]. While early results of computer-assisted navigation in shoulder arthroplasty are promising, further long-term studies are needed to fully assess its value and establish best practices for its routine use [41]. Additionally, implant design, evidence level, and indications for reverse shoulder arthroplasty changed significantly over two decades, alongside, but not statistically linked to, complication reporting [56].

Anatomy & Pathophysiology

Bony Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [73]. The articular head is spherical with a diameter of 37 to 57 mm [73]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [73], while the superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [83]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [83]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [83].

Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [73]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [73]. The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [83]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [75]. Additionally, the humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [86].

The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [73]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [73]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [73]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [73]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [83].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [73]. The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [74]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [75].

The scapula spans second through seventh ribs and serves as an attachment for 17 muscles [86]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [86]. The clavicle is the first bone to ossify (fifth week of gestation) and is the only long bone to ossify by intramembranous ossification [75]. The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [75]. The acromion has three ossification centers: the metacromion (base), the mesoacromion (middle), and the preacromion (tip) [75]. Failure of fusion of the acromial ossification centers results in os acromiale [75].

The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [75]. The proximal humeral ossification centers fuse to the shaft at age 17 to 20 years [75]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [79]. Humeral retroversion averages 65 degrees in infants and young children and gradually decreases, approaching adult values by 11 years of age [79]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis, accounting for approximately 40% of the growth of the entire upper extremity [79].

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 [73]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [73]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [75]. 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 [74]. The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [73]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [75]. 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 [73].

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 [73]. Recent quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [79]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [73]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [73].

Soft Tissue Anatomy

The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus, and teres minor [74]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [74]. The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [74]. The subscapularis is the largest and strongest of the rotator cuff tendons [246]. The subscapularis is responsible for active internal rotation of the humerus and contributes to the stability of the shoulder [246]. The subscapularis forms the anterior portion of the transverse plane “force couple” of the rotator cuff [246].

The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [84]. The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [84]. The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [84]. The infraspinatus and teres minor fuse near their musculotendinous junctions [84].

The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [86]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [86]. The coracoacromial ligament is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [86].

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 [84]. 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 [84]. 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 [91].

The shoulder capsule is large and has twice the surface area of the humeral head [91]. The shoulder capsule typically accepts approximately 28 to 35 mL of fluid, with a greater amount in women than in men [91]. In patients with adhesive capsulitis, the shoulder capsule accepts only 5 mL or less of fluid [91]. The capsule is lined by synovium and extends from the glenoid neck (or occasionally the labrum) to the anatomic neck and the proximal shaft of the humerus [91]. The capsule often extends and attaches to the coracoid process superiorly via the coracohumeral ligament [91]. 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 [91]. The rotator cuff tendons blend into the capsule over varying lengths and average approximately 2.5 cm [91].

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 [76]. 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 [76]. The subscapular bursa often houses loose bodies in the shoulder and is a region in which synovitis of the shoulder may be most intense [76].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [75]. The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [75]. Laxity of the rotator interval results in inferior laxity (the sulcus sign) [75]. Contracture of the rotator interval is seen with adhesive capsulitis [75]. The average area of the rotator interval is 20.96 mm [76]. Dynamic testing has shown that the subscapularis and supraspinatus dimensions as well as the total area of the rotator interval decrease significantly with internal rotation and open with external rotation [76].

Ligaments and Stability

The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [75]. The fibrocartilaginous glenoid labrum deepens the socket by 50% around the humeral head and increases stability [84]. 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 [84]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [84].

The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [75]. 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 [84]. 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 [75].

The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [75]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [75]. 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 [84]. The middle glenohumeral ligament is absent in up to 30% of shoulders [86].

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 [84]. 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 (position of apprehension) [75]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [75]. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out [84]. With internal rotation, the opposite occurs to the inferior glenohumeral ligament bands [84]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [84]. Tightening of the rotator interval decreases posterior and inferior translation [84].

The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability of the sternoclavicular joint [86]. The coracoclavicular ligaments prevent superior displacement of the distal clavicle [86]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [86]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [86]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior (horizontal) translation of the clavicle [75]. The coracoclavicular ligaments (conoid: medial; trapezoid: lateral) are the primary stabilizers to superior (vertical) translation of the distal clavicle [75]. The posterior SC joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [75].

Nerve Anatomy

The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [78]. The axillary nerve passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [78]. The axillary nerve is adjacent to the inferior capsule before entering the quadrilateral space posteriorly [78]. The axillary nerve splits into the anterior and posterior branches within the quadrangular space [78]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [78]. Posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [78]. The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [78].

In the anterior deltopectoral approach, the axillary nerve can be palpated by sweeping a finger inferiorly across the subscapularis muscle tendon interface [78]. In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [78]. In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [78].

The suprascapular artery runs superior to the superior transverse scapular ligament, and the suprascapular nerve runs deep to the ligament at the suprascapular notch [75]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [75]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [75]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [75].

The brachial plexus and axillary artery are anterior to the coracoid process of the scapula and humeral head [74]. Nerves innervating muscles around the shoulder include the axillary, suprascapular, subscapular, and musculocutaneous nerves [74]. The radial nerve is commonly injured in humeral shaft fractures, particularly at the junction of the

Classification

Glenoid Morphology and Osteoarthritis

Samilson-Prietro: This is the most widely adopted radiographic classification for determining the extent of osteoarthritis of the glenohumeral joint [69]. 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 [69].

Walch: This classification allows for fair to substantial agreement in grading glenoid wear patterns [292]. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses than the Walch classification [227]. In a study of anatomic total shoulder arthroplasty with keeled glenoids in patients younger than 60 years, there were no significant differences in survival or glenoid loosening rates between Walch type A and B/C glenoids at long-term follow-up [292]. In a separate study of anatomic total shoulder arthroplasty, preoperative osteoarthritis was graded at the highest level in most shoulders across four different classifications, and the distribution across stages within each classification did not differ significantly [100].

Rotator Cuff Integrity

Hamada-Fukuda: This radiographic morphological description of the natural course of massive rotator cuff tear assesses the height of the acromiohumeral space [69]. Type 1 indicates normal joint morphology and an acromiohumeral distance of more than 6 mm [69].

Scapular Notching

Nerot-Sirveaux: This is the most commonly used grading system to define the extent of scapular notching in reverse shoulder arthroplasty [9]. Scapular notching is identified as the osseous defect of the lateral scapular pillar and neck created by impingement of the humeral component when the arm is adducted [9]. Grade 1 notching concerns only the scapular pillar; grade 2 is demarcated by erosion to the inferior screw of the baseplate; grade 3 describes erosion beyond the inferior screw; and grade 4 describes progression of the defect to the central baseplate peg [9]. Some authors prefer to simplify the Nerot-Sirveaux classification by regrouping grades 1 and 2 into a single group and grades 3 and 4 into another group [9]. In a study of reverse shoulder arthroplasty, inferior scapular notching was detected in 43% of patients, with grade 1 in 28%, grade 2 in 4%, grade 3 in 7%, and grade 4 in 5% [322]. Patients with no inferior overlap of the glenosphere had a significantly higher incidence of inferior scapular notching (73%) compared to those with mild overlap (35%) [322]. Patients with pronounced glenosphere overlap had a significantly lower incidence of scapular notching (7%) compared to patients with mild overlap [322].

Complications and Infection

Complication Categories: A system of three complication categories was introduced to standardize the presentation of complications in shoulder arthroplasty, where category 1 includes intraoperative findings or events treated during index surgery or not requiring revision [21]. The overall complication rate in a study of 485 shoulder arthroplasty cases was 11.6% [21]. A clear standardised set of shoulder arthroplasty complication definitions is lacking [194].

Infection Criteria: The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these complications [40]. The 2018 ICM shoulder infection criteria provided a new scoring system to diagnose periprosthetic joint infection, with Cutibacterium acnes identified as the most common infectious organism [219]. Less than 10% of revision shoulder arthroplasties meet ICM criteria for definite periprosthetic joint infection [223].

Revision and Bone Loss

PHAROS: The PHAROS (Proximal Humeral Arthroplasty Revision Osseous inSufficiency) classification system may be useful to anticipate the complexity of humeral reconstruction in revision total shoulder arthroplasty [133].

Glenoid Bone Loss: A proposed classification system for glenoid bone loss is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty [103]. Current classification systems demonstrate limited reliability for assessing glenoid defects in the context of revision reverse total shoulder arthroplasty [146]. Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal [169]. The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system [204]. A proposed 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 [98].

Fracture Sequelae

Proximal Humerus Fracture Sequelae: Four basic pathophysiologic types of lesions were distinguished to categorize the sequelae of fractures of the proximal humerus, allowing these sequelae to be grouped for consistent comparison [70].

Larsen: This classification grades rheumatoid arthritis shoulder disease, where grade I represents medium destructive abnormality with erosions and joint space narrowing, grade IV includes severe destructive abnormality with bone deformation, and grade V includes a mutilating abnormality where the original articular surface has disappeared [345].

Radiographic Outcomes and Loosening

Glenoid Radiolucency: Radiolucent lines around glenoid components are graded on a 0–5 scale, with Grade 0 representing no radiolucency, Grade 1 showing radiolucency at the superior and/or inferior flange, Grade 2 showing radiolucency at the keel, Grade 3 with complete radiolucency 2 mm wide around the keel, Grade 4 with complete radiolucency >2mm wide around the keel, and Grade 5 with gross loosening [307].

Metallic Debris: Metallic debris is graded on a 0–4 scale, with Grade 0 meaning no radiographic evidence, Grade 1 meaning debris only at the bone–metal interface, Grade 2 meaning debris noted in the soft tissues intra-articularly, Grade 3 meaning incomplete fracture or cracking of the component, and Grade 4 meaning complete component fracture and displacement [307].

Humeral Stem Radiolucency: Humeral stem radiolucencies are graded on a scale where grade 4 indicates a specific level of radiolucency, and stems with grade 4 lucent lines or shifted position may be classified as at risk [275].

Clinical Presentation

General Evaluation and History

Evaluating failed shoulder arthroplasty requires a thorough, systematic approach integrating history, physical examination, and diagnostic studies, as pain and disability are often multifactorial [115]. Patients with unsatisfactory outcomes typically present with poor shoulder function and pain [8]. The diagnosis of a stiff shoulder relies on clinical awareness, with history and physical examination being paramount [5]. Preoperative clinical examination and radiological assessment are fundamental for anticipating specific difficulties in glenoid exposure [34] and recognizing altered glenoid morphology or diminished bone stock [28]. Surgeons must also be familiar with the clinical manifestations of fibrous dysplasia and its unique surgical challenges [171].

Systemic comorbidities significantly influence presentation and outcomes. A preoperative diagnosis of stroke is associated with higher rates of perioperative complications and mortality compared to matched cohorts [138]. Patients presenting from areas of higher social deprivation experience higher complication rates following primary total shoulder arthroplasty [20]. Conversely, patients with a diagnosis of depression should be counseled that they will experience significant clinical improvement from baseline after total shoulder arthroplasty [145].

Painful Shoulder Arthroplasty

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 most common complications after anatomic total shoulder arthroplasty are component loosening, glenoid wear, instability, rotator cuff tear, periprosthetic fracture, neural injury, infection, hematoma, deltoid injury, and venous thromboembolism [150]. While 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 [11], complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage [23]. An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival [149].

Radiographic osteolysis may not initially manifest clinically apparent symptoms but can lead to clinically important complications, such as aseptic loosening [3]. Symptoms of osteolysis often progress to vague pain or discomfort due to subtle component loosening [3]. Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs [16]. Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%) [38]. The utility of ultrasound examination of the subscapularis tendon following shoulder arthroplasty is limited by timing and may be most useful when used by the physician within clinical context [152].

In young patients, early results of total shoulder arthroplasty for shoulder chondrolysis show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop [10]. 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 [121].

Periprosthetic Joint Infection (PJI)

The clinical presentation of periprosthetic joint infection (PJI) of the shoulder varies widely, from obvious infection with gross purulence and sinus tract formation to insidious presentations of stiffness and pain without overt signs of infection [137]. Patients with indolent PJI due to C. acnes or other similar organisms do not typically have acute symptoms and instead present later after surgery with more subtle symptoms [153]. Shoulder arthroplasty performed on the male population must be carefully checked after surgery for the possible presence of P. acnes [154]. Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology [166].

Diagnostic testing for PJI presents significant challenges. 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 [123]. Joint aspiration and culture findings are unreliable, with only a 16.7% sensitivity [136]. 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]. In a patient with normal labs, no lucency on radiographs, and a negative or dry aspiration, other causes of pain such as acromial stress reaction or fracture should be ruled out, and repeat evaluation recommended to detect progressive lucency/loosening [153].

The 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 [126]. 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 [26]. 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 [108]. The evaluation workup and criteria used to diagnose shoulder PJI remain inconsistent [27]. The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications [40]. While the 2018 International Consensus Meeting criteria have strengthened validation, many studies have not adopted them, affecting reported sensitivities and specificities [117].

Periprosthetic Fractures

Diagnosis of periprosthetic fractures is often subtle and requires a high index of suspicion [288]. Typically, patients will present around their 8th decade of life after a sudden increase in pain or loss of function in an otherwise smooth postoperative course [288]. This is generally within 1 year but up to 2 years from surgery [288]. Patients who go on to have periprosthetic scapular fractures initially outperform those who don't [288].

In the case of a stress reaction, new pain at the base of the acromion may be the only finding, and should raise suspicion and spark further imaging or a period of rest [288]. Often these stress fractures can actually be more painful than after it propagates into a displaced fracture [288]. Deformity is concerning for dislocation, hematoma, or displaced fracture [288]. Erythema or incisional dehiscence is concerning for infection [288]. Tenderness along the acromion or scapular spine raises suspicion for fracture which should be confirmed with imaging [288]. Fracture can result in motion limited by pain, new weakness, or loss of function [288]. A sudden loss of function or increase in pain is consistent with both scapular fracture and infection and should trigger further workup [288].

Workup for periprosthetic humeral fractures should begin with a thorough history including review of the operative note, and underlying diagnosis [235]. Any red flags concern for periprosthetic infection should be ruled out and a clear understanding of preinjury shoulder function should be elicited [235]. History should identify risk factors for nonunion such as smoking that has not only been correlated with nonunion but also with periprosthetic infection, higher overall complications, and periprosthetic fracture [235]. Bone fragility workup and treatment is mandatory in all low-energy fractures and females over age 60 [235].

Inspection should note open fractures, pallor, and deformity, as well as muscle wasting (supraspinatus fossa, infraspinatus fossa, and deltoid flattening) [235]. Anterosuperior escape of a previous TSA or hemiarthroplasty can often be identified clinically in thin individuals [235]. Specific attention should be paid to the axillary nerve, since many of these patients may require conversion to an RSA which is dependent on a functional deltoid neuromuscular unit [235]. Most acute traumatic axillary nerve palsies are neuropraxias and have a good natural history [235]. When injury is suspected and the surgeon is considering revision to an RSA, an electromyogram (EMG) may better elicit the status of the nerve and prognosticate recovery prior to proceeding [235].

Diagnostic Arthroscopy

Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations [18]. 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 [19]. 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 [31]. 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 [104]. 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 [147].

Diagnostic arthroscopy supports considering it in the evaluation of painful anatomic shoulder arthroplasties when there is a high likelihood of infection but cultures of aspirated fluid are negative [157]. Arthroscopically obtained tissue biopsies offer high sensitivity and specificity in the diagnosis of periprosthetic shoulder infections [150]. An infection must be considered if at least 2 cultures are positive for the same microorganism [150].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder arthroplasty planning [6]. Radiographs are the first imaging modality used to evaluate the presence and degree of arthritis of the glenohumeral joint [69]. Common projections include an anteroposterior view, a Grashey view, and an axillary view [69]. The anteroposterior view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, joint space narrowing, degree of medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [6]. The Grashey view is obtained by a 30° lateral oblique projection, tangential to the glenohumeral joint, to obtain a view directly parallel to the glenoid face [69]. The status of the rotator cuff can be inferred by radiographic evaluation on the Grashey view [69]. The Samilson-Prietro classification is the most widely adopted classification to determine the extent of osteoarthritis of the glenohumeral joint [69]. The Hamada-Fukuda classification is a radiographic morphological description of the natural course of massive rotator cuff tear assessing the height of the acromiohumeral space [69].

The axillary view taken with the arm in the functional position of elevation is referred to as the "truth view" because it demonstrates glenohumeral relationships in the functional position [6]. The standardized axillary "truth view" can show posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [6]. 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 [6]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [6]. Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible [357].

CT: CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not necessarily improve the quality of the surgery or the clinical outcome [6]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary "truth view" which is taken in elevation [6]. Three-dimensional reconstructions can reveal fine details of shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [6]. 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 [148]. 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 [158]. 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 [215]. Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients [37].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [148]. 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 [148]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [148]. MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty [198]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [338].

Arthrography and Arthroscopy: 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 [148]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [148]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [148]. Arthroscopy is a valuable tool for identifying loosening missed by computed tomography arthrography in painful total shoulder arthroplasty [362].

Ultrasound: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [148]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [148]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [148]. Ultrasonography can evaluate impingement in various positions and motions due to real-time imaging [148]. Ultrasonography 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 [148]. Sonography is a useful tool for examining soft tissues after shoulder arthroplasty in order to demonstrate pathological changes and is not negatively affected by the implant [365].

Infection Workup: The evaluation workup and criteria used to diagnose shoulder periprosthetic joint infection remain inconsistent [27].

Monitoring and Registries: A structured core set of radiographic parameters has been developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty [29]. An algorithm exists to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries [51].

Other Considerations: Fluoroscopically positioned localized views are recommended to supplement plain shoulder radiographs of total shoulder arthroplasties at the first follow-up visit and at subsequent visits [341]. Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care [364]. Elimination of immediate postoperative radiographs and their interpretation after shoulder arthroplasty may reduce charges without changing clinical care [364]. Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty [379]. CT scans are often needed to identify acromial fractures after reverse total shoulder arthroplasty [379]. No signs of loosening were observed in 88% of patients with an uncemented all-polyethylene glenoid on computed tomography scans [377].

Treatment

Non-Operative

Nonoperative management is a prerequisite for surgical intervention in specific indications; reverse total shoulder arthroplasty is indicated for patients with cuff tear arthropathy who do not have a repair option and when nonoperative management has failed [306].

Operative

Indications: 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 [304]. However, nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty [321]. Younger patients 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 [303]. Previous lower extremity periprosthetic joint infection should not be considered a relative contraindication to shoulder arthroplasty [35], and axillary lymph node dissection is not a contraindication [156]. In the presence of previous non-arthroplasty operative interventions, there is a significantly higher risk for infection in shoulders undergoing reverse total shoulder arthroplasty [294]. A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with diabetes is critical [143].

Surgical Approach / Technique: Preoperative clinical examination and radiological assessment are fundamental to anticipating specific difficulties in glenoid exposure [34]. The long deltopectoral approach is the standard surgical exposure for shoulder arthroplasty in osteoarthritis and rheumatoid arthritis [344] and is generally preferred for accessing the glenohumeral joint during reverse shoulder arthroplasty [348]. The anteromedial approach is a reliable technique to improve surgical exposure in difficult cases [90], while the superior approach provides good exposure with a low rate of complication [125]. The anterosuperior approach uses a more limited superiorly based incision and a deltoid split, with potential advantages including greater tuberosity access [349]. Total shoulder arthroplasty performed entirely through the rotator interval (subscapularis-sparing approach) has been used to potentially reduce postoperative subscapularis failure [354]. Glenoid exposure is a key step that should offer frontal access to allow ancillary tools to be used freely and facilitate good positioning of the glenoid implant [165]. The glenoid is not adequately exposed until the anterior, posterior, superior, and inferior aspects of the glenoid can be seen [243]. The creation of the anterior cortical window is an excellent technique for selecting cases of revision total shoulder arthroplasty [167]. 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 [151]. 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 [36].

Implant Selection: Knowledge of the array of shoulder prostheses currently available and the indications for each can lead to optimized patient outcomes [53]. The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual [231]. Restoration of glenohumeral mobility and stability is the priority rather than trying to recreate "normal anatomy" [62]. The ideal humeral component allows secure and durable placement of an ample articular surface in the position that optimizes glenohumeral motion and stability [13]. Head replacement prostheses allow extensive versatility in the selection of the humeral head component and excellent access to the glenoid bone [13]. Partial resurfacing prostheses create a major discontinuity in the deformation of the joint surface under load at the margin of the prosthesis due to the modulus of elasticity difference between metal and cartilage [13]. Registry data indicate a 2.5-year revision rate for resurfacing prostheses, which is more than three times the revision rate for stemmed hemiarthroplasty [13]. Reverse total shoulder arthroplasty has become the standard of care for patients with cuff tear arthropathy who do not have a repair option and when nonoperative management has failed [306]. The CTA prosthesis remains a favored option for active individuals without anterosuperior escape and with more than 90 degrees of active elevation before surgery [14]. The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency [49]. Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis [161]. 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 [301]. Total Shoulder Arthroplasty with an all-polyethylene, pegged glenoid component, utilising hybrid fixation, demonstrates excellent clinical and radiological outcomes at long term follow-up [277]. Shoulder arthroplasty with an all-polyethylene, hybrid-fixation (bone ingrowth and cement) pegged glenoid component has durable clinical and radiographic outcomes at medium-term follow-up [291]. 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 [278]. 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 [302]. The materials that are used in total shoulder arthroplasty implants have been carefully chosen in an attempt to minimize hardware-related complications [286].

Alignment / Balancing Strategy: With posterior pressure on the lesser tuberosity, the ideal cuff tension allows the humeral head to translate approximately 50% of the glenoid component width and then recenter it when pressure is removed [243]. Cement cannot be used to adjust for poor seating of the glenoid component [243].

Pain Management: Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist [199]. The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings [206]. 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 [218]. In patients undergoing shoulder arthroplasty, a non-opioid, multimodal pain protocol provided non-inferior pain relief compared to an opioid-based regimen [232]. Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen [226]. Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty [244]. With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets [279]. 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 [272]. 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 [273]. Anatomic total shoulder arthroplasty in general provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively [315]. Local infiltration analgesia and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty [287]. When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of liposomal bupivacaine to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine [318]. Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement [248].

Adjuncts: Robotic-assisted arthroplasty is now available for shoulder arthroplasty with some limitations, and shoulder surgeons should become familiar with the nature of this technology, potential benefits and disadvantages, and the surgical techniques employed [164].

Setting of Care: Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty [276]. Prolonged length of stay after shoulder arthroplasty is multifactorial, with non-modifiable demographic factors compounded by modifiable social and structural elements [331].

Revision: The creation of the anterior cortical window is an excellent technique to implement in selecting cases of revision total shoulder arthroplasty [167]. Two-stage reimplantation remains the gold standard for chronic infections of the shoulder arthroplasty [12]. P. acnes can be slow growing and the average time to a positive culture can be greater than 5 days, requiring cultures to be kept for a minimum of 10 to 14 days [12]. Preoperative blood work and aspiration are less reliable in determining whether a shoulder prosthesis is infected compared to hip or knee prostheses [12].

Other Considerations: The most common intraoperative complications in shoulder arthroplasty are fracture, usually of the humeral shaft in the mid to distal diaphysis; nerve injury, most often to the axillary nerve; and malpositioning of components [68]. Simple cerclage wiring of the proximal end of the humerus and implantation of a standard-size prosthesis usually are sufficient for fractures proximal to the tip of the humeral prosthesis [68]. The use of a longer stem prosthesis, extending at least two humeral cortical diameters beyond the most distal extent of the fracture, has advantages over dynamic compression plating or cerclage wiring alone for unstable intraoperative humeral fractures [68]. Fractures of the glenoid are extremely rare and usually occur in osteopenic bone [68]. Suture cerclage may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty [299]. Under optimal circumstances simultaneous shoulder arthroplasty is feasible [175]. Complications of shoulder arthroplasty depend on the prosthesis type used [46]. With advances in implant design and techniques, the complication profile after anatomic shoulder arthroplasty is changing and outcomes are improving [160]. Scapular notching in reverse shoulder arthroplasty is identified as the osseous defect of the lateral scapular pillar and neck that is created by impingement of the humeral component when the arm is adducted [9]. Heterotopic ossification after reverse shoulder arthroplasty is a non-progressive condition without long-term clinical consequences [326]. 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 [285]. The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [282]. Arthroscopy can serve as both a diagnostic and therapeutic tool for patients who have pain after shoulder arthroplasty [59]. Failure of standard investigations to identify the cause of pain after shoulder arthroplasty is an indication for diagnostic arthroscopy [59]. Arthroscopic examination for more than 2 mm of motion at the interface correctly diagnosed all five of the loose glenoid components in a reported series [59]. Periprosthetic fracture around the glenoid component is rare; when it occurs, it typically occurs intraoperatively [67]. Most periprosthetic fractures associated with shoulder arthroplasty occur on the humeral side [67]. Nonsurgical management is an option for all periprosthetic humeral fracture types and especially for patients with several comorbidities, minimal function, and/or minimal displacement [67]. Patients with type A fractures with minimal displacement can be managed with a protocol similar to that used for nonsurgical rotator cuff management [67]. For type A, B, and even C fractures with a loose implant, some surgeons have recommended exchange for a longer implant to bypass the fracture by at least two cortical diameters [67]. Surgical management of periprosthetic fractures around a stable humeral implant is amenable to open reduction and internal fixation (ORIF) with several options for fixation [67]. A plate of an appropriate size and length should not only span the fracture but also provide adequate overlap with the implant to avoid gaps that can be stress risers [67]. Nondisplaced or minimally displaced fractures about a stable humeral implant are indications for nonoperative treatment [274]. Open fracture, polytrauma, periprosthetic infection, humeral component loosening, failure of conservative management, upper extremity weight-bearing, and premorbid shoulder arthroplasty dysfunction are relative contraindications for nonoperative treatment of periprosthetic humeral fractures [274]. Greater tuberosity fractures are generally associated with stable implants and can be managed nonoperatively if minimally displaced [274]. Fracture about the stem (Wright and Cofield types A and B) are suspicious for humeral loosening and should be interrogated clinically and radiographically [274]. Nonoperative management of periprosthetic humeral fractures requires a period of shoulder immobilization which can lead to a decrease in glenohumeral function [274]. In patients with a shoulder replacement, the number of shoulder elevations > 60° on the operative side approaches 1.0 Mc per year [144]. Total shoulder arthroplasty can provide substantial and durable improvement in shoulder function [52]. The preponderance of evidence suggests that total shoulder arthroplasty generally provides superior results in terms of patient satisfaction, function, and strength compared to hemiarthroplasty, especially at longer-term follow-up [352]. Loosening of the glenoid component has been reported in almost half of shoulders at more than 10-year follow-up and is often associated with pain [352]. The durability of total shoulder replacement is similar to that of hip and knee replacements, with 85% component retention at 20 years of follow-up and revision rates for all causes averaging less than 10% [352]. Shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties [7]. Shoulder arthroplasty is now an effective and safe treatment option [25]. Anatomic shoulder arthroplasty remains an attractive option for primary arthroplasty in selected cases [122]. These findings should be considered when choosing a shoulder arthroplasty technique with non-oncologic indications [24]. 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]. The goal of this special issue is to provide the reader with an understanding of the best practices in shoulder arthroplasty in 2016, and to address some of the current controversies in the field [2]. This article discusses the designs of prostheses used around the shoulder joint, delineates indications and alternatives for each of the different types of hardware, reviews radiographic and cross-sectional preoperative imaging of shoulder arthroplasty, illustrates normal postoperative imaging findings and measurements, and provides examples of hardware complications [4]. Implant design, evidence level, and indications changed significantly, alongside, but not statistically linked to, complication reporting, informing future

Complications

Overall Rates and Trends: The overall complication rate after total shoulder arthroplasty (TSA) is approximately 15% [58], with specific rates of 10% for anatomic TSA (ATSA) and 16% for reverse TSA (RTSA) [270]. Complication rates have declined significantly over the past decade, marked by a striking diminution of component loosening [400, 270]. Primary shoulder arthroplasty is associated with low 90-day reoperation and complication rates [63], and short-term reoperation remains infrequent [107]. The 1-year mortality rate is approximately 1% [270], while readmission within the first 90 days occurs in 5.9% of patients, with a 1% incidence of never events [389]. In the Kaiser Permanente Shoulder Arthroplasty Registry, 200 all-cause revisions (4%) were reported in elective procedures [404]. Cumulative revision rates exceed 20% at 8 years, influenced by primary type, class, and revision type [50]. Although complication and reoperation rates are higher in patients with anterior instability arthropathy compared to primary glenohumeral arthritis, this difference is not statistically significant [101]. The relative risk of revision after failed osteosynthesis is 2, using primary arthroplasty for fracture as reference [391]. Higher complication rates are observed in patients from areas of higher social deprivation [20], and male patients have significantly higher odds of adverse events, death, myocardial infarction, and sepsis [411]. Long-term corticosteroid users face heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism [395]. Shoulder arthroplasty for primary or secondary native shoulder infections carries a high complication rate and low functional outcome, though short-term re-infection rates are low [367].

Infection (PJI): Prosthetic joint infection (PJI) is the most devastating cause of failure in shoulder arthroplasty, with poor results compared to other failure modes [327]. Incidence ranges from 0.4% to 3% for primary ATSA, 1% to 10% for primary RSA, and up to 15.4% for revision arthroplasty [381]. Reported rates are 1.2% to 3.0% overall, with 0.5% to 3.9% for ATSA and 5.1% to 10.0% for RTSA [270]. Incidence reportedly reaches 4% in primary unconstrained arthroplasty and 15% in revision arthroplasty [327]. Periprosthetic shoulder infection incidence remained stable at 0.98% from 2002 to 2011 despite increasing volumes [419], yet PJIs are increasing due to higher primary arthroplasty numbers and more infections within 90 days [382]. Shoulder PJI commonly presents as a painful arthroplasty with minimal clinical and laboratory findings [270]. Indolent organisms predominate, including Cutibacterium acnes (39% to 66%) and coagulase-negative staphylococci (24% to 28%) [270]. Intraoperative cultures at revision for presumed aseptic loosening are positive in up to 11% of cases, necessitating routine culture taking even when infection is not suspected [327]. Risk factors include prior nonarthroplasty-related surgery [378], one or more nonarthroplasty operative procedures before primary rTSA [425], and younger male sex [380]. Cefazolin administration is associated with significantly lower PJI rates compared to vancomycin or clindamycin [359]. Incomplete vancomycin administration (infusion to incision time under 30 min) adversely increases infectious complications and PJI [337], whereas complete administration does not increase rates compared to cefazolin [399]. Two-stage revision with aggressive débridement, antibiotic spacer, prolonged IV antibiotics, and reimplantation shows 63% to 100% success in eradicating infection [270]. One-stage revision is advocated for indolent infections, with similar eradication rates and comparable infection control and complication rates to two-stage revision [270, 340]. Average Constant scores are 51 after one-stage and 41 after two-stage revision [270]. Two-stage revision for complex or late presentation PJI achieves 80% infection eradication [409]. Numerous independent risk factors exist for repeat stage 1, no re-implantation, or death within one year following index stage 1 [402].

Instability: Instability is the second leading cause of complications, with a prevalence of 4% and accounting for 30% of all complications [347]. A meta-analysis of 11 series (838 patients) reported a 1.2% incidence of postoperative dislocation over 20 to 54 months [347]. Approximately 80% of instability involves anterior or superior instability, mostly due to soft-tissue deficiency [347]. Anterior instability is associated with subscapularis failure, glenoid component malposition, or anterior deltoid dysfunction [347]. Subscapularis rupture-related anterior instability results from operative technique, tissue quality, inappropriate physical therapy, or oversized components [347]. It can also be caused by a humeral head too small for the joint volume [347]. Posterior instability is attributed to component malposition, posterior glenoid erosion with excessive retroversion, and soft-tissue imbalance [347]. Patients with posterior glenohumeral subluxation from long-standing osteoarthritis or chronic posterior instability are at increased risk [347]. Inferior instability relates to loss of normal humeral height, most common after hemiarthroplasty for proximal humeral fractures, and can result from excessive proximal humerus removal [347]. Instability may also result from falls, suboptimal component selection, malposition, bulky posterior tissues, leverage against the glenoid, or insufficient deltoid compressive effect in RTSA [14]. Early closed reduction can be successful for RTSA instability [14], while recurrent or chronic instability may require surgical revision [14]. Stability in RTSA may be restored by increasing the diameter of curvature and polyethylene humeral cup thickness [14]. In a systematic review of return to work, the most common postoperative complications were stiffness/pain (n = 47), anterior dislocation or instability (n = 16), and progressive arthritis requiring revision (n = 7) [45].

Periprosthetic Fracture: The overall rate of periprosthetic humeral fracture is 0.5% to 3%, representing the most common complication and accounting for 11% to 20% of TSA complications [65]. In a series of 2,588 TSAs, the rate was 2.1% for humeral fracture versus 0.4% for glenoid fracture [65]. Intraoperative fracture is the most common complication, occurring in 0.9% to 1.5% of cases [65]. Singh reported a 1.2% intraoperative rate versus 0.9% postoperatively [65], and two other studies confirm intraoperative fracture is about twice as common as postoperative fracture [65]. Intraoperative fractures are likely underreported as they can be undetected or managed conservatively with simple cerclage fixation [65]. According to the Swedish registry, intraoperative fractures are three times more common than postoperative fractures [270]. Risk factors include female gender, older age, TSA (vs. hemiarthroplasty), revision arthroplasty, press-fit humeral stem, proximal stress shielding, osteopenia, rheumatoid arthritis (RA), posttraumatic osteoarthritis (OA), severe joint stiffness, manipulation under anesthesia (MUA), malunion, or deformity [65]. Athwal et al. showed a relative risk of 3.3 for intraoperative fracture in females (1.7% vs. 0.5%; p = 0.006) [65]. Fracture incidence in RA patients was 1.8% versus 1.5% for other diagnoses in Boyd's series [65], while Wright and Cofield reported 3.4% in RA patients versus 1.1% in others [65]. A Mayo Clinic study found a low overall postoperative fracture incidence of 0.6% (19/3,091) [65]. Osteopenia or severe cortical thinning is a risk factor, especially with revision stems [65]. Campbell et al. found 25% of fracture patients had normal bone, 45% mild osteopenia, and 30% severe osteopenia [65], whereas Kumar et al. found all fracture patients had osteopenia (44% severe) [65]. Glenoid aseptic loosening is the weak link in TSA, but periprosthetic fracture is exceedingly rare at this location due to bone scarcity [65]. Most glenoid fractures occur intraoperatively, related to retraction, poor bone stock, or implantation errors [65]. Fractures can occur during or after surgery, with women and those with poor morbidity index scores at substantial risk [67]. The Wright and Cofield classification divides fractures into type A (proximal from distal stem), type B (centered over distal stem), and type C (distal to stem tip) [67]. Nonsurgical management is an option for all types, especially for patients with comorbidities, minimal function, or minimal displacement [67]. Nondisplaced type B and C fractures may undergo a trial of nonsurgical management with a fracture brace, but due to higher delayed union and nonunion rates, a low threshold for surgical intervention is recommended at 3-month follow-up [67]. Cerclage cables alone can be used for very proximal type A fractures, especially intraoperatively [67]. For postoperative fractures, careful circumferential dissection is required to avoid neurovascular injury [67]. Biomechanical and clinical data support surgical fixation using cables, plates, and/or screws [67]. For type B and C fractures, implant overlap is necessary [67]. Lateral plate overlap in a femur model decreased stem strain and increased construct stiffness [67]. Adding proximal screws increases stiffness but not significantly [67]. For type B and C fractures extending into an ipsilateral total elbow arthroplasty (TEA) humeral component, adequate overlap of both stems with a long plate is recommended [67]. If the humeral component is loose with a concomitant fracture between a distal TEA, exchange to a long-stemmed component with a plate overlapping both stems is indicated [67]. A 2013 series of 36 patients (17 ORIF alone, 19 ORIF and revision) reported a 97% union rate and acceptable outcomes, but a 39% complication rate [67]. The incidence of periprosthetic humeral fractures is reported as high as 4.6% after shoulder arthroplasty, commonly associated with revision, osteoporosis, RA, prolonged steroid use, and frequent falls [270]. If the humeral implant is well-fixed, open reduction and internal fixation using a locking plate and screws or strut graft with cerclage wires is preferred [270]. Loose implants should be revised with a longer humeral stem augmented with a locking plate or strut graft with bicortical screws distally and unicortical screws proximally reinforced by cerclage wires [270]. In cases of severe proximal humeral bone loss precluding rotational stability, a proximal humeral allograft or tumor prosthesis should be considered [270]. In a series of 612 revision shoulder arthroplasties with 110 (18%) patients treated with an intermediate or long stem, Owens et al. reported 13 (16.3%) intraoperative complications including cement extrusion, distal cortical perforation, nonunions, and deep infections [289]. Wagner et al. presented 36 periprosthetic humeral fractures out of 230 revision reverse shoulder arthroplasties [289].

Other Considerations: The text provided for the "Periprosthetic Fracture" section ends abruptly with "Most of the fractures in Wagner et al.'s series" [289], leaving the specific characteristics of those fractures undefined in the evidence base.

Recovery

Light activity (weeks): Driving performance returns to preoperative levels at 6 weeks after shoulder arthroplasty, with performance improving beyond preoperative levels by 12 weeks postoperatively [128]. This improvement in driving is associated with the mitigation of shoulder pain and discomfort [201]. Sleep quality shows meaningful improvement between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter [427].

Full activity (months): Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively [265]. Patients who were active in sports 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 [408]. 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 [414].

Complete recovery / outcome plateau (months): Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications [407]. Patients achieve maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [424]. 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 [429].

Rehabilitation protocol: A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty [196]. Rehabilitation after total shoulder arthroplasty should be tailored to the biomechanical principles and soft-tissue considerations unique to each form of total shoulder arthroplasty [266]. A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented [200]. Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme [239]. Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation [255]. There is a paucity of high-quality evidence to guide rehabilitation protocols and practice following shoulder arthroplasty [247].

Functional milestones: 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 [61]. Total shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status [259]. Acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively [435]. 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 [430].

Other Considerations: 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 [393]. Total shoulder arthroplasty demonstrates excellent long-term survivorship with significant improvements in pain and function [434]. Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications [428]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [431]. Primary shoulder arthroplasty is an effective treatment modality for the improvement of pain, motion, and strength in patients with a history of prior external beam radiation therapy [262]. Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries [233]. 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 [433]. 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 [432].

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) [45]. In total, 14 patients were reported to have returned to the operating room for revision [45]. Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients [10]. Immediately before revision surgery, the SST scores had dropped by 6.7 ± 2.7 to a mean of 4.6 ± 3.1 at a mean of 7.4 years after the index arthroplasty (range, 2.9-11.1 years) [22]. This was essentially the same level of self-assessed function as these patients had documented before their index arthroplasty [22]. Prevalent deficits included the inability to sleep comfortably and the inability to reach the back of the opposite shoulder, as well as difficulty lifting loads to shoulder level [22]. None of the shoulders had infections, and none of the humeral components were loose [22]. 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 [213]. 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 [252].

Rankabilities were low, meaning that much of the other (smaller) variation in performance could not be detected, rendering revisions unsuitable to rank hospital performances following primary shoulder arthroplasty [405]. Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty [249]. Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment [236].

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)
• [Paper] The goal of this special issue is to provide the reader with an understanding of the best practices in shoulder arthroplasty in 2016, and to address some of the current controversies in the field. [2] (10.1097/bte.0000000000000080)
• [L5] [3] (10.5397/cise.2021.00738)
• [L5] This article discusses the designs of prostheses used around the shoulder joint, delineates indications and alternatives for each of the different types of hardware, reviews radiographic and cross-sectional preoperative imaging of shoulder arthroplasty, illustrates normal postoperative imaging findings and measurements, and provides examples of hardware complications. [4] (10.1055/s-0034-1384833)
• [L2] The authors believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties. [7] (10.1097/01.blo.0000238839.26423.8d)
• [L4] Patients with an unsatisfactory outcome after shoulder arthroplasty present with poor shoulder function and pain. [8] (10.1016/j.jse.2006.11.004)
• [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. [10] (10.1016/j.jse.2007.11.004)
• [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. [11] (10.1016/s0030-5898(05)70025-0)
• [L4] Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs. [16] (10.1016/j.jse.2010.04.001)
• [L4] Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations. [18] (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. [19] (10.1007/s12178-016-9318-y)
• [L3] [20] (10.1302/0301-620x.106b2.bjj-2023-0785.r1)
• [Paper] [21] (10.1007/s00264-009-0780-7)
• [L4] [22] (10.1016/j.jse.2004.10.008)
• [L5] Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage. [23] (10.1007/s12178-014-9249-4)
• [L4] These findings should be considered when choosing a shoulder arthroplasty technique with non-oncologic indications. [24] (10.1177/17585732251403536)
• [L5] Shoulder arthroplasty is now an effective and safe treatment option. [25] (10.1016/j.jbspin.2010.09.004)
• [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. [26] (10.1016/j.jseint.2019.12.011)
• [L4] This systematic review demonstrates that the evaluation workup and criteria used to diagnose shoulder PJI remain inconsistent. [27] (10.1016/j.jseint.2024.09.022)
• [L5] Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty. [28] (10.5435/jaaos-20-09-604)
• [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. [29] (10.2106/jbjs.oa.19.00025)
• [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. [31] (10.1016/j.jse.2007.02.131)
• [L4] Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic GD, offering improved clinical outcomes and favorable satisfaction following surgery. [33] (10.1016/j.xrrt.2025.03.001)
• [Paper] [34] (10.1016/j.otsr.2017.10.008)
• [L4] Thus, previous lower extremity PJI should not be considered a relative contraindication to shoulder arthroplasty. [35] (10.1016/j.jse.2016.05.024)
• [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. [36] (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. [37] (10.5397/cise.2023.00836)
• [L4] Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%). [38] (10.1177/17585732261441853)
• [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. [39] (10.1177/2325967115s00168)
• [L5] The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications. [40] (10.2106/jbjs.m.00402)
• [Paper] While early results are promising, further long-term studies are needed to fully assess its value and establish best practices for its routine use in shoulder arthroplasty. [41] (10.3390/jcm14082763)
• [Abstract] At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty. [43] (10.1016/j.jse.2022.01.004)
• [L4] Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. [44] (10.1016/j.jse.2019.04.006)
• [L1] [45] (10.1016/j.jse.2018.12.011)
• [L5] Complications of shoulder arthroplasty depend on the prosthesis type used. [46] (10.1007/s00330-008-1093-8)
• [L4] The reverse shoulder arthroplasty has been highly successful in cuff deficient shoulders, with indications continuing to broaden. [48] (10.1007/s12178-011-9097-4)
• [L3] The cumulative percentage of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. [50] (10.1080/17453674.2020.1871559)
• [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. [51] (10.1016/j.jse.2023.09.021)
• [L3] Total shoulder arthroplasty can provide substantial and durable improvement in shoulder function. [52] (10.1067/mse.2001.117122)
• [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. [53] (10.5435/00124635-200907000-00002)
• [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. [54] (10.5435/jaaos-d-23-00758)
• [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. [55] (10.1016/s1048-6666(03)00084-3)
• [Paper] Implant design, evidence level, and indications changed significantly, alongside, but not statistically linked to, complication reporting, informing future shoulder reconstruction research directions. [56] (10.1016/j.jse.2026.10.008)
• [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. [61] (10.1016/j.jse.2025.06.016)
• [L4] Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. [63] (10.1016/j.jse.2019.12.008)
• [L5] [69] (10.1007/s00256-019-03183-3)
• [L4] [70] (10.1067/mse.2001.115985)
• [L4] The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases. [90] (10.1016/j.jse.2009.10.016)
• [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. [98] (10.1016/j.jse.2011.01.035)
• [L4] [100] (10.1007/s00402-019-03328-y)
• [L1] Complication and reoperation rates are higher compared to shoulder arthroplasty for primary glenohumeral joint arthritis; however, the difference is not statistically significant. [101] (10.1007/s00402-020-03400-y)
• [L4] The proposed classification system is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. [103] (10.1302/0301-620x.98b3.36664)
• [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. [104] (10.1016/j.jse.2015.09.013)
• [L4] Short-term reoperation after shoulder arthroplasty was infrequent. [107] (10.2106/jbjs.m.00127)
• [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. [108] (10.1016/j.jse.2014.10.005)
• [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. [111] (10.1016/j.xrrt.2023.01.004)
• [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. [115] (10.1016/j.jse.2013.12.003)
• [L4] The article reviews current approaches to diagnosing and treating prosthetic joint infection of the shoulder, noting that while the 2018 International Consensus Meeting criteria have strengthened validation, many studies have not adopted them, affecting reported sensitivities and specificities. [117] (10.5435/jaaos-d-24-00720)
• [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. [121] (10.1016/j.arthro.2017.08.204)
• [L3] Thus, anatomic shoulder arthroplasty remains an attractive option for primary arthroplasty in selected cases. [122] (10.1016/j.jseint.2024.05.006)
• [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. [123] (10.1016/j.jseint.2025.02.005)
• [L4] The superior approach is reliable for shoulder surgery and provides good exposure with a low rate of complication. [125] (10.1016/s1058-2746(95)80088-3)
• [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. [126] (10.2106/jbjs.rvw.m.00055)
• [L4] Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty, with improved performance compared with preoperative levels by 12 weeks postoperatively. [128] (10.2106/jbjs.15.00162)
• [L3] This classification system may be useful to anticipate the complexity of humeral reconstruction. [133] (10.1097/corr.0000000000000590)
• [L4] [136] (10.1016/j.arthro.2020.01.045)
• [L3] [137] (10.1016/j.jse.2026.04.036)
• [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. [138] (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. [143] (10.1007/s00264-018-3874-2)
• [L4] In patients with a shoulder replacement, the number of shoulder elevations > 60° on the operative side approaches 1.0 Mc per year. [144] (10.1016/j.jse.2017.09.023)
• [L3] Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. [145] (10.2106/jbjs.16.00541)
• [L4] Current classification systems demonstrate limited reliability for assessing glenoid defects in this context. [146] (10.1016/j.jseint.2026.101804)
• [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. [147] (10.1067/mse.2002.122257)
• [L5] An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival. [149] (10.5435/jaaos-21-01-23)
• [L5] [150] (10.1016/j.xrrt.2025.06.011)
• [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. [151] (10.1097/corr.0000000000001779)
• [L4] The utility of ultrasound examination of the subscapularis tendon following shoulder arthroplasty is limited by timing and may be most useful when used by the physician within clinical context. [152] (10.1177/2471549219832442)
• [L5] [153] (10.1007/s12178-020-09670-8)
• [L2] Shoulder arthroplasty performed on the male population must be carefully checked after surgery for the possible presence of P. [154] (10.1186/s12891-020-03332-z)
• [L4] Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. [156] (10.1177/1758573218780519)
• [L4] Diagnostic arthroscopy supports considering it in the evaluation of painful anatomic shoulder arthroplasties when there is a high likelihood of infection but cultures of aspirated fluid are negative. [157] (10.2106/jbjs.n.00961)
• [L4] With advances in implant design and techniques, the complication profile after anatomic shoulder arthroplasty is changing and outcomes are improving. [160] (10.1016/j.ocl.2021.03.002)
• [L4] Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis. [161] (10.2106/00004623-198870080-00006)
• [L5] Robotic-assisted arthroplasty is now available for shoulder arthroplasty with some limitations, and shoulder surgeons should become familiar with the nature of this technology, potential benefits and disadvantages, and the surgical techniques employed. [164] (10.1016/j.xrrt.2025.08.013)
• [L5] Glenoid exposure is a key step in total shoulder arthroplasty that should offer frontal access to the glenoid to allow ancillary tools to be used freely and facilitate good positioning of the glenoid implant. [165] (10.1302/2058-5241.4.180057)
• [L3] Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology. [166] (10.1302/0301-620x.99b11.bjj-2017-0469.r1)
• [L4] The creation of the anterior cortical window is an excellent technique to implement in selecting cases of revision total shoulder arthroplasty. [167] (10.1097/00132589-200606000-00008)
• [Paper] Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal. [169] (10.1016/j.jseint.2024.08.170)
• [L4] Shoulder surgeons should be familiar with the clinical manifestations of fibrous dysplasia and the unique surgical challenges they present as the incidence of shoulder arthroplasty continues to increase. [171] (10.1016/j.xrrt.2020.100002)
• [L5] Under optimal circumstances simultaneous shoulder arthroplasty is feasible. [175] (10.1016/s1058-2746(96)80400-9)
• [L1] A clear standardised set of shoulder arthroplasty complication definitions is lacking. [194] (10.1007/s00402-017-2635-9)
• [L5] A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty. [196] (10.1016/j.csm.2018.05.007)
• [L4] Sixty-seven percent of patients successfully returned to work after shoulder arthroplasty. [197] (10.1016/j.jsea.2026.100058)
• [L4] MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty. [198] (10.1007/s11420-014-9399-3)
• [L5] Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist. [199] (10.1016/j.ocl.2017.08.010)
• [L5] A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented. [200] (10.2519/jospt.2005.35.12.821)
• [Abstract] The present study findings suggest that patients undergoing total shoulder replacement show improvement in driving performance with the mitigation of shoulder pain and discomfort. [201] (10.1016/j.jse.2014.06.005)
• [L3] Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty. [203] (10.1016/j.jse.2025.02.055)
• [L4] The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs for revision to rTSA cases. [204] (10.1016/j.jse.2026.04.002)
• [L5] The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. [206] (10.1016/j.jse.2017.10.005)
• [L3] There was no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications. [207] (10.1016/j.jse.2018.07.014)
• [L4] Outpatient total shoulder arthroplasty in appropriately selected patients is a safe and cost-effective alternative to inpatient total shoulder arthroplasty. [208] (10.5435/jaaos-d-21-00562)
• [L5] Outcomes following anatomic total shoulder arthroplasty have proven to be durable and reproducible. [209] (10.1097/bte.0000000000000075)
• [Abstract] When the glenoid component revision is the indication for revision total shoulder replacement, these patients tend to achieve good to excellent results. [210] (10.1016/j.jse.2007.02.098)
• [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. [213] (10.1016/j.jse.2018.10.007)
• [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. [215] (10.1177/1758573220908865)
• [L4] Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty. [216] (10.1177/23259671251326076)
• [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. [218] (10.1016/j.jse.2021.12.015)
• [L4] The 2018 ICM shoulder infection criteria provided a new scoring system to diagnose PJI, with C acnes identified as the most common infectious organism. [219] (10.1016/j.jse.2021.04.009)
• [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. [223] (10.1016/j.jse.2025.01.040)
• [L2] Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen. [226] (10.1016/j.jse.2017.11.015)
• [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. [227] (10.1016/j.jse.2023.08.029)
• [L5] The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual. [231] (10.5435/jaaos-d-23-00257)
• [L1] In patients undergoing shoulder arthroplasty, a non-opioid, multimodal pain protocol provided non-inferior pain relief compared to an opioid-based regimen. [232] (10.1016/j.jse.2026.04.063)
• [L4] Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries. [233] (10.5435/jaaosglobal-d-17-00073)
• [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. [236] (10.1016/j.jse.2006.10.016)
• [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. [237] (10.1007/s00167-017-4547-1)
• [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. [239] (10.1177/1758573220937394)
• [L2] Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty. [244] (10.1016/j.jse.2026.01.026)
• [L4] There is a paucity of high-quality evidence to guide rehabilitation protocols and practice following shoulder arthroplasty. [247] (10.2106/jbjs.rvw.19.00129)
• [L1] Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement. [248] (10.1007/s00590-015-1678-2)
• [L4] Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. [249] (10.1016/j.jse.2022.09.016)
• [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. [252] (10.1016/j.jse.2023.03.035)
• [L4] Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation. [255] (10.1016/j.jse.2005.02.013)
• [L1] A high return to sport can be expected after total shoulder arthroplasty. [257] (10.1016/j.jseint.2025.05.028)
• [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. [259] (10.1016/s1058-2746(95)80203-7)
• [L3] Primary shoulder arthroplasty is an effective treatment modality for the improvement of pain, motion, and strength in patients with a history of prior external beam radiation therapy. [262] (10.1016/j.jse.2022.08.014)
• [L4] Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively. [265] (10.1016/j.csm.2018.06.002)
• [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. [266] (10.1002/arj.70509)
• [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. [272] (10.1016/j.jse.2019.01.013)
• [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. [273] (10.1016/j.jse.2024.10.029)
• [L4] [275] (10.1016/j.jse.2015.07.019)
• [L4] Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty. [276] (10.1016/j.ocl.2017.08.011)
• [L3] Total Shoulder Arthroplasty with an all-polyethylene, pegged glenoid component, utilising hybrid fixation, demonstrates excellent clinical and radiological outcomes at long term follow-up. [277] (10.1016/j.jse.2021.03.003)
• [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. [278] (10.1016/j.jse.2007.02.112)
• [L2] With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets. [279] (10.1016/j.jseint.2021.02.005)
• [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [282] (10.1177/1758573217702333)
• [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. [285] (10.5435/jaaos-d-20-01205)
• [L4] The materials that are used in total shoulder arthroplasty (TSA) implants have been carefully chosen in an attempt to minimize hardware-related complications. [286] (10.2106/jbjs.rvw.19.00212)
• [L1] LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. [287] (10.2106/jbjs.22.00034)
• [L2] [289] (10.1530/eor-2024-0053)
• [L4] Shoulder arthroplasty with an all-polyethylene, hybrid-fixation (bone ingrowth and cement) pegged glenoid component has durable clinical and radiographic outcomes at medium-term follow-up. [291] (10.2106/jbjs.20.00084)
• [L4] [292] (10.1016/j.jse.2024.11.039)
• [L3] In the presence of previous non-arthroplasty operative interventions there is a significantly higher risk for infection in shoulders undergoing rTSA. [294] (10.1016/j.jse.2014.11.008)
• [L4] This technique may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty. [299] (10.1016/j.jseint.2020.03.002)
• [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. [301] (10.1016/s1058-2746(05)80013-8)
• [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. [302] (10.1016/j.jse.2013.06.001)
• [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. [303] (10.1016/j.jse.2014.09.029)
• [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. [304] (10.1016/j.jse.2007.09.005)
• [L5] Reverse total shoulder arthroplasty has become the standard of care for patients with cuff tear arthropathy who do not have a repair option and when nonoperative management has failed. [306] (10.1016/j.jse.2018.07.020)
• [L4] [307] (10.1177/1758573220909981)
• [L4] Anatomic total shoulder arthroplasty in general provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively. [315] (10.1016/j.jses.2019.11.005)
• [L1] When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine. [318] (10.1016/j.jse.2020.09.017)
• [L3] Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty. [321] (10.1177/17585732241269174)
• [Paper] [322] (10.1007/s00402-013-1688-7)
• [L3] HO after reverse shoulder arthroplasty is a non-progressive condition without long-term clinical consequences. [326] (10.1302/0301-620x.98b9.37761)
• [L4] [327] (10.1007/s11999-009-0875-x)
• [L3] Prolonged LOS after shoulder arthroplasty is multifactorial, with non-modifiable demographic factors compounded by modifiable social and structural elements. [331] (10.1016/j.xrrt.2026.100856)
• [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. [337] (10.1016/j.jse.2022.10.012)
• [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. [338] (10.1016/j.jse.2020.07.037)
• [L3] Single-stage revision demonstrated infection control and complication rates comparable with 2-stage revision for shoulder PJI. [340] (10.2106/jbjs.rvw.26.00055)
• [L4] The authors recommend supplementing plain shoulder radiographs of total shoulder arthroplasties with fluoroscopically positioned localized views at the first follow-up visit and at subsequent visits. [341] (10.1016/s1058-2746(09)80057-8)
• [L4] [344] (10.1016/j.cuor.2007.11.002)
• [L2] [345] (10.1016/s1058-2746(96)80030-9)
• [L5] [348] (10.1016/j.jisako.2023.05.007)
• [L5] [349] (10.1016/j.jse.2013.10.003)
• [L5] [354] (10.1016/j.ocl.2020.02.003)
• [L3] Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible. [357] (10.1016/j.jseint.2026.101648)
• [L3] In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. [359] (10.2106/jbjs.21.00445)
• [L1] Arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty. [362] (10.1016/j.jse.2015.06.027)
• [L3] Elimination of these radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care. [364] (10.1007/s11999-012-2551-9)
• [L4] Sonography is a useful tool for examining soft tissues after shoulder arthroplasty in order to demonstrate pathological changes and is not negatively affected by the implant. [365] (10.1007/s00256-002-0555-3)
• [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. [367] (10.1177/17585732241231758)
• [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. [377] (10.1016/j.jse.2013.01.036)
• [L2] The risk of infection after primary shoulder arthroplasty is significantly higher in patients with a history of prior nonarthroplasty-related surgery. [378] (10.1016/j.jse.2016.10.020)
• [L3] Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture. [379] (10.2106/jbjs.k.01516)
• [L2] Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. [380] (10.1007/s11999-014-3696-5)
• [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. [381] (10.5435/jaaos-d-24-00719)
• [L3] The PJIs are increasing, both because of an increase in the numbers of primary arthroplasties and due to an increase in PJIs occurring within 90 days. [382] (10.1016/j.arth.2026.01.042)
• [L3] Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients, with a 1% incidence of never events. [389] (10.1016/j.jse.2013.08.007)
• [L3] The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. [391] (10.1080/17453674.2018.1450207)
• [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. [393] (10.1016/j.jse.2023.07.005)
• [L3] Long-term corticosteroid users are at a heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism following total shoulder arthroplasty. [395] (10.1177/17585732261460807)
• [L3] Complete administration of vancomycin as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI compared to cefazolin. [399] (10.1016/j.jse.2024.03.059)
• [L4] The overall complication rate of total shoulder arthroplasty has decreased dramatically over time, with a striking diminution of component loosening. [400] (10.1016/j.jse.2005.05.005)
• [L3] Numerous independent risk factors exist for repeat stage 1, no re-implantation or death within one year following index stage 1 shoulder arthroplasty. [402] (10.1016/j.jse.2017.06.014)
• [L4] In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported. [404] (10.3109/17453674.2015.1024565)
• [L3] However, rankabilities were low, meaning that much of the other (smaller) variation in performance could not be detected, rendering revisions unsuitable to rank hospital performances following primary shoulder arthroplasty. [405] (10.1016/j.jse.2022.06.006)
• [L3] Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications. [407] (10.1177/1758573220922845)
• [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. [408] (10.1177/0363546514557940)
• [L4] Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). [409] (10.1177/1758573219841057)
• [L3] Male patients had significantly higher odds of adverse events, death, MI, and sepsis following shoulder arthroplasty. [411] (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. [414] (10.1177/03635465261423899)
• [L3] The incidence of periprosthetic shoulder infection remained stable at 0.98% from 2002 to 2011 despite increasing procedure volumes. [419] (10.1016/j.jse.2014.11.044)
• [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. [424] (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. [425] (10.1016/j.jse.2014.12.036)
• [L4] Shoulder arthroplasty is generally associated with meaningful improvement in sleep quality between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter. [427] (10.1177/17585732261450975)
• [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. [428] (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. [429] (10.1177/17585732221097415)
• [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. [430] (10.1016/j.jse.2021.03.033)
• [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. [431] (10.1016/j.jse.2018.05.030)
• [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. [432] (10.1016/j.jse.2014.06.042)
• [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. [433] (10.1016/j.jse.2023.10.007)
• [L3] Total shoulder arthroplasty demonstrates excellent long-term survivorship with significant improvements in pain and function. [434] (10.1016/j.jse.2005.02.009)
• [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. [435] (10.1016/j.jse.2019.01.003)

See Also

• Total Shoulder Arthroplasty
• Reverse Shoulder Arthroplasty
• Os Acromiale
• Rotator Cuff
• Fractures
• Proximal Humerus Fracture
• Shoulder Arthroscopy
• Shoulder Arthritis
• Shoulder Instability
• Internal Fixation

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