Shoulder Arthroplasty

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

Overview

Shoulder arthroplasty is a safe and reliable option for managing symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable patient satisfaction [5]. While many systems are available with new advances frequently introduced, newer, more costly, and complicated prosthetic approaches often lack evidence of superior patient outcomes compared to existing systems [7]. The ideal humeral component prioritizes the optimization of glenohumeral mechanics over the strict restoration of normal anatomy, allowing for secure, durable placement of an ample articular surface that facilitates motion and stability [7].

Outpatient shoulder arthroplasty is a safe and cost-effective alternative to inpatient procedures for appropriately selected patients, with transition to outpatient care yielding similar outcomes and complications at midterm follow-up [22, 90, 97]. Age 70 years or older is not a contraindication to stemless anatomic total shoulder arthroplasty, as postoperative improvements in outcome scores and range of motion are similar to those in younger patients [93]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential costs for total shoulder arthroplasty [25]. Knowledge of the array of available prostheses, their indications, and the use of treatment algorithms can lead to optimized patient outcomes [24].

Shoulder arthroplasty following prior surgery results in clinically improved outcomes, though these remain inferior to patients without a surgical history [16]. The outcome of revision shoulder arthroplasty can be predicted based on the indication for the procedure [21]. There is no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications [89]. The AAOS has developed appropriate use criteria to determine the appropriateness of various humeral component designs during primary anatomic total shoulder arthroplasty based on evidence-based information and clinical expertise [88].

Anatomy & Pathophysiology

Osseous Architecture

The glenohumeral joint achieves a near-global range of motion through the interaction of joint surface anatomy, volume, atmospheric pressure, and fluid cohesion [35]. The proximal humerus comprises the head, greater tuberosity, lesser tuberosity, and shaft [35]. The articular head is spherical (37–57 mm diameter) with the most superior portion averaging 8 mm above the greater tuberosity [35]. Humeral version averages 29.8 degrees (range 10–55 degrees), while the head is inclined approximately 130 degrees relative to the shaft [35]. The bicipital groove, situated between the tuberosities, is internally rotated distally relative to its proximal portion [35]. The anatomic neck marks the junction of the articular surface and tuberosities, whereas the surgical neck is an indistinct region below the tuberosities [35]. Fractures involving the anatomic neck carry a worse prognosis for avascular necrosis due to vascular disruption [35]. The greater tuberosity attaches the supraspinatus, infraspinatus, and teres minor tendons, while the lesser tuberosity anchors the subscapularis [35]. The glenoid is a shallow, inverted pear-shaped convex structure articulating with the humeral head [35]. The clavicle, the first bone to ossify via intramembranous ossification, fuses medially at age 20–25 years and relies on periosteal blood supply [37]. The scapula possesses a single true diarthrodial articulation at the acromioclavicular joint, with ossification beginning at the eighth week of gestation [37]. The acromion has three ossification centers; failure to fuse results in os acromiale [37]. The glenoid averages 5 degrees of retroversion relative to the scapular body axis [37]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination (neck-shaft angle) [37].

Ligamentous and Capsular Stability

The coracoacromial arch, formed by the acromion, coracoacromial ligament, and coracoid process, provides a rigid bony-ligamentous structure for stability [35]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass beneath this arch; in displaced fractures, these bursae may become fibrotic, limiting motion [35]. Dynamic stabilizers include the rotator cuff and scapulothoracic positioning [37]. Static stabilizers comprise articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the capsule/ligaments [37]. The labrum provides concavity and up to 50% of marginal socket depth [37]. The rotator interval is bounded medially by the coracoid base, superiorly by the supraspinatus, and inferiorly by the subscapularis [37]. It contains the coracohumeral ligament, superior glenohumeral ligament (SGHL), and intra-articular long head of the biceps tendon [37]. Laxity here causes inferior laxity (sulcus sign), while contracture indicates adhesive capsulitis [37]. The coracohumeral ligament restricts external rotation in adduction and restrains inferior/posterior translation [37]. The SGHL is a primary restraint against anterior translation with the arm at the side [37]. The middle glenohumeral ligament (MGHL) resists anterior translation in external rotation and 45 degrees of abduction [37]. The anterior band of the inferior glenohumeral ligament (IGHL) prevents anterior-inferior dislocation in 90 degrees abduction/external rotation [37]. The posterior IGHL band prevents posterior-inferior translation in internal rotation/adduction [37]. The superior transverse scapular ligament spans the suprascapular notch, with the artery running superiorly and the nerve deep to it [37]. Entrapment at this ligament denervates the supraspinatus and infraspinatus, while entrapment at the spinoglenoid notch affects only the infraspinatus [37].

Vascular and Neural Supply

The proximal humerus receives blood from the anterior and posterior humeral circumflex branches of the third axillary division [35]. The posterior circumflex artery travels with the axillary nerve through the quadrilateral space to supply the posterior cuff [35]. The anterior circumflex artery arises inferior to the subscapularis, supplying the head via the terminal anterolateral branch (artery of Laing/arcuate artery) [35]. This ascending branch courses parallel to the long head biceps tendon, entering the head at the bicipital groove/greater tuberosity interface [35]. Injury to the arcuate artery may cause osteonecrosis, though extraosseous collaterals can maintain perfusion [35]. The axillary nerve is a terminal branch of the posterior cord proximal to the coracoid [40]. It passes beneath the conjoined tendon 3–5 mm medial to the subscapularis musculotendinous junction and adjacent to the inferior capsule before entering the quadrilateral space [40]. Within the space, it splits into anterior and posterior branches [40]. The anterior branch innervates the anterior and middle deltoid; posterior branch innervation varies (2.3% anterior only, 8.5% posterior only, 89.1% both) [40]. The posterior branch supplies the teres minor and terminates as the superior lateral brachial cutaneous nerve [40]. In the anterior deltopectoral approach, the nerve is palpable inferior to the subscapularis interface [40]. In the anterolateral approach, it crosses 5 cm inferior to the anterolateral acromion; in the posterior approach, it is 7 cm from the posterior acromion [40].

Bursae and Synovial Variations

The subscapular bursa lies between the subscapularis tendon and scapular neck, communicating with the joint between the SGHL and MGHL [38]. It protects the tendon under the coracoid base and over the scapular neck [38]. In 28% of specimens, it merges with the subcoracoid bursa to form a wide bursa [38]. This bursa often houses loose bodies and may exhibit intense synovitis with fringes projecting into the joint [38]. DePalma described six variations of anterior capsular synovial recesses: Type 1 (30.2%) has one recess above the MGHL; Type 2 (2.0%) has one below; Type 3 (40.6%) has one above and one below; Type 4 (9.0%) has a large recess above the inferior ligament with an absent MGHL; Type 5 (5.1%) shows the MGHL as two small folds; Type 6 (11.4%) has no recesses despite defined ligaments [38]. The rotator interval includes the SGHL, coracohumeral ligament, and MGHL, with an average area of 20.96 mm² [38]. Dynamic testing shows the interval decreases in internal rotation and opens in external rotation [38].

Kinematics and Arthroplasty Pathophysiology

Normal shoulder motion is two-thirds glenohumeral and one-third scapulothoracic [37]. Reverse total shoulder arthroplasty (RTSA) kinematics are significantly altered, utilizing more scapulothoracic and less glenohumeral motion for elevation compared to healthy subjects [42, 48]. The anterior deltoid is biomechanically critical for balanced RTSA function [66]. In vivo, total shoulder arthroplasty (TSA) contact is not centered on the glenoid, suggesting non-ball-in-socket mechanics [86]. Custom non-spherical heads replicate native shape, rotation, and kinematics better than spherical prostheses [92]. Numerical studies emphasize anatomical reconstruction of glenohumeral surfaces for TSA success [94]. Restoration of mobility and stability is the priority over recreating "normal anatomy" [104]. Prosthetic components increasing joint volume cause "stuffing" and capsular tightening unless releases are performed [104]. Overstuffing of less than 10 mm reduces capsular laxity and increases torque required for motion [104]. In most arthroplasty conditions, the capsule and ligaments are contracted, limiting motion and increasing joint pressure [104].

Classification

Consensus Definition: A consensus definition of periprosthetic shoulder infection is critical to future investigations of these complications [20]. The 2018 ICM shoulder infection criteria provided a new scoring system to diagnose PJI, with C. acnes identified as the most common infectious organism [102]. However, 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 [105].

Wright and Cofield: The Wright and Cofield classification divides periprosthetic humeral fractures into three categories: type A, type B, and type C [32]. Type A fractures propagate proximally from the distal stem [32] or are centered at the tip of the stem and extend proximally more than one-third the length of the stem [157]. Type B fractures are centered over the distal stem [32] or centered at the tip of the stem and have less proximal extension [157]. Type C fractures are located distal to the tip of the stem [32] or involve the humeral shaft distal to the tip of the prosthesis and extend into the distal humeral metaphysis [157]. The Andersen et al. study found low interobserver reliability (kappa = 0.37) but high intraobserver reliability (kappa = 0.69) for this classification [157].

Groh: Groh et al. classified fractures of the shaft into three types: type I fractures occur proximal to the tip of the prosthesis, type II fractures originate proximal to the tip and extend distal to it, and type III fractures originate below the tip [157].

Worland: Worland et al. designated types A, B, and C by the location of the fracture: type A occur about the tuberosities, type B occur around the stem, and type C occur well distal to the stem [157]. Worland et al. subdivided type B fractures: B1 fractures were spiral with a stable stem; B2 were transverse or short oblique with a stable stem; and B3 were any fracture associated with a loose stem [157].

Campbell: Campbell et al. categorized fractures into four regions: region 1 included the greater or lesser tuberosities, region 2 the proximal metaphysis, region 3 the proximal humeral diaphysis, and region 4 the mid- and distal diaphysis [157]. Campbell et al. classified a cortical width ratio of 25% to 50% as mild osteopenia and less than 25% as severe osteopenia [157].

Gächter & Stutz: Septic arthritis can be divided into four stages arthroscopically according to Gächter and Stutz et al. [155]. Stage I of septic arthritis is characterized by opacity of fluid, redness of the synovial membrane, possible petechial bleeding, and no radiological alterations [155]. Stage II of septic arthritis is characterized by severe inflammation, fibrinous deposition, pus, and no radiological alterations [155]. Stage III of septic arthritis is characterized by thickening of the synovial membrane, compartment formation ("spongelike" arthroscopic view), and no radiological alterations [155]. Stage IV of septic arthritis is characterized by aggressive pannus with infiltration of the cartilage, possibly undermining the cartilage, radiological signs of subchondral osteolysis, and possible osseous erosions and cysts [155].

Proposed Septic Joint System: A proposed classification system for septic joints includes anatomic types, host classes, and clinical settings [155]. Anatomic type I is a periarticular soft-tissue infection without pyarthrosis [155]. Anatomic type II is isolated septic arthritis where purulent material is confined within the capsule [155]. Anatomic type III is septic arthritis with soft-tissue extension but no osteomyelitis [155]. Anatomic type IV is septic arthritis with contiguous osteomyelitis [155]. Host class A represents a patient with a normal immune system [155]. Host class B represents a compromised system, subdivided into B_L (local tissue compromise) and B_S (systemic immune compromise) [155]. Host class C is reserved for patients in whom the risks associated with aggressive treatment would outweigh the negative aspects of the infection [155]. Clinical setting 1 includes less than 5 days of symptoms and a nonvirulent organism [155]. Clinical setting 2 includes symptoms for 5 days or more, or a virulent organism [155]. The cut-off of 5 days for clinical setting was chosen because animal studies have shown that irreversible joint damage occurs if septic arthritis persists beyond this time [155]. Virulent organisms generally include methicillin-resistant S. aureus, gram-negative bacilli, vancomycin-resistant enterococcal species, and clostridia [155].

Other Considerations: Periprosthetic fractures around the glenoid component are rare and typically occur intraoperatively [32], whereas most periprosthetic fractures associated with shoulder arthroplasty occur on the humeral side [32]. Women and those with a poor morbidity index score are at substantial risk for periprosthetic fractures associated with shoulder arthroplasty [32]. There is no universally accepted classification system for septic arthritis of the shoulder at this time [155], and no classification system for periprosthetic humeral shaft fractures about shoulder arthroplasty stems is universally accepted [157]. An algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time [27]. 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 [31]. The proposed classification system for glenoid bone loss is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty [43]. Clusters based on glenoid morphology indicate that patterns exist in the types of glenoid defects [72]. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff [108].

Clinical Presentation

The diagnosis of a stiff shoulder relies on awareness of the problem, with history and physical examination being paramount [2]. Ancillary studies may be helpful in certain circumstances [2]. A comprehensive history is the first and arguably most important aspect of evaluating a patient with a suspected rotator cuff tear [113]. The clinical evaluation aims to carry out an evaluation that leads to a reasonable management plan rather than just a specific diagnosis [13]. It is more important to know what patient a disease has than what disease the patient has [13]. Asking "What can I help you with today?" allows the patient uninterrupted time to answer, revealing different problems even with the same diagnosis [13]. Rather than asking where the shoulder hurts, it is preferred to ask what the shoulder problem keeps the patient from doing and when it bothers them most [13]. Questions regarding overall health, activity level, medications, and prior surgeries help determine if a patient might benefit from a surgical approach [13].

The history should define the mechanism of injury, including the position of the arm, amount of force applied, and point of force application [119]. Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [119]. Electroschock, seizures, or a fall on the flexed and adducted arm are commonly associated with posterior dislocation [119]. If instability is recurrent, the history should define the initial injury, the position or action resulting in instability, duration out of joint, availability of radiographs with the shoulder out of joint, and means necessary for reduction [119]. The history should solicit evidence of neurologic or rotator cuff problems after previous episodes of shoulder instability [119]. Taking a history is an art requiring specific questions, active listening, and formulation of the next question only after the response to avoid tunnel vision [120]. Many widely varying diagnoses manifest with similar symptoms, and differentiation requires a complete history and examination [120]. A diagnosis is established only after each phase of the evaluation is complete; expedience does a disservice to patients [120].

Acute Injury vs. Chronic Arthropathy

Acute Dislocation: An acutely dislocated shoulder is usually very painful with muscles in spasm, and the humeral head may be palpable anteriorly [119]. The posterior and lateral aspect of the shoulder shows a hollow beneath the acromion in an anterior dislocation [119]. The arm is held in slight abduction in an anterior dislocation [119]. Passive and active motions are limited by pain in an anterior dislocation [119]. Recognition of a posterior dislocation may be impaired by the lack of a striking deformity and the shoulder being held in adduction and internal rotation [119]. Classic features of a posterior dislocation include limited external rotation (often <0 degrees) and limited elevation (often <90 degrees) [119]. Posterior dislocation presents with posterior prominence and rounding of the shoulder compared to the normal side [119]. Posterior dislocation presents with flattening of the anterior aspect of the shoulder [119]. Posterior dislocation presents with prominence of the coracoid process on the dislocated side [119]. Asymmetry of shoulder contours in posterior dislocation is best visualized by viewing from above while standing behind the patient [119]. With long-standing disuse of muscles about the shoulder in posterior dislocation, atrophy accentuates flattening of the anterior portion, prominence of the coracoid, and fullness of the posterior portion [119]. Patients with old, unreduced posterior dislocations can have 30 to 40 degrees of glenohumeral abduction and some humeral rotation due to enlargement of the groove [119]. The injury of a posterior dislocation may be misdiagnosed as a frozen shoulder, leading to mistaken vigorous therapy [119].

Chronic Arthropathy and Rotator Cuff: Glenohumeral arthritis is usually insidious in onset and chronic in duration, offering ample opportunity to try nonoperative management [121]. A period of nonoperative treatment offers the patient and surgeon the opportunity to get to know each other better and gives the patient time to learn postoperative rehabilitation exercises [121]. A comprehensive history is the first and arguably the most important aspect of evaluating a patient with a suspected rotator cuff tear [113]. Rotator cuff tears can be asymptomatic, and the amount of shoulder discomfort is not related to the size of the tear [113]. Pain may not be the primary symptom of rotator cuff failure, which may also produce weakness, stiffness, crepitus, or instability [113]. Degenerative rotator cuff tearing typically occurs in older patients, while a greater injury is required to tear the cuff of younger persons [113]. Traumatic glenohumeral dislocations in persons older than 40 years have a strong association with rotator cuff tears [113]. Older patients are less likely to achieve a durable repair of a rotator cuff tear if operative intervention is considered [113]. Acute rotator cuff tears from a distinct injury causing weakness often have good healing potential with early surgery [113]. Patients who present with a painful shoulder problem often have endured symptoms for years due to cuff degeneration rather than injury [113].

Physical Examination

A "no touch" physical exam approach involves asking patients to show which actions are difficult and how high they can reach overhead, externally rotate with the arm at the side, reach across their body, internally rotate the abducted arm, and reach up their back [13]. If patients cannot raise their arm actively, they should be asked to show how high they can raise it with the help of the opposite arm [13]. Tangible findings sought in a physical exam include loss of passive or active ROM, a palpable defect in the rotator cuff, minimal resistance to anterior translation of the humeral head, palpable subacromial crepitus, muscle atrophy, loss of the biceps reflex, or an obvious "clunk" on cross-body adduction [13]. Neck pain, numbness, tingling in the arm, symptoms radiating below the elbow, or medial scapular pain may be signs of cervical radiculopathy requiring a comprehensive cervical spine examination [113].

Periprosthetic Fracture Workup: Following a traditional trauma survey, focused physical examination starts with inspection for open fractures, pallor, deformity, and muscle wasting [109]. Anterosuperior escape of a previous TSA or hemiarthroplasty can often be identified clinically in thin individuals [109]. Neurovascular examination includes assessment of peripheral nerves and radial pulse [109]. Radial nerve status should be well documented in periprosthetic fracture workup [109]. Specific attention should be paid to the axillary nerve since many patients may require conversion to RSA which is dependent on a functional deltoid neuromuscular unit [109]. Axillary nerve function can be confirmed with symmetric sensation over the lateral shoulder and the ability to set the deltoid [109]. In acutely injured patients, the lateral muscle belly can be tested by asking the patient to push the elbow gently into the examiner's hand while noting contractility of the deltoid [109]. Most acute traumatic axillary nerve palsies are neuropraxias and have a good natural history [109].

Stability and Special Tests

An examination under anesthesia is critical to the success of arthroscopic stabilization and is more sensitive for determining the degree and direction of instability [124]. The axial load test or load-and-shift test is conducted under anesthesia to note translation in anterior, inferior, and posterior directions [124]. Grade 1+ translation corresponds to the humeral head reaching the edge of the glenoid [124]. Grade 2+ translation corresponds to the humeral head being subluxated over the glenoid rim but reducing spontaneously [124]. Grade 3+ translation corresponds to a frank dislocation of the humeral head over the glenoid rim that does not reduce spontaneously [124]. Diagnostic arthroscopy is critical for finalizing the surgical plan and includes evaluation of the glenoid labrum, capsular redundancy, tissue quality, Hill-Sachs defect size, anterior-inferior bony defects, osteochondral loose bodies, and glenohumeral ligament detachment [124]. Detachment or tearing of the glenoid labrum can confirm the presence and indicate the direction of the dominant instability vector [124]. Arthroscopic inspection of the intra-articular and bursal surfaces of the rotator cuff should be performed, particularly in older patients with high prevalence of concomitant rotator cuff pathology [124]. Approximately 20% to 25% of patients with instability undergoing arthroscopy have associated loose bodies, rotator cuff tears, biceps tendon pathology, or SLAP lesions [124]. Unrecognized or untreated associated lesions may compromise the surgical outcome [124]. Arthroscopic examination can clarify the diagnosis in ambiguous cases [124].

Red-Flag Patterns and Comorbidities

Infection: The incidence of infection after shoulder surgery has been reported to be between 0% and 2.9%, with an increase in more constrained implants up to 15.4% [23]. Patients undergoing primary reverse shoulder arthroplasty were found to have six times greater risk of infection than patients undergoing primary unconstrained total shoulder arthroplasty [23]. Arthroplasties for trauma were more at risk of infection than other etiologies [23]. Clinical findings of infection include erythema, pain, swelling, and warmth [23]. Patients can present with signs of infection such as fever and skin fluctuance [23]. Any antibiotic therapy started erroneously must be stopped for at least 2 weeks to not compromise culture results negatively [23]. The culture must be followed for 15 to 21 days because of the slow-growing nature of some bacteria such as P. acnes [23].

Systemic and Functional Risks: Patients with an unsatisfactory outcome after shoulder arthroplasty present with poor shoulder function and pain [10]. Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients [15]. 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 [18]. Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty [56]. 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 [55]. The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty [63].

Instability Failure Risks: A failed arthroscopic stabilization procedure often starts with the failure to identify red flags in the patient's history and physical examination [124]. Risk factors for treatment failure in shoulder instability include age, gender, presence of osseous Bankart or large Hill-Sachs lesions, participation in competitive collision or forced overhead sports, hypermobility, time lapse between dislocation and reduction, and number of instability episodes prior to operation [124].

Bone Fragility: Bone fragility workup and treatment is mandatory in all low-energy fractures and females over age 60 [109]. Bone fragility workup includes laboratory work (CBC, parathyroid hormone, TSH, calcium, vitamin D, phosphate) and initiation of calcium and vitamin D supplements [109]. Training on fall prevention is mandatory for bone fragility workup [109]. Underlying causes for future falls such as cardiac disease, syncope, visual impairment, gait imbalance, and living independence should be identified and treated [109]. Engagement of medical management and a social worker can be helpful in managing bone fragility and fall prevention [109]. The primary care or a bone-health expert should continue outpatient management with a DEXA scan and initiation of antiresorptive drugs [109].

Diagnostic Thresholds: If the problem is not apparent on history, physical examination, and plain radiographs, or if the patient does not appear to be an excellent surgical candidate, nonoperative management is likely recommended even if imaging shows acromioclavicular arthrosis, labral fraying, HAGL lesions, or supraspinatus tendinosis [13]. Hand dominance, smoking, genetic predisposition, medical comorbidities, and social factors affecting rehabilitation are variables to consider when deciding between nonoperative and operative care for rotator cuff tears [113]. Treatment should begin with a dialogue between surgeon and patient regarding diagnosis, probable natural history, and potential risks and benefits of treatment options [121]. Outcomes are discussed in light of the patient's expectations and the surgeon's personal experience [121]. Illustrated handouts and personal email contact information are provided to patients to assist with questions before and throughout treatment [121].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder arthroplasty [3]. The first key view is the anteroposterior (AP) view in the plane of the scapula, where the x-ray beam passes through the glenohumeral joint [3]. This view shows the superoinferior position of the humeral head relative to the glenoid, osteophytes on the humeral head and glenoid, joint space narrowing, medial displacement of the humerus relative to the lateral acromial line, bone quality, loose bodies, and humeral head collapse or deformity [3]. The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [3]. This "truth view" demonstrates glenoid bone amount, glenoid shape, glenoid version relative to the scapula plane, and the relationship of the humeral head to the glenoid fossa [3]. Properly taken standardized views indicate cartilage space thickness, relative positions of the humeral head and glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [3]. Arthritis usually involves the central aspect of the humeral head, making joint space narrowing most evident on the axillary truth view compared to images taken with the arm at the side [3]. The axillary truth view can show posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [3]. Posterior subluxation can be measured by the position of the center of the humeral head relative to the plane of the scapula, relative to the glenoid face, or by the point of contact of the humeral articular surface on the glenoid articular surface [3]. The point of contact of the humeral articular surface on the glenoid articular surface is preferred for measuring posterior subluxation because it reflects the degree of centering of the net humeral joint reaction force on the glenoid [3]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [3]. Many axillary views sent for consultation are nonstandardized, making it impossible to determine important features of the glenohumeral joint [3]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the functional axillary view [3]. Overimaging should be resisted unless a specific research protocol is in place [3]. Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients [15]. Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care [160]. Elimination of immediate postoperative radiographs and their interpretation after shoulder arthroplasty may reduce charges without changing clinical care [160]. Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture [168]. A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration on plain radiographs [179].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [57]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with MR arthrograms to provide a detailed picture of joint surfaces [57]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [57]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [154].

CT: CT scans may offer increased precision in measuring glenoid version, but this precision does not necessarily improve surgical quality or clinical outcomes [3]. 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 [57]. CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [57]. Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings [162]. The clinical and radiologic evaluation of an uncemented all-polyethylene glenoid is promising, with good clinical results and no signs of loosening in 88% of patients on CT scans [166].

Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating skeletal and soft-tissue structures of the shoulder [57]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [57]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [57]. Ultrasonography can evaluate impingement in various positions and motions due to providing images in real-time [57]. 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 [17]. 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 [57].

Arthroscopy: Shoulder arthroscopy after arthroplasty is most frequently used as a diagnostic tool but has utility in treating predetermined pathologies [4]. Arthroscopy is a valuable tool for identifying loosening missed by computed tomography arthrography (CTA) in painful total shoulder arthroplasty [159].

Other Considerations: Diagnosis of a stiff shoulder depends on awareness of the problem, with history and physical examination being paramount [2]. Ancillary studies may be helpful in certain circumstances for the diagnosis of a stiff shoulder [2]. The purpose of shoulder imaging is to establish the diagnosis, determine the severity of pathoanatomy, assist in surgical planning, and illustrate the condition to the patient [3]. If the problem is not apparent on history, physical examination, and plain radiographs, or if the patient is not an excellent surgical candidate, nonoperative management is recommended even if advanced imaging shows pathology [13]. Early results of total shoulder arthroplasty in young patients with chondrolysis show improvements in pain and function, though progressive glenoid radiolucencies may develop [6]. Evaluation workup and criteria used to diagnose shoulder periprosthetic joint infection (PJI) remain inconsistent in the literature [11]. Recognition and management of altered glenoid morphology and diminished bone stock are important for successful shoulder arthroplasty [12]. The clinical evaluation is the beginning of the doctor-patient relationship, aiming to lead to a reasonable management plan rather than just a diagnosis [13]. The four P's that determine treatment outcomes are the patient, the shoulder problem experienced, the procedure to treat the patient and problem, and the physician rendering the treatment [13]. It is more important to know what patient a disease has than what disease the patient has [13]. Asking patients what they can be helped with today allows them uninterrupted time to answer, revealing different problems even with the same diagnosis [13]. Physical exam should start with a "no touch" approach where patients show difficult actions and describe what they feel is happening [13]. Active motion assessment includes asking patients to show how high they can reach overhead, how far they can externally rotate with the arm at the side, how far they can reach across their body, how far they can internally rotate the abducted arm, and how high they can reach up their back [13]. If patients cannot raise their arm actively, they should be asked to show how high they can raise it with help from the opposite arm [13]. Tangible findings sought in physical examination include loss of passive or active ROM, palpable rotator cuff defects, minimal resistance to anterior translation of the humeral head, palpable subacromial crepitus, muscle atrophy, loss of the biceps reflex, or an obvious "clunk" on cross-body adduction [13]. Arthrography involves injection of a contrast agent in conjunction with either an MRI or CT scan to enhance imaging of the joint [57]. MR arthrography is considered the benchmark for evaluation for labral tears and is rarely indicated for evaluation of rotator cuff pathology [57]. A deep learning algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time [27]. The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group was formed to conduct large multicenter studies on conditions of the shoulder [45]. The MOON Shoulder Group developed and standardized imaging protocols for studying rotator cuff disease [45]. Validation studies were conducted on the classification of rotator cuff tears based on MRI and arthroscopy videotapes as well as radiographic findings associated with rotator cuff disease [45]. Duration of symptoms, pain, and activity level were not correlated with the severity of rotator cuff disease in a population of patients with symptoms and fewer than 25% undergoing surgery within the next 2 years [45]. MOON Shoulder Instability is an offshoot focusing on patients undergoing surgical treatment for shoulder instability [45]. Initially, all patients are usually asked to have AP and lateral plain radiographs of the shoulder related to their chief report [57]. Plain radiographs are often the only required studies needed for assessing acute shoulder trauma, including fractures or dislocations [57]. Arthritis, calcific tendinitis, and osteolysis of the distal clavicle can be observed on plain radiograph [57]. The clinical and radiologic results of short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty [161]. No correlations between functional outcomes and radiographic shoulder findings were identified at mid-term for shoulder superior capsular reconstruction using xenograft [165]. The functional and radiologic results of stemless shoulder arthroplasty are comparable to the third and fourth generation of standard stem arthroplasty [169]. The functional and radiographic outcomes of Eclipse total shoulder replacement are excellent [174]. The percentage of radiologic changes of the glenoid component in reverse shoulder arthroplasty is considerable, despite a decrease in their presence among arthroplasties implanted outside the initial period [177]. Radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty [178].

Treatment

Non-Operative

Nonoperative management is a prerequisite for surgical consideration in cuff tear arthropathy when nonoperative management has failed [139]. While nonsurgical and surgical treatment improves clinical outcomes from the preoperative state, outcomes for patients with scapular fractures after reverse shoulder arthroplasty are generally inferior to those of a control group [131].

Operative

Indications: Shoulder arthroplasty is a safe and reliable option for managing symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable satisfaction [5]. 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 [18]. Shoulder arthroplasty after prior shoulder surgery results in overall clinically improved outcomes, though these results are inferior compared to patients without prior shoulder surgery [16]. Patients with a history of prior nonarthroplasty shoulder surgery had significantly lower final ASES scores compared to those without prior surgery [156]. 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 [139]. Reverse shoulder arthroplasty is the replacement procedure of choice when arthroplasty is considered for proximal humeral fractures [143]. A flail shoulder remains a viable alternative after large scapulohumeral resections and for complications of a painful, infected, or failed arthroplasty or arthrodesis [112]. An arthrodesis is more durable than an arthroplasty and may be preferred in young, active patients [112].

Surgical Approach / Technique: Standardized plain films are almost always sufficient for shoulder arthroplasty planning, and CT scans do not necessarily improve surgical quality or clinical outcomes [3]. The anteroposterior view in the plane of the scapula shows the superoinferior position of the humeral head, osteophytes, joint space narrowing, medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [3]. The axillary "truth view" is taken with the arm in functional elevation and demonstrates glenoid bone amount, glenoid shape and version, and the relationship of the humeral head to the glenoid fossa [3]. The axillary "truth view" reveals posterior subluxation or functional decentering that is not evident in images taken with the arm at the side [3]. Posterior subluxation can be measured by the position of the humeral head center relative to the scapula plane, the glenoid face, or the point of contact on the glenoid articular surface [3]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and rocking horse loosening of prosthetic glenoid components [3]. Glenoid reaming is typically done in an eccentric fashion to plan down the anterior lip of the glenoid in cases of posterior wear [114]. For posterior shoulder dislocations present for more than 6 months, the humeral component is placed in approximately neutral version [115]. For posterior shoulder dislocations present for less than 6 months, the humeral component is placed in approximately 20 degrees of retroversion [115]. Reducing the usual amount of retroversion of the humeral component decreases the tendency of the head to sublux posteriorly in posterior dislocations [115]. For very old dislocations or large head defects (larger than 45% to 50%), most authors suggest proceeding directly to arthroplasty [115]. If insufficient internal rotation remains after reduction of a posterior dislocation, osteotomy is indicated [115]. Guided passive exercises are begun 1 week after surgery for posterior dislocation treatment, with a maximum of 90 degrees of flexion and abduction and external rotation only to the neutral position [115]. External rotation is not allowed up to the sixth postoperative week after posterior dislocation treatment [115]. Six to 8 weeks after surgery, if good range of motion and strength have returned, activities such as swimming and throwing can be allowed [115]. The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases [41].

Implant Selection: Total shoulder arthroplasty with an all-polyethylene, pegged glenoid component utilizing hybrid fixation demonstrates excellent clinical and radiological outcomes at long-term follow-up [129]. Shoulder arthroplasty with an all-polyethylene, hybrid-fixation pegged glenoid component has durable clinical and radiographic outcomes at medium-term follow-up [134]. Total shoulder arthroplasty with an all-polyethylene pegged glenoid component utilizing hybrid fixation demonstrated excellent clinical and radiographic results at early follow-up [144]. Both cemented and press-fit humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up [138]. Press-fit prosthetic systems for shoulder arthroplasty that are commonly used necessitate marked alterations of the original anatomy [147]. Biologic resurfacing of the glenoid may have a minimal and as yet undefined role in the management of glenohumeral arthritis in young active patients over more traditional methods [135]. Younger patients with shoulder arthroplasty are likely to experience implant failure in their lifetime, leading to a focus on avoiding prosthetic glenoid implants and preserving glenoid bone stock [136]. Pyrocarbon interposition shoulder arthroplasty should remain to be tested in a few specialized shoulder centers until long-term results are available [137]. The CTA prosthesis remains a favored option for active individuals without anterosuperior escape and with more than 90 degrees of active elevation before surgery [8]. Maintaining the integrity of the subscapularis appears to be important to the outcome of CTA prosthesis [8]. The primary causes of failure of the CTA prosthesis are weakness and instability [8]. In the Grammont reverse prosthesis, the center of rotation is medial to the glenoid component-bone interface to decrease shear stress and provide compressive stress [143]. In the Grammont reverse prosthesis, the humeral component is inset and the opening angle of the polyethylene is relatively horizontal (155 degrees) [143]. In the Grammont reverse prosthesis, the humerus is more medial and more distal than preoperatively, providing a mechanical advantage to the deltoid [143]. In the Grammont reverse prosthesis, the humeral component is recommended to be implanted in more anteversion (0 to 10 degrees of retroversion) than conventional arthroplasty [143]. Subsequent reverse designs have modified features including a larger portion of a sphere, placing the center of rotation more lateral, and using a 135-degree opening angle [143]. Later reverse designs introduced humeral components with an onlay humeral bearing to lateralize the position of the humerus without changing the center of rotation [143]. Use of a stem with fracture-dedicated features (proximal ingrowth surface, small cross section, holes for suture fixation) may be beneficial in reverse arthroplasty for fractures [143].

Alignment / Balancing Strategy: Three-dimensional preoperative planning software and novel information transfer techniques improve glenoid component positioning [118]. Three-dimensional imaging and templating improve glenoid implant positioning [118]. Patient-specific targeting guides compared with traditional instrumentation for glenoid component placement in shoulder arthroplasty have been studied in cadaver specimens [118]. Comparing conventional and computer-assisted surgery baseplate and screw placement in reverse shoulder arthroplasty has been evaluated [118]. The lateralization and distalization shoulder angles are important determinants of clinical outcomes in reverse shoulder arthroplasty [118]. The influence of humeral neck shaft angle and glenoid lateralization on range of motion in reverse shoulder arthroplasty has been studied [118]. Avoiding superior tilt in reverse shoulder arthroplasty is a technical consideration supported by literature reviews [118]. Accuracy of patient-specific guided glenoid baseplate positioning for reverse shoulder arthroplasty has been assessed [118]. Ideal cuff tension allows the humeral head to translate approximately 50% of the glenoid component width and then recenter it when pressure is removed [114]. Cement cannot be used to adjust for poor seating of the glenoid component [114].

Pain Management: A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief compared to a traditional opioid-containing pathway at 12 hours, 24 hours, and 2 weeks postoperatively [101]. 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 [128]. Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen [107]. Local infiltration analgesia and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty [132]. The addition of liposomal bupivacaine to plain bupivacaine for an interscalene block provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine [146]. The majority of shoulder surgeons use standardized perioperative and postoperative pain management protocols [95].

Adjuncts: The use of intraoperative navigation shoulder arthroplasty is safe and produces at least equally good outcomes at 2 years as standard instrumentation without any increased risk of complications [61].

Setting of Care: Outpatient shoulder arthroplasty is a safe option for appropriately selected patients [22].

Revision: Two-stage reimplantation remains the gold standard for chronic infected shoulder arthroplasty [1]. One-stage exchange is an option of interest for chronic infections due to significant scarring at delayed reimplantation, though additional data are necessary to determine outcomes [1]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [21]. Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent [65]. The use of a convertible prosthetic system to revise a failed anatomical shoulder arthroplasty reduces morbidity and minimizes the rate of complications [28]. Complication rates are higher and functional improvement more modest when reverse shoulder arthroplasty is performed as a revision of a prior arthroplasty [8]. Infection is one of the most common modes of failure following reverse total shoulder arthroplasty [8]. Propionibacterium species is a frequently cultured organism from failed reverse total shoulders, which can present with loosening in the absence of usual clinical signs of infection [8]. Instability following reverse total shoulder arthroplasty can result from falls, suboptimal component selection, component malposition, bulky tissues in the posterior shoulder, leverage of the humeral component against the glenoid, or lack of sufficient compressive effect by the deltoid [8]. Stability in reverse total shoulder arthroplasty may be restored by changing to a larger diameter of curvature and increasing the thickness of the polyethylene humeral cup [8]. The risk of humeral fracture is increased by revision surgery, falls, and abrupt transitions between cemented or press-fitted diaphyseal stem tips and osteopenic bone distal to the prosthesis [8].

Other Considerations: Preoperative blood work and aspiration are less reliable for diagnosing shoulder periprosthetic infection compared to hip or knee periprosthetic infection [1]. Propionibacterium acnes is a common cause of shoulder infection in rotator cuff repair, instability surgery, open reduction internal fixation, and shoulder arthroplasty [1]. Propionibacterium acnes is slow-growing, with the average time to a positive culture often exceeding 5 days [1]. Laboratories must keep cultures for a minimum of 10 to 14 days to detect Propionibacterium acnes [1]. Shoulder arthroscopy after arthroplasty is most frequently used as a diagnostic tool but has utility in treating predetermined pathologies [4]. Arthroscopy is a powerful tool for managing painful total shoulder arthroplasty when a clear cause of pain is not present [9]. Diagnostic arthroscopy is indicated when standard investigations fail to identify the cause of pain after shoulder arthroplasty [30]. Arthroscopy allows direct visualization and evaluation of intra-articular and extra-articular parts of the shoulder in postarthroplasty patients [30]. Indications for therapeutic arthroscopy after arthroplasty include removal of a loose glenoid component and treatment of shoulder instability [30]. A 30-degree arthroscope should be used and turned away from the humeral head or glenosphere to avoid the "mirror effect" during postarthroplasty arthroscopy [30]. Serial radiographs correctly predicted glenoid loosening in only two of six patients in a series of nine cases, while arthrography did so in only one of three cases [30]. Arthroscopic examination for more than 2 mm of motion at the interface correctly diagnosed all five loose glenoid components in a specific series [30]. Arthroscopic removal of an all-polyethylene glenoid component can be considered for failed total shoulder arthroplasty with a loose glenoid component in patients with large rotator cuff defects or medical comorbidities precluding revision [30]. Arthroscopic removal of a loose glenoid component and bone grafting of the defect involves debridement, drainage, and packing cancellous bone graft into the defect [30]. Impingement syndrome after total shoulder arthroplasty is relatively rare and can sometimes be prevented with prophylactic acromioplasty [30]. Arthroscopic subacromial decompression yielded excellent or good results in five of six patients with refractory impingement after total shoulder arthroplasty [30]. Arthroscopy in painful shoulder arthroplasties has been used for subacromial decompression, distal clavicle excision, capsular release, mini-open rotator cuff repairs, biceps tenodesis or debridement, and loose body or suture granuloma removal [30]. All patients in a series of 12 painful shoulder arthroplasties treated with arthroscopy had significant improvement in Hospital for Special Surgery shoulder scores [30]. Biceps tendon pathology, including bowstringing over the humeral head component, has been described as a cause of pain after shoulder arthroplasty [30]. Diagnostic arthroscopy can identify the cause of failure after reverse shoulder arthroplasty, such as dissociation of the polyethylene component from the metaphyseal component [30]. Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty [148]. Previous lower extremity periprosthetic joint infection should not be considered a relative contraindication to shoulder arthroplasty [14]. Axillary lymph node dissection is not a contraindication to shoulder arthroplasty [58]. Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications [60]. Knowledge of the array of shoulder prostheses currently available and the indications for each can lead to optimized patient outcomes [24]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty [25]. Regional differences in bone quality in type E2 glenoid in cuff tear arthropathy may influence surgical technique and implant fixation in reverse shoulder arthroplasty [140]. Heterotopic ossification after reverse shoulder arthroplasty is a non-progressive condition without long-term clinical consequences [150]. A case of incomplete glenosphere seating demonstrated spontaneous reversal with non-operative management within one-year follow-up in an elderly patient with low demand [141]. Healing of at least the greater tuberosity in good position provides a higher chance of restoration of active external rotation in reverse arthroplasty for proximal humeral fractures [143]. Not performing a tuberosity repair at the time of reverse arthroplasty for proximal humeral nonunion has been correlated with a higher rate of dislocation [143]. A flail shoulder is functionally inferior to arthroplasty or arthrodesis but superior to a painful arthroplasty or arthrodesis [112]. An arthrodesis is more durable than an arthroplasty and may be preferred in young, active patients [112]. A well-innervated deltoid is the minimal requirement for a functional, stable arthroplasty [112]. Press-fit stems and improved screw and washer constructs that better reconstruct the rotator cuff-prosthesis attachment can offer improved results compared with earlier methods [112]. A reverse prosthesis may be especially useful in tumor resections of the shoulder necessitating sacrifice of the rotator cuff [112]. Composite proximal humeral allografts are the preferred type of allograft reconstruction because of the relatively high failure rate (50%) with osteochondral grafts [112]. With composite reconstruction, reattachment of the deltoid or rotator cuff to the allograft has a distinct advantage over reattachment to metal prostheses [112]. Operative time for total shoulder arthroplasty has decreased from 2008 to 2018 [67].

Complications

Infection (PJI): The overall infection rate after shoulder arthroplasty ranges from 1.2% to 3.0%, with rates of 0.5% to 3.9% for anatomic total shoulder arthroplasty (ATSA) and 5.1% to 10.0% for reverse total shoulder arthroplasty (RTSA) [126]. Infection is one of the most common modes of failure following RTSA [8]. Indolent organisms such as Cutibacterium acnes account for 39% to 66% of shoulder PJI cases, while coagulase-negative staph species account for 24% to 28% [126]. Propionibacterium species are frequently cultured from failed reverse total shoulders [8]. Shoulder PJI commonly presents as a painful arthroplasty with minimal clinical and laboratory findings typical for infection [126]. Infection in reverse total shoulders can present with loosening in the absence of usual clinical signs of infection [8]. Two-stage revision for shoulder PJI showed 63% to 100% success in eradicating infection in short- to midterm follow-up, while one-stage revision has similar rates of eradication [126]. The average Constant score was 51 after one-stage revision and 41 after two-stage revision [126].

Aseptic loosening: Component loosening is a commonly reported complication after total shoulder arthroplasty, occurring approximately 8 years postoperatively [29]. In studies of ATSA from 2006 to 2015, component loosening accounted for 4.0% of all shoulders and 39.1% of all complications [126]. Glenoid aseptic loosening is the weak link in total shoulder arthroplasty, while periprosthetic fracture is exceedingly rare at this location [152]. Glenoid component survivorship with revision as the end point was 94.5% in a large multicenter study of total shoulder arthroplasty [142]. In studies of RTSA from 2006 to 2015, component loosening accounted for 1.8% of all shoulders and 11.3% of all complications [126].

Instability: Complications after total shoulder arthroplasty tend to occur late in the postoperative course, specifically 5 to 10 years after surgery [29]. In studies of RTSA from 2006 to 2015, instability accounted for 5.0% of all shoulders and 31.3% of all complications [126]. Instability following RTSA can result from falls, suboptimal component selection, component malposition, bulky tissues in the posterior shoulder, leverage of the humeral component against the glenoid, or lack of a sufficient compressive effect by the deltoid [8]. In studies of ATSA from 2006 to 2015, instability accounted for 1.0% of all shoulders and 10.1% of all complications [126]. A multicenter study showed that 16.8% of patients develop moderate to severe superior subluxation of the humeral head on AP radiographs after ATSA with secondary rotator cuff failure [126].

Periprosthetic fracture: Periprosthetic fractures associated with shoulder arthroplasty can occur both during and after surgery, with most occurring on the humeral side [32]. The incidence of periprosthetic humeral fractures is reported as high as 4.6% after shoulder arthroplasty [126]. Periprosthetic fracture represents the most common complication, accounting for approximately 11% to 20% of total shoulder arthroplasty complications [152]. The overall rate of periprosthetic humeral fracture after ATSA is approximately 0.5% to 3% [152]. In a large series of 2,588 total shoulder arthroplasties, the rate of periprosthetic humeral fracture was 2.1% compared with a 0.4% rate of glenoid fracture [152]. Periprosthetic humeral fractures occur more commonly intraoperatively than postoperatively, with the incidence of intraoperative fracture being about twice as common as those occurring later [152]. According to the Swedish registry, intraoperative periprosthetic fractures are three times more common than postoperative fractures [126]. Risk factors for periprosthetic humeral fracture include female gender, older age, revision arthroplasty, press-fit humeral stem, proximal stress shielding, osteopenia, rheumatoid arthritis, posttraumatic osteoarthritis, severe joint stiffness, manipulation under anesthesia, and malunion or deformity [152]. In a series by Krakauer and Cofield, 85% of fractures occurred in females [152]. Athwal et al. showed a relative risk of 3.3 for intraoperative fracture in females [152]. Rheumatoid arthritis has been implicated as a significant risk factor, with incidence rates of 1.8% to 3.4% compared with 1.1% to 1.5% for other diagnoses [152]. Osteopenia or severe cortical thinning is a cited risk factor, especially among patients with revision arthroplasty stems [152]. In a study by Campbell et al., 75% of patients with fractures had osteopenia [152]. In a study by Kumar et al., all patients with fractures had osteopenia, with 44% having severe osteopenia [152]. Women and those with a poor morbidity index score are at substantial risk for periprosthetic fractures associated with shoulder arthroplasty [32]. The risk of humeral fracture is increased by revision surgery and by falls [8]. The risk of humeral fracture is increased when the humeral component fixation results in an abrupt transition between a cemented or press-fitted diaphyseal stem tip and osteopenic bone distal to the stem [8]. Most intraoperative periprosthetic fractures of the humerus or glenoid are caused by errors in surgical technique, such as inadvertent reaming, overzealous impaction, or manipulation of the upper extremity during exposure of the glenoid [151]. Spiral fractures of the humerus usually are caused by excessive external rotation of the shoulder during attempts to improve exposure [151]. A humeral shaft fracture is most likely during the reaming process when resistance is met and excessive torque is generated [151]. A humeral shaft fracture is most likely during the reduction and dislocation maneuver to test implant stability if longitudinal distraction is not used [151]. Fractures of the glenoid are extremely rare and usually occur in osteopenic bone [151]. Most glenoid fractures occur intraoperatively [152]. Periprosthetic fractures around the glenoid component are rare and typically occur intraoperatively [32]. The Wright and Cofield classification divides periprosthetic humeral fractures into three categories: type A (propagate proximally from the distal stem), type B (centered over the distal stem), and type C (located distal to the tip of the stem) [32]. Nonsurgical management is an option for all periprosthetic fracture types, especially for patients with several comorbidities, minimal function, and/or minimal displacement [32]. Patients with nondisplaced type B and C periprosthetic fractures can undergo a trial of nonsurgical management, though a higher incidence of delayed union and nonunion has resulted in a recommendation for a low threshold before considering surgical intervention at the 3-month follow-up evaluation [32]. For type A, B, and 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 [32]. 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 the preferred surgical treatment for periprosthetic humeral fractures [126]. Loose implants with concomitant periprosthetic fractures should be revised with a longer humeral stem augmented with a locking plate or strut graft [126]. Surgical management of periprosthetic fractures around a stable humeral implant is amenable to open reduction and internal fixation (ORIF) using cables, plates, and/or screws [32]. A plate used for surgical fixation of periprosthetic fractures should span the fracture and provide adequate overlap with the implant to avoid gaps that can be stress risers [32]. Implant overlap is a necessary aspect of surgical management for type B and C periprosthetic fractures [32]. Simple cerclage wiring of the proximal end of the humerus and implantation of a standard-size prosthesis are usually sufficient for fractures proximal to the tip of the humeral prosthesis [151]. Converting to a longer-stem prosthesis for unstable intraoperative humeral fractures has advantages over dynamic compression plating or cerclage wiring alone, including obviating the need for secure screw purchase in poor quality bone and minimizing stress shielding [151]. A large 2013 series of 36 patients with periprosthetic shoulder fractures reported an overall 97% union rate and a 39% complication rate [32].

Thromboembolism: The prevalence of deep vein thrombosis (DVT) after reconstructive shoulder arthroplasty was 13.0% [149]. The rate of DVT after shoulder arthroplasty is comparable to that after hip arthroplasty but lower than that after knee arthroplasty [149]. The risk of venous thromboembolism after shoulder arthroplasty is low, and routine use of pharmacologic venous thromboembolism prophylaxis may not be necessary [158]. Routine use of low-dose aspirin results in a very low risk of venous thromboembolism and medication-associated complications following primary shoulder arthroplasty [164].

Nerve palsy: The most common intraoperative complications in shoulder arthroplasty include nerve injury, most often to the axillary nerve [151]. Permanent nerve injury during total shoulder arthroplasty is rare but devastating when it does occur [151]. Most reported instances of permanent axillary nerve injury involved revision surgery or primary surgery in a shoulder that had multiple previous operations [151]. In studies of RTSA from 2006 to 2015, neural injury accounted for 1.2% of all shoulders and 7.5% of all complications [126]. In studies of ATSA from 2006 to 2015, neural injury accounted for 0.63% of all shoulders and 6.1% of all complications [126]. The radial nerve can be injured by an intraoperative humeral shaft fracture and internal fixation of the fracture [151]. Extrusion of cement through a defect in the humeral canal has been reported to result in radial nerve injury [151].

Other Considerations: The overall complication rate after total shoulder arthroplasty is estimated to be approximately 15% [29]. Component loosening, glenohumeral instability, rotator cuff tear, periprosthetic fracture, infection, implant failure including dissociation of modular prostheses, and deltoid weakness or dysfunction are the most commonly reported complications after total shoulder arthroplasty [29]. A study of over 400 total shoulder arthroplasties with cemented all-polyethylene glenoid components found a 12% complication rate, with only one reoperation required for component loosening [29]. Reverse total shoulder arthroplasty initially resulted in complication rates of approximately 50% [29]. The complication rate for reverse total shoulder arthroplasty has fallen to 6% in recent reports due to improved techniques and device understanding [29]. Complication rates are higher and functional improvement more modest when reverse shoulder arthroplasty is performed as a revision of a prior arthroplasty [8]. The most common complications after reverse total shoulder arthroplasty include scapular notching, hematoma formation, glenoid dissociation, glenohumeral dislocation, acromial and scapular spine fractures, infection, loosening or dissociation of the humeral component, and nerve injury [29]. In studies of RTSA from 2006 to 2015, periprosthetic fracture accounted for 3.3% of all shoulders and 20.8% of all complications [126]. In studies of RTSA from 2006 to 2015, infection accounted for 2.9% of all shoulders and 17.8% of all complications [126]. In studies of ATSA from 2006 to 2015, glenoid wear accounted for 2.3% of all shoulders and 22.6% of all complications [126]. In studies of ATSA from 2006 to 2015, rotator cuff tear accounted for 0.9% of all shoulders and 9.0% of all complications [126]. In studies of ATSA from 2006 to 2015, infection accounted for 0.51% of all shoulders and 4.9% of all complications [126]. In studies of RTSA from 2006 to 2015, acromial and/or scapular spine fracture accounted for 1.0% of all shoulders and 6.0% of all complications [126]. In studies of ATSA from 2006 to 2015, periprosthetic fracture accounted for 0.69% of all shoulders and 6.7% of all complications [126]. The rate of complications after shoulder arthroplasty has declined compared with a decade earlier [126]. The 1-year mortality rate following shoulder arthroplasty is approximately 1% [126]. The overall rate of complications is 10% for anatomic total shoulder arthroplasty (ATSA) and 16% for reverse total shoulder arthroplasty (RTSA) [126]. Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates [33]. Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival [34]. Smoking increases the risk for revision, reoperation, and complications in patients undergoing primary reverse shoulder arthroplasty aged 65 years or younger [34]. Rotator cuff tears are uncommon in the setting of primary glenohumeral arthritis [126]. Repair of partial and small full-thickness supraspinatus tears at the time of anatomic total shoulder arthroplasty did not affect short-term clinical outcomes [126]. Attritional rotator cuff tear is a cause of possible late failure and revision of anatomic total shoulder arthroplasty [126]. In patients older than 80 years, total shoulder arthroplasty remains a reliable option, with 80% attaining an excellent or satisfactory result at an average of 5.5 years [142]. In patients younger than 50 years, total shoulder arthroplasty outcomes tend to decline, ultimately with a large number of unsatisfactory results [142]. The incidence of primary shoulder arthroplasty has increased by 160% during the study period in Finland [163]. The risk of infection after primary shoulder arthroplasty is significantly higher in patients with a history of prior nonarthroplasty [126].

Recovery

Light activity (weeks): Driving performance returns to preoperative levels by 6 weeks postoperatively, with significant improvement in simulated driving performance and a decrease in collisions observed by 12 weeks [50, 99]. Most patients return to work at an average of 2.3 months postoperatively, though workers' compensation patients experience higher reoperation rates and inferior outcomes compared to non-workers' compensation patients [70, 96].

Full activity (months): Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty demonstrating the highest rate of return [111]. The recommended activity level should be based on the type of arthroplasty performed as well as the patient's preoperative athletic experience [127]. Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications in this demographic [34].

Complete recovery / outcome plateau (months): Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications after total shoulder arthroplasty [187]. Patients achieve maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [199]. Early results show improvements in pain and function, though progressive glenoid radiolucencies may develop [6]. Six distinct early recovery trajectories were identified, with 83.7% of patients in the 'Faster group' experiencing very low pain scores after only 2 weeks [31].

Rehabilitation protocol: Primary shoulder arthroplasty is associated with low 90-day reoperation and complication rates [33]. Reverse total shoulder arthroplasty restores function with significant improvements in function and moderate complications [130]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [202]. Reverse shoulder arthroplasty could be considered primary treatment for proximal humerus fractures, especially when optimal range of motion is of great importance to the patient [133].

Functional milestones: Clinical experience shows many patients do well with glenohumeral preservation techniques and delay the need for prosthetic shoulder arthroplasty, though long-term outcomes are presently unknown [19]. Patients with an unsatisfactory outcome after shoulder arthroplasty present with poor shoulder function and pain [10]. 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 [181]. At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis [194]. 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 [123].

Other Considerations: Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment [110]. 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 [116]. The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011 [122]. Over the past decade, reverse total shoulder arthroplasty (RTSA) has become the most common primary shoulder arthroplasty [189].

Key Evidence

• [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. (10.1016/j.jse.2015.09.013)
• [L4] Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic GD, offering improved clinical outcomes and favorable satisfaction following surgery. (10.1016/j.xrrt.2025.03.001)
• [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. (10.1016/j.jse.2007.11.004)
• [Commentary] Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and should be considered when evaluating cases in which a clear cause of pain is not present. (10.1016/j.arthro.2020.02.031)
• [L4] Patients with an unsatisfactory outcome after shoulder arthroplasty present with poor shoulder function and pain. (10.1016/j.jse.2006.11.004)
• [L4] This systematic review demonstrates that the evaluation workup and criteria used to diagnose shoulder PJI remain inconsistent. (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. (10.5435/jaaos-20-09-604)
• [L4] Thus, previous lower extremity PJI should not be considered a relative contraindication to shoulder arthroplasty. (10.1016/j.jse.2016.05.024)
• [L3] Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. (10.5397/cise.2023.00836)
• [L3] Shoulder arthroplasty after undergoing prior shoulder surgery results in overall clinically improved outcomes, however these results are inferior compared to patients without a history of prior shoulder surgery. (10.1177/2325967115s00168)
• [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. (10.1177/2471549219832442)
• [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. (10.1016/j.jse.2007.09.005)
• [L4] The long-term outcomes of glenohumeral preservation techniques are presently unknown, but clinical experience shows many patients do well and delay the need for prosthetic shoulder arthroplasty. (10.1155/2012/160923)
• [L5] The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications. (10.2106/jbjs.m.00402)
• [L4] Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. (10.1016/j.jse.2019.04.006)
• [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. (10.5435/00124635-200907000-00002)
• [L3] Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty. (10.1016/j.jse.2025.02.055)
• [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. (10.1016/j.jse.2023.09.021)
• [L4] The use of a convertible prosthetic system to revise a failed anatomical shoulder arthroplasty reduces morbidity and minimises the rate of complications. (10.1302/0301-620x.97b12.35176)
• [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. (10.1016/j.jse.2025.06.016)
• [L4] Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. (10.1016/j.jse.2019.12.008)
• [L3] Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications. (10.1016/j.jse.2016.05.026)
• [L4] The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases. (10.1016/j.jse.2009.10.016)
• [L4] Kinematics of the rTSA shoulders are significantly altered, and more scapulothoracic motion is used to achieve shoulder elevation compared to healthy subjects. (10.1016/j.jse.2011.07.031)
• [L4] The proposed classification system is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. (10.1302/0301-620x.98b3.36664)
• [Abstract] RTSA shoulders show kinematics that are significantly different from normal shoulders, utilizing much more scapulothoracic motion and much less glenohumeral motion to elevate the arm. (10.1016/j.jse.2014.11.012)
• [L4] Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty, with improved performance compared with preoperative levels by 12 weeks postoperatively. (10.2106/jbjs.15.00162)
• [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. (10.1016/j.jse.2022.10.014)
• [L3] Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. (10.2106/jbjs.16.00541)
• [L4] Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. (10.1177/1758573218780519)
• [L3] Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement. (10.1016/j.jse.2023.09.014)
• [L3] The use of intraoperative navigation shoulder arthroplasty is safe, produces at least equally good outcomes at 2 years as standard instrumentation does without any increased risk of complications. (10.1016/j.jse.2023.05.021)
• [L3] The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty. (10.1302/0301-620x.103b5.bjj-2020-1503.r1)
• [L4] Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent. (10.1016/j.jse.2008.09.006)
• [L5] The anterior deltoid is important biomechanically for balanced function after a reverse total shoulder arthroplasty. (10.1016/j.jse.2012.02.002)
• [L3] Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. (10.1177/17585732211008900)
• [L1] A majority of patients return to work after shoulder arthroplasty at an average of 2.3 months postoperatively. (10.1016/j.jse.2018.12.011)
• [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. (10.1016/j.jse.2026.04.002)
• [L4] In vivo, glenohumeral joint contact after total shoulder arthroplasty is not centered on the glenoid surface, suggesting that kinematics after shoulder arthroplasty may not be governed by ball-in-socket mechanics as traditionally thought. (10.2106/jbjs.h.01610)
• [L3] Though the differences in patient indications led to higher humeral complications, no difference in glenoid complications were noted. (10.1177/24715492241259470)
• [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. (10.5435/jaaos-d-23-00758)
• [L3] There was no difference in final outcomes between patients with shoulder periprosthetic joint infection and those revised for noninfectious indications. (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. (10.5435/jaaos-d-21-00562)
• [L5] The custom, non-spherical prosthetic head more accurately replicated the head shape, rotational range of motion, and glenohumeral joint kinematics than the commercially available, spherical prosthetic head compared with the native humeral head. (10.1016/j.jse.2013.01.002)
• [L3] Age 70 years or older does not appear to be a contraindication to stemless anatomic total shoulder arthroplasty, as postoperative improvements in patient-determined outcome scores and range of motion were similar between patients aged <70 years and those aged 70 years or older. (10.1016/j.jse.2022.08.003)
• [L5] This numerical study highlights the importance of an anatomical reconstruction of the glenohumeral surfaces for the success rate of anatomical total shoulder arthroplasty. (10.1016/j.jse.2010.06.006)
• [L4] The majority of shoulder surgeons use standardized perioperative and postoperative pain management protocols. (10.1016/j.jse.2017.10.005)
• [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. (10.1016/j.jse.2018.10.007)
• [L3] Transitioning appropriate patients to outpatient total shoulder arthroplasty results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up. (10.1016/j.jse.2024.05.012)
• [Abstract] At 12 weeks status post anatomic or reverse total shoulder arthroplasty, patients showed improved driving performance, with a significant decrease in the number of collisions in the simulated driving course compared to preoperative and 2-week post-operative trials. (10.1016/j.jse.2014.06.005)
• [L1] A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively. (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. (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. (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. (10.1016/j.jse.2017.11.015)
• [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. (10.1016/j.jse.2023.08.029)
• [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. (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. (10.1007/s00167-017-4547-1)
• [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. (10.1016/j.jse.2022.09.016)
• [L3] The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011. (10.1016/j.jse.2014.06.055)
• [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. (10.1016/j.jse.2022.08.014)
• [L5] The recommended activity level after shoulder arthroplasty should be based on the type of arthroplasty performed as well as on the patient's preoperative athletic experience. (10.1016/j.jse.2010.07.021)
• [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. (10.1016/j.jse.2019.01.013)
• [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. (10.1016/j.jse.2021.03.003)
• [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. (10.1177/1758573220977184)
• [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. (10.5435/jaaos-d-20-01205)
• [L1] LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. (10.2106/jbjs.22.00034)
• [L3] Therefore, reverse shoulder arthroplasty could be considered primary treatment, especially when optimal range of motion is of great importance to the patient. (10.1177/17585732231190038)
• [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. (10.2106/jbjs.20.00084)
• [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. (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. (10.1016/j.jse.2014.09.029)
• [L4] Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers. (10.1016/j.jse.2017.01.002)
• [L3] Both cemented and press-fit humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up. (10.1016/j.jse.2023.11.029)
• [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. (10.1016/j.jse.2018.07.020)
• [L4] These regional differences in bone quality may influence surgical technique and implant fixation in reverse shoulder arthroplasty. (10.1016/j.jse.2019.05.046)
• [L5] This case demonstrates spontaneous seating of the glenosphere component with non-operative management within one-year follow-up in an elderly patient with low demand for the affected joint. (10.1177/2471549220949147)
• [L4] Total shoulder arthroplasty with an all-polyethylene pegged glenoid component, utilizing hybrid fixation, demonstrated excellent clinical and radiographic results at the time of early follow-up. (10.2106/jbjs.15.00475)
• [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. (10.1016/j.jse.2020.09.017)
• [L4] Press-fit prosthetic systems for shoulder arthroplasty that are commonly used necessitate marked alterations of the original anatomy. (10.2106/00004623-199905000-00007)
• [L3] Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty. (10.1177/17585732241269174)
• [L2] The prevalence of DVT after reconstructive shoulder arthroplasty was 13.0%, a rate comparable to that after hip arthroplasty but lower than that after knee arthroplasty. (10.1016/j.jse.2008.07.011)
• [L3] HO after reverse shoulder arthroplasty is a non-progressive condition without long-term clinical consequences. (10.1302/0301-620x.98b9.37761)
• [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. (10.1016/j.jse.2020.07.037)
• [L3] Patients with a history of prior nonarthroplasty shoulder surgery had significantly lower final ASES scores compared to those without prior surgery. (10.1016/j.jseint.2024.07.011)
• [L4] The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. (10.2106/jbjs.18.01200)
• [L1] Arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty. (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. (10.1007/s11999-012-2551-9)
• [L4] The clinical and radiologic results of the short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty. (10.1016/j.jse.2015.08.044)
• [L2] Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings. (10.1016/j.jse.2019.04.005)
• [L3] The incidence of primary shoulder arthroplasty has increased by 160% during the study period in Finland. (10.1186/s12891-018-2150-3)
• [L3] Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. (10.1016/j.jse.2020.09.030)
• [L5] No correlations between functional outcomes and radiographic shoulder findings at mid-term were identified. (10.1016/j.arthro.2025.07.020)
• [L4] The clinical and radiologic evaluation of an uncemented all-polyethylene glenoid is promising, with good clinical results and with no signs of loosening in 88% of the patients on computed tomography scans. (10.1016/j.jse.2013.01.036)
• [L3] Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture. (10.2106/jbjs.k.01516)
• [L4] The functional and radiologic results of the stemless shoulder arthroplasty are comparable to the third and fourth generation of standard stem arthroplasty. (10.1016/j.jse.2015.02.023)
• [L4] The functional and radiographic outcomes of Eclipse total shoulder replacement are excellent. (10.1016/j.jse.2018.05.039)
• [L4] The percentage of radiologic changes of the glenoid component in RSA is considerable, despite the detection of a decrease in their presence among the arthroplasties implanted outside the initial period. (10.1016/j.jse.2020.10.007)
• [L3] The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty. (10.1016/j.jse.2024.10.016)
• [L3] This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. (10.1016/j.jse.2010.03.010)
• [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. (10.1016/j.jse.2023.07.005)
• [L3] Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications. (10.1177/1758573220922845)
• [L4] Over the past decade, RTSA has become the most common primary shoulder arthroplasty, reflecting the clinical success of the procedure. (10.5435/jaaos-d-17-00075)
• [L3] At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. (10.1016/j.jse.2019.12.009)
• [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. (10.1016/j.jse.2018.05.029)
• [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. (10.1016/j.jse.2018.05.030)

See Also

• Total shoulder arthroplasty
• Fractures
• Os Acromiale
• Rotator Cuff
• Shoulder Instability
• Frozen Shoulder
• Cuff Pathology
• Reverse Shoulder Arthroplasty
• Shoulder Arthritis
• Shoulder Arthroscopy
• Calcific Tendinitis
• Rotator cuff repair
• Internal Fixation
• Subacromial Decompression
• Capsular Release for Frozen Shoulder
• Biceps Tenodesis
• Shoulder Fractures

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[89] Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.07.014

[90] Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-21-00562

[92] The effects of prosthetic humeral head shape on glenohumeral joint kinematics: a comparison of non-spherical and spherical prosthetic heads to the native humeral head. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.002

[93] Is stemless total shoulder arthroplasty indicated in elderly patients?. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.08.003

[94] Biomechanical consequences of humeral component malpositioning after anatomical total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.06.006

[95] Current pain prescribing habits for common shoulder operations: a survey of the American Shoulder and Elbow Surgeons membership. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.10.005

[96] Inferior outcomes and higher complication rates after shoulder arthroplasty in workers' compensation patients. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.10.007

[97] Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.012

[99] Driving Performance after Shoulder Arthroplasty. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.005

[101] Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.12.015

[102] Validation of new shoulder periprosthetic joint infection criteria. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.04.009

[104] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Mechanics of Anatomic Arthroplasty.

[105] Assessment of periprosthetic joint infection in revision shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.040

[107] Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.11.015

[108] Prognostic value of the Walch classification for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.029

[109] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Signs and Symptoms of Periprosthetic Humeral Fractures About Shoulder Arthroplasty.

[110] Effect of total shoulder replacements on airport security screening in the post-9/11 era. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.10.016

[111] Return to sport after shoulder arthroplasty: a systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4547-1

[112] Rockwood And Matsen S The Shoulder. Risk Factors for Failure of Arthroscopic Stabilization > Reconstructive Procedures.

[113] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > CLINICAL EVALUATION AND PHYSICAL EXAMINATION.

[114] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > SURGICAL TECHNIQUE.

[115] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC TRANSFER OF THE CORACOACROMIAL LIGAMENT FOR CHRONIC ACROMIOCLAVICULAR JOINT DISLOCATION > DELTOPECTORAL APPROACH FOR CHRONIC POSTERIOR SHOULDER DISLOCATION.

[116] Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.016

[118] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > RECONSTRUCTIVE PROCEDURES OF THE SHOULDER > HISTORY, ANATOMY, PROSTHESIS DESIGN.

[119] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Clinical Findings.

[120] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > PATIENT HISTORY.

[121] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > TREATMENT.

[122] The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.055

[123] Shoulder arthroplasty after prior external beam radiation therapy: a matched cohort analysis. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.08.014

[124] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > DIAGNOSIS AND DIAGNOSTIC ARTHROSCOPY IN SHOULDER INSTABILITY.

[126] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Arthritis and Arthroplasty > Imaging > Complications of Shoulder Arthroplasty.

[127] Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.07.021

[128] Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.01.013

[129] Long Term Clinical and Radiological Results of an All-Polyethylene, Pegged, Bone Ingrowth Glenoid Component. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.003

[130] Prospective multicentre mid-term clinical and radiological outcomes of 159 reverse total shoulder replacements and assessment of the influence of post-operative complications. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220977184

[131] Scapular Fractures After Reverse Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-20-01205

[132] Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00034

[133] Does primary treatment of proximal humerus fractures show favourable functional outcomes over secondary treatment with reverse shoulder arthroplasty?. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231190038

[134] Medium-Term Clinical and Radiographic Results of an All-Polyethylene, Pegged, Bone-Ingrowth Glenoid Component. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00084

[135] The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.06.001

[136] Shoulder arthroplasty options in young (<50 years old) patients: review of current concepts. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.09.029

[137] Pyrocarbon interposition shoulder arthroplasty: preliminary results from a prospective multicenter study at 2 years of follow-up. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.01.002

[138] Cemented vs. press-fit humeral stems: a matched cohort analysis at a mean follow-up of 10 years. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.029

[139] The pathogenesis and management of cuff tear arthropathy. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.07.020

[140] Density distribution of the type E2 glenoid in cuff tear arthropathy. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.046

[141] Case Report: Watching and Waiting? A Case of Incomplete Glenosphere Seating With Spontaneous Reversal in Reverse Shoulder Arthroplasty. Journal of Shoulder and Elbow Arthroplasty. 2020. DOI: 10.1177/2471549220949147

[142] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > OSTEOARTHRITIS.

[143] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Reverse Shoulder Arthroplasty.

[144] Clinical and Radiographic Results of an All-Polyethylene Pegged Bone-Ingrowth Glenoid Component. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00475

[146] Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.017

[147] Geometric Analysis of Commonly Used Prosthetic Systems for Proximal Humeral Replacement. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199905000-00007

[148] Perioperative complications and readmission rates following total shoulder arthroplasty in patients aged 90 and older. Shoulder & Elbow. 2024. DOI: 10.1177/17585732241269174

[149] Deep vein thrombosis after reconstructive shoulder arthroplasty: A prospective observational study. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.07.011

[150] Heterotopic ossification after reverse total shoulder arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b9.37761

[151] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > INTRAOPERATIVE COMPLICATIONS.

[152] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Periprosthetic Humeral Fractures About Shoulder Arthroplasty > Introduction to Periprosthetic Humeral Fractures About Shoulder Arthroplasty.

[154] Preoperative partial-thickness rotator cuff tears do not compromise anatomic total shoulder replacement outcomes: medium-term follow-up. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.037

[155] Classifications And Scores Of The Shoulder. 16 Classification of septic arthritis.

[156] Prior nonarthroplasty shoulder surgery and modifiable risk factors negatively affect patient outcomes after shoulder arthroplasty. JSES International. 2024. DOI: 10.1016/j.jseint.2024.07.011

[157] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Classification of Periprosthetic Humeral Fractures About Shoulder Arthroplasty.

[158] Symptomatic Thromboembolic Complications After Shoulder Arthroplasty. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.01200

[159] Assessment of painful total shoulder arthroplasty using computed tomography arthrography. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.06.027

[160] Immediate Postoperative Radiographs After Shoulder Arthroplasty Are Often Poor Quality and Do Not Alter Care. Clinical Orthopaedics & Related Research. 2013. DOI: 10.1007/s11999-012-2551-9

[161] Radiologic bone adaptations on a cementless short-stem shoulder prosthesis. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.044

[162] Improving preoperative planning of revision surgery after previous anatomic total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.005

[163] Increasing incidence of primary shoulder arthroplasty in Finland – a nationwide registry study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2150-3

[164] Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.030

[165] Shoulder Superior Capsular Reconstruction Using Xenograft Shows No Deterioration in Functional Improvement at 5-Year Follow-Up. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2025.07.020

[166] Fully uncemented glenoid component in total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.036

[168] Classification of Postoperative Acromial Fractures Following Reverse Shoulder Arthroplasty. The Journal of Bone and Joint Surgery-American Volume. 2013. DOI: 10.2106/jbjs.k.01516

[169] Midterm results of stemless shoulder arthroplasty: a prospective study. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.02.023

[174] Clinical and radiologic outcomes following total shoulder arthroplasty using Arthrex Eclipse stemless humeral component with minimum 2 years' follow-up. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.039

[177] Radiographic changes around the glenoid component in primary reverse shoulder arthroplasty at mid-term follow-up. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.007

[178] The validity of radiographic measurements compared to 3-dimensional-surface model-based measurements in shoulders with reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.10.016

[179] A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.03.010

[181] Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.005

[187] Reassessing the minimum two-year follow-up standard after total shoulder arthroplasty—Is one year sufficient?. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220922845

[189] Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00075

[194] Outcomes of total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure: a retrospective review and matched cohort. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.009

[199] Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.029

[202] How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.030