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Total shoulder arthroplasty

Surgeon-side topic for total shoulder arthroplasty. Backed by 412 articles from the corpus, retrieved via combined MeSH + title-text matching.

234 citationsUpdated Nov 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Total shoulder arthroplasty is an effective and safe treatment option, with outcomes that are durable and reproducible [17, 200]. The procedure yields good to excellent clinical results in greater than 90% of shoulders in early to midterm follow-up [2], relieving pain in approximately 90% to 95% of all patients [2]. It provides substantial and durable improvement in shoulder function [8] and demonstrates excellent long-term survivorship with significant improvements in pain and function [43]. The authors consider shoulder arthroplasty as safe as more commonly performed major joint arthroplasties [6], with reported 30-day, 90-day, and 1-year mortality rates of 0%, 0.16%, and 2% in a cohort of 640 patients [42].

Indications for the procedure continue to broaden, particularly for reverse shoulder arthroplasty in cuff-deficient shoulders [38]. 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 [202]. While patients with a history of prior shoulder surgery achieve overall clinically improved outcomes, these results are inferior compared to patients without such a history [27]. Outpatient total shoulder arthroplasty in appropriately selected patients is a safe and cost-effective alternative to inpatient care, resulting in similar outcomes and complications compared to inpatient cohorts with midterm follow-up [195, 197, 203].

Optimized patient outcomes depend on knowledge of the array of shoulder prostheses available and the indications for each, as well as the use of treatment algorithms [45]. 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 [40]. Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost [35]. While early results for computer-assisted navigation are promising, further long-term studies are needed to fully assess its value and establish best practices for routine use [31]. Consensus recommendations from a real-time Delphi technique can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1].

Anatomy & Pathophysiology

Bony Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [58]. The articular head is spherical with a diameter of 37 to 57 mm [58] and a radius of curvature of approximately 25 mm [70]. The articular surface is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [70]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [58], while the superior margin is normally superior to the top of the greater tuberosity by 8 to 10 mm [70]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [58], and the humeral head is retroverted an average of 30 degrees relative to the transepicondylar axis [74]. Other measurements indicate the humeral head averages 19° of retroversion [61], with a version range of 0-55 degrees retroversion [70]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [58], with an inclination range of 30-55 degrees [70] and an average of 41° [61]. The anatomic neck is located at the junction of the articular surface and the tuberosities [58], while the surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [58]. The neck-shaft angle measures an average of 135 degrees [59], though another source reports an average of 45 degrees with a range of 30 to 50 degrees [70].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [58]. The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [59]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [70], with specific radii of 22-28 mm for the glenoid and 23-28 mm for the humeral head [70]. The glenoid diameter ranges from 18-30 mm superior anteroposteriorly, 21-35 mm inferior anteroposteriorly, and 30-48 mm superoinferiorly [70]. Glenoid inclination averages 4.2 degrees, with a range of –7 to 20 degrees [70]. Glenoid version averages 5° of retroversion in relation to the axis of the scapular body [61] and approximately 5 degrees relative to the scapular body [74], with another measurement averaging 1.5 degrees retroversion and a range of 10.5-9.5 degrees anteversion [70]. The glenoid surface area is 4-6 mm and the humeral head surface area is 11-19 mm [70]. The glenoid cartilage thickness is 2.16 mm and the humeral head cartilage thickness is 1.44 mm [70]. The medial humeral offset is 4-14 mm and the posterior humeral offset is –2 to 10 mm [70].

The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [60]. The glenoid is connected with the flat body of the scapula by the scapular neck [60]. The coracoid process curves forwards from the superior surface of the scapular neck [60], and the acromion is a flattened bony process that curves forwards from the scapular spine [60]. The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula [60], while the spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [60]. The weakest bone in the scapula is located primarily in the central part of the infraspinous fossa [60], and the weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [60]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [70].

Soft Tissue Anatomy

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [59]. These muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [59]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [59]. The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity [66], with the subscapularis inserted into the lesser tuberosity [66]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [58], and the lesser tuberosity serves as the attachment site for the subscapularis tendon [58]. The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion [71]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [71].

The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch [58]. This arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [66]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [58]. The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch [66]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [62] and communicates with the joint cavity between the superior and middle glenohumeral ligaments [62]. The humeroscapular motion interface lies between the inner structures of the proximal humerus, rotator cuff, coracohumeral ligament, and biceps tendon sheath and the superficial layer of the acromion, deltoid, coracoacromial ligament, coracoid process, and conjoined tendon [64].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [61]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [61]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [71]. It restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [61]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [61] and is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [71]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [61] and limits external rotation when the arm is in the lower and middle ranges of abduction [71]. The inferior glenohumeral ligament is composed of an anterior band, a posterior band, and a thinner intervening axillary pouch [71]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation in 90° of abduction and external rotation [61], while the posterior band is a primary static restraint against posterior-inferior translation in internal rotation and adduction [61]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [71].

The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [61]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [74]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [71]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [71].

Vascular Supply

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [58]. The primary blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [59]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [58]. The ascending branch of the anterior humeral circumflex artery enters the humeral head at the interface of the bicipital groove and greater tuberosity [58]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [61]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [61]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [65]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [58]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [58], although additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [58]. The primary blood supply to the clavicle is periosteal; there is no nutrient blood supply [67]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [74].

Neural Anatomy

The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [64]. It passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [64]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [65]. It splits into the anterior and posterior branches within the quadrangular space [64]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [64]. Posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [64]. The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [64]. In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [64]. In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [64]. The brachial plexus and axillary artery are anterior to the coracoid process of the scapula and humeral head [59]. The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [61]. The suprascapular artery runs superior to the superior transverse scapular ligament, and the nerve runs deep to the ligament [61]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [61].

Biomechanics and Kinematics

Normal shoulder motion is approximately two-thirds glenohumeral and one third scapulothoracic [61]. The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [71]. The bony anatomy contributes little to stability and has been compared with a golf ball on a tee [71]. The rotator cuff stabilizes the glenohumeral joint while allowing greater freedom of motion and fixes the fulcrum of the upper extremity against which the deltoid can contract [70]. The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [70]. Maintaining lateral humeral offset is important because a significant decrease reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction [70]. A significant increase in lateral humeral offset causes excessive tension on the soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [70]. Humeral articular malposition of more than 4 mm led to increased subacromial contact [70]. Offset of 8 mm in any direction significantly decreased passive range of motion [70]. Anatomic reconstruction of the humeral head/humeral shaft offset should be within 4 mm of normal to minimize subacromial contact and maximize glenohumeral motion [70].

The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [61]. The posterior SC joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [61]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability [74]. The superior and posterior AC ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [61]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [61]. The trapezoid ligament is approximately 25 mm from the AC joint [74], and the conoid ligament is approximately 45 mm from the AC joint [74]. The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [61]. It is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, AC joint, and acromion [61]. The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [61], and the inferior strut comprises the lateral scapular border and spine of the scapula [61].

The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency [74]. It is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [74]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [74]. The sternoclavicular joint rotates 30 degrees with shoulder motion [74]. The middle glenohumeral ligament is absent in up to 30% of shoulders [74]. Labral anatomic variants include sublabral foramen and Buford complex [74]. The Buford complex is characterized by the absence of the anterosuperior labrum and a cordlike middle glenohumeral ligament [74]. Kinematics of reverse total shoulder arthroplasty shoulders are significantly altered, using more scapulothoracic motion to achieve shoulder elevation compared to healthy subjects [79]. The shoulder kinematics after reverse total shoulder arthroplasty showed significant differences from the contr

Classification

Preoperative Glenoid and Arthritis Classification

Samilson-Prietro: This is the most widely adopted radiographic classification for determining the extent of osteoarthritis of the glenohumeral joint [53]. Grade 0 represents a normal joint, while Grade 1 indicates mild disease with osteophytes less than 3 mm on the humeral head [53]. Grade 2 denotes moderate disease with osteophytes between 3 and 7 mm on the humeral head or glenoid rim, and Grade 3 signifies severe disease with osteophytes of more than 7 mm, with or without articular incongruity [53].

Walch: The Walch classification grades glenoid wear patterns in preoperative imaging for total shoulder arthroplasty [273]. It allows for fair to substantial agreement in categorizing glenoid types [279]. In anatomic total shoulder arthroplasty with keeled glenoids in patients younger than 60 years, long-term survival rates and rates of glenoid free from loosening were not significantly different between type A and B/C Walch glenoids [279].

Hamada-Fukuda: This radiographic morphological description assesses the height of the acromiohumeral space to describe the natural course of massive rotator cuff tear [53]. It includes five distinctions, with Type 1 defined as normal joint morphology and an acromiohumeral distance of more than 6 mm [53].

Larsen: Used to grade shoulder disease in rheumatoid arthritis, this system defines Grade I as a medium destructive abnormality with erosions and joint space narrowing [312]. Grade IV includes severe destructive abnormality with bone deformation, and Grade V includes a mutilating abnormality where the original articular surface has disappeared [312].

Other Considerations: Preoperative 3-dimensional CT bone density measures provide objective classifications of bone quality for stemless anatomic total shoulder arthroplasty [215].

Postoperative and Revision Classification

PHAROS: The Proximal Humeral Arthroplasty Revision Osseous inSufficiency classification system categorizes humeral bone loss in revision total shoulder arthroplasty [132]. It may be useful to anticipate the complexity of humeral reconstruction [132].

Glenoid Defect Classifications: Current classification systems demonstrate limited reliability for assessing glenoid defects in revision reverse total shoulder arthroplasty [161]. Similarly, current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal [167]. A proposed post-treatment glenoid classification system addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements [78].

Sirveaux: This classification detects and grades inferior scapular notching in reverse shoulder arthroplasty, with grades ranging from 1 to 4 [300].

Trabecular Metal Component Grading: Radiolucent lines around trabecular metal glenoid components are graded on a 0–5 scale [273]. Grade 0 represents no radiolucency, Grade 1 shows radiolucency at the superior and/or inferior flange, and Grade 2 shows radiolucency at the keel [273]. Grade 3 indicates complete radiolucency 2 mm wide around the keel, Grade 4 indicates complete radiolucency >2mm wide around the keel, and Grade 5 indicates gross loosening [273]. Metallic debris in trabecular metal glenoid components is graded on a 0–4 scale [273]. Grade 0 means no radiographic evidence of metallic debris, Grade 1 means debris only at the bone–metal interface, and Grade 2 means debris noted in the soft tissues intra-articularly [273]. Grade 3 means incomplete fracture or cracking of the tantalum component, and Grade 4 means complete component fracture and displacement [273].

Superior Humeral Subluxation: This is classified as none, mild, moderate, or severe based on the position of the center of the prosthetic humeral head relative to the center of the glenoid component measured in terms of the diameter of the prosthetic head [273].

Complication Categories: A system of three complication categories was introduced to standardize the presentation of complications in shoulder arthroplasty [16]. Category 1 complications are intraoperative findings or events treated during index surgery or not requiring revision [16].

Etiologic and Pathophysiologic Classification

Fracture Sequelae: Four basic pathophysiologic types of lesions were distinguished to categorize the sequelae of fractures of the proximal humerus for shoulder arthroplasty planning [55]. Historically, these sequelae were grouped as a heterogeneous series including malunion with avascular necrosis, nonunion, or locked fracture-dislocation, leading to inconsistent results due to variability in anatomic lesions [55].

Etiology: The etiology of shoulder arthroplasty is classified into categories such as rotator cuff arthropathy and revision arthroplasty, which influence postoperative outcomes and complication profiles [300].

Clinical Presentation

General Outcomes and Demographics

Total shoulder arthroplasty relieves pain in approximately 90% to 95% of all patients [2]. Elective shoulder arthroplasty can be performed in patients 90 years of age and older, providing excellent pain relief, improved functional outcome, and enhanced general health status [32]. In young patients, prosthetic shoulder arthroplasty provides substantial improvement in active range of motion irrespective of diagnosis and glenoid management [100], though residual shoulder pain is common in this demographic [100]. Early results in young patients show an opportunity for improvements in pain and function [7], but progressive glenoid radiolucencies may develop following total shoulder arthroplasty [7]. Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty [114].

The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes in shoulder arthroplasty [94]. Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis [162], with few differences across diagnostic groups regarding preoperative to postoperative improvement [162]. Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable satisfaction following surgery [144].

Evaluation of Painful or Failed Arthroplasty

A thorough and systematic approach including history, physical examination, and appropriate diagnostic studies is necessary to evaluate failed shoulder arthroplasty [112]. The cause of pain and disability in failed shoulder arthroplasty is often multifactorial [112]. Common causes of pain after shoulder arthroplasty include: * Instability * Periprosthetic joint infection * Component loosening or malposition * Acromioclavicular joint osteoarthritis * Subacromial impingement * Rotator cuff tear * Adhesive capsulitis * Synovitis [136]

Periprosthetic joint infection occurs in up to 3.9% of total shoulder arthroplasty cases [136] and up to 18% of reverse total shoulder arthroplasty cases [136]. Joint aspiration and culture findings are unreliable for evaluating painful shoulder arthroplasty, with only a 16.7% sensitivity [136]. Frequently used serologic markers such as the erythrocyte sedimentation rate and C-reactive protein level can yield negative findings or can be only modestly elevated even in the presence of periprosthetic joint infection, especially with Cutibacterium acnes [136]. Radiographs, computed tomography, and magnetic resonance imaging are all imperfect methods of evaluating patients with painful shoulder arthroplasty [136].

Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations [13]. When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty [14]. Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool [95] and has utility in treating a number of predetermined pathologies after shoulder arthroplasty [95]. Arthroscopy after shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients [158], although it can be technically challenging [158]. Diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear [22]. An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival [125]. The case of metastatic carcinoma to the acromion underscores the need to entertain a broad differential when evaluating a painful shoulder, even after total shoulder arthroplasty [163].

Infection Diagnosis and Presentation

The clinical presentation of periprosthetic joint infection of the shoulder can vary widely, from obvious infection with gross purulence and sinus tract formation to insidious presentations of stiffness and pain without overt signs of infection [141]. The diagnosis of periprosthetic joint infection at the shoulder can be difficult to establish prior to revision surgery in the setting of a potentially low-virulence bacterium such as Cutibacterium [141]. An infected shoulder arthroplasty can have a devastating effect on the function of the shoulder [25]. Indolent infections caused by low virulent organisms such as P. acnes are more common in shoulder arthroplasty than in hip and knee arthroplasty [25]. Patients with P. acnes-infected shoulder do not typically present with severe pain, limited motion, large effusion, warmth, induration, erythema, or drainage [25].

Diagnostic tools such as WBC, ESR, and CRP may not be helpful in diagnosing P. acnes infection because they often remain within normal limits [25]. Shoulder aspirations for cultures are not reliable and require at least 2 weeks of incubation in the appropriate growth media to detect P. acnes [25]. A single aspiration will never answer the question as to whether the result is a false positive or a false negative for P. acnes [25]. Radiographic findings of loosening, shift in position, or bone erosion are suggestive of infection in shoulder arthroplasty [25]. Diagnosis of periprosthetic shoulder infection should be based on clinical suspicion, patient factors, and intraoperative findings when perioperative testing is equivocal [137]. Specific clinical symptoms including pain at rest, systemic symptoms including fevers, chills, or sweats, and WBC bone scan are poorly associated with the presence of infection in revision shoulder arthroplasty [113]. Determining the presence of infection in revision shoulder arthroplasty can be difficult [101], and a standardized approach is needed to determine the best course of treatment for infection in revision shoulder arthroplasty [101].

About 45% of patients with no clinical signs of infection and a history of prior ipsilateral shoulder surgery undergoing primary shoulder arthroplasty grew positive intraoperative cultures [20]. Around one in 25 cases develop a fever following shoulder arthroplasty [160], but most cases of fever following shoulder arthroplasty have no infective aetiology [160].

Specific Complications and Findings

Subscapularis tear after total shoulder arthroplasty is a common finding [12] but cannot be diagnosed reliably by physical examination or radiographs [12]. Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare, occurring in 1.4% of patients greater than 70 years of age [23]. The utility of ultrasound examination of the subscapularis tendon following shoulder arthroplasty is limited by timing [168], and may be most useful when used by the physician within clinical context [168].

Radiographic osteolysis after total shoulder arthroplasty may not initially manifest clinically apparent symptoms [3]. However, radiographic osteolysis after total shoulder arthroplasty can lead to clinically important complications, such as aseptic loosening [3]. Symptoms of osteolysis often progress to vague pain or discomfort due to subtle component loosening [3]. A thorough consideration of medical history and physical examination is essential to rule out other causes of symptomatic TSA, namely periprosthetic joint infection [3].

Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients [26]. Higher complication rates following primary total shoulder arthroplasty are observed in patients presenting from areas of higher social deprivation [15]. 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 [133].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder arthroplasty planning [10]. Radiographs are the first imaging modality used to evaluate the presence and degree of arthritis of the glenohumeral joint [53]. At least two X-ray views should be obtained for shoulder imaging: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the relationship of the humeral head to the glenoid [97]. Common radiographic projections for evaluating glenohumeral arthritis include an anteroposterior view, a Grashey view, and an axillary view [53]. The anteroposterior view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, joint space narrowing, degree of medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [10]. The Grashey view is obtained by a 30° lateral oblique projection, tangential to the glenohumeral joint, to obtain the view directly parallel to the glenoid face [53]. The status of the rotator cuff can be inferred by radiographic evaluation on the Grashey view [53].

The axillary view taken with the arm in the functional position of elevation is referred to as the "truth view" because it demonstrates glenohumeral relationships in the functional position of elevation [10]. The standardized axillary "truth view" enables measurement of posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [10]. The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [10]. The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [10]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [10].

The Samilson-Prietro classification is the most widely adopted classification to determine the extent of osteoarthritis of the glenohumeral joint [53]. The Hamada-Fukuda classification is a radiographic morphological description of the natural course of massive rotator cuff tear assessing the height of the acromiohumeral space [53]. In the Hamada-Fukuda classification, Type 1 indicates normal joint morphology and acromiohumeral distance of more than 6 mm [53]. Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible [299]. In 68 of 100 total shoulder arthroplasties evaluated, clinical information that was not seen on standard radiographs was identified on fluoroscopic views [292]. Patients with mild radiographic signs of arthritis have about sevenfold higher odds of failing to achieve the minimum clinically important difference (MCID) after anatomic total shoulder replacement compared to patients with severe arthritis [336].

CT: CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not necessarily improve the quality of the surgery or the clinical outcome [10]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary "truth view" which is taken in elevation [10]. Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [10]. CT is helpful for planning fracture surgery and shoulder joint replacement [97]. CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [142]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [153]. The use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis has increased dramatically, with the use of computed tomography increasing the most [208]. Advanced 3-dimensional computed tomography imaging software can be used to improve the accuracy of bony measurements and provide detailed planning specifications in patients undergoing anatomic total shoulder arthroplasty [331]. An automated muscle elongation measurement method using CT showed accurate results for arthritic shoulder joints and can be used during preoperative shoulder arthroplasty planning [294].

MRI: MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [97]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [142]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [142]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [142]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [97]. MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty [204]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [271]. Magnetic resonance (MR) accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [126].

Magnetic resonance (MR) arthrography (MRA) refers to MRI of a joint that has been injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [126]. MRA has proven utility by increasing both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [126]. In a meta-analysis of 4,667 shoulders, MRA had greater diagnostic test accuracy for the detection of glenoid labral lesions than MRI, with MRA sensitivity of 88% and specificity of 93% versus MRI sensitivity of 76% and specificity of 87% [126]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury on MRA [126]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [126]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [142]. When MRI or MR arthrography is contraindicated (eg, pacemaker, vascular clips), CT arthrography is indicated [142].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [97]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [142]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [142]. As a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [142]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [142]. Ultrasonography can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [97]. The most commonly performed joint examination using ultrasonography is the shoulder examination [89]. Accuracy of rotator cuff ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [89]. 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 [142]. Sonography is a useful tool for examining soft tissues after shoulder arthroplasty in order to demonstrate pathological changes and is not negatively affected by the implant [330].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum and rotator cuff tears [97]. Arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty [313].

Other Considerations: The purpose of imaging of the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [10]. Unless a specific research protocol is in place, the temptation to "overimage" should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [10]. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [10]. Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs [12]. A deep learning algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries [44].

Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care [329]. Elimination of immediate postoperative radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care [329]. Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty [325]. CT scans are often needed to identify acromial fractures after reverse total shoulder arthroplasty [325]. The radiographic changes seen at the implant-bone interfaces of cementless short-stem shoulder prostheses are much less frequent than those seen following cementing of the glenoid component [319]. Radiolucencies were noted around the glenoid component and/or screws in 45% of shoulders with an uncemented glenoid component [317]. Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up after primary total shoulder arthroplasty using a cementless metal-backed pegged polyethylene glenoid [301]. Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings [334]. The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty [332]. Postoperative 3-D CT imaging analysis following TSA identified changes in glenoid component position over time not detectable with standard imaging methods [335]. A core set of radiographic parameters has been developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty [18].

Treatment

Non-Operative

Nonoperative treatment of osteolysis after total shoulder arthroplasty should be pursued first to avoid surgery-associated risks [3].

Operative

Indications: Anatomic total shoulder arthroplasty remains an attractive option for primary arthroplasty in selected cases [106]. The procedure is considered as safe as more commonly performed major joint arthroplasties [6] and is an effective and safe treatment option [17]. While nonagenarians face increased risks of medical complications, longer hospital stays, periprosthetic fractures, and death [276], previous lower extremity periprosthetic joint infection [29] and axillary lymph node dissection [156] are not contraindications. Under optimal circumstances, simultaneous bilateral shoulder arthroplasty is feasible [152]. A collaborative and comprehensive approach to pre-operative medical evaluation is critical for patients with diabetes mellitus [134].

Surgical Approach / Technique: The long deltopectoral approach is the standard surgical exposure for shoulder arthroplasty in osteoarthritis and rheumatoid arthritis [307]. This approach allows adequate access to fracture fragments for suture fixation and provides excellent glenoid exposure after fracture fragment mobilization in reverse shoulder arthroplasty for proximal humeral fractures [316]. The anteromedial approach is a reliable technique to improve surgical exposure in difficult cases [81]. A modified lateral deltoid-splitting approach offers better visualization and easier manipulation of the greater tuberosity, but carries a risk of iatrogenic damage to the axillary nerve and potential anterior deltoid dysfunction [293]. The posterior approach is not recommended for shoulder arthroplasty at this time and should only be performed in prospective research trials after sufficient training [128]. During anatomic total shoulder arthroplasty, careful dissection and meticulous soft tissue management ensure adequate visualization of the articular and bony surfaces, allowing the proper use of surgical instrumentation and ensuring accurate placement of prosthetic components [129]. The first and most important step in any reconstructive glenoid surgery is the exposure, which requires circumferential tissue release through a deltopectoral approach without iatrogenic damage to the rotator cuff and neurovascular structures [308]. Unique radiographic outcomes and complications exist for both surgical approaches and should factor into the decision-making process regarding the appropriate surgical approach for reverse total shoulder arthroplasty [24].

Subscapularis Management: The optimal management of the subscapularis tendon during total shoulder arthroplasty remains controversial [285]. Standard exposure uses the deltopectoral interval and necessitates takedown of the subscapularis tendon for access to the glenohumeral joint [310]. The most commonly used techniques for subscapularis management include the tenotomy, peel, and lesser tuberosity osteotomy [310]. Each of these techniques has been shown to be effective and safe in the short term with no proven difference [315]. A subscapularis-sparing approach is becoming increasingly popularized because it obviates the need for subscapularis takedown and allows for accelerated postoperative rehabilitation [310]. Total shoulder arthroplasty performed entirely through the rotator interval (subscapularis-sparing approach) has been used to potentially reduce postoperative subscapularis failure [52]. Patient selection is crucial to successfully perform subscapularis-sparing total shoulder arthroplasty without jeopardizing the intact supraspinatus and subscapularis tendons [52]. Specialized instrumentation allows the subscapularis-sparing technique to be performed more efficiently and reproducibly [52]. If optimal visualization cannot be obtained during a subscapularis-sparing approach, the procedure can be converted to the standard technique by releasing the subscapularis tendon through tenotomy, peel, or lesser-tuberosity osteotomy [52]. A combined minimally invasive approach to the glenohumeral joint that preserves most of the subscapularis will decrease the risk of a potentially devastating complication while allowing full access to the glenohumeral joint for replacement [302]. The subscapularis-sparing approach allows rapid and complete rehabilitation compared with all other subscapularis takedown procedures [302]. Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%) [23]. The use of a novel technique for subscapularis repair has led to improved patient outcomes with regard to range of motion postoperatively following anatomic total shoulder arthroplasty [90]. Pectoralis major tendon transfer is a management option for subscapularis failure after anatomic total shoulder arthroplasty when primary repair is not possible [314].

Implant Selection: The materials that are used in total shoulder arthroplasty implants have been carefully chosen in an attempt to minimize hardware-related complications [243]. Although much attention has been directed to the development of the humeral components used in shoulder arthroplasty, the major unsolved challenge lies on the glenoid side of the articulation [253]. Complications of shoulder arthroplasty depend on the prosthesis type used [36]. Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis [148]. 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 [278]. The semiconstrained total shoulder arthroplasty is an effective means of treatment for arthritis of the glenohumeral joint [280]. The overall results of nonconstrained total shoulder replacements have been very satisfactory, with an average of 90% of patients having significant relief of pain regardless of their preoperative diagnosis [246]. 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 [266]. Pyrocarbon interposition shoulder arthroplasty should remain to be tested in a few specialized shoulder centers until long-term results are available [281]. The purpose of reviewing press-fit fixation of the humeral component is to propose minimum requirements for radiographic descriptions of stress shielding [258].

Pain Management: Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist [191]. A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively [206]. Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen [211]. In patients undergoing shoulder arthroplasty, a non-opioid, multimodal pain protocol provided non-inferior pain relief compared to an opioid-based regimen [225]. Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty [227]. With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets [245]. Anatomic total shoulder arthroplasty in general provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively [260]. An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids [249]. Local infiltration analgesia and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty [250]. Continuous interscalene brachial plexus block provides superior analgesia compared with single-injection interscalene brachial plexus block and local infiltration analgesia in the first 24 hours after total shoulder arthroplasty [284]. Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement [232]. There was a dose-dependent increase in the risk of surgical and medical complications with increasing totals of perioperative opioid consumption following total shoulder arthroplasty [238].

Setting of Care: Total shoulder arthroplasty may be performed on an outpatient basis using perineural local anesthetic infusion [261]. Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty [248].

Revision: Current surgical options for osteolysis after total shoulder arthroplasty include glenoid polyethylene revision and conversion to reverse shoulder arthroplasty [3]. Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent [143]. The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [270]. Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with scapular fractures after reverse shoulder arthroplasty are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture [251]. An infected shoulder arthroplasty can have a devastating effect on the function of the shoulder, but so can its treatment [25]. In the presence of previous non-arthroplasty operative interventions there is a significantly higher risk for infection in shoulders undergoing reverse total shoulder arthroplasty [265]. Arthroscopic removal of a loose glenoid component in anatomic total shoulder arthroplasty involves diagnostic arthroscopy, evaluation of the rotator cuff, and confirmation of gross looseness before bone grafting [57]. Distal clavicle autograft augmentation is a technique for managing glenoid bone loss in revision shoulder arthroplasty [304]. Allograft-prosthetic composite reconstruction is a technique for managing massive proximal humeral bone loss in reverse shoulder arthroplasty [287]. These findings regarding allograft-prosthetic composite versus megaprosthesis should be considered when choosing a shoulder arthroplasty technique with non-oncologic indications [21].

Other Considerations: Preoperative clinical examination and radiological assessment is fundamental to anticipating specific difficulties in glenoid exposure [30]. The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual [223]. Operative time for total shoulder arthroplasty has decreased from 2008 to 2018 [150]. Suture cerclage may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty [277]. Total shoulder arthroplasty is a good procedure with a successful long-term record [48]. The deltopectoral approach is generally preferred for accessing the glenohumeral joint during reverse shoulder arthroplasty [315]. A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented [28]. In patients with a shoulder replacement, the number of shoulder elevations > 60° on the operative side approaches 1.0 Mc per year [118]. Consensus recommendations can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1]. Controversial management areas in reverse shoulder arthroplasty have been highlighted and require exploration by further clinical studies [254]. These findings highlight the need for further research and consensus to establish evidence-based perioperative protocols in elective shoulder replacement surgery [241].

Complications

General Complication Rates and Outcomes: Total shoulder arthroplasty yields good to excellent clinical results in greater than 90% of shoulders in early to midterm follow-up studies, with pain relieved in approximately 90% to 95% of all patients [2]. The overall complication rate in a study of 485 shoulder arthroplasty cases was 11.6% [16]. Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates [50], and short-term reoperation after shoulder arthroplasty was infrequent [98]. The overall complication rate of total shoulder arthroplasty has decreased dramatically over time, with a striking diminution of component loosening [352]. Approximately 90% of shoulder replacements last up to 15 years without revision [369]. In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported in the Kaiser Permanente Shoulder Arthroplasty Registry [364]. The cumulative percentage of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision [39]. Shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties [6].

Revision and Fracture-Related Complications: Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage [19]. Although clinical results of revision shoulder arthroplasty are, in general, inferior to primary shoulder arthroplasty, careful patient selection and adherence to surgical principles can lead to satisfactory results [255]. Complications and reoperation rates were higher than those for primary reverse shoulder arthroplasty but outcomes were comparable for revision of failed anatomic shoulder arthroplasty [355]. Revision shoulder arthroplasty remains challenging with a high rate of complications [371]. The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference [350]. In a series of reverse total shoulder arthroplasty for proximal humerus fractures, the revision rate was 2.4% and mortality was 17% [86]. In a study of 38 consecutive cases of reverse total shoulder arthroplasty during the early learning curve period, the complication rate was 15.7% (6 of 38 patients) [104].

Risk Factors and Patient-Specific Variables: Higher complication rates following primary total shoulder arthroplasty were observed in patients presenting from areas of higher social deprivation [15]. Male patients had significantly higher odds of adverse events, death, MI, and sepsis following shoulder arthroplasty [372]. Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty [340]. Long-term corticosteroid users are at a heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism following total shoulder arthroplasty [359]. Readmission within the first 30 days after shoulder arthroplasty occurred in 5.9% of patients, with a 1% incidence of never events [357]. Factors associated with conversion of outpatient total shoulder arthroplasty to inpatient include older age, female sex, Black race, Hispanic ethnicity, higher BMI, longer operation time, ASA ≥3, preoperative functional dependence, diabetes mellitus, COPD, and hypertension [91]. In a study of 6755 patients undergoing planned outpatient total shoulder arthroplasty, 453 patients (6.7%) were converted to inpatient status (LOS ≥2) [91].

Mortality and Survival Data: This study reports 30-day, 90-day and 1-year mortality of 0%, 0.16% and 2% in 640 patients undergoing shoulder arthroplasty for all indications [42]. In a cohort of 60 patients undergoing press-fit short stem reverse shoulder arthroplasty, 9 (15%) died of causes unrelated to RSA, 2 (3%) had revision for infection with the removal of all components, and 3 (5%) had revision of the glenoid component for dislocation [109]. In a multicenter study of 176 shoulders undergoing shoulder arthroplasty for primary osteoarthritis, 6 patients were lost as a result of death within 24 months after surgery and 2 shoulders had the humeral component revised [75]. In a study of 485 shoulder arthroplasty cases, the survival rate for all complications was 94.2% for the fracture implant group [16]. The confidence interval for survival rate for all complications in the fracture implant group was 88.4 -100% [16].

Implant-Specific and Stature-Related Complications: The risk of clinically noted complications was 6.5% (n = 27) in total of 418 shoulders in a systematic review of stemless reverse total shoulder arthroplasty [288]. Complications occurred in 10 (7.7%) small-stature shoulders, 2 (5.2%) tall-stature shoulders, and 21 (5.5%) average-stature shoulders in a study of reverse shoulder arthroplasty, with no significant difference in complication rates among groups [269]. The overall complication rate during follow-up was 13.7% (n = 11) in a study of the Affinis Short stemless shoulder arthroplasty system, with the rate significantly higher in the nonanatomic positioning group (35%) than in the anatomic positioning group (6%) [259]. In a study of anatomic total shoulder arthroplasty for primary shoulder osteoarthritis in Japanese patients, complications other than rotator cuff tears were observed in 5 shoulders (6%): intraoperative humeral fracture (1), postoperative stiffness (1), and temporary nerve palsy (3) [240].

Other Considerations: In a study of 485 shoulder arthroplasty cases, the survival without category 1 complication was 95.6%, without category 2 complication was 98.5%, and without category 3 complication was 97.7% for the fracture implant group [16]. The confidence interval for survival without category 1 complication in the fracture implant group was 90.4 -100.8% [16]. The confidence interval for survival without category 2 complication in the fracture implant group was 95.5 -101.5% [16]. The confidence interval for survival without category 3 complication in the fracture implant group was 93.2 -102.3% [16]. In a study of 485 shoulder arthroplasty cases, 24 (34.3%) cases had a very satisfying result, 30 (42.9%) a satisfying result, 12 (17.1%) a somewhat disappointing result, and 4 (5.7%) a very disappointing result [16]. In a study of 485 shoulder arthroplasty cases, most complications were intraoperative findings or events that were treated during the index surgery or did not require revision (7%; category 1) [16]. In a study of 485 shoulder arthroplasty cases, revision for a complication was required for category 2 and 3 complications [16]. In a study of 485 shoulder arthroplasty cases, the lack of standardised methodology for classification of types and severity of complications in shoulder arthroplasty was noted [16]. In a study of 485 shoulder arthroplasty cases, different complication rates described in the literature can relate to different initial diagnoses, surgical techniques, surgeons' experience, implants and classification systems [16]. In a study of 485 shoulder arthroplasty cases, a system of three complication categories was introduced that can easily be applied to other cohorts and can be used as a standardised routine for the presentation of complications in shoulder arthroplasty [16]. In a study of 485 shoulder arthroplasty cases, the overall complication rate was comparable to other reported complication rates after shoulder arthroplasty [16]. In a study of 485 shoulder arthroplasty cases, all events were rated as a complication [16]. In a study of 485 shoulder arthroplasty cases, the median follow-up for the fracture implant was one year [16]. In a study of 485 shoulder arthroplasty cases, the range of follow-up for the fracture implant was 1 -8.5 years [16]. In a study of 485 shoulder arthroplasty cases, the median follow-up for survival without category 2 and 3 complications in the fracture implant group was 1.1 years [16]. In a study of 485 shoulder arthroplasty cases, the range of follow-up for survival without category 2 and 3 complications in the fracture implant group was 1 -8.5 years [16]. In a study of 485 shoulder arthroplasty cases, the median follow-up for survival without category 1 complication in the fracture implant group was one year [16]. In a study of 485 shoulder arthroplasty cases, the range of follow-up for survival without category 1 complication in the fracture implant group was 1 -8.5 years [16]. In a study of 485 shoulder arthroplasty cases, the median follow-up for survival without category 2 complication in the fracture implant group was 1.1 years [16]. In a study of 485 shoulder arthroplasty cases, the range of follow-up for survival without category 2 complication in the fracture implant group was 1 -8.5 years [16]. In a study of 485 shoulder arthroplasty cases, the median follow-up for survival without category 3 complication in the fracture implant group was 1.1 years [16]. In a study of 485 shoulder arthroplasty cases, the range of follow-up for survival without category 3 complication in the fracture implant group was 1 -8.5 years [16].

In a study of 512 patients who underwent shoulder arthroplasty, 153 patients (157 shoulders) were included in final analysis for outcome threshold evaluation [11]. In a study of 391 patients who had undergone shoulder arthroplasty, the final patient population was 207 patients following inclusion/exclusion criteria [83]. In a systematic review of shoulder arthroplasty for sequelae of anterior instability arthropathy, 13 patients were lost to follow-up leaving 352 patients available for evaluation [84]. The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most cases performed for primary osteoarthritis [85]. The incidence of primary shoulder arthroplasty has increased by 160% during the study period in Finland [333]. The incidence of shoulder arthroplasty per 100,000 members increased from 6.1 in 2005 to 13.4 in 2013 [386]. We found more than 2-fold higher primary rates for hemiarthroplasty than for total shoulder arthroplasty and up to 3-fold higher shoulder arthroplasty rates for women than for men in Germany [374]. Direct costs of revision shoulder arthroplasty are primarily driven by implant-related costs, and the cost per improvement in patient-reported outcomes is high compared to primary arthroplasty [51]. Postoperative bisphosphonate initiation was associated with lower rates of composite implant-related complications and revision surgery following shoulder arthroplasty in osteoporotic patients [379]. The analysis did not identify evidence that the results of total shoulder arthroplasty were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes [373]. Less than half of shoulder arthroplasty RCTs are registered and more than 30% of registered trials have at least 1 inconsistency with their registry record [384]. We anticipate that these recommendations, in addition to the limited applicable published evidence available, can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1]. The conversion equations generated for the Normalized Constant Score may provide utility in the evaluation of shoulder arthroplasty outcomes across studies in systematic reviews and meta-analyses [47]. Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty [83]. Establishing clinically significant outcome thresholds for the Single Assessment Numeric Evaluation 2 years following total shoulder arthroplasty was the aim of a study including 153 patients [11]. In a study of 83 patients with reverse shoulder arthroplasty for proximal humerus fractures, the mean ASES score was 65.9, OSS was 34.6, and SANE was 68.8 [86]. In a study of 42 patients with press-fit short stem reverse shoulder arthroplasty, net improvements in functional outcomes were 34.7 ± 21.2 for the absolute Constant Score and 54% ± 32% for the age-/sex-adjusted Constant Score [109]. In a study of 38 patients with reverse total shoulder arthroplasty, the UCLA score improved from 16.0 to 27.9, Constant score from 41.4 to 78.9, and VAS score from 4.0 to 2.8 [104]. In a study of 126 shoulders with minimum 2-year follow-up after shoulder arthroplasty for primary osteoarthritis, active total elevation improved from 102° to 138° and external rotation increased from 14° to 45° [75]. In a study of 11 patients with late glenoid component failure, the mean SST score dropped by 6.7 ± 2.7 to a mean of 4.6 ± 3.1 at a mean of 7.4 years after the index arthroplasty, essentially the same level as before the index arthroplasty [107]. In a study of 12 shoulders with late glenoid component failure, none of the shoulders had infections, and none of the humeral components were loose [107].

Recovery

Light activity (weeks): Driving performance returns to preoperative levels at 6 weeks after shoulder arthroplasty, with improved performance compared with preoperative levels by 12 weeks postoperatively [116]. Patients undergoing total shoulder replacement show improvement in driving performance with the mitigation of shoulder pain and discomfort [192]. Shoulder arthroplasty is generally associated with meaningful improvement in sleep quality between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter [391].

Full activity (months): Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively [362]. Sixty-seven percent of patients successfully returned to work after shoulder arthroplasty [194]. Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return [234]. A high return to sport can be expected after total shoulder arthroplasty [242]. Patients with active sports participation before total shoulder arthroplasty are successfully able to return to sports activities after surgery, whereas those not participating before surgery are unlikely to resume sports [367]. Most patients being active prior to reverse shoulder arthroplasty surgery are successfully able to return to their activity afterwards [382]. In patients aged 65 years and younger, anatomic total shoulder arthroplasty on the nondominant shoulder was associated with a significantly higher rate of return to sport [377]. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty [214].

Complete recovery / outcome plateau (months): Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications [368]. Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [385]. After shoulder joint replacement, the range of shoulder motion showed substantial changes during the first year only [239].

Rehabilitation protocol: A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty [183]. Rehabilitation after total shoulder arthroplasty should be tailored to the biomechanical principles and soft-tissue considerations unique to each form of total shoulder arthroplasty [229]. Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme [216]. There is insufficient literature to support the use of formal physical therapy over a physician-directed program, and no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty [228]. Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation [233].

Functional milestones: Within a group of patients with primary glenohumeral degenerative joint disease, shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status [237]. Six distinct early recovery trajectories were identified after total shoulder arthroplasty [41]. 83.7% of patients (the 'Faster group') experienced very low pain scores after only 2 weeks following total shoulder arthroplasty [41]. 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 [353]. Acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively [395]. Preoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols [397]. Although significant strength improvement from baseline was observed at 2 years after shoulder arthroplasty, subscapularis strength returned to normal in only a minority of patients [398].

Other Considerations: The most common postoperative complications reported in a systematic review were postoperative stiffness/pain (n = 47), anterior dislocation or shoulder instability (n = 16), and progressive arthritis requiring revision (n = 7) [37]. Periprosthetic fracture (n = 3) and infection (n = 1) were reported as postoperative complications in a systematic review of return to work after shoulder arthroplasty [37]. In total, 14 patients were reported to have returned to the operating room for revision in a systematic review of return to work after shoulder arthroplasty [37]. Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients [7]. 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 [210]. Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively [236]. Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications [392]. Recommendations from a real-time Delphi technique can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty [1]. Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries [224]. Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [396]. Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications [393]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [394].

Key Evidence

• [L4] We anticipate that these recommendations, in addition to the limited applicable published evidence available, can contribute to guidelines on long-term follow-up and surveillance of elective primary shoulder arthroplasty. [1] (10.1177/17585732251356963)
• [L5] Total shoulder arthroplasty yields good to excellent clinical results in greater than 90% of shoulders in early to midterm follow-up studies, with pain relieved in approximately 90% to 95% of all patients. [2] (10.1016/s0030-5898(05)70025-0)
• [L5] [3] (10.5397/cise.2021.00738)
• [L2] The authors believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties. [6] (10.1097/01.blo.0000238839.26423.8d)
• [L4] Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients. [7] (10.1016/j.jse.2007.11.004)
• [L3] Total shoulder arthroplasty can provide substantial and durable improvement in shoulder function. [8] (10.1067/mse.2001.117122)
• [L4] [11] (10.1016/j.jse.2020.07.011)
• [L4] Subscapularis tear after total shoulder arthroplasty is a common finding that cannot be diagnosed reliably by physical examination or radiographs. [12] (10.1016/j.jse.2010.04.001)
• [L4] Diagnostic shoulder arthroscopy provided clinically meaningful diagnostic information in patients with painful shoulder arthroplasty and nondiagnostic preoperative evaluations. [13] (10.1016/j.jse.2026.07.016)
• [L4] When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty. [14] (10.1007/s12178-016-9318-y)
• [L3] [15] (10.1302/0301-620x.106b2.bjj-2023-0785.r1)
• [Paper] [16] (10.1007/s00264-009-0780-7)
• [L5] Shoulder arthroplasty is now an effective and safe treatment option. [17] (10.1016/j.jbspin.2010.09.004)
• [L4] Our work presents a monitoring tool developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty and including a structured core set of radiographic parameters. [18] (10.2106/jbjs.oa.19.00025)
• [L5] Complications after revision shoulder arthroplasty are similar to those in the primary setting but are more frequently encountered and difficult to manage. [19] (10.1007/s12178-014-9249-4)
• [L3] About 45% of patients with no clinical signs of infection and a history of prior ipsilateral shoulder surgery undergoing primary shoulder arthroplasty grew positive intraoperative cultures. [20] (10.1016/j.jseint.2019.12.011)
• [L4] These findings should be considered when choosing a shoulder arthroplasty technique with non-oncologic indications. [21] (10.1177/17585732251403536)
• [L4] Diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear. [22] (10.1016/j.jse.2007.02.131)
• [L4] Clinically symptomatic subscapularis failure after anatomic total shoulder arthroplasty is rare (1.4%). [23] (10.1177/17585732261441853)
• [L5] Unique radiographic outcomes and complications exist for both surgical approaches and should factor into the decision-making process regarding the appropriate surgical approach for reverse total shoulder arthroplasty. [24] (10.1016/j.ocl.2014.09.015)
• [L3] Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. [26] (10.5397/cise.2023.00836)
• [L3] Shoulder arthroplasty after undergoing prior shoulder surgery results in overall clinically improved outcomes, however these results are inferior compared to patients without a history of prior shoulder surgery. [27] (10.1177/2325967115s00168)
• [L5] A postoperative total shoulder arthroplasty rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented. [28] (10.2519/jospt.2005.35.12.821)
• [L4] Thus, previous lower extremity PJI should not be considered a relative contraindication to shoulder arthroplasty. [29] (10.1016/j.jse.2016.05.024)
• [Paper] [30] (10.1016/j.otsr.2017.10.008)
• [Paper] While early results are promising, further long-term studies are needed to fully assess its value and establish best practices for its routine use in shoulder arthroplasty. [31] (10.3390/jcm14082763)
• [L4] Elective shoulder arthroplasty can be performed in patients 90 years of age and older, providing excellent pain relief, improved functional outcome, and enhanced general health status. [32] (10.1016/j.jse.2007.09.005)
• [Abstract] At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty. [33] (10.1016/j.jse.2022.01.004)
• [L3] Surgical implant type, indication, patient comorbidities, and hospital factors contribute to differential surgical cost for total shoulder arthroplasty. [35] (10.1016/j.jse.2025.02.055)
• [L5] Complications of shoulder arthroplasty depend on the prosthesis type used. [36] (10.1007/s00330-008-1093-8)
• [L1] [37] (10.1016/j.jse.2018.12.011)
• [L4] The reverse shoulder arthroplasty has been highly successful in cuff deficient shoulders, with indications continuing to broaden. [38] (10.1007/s12178-011-9097-4)
• [L3] The cumulative percentage of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. [39] (10.1080/17453674.2020.1871559)
• [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. [40] (10.5435/jaaos-d-23-00758)
• [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. [41] (10.1016/j.jse.2025.06.016)
• [L4] This study reports 30-day, 90-day and 1-year mortality of 0%, 0.16% and 2% in 640 patients undergoing shoulder arthroplasty for all indications. [42] (10.1016/j.jor.2020.04.005)
• [L3] Total shoulder arthroplasty demonstrates excellent long-term survivorship with significant improvements in pain and function. [43] (10.1016/j.jse.2005.02.009)
• [L5] This algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries. [44] (10.1016/j.jse.2023.09.021)
• [L5] Knowledge of the array of shoulder prostheses currently available and the indications for each, as well as the use of treatment algorithms, can lead to optimized patient outcomes. [45] (10.5435/00124635-200907000-00002)
• [L3] In addition, the conversion equations generated here may provide utility in the evaluation of shoulder arthroplasty outcomes across studies in systematic reviews and meta-analyses. [47] (10.5435/jaaosglobal-d-22-00247)
• [L5] Total shoulder arthroplasty is a good procedure with a successful long-term record. [48] (10.1097/bte.0b013e3181e0b319)
• [L4] Primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. [50] (10.1016/j.jse.2019.12.008)
• [L3] Direct costs of revision shoulder arthroplasty are primarily driven by implant-related costs, and the cost per improvement in patient-reported outcomes is high compared to primary arthroplasty. [51] (10.1177/17585732251404026)
• [L5] [52] (10.1016/j.ocl.2020.02.003)
• [L5] [53] (10.1007/s00256-019-03183-3)
• [L4] [55] (10.1067/mse.2001.115985)
• [L5] [57] (10.1016/j.eats.2024.102987)
• [L2] [75] (10.1067/mse.2002.121146)
• [L5] The proposed classification system addresses the surgical management of the glenoid during prosthetic replacement and allows direct follow-up comparison of similarly treated glenoid replacements. [78] (10.1016/j.jse.2011.01.035)
• [L4] Kinematics of the rTSA shoulders are significantly altered, and more scapulothoracic motion is used to achieve shoulder elevation compared to healthy subjects. [79] (10.1016/j.jse.2011.07.031)
• [L4] The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases. [81] (10.1016/j.jse.2009.10.016)
• [L3] [83] (10.1016/j.jse.2019.04.041)
• [L1] [84] (10.1007/s00402-020-03400-y)
• [L4] The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most cases performed for primary osteoarthritis. [85] (10.1016/j.jse.2023.01.040)
• [L3] [86] (10.1016/j.jseint.2024.09.023)
• [L4] The use of our technique has led to improved patient outcomes with regard to range of motion postoperatively following anatomic total shoulder arthroplasty and we recommend its adoption into practice. [90] (10.1016/j.xrrt.2023.01.004)
• [L3] [91] (10.1016/j.jse.2026.04.043)
• [L2] The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes. [94] (10.1080/03009740600759720)
• [L4] Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies. [95] (10.1016/j.jse.2015.09.013)
• [L4] Short-term reoperation after shoulder arthroplasty was infrequent. [98] (10.2106/jbjs.m.00127)
• [L4] Prosthetic shoulder arthroplasty in young patients provides substantial improvement in active range of motion, irrespective of diagnosis and glenoid management, though residual shoulder pain is common. [100] (10.1016/j.arthro.2017.08.204)
• [L5] Determining the presence of infection in revision shoulder arthroplasty can be difficult, and a standardized approach is needed to determine the best course of treatment in this particular clinical setting. [101] (10.1016/j.jse.2014.10.005)
• [L4] [104] (10.1186/s13018-019-1077-1)
• [L3] Thus, anatomic shoulder arthroplasty remains an attractive option for primary arthroplasty in selected cases. [106] (10.1016/j.jseint.2024.05.006)
• [L4] [107] (10.1016/j.jse.2004.10.008)
• [L4] [109] (10.1016/j.jseint.2022.08.004)
• [L5] A thorough and systematic approach including history, physical examination, and appropriate diagnostic studies is necessary to evaluate failed shoulder arthroplasty, as the cause of pain and disability is often multifactorial. [112] (10.1016/j.jse.2013.12.003)
• [L4] Specific clinical symptoms including pain at rest, systemic symptoms including fevers, chills, or sweats, and WBC bone scan are poorly associated with the presence of infection in revision shoulder arthroplasty. [113] (10.1016/j.jseint.2025.02.005)
• [L3] Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. [114] (10.2106/jbjs.16.00541)
• [L4] Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty, with improved performance compared with preoperative levels by 12 weeks postoperatively. [116] (10.2106/jbjs.15.00162)
• [L4] In patients with a shoulder replacement, the number of shoulder elevations > 60° on the operative side approaches 1.0 Mc per year. [118] (10.1016/j.jse.2017.09.023)
• [L5] An organized approach to diagnose and manage stiff or unstable total shoulder arthroplasty is needed to improve patient satisfaction and long-term survival. [125] (10.5435/jaaos-21-01-23)
• [L5] The authors do not recommend the posterior approach for shoulder arthroplasty at this time and suggest it should only be performed in prospective research trials after sufficient training. [128] (10.1097/corr.0000000000001779)
• [L5] During anatomic total shoulder arthroplasty, careful dissection and meticulous soft tissue management ensure adequate visualization of the articular and bony surfaces, allowing the proper use of surgical instrumentation and ensuring accurate placement of prosthetic components. [129] (10.1016/j.eats.2023.07.007)
• [L3] This classification system may be useful to anticipate the complexity of humeral reconstruction. [132] (10.1097/corr.0000000000000590)
• [L3] A preoperative diagnosis of a stroke in patients undergoing primary shoulder arthroplasty is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. [133] (10.1016/j.jse.2022.10.014)
• [L4] A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with DM is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with DM. [134] (10.1007/s00264-018-3874-2)
• [L4] [136] (10.1016/j.arthro.2020.01.045)
• [L4] Diagnosis of periprosthetic shoulder infection should be based on clinical suspicion, patient factors, and intraoperative findings when perioperative testing is equivocal, particularly due to the indolent nature of organisms like P. acnes. [137] (10.2106/jbjs.rvw.m.00055)
• [L3] [141] (10.1016/j.jse.2026.04.036)
• [L4] Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent. [143] (10.1016/j.jse.2008.09.006)
• [L4] Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic GD, offering improved clinical outcomes and favorable satisfaction following surgery. [144] (10.1016/j.xrrt.2025.03.001)
• [L4] Deficient glenoid bone need not always be a contraindication to the use of an unconstrained total shoulder prosthesis. [148] (10.2106/00004623-198870080-00006)
• [L3] Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. [150] (10.1177/17585732211008900)
• [L5] Under optimal circumstances simultaneous shoulder arthroplasty is feasible. [152] (10.1016/s1058-2746(96)80400-9)
• [L4] Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. [156] (10.1177/1758573218780519)
• [L4] Arthroscopy after shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients but can be technically challenging. [158] (10.1067/mse.2002.122257)
• [L3] Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology. [160] (10.1302/0301-620x.99b11.bjj-2017-0469.r1)
• [L4] Current classification systems demonstrate limited reliability for assessing glenoid defects in this context. [161] (10.1016/j.jseint.2026.101804)
• [L4] Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. [162] (10.1016/j.jse.2020.10.003)
• [L5] The case underscores the need to entertain a broad differential when evaluating a painful shoulder, even after total shoulder arthroplasty. [163] (10.1067/mse.2002.126762)
• [Paper] Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal. [167] (10.1016/j.jseint.2024.08.170)
• [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. [168] (10.1177/2471549219832442)
• [L5] A well-designed, progressed, and executed rehabilitation program is vital to successful functional outcomes after shoulder arthroplasty. [183] (10.1016/j.csm.2018.05.007)
• [L5] Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between the patients, surgeon, and anesthetist. [191] (10.1016/j.ocl.2017.08.010)
• [Abstract] The present study findings suggest that patients undergoing total shoulder replacement show improvement in driving performance with the mitigation of shoulder pain and discomfort. [192] (10.1016/j.jse.2014.06.005)
• [L4] Sixty-seven percent of patients successfully returned to work after shoulder arthroplasty. [194] (10.1016/j.jsea.2026.100058)
• [L4] Outpatient total shoulder arthroplasty in appropriately selected patients is a safe and cost-effective alternative to inpatient total shoulder arthroplasty. [195] (10.5435/jaaos-d-21-00562)
• [Abstract] When the glenoid component revision is the indication for revision total shoulder replacement, these patients tend to achieve good to excellent results. [196] (10.1016/j.jse.2007.02.098)
• [L4] Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. [197] (10.1016/j.jse.2019.04.006)
• [L5] Outcomes following anatomic total shoulder arthroplasty have proven to be durable and reproducible. [200] (10.1097/bte.0000000000000075)
• [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. [202] (10.1016/j.jse.2022.08.003)
• [L3] Transitioning appropriate patients to outpatient total shoulder arthroplasty results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up. [203] (10.1016/j.jse.2024.05.012)
• [L4] MRI provides information not otherwise afforded by other imaging modalities, aiding in the complex decision-making process for managing a painful shoulder arthroplasty. [204] (10.1007/s11420-014-9399-3)
• [L1] A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively. [206] (10.1016/j.jse.2021.12.015)
• [L3] The use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis has increased dramatically, with the use of computed tomography increasing the most. [208] (10.1177/1758573220908865)
• [L3] 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. [210] (10.1016/j.jse.2018.10.007)
• [L2] Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen. [211] (10.1016/j.jse.2017.11.015)
• [L4] Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty. [214] (10.1177/23259671251326076)
• [L4] Preoperative 3-dimensional CT bone density measures provide objective classifications of bone quality for stemless anatomic total shoulder arthroplasty. [215] (10.1016/j.jse.2023.11.005)
• [L1] Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. [216] (10.1177/1758573220937394)
• [L5] The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual. [223] (10.5435/jaaos-d-23-00257)
• [L4] Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries. [224] (10.5435/jaaosglobal-d-17-00073)
• [L1] In patients undergoing shoulder arthroplasty, a non-opioid, multimodal pain protocol provided non-inferior pain relief compared to an opioid-based regimen. [225] (10.1016/j.jse.2026.04.063)
• [L2] Multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty. [227] (10.1016/j.jse.2026.01.026)
• [L4] There is insufficient literature to support the use of formal physical therapy over a physician-directed program, and no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty. [228] (10.2106/jbjs.rvw.19.00129)
• [L5] Rehabilitation after total shoulder arthroplasty should be tailored to the biomechanical principles and soft-tissue considerations unique to each form of total shoulder arthroplasty. [229] (10.1002/arj.70509)
• [L1] Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement. [232] (10.1007/s00590-015-1678-2)
• [L4] Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation. [233] (10.1016/j.jse.2005.02.013)
• [L1] Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return. [234] (10.1007/s00167-017-4547-1)
• [L3] Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. [236] (10.1016/j.jse.2023.03.035)
• [L4] The data presented indicate that within a group of patients with primary glenohumeral degenerative joint disease, shoulder arthroplasty was effective within a relatively short time frame in improving the patients' assessment of both shoulder function and overall health status. [237] (10.1016/s1058-2746(95)80203-7)
• [L3] There was a dose-dependent increase in the risk of surgical and medical complications with increasing totals of perioperative opioid consumption following total shoulder arthroplasty. [238] (10.1016/j.jse.2024.10.029)
• [L4] After shoulder joint replacement, the range of shoulder motion showed substantial changes during the first year only. [239] (10.1007/s00590-016-1795-6)
• [L4] [240] (10.1016/j.xrrt.2021.06.006)
• [L5] These findings highlight the need for further research and consensus to establish evidence-based perioperative protocols in elective shoulder replacement surgery. [241] (10.1016/j.jseint.2026.101758)
• [L1] A high return to sport can be expected after total shoulder arthroplasty. [242] (10.1016/j.jseint.2025.05.028)
• [L4] The materials that are used in total shoulder arthroplasty (TSA) implants have been carefully chosen in an attempt to minimize hardware-related complications. [243] (10.2106/jbjs.rvw.19.00212)
• [L2] With a multimodal approach, most patients undergoing shoulder arthroplasty can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets. [245] (10.1016/j.jseint.2021.02.005)
• [L4] The overall results of nonconstrained total shoulder replacements have been very satisfactory, with an average of 90% of patients having significant relief of pain regardless of their preoperative diagnosis. [246] (10.1016/s1058-2746(05)80013-8)
• [L4] Appropriate patient selection, multimodal pain management strategies, minimizing blood loss, and efficient operative times are paramount to successful outpatient shoulder arthroplasty. [248] (10.1016/j.ocl.2017.08.011)
• [L4] An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. [249] (10.1016/j.jse.2019.01.013)
• [L1] LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. [250] (10.2106/jbjs.22.00034)
• [L2] Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with fractures are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture. [251] (10.5435/jaaos-d-20-01205)
• [L5] Although much attention has been directed to the development of the humeral components used in shoulder arthroplasty, the major unsolved challenge lies on the glenoid side of the articulation. [253] (10.1016/j.jse.2007.02.112)
• [L5] Controversial management areas in reverse shoulder arthroplasty have been highlighted and require exploration by further clinical studies. [254] (10.5604/15093492.1119621)
• [L5] Although clinical results of revision shoulder arthroplasty are, in general, inferior to primary shoulder arthroplasty, careful patient selection and adherence to surgical principles can lead to satisfactory results. [255] (10.1016/s1048-6666(03)00084-3)
• [L5] The purpose of this report is to review the current literature on press-fit fixation of the humeral component during total shoulder arthroplasty and propose minimum requirements for radiographic descriptions of stress shielding. [258] (10.1016/j.jse.2017.12.020)
• [L3] [259] (10.1016/j.jse.2024.01.051)
• [L4] Anatomic total shoulder arthroplasty in general provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively. [260] (10.1016/j.jses.2019.11.005)
• [L4] Total shoulder arthroplasty may be performed on an outpatient basis using perineural local anesthetic infusion. [261] (10.1213/01.ane.0000180199.52383.ce)
• [L3] In the presence of previous non-arthroplasty operative interventions there is a significantly higher risk for infection in shoulders undergoing rTSA. [265] (10.1016/j.jse.2014.11.008)
• [L4] Our results suggest that biologic resurfacing of the glenoid may have a minimal and as yet undefined role in the management of glenohumeral arthritis in the young active patient over more traditional methods of hemiarthroplasty or total shoulder arthroplasty. [266] (10.1016/j.jse.2013.06.001)
• [L3] [269] (10.1016/j.jse.2017.11.011)
• [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [270] (10.1177/1758573217702333)
• [L4] The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term. [271] (10.1016/j.jse.2020.07.037)
• [L4] [273] (10.1177/1758573220909981)
• [L3] Nonagenarians are at an increased risk of medical complications, longer hospital stays, periprosthetic fractures, and death following total shoulder arthroplasty. [276] (10.1177/17585732241269174)
• [L4] This technique may be used as an alternative to metallic or polymer materials for cerclage fixation of the humerus during shoulder arthroplasty. [277] (10.1016/j.jseint.2020.03.002)
• [L4] Total shoulder arthroplasty with an all-polyethylene pegged glenoid component, utilizing hybrid fixation, demonstrated excellent clinical and radiographic results at the time of early follow-up. [278] (10.2106/jbjs.15.00475)
• [L4] [279] (10.1016/j.jse.2024.11.039)
• [L4] The semiconstrained total shoulder arthroplasty is an effective means of treatment for arthritis of the glenohumeral joint. [280] (10.2106/00004623-197961040-00014)
• [L4] Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers. [281] (10.1016/j.jse.2017.01.002)
• [L1] Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after total shoulder arthroplasty. [284] (10.1016/j.jse.2019.05.013)
• [Paper] The optimal management of the subscapularis tendon during total shoulder arthroplasty remains controversial. [285] (10.1097/bte.0000000000000076)
• [L4] [287] (10.2106/jbjs.st.17.00051)
• [L2] [288] (10.1007/s12306-021-00710-1)
• [L4] In 68 of 100 total shoulder arthroplasties evaluated, clinical information that was not seen on standard radiographs was identified on fluoroscopic views. [292] (10.1016/s1058-2746(09)80057-8)
• [L4] [293] (10.1097/bte.0b013e3181a61de8)
• [L5] Because the presented method also showed accurate results for arthritic shoulder joints, it can be used during preoperative shoulder arthroplasty planning, in which typically only the proximal humerus is present in the scan and in which bone arthropathy can be present. [294] (10.1016/j.jse.2020.07.007)
• [L3] Measurement of soft tissue thickness about the shoulder prior to anatomic total shoulder arthroplasty using plain radiographs is reliable and reproducible. [299] (10.1016/j.jseint.2026.101648)
• [Paper] [300] (10.1007/s00402-013-1688-7)
• [L4] Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. [301] (10.1177/1758573218789339)
• [L4] [302] (10.1016/j.csm.2018.05.006)
• [L4] [304] (10.1016/j.jse.2020.05.009)
• [L4] [307] (10.1016/j.cuor.2007.11.002)
• [L5] [308] (10.1097/00132589-200112000-00005)
• [L5] [310] (10.5435/jaaos-d-22-00222)
• [L2] [312] (10.1016/s1058-2746(96)80030-9)
• [L1] Arthroscopy is a valuable tool for identifying loosening missed by CTA in painful total shoulder arthroplasty. [313] (10.1016/j.jse.2015.06.027)
• [L4] [314] (10.1016/j.xrrt.2022.05.001)
• [L5] [315] (10.1016/j.jisako.2023.05.007)
• [L5] [316] (10.1016/j.jse.2013.10.003)
• [L4] Radiolucencies were noted around the glenoid component and/or screws in 45% of shoulders. [317] (10.1097/00132589-200412000-00002)
• [L4] The radiographic changes seen at the implant-bone interfaces are much less frequent than those seen following cementing of the glenoid component. [319] (10.1016/s1058-2746(98)90096-9)
• [L3] Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture. [325] (10.2106/jbjs.k.01516)
• [L3] Elimination of these radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care. [329] (10.1007/s11999-012-2551-9)
• [L4] Sonography is a useful tool for examining soft tissues after shoulder arthroplasty in order to demonstrate pathological changes and is not negatively affected by the implant. [330] (10.1007/s00256-002-0555-3)
• [Paper] Advanced 3-dimensional computed tomography imaging software can be used to improve the accuracy of bony measurements and provide detailed planning specifications in patients undergoing anatomic total shoulder arthroplasty. [331] (10.1097/bte.0b013e318256022c)
• [L3] The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty. [332] (10.1016/j.jse.2024.10.016)
• [L3] The incidence of primary shoulder arthroplasty has increased by 160% during the study period in Finland. [333] (10.1186/s12891-018-2150-3)
• [L2] Preoperative radiographic evaluation of glenoid component loosening may often differ from intraoperative findings. [334] (10.1016/j.jse.2019.04.005)
• [L4] Postoperative 3-D CT imaging analysis following TSA identified changes in glenoid component position over time not detectable with standard imaging methods. [335] (10.1016/j.jse.2015.11.021)
• [Paper] Patients with mild radiographic signs of arthritis have about sevenfold higher odds of failing to achieve the minimum clinically important difference (MCID) after anatomic total shoulder replacement compared to patients with severe arthritis. [336] (10.1097/corr.0000000000002747)
• [L2] Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. [340] (10.1007/s11999-014-3696-5)
• [L3] The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. [350] (10.1080/17453674.2018.1450207)
• [L4] The overall complication rate of total shoulder arthroplasty has decreased dramatically over time, with a striking diminution of component loosening. [352] (10.1016/j.jse.2005.05.005)
• [L3] At mid-term follow-up, patients with a history of anterior shoulder instability undergoing total shoulder arthroplasty can expect continued improvement in function compared with preoperative values. [353] (10.1016/j.jse.2023.07.005)
• [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. [355] (10.1016/j.jse.2023.06.039)
• [L3] Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients, with a 1% incidence of never events. [357] (10.1016/j.jse.2013.08.007)
• [L3] Long-term corticosteroid users are at a heightened risk for 90-day medical complications, including pneumonia and venous thromboembolism following total shoulder arthroplasty. [359] (10.1177/17585732261460807)
• [L4] Most patients return to preoperative sports activities following shoulder arthroplasty, usually within 6 months postoperatively. [362] (10.1016/j.csm.2018.06.002)
• [L4] In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported. [364] (10.3109/17453674.2015.1024565)
• [L4] Patients with active sports participation before total shoulder arthroplasty are successfully able to return to sports activities after surgery, whereas those not participating before surgery are unlikely to resume sports. [367] (10.1177/0363546514557940)
• [L3] Patient-reported outcomes and range of motion plateau at one year postoperatively without additional complications. [368] (10.1177/1758573220922845)
• [L1] Our analysis suggests approximately 90% of shoulder replacements last up to 15 years without revision. [369] (10.1177/17585732261469128)
• [L4] Nevertheless, revision shoulder arthroplasty remains challenging with a high rate of complications. [371] (10.1016/j.jse.2013.07.041)
• [L3] Male patients had significantly higher odds of adverse events, death, MI, and sepsis following shoulder arthroplasty. [372] (10.1007/s00264-017-3547-6)
• [L4] The analysis did not identify evidence that the results of total shoulder arthroplasty were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes. [373] (10.2106/jbjs.20.01853)
• [L3] We found more than 2-fold higher primary rates for HA than for TSA and up to 3-fold higher shoulder arthroplasty rates for women than for men. [374] (10.1016/j.jse.2013.12.008)
• [L3] In patients aged 65 years and younger, anatomic total shoulder arthroplasty on the nondominant shoulder was associated with a significantly higher rate of return to sport. [377] (10.1177/03635465261423899)
• [L3] In this large real-world cohort, postoperative bisphosphonate initiation was associated with lower rates of composite implant-related complications and revision surgery following shoulder arthroplasty. [379] (10.1186/s12891-026-09981-w)
• [L4] Most patients being active prior to reverse shoulder arthroplasty surgery are successfully able to return to their activity afterwards. [382] (10.1007/s00402-016-2494-9)
• [L1] Less than half of shoulder arthroplasty RCTs are registered and more than 30% of registered trials have at least 1 inconsistency with their registry record. [384] (10.1016/j.jse.2023.04.004)
• [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. [385] (10.1016/j.jse.2018.05.029)
• [L3] The incidence of shoulder arthroplasty per 100,000 members increased from 6.1 in 2005 to 13.4 in 2013. [386] (10.1002/acr.23167)
• [L4] Shoulder arthroplasty is generally associated with meaningful improvement in sleep quality between 6 weeks and 6 months postoperatively, with improvements plateauing thereafter. [391] (10.1177/17585732261450975)
• [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. [392] (10.1177/1758573220977184)
• [L3] Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications. [393] (10.1177/17585732221097415)
• [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. [394] (10.1016/j.jse.2018.05.030)
• [L4] This study demonstrates that acute and chronic recovery after total shoulder arthroplasty can be assessed via maximum elevation and time above 90 degrees, respectively. [395] (10.1016/j.jse.2019.01.003)
• [L4] Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. [396] (10.1016/j.jse.2023.10.007)
• [L3] Preoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols. [397] (10.1016/j.jse.2021.03.033)
• [L4] Although significant strength improvement from baseline was observed at 2 years after shoulder arthroplasty, subscapularis strength returned to normal in only a minority of patients. [398] (10.1016/j.jse.2014.06.042)

See Also

• Shoulder Arthroplasty
• Reverse Shoulder Arthroplasty
• Rotator Cuff
• Fractures
• Cuff Arthropathy
• Shoulder Arthroscopy
• Shoulder Arthritis
• Shoulder Instability
• Calcific Tendinitis

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