Comorbidity-specific long-term complication risks on postoperative outcomes in total shoulder arthroplasty

Total shoulder arthroplasty (TSA) is frequently performed becoming the gold standard for glenohumeral end-stage arthritis; however, complications such as periprosthetic fractures, prosthetic joint infections, and aseptic loosening rarely occur but often require revision surgery. Despite prior studies on isolated comorbidities and their impact on outcome and complications, a comprehensive analysis of their collective impact on TSA outcomes and complications is lacking. This study systematically evaluated 10-year complication risks associated with the most common comorbidities, providing a practical reference for shoulder surgeons.

A retrospective analysis was performed using the PearlDiver national database to identify TSA patients with isolated comorbidities from 2010 to 2020. The study included patients with 1 of 19 predefined comorbidities (eg, dementia, asthma, congestive heart failure, rheumatoid arthritis, and systemic lupus erythematosus [SLE]) and excluded those with multiple comorbidities, bilateral or concurrent procedures, or incomplete follow-up data. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals for complications, including irrigation and débridement, rotator cuff repair, spacer placement, and all-cause revision. Each comorbidity's impact was assessed independently, ensuring systematic exclusion of confounding variables. A Bonferroni correction was applied in which the significance threshold was set to P≤ .00026.

Over a 10-year follow-up of 132,319 patients (mean age 65.2 years, standard deviation 8.2), specific comorbidities were significantly associated with increased complications following TSA. Depression (HR: 2.85, P < .001) was linked to higher irrigation and débridement rates. Spacer placement was more frequent in patients with SLE (HR: 17.98, P < .001). Stroke (HR: 3.25, P < .001) elevated the need for relocation and reduction procedures. Asthma heightened the risk of revision for dislocation (HR: 11.63, P < .001), while chronic back pain (HR: 3.55, P < .001) and SLE (HR: 51.21, P < .001) were linked to increased revision rates for rotator cuff tears.

This study is the first to systematically analyze the long-term risk of TSA complications across multiple comorbidities. Comorbidities such as asthma, depression, stroke, chronic back pain, and SLE significantly increase the risk of complications, including irrigation and débridement, spacer placement, relocation and reduction, and revision due to dislocation or rotator cuff tears, following TSA. These findings help shoulder surgeons assess patient-specific revision risks, guiding planning and care to reduce complications and improve outcomes.