Trends in 1030 revision shoulder arthroplasty cases: changing rates, indications, and treatments

Introduction of reverse total shoulder arthroplasty (rTSA) has contributed to a large increase in primary rTSA volume. The impact of rTSA on revision TSA has not been well described. This study aims to describe the change of 1) the volume of revision and re-revision TSA, 2) the indications for revision TSA, and 3) patient reported outcomes related to revision indication.

This is a retrospective review of a prospectively collected single surgeon database from 2002 to 2022. Patients undergoing revision TSA were identified using CPT codes 23472 and 23332 (before 2014) and 23474 (2014 and later). The primary outcome was the change in the rate of revision surgery year-over-year. Secondary outcomes include type of revision preformed, revision indication, re-revision rate, and patient reported outcomes.

Eight hundred fifty-nine patients underwent 1,030 revision surgeries, averaging 52 revisions per year (range 14-66). This reflects 20% of the surgeon's overall shoulder arthroplasty volume. Average time to revision was 41 months (range 0-229). Three hundred fifty-eight failed hemiarthroplasties (HA), 312 failed anatomic total shoulder arthroplasties (aTSAs), 358 failed reverse shoulder arthroplasties (rTSAs) and 2 failed resection arthroplasties were revised. Revisions of failed HA decreased; revisions of both failed aTSA and rTSA increased. Most patients were revised to rTSA (85%); revisions to hemiarthroplasty (8%), aTSA (6%), and resection arthroplasty (<1%) were less common. The most common revision indication by implant type was HA failed because of rotator cuff failure (45%) and glenoid wear (34%); aTSA failed because of glenoid loosening (41%) and rotator cuff failure (33%); rTSA failed because of instability (32%), baseplate failure (27%), and infection (22%). The mean American Shoulder and Elbow Surgeons score improvement from pre-to-postoperative was highest in revisions for aTSA with glenoid loosening and rotator cuff failure, HA with osteoarthritis progression, and rTSA with baseplate failure. A total of 131 patients required multiple revisions, an overall 15% re-revision rate. The re-revision rate by implant was 15% HA, 13% aTSA, and 21% rTSA. Humeral loosening, infection, and instability had the highest rates of re-revision.

There is an increasing burden of revision TSA; aTSA and rTSA failures are rising. Patients revised for both glenoid loosening and rotator cuff failure (aTSA), baseplate failure (rTSA), and osteoarthritis progression (HA) had the largest clinical benefit by American Shoulder and Elbow Surgeons score improvement. Revisions performed for humeral loosening, infection, and instability had the highest rate of multiple revisions. These failures pose unique challenges and are opportunities for innovation.