Revision Shoulder Arthroplasty

Sirveaux Classification (Glenoid Bone Loss in Failed RSA)

E3 or E4. The distinction is critical. E3 has deep central erosion but an intact superior and medial glenoid cortex, and can be managed with an augmented baseplate or bone graft impaction. E4 has extensive superior and medial loss with loss of structural integrity, and requires a structural allograft (scapular spine bone graft, iliac crest strut graft) or BIO-RSA; without structural grafting it has significantly higher failure rates.

Morrey Classification (Humeral Bone Stock)

Revision Shoulder Infection Classification

Cutibacterium acnes. Formerly Propionibacterium, it is the most common organism in shoulder prosthetic joint infection, found in 30-40% of cases. Its infections are indolent and often culture-negative at first, which is why cultures are held for 14 days (see Investigations).

One stage or two. Two-stage revision is the gold standard for chronic infection, with 70-85% infection eradication rates. The exception the table allows, single-stage exchange for low-virulence Cutibacterium with low biofilm, is set against the Belay meta-analysis in the Evidence section, which found single-stage revision effective for low-virulence, sensitive organisms with comparable reinfection rates.

Aseptic Revision Shoulder Arthroplasty Algorithm

Goal. Restore shoulder function with durable fixation despite bone loss and soft-tissue compromise.

Default to reverse. Choose reverse shoulder arthroplasty for most revision cases. It compensates for rotator cuff deficiency, which is common after failed TSA; it accommodates glenoid bone loss better than an anatomic TSA, because medialisation is less detrimental; and it is the dominant revision construct across the major joint registries. If in doubt, choose RSA.

When anatomic is possible. Convert a failed hemiarthroplasty to anatomic TSA only if all of these hold:

1. Intact rotator cuff, confirmed on MRI or intraoperatively
2. Adequate glenoid bone stock (Sirveaux E0-E1)
3. No component malposition requiring excessive bone removal

Revising a failed anatomic TSA to another anatomic TSA is considered only with an intact cuff, minimal bone loss and a young, active patient.

The operation itself, from extended deltopectoral exposure and careful extraction to defect reconstruction, baseplate fixation and subscapularis management, is set out under Surgical Technique.

Two-Stage Revision for Infected Shoulder Arthroplasty

Goal. Eradicate infection, maintain the joint space and allow reimplantation with a low risk of reinfection. This is the protocol for chronic infection; an acute infection within 4 weeks may be salvaged by DAIR (see Complications).

Stage 1: explantation and spacer.

• Complete synovectomy and debridement of all infected tissue
• Remove all components and cement, leaving no retained cement fragments
• Send a minimum of 5 tissue samples from different sites for culture (14-day hold)
• Irrigate extensively with 9L of normal saline (3L pulse lavage, 3L bulb syringe, 3L gravity)
• Insert an antibiotic-laden cement spacer: vancomycin 4g and tobramycin 2.4g per 40g of cement

The spacer may be static, articulating (which maintains range of motion), or a prosthesis of antibiotic-loaded acrylic cement (PROSTALAC). Six weeks of IV antibiotics follow, chosen by culture: vancomycin for staphylococci, ceftriaxone for streptococci, penicillin for Cutibacterium.

The interval (6-12 weeks). Complete the 6 weeks of IV antibiotics, then hold antibiotics for a minimum of 2 weeks (ideally 4) and repeat CRP and ESR at 2 weeks off antibiotics. The target is CRP less than 10 mg/L and ESR less than 30 mm/hr, with a normalising trend. If the markers stay elevated, consider repeat aspiration (though its sensitivity is low after stage 1), and extend the antibiotic holiday or repeat the debridement.

Stage 2: reimplantation (weeks 6-12).

• Take 5 fresh tissue samples for frozen section and culture before reimplanting
• Remove the spacer and debride residual cement
• Proceed to revision arthroplasty, usually RSA, if frozen section shows fewer than 5 PMN/HPF; if more, replace the spacer and extend antibiotics
• Fix the humeral stem with antibiotic-impregnated cement
• Continue oral suppressive antibiotics for 3-6 months, an infectious disease decision

Surveillance. Monitor CRP at 6 weeks, 3 months, 6 months and then yearly, and assess clinically for recurrent infection. Reinfection occurs in 10-15% despite an appropriate two-stage protocol, and persistent infection may require resection arthroplasty or chronic suppressive antibiotics (see Salvage).

Revision for Recurrent Shoulder Instability

Goal. Restore stability with soft-tissue balancing and component optimisation.

Find the cause. The common causes of instability after shoulder arthroplasty:

• Component malposition (excessive glenoid or humeral retroversion)
• Subscapularis failure or insufficiency
• Glenoid bone loss (posterior or superior deficiency)
• Deltoid insufficiency (axillary nerve injury)
• Inadequate soft-tissue tension (overlengthening or undersizing)

CT shows component version and bone stock, and examination under anaesthesia shows the direction and magnitude of the instability.

The unstable anatomic TSA. Revise to RSA, which is inherently more stable because of its medialised centre of rotation. Address glenoid bone loss with an augmented baseplate, and repair or reconstruct a deficient subscapularis.

The unstable RSA.

• Increase lateralisation: a 36mm rather than a 32mm glenosphere, or a lateralised glenosphere
• Increase humeral offset with plus 6mm or plus 9mm polyethylene inserts
• Correct glenoid version (anteriorise the baseplate)
• A constrained polyethylene insert only as a last resort, because it increases stress on glenoid fixation

Soft-tissue balancing. Subscapularis repair or lesser tuberosity osteotomy addresses anterior instability, and deltoid advancement is used if deltoid insufficiency is identified. Assess stability through full range before closure.

Preoperative Planning and Consent

Consent. The discussion should cover:

• Infection, nerve injury (axillary most commonly) and instability, at the rates given under Complications
• The possible need for bone grafting, from iliac crest or allograft, if bone loss is severe
• The need for re-revision (see Overview)
• Stiffness and persistent pain: 20% have persistent pain despite revision
• Medical risks: DVT/PE (1-2%) and anaesthetic complications

Patient Positioning

Position. Beach chair on a specialised shoulder positioner, 30-40 degrees upright with the torso stabilised and the head neutral in a foam head ring or pins. Drape the operative arm free from hand to scapula so that range can be assessed, and secure the contralateral arm across the body on a padded arm board. Hypotensive anaesthesia, a mean arterial pressure of 55-65 mmHg if tolerated, reduces bleeding and improves visualisation.

Padding.

• Bony prominences: sacrum, heels, contralateral elbow
• Ulnar nerve at the contralateral elbow: pad it and avoid pressure
• Peroneal nerve at the lateral knee: keep the legs uncrossed
• No axillary roll: it is not needed in the beach chair and can compress the brachial plexus

Draping. Expose from the sternoclavicular joint to the deltoid insertion and medially to the spine, with the entire limb free. Confirm adequate AP and axillary C-arm views before draping, and use impervious drapes (a waterproof U-drape and extremity stockinette).

Surgical Approach: Extended Deltopectoral

Incision. From the coracoid process to the deltoid insertion, 15-20cm, slightly lateral to the deltopectoral interval to account for skin contraction. Use the previous scar if it is cosmetically acceptable, extending it proximally and distally as exposure requires.

Cephalic vein. At revision it is often scarred into the interval. Ligate it if densely adherent, which avoids avulsion and bleeding, or take it laterally with deltoid or medially with pectoralis as the anatomy dictates. Meticulous haemostasis matters because bleeding increases infection risk.

The interval. Between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves). Expect dense scar: dissect sharply, use cautery for haemostasis, and hold the exposure with a self-retaining retractor (Kolbel or equivalent). Palpate the musculocutaneous nerve medially at its entry into coracobrachialis, and avoid excessive inferior retraction, which endangers the axillary nerve at the inferior capsule.

The subscapularis decision. One of the most important decisions in revision shoulder surgery. The tendon may be scarred, atrophic or absent, so establish its integrity and how it was previously repaired:

• Intact, good-quality tendon, or an intact previous tenotomy or repair: direct repair with transosseous sutures or suture anchors
• Poor tissue or a failed previous repair: lesser tuberosity osteotomy, which heals bone to bone, with success in 80-90% against 50-60% for tendon repair in revision
• Irreparable: proceed without it, accepting a higher anterior instability risk and compensating with increased component constraint or glenosphere lateralisation

Lesser tuberosity osteotomy. Mark the osteotomy 1cm medial to the bicipital groove with electrocautery and cut a 10-15mm thick wafer with an oscillating saw. Tag it with two heavy sutures (number 5 Ethibond) for the later repair, and elevate it with subscapularis attached.

Capsular release. Release the capsule circumferentially, 360 degrees, from the glenoid rim with electrocautery. Inferiorly, a blunt retractor protects the axillary nerve; stay on bone. Extend the release posteriorly to see the posterior glenoid for baseplate placement, and superiorly through the rotator interval and, if exposure needs it, the coracoacromial ligament. The goal is complete exposure of the glenoid face, scapular neck and inferior capsule for extraction and implantation.

Component Removal Technique

The humeral component first. Externally rotate and extend the arm to deliver the component into the wound, and remove the polyethylene insert or the humeral head if modular. The stem comes out according to how it is fixed:

• Press-fit: flexible osteotomes at the bone-implant interface, then gentle extraction with a mallet and extraction device
• Cemented: a high-speed burr window in the lateral cortex, osteotomes to disrupt the cement-bone interface, extraction with a mallet
• Severely ingrown (rare in the shoulder): may require an extended trochanteric osteotomy

Thin flexible osteotomes minimise bone loss; aggressive levering fractures the proximal humerus.

The glenoid component second. Preserve maximum glenoid bone stock: it is the limiting factor for revision. For a reverse, remove the glenosphere first (unscrew it with a torque driver), then identify and remove every screw, typically 4-6, then loosen the central peg or keel with curved osteotomes around the periphery; excessive force risks glenoid fracture if the baseplate is well fixed. An all-polyethylene anatomic glenoid comes out with curved osteotomes at the bone-implant interface, and a metal-backed one needs its screws removed before the baseplate is extracted. Remove any glenoid cement by curettage and high-speed burr.

Clearing the bed. Remove all cement fragments (curettage, pulsed lavage, high-speed burr) and debride the fibrous membrane from the bone surfaces, which improves fixation of the revision implants. Irrigate copiously, 9L in total as in stage 1 of a septic revision. Only with the components out can the true extent of bone loss be assessed.

Glenoid Bone Defect Management

BIO-RSA. Bony-increased-offset reverse shoulder arthroplasty (Boileau) lateralises the joint line and centre of rotation with autograft bone rather than metal, and at revision it doubles as a way to restore lost glenoid bone stock. A disc of bone, classically the patient's resected humeral head at a primary or a structural femoral head allograft at revision when autograft is unavailable, is placed between the baseplate and the native glenoid. A long central peg or post and long peripheral screws pass through the graft into native scapular bone, compressing it against the glenoid so that it can heal and incorporate.

What it gains and what it risks. Lateralising the centre of rotation improves rotation, soft-tissue wrap and stability and reduces inferior scapular notching, and the graft rebuilds glenoid bone for any future revision, which is why BIO-RSA recurs across Favard/Sirveaux E1-E4 erosion at revision. Success depends on graft incorporation: resorption or nonunion can loosen the baseplate, so firm compression and good native-bone screw purchase are essential. The broader medialised Grammont versus lateralised RSA design concept is developed in the reverse-shoulder-arthroplasty topic.

E0-E2, mild to moderate loss. A standard baseplate with eccentric reaming, or BIO-RSA:

• E0 (no bone loss): standard glenoid baseplate, central fixation
• E1 (round central erosion): eccentric reaming to a flat surface, or BIO-RSA with bone graft impaction
• E2 (oblique erosion): eccentric reaming to correct version, considering a small posterior augment, or BIO-RSA

Reaming principles. Ream to a flat, stable surface for baseplate contact and correct glenoid version to neutral, 0-10 degrees of retroversion, without excessive medialisation (see Biomechanics). Confirm fixation with a minimum of 4 screws, preferably 6.

Impaction BIO-RSA for E1-E2. Ream the glenoid to bleeding bone, impaction-graft it with cancellous autograft or allograft chips, and compress the graft by impacting the baseplate; this restores bone stock for a potential future revision. For E0-E2 loss this approach is adequate, with good outcomes.

E3-E4, severe loss. These need an augmented baseplate, a structural bone graft, or BIO-RSA with graft. They are advanced techniques with higher complication rates, but can achieve acceptable outcomes.

Augmented baseplate (E3).

• Prepare the glenoid to bleeding bone
• Select the augmented baseplate: a posterior augment is most common, for E3 with posterior deficiency
• Position it to correct version and restore glenoid anatomy
• Secure it with a minimum of 4 screws, preferably 6, into good bone; if a screw fails to engage bone, upsize it or add bone graft

Structural graft (E4). An iliac crest tricortical autograft (2-3cm × 3-4cm) suits posterior column deficiency, and a distal femoral condyle allograft large superior or medial defects. Fix the graft to native glenoid with 3.5mm cortical screws or headless compression screws, and place the baseplate over it with screws into both native bone and graft.

BIO-RSA with structural graft. A structural graft placed medially restores glenoid depth, cancellous chips are impaction-grafted around it, and the baseplate is impacted over the construct. Long screws (35-45mm) penetrate the graft and engage native scapular bone.

Humeral Bone Defect Management

Stem length and fixation follow the Morrey type (see Classification).

Impaction bone grafting. For contained defects it is preferred over cortical strut allografts. It restores bone stock for future revision, enhances cement mantle quality and improves stress distribution, with 85-90% stem stability at 5 years. The technique:

1. Prepare the humeral canal by reaming 0.5mm undersized
2. Pack morselised cancellous allograft or autograft into the canal in 1cm layers
3. Impact each layer with progressively larger impactor dowels
4. Impact the final layer firmly until stable
5. Insert a cemented long stem into the grafted canal
6. Pressurise the cement to achieve interdigitation with the impacted graft

Glenoid Baseplate Fixation

Preparing the surface. Ream to bleeding bone and a flat surface, correcting version with eccentric reaming and superior tilt to the targets above, and aim for greater than 80% bone contact under the baseplate.

Central peg or keel. Drill the central hole, typically 10-15mm deep, so that the peg engages good bone. Excessive depth risks glenoid fracture or neurovascular injury.

Impaction. Position the baseplate in neutral version, confirmed with guide wires, and impact it until it sits flush on bone without rocking; firm seating is critical for stability.

Screws. Superior screws into the coracoid base give the strongest fixation. The inferior screw goes into the scapular spine and the posterior screws into the scapular body. Use locking or compression screws of 30-45mm, longer in revision for bicortical purchase, and upsize or redirect any screw without firm purchase.

Glenosphere. Choose 32mm, 36mm or 42mm according to bone stock and stability needs: a larger glenosphere (36-42mm) increases stability but requires adequate bone stock. Secure it to the baseplate with the locking mechanism, torqued to the manufacturer's specification. A lateralised glenosphere improves deltoid efficiency and range of motion, and is considered if bone stock is adequate.

Humeral Component Preparation

Canal. Ream to a diameter set by stem size and cortical thickness, taking the stem length from the Morrey type.

Cemented stem, preferred in revision.

• Clean and dry the canal thoroughly
• Insert a cement restrictor 2cm beyond the stem tip
• Insert cement retrogradely with a cement gun
• Insert the stem with gentle pressure in 20-30 degrees of retroversion
• Remove excess cement before polymerisation, and hold the position until the cement polymerises (5-8 minutes)

Press-fit, if bone quality is excellent. Ream undersized to ensure a tight press-fit, impact the stem with gentle mallet blows, and confirm stable fixation with a manual stress test.

Tray and polyethylene. Attach the humeral tray (locking mechanism or cement, depending on the system) and choose an insert: standard, plus 3mm, plus 6mm or plus 9mm. Thicker inserts increase soft-tissue tension and stability, but decrease range of motion and increase stress on glenoid fixation. Thinner inserts improve range but may compromise stability.

Trial reduction. Start with the standard insert and assess stability through forward elevation, abduction and rotation, checking for acromial impingement and scapular notching. If the shoulder is unstable, increase thickness in 3mm increments to a maximum of plus 9mm; beyond that, look for another cause, such as component malposition. The acceptable reduction is stable through range with no clunking and slight inferior subluxation, 1-2mm with gentle traction, which indicates appropriate tension without overtightening. Overtensioning causes stiffness and glenoid loosening; undertensioning causes instability.

Subscapularis Repair and Closure

Osteotomy repair. Reduce the lesser tuberosity fragment to its anatomic position and fix it with 2 heavy screws (4.5mm or 4.0mm cannulated), heads countersunk to avoid impingement. Supplement with heavy sutures (number 5 Ethibond) through bone tunnels, and confirm stable fixation with a manual stress test.

Direct tendon repair. Repair tendon to bone through transosseous tunnels or with suture anchors, using heavy non-absorbable sutures (number 2 FiberWire or Ethibond), a minimum of 4-6 of them, tension-free in neutral rotation. At closure test belly press and lift-off strength: a strong belly press indicates an intact subscapularis, and a weak one suggests subscapularis deficiency and the need for increased anterior-posterior stability.

Closure. Approximate deltoid and pectoralis with interrupted absorbable sutures (0 or 1 Vicryl), without overtightening, which can cause deltoid denervation or stiffness. Close the subcutaneous layer with 2-0 Vicryl, interrupted or running, and the skin with staples, interrupted 3-0 nylon or running subcuticular 3-0 Monocryl, under a sterile dressing with ABD pads for drainage.

Immobilisation. An abduction sling with pillow, or an abduction brace if available, holds the arm in 30 degrees of abduction and neutral rotation. It protects the subscapularis repair and prevents inferior subluxation, and continues for 6 weeks if subscapularis was repaired or osteotomised.

Day 0-1. The arm rests in the abduction sling.

• Drain, if placed, removed when output is under 30mL per 8 hours
• Analgesia: regional block (interscalene catheter for 2-3 days) and oral opioids
• DVT prophylaxis: mechanical (sequential compression devices), with enoxaparin 40mg daily if bleeding risk is low
• Out of bed to a chair on day 0-1, and discharge usually on day 1-2 for uncomplicated cases

Weeks 1-6: passive motion only. The sling is worn full-time, removed only for exercises and hygiene, and there is no active internal rotation, to protect the subscapularis repair. Therapist-assisted passive motion reaches forward elevation to 120 degrees, abduction to 90 degrees and external rotation to 30 degrees, with pendulum exercises three times daily, grip strengthening, and elbow, wrist and hand range to prevent stiffness. Review at week 2 (wound check, staples out) and week 6 (radiographs to assess healing, progress physiotherapy).

Weeks 6-12: active motion. Wean the sling at 6 weeks if radiographs are satisfactory and examination is reassuring. Progress to active-assisted range (pulleys, cane-assisted elevation) if radiographs show a healed osteotomy or examination shows an intact belly press; if the belly press is weak, continue protection and reassess at 8 weeks. Then begin active, deltoid-driven elevation and abduction at week 8 and light internal rotation (hand to belly, hand to opposite shoulder) at weeks 8-10. Forceful internal rotation stays off while subscapularis is still healing, and resisted internal rotation to strengthen it begins at 10-12 weeks. The targets by week 12, reviewed with radiographs, are active forward elevation to 140 degrees, abduction to 100 degrees and external rotation to 45 degrees.

Weeks 12-24: strengthening. Resistance-band exercises for deltoid and rotator cuff (avoiding heavy internal rotation), scapular stabilisation (rows, scapular squeezes) and functional activities such as reaching and lifting light objects, with a gradual return to daily living and a home programme continued indefinitely. The goals are functional strength, forward elevation of 150-160 degrees, abduction of 120-140 degrees and functional internal rotation, though typical final range after revision RSA is lower (see Outcomes). Follow-up is at 6 months, 1 year and then yearly with radiographs.

Long term. Annual clinical review of pain, function, range and strength, with AP and axillary radiographs for component position, lucencies and scapular notching, watching for late infection, loosening, instability and progressive notching. Patients should avoid heavy overhead lifting (over 10kg), contact sports and high-impact activity, report new pain, clicking or instability immediately, and maintain range with home exercises.

Rehabilitation After Two-Stage Revision for Infection

Spacer phase (weeks 0-6). The aim is to keep some motion to prevent contracture while the infection is eradicated; the spacer is temporary and function is not its purpose. Use an abduction sling for comfort and protection, gentle passive range only, pendulums for pain relief, and elbow, wrist and hand range, while IV antibiotics run for typically 6 weeks as infectious disease advise. Review weekly during IV antibiotics, with CRP and ESR monitoring.

Antibiotic holiday. Gentle range continues with the spacer in place while the markers are checked; the decision to reimplant is set out under Management.

After reimplantation. Follow the standard revision RSA protocol, which may progress slightly slower because of soft-tissue compromise from the previous surgery. The functional goals are the same as for aseptic revision, but infection eradication is the primary outcome.

Global Epidemiology

Major Guidelines and Consensus, Side by Side

Registry Evidence

Global Practice Variation