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It's the "Era of the Reverse" for Revision Shoulder Arthroplasty

Key findings

  • The percentage of revision shoulder arthroplasties that two high-volume surgeons performed using the reverse prosthesis increased significantly from 51% in 2005–2010 to 78% in 2011–2016
  • By 2015–2016, 93% of all shoulder arthroplasty revisions by these surgeons involved the reverse prosthesis, compared with 36% a decade earlier
  • The use of reverse shoulder arthroplasty for revision increased in patients under 60, obese patients, those with rheumatoid arthritis, those with diabetes mellitus and those with glenoid loosening

Reverse shoulder arthroplasty (RSA) was approved by the U.S. Food and Drug Administration in late 2004 and quickly became successful. By 2011, 42% of shoulder arthroplasties performed in the United States were RSAs.

RSA may be particularly useful for revisions, as it can compensate for soft tissue and bony deficiencies because of its semiconstrained articulation, medialized center of rotation and glenoid ingrowth and compression capabilities. Jon J.P. Warner, MD, chief of the Shoulder Service at Massachusetts General Hospital, and colleagues recently found that the reverse prosthesis is now overwhelmingly the predominant implant for revision shoulder arthroplasty at two tertiary referral centers. The report is published in the Journal of Shoulder and Elbow Surgery.

Dr. Warner's group reviewed the clinical databases of two high-volume shoulder surgeons at two tertiary referral centers for the period January 1, 2005, through December 31, 2016, which they call the "era of the reverse." Patients were included if they underwent revision to a hemiarthroplasty, anatomic total shoulder arthroplasty or RSA.

Trends in Revision Procedures

Over the 12-year study period, the number of revision shoulder arthroplasties performed at the two centers gradually increased from 117 in 2005–2010 to 157 in 2011–2016. In the first six years of the study period, 51% of revisions were RSAs, whereas in the most recent six years, 78% were RSAs (< .01).

The use of RSAs for revision began to increase exponentially in 2013. By 2015 and 2016, 93% of all revisions were RSAs, compared with only 36% in 2005 and 2006 (< .01).

RSAs as a percentage of all revisions increased in a number of patient subgroups over the study period:

  • Patients younger than 60: From 28% in 2005–2010 to 55% in 2011–2016
  • Obese patients: From 53% to 80%
  • Patients with rheumatoid arthritis: From 59% to 88%
  • Patients with diabetes: From 65% to 100%
  • Men: From 41% to 71%
  • Women: From 60% to 84%

Glenoid loosening was responsible for 15% of all revisions in 2005–2010, versus 36% in 2011–2016 (< .01). The percentage of patients who had glenoid loosening revised with RSA increased from 17% to 86% during those periods, respectively (< .01).

Take-home Messages

The increasing use of RSA for revisions indicates surgeons' increasing confidence in its ability to overcome complex pathologies, to withstand large loads and high demands through the shoulder and to endure long term.

The authors predict that the increasing use of shoulder arthroplasty will be accompanied by a gradual increase in the need for revision surgery for implants that fail. They consider the reverse prosthesis likely to continue to be the dominant implant in the revision setting.

of shoulder arthroplasty revisions between 2005–2006 were RSAs

of shoulder arthroplasty revisions between 2015–2016 were RSAs

of revision RSAs in 2005–2010 were performed for glenoid loosening

of revision RSAs from 2011–2016 were performed for glenoid loosening

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Three-dimensional planning software may improve outcomes for shoulder arthroplasty. A new technology allows surgeons to install the prosthetic joint with greater foresight and precision.


At the AAOS Annual Meeting 2018, Jon J.P. Warner, MD, chief of the Shoulder Service at Massachusetts General Hospital, described how he used virtual planning to perform shoulder replacement surgery in a patient with a severe glenoid socket deformity.