Quick answer: Most shoulder replacements last a long time; about 90% are still functioning more than 10 years after surgery [1]. When one fails, the common causes are loosening or wear of the components, rotator cuff failure, instability (dislocation), infection, and fracture around the implant [2, 3]. New or worsening pain, loss of motion, weakness, or a feeling of instability years after a good result should prompt an evaluation. Revision surgery, often converting to a reverse shoulder replacement, can relieve pain and restore function, though it is more complex than a first-time replacement [4, 5].
What Is a Revision Shoulder Replacement?
A revision is an operation to remove, replace, or adjust some or all of a previous shoulder replacement. It may involve exchanging a worn plastic liner, replacing a loose component, converting an anatomic replacement to a reverse replacement, or treating an infection in stages [2, 3].
Warning Signs Your Shoulder Replacement May Be Failing
- New or increasing pain after a period of doing well
- Loss of motion or strength, especially difficulty lifting the arm
- A clicking, clunking, or "giving way" sensation, or a dislocation
- Swelling, warmth, wound drainage, fever, or chills, which can signal infection
- Changes on X-ray at a routine follow-up visit, even without symptoms
Not every change on X-ray needs surgery, but these findings deserve a careful evaluation.
Common Reasons Replacements Fail
Glenoid (socket) loosening
In anatomic replacements, the plastic socket component is a common source of long-term problems. A systematic review found that radiolucent lines (early signs of loosening) appear in about 7% of shoulders per year, symptomatic loosening in about 1% per year, and revision for socket failure in just under 1% per year [6].
Rotator cuff failure
Anatomic replacements depend on a healthy rotator cuff. If the cuff tears or wears out over time, the ball can ride up and the shoulder can become painful and weak. Converting to a reverse replacement is the usual solution [4, 5].
Instability
The implant can dislocate or become unstable because of component position, soft-tissue failure, or deltoid weakness [3].
Infection
Infection after shoulder replacement occurs in about 1% of cases nationally, with younger age and male sex among the identified risk factors [7]. In the shoulder, infections are often caused by Cutibacterium acnes (formerly Propionibacterium acnes), a slow-growing skin bacterium. In a series of revisions performed for pain, stiffness, or loosening, more than half had positive cultures, most commonly C. acnes, and many cultures took more than a week to turn positive [8]. This is why infection must be carefully considered in any painful or loose shoulder replacement, even without obvious signs.
Fracture
A fall can break the bone around the implant (a periprosthetic fracture), which may require fixation or revision [3].
How Is a Failing Replacement Evaluated?
A thorough workup usually includes:
- A detailed history and examination
- X-rays compared with prior films, and often a CT scan to assess bone stock and component position
- Blood tests for inflammation
- Sometimes a joint aspiration (drawing fluid) or tissue biopsy to look for infection
What Does Revision Surgery Involve?
The plan depends on the cause:
- Converting anatomic to reverse replacement is the most common revision for rotator cuff failure or socket loosening. In one series, patients converted to a reverse replacement for a failed total shoulder had large improvements in pain, motion, and function scores [4].
- Infection may be treated with a one-stage exchange or a two-stage approach, depending on the organism and the condition of the tissues.
- Bone loss may require bone grafting or specialized augmented components.
What Results Can I Expect?
Revision surgery can meaningfully relieve pain and restore function, but results are generally less predictable than with a first-time replacement. In a matched study, patients converted from an anatomic to a reverse replacement achieved function comparable to first-time reverse replacements, but had more complications (31% vs. 13%) and lower satisfaction [5]. Earlier experience with reverse replacement found a reoperation rate of 39% after revision cases compared with 18% after primary cases [9]. These numbers underscore why revision surgery is best done by surgeons experienced in complex shoulder reconstruction.
Frequently Asked Questions
How long should a shoulder replacement last?
About 90% of shoulder replacements are still functioning more than 10 years after surgery [1].
Can a shoulder replacement be revised more than once?
Yes, although each revision tends to be more complex, often because of bone loss and scar tissue.
My replacement still hurts a year after surgery. Is that normal?
Most patients continue to improve for up to a year, but persistent or worsening pain should be evaluated. Low-grade infection, component problems, or rotator cuff issues can all cause pain [3, 8].
Should I get a second opinion before revision surgery?
For complex surgery like a revision, a second opinion from a shoulder specialist is very reasonable. See Should I Get a Second Opinion Before Shoulder or Elbow Surgery?
Getting Evaluated
Dr. Tej Joshi evaluates painful and failed shoulder replacements and performs revision shoulder replacement at NYU Langone offices in Manhattan, Lake Success, and Bay Ridge, Brooklyn.
References
- Evans JP, Evans JT, Craig RS, et al. How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up. Lancet Rheumatol. 2020;2(9):e539-e548. PubMed 38273618 · doi:10.1016/S2665-9913(20)30226-5
- American Academy of Orthopaedic Surgeons. Shoulder Joint Replacement. OrthoInfo. orthoinfo.org
- Bohsali KI, Bois AJ, Wirth MA. Complications of shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(3):256-269. PubMed 28145957 · doi:10.2106/JBJS.16.00935
- Walker M, Willis MP, Brooks JP, et al. The use of the reverse shoulder arthroplasty for treatment of failed total shoulder arthroplasty. J Shoulder Elbow Surg. 2012;21(4):514-522. PubMed 21641825 · doi:10.1016/j.jse.2011.03.006
- Shields E, Wiater JM. Patient outcomes after revision of anatomic total shoulder arthroplasty to reverse shoulder arthroplasty for rotator cuff failure or component loosening: a matched cohort study. J Am Acad Orthop Surg. 2019;27(4):e193-e198. PubMed 30216243 · doi:10.5435/JAAOS-D-17-00350
- Papadonikolakis A, Neradilek MB, Matsen FA 3rd. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. PubMed 24352774 · doi:10.2106/JBJS.L.00552
- Padegimas EM, Maltenfort M, Ramsey ML, et al. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015;24(5):741-746. PubMed 25595360 · doi:10.1016/j.jse.2014.11.044
- Pottinger P, Butler-Wu S, Neradilek MB, et al. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012;94(22):2075-2083. PubMed 23172325 · doi:10.2106/JBJS.K.00861
- Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486. PubMed 15995114 · doi:10.2106/JBJS.D.02342