Prevention and management of reverse shoulder arthroplasty complications: A structured current concepts review

Table 1 Kirchhoff et al[36] classification for periprosthetic humeral fractures after reverse shoulder arthroplasty

Humeral fracture	Prosthesis stability	Management option
1: Tuberosities	S: Stable	1-S: Conservative or ORIF
2: Spiral	L: Loose	2-S: ORIF
3: Oblique		3-S: ORIF
4: Distal		L: Revision by long stem RSA ± ORIF

ORIF: Open reduction and internal fixation; RSA: Reverse shoulder arthroplasty.

Table 2 Differential complication risk in special reconstructive indications relative to primary reverse shoulder arthroplasty

Context	Complications increased	Representative evidence
Acute PHFs/fracture sequelae	Instability, neurologic injury, intraoperative fracture, revision	National Joint Registry study: Significantly increased revision risk vs other indications; systematic review of RSA for PHF reporting higher complication/revision rates
Oncologic reconstruction	Instability/dislocation (especially with modular endoprostheses and deltoid deficiency)	Systematic reviews and meta-analyses of oncologic RSA reconstruction
Revision arthroplasty	Intraoperative fracture, infection, re-revision	Registry data showing stepwise increase in re-revision risk with successive revisions

PHFs: Proximal humeral fractures; RSA: Reverse shoulder arthroplasty.

Table 3 Summary of reverse shoulder arthroplasty complications: Incidence, risk factors, prevention, and management

Phase/complication	Incidence	Key risk factors	Prevention and management
Intraoperative complications
Intraoperative humeral fracture	1.4% overall; up to 13.6% in revision RSA	Osteoporosis, prior hardware/deformity, narrow canal, revision	Hand-reaming, avoid excessive stem impaction; ORIF or long-stem revision if displaced or stem loose
Intraoperative glenoid fracture	0.3%-0.4%	Long-standing CTA, rheumatoid erosion, AVN, revision	Autograft/allograft with augmented or BIO baseplate, longer central posts/cages, staged grafting in significant loss
Postoperative complications
Prosthetic instability	0.24%-4.7%	Prior arthroplasty, component malposition, undersized glenosphere, subscapularis deficiency, deltoid/axillary nerve dysfunction	Closed reduction for first-time events; revision (liner exchange, larger/Lateralized glenosphere, subscapularis reconstruction) for recurrent or structural instability
Neurologic injury	1%-4%	Excessive arm lengthening (> 2-2.5 cm), extensive retraction, glenoid bone grafting	Limit distalization, gentle intermittent retraction, tug test, low threshold for neuromonitoring in revisions
Hematoma	1%-20%	Inferior glenosphere placement, glenosphere medialization, valgus humeral component	Meticulous hemostasis, layered closure, drain use; early evacuation if infection suspected
Early PJI	1%-4%	Male sex, younger age, prior ipsilateral surgery, diabetes, obesity, immunosuppression, hematoma	DAIR with modular exchange and culture-directed antibiotics for acute, well-fixed implants
Glenoid dissociation	Uncommon	Incomplete glenosphere seating, soft-tissue interposition, inadequate impaction force	Rim-reamer sizing, verification by pull test and flush radiographic appearance
Long-term complications
Scapular notching	50%-70% (medialized RSA) vs < 30% (lateralized)	Medialized design, inferior baseplate tilt, glenosphere positioning	Inferior baseplate overhang/tilt, lateralized glenosphere/humeral geometry; largely observational once established
Aseptic loosening (glenoid/humeral)	0.7%-5.7%	Baseplate malposition, inadequate screw purchase, glenoid bone loss, cementless fixation in poor bone	Meticulous baseplate fixation technique, revision with bone-stock reconstruction when needed
Acromial/scapular spine stress fracture	1%-5%	Osteoporosis, female sex, rheumatoid arthritis, prior acromioplasty, excessive humeral distalization (> 2.5 mm)	Limit humeral distalization, activity modification/bracing for Levy I-II, surgical fixation for type III
Chronic PJI	1.4%	Cutibacterium acnes, coagulase-negative staphylococci, biofilm formation	Extended cultures and biomarkers; single- or two-stage revision individualized to organism virulence and host factors

RSA: Reverse shoulder arthroplasty; ORIF: Open reduction and internal fixation; CTA: Cuff tear arthropathy; AVN: Avascular necrosis; BIO: Bony increased offset; PJI: Prosthetic joint infection; DAIR: Debridement, antibiotics, and implant retention.