Risk factors for early revision following primary total shoulder arthroplasty in a single health system.

Background

Shoulder arthroplasty has emerged as a reliable treatment for end-stage glenohumeral arthritis. However, as the volume of total shoulder arthroplasty (TSA) increases nationwide, revision procedures are expected to rise in parallel. These surgeries are already known to be technically challenging and associated with higher complication rates, longer recovery, and increased costs. Despite this growing demand, limited large-scale data exist to identify which patient factors predict early failure and adverse outcomes. This study aimed to evaluate predictors of revision and postoperative complications following TSA using a national health system database to guide preoperative optimization and surgical planning.

Methods

A retrospective cohort study was performed using the Hospital Corporation of America Healthcare database to identify adults (≥18 years) who underwent primary or revision TSA between 2016 and 2022. Variables included patient demographics (age, sex, race, body mass index), and Elixhauser Comorbidity Index. The primary outcomes were revision within 2 years and incidence of postoperative complications (including infections, cardiac events, thromboembolic events, and prosthetic complications). Secondary outcomes included time to revision and length of hospital stay. Multivariable logistic regression was used to assess predictors of revision and complications, while linear regression evaluated associations with timing of revision.

Results

Among 44,952 TSA cases, 579 patients (1.3%) underwent revision within two years. Male sex (odds ratio [OR] 1.77; 95% confidence interval [CI] 1.50-2.10; P < .001) and higher Elixhauser Comorbidity Index (OR 1.09, 95% CI 1.03-1.14, P = .001) were significantly associated with increased revision risk. Increasing age was associated with a 2% decrease in odds per additional year of age (OR 0.98; 95% CI 0.97-0.99; P < .001). Postoperative complications occurred in 1,413 patients (3.1%) and were more common among younger patients (OR 0.98 per year; P < .001), males (OR 1.52; P < .001), and those with higher comorbidity burden (OR 1.12 per unit; P < .001). Race and body mass index were not significantly associated with revision or postoperative complications. Among patients who underwent revision, the mean time to revision was 205 days, and no patient-level variables were significantly associated with time to revision on multivariable analysis.

Conclusion

This large-scale analysis identifies male sex, younger age, and higher comorbidity burden as independent factors associated with revision surgery and postoperative complications following TSA. These findings highlight the need for risk-informed patient selection, counseling, and perioperative optimization. As the volume of TSA continues to grow, these results support the development of targeted care pathways aimed at minimizing revision rates and improving outcomes across diverse patient populations.