A thorough evaluation and work-up is essential before performing a revision total shoulder arthroplasty (TSA). Unlike primary replacements, revision surgery must account for altered anatomy, potential infection, and complex mechanical failure patterns. Proper assessment allows the surgeon to select the right surgical strategy and set realistic expectations for recovery.

Clinical History

A detailed patient history provides clues to the underlying cause of prosthesis failure.

  • Symptom Onset and Progression: Was pain sudden (suggesting loosening or fracture) or gradual (indicating wear or cuff dysfunction)?
  • Prior Surgical History: Number of previous shoulder procedures, implant type, and complications.
  • Functional Limitations: Activities of daily living, occupational demands, and sport participation.
  • Medical Comorbidities: Diabetes, smoking, or systemic inflammatory disease may impact revision success.
  • Infection Risk Factors: Recent fevers, wound drainage, or unexplained pain raise suspicion for periprosthetic infection.

Physical Examination

  • Range of Motion: Both active and passive motion assessed for stiffness, pseudoparalysis, or instability.
  • Strength Testing: Evaluation of rotator cuff and deltoid function.
  • Palpation and Inspection: Identifies swelling, effusion, erythema, or tenderness over implant sites.
  • Instability Tests: Detects malpositioned components or cuff failure.

Imaging Studies

X-Rays

  • Standard AP, axillary, and scapular Y views.
  • Identify loosening, migration, fractures, or malposition of components.

CT Scans

  • 3D reconstructions clarify bone stock, glenoid wear, and anchor positioning.
  • Helpful in preoperative planning for bone grafting or augmented components.

MRI or Ultrasound

  • Evaluate rotator cuff integrity and detect fluid collections.
  • Metal artifact reduction sequences improve visualization around implants.

Laboratory Tests

  • ESR and CRP: Elevated levels raise suspicion for infection.
  • Joint Aspiration: Gold standard for diagnosing periprosthetic infection; fluid analyzed for cell count, differential, and culture.
  • Other Labs: CBC and metabolic panel to assess systemic health prior to surgery.

Functional Scores

Functional assessments help document baseline status and measure postoperative improvement.

  • American Shoulder and Elbow Surgeons (ASES) score – pain and daily function.
  • Constant score – strength, motion, and activities.
  • Simple Shoulder Test (SST) – practical assessment of functional tasks.
  • Visual Analog Scale (VAS) – subjective pain evaluation.

Putting It All Together

The revision decision is rarely based on a single factor. Instead, it requires a multidimensional assessment:

  1. History for symptom pattern and prior surgeries.
  2. Physical exam for motion, strength, and signs of infection.
  3. Imaging to evaluate implants and bone quality.
  4. Laboratory work-up to exclude infection.
  5. Functional scores to establish expectations.

Frequently Asked Questions

1. Why is infection work-up so critical before revision?
Infection alters surgical planning, often requiring staged revision with implant removal before reimplantation.

2. Do all patients need a CT scan?
Not always, but CT is invaluable in cases with suspected bone loss or glenoid malposition.

3. Can MRI be used with implants?
Yes, with artifact reduction sequences, though CT is usually better for assessing bone and implant position.

4. What role do functional scores play?
They provide objective benchmarks to evaluate surgical success and patient satisfaction over time.

5. How long does the evaluation process take?
Work-up can be completed in a few days, though aspiration results may take up to a week.