Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty

Aaron J. Casp, MD; Samuel R. Montgomery, Jr, BS; Jourdan M. Cancienne, MD; Stephen F. Brockmeier, MD; Brian C. Werner, MD


J Am Acad Orthop Surg. 2020;28(3):121-127. 

In This Article

Abstract and Introduction


Introduction: Osteoporosis is a widespread and growing medical condition, with significant orthopaedic implications. However, the effect of osteoporosis on outcomes after total shoulder arthroplasty (TSA) is not well understood. The goal of the present study was to characterize the incidence of osteoporosis in patients undergoing shoulder arthroplasty and to examine whether patients with osteoporosis undergoing anatomic and reverse TSA are at an increased risk of prosthetic-related complications.

Methods: Complication rates were calculated for patients with osteoporosis who underwent anatomic and reverse TSA as separate cohorts within 2 years of surgery including loosening/osteolysis, periprosthetic fracture, periprosthetic dislocation, and revision shoulder arthroplasty and compared using a multivariable logistic regression analysis to control for patient demographics and comorbidities during comparisons, including the indication for reverse TSA.

Results: The prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients. Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls.

Discussion: A significant number of patients undergoing both anatomic and reverse TSA have a concurrent diagnosis of osteoporosis. Osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant. Patients with osteoporosis should be counseled on their increased risk of complications after shoulder arthroplasty.


Osteoporosis is a common condition characterized by low bone mineral density (BMD) that affects millions of Americans and continues to be a growing public health concern.[1,2] There are significant health and economic burdens associated with the complications from osteoporotic fractures, which have been well reported.[2–6] The effects of this disease process are far-reaching because it has been estimated that 50% of women and 20% of men aged 50 years and older will sustain an osteoporotic fracture in their lifetime, and the number of osteoporotic hip fractures continues to increase at an alarming rate.[5,7] As the population ages, total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) are being performed on patients with osteoporosis, especially as shoulder arthroplasty is becoming a more common procedure for comminuted proximal humerus fractures in the elderly.[8–10] The effect that this disease process has on outcomes has not been completely studied for these procedures.

Although osteoporosis is closely linked to implant failure and fragility fractures in orthopaedic literature,[11–13] the literature evaluating its effects on the outcomes of shoulder arthroplasty is limited. The purpose of the present study is to use a national database to evaluate and compare complications after TSA and reverse shoulder arthroplasty in patients with osteoporosis and to compare complication rates to those patients with and without osteoporosis. Our hypothesis is that a diagnosis of osteoporosis will confer an increased risk of prosthetic-related complications.