Skip to content

Revision shoulder replacement

Surgeon-side topic for revision shoulder replacement. Backed by 422 articles from the corpus, retrieved via combined MeSH + title-text matching.

Overview

The incidence of shoulder replacement and revision is expected to increase in the following years, constituting a burden for the healthcare systems [2]. Shoulder arthroplasties are generally designed to last 10-15 years, but revisions are being performed at a mean 3.9 years from the primary procedure [4]. The most revised implants for humeral loosening were anatomic total shoulder arthroplasties and reverse shoulder arthroplasties, with reverse shoulder arthroplasties being the most common implant used for revision [7]. In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [8]. The optimum shoulder arthroplasty revision rates vary for both the gender and implant type for the diagnosis of osteoarthritis (OA) [10].

The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a periprosthetic joint infection (PJI), with less than 10% meeting International Consensus Meeting (ICM) criteria for definite PJI [5]. Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible [11]. Complications and reoperation rates for revision reverse shoulder arthroplasty for baseplate failure were higher than those for primary reverse shoulder arthroplasty, but outcomes were comparable for revision of failed anatomic shoulder arthroplasty [12]. Patients undergoing treatment of shoulder PJI with débridement, antibiotics, and implant retention (DAIR) did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures [13].

Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [1]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [3]. Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed [25].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Scapulohumeral Rhythm: Shoulders with good elevation demonstrate significantly higher scapulohumeral rhythm than those with poor elevation [34]. Scapulothoracic Orientation: Posture types and scapulothoracic orientation play an important role in optimal implant configuration, positioning, and clinical outcomes in reverse total shoulder arthroplasty [45].

Reverse Shoulder Arthroplasty (RSA) Kinematics: Lateralization in reverse shoulder arthroplasty improves stability, notching rates, range of motion, and shoulder contour [40]. However, internal rotation after reverse total shoulder arthroplasty is associated with a limited range compared with other shoulder motions [43]. This restricted internal rotation is also associated with lower recovery rates for activities of daily living than expected [43].

Glenosphere Positioning and Strain: Glenoid lateralization is consistently associated with increased acromial and scapular spine strain [53]. Conversely, inferiorization of the glenosphere reduces acromial and scapular spine strain [53].

Humeral Component Factors

Humeral Height Variability: Variability in ultimate humeral height of an inlay humeral stem does not impact outcomes following reverse shoulder arthroplasty [48].

Failure Modes and Complications

Anatomic Total Shoulder Arthroplasty (aTSA): Component loosening is a common failure mode after anatomic total shoulder arthroplasty [27]. Instability is a challenging complication with high failure rates after revision procedures for anatomic total shoulder arthroplasty [22].

Reverse Shoulder Arthroplasty (RSA) Survival: Revision reverse shoulder arthroplasty demonstrates an implant survival rate of 85% at ten years [1].

Aseptic Loosening Risk Factors: Female sex is associated with aseptic humeral loosening [6]. Absence of glenoid loosening is associated with aseptic humeral loosening [6].

Implant Selection Considerations

Glenoid Components: Metal-backed glenoid components should be used with caution and not on a routine basis [24].

Classification

Indication-Based Stratification: The outcome of revision shoulder arthroplasty is predicted on the basis of the indication for the procedure [3]. The decision to revise a total shoulder arthroplasty requires assessment regarding infection, instability, wear, loosening, and rotator cuff status [17].

Failure Mode Classification: Component loosening is a common failure mode after anatomic total shoulder arthroplasty [27]. Female sex and absence of glenoid loosening are associated with aseptic humeral loosening [6]. Reverse shoulder arthroplasties are the most common implant used for revision due to humeral loosening [7].

Infection Classification: Less than 10% of revision shoulder arthroplasties meet ICM criteria for definite periprosthetic joint infection (PJI) [5]. Significant differences in skin Cutibacterium subtype distributions exist between shoulders undergoing revision shoulder arthroplasty and those undergoing primary shoulder arthroplasty [39].

Other Considerations: Revision shoulder arthroplasty demonstrates an implant survival rate of 85% at ten years [1]. Revisions are being performed at a mean 3.9 years from the primary procedure [4]. The incidence of shoulder replacement and revision is expected to increase, constituting a burden for healthcare systems [2]. Optimum shoulder arthroplasty revision rates vary for both gender and implant type for the diagnosis of osteoarthritis [10]. In patients under 55 years of age, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [8]. Patients undergoing treatment of shoulder PJI with débridement, antibiotics, and implant retention (DAIR) did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures [13]. The optimal management of symptomatic glenoid loosening remains unclear [26]. Metal-backed glenoid components should be used with caution and not on a routine basis [24].

Clinical Presentation

The incidence of shoulder arthroplasty and revision is rising, placing a growing burden on healthcare systems [2]. Revisions are typically performed at a mean of 3.9 years from the primary procedure [4]. The clinical outcome of revision shoulder arthroplasty is predictable based on the specific indication for the procedure [3]. Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [1].

The decision to revise a total shoulder arthroplasty requires a comprehensive assessment of Infection, Instability, Wear, Loosening, and Rotator cuff status [17]. Less than 10% of revision shoulder arthroplasties meet ICM criteria for definite periprosthetic joint infection (PJI) [5]. In cohorts using crosslinked polyethylene, loosening, rather than rotator cuff failure, is the most common diagnosis for revision [15].

Aseptic Humeral Loosening is a frequent indication for revision. Anatomic total shoulder arthroplasties and reverse shoulder arthroplasties are among the most revised implants for this complication [7]. Reverse shoulder arthroplasties are the most common implant used for revision due to humeral loosening [7]. Female sex and the absence of glenoid loosening are associated with aseptic humeral loosening [6]. Revisions for humeral loosening yield only modest clinical improvements and are associated with a higher likelihood of complications resulting in rerevision [9].

Instability presents as a challenging complication with high failure rates after revision procedures for anatomic total shoulder arthroplasty [22]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary reverse total shoulder arthroplasty [23]. This conversion is also associated with higher complication and revision rates compared to primary reverse total shoulder arthroplasty [23].

Patient Age and Diagnosis significantly influence presentation and outcomes. The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most procedures performed for primary osteoarthritis [19]. In patients under 55 years of age, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have lower short-term revision risks than stemmed anatomic total shoulder arthroplasty [8]. For patients aged >70 years with osteoarthritis, primary TSA is associated with a higher Oxford Shoulder Score than primary RTSA, while both have similar revision rates [35]. Optimum revision rates vary by gender and implant type for the diagnosis of osteoarthritis [10].

Neurologic Disorders are associated with higher reported complication and revision rates after shoulder arthroplasty compared with patients without such conditions [14]. Despite these risks, patients with neurologic disorders demonstrate improvements in pain and function after shoulder arthroplasty [14].

Glenoid Dysplasia is managed with shoulder arthroplasty, which offers improved clinical outcomes and favorable satisfaction [16]. A high prevalence of radiographic signs associated with rotator cuff failure and glenoid wear does not necessarily translate to a high complication rate or inferior outcome in anatomic total shoulder arthroplasty [20].

Antibiotic Administration complications are not infrequent after revision shoulder arthroplasty [21]. These complications are more common in patients whose initial protocol involves IV antibiotics [21].

Investigations

The incidence of shoulder replacement and revision is expected to increase in the following years [2]. Shoulder arthroplasties are generally designed to last 10-15 years [4], yet revisions are being performed at a mean of 3.9 years from the primary procedure [4].

Plain radiography: Radiographical analysis of reverse shoulder arthroplasty shows a high prevalence of signs associated with loosening [69]. However, this high prevalence does not seem to translate to high complication rates or inferior results [69]. In all-polyethylene glenoid components with hybrid fixation, progression of central-peg radiolucency is associated with revision surgery and clinical failure [55]. Worse Penn Shoulder Scores at follow-up are also associated with revision surgery and clinical failure in this context [55].

Other Considerations: The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a periprosthetic joint infection (PJI) [5]. Less than 10% of revision shoulder arthroplasties meet International Cartilage Repair Society (ICM) criteria for definite PJI [5]. Distinct demographic and radiographic factors, including female sex and absence of glenoid loosening, are associated with aseptic humeral loosening [6]. Anatomic total shoulder arthroplasties and reverse shoulder arthroplasties are the most revised implants for humeral loosening [7]. Reverse shoulder arthroplasties are the most common implant used for revision due to humeral loosening [7]. In patients under 55 years of age, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [8]. Optimum shoulder arthroplasty revision rates vary for both gender and implant type for the diagnosis of osteoarthritis (OA) [10]. Loosening, not rotator cuff failure, was the most common diagnosis for revision in cohorts analyzed for the impact of crosslinked polyethylene [15]. A higher critical shoulder angle (CSA) correlates with an increased revision rate following shoulder arthroplasty [32]. The increased revision rate associated with a higher CSA is primarily due to complications such as prosthetic loosening [32]. Second-stage revision to a total reverse procedure can be performed once imaging confirms bone graft and construct stability in the setting of severe glenoid bone loss [67].

Treatment

Non-Operative

The provided evidence does not contain specific data on conservative management options such as physical therapy, NSAIDs, or injections for revision shoulder arthroplasty.

Operative

Indications: Revision shoulder arthroplasty is indicated based on the specific reason for the primary failure, as outcomes are predicted by the indication for the procedure [3]. The majority of revisions are performed in patients unlikely to have periprosthetic joint infection (PJI), with less than 10% meeting International Consensus Meeting (ICM) criteria for definite PJI [5]. Distinct demographic and radiographic factors, including female sex and absence of glenoid loosening, are associated with aseptic humeral loosening [6]. Glenoid to the humeral head cut distance should be studied further as a potential indication for humeral stem revision, as it correlates with the space available for a revision implant [46]. Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic glenoid dysplasia, offering improved clinical outcomes and favorable satisfaction following surgery [16].

Surgical Approach / Technique: Revisions are being performed at a mean 3.9 years from the primary procedure [4]. Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible [11]. Humeral stem fixation with or without cement during primary shoulder arthroplasty demonstrated similar operative time, need for intraoperative humeral osteotomy, and postoperative complication rates in the setting of revision arthroplasty [36]. Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming [59].

Implant Selection: The most revised implants for humeral loosening were anatomic total shoulder arthroplasties and reverse shoulder arthroplasties, with reverse shoulder arthroplasties being the most common implant used for revision [7]. In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [8]. Convertible humeral and glenoid platforms address some challenges in minimizing complexity and complications during revisions from anatomic to reverse total shoulder arthroplasty, but these implants are not always convertible and can introduce additional challenges [18]. Anatomic total shoulder arthroplasty provides pain relief and improved quality of life with a 10-year survival rate of 96% [62].

Pain Management: Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery [60]. Rehabilitation guidelines for reverse total shoulder replacement aim to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery [31]. Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks [29]. Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [30].

Adjuncts: Anti-osteoporotic therapy is significantly associated with reduced rates of 2-year revision following total shoulder arthroplasty in patients with osteoporosis [61].

Setting of Care: Nearly 45% of reverse total shoulder arthroplasty (RTSA) and 42% of anatomic total shoulder arthroplasty (ATSA) patients returned to the hospital within one year, most often for shoulder or non-shoulder complications [58].

Revision: Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [1]. Complications and reoperation rates were higher than those for primary reverse shoulder arthroplasty but outcomes were comparable for revision of failed anatomic shoulder arthroplasty [12]. Revisions for humeral loosening yield modest clinical improvements, but patients are more likely to experience complications resulting in rerevision [9]. Patients undergoing treatment of shoulder PJI with débridement, antibiotics, and implant retention (DAIR) did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures [13]. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after hemiarthroplasty and cement spacer in staged revision with antibiotic spacers for shoulder PJI [54]. Patients with neurologic disorders demonstrate improvements in pain and function after shoulder arthroplasty but have higher reported complication and revision rates when compared with patients without neurologic conditions [14].

Complications

Infection (PJI): Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty [68]. Receiving a corticosteroid injection within three months of shoulder arthroplasty is associated with a significantly increased risk of revision surgery, primarily driven by periprosthetic joint infection [76]. Early aseptic reoperation within 90 days of primary TSA or primary RSA increases the risk of subsequent PJI [66]. Complications associated with antibiotic administration after revision shoulder arthroplasty are more common in patients whose initial protocol is IV antibiotics [21]. Staged revision RTSA for periprosthetic joint infection (PJI) eradication has a significant complication rate, with several patients requiring an additional stage of treatment [75]. When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty provide similar rates of infection eradication [77].

Aseptic loosening: Revision reverse shoulder arthroplasty has an implant survival rate of 85% at ten years [1]. Revisions for humeral loosening yield modest clinical improvements but patients are more likely to experience complications resulting in rerevision [9]. The cement-within-cement technique in revision reverse total shoulder arthroplasty is associated with higher rates of complications and re-revision surgery over time secondary to aseptic glenoid component loosening and instability [47]. A higher critical shoulder angle (CSA) correlates with an increased revision rate following shoulder arthroplasty, primarily due to complications such as prosthetic loosening [32]. Glenospheres <38 mm can be expected to increase revision rates in primary RTSAs [33].

Instability: The cement-within-cement technique in revision reverse total shoulder arthroplasty is associated with higher rates of complications and re-revision surgery over time secondary to aseptic glenoid component loosening and instability [47].

Periprosthetic fracture: Patients undergoing staged bilateral shoulder arthroplasty with the second procedure within 3 months have significantly higher rates of revision surgery, loosening/lysis, periprosthetic fracture, venous thromboembolism (VTE), and blood transfusions [56].

Thromboembolism: Patients undergoing staged bilateral shoulder arthroplasty with the second procedure within 3 months have significantly higher rates of revision surgery, loosening/lysis, periprosthetic fracture, venous thromboembolism (VTE), and blood transfusions [56].

Wound complications: Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty [68].

Other Considerations: Complications and reoperation rates for revision reverse shoulder arthroplasty for baseplate failure are higher than those for primary RSA [12]. The rate of re-revision after revision RTSA is 13% in the first 2 years postoperatively but increases to 35% at 5 years [73]. Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty, with risks more pronounced when surgery is performed within 2 years of bariatric surgery [71]. Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations in primary shoulder arthroplasties [65].

Recovery

Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements [1]. Implant survival for this procedure is 85% at ten years [1]. The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [3]. Revisions for humeral loosening yield modest clinical improvements [9]. Patients undergoing revision for humeral loosening are more likely to experience complications resulting in rerevision [9]. Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcomes [11]. Glenoid component reinsertion should be attempted whenever possible during revision shoulder arthroplasty [11]. Complication and reoperation rates for revision reverse shoulder arthroplasty for baseplate failure are higher than those for primary RSA [12]. Outcomes for revision of failed anatomic shoulder arthroplasty to reverse total shoulder arthroplasty are comparable to primary RSA [12]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA [23]. Revision of failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty is associated with worse PROMs, abduction, elevation, pain relief, and patient satisfaction compared with primary rTSA [23]. Revision of failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty is associated with higher complication and revision rates compared with primary rTSA [23]. Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed [25].

Light activity (weeks): Six distinct early recovery trajectories were identified after total shoulder arthroplasty [29]. 83.7% of patients (the 'Faster group') experienced very low pain scores after only 2 weeks following total shoulder arthroplasty [29].

Full activity (months): Rehabilitation guidelines for reverse total shoulder replacement aim to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery [31]. Reverse total shoulder arthroplasty remains a reliable method to ensure adequate muscle strength and return to play in patients with rotator cuff deficiency [37]. A high return to sport can be expected after total shoulder arthroplasty [51].

Complete recovery / outcome plateau (months): Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [30]. Functional recovery peaks at 12 months postoperatively following shoulder arthroplasty [79]. There is no clinically significant deterioration in functional recovery over the initial ten years following shoulder arthroplasty [79].

Rehabilitation protocol: Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective [41]. Early, active rehabilitation after reverse total shoulder arthroplasty may have early clinical benefits over a conservative, delayed mobilisation programme [41].

Functional milestones: Outcomes for revision of failed anatomic shoulder arthroplasty to reverse total shoulder arthroplasty are comparable to primary RSA [12]. Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA [23]. Revision of failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty is associated with worse PROMs, abduction, elevation, pain relief, and patient satisfaction compared with primary rTSA [23].

Other Considerations: The outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure [3]. Revisions for humeral loosening yield modest clinical improvements [9]. Patients undergoing revision for humeral loosening are more likely to experience complications resulting in rerevision [9]. Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcomes [11]. Glenoid component reinsertion should be attempted whenever possible during revision shoulder arthroplasty [11]. Complication and reoperation rates for revision reverse shoulder arthroplasty for baseplate failure are higher than those for primary RSA [12]. Revision of failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty is associated with higher complication and revision rates compared with primary rTSA [23]. Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed [25].

Key Evidence

  • [L3] Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years. (10.1302/0301-620x.107b11.bjj-2025-0436.r1)
  • [L3] The incidence of shoulder replacement and revision is expected to increase in the following years, constituting a burden for the healthcare systems. (10.1186/s12891-022-05849-x)
  • [L4] Generally, shoulder arthroplasties are designed to last 10-15 years; however, revisions are being performed at a mean 3.9 years from the primary procedure. (10.1016/j.jse.2019.12.015)
  • [L3] The majority of revision shoulder arthroplasties are performed for patients who are unlikely to have a PJI, with less than 10% meeting ICM criteria for definite PJI. (10.1016/j.jse.2025.01.040)
  • [L4] Distinct demographic and radiographic factors, including female sex and absence of glenoid loosening, are associated with aseptic humeral loosening. (10.1016/j.jse.2024.03.004)
  • [L4] The most revised implants for humeral loosening were anatomic total shoulder arthroplasties and reverse shoulder arthroplasties, with reverse shoulder arthroplasties being the most common implant used for revision. (10.1016/j.jse.2024.08.053)
  • [L3] In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty. (10.1016/j.jse.2024.07.032)
  • [L4] Revisions for humeral loosening yield modest clinical improvements, but patients are more likely to experience complications resulting in rerevision. (10.1016/j.jse.2023.02.006)
  • [L3] The optimum shoulder arthroplasty revision rates vary for both the gender and implant type for the diagnosis of OA. (10.1016/j.jse.2024.08.033)
  • [L4] Revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible. (10.1007/s11999-007-0108-0)
  • [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. (10.1016/j.jse.2023.06.039)
  • [L3] Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. (10.1016/j.jse.2023.06.012)
  • [L4] Patients with neurologic disorders demonstrate improvements in pain and function after shoulder arthroplasty but have higher reported complication and revision rates when compared with patients without neurologic conditions. (10.1016/j.jse.2024.05.023)
  • [L3] In all these cohorts, loosening, not rotator cuff failure, was the most common diagnosis for revision. (10.1016/j.jse.2022.04.015)
  • [L4] Shoulder arthroplasty represents a safe and reliable option for the management of symptomatic GD, offering improved clinical outcomes and favorable satisfaction following surgery. (10.1016/j.xrrt.2025.03.001)
  • [Paper] The decision to revise a total shoulder arthroplasty requires a rigorous assessment to answer five key questions regarding infection, instability, wear, loosening, and rotator cuff status. (10.1016/j.otsr.2012.11.010)
  • [L5] Convertible humeral and glenoid platforms address some challenges in minimizing complexity and complications during revisions from anatomic to reverse total shoulder arthroplasty, but these implants are not always convertible and can introduce additional challenges. (10.5435/jaaos-d-23-01134)
  • [L4] The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most cases performed for primary osteoarthritis. (10.1016/j.jse.2023.01.040)
  • [L4] Although a high prevalence of radiographic signs associated with rotator cuff failure and glenoid wear were reported, this did not translate to a high complication rate or inferior outcome. (10.1016/j.jse.2025.03.036)
  • [L4] Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. (10.2106/jbjs.19.00846)
  • [L5] Instability is a challenging complication with high failure rates after revision procedures, prompting a movement toward reverse shoulder arthroplasty, though this may not be ideal for all patients. (10.5435/jaaos-d-23-01072)
  • [L3] Patients undergoing revision of a failed anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty have worse clinical outcomes compared with those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief, and patient satisfaction, with higher complication and revision rates. (10.1016/j.jse.2024.09.019)
  • [L3] We advocate that metal-backed glenoid components should be used with caution and not on a routine basis. (10.1016/j.jse.2024.03.022)
  • [L3] Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed. (10.1016/j.jse.2021.03.094)
  • [L1] Overall, the optimal management of symptomatic glenoid loosening remains unclear. (10.1016/j.jse.2022.10.006)
  • [L4] Component loosening is a common failure mode after anatomic total shoulder arthroplasty. (10.1016/j.jse.2022.10.004)
  • [L2] Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks. (10.1016/j.jse.2025.06.016)
  • [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. (10.1016/j.jse.2018.05.029)
  • [L5] The review outlines rehabilitation guidelines developed to manage patients who have undergone reverse total shoulder replacement, aiming to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery. (10.1111/j.1758-5740.2011.00138.x)
  • [L4] A higher CSA correlates with an increased revision rate following shoulder arthroplasty, primarily due to complications such as prosthetic loosening. (10.1186/s13018-025-06655-6)
  • [L3] Glenospheres <38 mm can be expected to increase revision rates in primary RTSAs. (10.1016/j.jse.2021.11.013)
  • [L3] Shoulders with good elevation showed significantly higher scapulohumeral rhythm than those with poor elevation, while no other statistically significant kinematic differences were found between the groups. (10.1016/j.jseint.2021.02.002)
  • [L3] For patients aged >70 years with osteoarthritis as their primary diagnosis, a primary TSA is associated with a higher Oxford Shoulder Score than a primary RTSA, with similar revision rates. (10.1016/j.jse.2021.09.006)
  • [L3] Humeral stem fixation with or without cement during primary shoulder arthroplasty demonstrated similar operative time, need for intraoperative humeral osteotomy, and postoperative complication rates in the setting of revision arthroplasty. (10.1016/j.jse.2017.11.010)
  • [L5] Reverse total shoulder arthroplasty remains a reliable method to ensure adequate muscle strength and return to play in this patient group. (10.1016/j.arthro.2024.03.013)
  • [L3] Significant differences in the skin Cutibacterium subtype distributions were found between shoulders undergoing revision shoulder arthroplasty and those undergoing primary shoulder arthroplasty. (10.1016/j.jse.2020.02.007)
  • [L4] Lateralization addresses initial drawbacks of the Grammont design by improving stability, notching rates, range of motion, and shoulder contour, though the ideal extent of lateralization and maximal acceptable joint reaction force remain unclear. (10.3390/jcm10225380)
  • [L1] Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. (10.1177/1758573220937394)
  • [L4] However, IRp was associated with a limited range compared with the other shoulder motions; therefore, all ADLs associated with internal rotation demonstrated lower recovery rates than expected. (10.1016/j.jse.2019.05.031)
  • [L5] Posture types and scapulothoracic orientation play an important role in optimal implant configuration, positioning, and clinical outcomes, and should be considered during patient selection, preoperative planning, and implantation of a reverse total shoulder arthroplasty. (10.1530/eor-2024-0040)
  • [L3] Glenoid to the humeral head cut distance should be studied further as a potential indication for humeral stem revision, as it correlates with the space available for a revision implant. (10.1016/j.jse.2023.01.030)
  • [L4] Although a low rate of humeral component loosening was observed, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability. (10.1016/j.xrrt.2024.08.006)
  • [L3] Clinical outcomes were excellent, with minimal differences based on final humeral positioning. (10.1016/j.jseint.2025.04.017)
  • [L1] A high return to sport can be expected after total shoulder arthroplasty. (10.1016/j.jseint.2025.05.028)
  • [L1] Glenoid lateralization was consistently associated with increased acromial and scapular spine strain, whereas inferiorization of the glenosphere reduced strain. (10.3390/jcm11020361)
  • [L3] Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after hemiarthroplasty and cement spacer. (10.1007/s11999.0000000000000049)
  • [L3] Progression of central-peg radiolucency and worse Penn Shoulder Scores at follow-up are associated with revision surgery and clinical failure. (10.1016/j.jse.2020.07.039)
  • [L3] Patients with staged bilateral shoulder arthroplasty who have the second arthroplasty within 3 months have significantly higher rates of revision surgery, loosening/lysis, periprosthetic fracture, VTE, and blood transfusions. (10.1016/j.jse.2020.06.010)
  • [L4] Nearly 45% of RTSA and 42% of ATSA patients returned to the hospital within one year, most often for shoulder or non-shoulder complications. (10.1016/j.jse.2024.05.009)
  • [L4] Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming. (10.1016/j.jseint.2022.02.011)
  • [L3] Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. (10.1016/j.jse.2024.04.016)
  • [L3] This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following total shoulder arthroplasty. (10.1016/j.jse.2024.09.020)
  • [L4] Anatomic total shoulder arthroplasty provides pain relief and improved quality of life with a 10-year survival rate of 96%. (10.5435/jaaos-d-21-00302)
  • [L3] Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations in primary shoulder arthroplasties. (10.1016/j.xrrt.2024.12.012)
  • [L3] Aseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI. (10.1016/j.jseint.2021.06.002)
  • [L4] Additionally, second-stage revision to a total reverse procedure can be performed once imaging confirms bone graft and construct stability. (10.1016/j.jse.2022.02.018)
  • [L3] Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls. (10.1016/j.jse.2019.11.029)
  • [L4] Interestingly, the radiographical analysis showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results. (10.1016/j.jse.2023.09.015)
  • [L3] These risks were more pronounced when shoulder arthroplasty was performed within 2 years of bariatric surgery. (10.1016/j.jse.2023.02.120)
  • [L4] The rate of re-revision after revision RTSA is low in the first 2 years postoperatively (13%) but increases to 35% at 5 years. (10.1016/j.jse.2022.11.024)
  • [L4] Staged revision RTSA proved successful in the ultimate eradication of the PJI, although there were several patients who required an additional stage of treatment and a significant complication rate. (10.1016/j.jse.2022.09.006)
  • [L3] Receiving a corticosteroid injection within three months of shoulder arthroplasty is associated with a significantly increased risk of revision surgery, primarily driven by periprosthetic joint infection. (10.1302/0301-620x.104b5.bjj-2021-0024.r3)
  • [L1] When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. (10.1016/j.jse.2021.10.016)
  • [L4] The registry demonstrates that functional recovery peaks at 12 months postoperatively with no clinically significant deterioration over the initial ten years. (10.1186/s12891-024-08117-2)

See Also

References

[1] Long-term results and implant survival of revision reverse shoulder arthroplasty after a mean follow-up of ten years. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b11.bjj-2025-0436.r1

[2] Shoulder replacement: an epidemiological nationwide study from 2009 to 2019. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05849-x

[3] Retrospective, single-centre analysis comparing clinical outcomes of reverse total shoulder replacement for fracture, degenerative changes and revision procedure. 2025.

[4] Revision shoulder arthroplasty: a systematic review and comparison of North American vs. European outcomes and complications. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.015

[5] Assessment of periprosthetic joint infection in revision shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.040

[6] Humeral stem loosening is not always prosthetic joint infection. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.004

[7] Revision for humeral stem loosening: a systematic review. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.08.053

[8] Stemless anatomic and reverse shoulder arthroplasty in patients under 55 years of age with primary glenohumeral osteoarthritis: an analysis of the Australian Orthopedic Association National Joint Replacement Registry at 5 years. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.032

[9] Humeral loosening in reverse shoulder arthroplasty: an analysis of 2,342 cases. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.006

[10] Comparing optimum prosthesis combinations of total stemmed, stemless and reverse shoulder arthroplasty revision rates for men and women with glenohumeral osteoarthritis. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.08.033

[11] Glenoid Reconstruction in Revision Shoulder Arthroplasty. Clinical Orthopaedics & Related Research. 2008. DOI: 10.1007/s11999-007-0108-0

[12] Revision reverse shoulder arthroplasty for the management of baseplate failure: an analysis of 676 revision reverse shoulder arthroplasty procedures. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.039

[13] Outcomes after débridement, antibiotics, and implant retention for prosthetic joint infection in shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.012

[14] The impact of neurologic disorders on clinical and functional outcomes after shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.05.023

[15] Total shoulder replacement stems in osteoarthritis—short, long, or reverse? An analysis of the impact of crosslinked polyethylene. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.04.015

[16] Shoulder arthroplasty for the management of glenoid dysplasia: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.03.001

[17] Revision of total shoulder arthroplasty. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2012.11.010

[18] Convertible Humeral and Glenoid Components for Anatomic Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-23-01134

[19] Incidence of primary anatomic and reverse total shoulder arthroplasty in patients less than 50 years of age and high early revision risk. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.040

[20] Long-term functional and radiographic outcomes of anatomic total shoulder arthroplasty using an all-polyethylene cemented glenoid component with a minimum follow-up of 10 years. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.03.036

[21] The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision Shoulder Arthroplasty. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.00846

[22] Instability and the Anatomic Total Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01072

[23] Anatomic total shoulder arthroplasty revised to reverse total shoulder arthroplasty: clinical and radiographic outcomes compared to primary reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.019

[24] Comparable low revision rates of stemmed and stemless total anatomic shoulder arthroplasties after exclusion of metal-backed glenoid components: a collaboration between the Australian and Danish national shoulder arthroplasty registries. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.022

[25] Reverse Shoulder Arthroplasty for Rotator Cuff Tears with and Without Prior Failed Repair: A Comparative Analysis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.094

[26] What is the optimal management of a loose glenoid component after anatomic total shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.10.006

[27] Revision of total shoulder arthroplasty to hemiarthroplasty: results at mean 5-year follow-up. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.10.004

[29] Trajectories of pain recovery during the first 8 weeks after shoulder arthroplasty: results from the shoulder diary study using latent growth curve modeling. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.06.016

[30] Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.029

[31] Rehabilitation following Reverse Total Shoulder Replacement. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2011.00138.x

[32] Impact of the critical shoulder angle on shoulder arthroplasty outcomes: a systematic review. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06655-6

[33] Effect of glenosphere size on reverse shoulder arthroplasty revision rate: an analysis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.11.013

[34] Three-dimensional kinematics of reverse shoulder arthroplasty: a comparison between shoulders with good or poor elevation. JSES International. 2021. DOI: 10.1016/j.jseint.2021.02.002

[35] The outcomes of shoulder arthroplasty in those aged ≥70 years with glenohumeral arthritis: a New Zealand Joint Registry study. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.09.006

[36] Effects of cemented versus press-fit primary humeral stem fixation in the setting of revision shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.11.010

[37] Editorial Commentary : Even With a High Retear Rate, Shoulder Capsular Reconstruction Outcomes are Promising, But Are We Seeing an Increase in Strength?. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.03.013

[39] Cutibacterium subtype distribution on the skin of primary and revision shoulder arthroplasty patients. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.02.007

[40] Lateralization in Reverse Shoulder Arthroplasty. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10225380

[41] A randomised trial comparing two rehabilitation approaches following reverse total shoulder arthroplasty. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220937394

[43] Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.031

[45] The scapulothoracic conundrum in reverse shoulder arthroplasty: where do we stand and what is yet to expand?. EFORT Open Reviews. 2025. DOI: 10.1530/eor-2024-0040

[46] Factors associated with humeral stem revision in anatomic to reverse total shoulder arthroplasty revision. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.030

[47] Cement-within-cement technique in revision reverse total shoulder arthroplasty: complications, reoperations, and revision rates at 5-year mean follow-up. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2024.08.006

[48] Variability in ultimate humeral height of an inlay humeral stem does not impact outcomes following reverse shoulder arthroplasty. JSES International. 2025. DOI: 10.1016/j.jseint.2025.04.017

[51] Why do patients not return to sports or work after anatomical or reverse total shoulder arthroplasty? A systematic review and meta-analysis. JSES International. 2025. DOI: 10.1016/j.jseint.2025.05.028

[53] Factors Influencing Acromial and Scapular Spine Strain after Reverse Total Shoulder Arthroplasty: A Systematic Review of Biomechanical Studies. Journal of Clinical Medicine. 2022. DOI: 10.3390/jcm11020361

[54] Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1007/s11999.0000000000000049

[55] Central-peg radiolucency progression of an all-polyethylene glenoid with hybrid fixation in anatomic total shoulder arthroplasty is associated with clinical failure and reoperation. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.039

[56] The relationship of bilateral shoulder arthroplasty timing and postoperative complications. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.010

[58] Postoperative revision, complication and economic outcomes of patients with reverse or anatomic total shoulder arthroplasty at one year: a retrospective, United States hospital billing database analysis. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.009

[59] Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming. JSES International. 2022. DOI: 10.1016/j.jseint.2022.02.011

[60] Effects of socioeconomic burden on opioid use following total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.04.016

[61] Anti-osteoporotic treatment reduces risk of revision following total shoulder arthroplasty in patients with osteoporosis. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.020

[62] Survivorship of Anatomic Total Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00302

[65] Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations: a matched cohort analysis of primary shoulder arthroplasties. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2024.12.012

[66] Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection. JSES International. 2021. DOI: 10.1016/j.jseint.2021.06.002

[67] Hemi-reverse revision arthroplasty in the setting of severe glenoid bone loss. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.02.018

[68] Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.029

[69] Functional and radiographic outcomes of reverse shoulder arthroplasty with a minimum follow-up of 10 years. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.09.015

[71] Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.120

[73] Survivorship analysis of revision reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.11.024

[75] Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.006

[76] Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b5.bjj-2021-0024.r3

[77] Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.10.016

[79] Optimizing post-surgical outcomes: unveiling the importance of patient-reported outcomes with insights from the schulthess local shoulder arthroplasty registry. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08117-2

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.