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Return to Sport After Total Shoulder Arthroplasty and Hemiarthroplasty: A
Systematic Review
Article in Sports Medicine and Arthroscopy Review · December 2022
DOI: 10.1097/JSA.0000000000000306
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REVIEW ARTICLE
Return to Sport After Total Shoulder Arthroplasty
and Hemiarthroplasty: A Systematic Review
Edoardo Franceschetti, MD,* Pietro Gregori, MD,*
Edoardo Giovannetti de Sanctis, MD,† Alessio Palumbo, MD,*
Michele Paciotti, MD,* Nicola Maffulli, MD, MS, PhD, FRCP, FRCS,‡§∥
and Francesco Franceschi, MD¶
Purpose: One of the most frequent concerns of the increasing
number of patients undergoing shoulder arthroplasty is the possibility to resume sport after surgery. This systematic review determined the rate of return to sport after total shoulder arthroplasty
(TSA) and hemiarthroplasty (HA).
Materials and Methods: The PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review. A systematic electronic
search was performed using the PubMed (MEDLINE), EMBASE,
and Cochrane Library databases. All the studies analyzing the rates
of reverse shoulder arthroplasties were pooled; data were extracted
and statistically analyzed. Only studies with at least 10 adult
patients recruited were considered. All studies had to relate return to
sport after TSA or HA.
Results: A total of 76 studies were included for a total of 694 patients.
The mean age and average follow-up were, respectively, 64.5 years
(range: 24 to 92 y) and 4.5 years (range: 0.5 to 12 y). The mean rate of
return to sport ranged from 49.3% to 96.4%. The mean time to resume
sports was 8.1 months. The overall rate of return to sport after the
procedures, according to a random effect model, was 83%. The mean
level of sports at the time of the survey was worsened in 9.4%
( ± 2.82%), improved or reported from good to excellent in 55.6%
( ± 13.6%), and did not change in 40% ( ± 1.4) of patients.
function. Over the last decade, indications for this type of
surgery have been expanded, resulting in a marked increase
of procedures performed every year.1 Even though pain and
limited function of the shoulder remain the main reasons
why patient decide to undergo these procedures, the
expanded indications have led to a larger population of
young and active patients who place an increasing interest
on the ability to resume activities that were difficult or not
possible before replacement surgery.2,3 The abilities to
resume sport after total hip or knee replacement4,5 are well
documented. On the contrary, studies focusing on returning
to sport after TSA and HA are limited and do not seem to
clarify doubts of patients desiring a reliable prediction on
the probability of resuming their activities after surgery.
Also, the perspective could be extremely divergent given the
different physical activities undertaken in the United States
and Europe.6 This systematic review determined the rate of
return to sport after TSA and HA, providing surgeons
reliable information to make patients aware about the
probability of resuming sport following the procedures.
MATERIALS AND METHODS
Conclusions: On the basis of current available data, return to sports
after TSA and HA is possible and is highly frequent. The subjective
level of practice does not change or improve in most patients. More
studies and better designed trials are needed to enrich the evidence
on specific sport recovery after the procedure.
The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines have been utilized to carry out this systematic review.7 The PRISMA
statement is composed of a 27-item checklist relating to
review contents and a 4-phase flow chart of the study selection
process.
Key Words: shoulder, total shoulder arthroplasty, arthroplasty,
hemiarthroplasty
Eligibility Criteria
(Sports Med Arthrosc Rev 2021;00:000–000)
T
otal shoulder arthroplasty (TSA) and hemiarthroplasty
(HA) are well-established treatments for patients with
glenohumeral osteoarthritis with residual rotator cuff
From the *Department of Orthopaedic and Trauma Surgery, Campus
Bio-Medico University; †Department of Orthopaedics and Traumatology, Agostino Gemelli Hospital, Catholic University; ¶Department
of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli
Hospital, Rome; ‡Department of Musculoskeletal Disorders, Salerno,
Italy; §Centre for Sports and Exercise Medicine, Barts and The London
School of Medicine and Dentistry, Mile End Hospital, London; and
∥School of Pharmacy and Bioengineering, Keele University School of
Medicine, Stoke on Trent, England.
Disclosure: The authors declare no conflict of interest.
Reprints: Nicola Maffulli, MD, MS, PhD, FRCP, FRCS (Orth),
Department of Musculoskeletal Disorders, Via Salvador Allende,
43, Baronissi SA, Salerno 84081, Italy.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev Volume 00, Number 00, ’’ 2021
Studies published in English, Italian, French, Spanish,
and German were eligible for inclusion. Only peer-reviewed
journals were considered, and randomized controlled trials,
prospective and retrospective comparative studies and case
series (CS) were included. Exclusion criteria were reviews of
the literature, expert opinions, and studies that did not
evaluate return to play. The eligibility criteria were studies
with at least 10 adult participants recruited. All studies had
to relate to return to sport after TSA and HA.
Information Sources and Search
An electronic systematic search of CINAHL,
EMBASE, PubMed, and the Cochrane Central Registry of
Controlled Trials was carried out by 2 reviewers (P.G. and
E.F.), to identify eligible studies. Interrater reliability for
study eligibility was measured using the κ statistic. A κ of 0
to 0.2 represents slight agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60 moderate agreement, and 0.61 to 0.80
substantial agreement. A value > 0.80 is considered almost
perfect agreement, according to the guidelines of Landis and
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Sports Med Arthrosc Rev Volume 00, Number 00, ’’ 2021
Franceschetti et al
TABLE 1. Study Details
References
Level of Evidence
Study Type
Year of Publication
Follow-up [Mean (Range)]
MINORS
IV
IV
IV
IV
IV
IV
IV
III
IV
IV
IV
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
1998
1998
2008
2010
2014
2015
2015
2016
2017
2017
2018
4.5 (2-10.6)
4.2 (0.5-8.2)
3.7 (2-9.4)
2.8 (1.3-4.6)
6.2 (2.5-12.6)
5.1 (2-7.5)
3.2 (1.0-7)
5.2 (2-7.5)
5.5 (2.5-12)
5 (2-8.6)
3.7 (2-10)
6/16
6/16
15/24
10/16
9/16
11/16
9/16
17/24
10/16
12/16
11/16
Jensen and Rockwood8
Skutek et al9
McCarty et al10
Schumann et al11
Buhloff et al12
Garcia et al13
Papaliodis et al14
Garcia et al15
Bulhoff et al16
Garcia et al17
Mannava et al18
CS indicates case series; MINORS, Methodological Index for Nonrandomized Studies.
Koch. The search was executed on September 28, 2020. The
search strings used were: ((Return to sports [MeSH Terms])
AND TSA [MeSH Terms] AND HA [MeSH Terms]);
(((TSA [MeSH Terms]) AND Sports [MeSH Terms]) AND
surgery) AND outcomes.
Study Selection
Once the duplicates had been removed, relevant articles
from the electronic search were retrieved in full text and
evaluated. A manual search of the bibliography of each published study was performed, to find relevant articles that could
potentially have been missed. Reviews, systematic reviews, and
meta-analyses were also retrieved and read, to broaden the
search to include studies that might have been missed. The
remaining articles were analyzed by 2 reviewers (P.G. and
E.F.), to exclude studies not fulfilling the eligibility criteria.
The reviewers were not blinded to the authors, year, and
journal of publication. Studies eligible for inclusion were
categorized by study type, according to the Oxford Centre for
Evidence-Based Medicine (www.cebm.net). The following
categories were utilized: case report, randomized controlled
trial, and CS. Case reports (reporting data of 10 or fewer
patients) were excluded because of low significance.
Data Collection Process
Two assessors independently extracted data from the
eligible studies using a predefined data extraction. For each
study, we extracted data concerning the epidemiological
characteristics of participants (age, sport, level) and assessment of results (return to sport, mean follow-up, type of
sport, time to return to sport, level after surgery). Data were
analyzed using the R software (2020; R Core Team). The
primary end point was the rate of resuming sport after
shoulder replacement surgery. The I2 index was used to
measure the heterogeneity of results within the included
studies. Substantial heterogeneity was defined as I2 > 75%.
The mean rate for resuming sport was calculated with a 95%
confidence interval. Results were displayed using a forest
plot (Fig. 3).
Quality of the Studies
The quality of included studies was evaluated using the
MINORS (Methodological Index for Nonrandomized Studies) score. The following domains were assessed: a clearly
stated aim, inclusion of consecutive patients, prospective data
collection, end points appropriate to the aim of the study,
unbiased assessment of study end points, follow-up period
appropriate to the aim of the study, loss to follow-up of <5%,
prospective calculation of the study size, adequate control
group, contemporary group, baseline group equivalence, and
adequate statistical analysis (Table 1). Two authors (P.G. and
E.F.) performed this evaluation, which included a discussion
to reach a consensus in case of disagreement. We also analyzed the quality of the studies over the years through a
graphic representation (Fig. 2).
RESULTS
A total of 76 studies were identified in the electronic
search; of these, 11 were eligible for inclusion in this systematic review. No further studies were identified as relevant
through the manual search. All the individuated studies
were retrospective CS (interrater agreement κ value = 0.79).
The study selection process is shown in Figure 1. Study
details are summarized in Table 1. The main indication for
the procedures was primary shoulder osteoarthritis. Other
indications included proximal humerus fracture, rheumatoid
arthritis, avascular necrosis, posttraumatic arthritis, postinstability arthritis, and rotator cuff arthropathy. The most
common reported sports were golf (9 studies), swimming (8
studies), and tennis (8 studies). None of these studies
included professional athletes. A total of 694 patients were
included in the 11 studies. The mean age, which was calculated in only 8 of the selected studies, was 64.5 years
(range: 24 to 92 y), with an average follow-up of 4.5 years
(range: 0.5 to 12 y) (Table 2).
Methodological Quality
The average value was 9.3 on the MINORS scale,
although 2 comparative studies were evaluated on a
24-point scale and not on a 16-point scale. These studies had
a MINORS score of 16 and 17. Also, there was progressive
improvement in the quality of studies from 1998 to 2018
(Fig. 2).
Return to Sport
The mean rate of return to sport ranged from 49.3% to
96.4%. The mean time for resuming sports was 8.1 months.
All the included studies concluded that a return to sport
after TSA and HA is possible. The overall rate of return to
sport after the procedures, according to the random effect
model, was 83% (95% confidence interval: 71%-91%). I2
index was 91% (Fig. 3).
In the studies reporting this parameter, the mean level
of sports at the time of the survey worsened in 9.4%
( ± 2.82%), improved or reported from good to excellent in
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Sports Med Arthrosc Rev Volume 00, Number 00, ’’ 2021
Return to Sport After TSA and HA
FIGURE 1. Prisma flowchart of the study selection process.
55.6% ( ± 13.6%), and did not change in 40% ( ± 1.4) of the
patients. Two studies15,18 did not distinguish 2 variables
(“no change” and “improved”), thus they have been
excluded from this calculation.
Functional Outcome and Patient Satisfaction
The rate of patient satisfaction with surgery was
reported in 4 studies13,15,17,18 with a mean of 90.4%
( ± 11.3%). None of the studies reported sport-specific satisfaction. The Visual Analog Scale, or other investigations
evaluating pain after surgery, were reported in 5
studies11,13,15,17,18 showing statistically significant improvement in all reported cases. The American shoulder and elbow
surgeons score was reported in 4 studies13,15,17,18 with a mean
of 82.9% ( ± 7.9%).
DISCUSSION
TSA and HA have been more extensively performed in
recent years for a variety of reasons, most commonly to
reduce pain in patients with advanced osteoarthritis and
proximal fractures. Patients undergoing total joint arthroplasty increasingly wish to continue to participate in sports
and recreational activities following surgery. Over time, in
addition to reducing pain, the procedure aims to restore
shoulder function and increase patient’s quality of life,
including not only daily living but also sporting activities.
Commonly, during preoperative and postoperative consultations, surgeons are asked by patients whether they will
be allowed to participate in the activities they enjoyed before
the onset of shoulder pathology and/or surgery. There is a
lack of consensus concerning the recommendations to give
patients about resuming sport activities after TSA and HA.
This systematic review aimed to evaluate the rate of return
to sport after these procedures. The overall return rate to
sport averaged > 83%, which suggests that resuming sports
after surgery is realistic and frequent. The activity level was
investigated through a questionnaire. Most of the studies did
not collect all 3 variables “worsened,” “improved,” or “no
change.” The ones reporting a worsening of the subjective
sports performance had a mean of 9.4%, while the ones
analyzing an improvement or full recovery of the same
sports level before the onset of osteoarthritis reported a total
mean of 95.6%. Even though the quality of the published
evidence is low, return to sport is a realistic aim. Our results
are in accordance with Liu et al19 who conducted a systematic review and meta-analysis evaluating return to sport
after shoulder replacement. The overall return to sport in
the TSA group was 92.6% and averaged 71.1% in the HA
group. Aim et al,20 in 2017, showed that patients undergoing
TSA and HA were still able to return to sport with a slightly
higher rate of the ones undergoing reverse shoulder
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Sports Played
Rate of Return
to Sport (%)
Level of Sport
After Surgery
Time to Return
to Sport After
Surgery (mo)
Golf
95.8
NR
4.5
8.3
81
Good to
excellent: 61.5%
Improved: 71%
Types of Shoulder
Arthroplasty (N)
Age [Mean (Range)]
(y)
Jensen and
Rockwood8
Skutek et al9
24
TSA: 20
HA: 6
HA: 13
53.4 (26.4-78.7)
62 (47-82)
Swimming, cycling, dancing, shooting
McCarty et al10
75
TSA: 61
HA: 25
65.5 (24-88)
Schumann et al11
100
TSA: 155
68.9 (26-92)
Buhloff et al12
105
TSA: 105
NR
Garcia et al13
79
69 (27.6-97.1)
Papaliodis et al14
35
All HA, N:
nonreported
TSA: 36
Swimming, skiing, softball, tennis, fishing, golf,
weight lifting, bowling, hiking, basketball,
hunting, dancing, equestrian, Racquetball,
Kayaking, sailing, squash, aerobics, snorkeling,
darts, baseball, wrestling, sculpting, cycling,
handball
Swimming, cycling, alpine skiing, fitness,
Windsurfing, volleyball, tennis, table tennis,
squash, soccer, snowboarding, sailing, Nordic
walking, Nordic skiing, jogging, inline skating,
ice hockey, horse riding, hiking, gymnastic, golf,
classic ballet, bowling, biking, aquafit
Swimming, skiing coma bowling, tennis, handball,
athletics, volleyball, golf
Swimming, skiing, tennis
67.2 (57.2-80.4)
Garcia et al15
80
TSA: 40
HA: 40
66 (42-88)
Buhloff et al16
29
All HA, N:
nonreported
NR
Garcia et al17
59
TSA: 61
NR
Mannava et al18
95
TSA: 112
64 (18-82)
References
13
HA indicates hemiarthroplasty; NR, not reported; TSA, total shoulder arthroplasty.
3.6
89
No change:
40.8%
5
57.1
Worsened: 9%
24
49.3
Improved: 50.8%
6.5
Golf
88
8.8
Baseball, basketball, nature sports, golf, fitness
sports, swimming, running, cycling, double
tennis, softball, single tennis
Swimming, tennis, skiing, bowling, athletics,
volleyball, handball, golf, other sports not
specified
Fitness, running, golf, basketball, single tennis,
swimming, cycling, double tennis, football,
skiing, softball, lacrosse, volleyball, yoga,
wrestling, baseball, martial arts, racquetball,
hockey, paddle tennis, dancing, cross country,
gymnastic
Skiing, snowboarding, hockey, golf, biking, tennis,
fitness, swimming, hunting, horseback riding,
fishing, hiking, running
81.4
Improved: 48%
Worsened: 13%
No change: 39%
No change or
improved: 76%
5.5
67
NR
NR
96.4
Improved: 47.3%
6.7
93.7
No change or
improved: 69.7%
Worsened: 6.3%
NR
Sports Med Arthrosc Rev Volume 00, Number 00, ’’ 2021
Patients
(N)
Franceschetti et al
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TABLE 2. Main Outcome Rates
Sports Med Arthrosc Rev Volume 00, Number 00, ’’ 2021
Return to Sport After TSA and HA
FIGURE 2. Diagram representing the quality of the study in relation to the year of publication. A positive trend, with increasing quality
along ages, is shown. MINORS indicates Methodological Index for Nonrandomized Studies.
arthroplasty, a likely consequence of the presence in this
group of elderly patients, eccentric shoulder arthritis
involving rotator cuff tears, and worse shoulder function
with altered natural biomechanics after surgery. Furthermore, the reported scores in all the included studies
increased after surgery, which further underlines the benefits
of shoulder arthroplasty. A subgroup analysis on the return
rate for specific sports could not be conducted given the
limited data in the literature. Also, considering the limited
number of investigations studying separately the rates of
return to sports for the 2 procedures, a separate analysis
would not have been reliable. Nevertheless, Garcia et al,15
comparing HA and TSA, demonstrated that TSA led to
higher rates of return to sports. The analysis of the quality of
the studies revealed an increased quality over the years. Our
study had several limitations. The most relevant limitation is
the low evidence level of the included studies as most are
level IV studies and the low number of studies available on
this topic. Moreover, indications for arthroplasty were heterogeneous as were the sports assessed. Finally, lack of a
subgroup analysis for the specific sport could produce a high
risk of bias.
CONCLUSIONS
In the vast majority of cases, sport can be resumed with
return to the predisease status or an improvement. Further
research and well-designed studies should be carried out to
FIGURE 3. Forest plot on the overall return to sport. CI indicates
confidence interval.
better define specific sports recovery level and mean time. In
addition, it would be interesting to evaluate whether return
to sport after TSA and HA may influence the degree of
radiographic wear or increase the rate of loosening.
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