Revision rates following total shoulder arthroplasty in rural and urban hospitals : an Australian Orthopaedic Association National Joint Replacement Registry analysis of high-volume surgeons

Zac Dragan; Ryan J Campbell; Madeleine Tropman; Peiyao Du; David R J Gill; Cameron Handford; Benjamin Cass; Allan Young

doi:10.1302/2633-1462.73.BJO-2025-0299.R1

Revision rates following total shoulder arthroplasty in rural and urban hospitals : an Australian Orthopaedic Association National Joint Replacement Registry analysis of high-volume surgeons

Bone Jt Open. 2026 Mar 25;7(3):425-432. doi: 10.1302/2633-1462.73.BJO-2025-0299.R1.

Authors

Zac Dragan^{1

2}, Ryan J Campbell^{3

4}, Madeleine Tropman⁴, Peiyao Du⁵, David R J Gill⁶, Cameron Handford^{4

7

8}, Benjamin Cass^{3

4

7

8}, Allan Young^{4

7

8}

Affiliations

¹ The University of Newcastle, School of Medicine and Public Health, Callaghan, Australia.
² Department of Orthopaedic Surgery, John Hunter Hospital, New Lambton Heights, Australia.
³ Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia.
⁴ Department of Orthopaedic Surgery, Dubbo Base Hospital, Dubbo, Australia.
⁵ South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.
⁶ Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, Australia.
⁷ Department of Orthopaedic Surgery, St George Hospital, Kogarah, Australia.
⁸ Sydney Shoulder Research Institute, St Leonards, Australia.

PMID: 41878862
PMCID: PMC13014324
DOI: 10.1302/2633-1462.73.BJO-2025-0299.R1

Abstract

Aims: Total shoulder arthroplasty (TSA) outcomes may be affected in rural settings where resources can differ from urban hospitals.

Methods: This study compared revision rates of primary TSA performed in rural and urban hospitals analyzed from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 January 2008 and 31 December 2023. Rural and urban hospital location was defined by nationally accepted criteria. We included high-volume surgeons (upper two quartiles and undertook TSA in both settings) stratified for anatomical or reverse shoulder arthroplasty, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for age and sex.

Results: A total of 16,179 TSA procedures were performed; 3,456 (21%) in rural and 12,723 (79%) in urban hospitals. CPR at five years was 4.1% (95% CI 3.4 to 4.9) for rural TSA and 5.5% (95% CI 5.0 to 6.0) for urban hospitals. Rural hospitals had lower overall revision rates compared with urban hospitals (entire period, HR 0.81 (95% CI 0.66 to 0.99); p = 0.037). There was a higher rate of revision for primary anatomical TSA in rural centres for the first six months, followed by lower rates of revision (rural vs urban 0.6 months, HR 2.04, p = 0.011; six months to 1.5 years, HR 0.52, p 0.008; 1.5 years +, HR 0.36, p < 0.001). The revision rate for primary reverse TSA did not differ between rural and urban hospitals (entire period, HR 0.87, p = 0.233). Patients aged < 65 years had a lower revision risk in a rural hospital, but there was no difference in patients aged > 65 years. Sex did not change TSA revision rates in rural and urban hospitals.

Conclusion: Revision rates for TSA procedures performed in rural hospitals were equivalent to urban hospitals. Our study supports the provision of TSA services in rural hospitals when undertaken by high-volume surgeons.