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.
Cite this article: Bone Jt Open 2026;7(3):425–432.
Keywords: Registries, Shoulder, Arthroplasty, Revision, Replacement, Shoulder Joint, Reoperation, Rural Health Services, Epidemiology, Database, Australia, total shoulder arthroplasty, Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), higher-volume surgeons, shoulder arthroplasty procedures, Cox proportional hazard models, reverse shoulder arthroplasty, glenoid, Anesthesiologists, Primary total shoulder arthroplasty, knee arthroplasty procedures
Introduction
Total shoulder arthroplasty (TSA) is increasingly used globally in the treatment of glenohumeral osteoarthritis, rotator cuff arthropathy, and proximal humeral fractures.1 The ongoing growth in TSA is due to procedural advancements, an ageing population, and a broadening range of clinical indications.2-4 In Australia, TSA procedures are projected to grow three- to five-fold by 2035.5 Revision procedures have yielded acceptable implant survival and long-term functional outcomes for a variety of indications,6 and it is likely the revision burden will rise in keeping with increasing primary procedures.
TSA offers substantial clinical benefit for patients,7 and there is an increasing imperative to offer this surgery in both rural and urban hospitals. However, TSA procedures are currently perceived as a more specialized and lower-volume procedure compared with hip and knee arthroplasty8 which may influence provision of care, particularly in rural areas. Between rural and urban hospitals, surgical outcomes may differ due to disparities in surgical volume,9 rates of complications,10 level of expertise among healthcare providers,11 and the quality and availability of operating theatres, hospital facilities, and rehabilitation services.12,13
The aim of this study was to analyze TSA revision rates when performed by high-volume surgeons from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)14 to determine whether the geographical location of TSA surgery affects clinical outcomes, and thus, whether TSA can be safely conducted in rural hospitals by experienced surgeons.
Methods
This is a survivorship analysis of prospectively collected data from a national joint arthroplasty registry. The AOANJRR began data collection on 1 September 1999 for all hip and knee arthroplasty procedures performed in Australia. Data collection was expanded to include shoulder arthroplasty procedures in April 2004 and has documented almost all shoulder arthroplasty procedures Australia-wide since November 2007. The AOANJRR now has data on 99% of hip, knee, and shoulder joint arthroplasty procedures performed in Australia.15 These data are externally validated against patient-level data provided by all Australian state and territory health departments. A sequential, multilevel matching process is used to identify any missing data which are subsequently obtained by follow-up with the relevant hospital. Each month, in addition to internal validation and data quality checks, all primary procedures are linked to any subsequent revision involving the same patient, joint, and side. Data are also matched bi-annually to the Australian National Death Index data to identify patients who have died.
Patient characteristics
A total of 16,179 TSA procedures were performed by during the study period which met the inclusion criteria. This composed of 3,456 (21%) procedures in rural hospitals and 12,723 (79%) procedures in urban hospitals. The mean age, proportions of male and female patients, American Society of Anesthesiologists (ASA) grades,16 and BMI were similar between the two groups (Table I).
Table I.
Summary of primary total shoulder replacement by hospital locality (all diagnoses).
| Variable | Urban hospitals | Rural hospitals | Total |
|---|---|---|---|
| Follow-up, yrs | |||
| Mean (SD) | 4.2 (3.3) | 4.1 (3.2) | 4.2 (3.3) |
| Median (IQR) | 3.5 (1.6 to 6.2) | 3.5 (1.6 to 5.9) | 3.5 (1.6 to 6.2) |
| Minimum to maximum | 0 to 15.9 | 0 to 15.6 | 0 to 15.9 |
| Age, yrs | |||
| Mean (SD) | 71.7 (9.3) | 72.2 (7.9) | 71.8 (9) |
| Median (IQR) | 72 (66 to 78) | 73 (67 to 78) | 73 (66 to 78) |
| Age group, yrs, n (%) | |||
| < 55 | 536 (4.2) | 72 (2.1) | 608 (3.8) |
| 55 to 64 | 2,025 (15.9) | 482 (13.9) | 2,507 (15.5) |
| 65 to 74 | 5,030 (39.5) | 1,496 (43.3) | 6,526 (40.3) |
| ≥ 75 | 5,132 (40.3) | 1,406 (40.7) | 6,538 (40.4) |
| Sex, n (%) | |||
| Male | 5,137 (40.4) | 1,437 (41.6) | 6,574 (40.6) |
| Female | 7,586 (59.6) | 2,019 (58.4) | 9,605 (59.4) |
| Shoulder class, n (%) | |||
| Total stemmed anatomical | 1,628 (12.8) | 439 (12.7) | 2,067 (12.8) |
| Total stemmed reverse | 10,193 (80.1) | 2,890 (83.6) | 13,083 (80.9) |
| Total stemless anatomical | 902 (7.1) | 127 (3.7) | 1,029 (6.4) |
| ASA grade, n (%) | |||
| I | 366 (3.2) | 98 (3.1) | 464 (3.2) |
| II | 4,421 (39.2) | 1,483 (47.0) | 5,904 (40.9) |
| III | 6,236 (55.3) | 1,508 (47.8) | 7,744 (53.7) |
| IV | 257 (2.3) | 63 (2.0) | 320 (2.2) |
| V | 1 (0%) | 1 (0%) | |
| BMI, kg/m 2 , n (%) † | |||
| Underweight (< 18.50) | 63 (0.6) | 15 (0.5) | 78 (0.6) |
| Normal (18.50 to 24.99) | 1,760 (17.5) | 395 (13.8) | 2,155 (16.7) |
| Pre obese (25.00 to 29.99) | 3,362 (33.5) | 957 (33.5) | 4,319 (33.5) |
| Obese class 1 (30.00 to 34.99) | 2,730 (27.2) | 790 (27.6) | 3,520 (27.3) |
| Obese class 2 (35.00 to 39.99) | 1,342 (13.4) | 483 (16.9) | 1,825 (14.2) |
| Obese class 3 (≥ 40.00) | 776 (7.7%) | 218 (7.6%) | 994 (7.7%) |
| Total, n | 12,723 | 3,456 | 16,179 |
Excludes 1,746 procedures with unknown ASA grade.
Excludes 3,288 procedures with unknown BMI.
ASA, American Society of Anesthesiologists.
The study period of 1 January 2008 until 31 December 2023 was used. There were two cohort groups; primary TSA performed in rural and urban hospitals. The Modified Monash Model (MMM)17 is used to describe the population distribution and socio-economic situation of residents across Australian states and territories, stratified utilizing seven classifications (MM 1 to 7).17 Procedures were classified as having been performed in an urban hospital if from an area classified as MM 1, whereas procedures were classified as having been performed in a regional, rural or remote hospital if from areas classified as MM 2 to MM 7.17 Hospitals located in MM 2 to MM 7 were referred to as rural hospitals.
Only surgeons who were high-volume and work in both urban and rural hospitals were included to reduce any data confounding from inexperienced or junior surgeons. A high-volume surgeon was defined as a surgeon that was in the upper two quartiles of total shoulder surgeries in both an urban and rural setting as recorded by the AOANJRR. The data for surgical volume defining the threshold for quartile ranges were not available. The study population included all cases of primary TSA (total stemless anatomical, total stemmed anatomical, and total stemmed reverse) procedures undertaken for all diagnoses. We excluded total resurfacing anatomical and partial hemi anatomical shoulder arthroplasty due to low numbers in both cohort groups. The primary outcome measure was time to revision. All AOANJRR primary procedures are routinely linked to subsequent revisions regardless of urban or rural location. Specific counts of same-site compared with cross-site revisions are not provided by the present dataset. STROBE guidelines regarding descriptive data have been followed precluding the use of significance tests and p-values of demographic data.18
Statistical analysis
Kaplan-Meier estimates of survivorship were used to report the time to first revision, with censoring at the time of death and closure of the dataset at the end of December 2023. The unadjusted cumulative percent revision (CPR), with 95% CI, were calculated using unadjusted point wise Greenwood estimates. Age and sex adjusted hazard ratios (HRs) were calculated from Cox proportional hazard models to compare the rate of first revision between groups. The assumption of proportional hazards was checked analytically for each model. If the interaction between the predictor and the log of time was statistically significant in the standard Cox model, then a time varying model was estimated. Time points were selected based on the greatest change in hazard, weighted by a function of events. Time points were iteratively chosen until the assumption of proportionality was met and HRs were calculated for each selected time. For the current study, if no time was specified, the HR was calculated over the entire follow-up period. All tests were two-tailed at 5% levels of significance. Statistical analysis was performed using SAS software v. 9.4 (SAS, USA).
Ethics approval statement
The AOANJRR is approved by the Commonwealth of Australia as a Federal Quality Assurance Activity (F2022L00986) Part VC of the Health Insurance Act 1973 (HIA) and Part 10 of the Health Insurance Regulations 2018. All AOANJRR studies are conducted in accordance with ethical principles of research (the Helsinki Declaration II).19
Results
The proportion of reverse stemmed, anatomical stemmed and anatomical stemless cases were similar between the two groups (Table I). In both rural and urban hospitals, the three most common indications for TSA were osteoarthritis, rotator cuff arthropathy, and fracture (Table II).
Table II.
Primary total shoulder arthroplasty by primary diagnosis and hospital locality.
| Urban hospitals | Rural hospitals | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Primary diagnosis | N | Col, % | Total, % | N | Col, % | Total, % | N | Col, % | Total, % |
| Osteoarthritis | 6,478 | 50.9 | 40.0 | 1,993 | 57.7 | 12.3 | 8,471 | 52.4 | 52.4 |
| Rotator cuff arthropathy | 4,082 | 32.1 | 25.2 | 968 | 28.0 | 6.0 | 5,050 | 31.2 | 31.2 |
| Fracture | 1,554 | 12.2 | 9.6 | 349 | 10.1 | 2.2 | 1,903 | 11.8 | 11.8 |
| Rheumatoid arthritis | 222 | 1.7 | 1.4 | 52 | 1.5 | 0.3 | 274 | 1.7 | 1.7 |
| Osteonecrosis | 170 | 1.3 | 1.1 | 41 | 1.2 | 0.3 | 211 | 1.3 | 1.3 |
| Instability | 123 | 1.0 | 0.8 | 36 | 1.0 | 0.2 | 159 | 1.0 | 1.0 |
| Other inflammatory arthritis | 83 | 0.7 | 0.5 | 13 | 0.4 | 0.1 | 96 | 0.6 | 0.6 |
| Tumour | 7 | 0.1 | 0.0 | 3 | 0.1 | 0.0 | 10 | 0.1 | 0.1 |
| Other | 4 | 0.0 | 0.0 | 1 | 0.0 | 0.0 | 5 | 0.0 | 0.0 |
| Total | 12,723 | 100.0 | 78.6 | 3,456 | 100.0 | 21.4 | 16,179 | 100.0 | 100.0 |
The CPR at five years was 4.1% (95% CI 3.4 to 4.9) in rural hospitals and 5.5% (95% CI 5.0 to 6.0) in urban hospitals. There was a significantly reduced rate of revision in rural hospitals compared with urban hospitals (HR 0.81 (95% CI 0.66 to 0.99); p = 0.037, Figure 1) adjusted for age and sex. The cumulative incidence revision diagnosis instability/dislocation occurred most frequently in both cohort groups (Figure 2).
Fig. 1.
Cumulative percent revision of primary total shoulder arthroplasty by hospital locality (all diagnoses, revision in five years).
Fig. 2.
Cumulative incidence primary total shoulder arthroplasty by hospital locality (all diagnoses, revision in five years).
When stratified by the type of primary shoulder arthroplasty performed there was a higher revision rate for primary total anatomical shoulder arthroplasty in rural centres compared with urban centres in the first six months only (zero to six months, HR 2.04, 95% CI 1.18 to 3.45, p = 0.011, Figure 3). After six months, rural hospitals have a lower rate of revision for primary total anatomical shoulder arthroplasty compared with urban hospitals (six months to 1.5 years, HR 0.52 (95% CI 0.32 to 0.85), p = 0.008; 1.5 years +, HR 0.36 (95% CI 0.23 to 0.57), p < 0.001, Figure 3). However, there was no difference in the rate of revision for primary total reverse shoulder arthroplasty in rural compared with urban centres (entire period, HR 0.87 (95% CI 0.69 to 1.10), p = 0.233, Figure 3). Analysis by age revealed a reduced revision rate in rural centres for patients aged under 65 years of age (entire period, HR 0.66 (95% CI 0.43 to 1.00), p = 0.050, Figure 4), and no difference for patients aged 65 years or older (HR 0.85 (95% CI 0.68 to 1.08), p = 0.189, Figure 4). There was no difference in the rate of revision when rural hospitals were compared with urban hospitals when stratified by sex (males p = 0.147, females p = 0.133).
Fig. 3.
Cumulative percent revision of primary total shoulder arthroplasty by hospital locality and shoulder class (all diagnoses, revision in five years).
Fig. 4.
Cumulative percent revision of primary total shoulder arthroplasty by hospital locality and age (All diagnoses, revision in five years).
Discussion
We present the outcome of primary TSA for procedures performed by high-volume surgeons in rural compared with urban hospitals utilizing a national registry database. The principal finding of the current study was a reduction in TSA revision rates for cases performed by experienced surgeons in rural hospitals compared with those performed in urban hospitals. Therefore, TSA in rural hospitals demonstrates equivalent efficacy to urban hospitals when performed by high-volume surgeons, despite the inherent challenges of rural healthcare.
Previous studies in hip and knee arthroplasty have demonstrated no difference when rural patients undergo joint arthroplasty in an urban hospital before returning rurally. A prospective cohort study by Dowsey et al20 found rural patients reported similar pain and functional outcomes to their urban counterparts at 24 months since THA and TKA within a single Australian metropolitan centre (n = 2,193). Garlapaty et al21 similarly found equivalent one-year postoperative outcomes after TKA within a single USA urban centre between BMI-matched urban and rural patients (n = 882). A recent AOANJRR study by Handford et al22 found that hospitals with increased hip arthroplasty volume had a lower rate of early revision surgery. This has also been demonstrated in the USA, wherein centres with a higher volume of surgery had reduced rates of prosthetic joint infection.23 However, to our knowledge, no prior studies have directly compared arthroplasty outcomes in rural and urban hospitals, even in hip and knee arthroplasty. Furthermore, TSA remains a more sub-specialized large joint arthroplasty with lower surgical volume, which may be more susceptible to influence from confounding factors in the rural setting, hence the inclusion of only high-volume surgeons in this study.
The selection of patients and perioperative management strategies may differ between rural and urban settings, which may contribute to lower revision rates in rural hospitals. For example, perceived difficulty in rural cases, anaesthetically or surgically, may be sent for management in an urban centre. However, the current analysis showed an overall similarity in demographics, including BMI and ASA grades (Table I). There may also be a greater loss to follow-up, with potential lower demand for surgical revision in rural settings where travel- and financial-related burdens are significant.24 Rural patients may also have different perioperative expectations regarding functional improvements based on the lesser provision of rehabilitation services and follow-up.13,25 Finally, rural hospitals, as with urban hospitals, do ultimately benefit from having highly skilled, high-volume surgeons operating on a diverse range of cases, which could mitigate the perceived disadvantages of performing TSA in rural areas.
The current study found a lower revision rate for anatomical TSA in rural hospitals relative to urban hospitals when undertaken by high-volume surgeons (Figure 3). While it is not clear from the present study the reasons for this difference, several factors might contribute. The AOANJRR does not capture indicators of case complexity beyond the provided baseline characteristics (Table I). Some unmeasured baseline patient and clinical factors may differ substantially between rural and urban referral patterns. Thus, a lower revision rate for anatomical TSA in rural hospitals may simply reflect a lower complexity of cases. Further, lower revision rates in rural hospitals may result from a higher threshold for pursuing revision operations, influenced by logistical and patient-related barriers, rather than a true difference in outcomes. Follow-up limitations in rural patients may also contribute to an underestimation of revision rates. Generally, the most important predictors for TSA revision are age and sex, then polyethylene type.26 With similar age and sex between the two groups (Table I), adjusting for polyethylene type would be of interest for further study. Ultimately, hazard intervals are determined empirically for exploratory purposes. Accordingly, observed temporal patterns should be interpreted as hypothesis-generating rather than necessarily causal.
The strengths of the current study include the use of national population-based data from the AOANJRR, which offers a robust and comprehensive dataset and is highly representative of the broader Australian population undergoing TSA. The number of cases included and the near universality of the sample population contributes to the significance of the study. Further, limiting the analysis to surgeons operating in both urban and rural hospitals with higher procedural volumes reduces potential confounding from surgical inexperience.
As a retrospective observational study, it is inherently limited by unmeasured and possibly confounding variables. AOANJRR data does not record patient-reported outcome measures (PROMs), clinical examination findings, return to work times or radiological outcomes, which would be useful to elicit further clinically significant comparisons of outcomes between rural and urban hospitals. Focusing on higher-volume surgeons may also impede the generalizability of this study, where up to 78% of surgeons undertake fewer than ten TSA procedures annually.27 Generalizability may be impeded by defining ‘rural’ as MM 2 to MM 7. Thus, ‘rural’ cases may be skewed towards MM 2 to MM 3 regional centres, and results should be interpreted cautiously. It is important to acknowledge that the study design intentionally restricted analysis to this high-volume surgeon population to minimize confounding by surgical experience. Further research is required to evaluate outcomes among low-volume surgeons and their distribution across Australia. Further, sub-group analyses of anatomical TSR sub-types was not performed. There is a paucity of other population-level data comparing urban and rural centre outcomes of total joint arthroplasties, and thus, comparison with other procedures and countries with significant rurality is limited. Specific counts of same-site compared with cross-site revisions are unfortunately not provided by the present AOANJRR dataset, which may impede generalizability of results, given that non-index hospital re-admission has been demonstrated to lead to worse outcomes.28 Outcomes-based demographic variables, primary TSA indication, and urban compared with rural centres were unable to be performed in a unified Cox regression due to limitations with the present AOANJRR dataset and may be considered for study in future analyses.
In conclusion, this study supports the safety and efficacy of TSA procedures performed in rural hospitals by experienced surgeons, reinforcing their continued provision. Future research may investigate the reasons as to why rural settings exhibit a lower revision rate for TSA procedures performed by high-volume surgeons, as well as clinical outcomes for low-volume surgeons across rural and urban centres.
Take home message
- This study supports the continued provision of total shoulder arthroplasty procedures performed in rural hospitals by experienced surgeons.
Author contributions
Z. Dragan: Investigation, Methodology, Writing – original draft, Writing – review & editing
R. J. Campbell: Conceptualization, Investigation, Validation, Visualization, Writing – original draft, Writing – review & editing
M. Tropman: Writing – original draft, Writing – review & editing
P. Du: Investigation, Validation, Visualization, Writing – review & editing
D. R. J. Gill: conception, clinical expertise, project supervision, read and approved the final manuscript
C. Handford: Conceptualization, Investigation, Writing – review & editing, Project administration
B. Cass: Resources, Supervision, Writing – review & editing
A. Young: Investigation, Project administration, Resources, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
B. Cass reports consulting fees from Zimmer Biomet. D. R. J. Gill discloses being chair of the Specialist Orthopaedic Expert Clinical, on the advisory group and committee of the Australian Federal Government Department of Health Disability and Ageing, and a member of the Medical Devices and Human Tissue, being a statutory board director of the Australian Orthopaedic Association, and assistant deputy clinical director of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). A. Young discloses consulting fees from Arthrex and Stryker, and being a director of the Sydney Shoulder Research Institute.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to ustralian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data is limited to the researchers who have obtained permission for data processing. Further data policy guidance can be obtained at https://aoanjrr.sahmri.com/policies.
Open access funding
The open access fee was self-funded.
Supplementary material
STROBE statement: checklist of items that should be included in reports of cohort studies.
© 2026 Dragan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to ustralian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data is limited to the researchers who have obtained permission for data processing. Further data policy guidance can be obtained at https://aoanjrr.sahmri.com/policies.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to ustralian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data is limited to the researchers who have obtained permission for data processing. Further data policy guidance can be obtained at https://aoanjrr.sahmri.com/policies.