Both anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) are considerations for patients with cuff-intact glenohumeral osteoarthritis. Currently many, if not most shoulder surgeons are trending toward RSA. In fact many surgeons have little working experience in performing aTSA. For example, per the Australian registry, the share of primary total shoulder replacements that is anatomic has collapsed from roughly 57% in 2008 to about 4% by 2024, while stemmed reverse has risen to nearly 90% (see figure below) [1]. In some circles the pro RSA argument is based on the contentions that (1) the RSA is easier to perform by less experienced-as well as experienced-surgeons and (2) the RSA as a lower rate of revision.
A look at the published evidence may inform the choice for patients and surgeons:
1. Patient-reported outcomes
With commonly used scores, the two types of arthroplasty seem similar for cuff-intact arthritis. A 2026 meta-analysis of 1,716 patients aged ≥70 with a competent cuff found no significant differences in ASES, Constant, or SST scores [2]. A meta-analysis of 14 studies (4,819 cases) found similar ASES, Constant, SST, SSV, and VAS pain scores [3], as did an earlier systematic review [4] and a propensity score–matched JBJS analysis [5].
However, in the UK National Joint Registry, roughly a quarter of 21,918 RSA patients had an “unsatisfactory” Oxford Shoulder Score (<29) [6]. Single-center series using patient-acceptable-symptom-state (PASS) thresholds put the figure higher — 25–40% of RSA patients failed to reach PASS for ASES or SANE at two years [7], and 34–35% still failed at minimum five years [8], with pain the primary factor in these adverse outcomes.
With the Shoulder Arthroplasty Smart score, aTSA achieved higher absolute postoperative scores even though the improvement from baseline was similar [9]. Among patients who reached a “new normal” (defined as a SANE score ≥95), aTSA significantly outperformed RSA on higher-demand tasks, motion, and return to sport and work [10].
2. Motion
Across the comparative meta-analyses, aTSA delivered better external and internal rotation, with differences that exceed the MCID and reached 10–11° of external rotation in pooled estimates [2,3,4] as well as better overall motion in matched cohorts [5]. Rotation enables the patient to perform basic activities of daily living: dressing, toileting, perineal care, and reaching behind the back.
3. Complications
In pooled comparative data, RSA carried a lower overall complication rate than aTSA in the cuff-intact population [2,3]. But the complications the two implants produced differed in kind. Historically, primary stemmed anatomic shoulders done for osteoarthritis using legacy techniques and implants have been revised chiefly for glenoid component loosening (29.1%), rotator cuff insufficiency (27.6%), and instability/dislocation (23.1%), with loosening being predominant [1]. Stemmed reverse shoulders have been revised chiefly for instability/dislocation, infection, loosening, and fracture [1].
4. Revision
At ten years, cumulative percent revision (all diagnoses, modern prostheses) was 5.5% for stemmed reverse, 5.2% for stemless aTSA, and 7.9% for stemmed aTSA (Figure 2 below) [1].
It is worthwhile noting that the 7.9% ten-year revision rate for stemmed aTSA includes decades of older, non-crosslinked polyethylene. When the glenoid is crosslinked, aTSA durability improves markedly: in a dedicated AOANJRR study of 10,102 stemmed aTSAs done for osteoarthritis, non-crosslinked polyethylene had more than double the revision risk of crosslinked polyethylene after 18 months (HR 2.3; 95% CI 1.6–3.1), with 12-year cumulative revision of 9% versus 5% [22]. Considering only crosslinked anatomic glenoids, the revision rate for stemmed aTSAs (5%) was comparable to stemmed RSA (5.5%) and stemless aTSA (5.2%).
Vitamin E–stabilized polyethylene is a type of crosslinked polyethylene, and registries tend to pool the two. Vitamin E reduces wear and osteolytic particle debris on the bench [23], but no study has yet demonstrated a vitamin-E–versus–plain-crosslinked revision difference in shoulder arthroplasty.
The revision rates for stemless aTSA match those for the RSA; the reasons for this are not clear - perhaps more experienced surgeons, greater ability to achieve the desired humeral component position, a higher rate of use of modern glenoid components, and/or preferential selection of healthier shoulders with better quality bone.
Comparative meta-analyses report RSA revision rates about four-fold lower than aTSA in the cuff-intact analysis, OR 0.43; 95% CI 0.29–0.65; p<0.001) [3], although an earlier meta-analysis found no mid-term difference (OR 0.33; p=0.16) [4]. A 2026 propensity-matched study showed a lower early revision rate for aTSAs, but at midterm followup the revision rate increased [12].
However, it is critical to recognize that revision is a poor proxy for clinical failure in RSA. A National Joint Registry analysis concluded that low RSA revision rates may not signify implant success. Instead, patients with poor outcomes and their surgeons may be reluctant to undertake complex RSA revisions which have unpredictable results.[6]. The point is apparent for the most common mode of RSA failure — a painful, poorly functioning but radiographically satisfactory RSA. Such an outcome is experienced by about a quarter of RSA patients [6,7,8], yet RSAs are rarely revised for this indication. A failure that is not revised never appears in the revision rate.
[Complication frequencies were drawn from indexed systematic reviews [26–29] (e.g., PJI 2.4%, acromial/scapular fracture 2.5%, primary-RSA instability 2.5%); the revisability column reflects their reported management — acromial fractures are predominantly treated non-operatively, instability usually presents within 90 days and is treated by component revision, and infection is nearly always surgical. The registry anchor for pain/PROM failure is O’Malley [6].]
The different failure types are not equally salvageable. If an anatomic shoulder fails, it can usually be converted to a RSA with outcomes that approach those of primary RSA. Primary stemmed anatomic shoulders done for osteoarthritis are revised to a reverse in 89% of cases, keeping the original humeral stem 58% of the time [1]; 93.8% of failed stemless aTSAs are converted to RSAs. On the other hand, revision of a failed reverse to another reverse often fails to yield the desired improvement in comfort and function.
5. Durability
Durability matters most for the patient with decades of active use ahead. At minimum ten-year follow-up, aTSAs sustain their functional gains for primary osteoarthritis [13], the large concurrent aTSA experience supports this option in the high-demand patient who wishes to avoid a RSA [14]. The Australian registry shows modern stemless anatomic matching reverse on revision out to ten years, and crosslinked stemmed-anatomic glenoids more than halve the revision risk of older non-crosslinked ones [1,22].
6. Return to sport
Return-to-sport rates are high after both implants and highest after aTSA in pooled data [15]. A recent large weightlifting series reported high self-rated comfort, yet its endpoint is a single ordinal “difficulty” item — capturing neither the amount of load nor performance. [16]. When actual one-repetition-max recovery is measured, returners perform below their presymptomatic level, with the largest decrement in bench press [17].
7. Surgeon capability. It is often said that a good aTSA outperforms a good RSA, which outperforms a bad aTSA, which outperforms a bad RSA [18]. Some say it is technically easier to do a good RSA than an aTSA (not my view). However it is for sure that as aTSA volume falls, fewer surgeons will be able to reliably provide a good anatomic to their patients with cuff intact arthritis. While some hold that navigation, patient-specific instrumentation, and robotics may improve component positioning; none has been shown to improve patient-reported outcomes or reduce complications for any type of arthroplasty [19,20,21]. It appears that the surgeon is sill the method.
So, in rough summary
Bottom line:
The patient and the surgeon considering arthroplasty for cuff intact shoulder arthritis should discuss the available evidence on aTSA and RSA.
An aTSA - when performed by a surgeon who can deliver a reliable aTSA - may be attractive when function and salvageability matter most — particularly in the more active patient with a reconstructable glenoid.
A RSA may be more attractive in the less active patient, or one whose glenoid morphology or bone quality makes a durable aTSA less certain or when the shoulder surgeon is not comfortable performing an anatomic shoulder arthroplasty.
Two cautions bear on the consideration: the revision rate understates RSA failure, because its most common failure — a painful but intact shoulder — is rarely revised [6]; and roughly a quarter of RSA patients do not reach a satisfactory outcome at all [6,7,8].
A choice
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References
[1]Lewis PL, Gill DR, McAuliffe MJ, et al. Hip, Knee and Shoulder Arthroplasty: 2025 Annual Report. Australian Orthopaedic Association National Joint Replacement Registry. AOA: Adelaide; 2025. doi:10.25310/MXFR3061. (Figures ST1, ST2; Tables ST6, ST39, ST46–47, ST76.)
[2]Gupta MS, Krishan A, Rashid A, et al. Reverse versus anatomic total shoulder arthroplasty in patients over 70 with a competent rotator cuff and glenohumeral osteoarthritis: a meta-analysis. J Shoulder Elbow Surg. 2026 (online 2025). PMID: 41276069.
[3]Thamrongskulsiri N, Limskul D, Tanpowpong T, et al. Comparison of revision rates and clinical outcomes between anatomic and reverse total shoulder arthroplasty for rotator cuff-intact osteoarthritis: a systematic review and meta-analysis. Clin Orthop Surg. 2025;17(6):907–921. doi:10.4055/cios25012.
[4]Kim H, Kim CH, Kim M, et al. Is reverse total shoulder arthroplasty more advantageous than anatomic TSA for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis. J Orthop Traumatol. 2022;23(1):3. PMID: 34993646.
[5]Kirsch JM, Puzzitiello RN, Swanson D, et al. Outcomes after anatomic and reverse shoulder arthroplasty for glenohumeral osteoarthritis: a propensity score-matched analysis. J Bone Joint Surg Am. 2022. PMID: 35867705.
[6]O’Malley O, Davies A, Sabharwal S, et al. Is there a difference in thresholds for revision between shoulder arthroplasty types? A National Joint Registry study. PLoS One. 2025. doi:10.1371/journal.pone.0330975.
[7]Werner BC, Lederman E, Gobezie R, et al. Understanding the variables associated with failure to achieve an acceptable symptom state after reverse shoulder arthroplasty. Semin Arthroplasty JSES. 2021.
[8]Ardebol J, et al. Defining the MCID and PASS following reverse shoulder arthroplasty for glenohumeral arthritis or cuff tear arthropathy at minimum 5-year follow-up. JSES Int. 2025.
[9]Marigi EM, Hao KA, Friedman RJ, et al. Exactech Equinoxe anatomic versus reverse total shoulder arthroplasty for primary osteoarthritis: case-controlled comparisons using the machine learning-derived Shoulder Arthroplasty Smart score. J Shoulder Elbow Surg. 2023. PMID: 39292145.
[10]Beleckas CM, Schodlbauer DF, Mousad AD, et al. Evaluation of new normal after shoulder arthroplasty: comparison of anatomic vs. reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34:S43–S49. doi:10.1016/j.jse.2025.02.010. PMID: 40074195.
[11]Barco R, Savvidou OD, Sperling JW, et al. Complications in reverse shoulder arthroplasty. EFORT Open Rev. 2016;1:72–80. doi:10.1302/2058-5241.1.160003.
[12]Leinweber KA, Bowler AR, Diestel DR, et al. Reverse and anatomic total shoulder arthroplasty for glenohumeral osteoarthritis: a propensity-matched comparison at early and midterm follow-up. J Shoulder Elbow Surg. 2026. PMID: 41564999.
[13]Sharareh B, Whitson AJ, Matsen FA III, et al. Minimum 10-year follow-up of anatomic total shoulder arthroplasty and ream-and-run arthroplasty for primary glenohumeral osteoarthritis. J Shoulder Elbow Surg. 2024;33(6):1276–1284. PMID: 37777045.
[14]Matsen FA III, Whitson A, Jackins SE, et al. Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases. Int Orthop. 2019;43(9):2105–2115. PMID: 31240359.
[15]Liu JN, Steinhaus ME, Garcia GH, et al. Return to sport after shoulder arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):100–112. PMID: 28409200.
[16]Abdelshaheed J, Chatterji R, Levy J, et al. Return to weightlifting following anatomic and reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2026;35:1660–1666. doi:10.1016/j.jse.2026.02.002.
[17]Ames A, Shah SS, Pettit R, et al. Against surgeons’ advice: the return to sport in high-demand weightlifters following anatomic total shoulder arthroplasty at average 3.6 years’ follow-up. J Shoulder Elbow Surg. 2023;32(4):e153–e159. doi:10.1016/j.jse.2022.09.027.
[18]Menendez ME, Garrigues GE, Jawa A. Clinical Faceoff: anatomic versus reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis. Clin Orthop Relat Res. 2022;480(11):2095–2100.
[19]Daher M, Fares MY, Boufadel P, et al. Patient-specific instrumentation in primary total shoulder arthroplasty: a meta-analysis of clinical outcomes. Clin Shoulder Elb. 2025;28(2):129–136. doi:10.5397/cise.2024.01095.
[20]Patient-specific instrumentation in shoulder arthroplasty: high tech, low yield? [editorial]. Clin Shoulder Elb. 2025;28(2). doi:10.5397/cise.2025.00423.
[21]Gaj E, Pagnotta SM, Berlinberg EJ, et al. Intraoperative navigation system use increases accuracy of glenoid component inclination but not functional outcomes in reverse total shoulder arthroplasty. Arch Orthop Trauma Surg. 2024;144(1):91–102. doi:10.1007/s00402-023-05038-y.
[22]Page RS, Alder-Price AC, Rainbird S, et al. Reduced revision rates in total shoulder arthroplasty with crosslinked polyethylene: results from the Australian Orthopaedic Association National Joint Replacement Registry. Clin Orthop Relat Res. 2022;480(10):1940–1949. doi:10.1097/CORR.0000000000002293. PMID: 35901440.
[23]Khan AZ, Maxwell MJ, Parrott RM, et al. Effect of vitamin E–enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene. J Shoulder Elbow Surg. 2024. PMID: 38182025.
[24]Gowd AK, Liu JN, Cabarcas BC, et al. Single Assessment Numeric Evaluation and patient acceptable symptom state thresholds following shoulder arthroplasty. J Shoulder Elbow Surg. 2021. (PASS: ASES 81.9, SANE 75.5; n=207, mixed TSA/RSA.)
[25]DeVito P, Damodar D, Berglund DD, et al. Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement. J Shoulder Elbow Surg. 2019;28(6):1223–1231. PMID: 30910258. (SST threshold 61.3% MPI; n=198.)
[26]Shah SS, Gaal BT, Roche AM, et al. The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part I. JSES Int. 2020;4(4):929–943. (Periprosthetic joint infection 2.4% for primary RSA.)
[27]Shah SS, Roche AM, Sullivan SW, et al. The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II. JSES Int. 2020;5(1):121–137. doi:10.1016/j.jseint.2020.07.018. PMID: 33554177. (Instability, humerus/glenoid fracture, acromial/scapular-spine fracture.)
[28]Zumstein MA, Pinedo M, Old J, et al. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20(1):146–157.
[29]Lau SC, Large R. Acromial fracture after reverse total shoulder arthroplasty: a systematic review. Shoulder Elbow. 2020;12(6):375–389. doi:10.1177/1758573219876486. PMID: 33281942.
