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 RSA patients had an “unsatisfactory” Oxford Shoulder Score (<29) among 21,918 patients [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 achieves higher absolute postoperative scores even when the improvement from baseline is similar [9]; and among patients who reach 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 delivers better external and internal rotation, with differences that exceed the MCID and reach 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 carries a lower overall complication rate than aTSA in the cuff-intact population [2,3]. But the complications the two implants produce differ 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) [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 after 18 months (HR 2.3; 95% CI 1.6–3.1), with 12-year cumulative revision of 9% versus 5% [22]. Restricted to crosslinked glenoids, revisions for stemmed aTSAs (5%) is comparable to stemmed RSA (5.5%) and stemless aTSA (5.2%).
A word on terminology: vitamin E–stabilized polyethylene is a subtype of crosslinked polyethylene, and registries pool the two — so the revision benefit shown here is the benefit of crosslinking. Vitamin E specifically reduces wear and osteolytic particle debris on the bench [23], but no study has yet isolated 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, a higher use of modern glenoid components, or selection of healthier shoulders with better quality bone.
The pooled literature suggests that RSA is revised less often. Comparative meta-analyses report lower RSA revision rates about four-fold lower 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 aTSA’s lower early rate narrows by midterm while later on it accrued more revisions [12].
However, it is critical to recognize that revision is a poor proxy for 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 that have uncertain results.[6]. The point is apparent for the most common mode of RSA failure — a painful, poorly functioning but radiographically satisfactory RSA. Such a situation confronts on the order of a quarter of RSA patients [6,7,8] yet is revised rarely, because there is often nothing straightforward to revise. A failure that never becomes a revision 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. When an anatomic shoulder does fail, it can be converted to a RSA with outcomes that are usually favorable. 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] (stemless anatomic converts to reverse in 93.8% of revisions). One 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; hemiarthroplasty was included in the anatomic arm [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 deliver a good anatomic. 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 [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 may be attractive when function, the highest functional ceiling, and salvageability matter most — particularly in the more active patient with a reconstructable glenoid and a surgeon who can deliver a reliable aTSA.
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
Registry and comparative references verified against PubMed / the registry record (PMIDs and DOIs below). Figures 1–2 are the author’s own redrawings of AOANJRR data, used under attribution.
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