Loose glenoid in aTSA
Baseplate failure in RSA
Dislocation in RSA
Acromial fracture in RSA
Summary
Conventionally, anatomic total shoulder arthroplasty (aTSA) has been used for patients with arthritis and a functioning rotator cuff. The reverse total shoulder arthroplasty (RSA) was developed for shoulders whose rotator cuff had failed. RSA now accounts for about seven of every ten shoulder replacements in the United States. More than half of them are used for patients with cuff-intact arthritic shoulders.
The question surgeons and patients would like answered is: how do the clinical outcomes of these two procedures compare for shoulders with cuff-intact arthritis?
The short answer: the existing evidence does not show major differences in clinical outcomes between the two procedures. However, the published literature does show differences in the types, seriousness and frequency of complications. These differences are not reflected in revision rates because of the relatively poor outcomes for revision of a failed RSA, which contrasts with the better outcomes for revision of a failed aTSA.
Considering only studies limited to the treatment of cuff-intact arthritis, the evidence suggests: (1) on numeric scores (SANE, ASES, VAS), the two are about the same; (2) on motion and certain specific tasks, the anatomic often does better; (3) on durability, controlled studies are in the works and the results are as yet unknown.
Numeric scores look alike. Matched comparisons from single practices, a national English registry of more than 7,000 operations, and several pooled reviews all found that shoulder scores after the two operations differed by less than the amount that patients would notice.
The best results may differ. One study looked only at patients who rated their shoulder 95 or more out of 100. Among patients with osteoarthritis and an intact cuff, 41% of those with an anatomic and 35% of those with a reverse reached that level. Among those who did, patients receiving aTSA could more often lift 10 pounds overhead without difficulty (73% vs 55%) and carry 20 pounds at the side (86% vs 70%).
Time may change the comparison. The longest comparison came from one surgeon, in shoulders with advanced wear of the socket that were followed for about eight years. The anatomic was better at two years. By eight years the reverse had slightly better scores, more satisfied patients (95% vs 82%) and fewer revisions (2% vs 8%).
The complications differ, and revision rates do not show it. The complications differ in type: after an aTSA, mainly subscapularis failure early and glenoid loosening and cuff failure later; after an RSA, mainly acromial and scapular spine fractures, instability, and baseplate failure. These complications differ in seriousness: a failed anatomic can usually be successfully converted to a reverse, while a failed reverse is harder to salvage and some of its complications are not revised at all. In a national registry, fewer than one in 20 patients with an unsatisfactory result after an RSA was revised, about half the rate for aTSA.
Can patients forget their shoulder? A new questionnaire, the Forgotten Joint Score, has now been applied to shoulder replacement, but no one has yet used it to compare aTSA and RSA.
What we know and what we don't. Every comparison of anatomic and reverse so far is observational. Surgeons chose the operation based on their experience, the characteristics of the patient and the characteristics of the shoulder. These factors strongly influence the outcome—perhaps more than which type of arthroplasty is used.
Much needed randomized clinical trials are underway in the United Kingdom and Switzerland. Until these studies are complete, the relative value to the patient of aTSA and RSA will remain uncertain.
Now for the details
Clinical Outcomes Are Not Significantly Different Between
aTSA and RSA for Cuff-Intact Arthritis
The reverse is now the most common shoulder arthroplasty. In a national cohort it rose from about 55% to about 70% of shoulder arthroplasties between 2016 and 2020, while the anatomic fell from about 37% to 27%. Of 95,808 reverses, 53% (51,150) were done for glenohumeral arthritis with an intact cuff (Mayfield et al. [1]).
This post asks what recent clinical studies show about function after an anatomic versus a reverse for the arthritic shoulder with an intact cuff, including whether patients come to forget the shoulder. It also covers what happens when the initial arthroplasty fails.
Only clinical studies of primary osteoarthritis with an intact rotator cuff are considered: studies of patients with outcomes reported by patients or measured on them. Cadaver, finite element and computer models were not included.
Anatomic or reverse for the arthritic shoulder with an intact cuff
In studies of the cuff-intact arthritic shoulder, no difference in patient-reported scores exceeded the minimal clinically important difference (MCID). Where motion differed, it favored the anatomic, but in a matched single-center series the difference was small.
Study | Design (all cuff-intact OA) | What it showed |
One surgeon; propensity-matched, 61 pairs; mean follow-up about 2 and 5 years | Over 96% in both groups reached the ASES MCID at both times. Substantial clinical benefit: 95.1% aTSA vs 80.3% rTSA early (P = .027), 91.8% vs 78.7% at midterm (P = .074). Internal and external rotation better early after aTSA, not at midterm. | |
One center; propensity-matched, 44 pairs, also matched for cuff fatty infiltration; minimum 3 years | No difference in ASES, Constant, SANE, pain, or elevation, external or internal rotation. Same result at age 70 or younger and over 70. Complications 18.2% after rTSA (4 acromial or spine fractures, 3 notching) vs 4.5% after aTSA (P = .089); one revision in each group. Note the difference in the ratio of complications to revisions for each procedure. | |
One surgeon; B2, B3 or C glenoids; 101 aTSA with high-side reaming vs 93 rTSA; minimum 7 years; not matched | At 2 years the anatomic was better: ASES 85 vs 80, elevation 162° vs 151°. At a mean of about 8 years the reverse was better: ASES 80 vs 77, satisfaction 95% vs 82%, revision 2% vs 8% of the starting cohorts. Note again that revision rate is relatively insensitive to complication rate. | |
National Joint Registry for England; propensity-matched, 7,124 procedures, age 60 or older | Fewer reoperations at 12 months after rTSA (absolute difference 0.51%). No clinically important difference in long-term revision-free survival. Similar change in Oxford Shoulder Score at 6 months. | |
Systematic review, 18 studies | Better motion after aTSA. No significant difference in ASES, pain, complications or revision. | |
Meta-analysis of retrospective studies | rTSA scored higher on UCLA, SST and SPADI. None of the differences exceeded the MCID. | |
Evidence review, patients 70 or older | Very low-quality evidence that rTSA has a lower reoperation rate. |
Cuff's series is the only one with more than five years of follow-up. The ASES differences were smaller than the MCID, and patients who were revised or lost were omitted from the final outcome comparison. In the Valsamis study, patient-reported outcomes were measured only at six months.
Every one of these comparisons is observational. The surgeon chose the procedure, and the reasons for that choice also affect the outcome. Propensity matching cannot control for variables the surgeon considered but did not record.
Randomized trials are underway, including RAPSODI-UK [9] and a Swiss trial [10].
Until the results are published, the relative value of aTSA and RSA for the patient with cuff-intact arthritis will remain uncertain.
The forgotten shoulder
Numerical scores hide what matters to the active patient: does the replaced shoulder feel and work like a normal one? A shoulder version of the 12-item Forgotten Joint Score (FJS-12) was tested in 60 patients after arthroplasty for osteoarthritis, 49 anatomic and 11 reverse (Feik et al., JSEA 2026 [11]). Mean scores were 64 ± 33 at six months and 70 ± 29 at one year, out of 100. The minimal detectable change was about 14 points. The wide spread shows that many patients are still aware of the shoulder at one year, even when standard scores sit near their ceiling. At present no published study compares a forgotten-joint score between anatomic and reverse arthroplasty.
Near normal
Beleckas et al. (JSES 2025) [12] studied patients who rated their shoulder at least 95 of 100 on the Single Assessment Numeric Evaluation (SANE), at a minimum of two years. In the subgroup treated for osteoarthritis without a cuff tear, 41% of anatomic and 35% of reverse patients reached that level. Among those who did, the anatomic patients had higher ASES (98 vs 95) and SST (12 vs 10) scores. More of them could lift 10 pounds above the shoulder without difficulty (73% vs 55%), lift 8 pounds to shoulder level (86% vs 66%) and carry 20 pounds at the side (86% vs 70%). External rotation was 60° vs 45°. Pain did not differ. The ASES difference was smaller than the MCID; the differences in specific tasks were ones patients noticed. Note that the anatomic patients were younger (median 70 vs 74 years) and followed longer, and the groups were not matched.
Complications Are Different Between
aTSA and RSA for Cuff-Intact Arthritis
When neither operation has a complication, the outcomes are similar. The procedures differ in how often complications occur, what kind they are, how serious they are, and which of them can be successfully revised.
How often. Short-term complication rates are low after both operations, and the direction of the difference varies between series. In a matched comparison of 370 anatomic and 370 reverse arthroplasties for cuff-intact arthritis in patients without previous surgery (mean age 73, mean follow-up 41 months), complications occurred in 4.9% after the anatomic and 2.2% after the reverse (P = .045), and revisions in 3.2% and 1.4% (P = .086; the study had 37% power to detect a difference in revisions) (Friedman et al., JAAOS 2022 [13]; single manufacturer’s registry, several authors with financial ties to the manufacturer). In Baek’s matched series the direction was the opposite: complications in 18.2% after the reverse and 4.5% after the anatomic [3]. A meta-analysis of eight comparative studies in patients 70 or older (1,716 patients, follow-up under five years) found more complications after the anatomic (risk ratio 1.75, 95% CI 1.04–2.96) and more revisions (risk ratio 3.96, 95% CI 1.54–10.15) (Gupta et al., JSES 2026 [14]). In the two included studies that gave reasons, anatomic revisions were mostly for glenoid loosening (9 of 21) and cuff tears (6 of 21); the three reverse revisions were for infection (2) and humeral component dissociation (1). The authors caution that reverses are often chosen for older patients less likely to undergo revision, and that symptomatic reverses managed without surgery are not counted as failures.
What kind. After an anatomic, the early complication is mainly subscapularis failure; the late ones are glenoid component loosening and secondary cuff failure. After a reverse, the complications are mainly acromial and scapular spine fractures, instability, scapular notching, and baseplate failure [3]. A loose anatomic glenoid can usually be revised to a reverse; an acromial fracture after a reverse is seldom revised at all. For this reason, complications should be reported by type, together with revisions.
Revised or not. A national registry study of 21,918 shoulder arthroplasties with Oxford Shoulder Scores asked how often patients with an unsatisfactory result (mean score below 29 of 48) were revised. Unsatisfactory scores were more common after a reverse than after a total shoulder (27% vs 15%), yet fewer of these patients were revised (4.9% vs 10.6%) (O’Malley et al., PLoS One 2025 [15]). The authors attribute this to a lower threshold for revising an aTSA, which has a reasonable salvage option in conversion to a reverse. The study included all indications rather than only cuff-intact arthritis, and the reverses included shoulders with cuff tear arthropathy and fractures; the results were similar when only elective indications were analyzed. Only about a third of patients had postoperative scores recorded. Even so, it shows directly that the threshold for revising a reverse is higher: a lower revision rate after a reverse does not mean fewer patients doing poorly. The gap between complications and revisions after a reverse is not new: in a systematic review of 782 reverses, mostly for cuff deficiency, complications likely to worsen the final outcome occurred in 24%, but only 10% were revised (Zumstein et al., JSES 2011 [16]).
When. The main late complication for aTSA accumulates slowly. In a meta-analysis of 15 studies of cemented all-polyethylene glenoids, mostly for primary osteoarthritis but including some rheumatoid arthritis, followed for a mean of 11.8 years, radiographic glenoid loosening was present in 41% and cuff deficiency in 44%; 17% had been revised. Implant survival was 93% at 10 years, 85% at 15 years and 82.5% at 20 years (Ranieri et al., Int Orthop 2026 [17]). Revision depends on design, technique and patient selection as well as time. In our consecutive series of 458 anatomics for cuff-intact arthritis with a cemented, pegged all-polyethylene glenoid (mean follow-up 6.7 years), 2.6% were revised: seven in the first two years, four between two and five years and one between five and ten years. Six were for subscapularis failure and only one for glenoid loosening, and Simple Shoulder Test scores did not decline after two years (Schiffman et al., Int Orthop 2026 [18]).
Most comparisons of anatomic and reverse stop at two to five years, before many of these failures appear. Comparable long-term data for the reverse in cuff-intact arthritis do not yet exist.
When the first operation fails, and what comes after
Patients undergoing revision reverse arthroplasty had significantly worse motion, patient-reported outcomes and satisfaction than patients undergoing primary reverse arthroplasty (Tobin et al., JSES 2026 [19]; single manufacturer's registry). These are different patients, and revision patients start with worse shoulders, so the comparison is observational. In Dr. Frankle's single-surgeon registry of 267 reverses done after a failed anatomic, 10.5% were revised again at a mean of 33 months, most often for baseplate failure. In the 188 with one-year follow-up, the Simple Shoulder Test rose from 2.4 to 6.0 of 12 and the ASES score from 30 to 66 (Narain et al., JSEA 2026 [20]). In a larger series from the same group, 320 first-time revision reverses were done for mechanical failure between 2002 and 2022. Implant survival at 10 years was 82.1% when the failed implant was an anatomic and 59.5% when it was a reverse (P < .001). ASES scores at one year were 64 and 53 (P = .008) (Patel et al., JSES 2026 [21]). The worse result after revising a reverse may make surgeons and patients more reluctant to revise one, so a lower revision rate after a reverse does not by itself mean fewer failures. In one series of 202 reverses, baseplate loosening occurred after 1.2% of primary reverses but after 10% of revision reverses (Bitzer et al., JSES 2018 [22]).
Where this leaves us
The existing evidence does not show major differences in clinical outcomes between the anatomic and the reverse for the patient with cuff-intact arthritis. It does show differences in the types, seriousness and frequency of complications, and these differences are not reflected in revision rates.
In deciding between the two operations, patients need to know what can go wrong with each, how often, and what can be done if it happens.
Considering the options.
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References
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