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Reverse shoulder arthroplasty

Surgeon-side topic for reverse shoulder arthroplasty. Backed by 399 articles from the corpus, retrieved via combined MeSH + title-text matching.

151 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Reverse total shoulder arthroplasty (RTSA) is a surgical intervention that restores shoulder function through significant improvements in pain, motion, and functional capacity [3, 4]. While the procedure has been highly successful in cuff-deficient shoulders [17], its indications continue to broaden [17]. RTSA is not indicated as a first-line treatment for primary osteoarthritis with an intact rotator cuff and no glenoid deformity, as it does not offer functional benefits over anatomic total shoulder arthroplasty in this specific population [1]. Similarly, for glenohumeral osteoarthritis with an intact rotator cuff, anatomic total shoulder arthroplasty provides better value at an average of four years [7]. However, RTSA provides optimal outcomes and is associated with low complication rates for glenohumeral osteoarthritis with an intact rotator cuff across short-term follow-up [154]. The procedure is also utilized for rheumatoid arthritis, where it improves shoulder function with a low incidence of complications [20], and for acute proximal humeral fractures in geriatric patients, showing promising results with mean active anterior elevation improving from 97 to 122 degrees [23].

Clinical outcomes are generally favorable, with benefits maintained out to ten years [38]. Primary RTSA in patients aged 65 years or younger yields good short- to medium-term outcomes and high implant survival [13]. In morbidly obese patients, RTSA appears as safe and effective as in the general population, though it is associated with increased cost, a lower rate of discharge to home, and greater post-discharge care needs [61]. Complication rates for primary RTSA are within an acceptable range, with a low rate of revision [29]. However, patients younger than 60 years experience significantly higher rates of 90-day surgical complications compared to older patients [11], and smoking increases the risk for revision, reoperation, and complications in patients aged 65 years or younger [13]. For acute proximal humeral fractures in the geriatric patient, complication rates range from 15% to 28% in short-term studies [23].

Revision RTSA outcomes are generally inferior to primary procedures, with complications and revision surgeries being common [2]. Despite this, revision RTSA leads to notable improvements in pain, motion, and function [2] and demonstrates significant long-term clinical improvements [5]. The implant survival rate for revision RTSA is 85% at ten years [5]. Indications for initial shoulder replacement do not influence the clinical outcome after conversion to RTSA at long-term follow-up [8]. RTSA is related to promising subjective, objective, and radiologic long-term results for the treatment of failed anatomic shoulder arthroplasty [9]. At mid-to-long-term follow-up, RTSA demonstrates significantly fewer complications and reoperations than anatomic total shoulder arthroplasties [10]. The utilization of primary shoulder arthroplasty has increased significantly, with RTSA making a major contribution to this rise in 2011 [6]. Pre-operative glenoid bone mineral density varies significantly by indication for RTSA [62].

Anatomy & Pathophysiology

Bony Anatomy and Implant Biomechanics

The glenoid is suspended from the scapular body by the neck and fixed to the clavicle via the acromioclavicular and coracoclavicular ligaments [45]. As the glenoid face transitions into the neck, the vault narrows [45]. The scapular spine is subcutaneous posteriorly and widens laterally into the acromion base [45]. The acromion curves anteriorly to meet the clavicle at the acromioclavicular joint and the coracoid via the coracoacromial ligament, which originates under the anterior acromial margin [45].

Reverse shoulder arthroplasty (RSA) reverses natural glenohumeral anatomy by replacing the concave glenoid with a convex hemispherical glenosphere and the convex humeral head with a concave polyethylene cup [200]. Unlike anatomic total shoulder arthroplasty, which reproduces premorbid kinematics, RSA achieves stability through a semi-constrained design [88]. This semiconstrained nature provides a stable fulcrum that allows the deltoid to elevate the shoulder even in the absence of a functional rotator cuff [68].

In the Grammont reverse prosthesis, the glenoid component articulating portion is shaped as one-third of a sphere [68]. The center of rotation is medial to the glenoid component–bone interface to decrease shear stress and provide compressive stress [68]. The humeral component is inset, resting almost completely inside the proximal humerus metaphysis [68]. The polyethylene opening angle is 155 degrees [68]. Once articulated, the humerus is more medial and distal than preoperatively, providing a mechanical advantage to the deltoid for active elevation [68]. The humeral component is recommended for implantation in 0 to 10 degrees of retroversion [68].

Subsequent reverse designs with a larger portion of a sphere place the center of rotation more lateral than the Grammont prosthesis and select an opening angle of 135 degrees for the humeral component [68]. Later designs introduced onlay humeral bearings, which lateralize the humerus without changing the center of rotation, using a 145-degree opening angle for the bearing [68]. The polyethylene cup in RSA is relatively shallow compared with ball-in-socket articulations, resulting in low coverage of the hemispherical glenosphere [200]. During humeral elevation, the RSA articulation is subjected to oblique loading with a shear component of deltoid force acting perpendicular to the central axis of the polyethylene cup [200].

The traditional Grammont style decreases shear forces on the glenoid and lowers baseplate failure by medializing the center of rotation [152]. Distalization in RSA doubles the deltoid lever arm and optimizes its length–tension curve, increasing efficiency by 30% at the cost of rotational strength [152]. Lateralized glenosphere and humerus designs aim to improve the rotational profile, deltoid function, implant stability, and decrease impingement [152]. Early RSA designs had a high failure rate due to the profound lever arm on the glenoid and baseplate bone [152]. Recent RSA designs have increased forces seen by the scapula and acromion [152].

Anatomic TSAs and hemiarthroplasties depend on the rotator cuff to center the head in the glenoid and optimize periscapular muscle function [152]. Without this centering force, the deltoid pulls the humerus proximally, shearing along the glenoid and resulting in eccentric glenoid wear, acetabularization of the acromion, and pseudoparalysis [152]. The RSA does not require the rotator cuff for function but is dependent on an intact deltoid neuromuscular unit [152]. Grammont et al. described RSA principles as: 1) the prosthesis must be inherently stable (perfectly concentric), 2) the weight-bearing part must be convex and supported part concave (reversed), 3) the center of the sphere must be at or within the glenoid neck (medialized), and 4) the center of rotation must be medialized and distalized [152].

The goal of RSA glenoid fixation is to implant the central peg or screw within the glenoid vault in the axis of the scapular body without perforation [45]. Peripheral locking screws guide fixation within specific bony landmarks: * Inferior and posterior screws: Lateral pillar of the scapula [45]. * Superior screw: Base of the coracoid [45]. * Anterior screw: Scapular spine [45].

The anterior deltoid is biomechanically important for balanced function after RSA [94]. Greater tuberosity healing does not impact RSA biomechanics during abduction or forward flexion but affects biomechanics during external rotation [110]. Even if the teres minor external rotation moment arm is higher in RSA than in a normal shoulder, decreased length could impair its force generation [113]. Varying glenosphere configurations leads to range of motion and muscle length changes following RSA [139]. Increasing glenosphere diameter alone did not alter the deltoid moment arm [141]. Although increasing glenosphere diameter significantly increased joint load and deltoid force, the clinical impact of these changes is presently unclear [148]. Moderate lateralization of the glenosphere of +5 mm has improved range of motion in a cadaveric setup [147]. Biomechanical analysis demonstrated that RSA models produce moment arms that vary between muscles, with some contributing more to abduction and some contributing less [144]. Key biomechanical parameters are frequently reported without clear, quantitative, or reproducible definitions, which may hinder interpretation and comparison of published findings [149]. Preoperative planning using supine CT may inaccurately pose bones, with consequent effects on the surgical plan, the resultant shoulder biomechanics, and clinical outcomes [138].

Kinematics

RTSA shoulders show kinematics significantly different from normal shoulders, utilizing much more scapulothoracic motion and much less glenohumeral motion to elevate the arm [90, 91]. The scapulothoracic contribution to overall shoulder movement is significantly increased in patients with an rTSA compared with a healthy shoulder [143]. Scaption kinematics of reverse shoulder arthroplasty do not change after the sixth postoperative month [92]. Shoulders with good elevation showed significantly higher scapulohumeral rhythm than those with poor elevation, while no other statistically significant kinematic differences were found between the groups [102]. Postoperative changes in scapular kinematics following a reverse total shoulder arthroplasty positively impact shoulder function and patient-reported outcome measures [142]. Scapular kinematics of patients with shoulder arthroplasty was influenced by implementation of external loads, but not by the type of load [87]. Impingement is determined by scapular motion, which should be included in all shoulder models [97]. Humeral version in reverse shoulder arthroplasty affects impingement in activities of daily living [26].

Neurovascular Anatomy and Nerve Injury

The suprascapular nerve arises from the C4–C5 nerve roots off of the supraclavicular brachial plexus at “Erb’s point” [45]. It runs just medial to the base of the coracoid, under the transverse scapular ligament within the suprascapular notch [45]. The nerve gives off branches to the supraspinatus within 1 cm of the suprascapular notch [45]. It continues through the supraspinatus fossa heading laterally and distally on the under surface of the supraspinatus [45]. The nerve runs under the ill-defined spinoglenoid ligament around the lateral base of the scapula within the spinoglenoid notch [45]. It terminates in posterior capsular sensory branches heading laterally and an infraspinatus motor branch heading medially within 1 cm of the lateral margin of the scapular spine [45].

Cadaver studies show the suprascapular nerve is present 29 mm (23 to 35 mm) from the superior rim of the glenoid at the suprascapular notch [45]. Cadaver studies show the suprascapular nerve is present 18 mm (14 to 24 mm) from the posterior rim at the spinoglenoid notch [45]. Injury to the suprascapular nerve can cause pain and denervation of the supraspinatus and infraspinatus [45]. It is recommended to limit superior screw length to ≤25 mm and posterior screws to ≤15 mm when possible to reduce the risk of suprascapular nerve injury [45]. The suprascapular nerve is commonly injured by the fracture itself or becomes encased in callus in the setting of periprosthetic scapular fractures [45].

Pathophysiology of Complications

Periprosthetic scapular fractures are universally associated with stable glenoid implants [43]. Periprosthetic scapular fracture is unlikely in the face of dislocation, glenosphere dissociation, or baseplate pullout at the bone–baseplate interface [43]. Periprosthetic scapular fracture has been noted to result in new glenohumeral instability due to the change of the orientation of the glenosphere and loss of deltoid tension [43]. Diagnosis of periprosthetic fractures is often subtle and requires a high index of suspicion [43]. New pain at the base of the acromion may be the only finding in a stress reaction and should raise suspicion for fracture [43]. Stress fractures can actually be more painful than after they propagate into a displaced fracture [43].

Patients typically present around their 8th decade of life after a sudden increase in pain or loss of function in an otherwise smooth postoperative course [43]. Periprosthetic scapular fractures generally occur within 1 year but up to 2 years from surgery [43]. Patients who go on to have periprosthetic scapular fractures initially outperform those who do not [43]. Risk factors for periprosthetic scapular fracture include a history of steroid use, osteoporosis, subacromial decompression, or rotator cuff tear arthropathy [43].

Clinical signs and symptoms include: * Deformity: Concerning for dislocation, hematoma, or displaced fracture [43]. * Erythema or incisional dehiscence: Concerning for infection [43]. * Tenderness along the acromion or scapular spine: Raises suspicion for fracture which should be confirmed with imaging [43]. * Motion limited by pain, new weakness, or loss of function: Consistent with fracture [43]. * Sudden loss of function or increase in pain: Consistent with both scapular fracture and infection and should trigger further workup [43].

Postoperative periprosthetic scapular fractures have been increasingly recognized following RSA, with rates of 0.9% to 11.2% reported in the literature [152]. Periprosthetic scapular fracture is an effect of the nonphysiologic forces transferred from the implant to the scapula, often in a suboptimal host [152]. Female gender has been implicated as a risk factor for periprosthetic scapular fracture, with females accounting for up to 100% of some series [152]. Periprosthetic scapular fractures typically occur in patients 70 to 80 years old [152]. A study looking specifically at patients under age 65 undergoing RSA showed a 0% (0/67) postoperative periprosthetic scapular fracture rate [152]. Patients with postoperative acromial fracture were found to be significantly older than those without fracture in a retrospective cohort study of 318 RSAs [152]. Osteoporosis is a significant risk factor for postoperative scapular spine fractures, with 30.8% of fracture patients having osteoporosis compared to 18.4% of controls (OR 1.97; p < 0.05) [152]. Smoking status and prolonged steroid use were nearly double in the fracture group but were not statistically significant risk factors for periprosthetic scapular fracture [152]. Endocrine disease, autoimmune disease, and alcohol abuse were not statistically found to be risk factors for periprosthetic scapular fracture [152]. Fatigue fracture has been found to occur through already weakened acromiums or those with preexisting lesions [152]. Acromial thinning and eventual fragmentation occurs at the final stages of rotator cuff-tear arthropathy as the humeral head acetabularizes [152].

Dislocation after reverse arthroplasty represents a major source of concern despite the semiconstrained nature of RSA [214]. Some authors have proposed that dislocation occurs in abduction and extension [214]. Failure to achieve deltoid tension may place the implants at risk of instability [214]. Medial centre of rotation RSA changes the line of pull of the deltoid, which may have a dislocating effect [214]. Factors that can influence the degree of stability of RSA are the soft tissue balance, glenosphere size, the inclination of the humeral articular joint line, the version of the humeral component and the position of the metaglene [214]. Impingement of either bone or soft-tissue structures may also contribute to dislocation [214]. The incidence of instability without subscapularis repair was double compared to when subscapularis repair was obtained in a study using a medial centre of rotation prosthesis and a deltopectoral approach [214]. Repair of the subscapularis was associated with a greater improvement in range of motion in internal rotation when compared to patients without repair [214]. A study of 284 arthroplasties found 11 cases of instability in 212 primary cases (5.2%) and six cases in 72 revision arthroplasty cases (8.3%) [214]. Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models [99]. Glenoid notching is associated with poorer results in traditional Grammont style RSA [152].

The main potential pitfalls of reverse shoulder arthroplasty for fracture include poor placement of the glenoid or the humeral component, and poor tuberosity reduction or fixation [171]. Excessive reaming must be avoided during RSA for fracture because the glenoid bone will not have the hard subchondral sclerosis present when reverse is performed for arthritis [171]. Placement of the humeral component too high, too low, or in poor version can lead to poor soft tissue tension and negatively affects tuberosity healing [171]. Reduction of the greater tuberosity over the shoulder of the prosthesis can be particularly problematic, and it is easy to leave the greater tuberosity too posterior [171]. Cement in the fracture planes may impede tuberosity healing [171]. The top priority in RSA for fracture is to achieve the right balance between adequate deltoid tension and satisfactory reconstruction of the tuberosities [158]. In the treatment of proximal humeral nonunion, not performing a tuberosity repair at the time of reverse arthroplasty has been correlated with a higher rate of dislocation [68]. Many believe that healing of at least the greater tuberosity in good position provides a higher chance of restoration of active external rotation, which is very important for the overall functional outcome [68]. Technical principles for RSA for fracture may need to be modified to enhance tuberosity healing, which may translate into avoiding translating the humeral shaft too lateral or too distal so that the tuberosities can actually overlap a few millimeters with the shaft [68]. Use of a stem with fracture-dedicated features (proximal ingrowth surface, small cross section, holes for suture fixation) may be beneficial for tuberosity healing [68]. Shoulder arthroplasty is considered for proximal humeral nonunion in the presence of severe cavitation and bone loss at the humeral head and metaphysis or collapse and degenerative change of the humeral articular surface [71]. Severe tuberosity malunion in the setting of a proximal humeral nonunion is more reliably compensated for with reverse arthroplasty than

Classification

Postoperative Acromial Fracture Classification: A classification system for postoperative acromial fractures following reverse shoulder arthroplasty was developed and found to be reliably reproducible among fellowship-trained shoulder surgeons [74]. Type I involves only a portion of the middle deltoid origin, similar to a pre-acromion or meso-acromion-type os acromiale [74]. Type II involves at least the entire middle deltoid origin and may include portions of the posterior deltoid origin [74]. Type III involves the entire middle and posterior deltoid origin, similar to an acromial base fracture [74].

Glenoid Wear Classification (Primary RSA): In primary reverse shoulder arthroplasty cases, glenoids were classified into four groups depending on the location and severity of glenoid wear [79]. Group 1 includes severe central glenoid erosion with medialization of the joint line [79]. Group 2 includes anterior glenoid bone loss [79]. Group 3 includes posterior glenoid bone loss with a posterior subluxation [79]. Group 4 includes small glenoids with osteoporotic bone with a glenoid vault ≤ 20 mm of depth in the coronal plane [79].

Sauzieres’ Classification (Revision RSA): In revision cases, glenoid bone loss was quantified according to the Sauzieres' classification into five different types [79]. Type A is a central defect respecting cortical bone [79]. Type B is a peripheral defect of the anterior wall of less than a third of the depth [79].

Favard Classification: The Favard classification evaluates glenoid erosion in the sagittal plane with types E0, E1, E2, and E3 [79]. E0 is defined as superior humeral head migration without erosion of the glenoid [179]. E1 is defined as concentric erosion of the glenoid [179]. E2 is defined as erosion limited to the superior part of the glenoid [179]. E3 is defined as erosion extending to the inferior part of the glenoid [179].

Hamada et al. Classification: The Hamada et al. classification is based on radiographic features including narrowing of the subacromial space and degenerative changes of the glenohumeral joint [80]. In a study of 527 reverse shoulder arthroplasties, patients were divided into three groups according to etiology and the five-grade classification of Hamada et al. [80]. The CTA group included shoulders with Grade 4 or 5 [80]. The MCT group included shoulders with Grade 1, 2, or 3 [80].

Other Considerations: Current classification systems exhibit poor reliability in categorizing glenoid defects following reverse shoulder arthroplasty removal [98]. Regarding postoperative acromial fractures, outcomes scores were universally improved from preoperative scores for all type-II acromial fractures [74]. Outcomes scores were not improved for any outcome measure for type-I acromial fractures [74]. Only the SANE score improved significantly for type-III acromial fractures [74]. No good or excellent results were observed for type-III acromial fractures [74]. Two revision arthroplasties were performed for type-III acromial fractures that sustained subsequent glenohumeral dislocations requiring revision surgery to increase deltoid tension [74]. No patient with a postoperative acromial fracture was treated with surgical fixation of the acromial fracture [74].

Clinical Presentation

Patients typically present in their 8th decade of life with a sudden increase in pain or loss of function following a smooth postoperative course [43]. The onset of periprosthetic scapular fracture symptoms generally occurs within 1 year but up to 2 years from surgery [43]. Notably, patients who subsequently develop periprosthetic scapular fractures initially outperform those who do not [43]. A sudden loss of function or increase in pain is consistent with both scapular fracture and infection [43].

Inspection: Deformity on inspection is concerning for dislocation, hematoma, or displaced fracture [43].

Palpation: Tenderness along the acromion or scapular spine raises suspicion for fracture [43]. New pain at the base of the acromion may be the only finding in cases of stress reaction and should raise suspicion for fracture [43]. Stress fractures can be more painful than after they propagate into a displaced fracture [43].

Stability and Special Tests: Periprosthetic scapular fractures have been noted to result in new glenohumeral instability due to the change of the orientation of the glenosphere and loss of deltoid tension [43].

Red-Flag Patterns: While reverse shoulder arthroplasty reliably relieves pain and improves function [3], with significant improvements in range of motion and markedly decreased pain [56], new acute symptoms warrant immediate evaluation. When patient selection is optimized, the procedure is a reliable means of relieving pain and improving function with excellent success [33]. Short-term studies report promising results, including mean active anterior elevation from 97 to 122 degrees [23], and onlay designs yield good short-term clinical results [51]. The clinical and radiographic evaluation of a bone preserving metaphyseal humeral component is also promising, with good clinical results [52].

Long-Term Outcomes: Patients who underwent reverse shoulder arthroplasty a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls [36]. Significant improvement in the ASES and VAS scales has been documented [53]. At short term, reverse total shoulder arthroplasty relieved pain and improved function [18]. This study confirms the clinical benefits of reverse shoulder arthroplasty, with improvements maintained out to 10 years [38]. Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty [25].

Specific Populations and Indications: Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [54]. The functional outcomes of reverse shoulder arthroplasty are good in the obese population after 4 years of follow-up [49]. All patients stated that they would undergo reverse shoulder arthroplasty again in the context of weight-bearing shoulders of wheelchair-dependent patients [12]. Reverse arthroplasty in rheumatoid arthritis improved shoulder function with a low incidence of complications [20]. Reverse shoulder arthroplasty can be used to treat deltoid myopathy due to corticosteroid usage and can produce reliable improvements in clinical manifestations and functions without an increased risk of dislocation [118]. Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side [24]. The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [39].

Investigations

Plain radiography: Radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty [172]. Preoperative assessment requires careful evaluation of radiographs to plan component positioning, version, inclination, and rotation, as well as anticipated screw length [70]. Radiographs of both humeri (affected and unaffected) with magnifier markers may be used to understand where the stem should be positioned in reference to the fracture line on the humeral shaft [70].

CT: Clinical CT is inconsistent at visualizing the presence or absence of bone graft resorption adjacent to a reverse shoulder arthroplasty glenoid baseplate due to metal artifact [199]. However, careful assessment of preoperative CT with three-dimensional reconstruction is extremely useful in preparation for surgery [70]. The glenoid should be assessed in CT to plan for component positioning, version, inclination, and rotation, as well as anticipated screw length [70].

Laboratory: Infection should be investigated with laboratory tests [43].

Other Considerations: The past medical history should elucidate the underlying diagnosis for the index surgery and subsequent surgeries, and any complications including infection should be accounted for [43]. Past medical history must identify risk factors including a history of steroid use, osteoporosis, subacromial decompression, or rotator cuff tear arthropathy [43]. Previous operative reports, clinic notes, and imaging can help provide a thorough understanding of any previous surgeries on the shoulder or history of radiation [43]. The examiner should understand the patient's shoulder function and level of disability before surgery, after surgery, and at present, as well as the time course of these changes [43]. A smaller subcoracoid distance is significantly associated with higher postoperative pain and reduced internal rotation at the spine level two years after reverse shoulder arthroplasty [81].

Physical Examination: Inspection for deformity is concerning for dislocation, hematoma, or displaced fracture [43]. A complete neurovascular examination is performed as well as assessment of active and passive motion [43]. In the case of a stress reaction, new pain at the base of the acromion may be the only finding, and should raise suspicion and spark further imaging or a period of rest [43].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions for reverse shoulder arthroplasty candidates.

Operative

Indications: Reverse shoulder arthroplasty (RSA) is a highly successful option for cuff-deficient shoulders, with indications continuing to broaden [17]. It serves as a versatile revision option following the failure of primary procedures, including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation [168]. For proximal humerus fractures, RSA is a powerful tool when joint-preserving options are not optimal, provided there is careful management of the tuberosities [115]. Management of complex superior humeral fractures by RSA is an accepted approach but is restricted to elderly patients [124]. In patients with glenohumeral osteoarthritis and an intact rotator cuff, total shoulder arthroplasty provides better value than RSA at an average of 4 years, despite higher rates of radiographic loosening without higher revision rates [7]. Conversely, the value of RSA was very low in comparison with controls for massive rotator cuff tears with poor functional improvement risk factors [30]. RSA is also a reasonable option for tumors of the proximal humerus, restoring a mean active abduction of 157 degrees and limiting impairment of activities of daily living [77]. Composite RSA is functionally effective after massive resection for proximal humerus tumors [41].

Patient Selection and Age Considerations: RSA use has increased among patients younger than 60 years, but this population experiences significantly higher rates of 90-day surgical complications compared to older patients [11]. Primary RSA in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications [13]. In the predominantly male patient population below the age of 55, RSA and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty [16].

Surgical Approach / Technique: The deltopectoral approach is generally preferred for accessing the glenohumeral joint during RSA [82]. A standard deltopectoral approach with the patient in the beach-chair position allows for exposure of the proximal humeral fracture as well as identification and mobilization of the greater and lesser tuberosities [197]. The anterosuperior approach uses a more limited superiorly based incision and a deltoid split, offering greater tuberosity access but requiring deltoid detachment with potential dehiscence and limited extensibility [191]. This approach can be used in primary and revision RSA, as well as in acute humeral head fracture [108]. The deltopectoral approach allows adequate access to fracture fragments for suture fixation and provides excellent glenoid exposure after fracture fragment mobilization, although exposure and reduction of the greater tuberosity can be challenging [191].

During the procedure, the long head of the biceps is systematically cut [82]. Different exposure techniques have been described to manage the subscapularis, including tenotomy, peel, and lesser tuberosity osteotomy; each technique has been shown to be effective and safe in the short term with no proven difference [82]. A resection of the humeral head is performed according to preoperative planning, frequently 2 mm below the articular cartilage [82]. In fracture cases, the fractured humeral head is extracted and measured, with no further humeral resection typically needed [197]. The humeral canal is sequentially reamed by hand to prevent iatrogenic fracture propagation [197]. A trial humeral component is placed to confirm proper humeral canal sizing and to approximate humeral height, although proper humeral height cannot be confirmed until after the glenosphere is placed [197]. The greater tuberosity is retracted posteriorly, and the lesser tuberosity is retracted anteriorly, with care being taken not to detach any remaining soft-tissue attachment [197]. A soft tissue biceps tenodesis is performed in all cases during the preferred deltopectoral technique for RSA in fractures [191].

For allograft-prosthetic composite reconstruction, the shoulder and humeral diaphysis are exposed through the deltopectoral interval proximally and through splitting of the brachialis (the Henry approach) distally [190]. The incision is at the junction between the medial third and the lateral two-thirds of the distance between the coracoid and posterolateral aspect of the acromion proximally, aiming distally toward the lateral aspect of the brachialis [190]. The deltoid is mobilized laterally and the pectoralis and conjoined tendon medially [190]. The axillary nerve is identified and protected throughout the procedure [190]. If the subscapularis is intact, it is isolated and tagged; if the posterosuperior cuff is intact, it is also isolated and tagged [190]. For longer defects, the deltoid and pectoralis may need to be isolated and tagged [190]. If the latissimus dorsi and/or teres major will be transferred to provide active external rotation, their tendons are identified, mobilized, and tagged [190]. If the tendon of the long head of the biceps is still intact, it is divided and tagged for tenodesis at the end of the procedure [190]. If the distal third of the humeral shaft needs to be exposed for plate fixation, the radial nerve is identified and isolated at the interval between the brachialis and common extensor group (brachioradialis) [190]. The brachialis is split in line with its fibers, leaving approximately 20% of the brachialis width laterally, with protection of the radial nerve [190]. A sufficient length of the distal aspect of the humerus is exposed to allow secure plate fixation, typically for 5 to 6 holes for plate and screw fixation [190].

Implant Selection: In the Grammont reverse prosthesis design, the center of rotation is medial to the glenoid component–bone interface, intended to decrease shear stress and provide compressive stress to reduce the chances of glenoid loosening [68]. The humeral component is recommended to be implanted in more anteversion (0 to 10 degrees of retroversion) than conventional arthroplasty in this design [68]. A more horizontal opening angle is selected to decrease the chances of dislocation [68]. Use of a stem with fracture-dedicated features, such as a proximal ingrowth surface, small cross section, and holes for suture fixation, may be beneficial for enhancing tuberosity healing in RSA for proximal humeral fractures [68]. The humeral component can be implanted in any retroversion between 0° and 20° [69]. Significant differences in initial fixation exist between reverse shoulder implants having an equivalent center of rotation, suggesting that design parameters other than center of rotation position significantly affect fixation [163].

Alignment / Balancing Strategy: Glenosphere position significantly affects humeral internal and external rotation after RSA [160]. The effect of humeral component retroversion on clinical outcomes is unclear, although the general consensus tends to agree on restoring 0 to 20 degrees of retroversion [82]. Concomitant subscapularis repair in lateralized RSA decreased glenohumeral abduction and increased internal rotation [109]. Surgeons recommend humeral lengthening of at least 24 mm after implanting a total reverse shoulder prosthesis [150].

Revision: Although outcomes are generally inferior to primary RSA and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function [2]. Revision RSA demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years [5]. At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty [8]. In the revision setting, the surgeon may need to remove a well-fixed humeral component to implant an RSA [193]. A useful technique for removing a well-fixed humeral component involves using a vertical split osteotomy to facilitate component removal [193]. A longitudinal humeral unicortical osteotomy is started in the proximal edge of the bicipital groove with an osteotome down to the implant [193]. Multiple osteotomes are then used to twist, wedge, and 'open book' the canal while preserving the medial cortex [193]. This approach can be implemented for a cemented stem or a press fit in the growth stem [193]. The osteotomy is then closed with wires before cementing the implant [193]. Convertible implants are available in some systems that allow modular transformation of a hemiarthroplasty or traditional shoulder replacement into a reverse prosthesis [193].

In a series of conversions from hemiarthroplasty to RSA, the humeral stem had to be removed in all 5 patients (35.7%) [189]. In two cases, the humeral stem was found 40–60° retroverted [189]. In two cases, the humeral stem was loose and was easily removed with an impactor from below without the need for osteotomy [189]. In three cases, the stem was well fixed and an L-type extended humeral osteotomy was performed [189]. Three cerclage wires were passed around the humerus prior to opening the osteotomy with extreme caution not to damage the axillary and radial nerves [189]. The distal cerclage wire was placed and directly tied, approximately 1 cm just below the end of the osteotomy [189]. The subscapularis and the rotator cuff, if in good condition, were tagged with heavy non-absorbable sutures and mobilized to be reattached at the humerus after implantation [189]. The contralateral humerus was used as a template to define the height of the prosthetic stem [189]. Specific implants used included the Delta III RSA (DePuy Inc., Warsaw, IN, USA) in 3 shoulders (21.4%), the Anatomical Shoulder Reverse system (Zimmer Inc., Warsaw, IN, USA) in 4 shoulders (28.6%), the Arrow Prime RSA (FH Ortho Inc., USA) in 6 shoulders (42.9%), and the Duocentric Reversed shoulder prosthesis (Aston Medical, France) in 1 patient (7.1%) [189].

Other Considerations: RSA is associated with a higher reported rate of infection compared with anatomic total shoulder arthroplasty [15]. This review identifies the most common and serious complications associated with RSA and discusses current methods of management [34]. Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with fractures are generally inferior to those of a control group undergoing RSA without fracture [156]. Results of nonoperative treatment of acromial/scapular spine fractures following RSA differ based on fracture location [162]. In-hospital complications are more likely to occur after RSA than after locked plating for proximal humeral fractures [170]. Surgeons may need to reconsider the routine use of RSA over locked plating until consistent evidence demonstrates an advantage, particularly regarding functional outcomes or reoperation risk [170]. The primary or secondary implantation of the reverse shoulder prosthesis in proximal humeral fractures has to be planned carefully, since long-term results are still lacking and treatment options after failed RSA are few [65].

A Fukuda posterior glenoid retractor is inserted with the arm in a forward flexed and internally rotated position [195]. The surgeon should aim to position the apex of the Fukuda retractor on the posterior glenoid and, once it is in place, externally rotate the arm to retract the resected humerus posteriorly [195]. The arm is then positioned resting in external rotation on the Mayo stand [195]. A wide anterior glenoid retractor is utilized.

Complications

General Complication Rates: The overall complication rate for reverse shoulder arthroplasty (RSA) varies by cohort, ranging from 5.1% in a series of 297 shoulders [176] to 17% in patients younger than 65 years [64]. While systematic reviews indicate modest complication and revision rates at minimum 5-year follow-up [230], long-term data suggest high revision rates [227]. Revision RSA outcomes are generally inferior to primary procedures, with higher complication and reoperation rates, though pain, motion, and function still improve notably [2]. Complications remain within an acceptable range for primary RSA with low revision rates [29], yet high rates of instability, infection, scapular notching, neurologic injury, and component loosening persist [231].

Infection (PJI): Periprosthetic joint infection (PJI) is a significant risk, particularly in patients with previous rotator cuff repair [220] or patient-reported penicillin allergy, the latter likely due to second-line antibiotic use [232]. RSA should be deferred at least 4 weeks after corticosteroid injection [19]. Staged RSA implantation is a reliable treatment for primary, secondary, and periprosthetic infections, offering satisfactory infection control and survival despite persistent functional impairment [222]. Two-stage reimplantation eradicated infection in 85% of shoulders [223].

Aseptic Loosening: Aseptic loosening of the RSA baseplate is rare (1.7% in long-term follow-up) compared to glenoid loosening in anatomic arthroplasty [73]. Early baseplate loosening suggests inadequate primary anchorage due to technical failure or poor bone stock [73]. Malposition with superior inclination exceeding 20° or >20mm above the inferior glenoid rim, and excessive lateralization, leads to shearing forces and pull-out [73]. If bone graft is used, central post or screw fixation in native bone must exceed 5-10mm to prevent loosening [73]. Humeral component loosening rates are low, but aseptic glenoid loosening and instability drive higher re-revision rates over time [194]. Primary inlay RSA has a higher revision rate than onlay RSA [215]. Long-stem humeral components are beneficial in revision RSA, though high rates of humeral loosening remain concerning [78].

Instability: Instability is a common complication, occurring in 5% of patients younger than 65 [64]. Suitable positioning of prosthesis components can effectively reduce common complications, including instability [217].

Periprosthetic Fracture: In a series of 297 shoulders, postoperative periprosthetic humeral fractures occurred in 3 cases (1.0%) and acromion/scapular spine stress fractures in 5 cases (1.7%) [176].

Nerve Palsy: The main anterior circumflex branch of the axillary nerve lies in close contact with the humeral metaphysis, with a mean distance of 5.2 ± 2.1 mm (range, 2.0 to 8.1 mm) [112]. Contact between this nerve branch and the humeral implant was observed in 3 of 6 specimens, with only the thin capsule separating them when present [112]. Nerve injury causes are multifactorial, including direct damage during dissection, compression from retractors or hematoma, and excessive mobilization [112]. One series reported a postoperative axillary nerve palsy that resolved spontaneously within 12 months [174].

Thromboembolism: Venous thromboembolism is infrequent following shoulder arthroplasty, with an incidence of 0.82% after RSA [198].

Other Considerations: Male sex is an independent risk factor for perioperative complications and unplanned reoperation after RSA for proximal humeral fracture [233]. Surgeon experience is associated with a substantial reduction in serious complications [40], although no trend in early complications was observed in the RSA cohort compared to the trend seen after 16 cases for anatomical shoulder replacement [44]. Total shoulder arthroplasty provides better value than RSA at an average of 4 years, despite higher radiographic loosening rates without higher revision rates [7]. Primary RSA for cuff-deficient shoulders or osteoarthritis leads to high 10-year survival, whereas revision RSA or primary RSA for fracture sequelae and tumors carry high revision risk [225]. In wheelchair-dependent patients with weight-bearing shoulders, all patients stated they would undergo RSA again [12]. For acute proximal humeral fractures in geriatric patients, RSA shows promising results with mean active anterior elevation improving from 97 to 122 degrees, though complication rates range from 15% to 28% in short-term studies [23]. A meta-analysis found no significant differences in clinical outcomes or complication rates between standard and fracture-specific components for proximal humerus fractures [226]. The value of RSA in specific case groups was very low compared to controls [30].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty, affecting range of motion and activities of daily living in the mid-term to long-term follow-up [119]. Early, active rehabilitation is safe and effective, potentially offering early clinical benefits over a conservative, delayed mobilisation programme [135]. Self-directed home therapy may serve as a viable alternative to formal supervised physical therapy, showing no significant differences in outcomes across multiple measures [146]. Rehabilitation guidelines aim to achieve optimal pain relief and maximize functional outcomes while mitigating surgical risks [66]. Active external rotation after reverse total shoulder arthroplasty is complex and not governed by a single muscle-tendon unit [128].

Functional milestones: Patients who underwent reverse shoulder arthroplasty a mean of 5 years earlier exhibit similar functionality and health-related quality of life compared to healthy controls [36]. Most patients active prior to surgery successfully return to their activity afterwards [107], and return to sports is possible and highly frequent [161]. All patients stated that they would undergo the procedure again [12]. Composite reverse shoulder arthroplasty is functionally effective after massive resection [41]. At medium-term follow-up, the procedure is a reasonable option for tumors of the proximal humerus with low morbidity, restoring a mean active abduction of 157 degrees and limiting the impairment of activities of daily living [77]. The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae [63]. Shoulder function and pain improved in patients treated with a second-stage reimplantation of a reverse prosthesis, with a low reinfection rate [76]. Two-stage revisions using a reverse total shoulder arthroplasty at the time of reimplantation generate superior range of motion and functional outcome scores [67]. Preoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols [167].

Other Considerations: Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications [218]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [83]. Functional outcome is improved following reverse shoulder arthroplasty for proximal humeral fractures when tuberosity healing occurs [216]. At mid-to-long-term follow-up, reverse shoulder arthroplasties demonstrated significantly fewer complications and reoperations than anatomic total shoulder arthroplasties [10]. Functional outcomes of proximal humerus fractures treated with reverse shoulder arthroplasty improve with surgical experience, and outcomes become less variable after approximately 20 procedures [37]. In comparison to the trend seen after 16 cases for anatomical shoulder replacement, no trend was seen in the reverse shoulder replacement cohort [44]. Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed [153].

Key Evidence

• [L3] Reverse total shoulder arthroplasty does not appear to offer functional benefits over anatomic total shoulder arthroplasty in this population. [1] (10.1016/j.jse.2025.01.038)
• [L5] Although the outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function. [2] (10.5435/jaaos-d-17-00535)
• [L2] Reverse total shoulder arthroplasty restores function in the shoulder with significant improvements in function and moderate complications. [3] (10.1177/1758573220977184)
• [L3] Reverse shoulder arthroplasty markedly improved shoulder function. [4] (10.1007/s00264-013-2277-7)
• [L3] Revision reverse shoulder arthroplasty demonstrates significant long-term clinical improvements and an implant survival rate of 85% at ten years. [5] (10.1302/0301-620x.107b11.bjj-2025-0436.r1)
• [L3] The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011. [6] (10.1016/j.jse.2014.06.055)
• [Abstract] Total shoulder arthroplasty provides better value than reverse shoulder arthroplasty at an average of 4 years, despite higher rates of radiographic loosening without higher revision rates. [7] (10.1016/j.jse.2014.11.013)
• [Abstract] At long-term follow-up, indications for initial shoulder replacement do not influence the clinical outcome after conversion to reverse total shoulder arthroplasty. [8] (10.1016/j.jse.2022.01.004)
• [L3] Reverse shoulder arthroplasty is related to promising subjective, objective and radiologic long-term results for the treatment of failed anatomic shoulder arthroplasty. [9] (10.1016/j.jse.2022.01.003)
• [L3] At mid-to-long-term follow-up, reverse shoulder arthroplasties demonstrated significantly fewer complications and reoperations than anatomic total shoulder arthroplasties. [10] (10.1177/1758573220921150)
• [L3] Reverse total shoulder arthroplasty use has increased among patients younger than 60 years of age, but this population experiences significantly higher rates of 90-day surgical complications compared to older patients. [11] (10.1016/j.jseint.2025.05.020)
• [L4] All patients stated that they would undergo reverse shoulder arthroplasty again. [12] (10.1016/j.pmrj.2017.10.010)
• [L3] Primary reverse shoulder arthroplasty in patients aged 65 years or younger yields good short-term to medium-term outcomes with high implant survival, though smoking increases the risk for revision, reoperation, and complications. [13] (10.1016/j.jse.2016.05.026)
• [Paper] The most-cited articles on reverse total shoulder arthroplasty are expert opinions, case studies, and cohort studies published by American authors. [14] (10.1177/17585732231155123)
• [L4] Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. [15] (10.1007/s12178-020-09670-8)
• [L3] In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless anatomic total shoulder arthroplasty have a lower short-term revision risk than stemmed anatomic total shoulder arthroplasty. [16] (10.1016/j.jse.2024.07.032)
• [L4] The reverse shoulder arthroplasty has been highly successful in cuff deficient shoulders, with indications continuing to broaden. [17] (10.1007/s12178-011-9097-4)
• [L4] At short term, reverse total shoulder arthroplasty relieved pain and improved function. [18] (10.1007/s11999-011-2055-z)
• [L3] Reverse shoulder arthroplasty should be deferred at least 4 weeks after a patient receives a corticosteroid injection. [19] (10.1016/j.jse.2023.01.008)
• [L4] Reverse arthroplasty in rheumatoid arthritis improved shoulder function with a low incidence of complications. [20] (10.1007/s11999-010-1654-4)
• [L4] [22] (10.1007/s12178-020-09597-0)
• [L4] Reverse shoulder arthroplasty has shown promising results with mean active anterior elevation from 97 to 122 degrees reported with complication rates of 15% to 28% in short-term studies. [23] (10.1177/2151458511420140)
• [L4] Patients with good outcomes after first reverse total shoulder arthroplasty can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. [24] (10.1016/j.jse.2023.10.007)
• [L2] Patients achieved maximum medical improvement at 1 postoperative year following reverse total shoulder arthroplasty. [25] (10.1016/j.jse.2018.05.029)
• [L4] The functional results of revision arthroplasty with reverse shoulder prosthesis in patients that sustained complex fracture of proximal humerus are altogether good, although less satisfactory than those of primary reverse prosthesis implant. [28] (10.1007/s12306-009-0006-6)
• [L4] Complications are within an acceptable range for primary reverse shoulder arthroplasty, with a low rate of revision. [29] (10.1016/j.xrrt.2022.08.008)
• [L3] The value of reverse shoulder arthroplasty in the case group was very low in comparison with controls. [30] (10.1016/j.jse.2015.05.007)
• [L4] When patient selection is optimized, reverse shoulder arthroplasty is a reliable means of relieving pain and improving function with excellent success. [33] (10.1007/s12178-018-9467-2)
• [L4] This review article identifies the most common and serious complications associated with reverse total shoulder arthroplasty and discusses current methods of management. [34] (10.1007/s12178-014-9252-9)
• [L3] Revision rates were lower for reverse shoulder arthroplasty but the difference was not statistically significant. [35] (10.1016/j.jse.2017.02.005)
• [L4] Patients who had undergone reverse shoulder arthroplasty a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls. [36] (10.1016/j.jse.2013.01.020)
• [L4] Functional outcomes of proximal humerus fractures treated with reverse shoulder arthroplasty improve with surgical experience, and outcomes become less variable after approximately 20 procedures. [37] (10.1016/j.jseint.2021.07.008)
• [L4] This study confirms the clinical benefits of reverse shoulder arthroplasty, with improvements maintained out to 10 years. [38] (10.1177/1758573219832283)
• [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [39] (10.1177/1758573217702333)
• [L4] While remaining a technically demanding operation, there does appear to be a substantial reduction in serious complications after reverse shoulder arthroplasty with increased surgeon experience. [40] (10.1016/j.jse.2007.02.059)
• [L4] Composite reverse shoulder arthroplasty is functionally effective after massive resection. [41] (10.1016/j.otsr.2021.102957)
• [L4] In comparison to the trend seen after 16 cases for anatomical shoulder replacement, no trend was seen in the reverse shoulder replacement cohort. [44] (10.1308/rcsann.2018.0062)
• [L3] The functional outcomes of reverse shoulder arthroplasty are good in the obese population after 4 years of follow-up, but these outcomes are worse than those recorded in the population with a BMI under 35. [49] (10.1007/s00402-017-2816-6)
• [L4] Onlay reverse shoulder arthroplasty yields good short-term clinical results. [51] (10.1016/j.jse.2017.05.021)
• [L4] The clinical and radiographic evaluation of a bone preserving metaphyseal humeral component in reverse shoulder arthroplasty is promising, with good clinical results, no signs of loosening or subsidence. [52] (10.1007/s00264-014-2328-8)
• [L4] Patients who underwent reverse shoulder arthroplasty had significant improvement in the ASES and VAS scales. [53] (10.1016/j.rboe.2017.04.007)
• [L1] Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. [54] (10.1016/j.jse.2024.02.023)
• [L3] Reverse shoulder arthroplasty indication is steadily increasing in acute displaced proximal humeral fracture. [55] (10.1007/s12306-014-0322-3)
• [L5] Patients experience a significant improvement in range of motion and markedly decreased pain after undergoing reverse shoulder arthroplasty. [56] (10.1148/rg.271065076)
• [L3] Reverse shoulder arthroplasty appears to be as safe and effective in morbidly obese patients, although it has an increased cost and patients have a lower rate of discharge to home and greater care needs after discharge. [61] (10.2106/jbjs.m.00735)
• [L4] Pre-operative glenoid bone mineral density (BMD) varies significantly by indication for reverse total shoulder arthroplasty. [62] (10.1016/j.jseint.2026.101720)
• [L4] The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. [63] (10.1007/s00776-011-0185-5)
• [L4] [64] (10.1016/j.jses.2019.06.003)
• [Case_report] The primary or secondary implantation of the reverse shoulder prosthesis in proximal humeral fractures has to be planned carefully, since long-term results are still lacking and treatment options after failed reverse shoulder arthroplasty are few. [65] (10.1007/s00402-007-0519-0)
• [L5] The review outlines rehabilitation guidelines developed to manage patients who have undergone reverse total shoulder replacement, aiming to achieve optimal pain relief and maximize functional outcomes while mitigating risks associated with the surgery. [66] (10.1111/j.1758-5740.2011.00138.x)
• [L3] Two-stage revisions using a reverse total shoulder arthroplasty at the time of reimplantation generate superior range of motion and functional outcome scores. [67] (10.1016/j.jse.2019.03.001)
• [L4] Therefore, the humeral component in reverse shoulder arthroplasty can be implanted in any retroversion between 0° and 20°. [69] (10.1007/s12306-016-0443-y)
• [L4] [73] (10.1007/s11678-020-00598-6)
• [L3] [74] (10.2106/jbjs.k.01516)
• [L4] Shoulder function and pain improved in patients treated with a second-stage reimplantation of a reverse prosthesis and the reinfection rate was low. [76] (10.1007/s11999-011-1774-5)
• [L4] At medium-term followup, reverse total shoulder arthroplasty is a reasonable option for tumors of the proximal humerus with low morbidity, restoring a mean active abduction of 157 degrees and limiting the impairment of activities of daily living. [77] (10.1007/s11999-010-1758-x)
• [L4] The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty, although the high percentage of patients with humeral loosening is concerning. [78] (10.1016/j.jse.2016.05.015)
• [Paper] [79] (10.1007/s00264-018-4249-4)
• [L4] [80] (10.1007/s11999-011-1833-y)
• [L4] A smaller subcoracoid distance is significantly associated with higher postoperative pain and reduced internal rotation at the spine level two years after reverse shoulder arthroplasty. [81] (10.1016/j.jseint.2024.01.010)
• [L5] [82] (10.1016/j.jisako.2023.05.007)
• [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. [83] (10.1016/j.jse.2018.05.030)
• [L4] Scapular kinematics of patients with shoulder arthroplasty was influenced by implementation of external loads, but not by the type of load. [87] (10.1016/j.clinbiomech.2012.04.009)
• [L5] The biomechanics of the shoulder relies on careful balancing between stability and mobility, with anatomic total shoulder arthroplasty aiming to reproduce premorbid kinematics and reverse shoulder arthroplasty achieving stability through a semi-constrained design. [88] (10.1302/2058-5241.6.210014)
• [Abstract] RTSA shoulders show kinematics that are significantly different from normal shoulders, utilizing much more scapulothoracic motion and much less glenohumeral motion to elevate the arm. [90] (10.1016/j.jse.2014.11.012)
• [L4] RTSA shoulders show kinematics that are significantly different from normal shoulders, using more scapulothoracic motion and less glenohumeral motion to elevate the arm. [91] (10.1016/j.jse.2014.11.043)
• [L4] Scaption kinematics of reverse shoulder arthroplasty do not change after the sixth postoperative month. [92] (10.1016/j.clinbiomech.2018.07.005)
• [L5] The anterior deltoid is important biomechanically for balanced function after a reverse total shoulder arthroplasty. [94] (10.1016/j.jse.2012.02.002)
• [L5] In addition, impingement is determined by scapular motion, which should be included in all shoulder models. [97] (10.1016/j.jse.2015.06.011)
• [Paper] Current classifications exhibit poor reliability in categorizing glenoid defects post-reverse shoulder arthroplasty removal. [98] (10.1016/j.jseint.2024.08.170)
• [L3] Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models. [99] (10.1016/j.jse.2016.09.027)
• [L3] Shoulders with good elevation showed significantly higher scapulohumeral rhythm than those with poor elevation, while no other statistically significant kinematic differences were found between the groups. [102] (10.1016/j.jseint.2021.02.002)
• [L4] Most patients being active prior to reverse shoulder arthroplasty surgery are successfully able to return to their activity afterwards. [107] (10.1007/s00402-016-2494-9)
• [L4] The anterosuperior approach can be used in primary and revision reverse shoulder arthroplasty, as well as in acute humeral head fracture. [108] (10.1007/s11999-011-1861-7)
• [L5] Concomitant subscapularis repair in lateralized reverse total shoulder arthroplasty decreased glenohumeral abduction and increased internal rotation. [109] (10.5397/cise.2025.00675)
• [L5] Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. [110] (10.1016/j.jse.2019.07.022)
• [L4] The study reports preliminary results of a novel surgical technique for pectoralis major transfer in reverse shoulder arthroplasty with deficient subscapularis, showing significant improvement in Constant scores from a mean of 17.7 pre-operatively to 61 post-operatively. [111] (10.1016/j.jse.2023.02.081)
• [Paper] [112] (10.1016/j.otsr.2013.09.006)
• [L5] Even if TM external rotation moment arm is higher in RTSA than in a normal shoulder, the decreased length could impair its force generation. [113] (10.1016/j.jse.2014.08.019)
• [L5] Reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae when joint-preserving options are not optimal, provided there is careful management of the tuberosities and understanding of associated pearls and pitfalls. [115] (10.5435/jaaos-d-23-00740)
• [Case_report] Reverse shoulder arthroplasty can be used to treat deltoid myopathy due to corticosteroid usage and can produce reliable improvements in clinical manifestations and functions without an increased risk of dislocation. [118] (10.5397/cise.2021.00241)
• [L3] Physical therapy plays an important role subsequent to reverse shoulder arthroplasty and has an effect in the mid-term to long-term follow-up regarding range of motion and activities of daily living. [119] (10.1007/s00402-018-3015-9)
• [L4] Reverse shoulder arthroplasty associated with a repair of deltoid tear could be a viable surgical option in cases of tear involving the anterior and middle deltoid. [121] (10.1016/j.jos.2016.06.016)
• [L3] Reverse total shoulder arthroplasty was effective in restoring forward elevation irrespective of latissimus dorsi and teres major transfer or lateralization. [122] (10.1016/j.jseint.2026.101636)
• [L3] Management of complex fractures of the superior extremity of the humerus by reverse shoulder arthroplasty is an accepted approach, but such treatment is restricted to elderly patients. [124] (10.1016/j.jse.2012.03.011)
• [L4] Active external rotation after reverse total shoulder arthroplasty is complex and not governed by a single muscle-tendon unit. [128] (10.1016/j.jse.2023.08.031)
• [L1] Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. [135] (10.1177/1758573220937394)
• [L4] Thus, preoperative planning using supine CT may inaccurately pose bones, with consequent effects on the surgical plan, the resultant shoulder biomechanics, and clinical outcomes. [138] (10.1016/j.xrrt.2025.08.006)
• [L5] Varying the glenosphere configurations leads to ROM and muscle length changes following RSA. [139] (10.1007/s00264-018-3850-x)
• [L5] Increasing the diameter of the glenosphere alone did not alter the deltoid moment arm. [141] (10.1302/0301-620x.98b2.35912)
• [L4] The current study's findings suggest that postoperative changes in scapular kinematics following a reverse total shoulder arthroplasty positively impact shoulder function and patient-reported outcome measures. [142] (10.1016/j.jisako.2025.100761)
• [L4] The ST contribution to overall shoulder movement is significantly increased in patients with an rTSA compared with a healthy shoulder. [143] (10.1016/j.jse.2024.12.018)
• [L5] Biomechanical analysis demonstrated that RSA and SCR models produce moment arms that vary between muscles, with some contributing more to abduction and some contributing less. [144] (10.1177/2325967121s00333)
• [L2] This study suggests that self-directed home therapy following reverse shoulder arthroplasty may be a viable alternative to formal supervised physical therapy, showing no significant differences in outcomes across multiple measures. [146] (10.1016/j.jseint.2025.02.012)
• [L5] Moderate lateralization of the glenosphere of + 5 mm has improved the range of motion in our experimental cadaveric setup. [147] (10.1016/j.jor.2021.02.016)
• [L5] Although increasing glenosphere diameter significantly increased joint load and deltoid force, the clinical impact of these changes is presently unclear. [148] (10.1016/j.jse.2014.10.018)
• [L4] Key biomechanical parameters are frequently reported without clear, quantitative, or reproducible definitions, which may hinder interpretation and comparison of published findings. [149] (10.1016/j.jse.2026.06.004)
• [L4] We recommend humeral lengthening of at least 24 mm after implanting a total reverse shoulder prosthesis. [150] (10.1016/j.jse.2018.05.027)
• [L3] Deciding on a primary repair does not seem to impact outcomes such as cost, length of stay, and readmission when revision by reverse shoulder arthroplasty is needed. [153] (10.1016/j.jse.2021.03.094)
• [L4] Reverse shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff. [154] (10.1016/j.jse.2021.06.010)
• [L2] Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with fractures are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture. [156] (10.5435/jaaos-d-20-01205)
• [L5] Glenosphere position significantly affected humeral internal and external rotation after reverse total shoulder arthroplasty. [160] (10.1016/j.jse.2012.07.013)
• [L4] Return to sports after reverse shoulder arthroplasty is possible and highly frequent. [161] (10.1136/jisakos-2020-000581)
• [L3] Results of nonoperative treatment of acromial/scapular spine fractures following reverse shoulder arthroplasty differ based on fracture location. [162] (10.1016/j.jse.2021.12.024)
• [L5] Significant differences in initial fixation exist between reverse shoulder implants having an equivalent center of rotation, suggesting that design parameters other than center of rotation position significantly affect fixation. [163] (10.1016/j.jse.2013.01.037)
• [L3] Preoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols. [167] (10.1016/j.jse.2021.03.033)
• [L5] Reverse shoulder arthroplasty is a versatile revision option following failure of primary procedures including failed shoulder arthroplasty, rotator cuff repair, or proximal humerus open reduction and internal fixation, with a large body of literature demonstrating its success. [168] (10.1016/j.jseint.2025.02.019)
• [L5] The author concludes that surgeons may need to reconsider the routine use of reverse total shoulder arthroplasty over locked plating until consistent evidence demonstrates an advantage, particularly regarding functional outcomes or reoperation risk, and suggests that future studies should include nonsurgical management and assess quality of life. [170] (10.1097/corr.0000000000001827)
• [L3] The study confirms that radiographic measurements are generally valid for evaluating postoperative parameters in reverse total shoulder arthroplasty. [172] (10.1016/j.jse.2024.10.016)
• [L4] Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved. [173] (10.5435/jaaos-d-13-00190)
• [L4] [174] (10.1016/j.jse.2014.05.022)
• [L3] [176] (10.1016/j.jse.2015.10.027)
• [L3] [179] (10.1016/j.jse.2008.02.010)
• [L3] Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. [181] (10.1302/0301-620x.96b9.33157)
• [L3] Patients with both proximal humerus fracture and rotator cuff arthropathy achieved similar postoperative pain levels after reverse total shoulder arthroplasty. [182] (10.5435/jaaosglobal-d-23-00169)
• [L4] [189] (10.1177/24715492221090742)
• [L4] [190] (10.2106/jbjs.st.17.00051)
• [L5] [191] (10.1016/j.jse.2013.10.003)
• [L3] Reverse shoulder arthroplasty provides satisfactory pain relief for proximal humerus fractures regardless of humeral fixation type. [192] (10.1016/j.jse.2017.06.027)
• [Paper] [193] (10.1016/j.ocl.2013.03.010)
• [L4] Although a low rate of humeral component loosening was observed, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability. [194] (10.1016/j.xrrt.2024.08.006)
• [Paper] [195] (10.1016/j.eats.2023.07.009)
• [L2] [197] (10.2106/jbjs.rvw.m.00140)
• [L3] VTE occurred infrequently following shoulder arthroplasty, with an incidence of 0.61% after aTSA and 0.82% after rTSA. [198] (10.1016/j.jsea.2026.100061)
• [L4] Clinical CT is inconsistent at visualizing the presence or absence of bonegraft resorption adjacent to a reverse shoulder arthroplasty glenoid baseplate due to metal artifact. [199] (10.1016/j.otsr.2015.03.010)
• [L5] [200] (10.1177/0954411916642801)
• [L4] Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty. [205] (10.1016/j.jse.2023.06.039)
• [L4] [214] (10.1302/2058-5241.1.160003)
• [L3] Primary inlay reverse total shoulder arthroplasty (in-rTSA) has a higher rate of revision than onlay reverse total shoulder arthroplasty (on-rTSA). [215] (10.1177/17585732221122275)
• [L4] Functional outcome is improved following reverse shoulder arthroplasty for proximal humeral fractures when tuberosity healing occurs. [216] (10.1007/s00590-020-02649-8)
• [Paper] Some common complications of the reverse shoulder arthroplasty could be effectively reduced by a suitable positioning of the prosthesis components. [217] (10.1016/j.injury.2019.01.039)
• [L3] Although initially exhibiting slower recovery, patients with proximal humerus fractures can expect similar functional recovery and satisfaction at 1-year compared to those who received reverse shoulder arthroplasty for degenerative indications. [218] (10.1177/17585732221097415)
• [L3] There is an increased risk of revision owing to periprosthetic joint infection after reverse shoulder arthroplasty for patients with previous rotator cuff repair. [220] (10.1016/j.jse.2022.07.001)
• [L4] Staged RSA implantation was confirmed to be a reliable treatment option for primary, secondary, and periprosthetic infections of the shoulder with satisfactory infection control and survival rates, though functional impairment persists. [222] (10.1016/j.jseint.2020.08.012)
• [L4] Two-stage reimplantation eradicated periprosthetic shoulder infection in 85% of the shoulders. [223] (10.1016/j.jse.2017.05.005)
• [L3] Primary RSA for cuff-deficient shoulders or primary osteoarthritis leads to a high 10-year survival, but revision RSA or primary RSA for fracture sequelae and tumors are at high risk for revision. [225] (10.3390/jcm11102677)
• [L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. [226] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
• [L4] Reverse shoulder arthroplasty leads to improvement in shoulder mobility and patient-reported outcomes with high satisfaction rates, though revision rates are high in the long term and more longer-term studies are needed to validate efficacy. [227] (10.1016/j.jisako.2023.10.005)
• [L4] This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up. [230] (10.1016/j.xrrt.2023.09.003)
• [L4] Reverse total shoulder arthroplasty continues to have high rates of complications, which include instability, infection, scapular notching, neurologic injury, and component loosening, among others. [231] (10.2106/jbjs.rvw.17.00152)
• [L3] Patients with patient-reported penicillin allergy were at an increased risk for prosthetic joint infection after total knee arthroplasty and total shoulder arthroplasty, likely due to receiving second-line antibiotics. [232] (10.1097/corr.0000000000001497)
• [L3] Males were more likely to sustain perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture than females, with male sex identified as an independent risk factor for any complication and unplanned reoperation. [233] (10.1016/j.jseint.2020.12.005)

See Also

• Total shoulder arthroplasty
• Rotator Cuff
• Shoulder Arthroplasty
• Fractures
• Subacromial Decompression
• Os Acromiale
• Rotator cuff repair
• Internal Fixation
• Biceps Tenodesis

References

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