Abstract
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Shoulder arthroplasty is increasingly utilised among patients under 55 years of age due to rising incidences of traumatic injuries, inflammatory arthritis, avascular necrosis, degenerative joint diseases and heightened participation in demanding sports and occupational activities.
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Anatomic shoulder arthroplasty (ASA) remains the preferred surgical option for younger patients with intact rotator cuffs and minimal glenoid deformities, preserving natural biomechanics, strength and range of motion, and demonstrating high long-term implant survival rates at 10–15 years. Despite favourable outcomes, ASA carries potential long-term risks including implant wear, prosthetic loosening, glenoid erosion and progressive rotator cuff degeneration, particularly relevant for physically active younger patients.
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Reverse shoulder arthroplasty (RSA) offers a valuable alternative in complex clinical scenarios characterised by irreparable rotator cuff tears, extensive glenoid bone loss, severe anatomical disruption or previous surgical failures. RSA can be used as an alternative to ASR for primary osteoarthritis and an intact rotator cuff, with excellent clinical outcomes and survivorship in patients over 60. RSA is also being used successfully in patients under the age of 55 with excellent short-term results.
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There remain concerns regarding the longevity and reliability of RSA in younger, highly active individuals. ASA can be revised to RSA with good clinical outcomes, while failure of RSA is extremely challenging to address.
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If we accept that ASA will fail with time, then the primary ASA should allow for ease of revision to an RSA. Recent advances in modular prosthetic designs facilitate simpler revisions from ASA to RSA.
Introduction
Shoulder arthroplasty has been increasingly used among patients under 55 years of age (1, 2), driven by higher incidences of trauma, avascular necrosis, degenerative conditions and more participation in demanding sports and occupational activities. The critical choice between anatomic shoulder arthroplasty (ASA) and reverse shoulder arthroplasty (RSA) in this relatively younger population involves evaluating clinical outcomes, advantages, limitations and long-term implications.
Comparative reviews of ASA versus RSA indicate clear advantages and disadvantages for each procedure. ASA consistently emerges as the superior choice for younger patients with well-preserved rotator cuffs and minimal anatomical compromise, offering preservation of natural shoulder biomechanics, greater postoperative strength and potentially fewer complications over time.
RSA, however, presents a compelling alternative for complex clinical scenarios characterised by significant anatomical disruption, rotator cuff deficiency or failed prior interventions. In these cases, RSA demonstrates superior outcomes, stable function and improved patient satisfaction compared to non-operative or alternative surgical interventions. The selection must be tailored based on individual patient profiles, detailed preoperative planning and clearly established patient goals and expectations.
RSA in those younger than 55 years where ASA are not an option
Originally introduced for elderly patients with severe rotator cuff arthropathy, RSA has expanded into younger populations facing complex shoulder pathologies, including irreparable rotator cuff tears, substantial glenoid erosion, prior failed shoulder surgeries and complex fractures (3, 4, 5, 6).
RSA provides substantial pain relief and improved shoulder function by biomechanically altering shoulder mechanics, shifting reliance from the rotator cuff to the deltoid muscle. This prosthesis design allows patients with deficient rotator cuffs to achieve functional shoulder elevation and rotation. Short-term and intermediate-term studies confirm high patient satisfaction, excellent functional recovery and rapid improvement in quality-of-life measures.
Otto et al. (3) reviewed 67 patients who were under 55 years of age and underwent RSA. Thirty-five underwent revision procedures for previous failed arthroplasty and the remainder had primary RSAs. They found that RSA provides significant clinical improvements with high implant retention at up to 12 years. Chelli et al. (4) undertook a systematic review of eight papers and identified 417 patients who underwent RSA with a mean age of 56 (range: 21–65). Seventy-nine percent had a primary total shoulder arthroplasty (TSA) and 21% had RSA for a failed arthroplasty. They concluded that ‘RSA provides reliable clinical improvements in patients younger than 65 years with cuff-deficient shoulders or failed arthroplasty and that the complication and revision rates are comparable to those in older patients’. Goldenberg et al. (5) performed a systematic review of primary RSA in patients younger than 65 and found that complications, reoperations and revision rates were similar to those in older cohorts.
Osteoarthritis of the shoulder with an intact cuff
The case for and against ASA for young patients
ASA restores normal shoulder anatomy by replacing damaged articular surfaces of the humerus and glenoid with prosthetic implants. It is ideally suited for younger patients who have preserved rotator cuff integrity, minimal glenoid deformities and adequate bone stock. Primary osteoarthritis, post-traumatic arthritis and select inflammatory conditions represent typical indications for ASA.
Clinical data strongly support ASA in younger patients, demonstrating substantial improvements in pain, range of motion, strength and patient-reported outcome measures such as the Constant–Murley score and American Shoulder and Elbow Surgeons (ASES) scores (7, 8, 9, 10, 11). Studies indicate high patient satisfaction rates and restoration of functional activities, particularly in active individuals who seek to maintain or return to physically demanding tasks or sports (12). Implant survival data, which frequently exceed 90% at 10–15 years. Data from the National Joint Registry (UK) (13), New Zealand (14) and the Nordic Arthroplasty Register Association (15) (which included data from Denmark, Norway and Sweden), report a 10-year cumulative survival rate of over 90% for anatomical TSA.
Despite favourable reported outcomes, ASA faces significant long-term risks, particularly related to implant wear, loosening, glenoid component erosion and progressive rotator cuff degeneration due to high mechanical demands. The available literature on the outcome of young and often high-demand, younger cohorts of patients consistently shows a higher revision rate when compared to a more elderly population (7, 8, 16).
Denard et al. (16) showed that, for patients under 56, there was a high rate of radiological glenoid loosening. They also demonstrated that at 5 years’ follow-up, ASA leads to improvement in functional outcome and a satisfactory implant survival rate of 98% in young adults with primary glenohumeral arthritis, but that the 10-year survival rate of TSA was a disappointingly low 62.5% in this cohort. Dillon et al. (8) found that patients younger than 59 years had double the revision rate when compared to those over the age of 59 years.
The case for and against RSA for young patients
Anatomical TSA remains the standard of care for younger patients with primary glenohumeral arthritis and an intact rotator cuff. However, an increasing subset of patients presents with glenoid bone loss, posterior subluxation or high functional demands that predispose them to early implant failure. Multiple studies have shown that RSA reliably improves pain and function in younger patients with severe arthritis (3, 4, 17). The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) indicates that a significant and increasing number of RSAs are being undertaken in patients under the age of 55 for primary osteoarthritis of the shoulder (18).
Glenoid bone loss and instability
Younger patients with primary or secondary glenohumeral arthritis frequently present with posterior glenoid wear leading to posterior humeral head subluxation (19, 20, 21). TSA in these cases may require augmented glenoid components or bone grafting, which carries a risk of early loosening and failure. RSA mitigates this issue by medialising the centre of rotation, reducing shear forces on the glenoid component and providing a more stable construct.
Walch et al. (19) reported high rates of glenoid loosening following anatomic TSA in a series of 92 patients with a biconcave glenoid and primary osteoarthritis. At a mean follow-up of 77 months, glenoid loosening was observed in 20.6%. In contrast, Mizuno et al. (20) reported excellent clinical outcomes in a series of 27 patients with primary osteoarthritis and a biconcave glenoid treated with RSA, with only one failure at a mean follow-up of 54 months.
Concerns regarding RSA in the young patient
Despite its clinical utility, RSA is associated with a distinct complication profile (4, 17, 22). Earlier studies on RSA reported somewhat alarmingly high complication rates (23). More recent publications report high patient satisfaction and complication rates well below 2% for a specific patient cohort of primary RSA (24), and the lower rates seem to be supported by hospital data from England (13).
A significant complication unique to RSA is scapular notching (25), characterised by erosion of the scapular neck (Fig. 1) due to repetitive mechanical contact between implant components and bone. This may precipitate implant loosening, discomfort and impaired shoulder function (26). Furthermore, the altered biomechanics associated with RSA place increased mechanical stresses upon the deltoid muscle and surrounding bony structures, elevating the risk of stress fractures affecting the acromion (Fig. 1) and scapular spine (27, 28). Additional complications particular to RSA include instability or dislocation, often occurring in the early postoperative period, and neurological injuries, most notably axillary nerve palsy, caused by intraoperative nerve traction or excessive deltoid tensioning.
Unique complications of reverse shoulder replacement. Left showing severe scapular notching. Right showing acromial fracture.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0052
Comparative analysis of the outcomes of ASA versus RSA
There are numerous articles in the literature that affirm the efficacy of both anatomic and RSA in the treatment of the arthritic shoulder with an intact rotator cuff. Systematic reviews from 2023 by Dradonas et al. (28) and by Su et al. (29) found broadly comparable results for ASA and RSA for elderly patients (over the age of 70) who presented with osteoarthritis and had an intact rotator cuff.
A 2024 article (13) from Volsamis et al. analysed data from the National Joint Registry (UK) comparing the outcomes of adults aged 60 and over who underwent ASA and RSA with arthritis and intact rotator cuff tendons. They found broadly comparable results and concluded that ‘in response to the rapid rise of RTSR to patients aged 60 years or older with osteoarthritis and an intact rotator cuff. This study’s findings provide reassurance that RTSR is an acceptable alternative in this patient group’.
A 2025 article (18) studied the results from the Australian Orthopaedic National Joint Registry (AOANJRR) with regard to young patients who underwent arthroplasty for primary osteoarthritis. In an observational study of all arthroplasties for osteoarthritic patients under the age of 55, it was found that ASA and stemless RSA were viable options for young patients with primary osteoarthritis and that their revision rates were comparable to those in older patients. They also found that for male patients under the age of 55, RSA and stemless ASA had a lower short-term revision risk than for stemmed ASA.
Long-term considerations and revision surgery
Studies have provided further evidence supporting the favourable long-term outcomes of RSA, with 10-year implant survival rates comparable to those of anatomical TSA (13, 30). A systematic review and meta-analysis published in The Lancet Rheumatology analysed global data on shoulder replacements and found that approximately 90% of shoulder replacements last for at least a decade. Specifically, the 10-year survival rate for RSA was reported to be 94.4% for patients with osteoarthritis and 93.6% for those with rotator cuff arthropathy. These rates are comparable to the 92.0% survival rate observed for TSA over the same period.
These findings reinforce the notion that RSA offers favourable long-term outcomes, with 10-year survival rates comparable to those of anatomical TSA. However, the higher rates of revision in younger patients seen after ASR will inevitably cause concern for younger patients undergoing RSA. Survivorship analysis (31) following RSA is lower in the young and in male patients. It is noteworthy that RSA was originally used as a salvage procedure, its utility has expanded and expectations have grown to allow return to sports (32).
Younger patients inherently have a higher lifetime risk of revision surgery. ASA failure often necessitates conversion to RSA (Fig. 2), a technically demanding procedure with higher complication rates and reoperation rates (33, 34). If we accept that an increasing proportion of our anatomic shoulder replacements will fail over time, then we are obliged to facilitate any subsequent revision surgery. It would be advantageous to employ an ASA that can be relatively easily extracted for revision surgery (Fig. 3).
Revision of failed anatomic shoulder to RSA. Top row shows revision of a well-fixed humeral stem hemiarthroplasty to a long stem RSR (DePuy Delta extend) at 5 years. Bottom row shows failure of ASA with extreme glenoid wear and bone loss. Revision to RSR and (DePuy Delta extend) with glenoid bone graft (femoral head allograft) at 5 years.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0052
Revision of ASA. Top left shows humeral head surface replacement with metal-backed glenoid component that has suffered rotator cuff failure. Top right shows the radiologic outcome following revision to RSA (DePuy Delta extend) at 3 years. Bottom row shows an excellent clinical outcome also at 3 years (Oxford shoulder score 48).
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0052
Newer prosthetic designs have recognised the requirements for possible future surgery and have an intrinsic modularity that allows conversion of an ASA to an RSA (Fig. 4) without having to remove the fixed components of the primary prosthesis (35).
Top row shows a shoulder replacement (Lima Corporation, Italy) that permits the conversion of an ASA by simply exchanging modular components while retaining the fixed humeral and glenoid components. Bottom row shows radiograph of an ASA that had sustained a rotator cuff failure. The patient underwent revision to an RSA merely by exchanging the modular components.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0052
Although RSA outcomes are promising in the short term, concerns persist regarding prosthesis durability in highly active younger patients. The increased mechanical stresses from rigorous physical activity (32) raise concerns regarding component loosening, wear-related complications, scapular notching and deltoid fatigue syndrome. Revision of failed RSA (Fig. 5) is possible but extremely challenging and associated with very unpredictable clinical and long-term outcomes.
Radiographs of two RSA cases where there has been a catastrophic failure of the glenoid component with corresponding glenoid bone loss. Surgical solutions are challenging.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0052
Future directions
Continued advancements in prosthetic design, surgical techniques and biomaterials promise enhanced durability and functionality for both ASA and RSA. Prospective long-term studies focused on younger patient populations, high-demand activities and rigorous outcome measures are essential for refining clinical practice guidelines and improving patient-specific outcomes.
Conclusion
The decision between ASA and RSA for patients under 55 years of age must be carefully considered in terms of factors including rotator cuff status, glenoid bone integrity, patient activity levels and postoperative expectations. ASA remains preferable in anatomically appropriate active patients, whereas RSA serves as a vital solution for complex pathologies. Ongoing research, patient education, individualised treatment strategies and technological innovations are critical for the achievement of optimal clinical outcomes in this challenging yet expanding patient population.
Reverse shoulder replacement can be a viable solution for younger patients with severe shoulder pathology when anatomic TSA is not an option. While it provides excellent pain relief and functional improvement, concerns regarding implant longevity, revision rates and activity limitations must be carefully considered.
Given these challenges, RSA in patients under 55 years of age should be reserved for carefully selected cases where alternative treatments are insufficient.
Ongoing research, patient education, individualised treatment strategies and technological innovations are critical to achieving optimal clinical outcomes in this challenging yet broad and difficult patient population. Future advancements in implant design, surgical techniques and revision strategies may improve outcomes and expand its role in younger populations.
ICMJE Statement of Interest
The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.
Funding Statement
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
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