Reverse versus anatomic total shoulder arthroplasty in patients over 70 with a competent rotator cuff and glenohumeral osteoarthritis: a meta-analysis

Reverse total shoulder arthroplasty (rTSA) is increasingly performed in elderly patients with primary glenohumeral osteoarthritis (GHOA) and preserved rotator cuff function. Once reserved for cuff deficiency, it is now often selected based on age rather than cuff status, driving a rapid rise in its use among older adults. This meta-analysis compares rTSA and anatomic total shoulder arthroplasty (aTSA) in patients aged ≥70 years with a competent cuff, focusing on range of motion, functional outcomes, and risks of complications, revisions, and reoperations. Following PRISMA 2020 guidelines, we systematically searched 5 databases from inception to March 2025 for comparative studies reporting on aTSA and rTSA in patients aged ≥70 years with primary GHOA and a competent rotator cuff. Inclusion was restricted to studies with ≥2 years' follow-up and validated outcome reporting. Continuous outcomes were pooled using inverse variance random-effects models, and dichotomous outcomes were assessed via Mantel-Haenszel risk ratios. Risk of bias was evaluated using ROBINS-I, and evidence certainty was appraised via GRADE. Eight studies encompassing 1716 patients met inclusion. Compared with rTSA, aTSA demonstrated significantly greater postoperative external rotation and internal rotation. There were no significant differences in forward elevation, abduction, and patient-reported outcomes (ASES, Constant, SST) between the groups. aTSA was associated with a nearly fourfold higher risk of revision and a higher overall complication rate while reoperation rates were comparable. Heterogeneity was low to moderate across most analyses, and no evidence of publication bias was detected. In patients aged ≥70 years with primary GHOA and a competent rotator cuff, aTSA provides superior rotational mobility, exceeding the MCID and potentially supporting improvements in daily activities such as dressing or toileting. rTSA offers superior implant survivorship and lower complication rates without compromising patient-reported outcomes, though at the expense of reduced rotational range of motion. aTSA remains preferable in select active patients prioritizing rotation-dependent tasks, provided cuff integrity is preserved. These findings support a patient-tailored approach to implant selection.