Comparing Anatomic vs. Reverse Shoulder Arthroplasty in Patients With an Intact Rotator Cuff

Written By Mike H

Shoulder arthroplasty has undergone remarkable evolution in recent decades. For patients with end-stage glenohumeral arthritis and an intact rotator cuff, two primary surgical options exist: anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). Although these procedures can achieve similar pain relief, they differ in biomechanics, functional outcomes, complications, and long-term survivorship. Understanding these differences is crucial for patients and surgeons making individualized treatment decisions.

Historical Context: Polyethylene Wear and Glenoid Loosening in TSA

Much of the historical concern about TSA has centered on glenoid loosening. Earlier implants used ultra-high molecular weight polyethylene (UHMWPE), which was prone to wear and particulate-induced osteolysis. This complication was a leading cause of revision, often cited in older long-term studies.

Today, modern implants use vitamin E–stabilized, highly crosslinked polyethylene, which has shown roughly one-tenth the wear rate of conventional UHMWPE. With this advancement, the risk of loosening and osteolysis is likely much lower than what historical data suggested. In other words, older revision rates for TSA may overstate the risk for patients receiving modern implants.

Functional Outcomes: TSA vs. RSA

Although both procedures reliably reduce pain, their functional profiles differ:

  • Range of Motion

    • TSA generally provides superior rotational range of motion, especially internal rotation—critical for tasks like tucking in a shirt or washing one’s back.

    • RSA tends to restore forward elevation and abduction reliably, even in patients with limited preoperative motion, but often at the cost of rotational deficits.

  • Activities of Daily Living

    • TSA patients are more likely to perform behind-the-back activities and overhead tasks.

    • RSA patients often struggle with fine rotational activities such as fastening a bra, styling hair, or lifting objects overhead, even when overall composite outcome scores look similar.

  • Speed of Recovery

    • TSA patients tend to reach functional recovery milestones earlier and more consistently, often plateauing by 6–12 months post-op.

    • RSA patients improve as well, but their recovery trajectory is more variable, with rotational limitations persisting in many cases.

Complications and Risks

Each procedure carries distinct risks:

  • TSA

    • Historically, the main failure mode has been glenoid loosening, but this is likely less concerning with modern polyethylene.

    • Subscapularis dysfunction may limit internal rotation in some patients.

  • RSA

    • Acromial and scapular spine stress fractures are unique and potentially debilitating complications.

    • Instability and mechanical complications, while less common, can be difficult to manage.

    • Once a reverse is in place, revision options are more limited compared with revising a failed TSA.

Revision Considerations

Another nuance lies in how revision rates are reported. TSA is often revised to RSA when failure occurs—commonly due to glenoid loosening. Because this transition is widely accepted as the standard salvage pathway, revision rates for TSA appear higher.

By contrast, failed RSAs are revised less frequently unless there is a clear, correctable problem. Thus, RSA may appear to have lower revision rates, but this partly reflects a different revision threshold, not necessarily superior durability.

Practical Takeaways

  • For patients with an intact rotator cuff, TSA remains the gold standard for maximizing function, particularly for tasks requiring rotation and behind-the-back motion. Modern implants with vitamin E–stabilized polyethylene likely reduce the historical risk of loosening.

  • RSA can be a strong option in select patients, particularly those with severe glenoid deformity, limited preoperative motion, or borderline cuff quality. However, patients should be counseled about the risk of acromial fractures and persistent rotational limitations.

  • Revision data should be interpreted cautiously: TSA revisions are more frequent in the literature because conversion to RSA is standard, while RSA revisions are less common unless catastrophic failure occurs.

Bottom Line

Both TSA and RSA provide excellent pain relief and improved quality of life for patients with arthritis and an intact rotator cuff. TSA offers better functional outcomes in rotation and activities of daily living, while RSA provides a more forgiving mechanical construct with lower reported revision rates—but at the cost of rotational trade-offs and fracture risk. With advances in implant materials, the balance may again tilt toward TSA as the preferred first-line procedure in appropriately selected patients.

Mike H