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. 2025 Mar 19;65:102976. doi: 10.1016/j.jcot.2025.102976

Shoulder arthroplasty in the elderly

P Raval a,⁎, Harvinder Singh b,c
PMCID: PMC11995757  PMID: 40235667

Abstract

Background

Shoulder arthroplasty is increasingly being used for definitive treatment of various shoulder pathologies, especially in more elderly patients. Controversy surrounds the optimal choice in total shoulder arthroplasty for elderly patients. In this review we discuss the options available when considering TSA for an elderly patient.

Review

Anatomical total shoulder arthroplasty (ATSA) relies upon an intact, functioning rotator cuff. Reverse total shoulder arthroplasty (RTSA) relies upon a functioning deltoid for optimal outcomes. The setting of partial cuff tears. Both options confer their own advantages and disadvantages.

ATSA are a valuable treatment option for elderly patients with severe shoulder arthritis or degenerative conditions, offering significant pain relief and functional improvement. While it provides numerous advantages, including pain relief, preservation of bone stock, and natural joint mechanics, careful patient selection and consideration of potential drawbacks such as rotator cuff integrity and surgical complexity are crucial for optimising outcomes in this population.

RTSA has become a valuable treatment solution for elderly patients with complex shoulder conditions, offering significant pain relief, improved functionality, and enhanced quality of life. While careful consideration of patient factors and potential complications is necessary, RTSA continues to demonstrate favourable outcomes and good survivorship in the elderly.

Discussion

Debate continues optimal shoulder arthroplasty management for elderly patients. Technology continues to advance the surgical technique for shoulder arthroplasty and address some of the challenges encountered. Research continues to try and help answer many of the debated areas of shoulder arthroplasty, but current evidence continues to show an improving trend in survivorship and long-term outcomes for most shoulder arthroplasty procedures.

Keywords: Shoulder prosthesis, Replacement, Elderly, Aged, Rotator cuff tears, Cuff arthropathy, Glenohumeral joint osteoarthritis

1. Introduction

Shoulder arthroplasty is a well-established management option for severe glenohumeral joint disease; encompassing inflammatory arthritis, avascular necrosis, post traumatic sequelae, rotator cuff arthropathy and osteoarthritis. Total shoulder arthroplasty (TSA) offers a solution, with studies showing that it provides substantial pain relief and functional improvement.1

Shoulder arthroplasty in the elderly offers challenges other than the shoulder pathology, often this cohort of patients have other co-morbidities that increase risk and complication from surgery compared to younger cohorts.2 However, despite these risks shoulder arthroplasty continues to offer good functional outcomes and improvements in quality of life for patients.1

In an ever-aging population the degenerative changes both at the joint surface and within the integrity of rotator cuff tendons have led to an increase in the requirements of shoulder arthroplasty as definitive management options in this cohort. There remains a debate over whether more elderly patients are suitable for anatomical total shoulder arthroplasty (ATSA), weighing up functional gains against the risks and complications, and potential for revision surgery or best to undergo reverse total shoulder arthroplasty (RTSA) from the outset.3,4

Rotator cuff tears are a recognised complication after TSA (5). A secondary rotator cuff dysfunction rate of 17 % following ATSA has been reported and understandably considerably poorer clinical outcomes were found in these patients compared to those with intact cuffs.5 In addition, rotator cuff quality has been shown to deteriorate with advancing age.6 One would therefore be cautious about ATSA in more elderly patients, and taking this onboard, it might be reasonable to therefore assume a detrimental longer-term outcome in patients over the age of 80 (7). Some studies have reported on overall outcome comparison between ATSA and RTSA with differing outcomes highlighting the debate in the field.7,8

While the choice between anatomic and reverse shoulder replacement designs remains a topic of debate, pragmatism often plays into a surgeon's mind, and it is influenced by considerations of functional benefits versus specific procedural complications. This decision-making process represents one of the unresolved questions in shoulder surgery research particularly in the elderly population in the setting of an intact or partial rotator cuff tear. Elderly patients are often lower demand, more likely to have rotator cuff pathology and medically more co-morbid. However, age is just a number and elderly patients are not homogenous as a population. This review discusses the role of ATSA and RTSA in elective shoulder surgery in the more elderly population and how we can look forward to improving outcomes in this population.

2. Trends

We have seen a significant increase in the volume of shoulder arthroplasty procedures being performed, worldwide, and a notable shift in the types of procedures performed. There are reports that the rate that shoulder arthroplasty number have been increasing exceeds that of hip and knee arthroplasty.9

Data from the UK national joint registry has shown a significant increase in the number of shoulder arthroplasty procedures being performed and a 5-fold increase of RTSA between 2012 and 2022 (11). The USA and Germany have observed a similar trend in overall shoulder arthroplasty and RTSA in particular.10,11 Overall, the global trend in shoulder arthroplasty among the elderly shows a clear shift towards RTSA likely been driven by its superior outcomes in patients with rotator cuff pathology and its expanding indications.12 There has certainly been a growing preference for RTSA in patients over 70 13,10,14, reflecting a shift towards this procedure in more elderly patients with the perceived functional benefits and lack of rotator cuff reliance.15 Further to the type of implant, registries show that there is an increase in the use of bone conserving implants with a stemless design. Additionally a registry data and cohorts are demonstrating good survivorship of RSA 13,16,17 even at 10 years.18

3. Anatomic total shoulder arthroplasty (ATSA) in the elderly

ATSA is a commonly performed procedure to address degenerative shoulder conditions in elderly patients, particularly for glenohumeral joint osteoarthritis. This procedure aims to restore the natural anatomy of the shoulder, thereby offering pain relief and improving functionality. A crucial aspect of ATSA is preserving the integrity of the superior rotator cuff, especially during head resection,19 as it plays an essential role in shoulder movement and stability.

The rotator cuff's importance in shoulder function is well-documented. The force-couple concept, described by Burkhart,20 emphasizes the importance of balance between the anterior cuff (subscapularis) and posterior cuff (infraspinatus and teres minor) to maintain the centering of the humeral head. Although the supraspinatus provides some superior restraint, its significance for ATSA outcomes remains uncertain21.

In recent years, stemless implants have emerged as a popular option in ATSA. These implants anchor directly into the humeral head, minimizing disruption to surrounding tissues, including the rotator cuff (Fig. 1). By relying on metaphyseal fixation, stemless implants avoid the need for an intramedullary stem, making them particularly beneficial for elderly patients with osteoporotic bone quality. This approach has gained favour for its bone-preserving characteristics and its potential to improve recovery times and surgical outcomes over stemmed implants (Fig. 2).

Fig. 1.

Fig. 1

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Radiographs demonstrating a stemless anatomical shoulder replacement.

Fig. 2.

Fig. 2

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Radiograph demonstrating a stemmed anatomical total shoulder replacement.

The advantages of ATSA in elderly patients are several. First, it offers substantial pain relief and improved functional outcomes. Research has shown that ATSA provides better pain relief and range of motion compared to reverse total shoulder arthroplasty (RTSA).22 Second, stemless ATSA implants preserve bone stock by minimizing the amount of bone excised, a key factor for elderly patients with osteopenic or osteoporotic conditions. This bone preservation also broadens the scope for future revision surgeries, reducing the risk of fractures. Third, by maintaining the shoulder's natural anatomy, ATSA enables more natural movement patterns and enhances overall joint stability. This can lead to higher patient satisfaction and functional recovery compared to RTSA 23. Lastly, modern implant materials have enhanced the long-term durability of anatomical replacements, offering elderly patients more reliable and long-lasting solutions24.

Despite these advantages, there are also notable disadvantages to ATSA in the elderly. The procedure's success heavily relies on the integrity of the rotator cuff. If the cuff is severely damaged or irreparable, outcomes may be less favourable, and revision surgery may be required. Secondary rotator cuff dysfunction is a common complication that can lead to significant functional impairment.5 Additionally, ATSA may not be suitable for all elderly patients, particularly those with extensive bone loss, severe glenoid wear, or abnormal glenoid morphology, in which cases RTSA may be a more appropriate option. Recovery from ATSA can also be longer for elderly patients, as rehabilitation protocols must be adapted to account for age-related factors, and the healing of the subscapularis muscle following surgery can limit early mobility.

There is also a risk of loosening or wear of the prosthesis over time, especially in patients with poor bone quality. This risk is particularly evident in the glenoid component due to the “rocking horse” phenomenon.25 However, studies have demonstrated that stemless implants show comparable longevity and durability to stemmed implants,26 making them an increasingly viable option for elderly patients. One meta-analysis found no significant differences in clinical outcomes between stemmed and stemless replacements, suggesting both can provide predictable results in terms of pain relief and function.27 ATSA, however a stemmed component often relies on a diaphyseal hold and can lead to problems of stress shielding.28

The choice between stemmed and stemless implants depends on various factors, including the patient's bone quality, rotator cuff integrity, and surgeon preference. Stemless implants are becoming more widely used due to their bone-preserving nature and promising outcomes, especially in patients with suitable anatomy.13,17,29 These implants have demonstrated reduced complication rates and greater long-term durability,30 making them an attractive option for elderly patients requiring shoulder arthroplasty.

4. Partial rotator cuff tears

ATSA in the elderly with partial rotator cuff tears presents a controversial clinical challenge but can still yield favourable outcomes under certain conditions. The decision to proceed with this type of shoulder arthroplasty hinges on several factors, including the degree of the rotator cuff tear, the patient's symptoms, and functional goals. Cuff failure is one of the most common complications for ATSA 23 and a likely reason some surgeons sway to opt for RTSA in the presence of a partial cuff tear rather than ATSA. However, ATSA performed in the presence of partial thickness cuff tears have still been shown to have good outcomes without compromise to function or demonstrable cuff failure.31

Partial rotator cuff tears in elderly patients may not always require extensive repair or reconstruction if they are asymptomatic or minimally symptomatic. In such cases, ATSA can address the underlying arthritis or joint degeneration while potentially providing pain relief and improving shoulder function. TSA when combined with intraoperative repair of the rotator cuff, represents a complex yet promising approach to addressing shoulder pathology, especially in cases where both severe joint arthritis and rotator cuff tears coexist. This combination procedure aims to restore joint function while addressing the structural integrity of the rotator cuff, which plays a crucial role in shoulder stability and movement. Simone et al.21 detail excellent results in patients with small full thickness rotator cuff tears repaired at the time of ATSA.

Research indicates that ATSA can be successful in patients with partial rotator cuff tears, particularly when the tears are manageable, and the remaining cuff tissue is sufficient to support joint stability and function. A cohort study highlighted that patients with partial-thickness rotator cuff tears, cuff atrophy, a positive tangents sign or fatty infiltration in the muscle may have diminished range of movement but these factors do not compromise the outcomes of ATSA.32

Therefore, based on current literature, ATSA remains a viable potential solution for elderly patients with partial rotator cuff tears, providing effective pain relief and improved function in selected cases. The topic of TSA in the presence of partial rotator cuff tears remains a topic of significant interest and debate and careful patient selection is crucial.

5. Reverse shoulder arthroplasty (RTSA) in the elderly

RTSA has transformed the treatment of complex shoulder conditions in elderly patients, particularly those with irreparable rotator cuff tears or cuff tear arthropathy. The procedure reverses the natural anatomy of the shoulder joint by placing a glenosphere component on the glenoid and a reciprocal concave insert on the humeral prosthesis (Fig. 3). This design shifts the reliance from the rotator cuff to the deltoid muscle, making it particularly beneficial for older adults whose rotator cuffs may be damaged or dysfunctional.

Fig. 3.

Fig. 3

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Radiograph demonstrating a stemmed reverse total shoulder replacement.

RTSA has shown better outcomes when performed on a rotator cuff-intact shoulder, compared to one that is rotator cuff-deficient.33 However, the procedure remains safe and effective in the elderly population even when the rotator cuff is compromised.34 A review of RTSA performed in patients with a mean age over 70 showed significant functional improvements, particularly in cases of isolated glenohumeral osteoarthritis.35 In contrast, other conditions like cuff tear arthropathy and massive rotator cuff tears without osteoarthritis may show less dramatic improvement but still benefit from RTSA.

Glenoid morphology also plays a crucial role in determining the suitability of RTSA. The design of RTSA offers superior stability, reducing the risk of complications such as glenoid wear or malposition, which can impact the effectiveness of ATSA. RTSA is less affected by glenoid malposition and is better suited to cases involving significant glenoid bone loss or deformity.36 Additionally, RTSA facilitates the correction of version deformities, ensuring robust fixation even in complex cases.

5.1. Outcomes in the elderly population

  • 1.

    Pain Relief and Functionality: RTSA has been shown to significantly reduce pain and improve shoulder function. Patients, especially elderly ones, often report the ability to perform daily tasks with greater ease.37 One study on elderly athletes found that 95 % returned to sports at the same level or higher after a minimum of three years.38

  • 2.

    Range of Motion and Strength: While concerns about restricted external rotation exist, RTSA generally results in functional outcomes that meet the needs of elderly patients. Many patients achieve sufficient range of motion for activities of daily living, with rehabilitation focusing on deltoid strength and shoulder stability.8,16 Studies have shown that even patients over 85 experience comparable functional improvements to younger cohorts, with durable prostheses contributing to long-term success.39

  • 3.

    Patient Satisfaction and Quality of Life: High levels of patient satisfaction are reported in the elderly following RTSA. Older patients often experience significant improvements in quality of life, enabling them to maintain their independence due to reduced pain and better shoulder function. These benefits can last over a decade,16 reflecting RTSA's long-term effectiveness.

  • 4.

    Complications: As with any major surgery, complications such as instability, scapular notching, and infection can occur.40,41 Revision surgeries for RTSA, however, can be more complex than for ATSA, especially when humeral components are cemented. Despite these challenges, advancements in implant design and surgical techniques have helped mitigate complications.

5.2. Considerations in the elderly

  • 1.

    Bone Quality and Healing: Elderly patients often experience compromised bone quality, such as osteoporosis, which can impact implant fixation and healing. In these cases, modifications to surgical technique and implant selection may be necessary to optimise outcomes. The use of stemless RTSA implants (Fig. 4) is an area of interest, as they preserve bone stock and may simplify revision surgeries, which is especially advantageous for elderly patients.42

  • 2. Rehabilitation Protocol: Effective postoperative rehabilitation is essential to maximize the benefits of RTSA. A gradual rehabilitation program focusing on deltoid strengthening and shoulder stability is crucial for elderly patients to restore function and ensure long-term success.

Fig. 4.

Fig. 4

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Radiograph demonstrating a stemless reverse total shoulder replacement.

RTSA offers substantial benefits for elderly patients with complex shoulder pathologies. It improves pain, functionality, and quality of life, although careful consideration of bone quality, rehabilitation, and potential complications is essential for achieving the best outcomes.

6. Complications of shoulder arthroplasty in the elderly

When evaluating complications associated with shoulder arthroplasty, it is essential to consider both medical and procedure-specific factors. Elderly patients often have comorbidities and reduced physiological reserves compared to younger individuals, which can increase their risk of complications. Factors like obesity may contribute to longer operative times, greater blood loss, higher infection rates, and overall complications. Additionally, functional improvements may be less significant in obese patients compared to those with lower BMI43.

RTSA is generally considered safe in elderly patients, though a higher 90-day mortality rate of around 3 % has been noted compared to 1.5 % in younger patients.44 Interestingly, while mortality is higher in the elderly, the complication rates—such as dislocation, fracture, and stiffness—are lower in the year following surgery.44 However, elderly patients, particularly those over 90, may experience longer hospital stays, higher care costs, and more postoperative medical complications.45 For elective RTSA, these patients are also at a higher risk for postoperative anaemia, blood transfusions, pneumonia, and acute renal failure, which should be considered when weighing the potential benefits of the surgery.45

ATSA presents its own risks, particularly cuff failure and instability, which are common causes of revision in elderly patients.13 While RTSA may offer a solution for some of these issues, evidence suggests that it may have a higher risk of instability and dislocation at 5 years compared to ATSA 46. Acromial stress fractures are another concern, especially for elderly patients with osteoporosis. The surgeon's implant selection plays a crucial role in managing these risks. Factors such as neck shaft angle, as well as the choice between onlay or inlay designs, can influence stability. An increased valgus angle raises the risk of scapular notching,47 while a more varus neck shaft angle can improve anterior stability but may increase the risk of fractures, such as acromial or scapular spine fractures,48 in patients with poor bone quality.49

Bone loss, especially on the humeral or glenoid side, poses a significant challenge, particularly during revision arthroplasty. While some centres report positive results with allograft prosthetic composites50 (Fig. 5), these techniques carry a higher risk of instability and non-union, particularly in elderly patients with osteoporotic bone.51 Alternatively, large prosthetic components and modular systems have shown improved outcomes in some cases (Fig. 6).52 However, soft tissue balance remains a challenge, especially in elderly patients.

Fig. 5.

Fig. 5

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Allograft Prosthesis Composite (APC) example.

Fig. 6.

Fig. 6

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Modular proximal humeral replacement.

Glenoid bone loss also complicates surgical decisions. Depending on the extent of bone loss, surgeons may choose strategies like eccentric reaming, autografting, or BIO-RSA approaches. These methods require caution in elderly patients with weakened bone stock, as they can lead to failure.53 Newer technologies, such as CAD-CAM total shoulder replacements and augmented glenoid implants, have shown promising results for complex cases, improving pain, patient satisfaction, and survivorship.54,55 However, there remains no clear consensus on the best approach for elderly patients.

7. Improving outcomes in shoulder arthroplasty

Advancements in surgical techniques have significantly improved outcomes in shoulder arthroplasty for elderly patients, addressing challenges specific to age-related factors such as bone quality, tendon integrity, and overall health. These innovations have led to reduced complication rates, improved functional outcomes, and increased patient satisfaction.

  • -

    Modular Platform Systems

With the rise in primary TSA, there has also been an increase in revision TSA procedures. Revision surgeries present unique challenges, such as longer operative times, increased blood loss, and the need for bone grafting or custom prostheses.56 The development of modular platform humeral stems has facilitated easier conversion from ATSA to RTSA without the need to remove the humeral stem.57 This advancement significantly reduces complications, operative times, and the need for complex revision procedures, offering a less invasive and more cost-effective solution.

  • -

    Glenoid Prosthesis Augmentation

Glenoid prosthesis augmentation is critical when dealing with extensive retroversion and posterior wear of the glenoid. Conditions such as a bi-concave glenoid (Walch B2) or excessive retroversion (Walch B3) pose significant risks of glenoid loosening with standard implants, leading to revision surgeries.58 Augmented glenoid components, which include full and partial wedge designs, help mitigate bone removal and shear stresses while retaining the benefits of ATSA over RTSA. Although long-term data is lacking, short-term results are encouraging, with low revision rates in follow-up periods of 2–3 years.59,60 For cases of advanced bone loss, RTSA may be preferred, as it offers better stability and reduces asymmetric wear due to its constrained component design. Despite this, successful glenoid implant placement still requires proper version alignment (within 5–10 degrees of neutral) and appropriate baseplate contact, which augmented glenoids can help achieve by reducing the need for extensive reaming and preserving more native bone stock.59

  • -

    Convertible Glenoid Prosthesis in ATSA

The cemented all-polyethylene glenoid component has been the standard for ATSA, but concerns about the difficulties of revising cemented glenoids have led to a growing interest in convertible metal-backed glenoid components.61 These newer designs offer improved stability, with the metal carrier anchoring more securely within the glenoid vault, increasing bone-implant contact and stability against shear forces.62 Follow-up results have been promising, with studies showing no instances of glenoid loosening and a low implant-related revision rate.62 The convertible design also facilitates conversion from ATSA to RTSA if necessary, while maintaining improvements in pain and shoulder function.63

  • -

    Patient-Specific Instrumentation and Pre-Operative Planning

Patient-Specific Instrumentation (PSI) and preoperative planning have revolutionised the precision of shoulder arthroplasty, particularly in cases with altered glenoid morphology. By utilising a patient's preoperative 3D CT scan, surgeons can create a virtual surgical plan, and PSI guides, enhancing the surgeon's ability to prepare the glenoid surface and securely place the implant. Studies show that PSI significantly reduces the rate of malpositioned components, with one meta-analysis reporting a decrease from 68.6 % to 15.3 %.64 This technique is particularly beneficial for patients with severe retroversion, where PSI can achieve optimal placement within 1.2 degrees of the ideal position.65 Although PSI has shown promise in improving implant accuracy, its impact on long-term clinical outcomes remains uncertain 66, and further studies are needed to confirm its benefits.

  • -

    Computer-Aided Navigation in TSA

Computer-aided navigation has significantly improved the precision of glenoid component placement, which is crucial for the success of TSA.67 Research has demonstrated that CT-based navigation systems enhance screw placement accuracy and reduce the variability in postoperative version, resulting in better alignment of glenoid components.68 These advancements are critical, as glenoid malposition is one of the leading causes of revision surgery. However, the long-term clinical outcomes of computer navigation in TSA remain understudied.69

  • -

    Augmented and Mixed Reality in TSA

Augmented Reality (AR) and Mixed Reality (MR) have emerged as valuable tools in both preoperative planning and intraoperative guidance.70 AR overlays digital displays on real-world surfaces, improving depth perception and enhancing the surgeon's ability to visualize anatomical structures. MR, which combines real-world views with interactive holograms, has been used in proof-of-concept studies to assist in standard RTSA surgeries, improving surgical accuracy and reducing operative time.71 Although these technologies hold great promise, their high costs currently limit widespread application. As AR and MR technologies advance and become more cost-effective, they have the potential to revolutionize surgical practice by improving training, surgical precision and reducing human error 84.

  • -

    Robotics in TSA

Robotic-assisted technology, already widely used in hip and knee arthroplasty, is now being applied to shoulder surgery. Robotic platforms, such as the MAKO system and the ROSA system, aim to enhance surgical precision by monitoring bone and tissue tension during the procedure. These systems are classified as active, passive, or semi-active, with the latter combining automated control with surgeon guidance to achieve predetermined surgical goals.72,73 The ROSA Shoulder system, is expected to improve precision and reduce intraoperative errors, paving the way for more accurate and reliable shoulder replacements.74 As robotic platforms continue to evolve, they are poised to become integral in shoulder arthroplasty, offering improved outcomes and better patient satisfaction.75

Surgical advancement, including modular platforms, augmented prostheses, and cutting-edge technologies like PSI, AR, and robotics, are significantly improving the outcomes of shoulder arthroplasty, particularly for elderly patients. These innovations not only enhance the precision of the procedure but also address specific challenges related to bone quality, tendon integrity, and overall patient health, leading to reduced complications and better functional outcomes. As technology becomes more accessible research into their benefits to patients and cost effectiveness will be important in individualising surgery for patients preoperatively, intraoperatively, and post-operatively. Artificial intelligence will be able to utilise patient specific information to counsel a patient on their predicted trajectory aiding decision making and reducing the burden of complications.76

8. Shoulder arthroplasty decision making for elderly patients

TSA has become the preferred treatment for end-stage glenohumeral joint disease. Advances in both ATSA and RTSA have proven effective in alleviating pain and restoring function, although current literature does not conclusively favour one design over the other for elderly patients. Initial assessment should involve a comprehensive evaluation of a patient's functional demands, comorbidities, and clinical status to determine their suitability for surgery.

3D imaging such as CT and MRI, plays a crucial role in confirming the integrity of the rotator cuff and assessing bone stock on the humeral and glenoid sides, as well as the morphology of the glenoid. This information aids in surgical planning and facilitates decision-making regarding the choice of implant, aiming to optimise functional outcomes and anticipate potential future revisions. When the rotator cuff is deficient through clinical, and or imaging, review the decision is simple in elderly patients and they would undergo a RTSA.

For those patients with preserved rotator cuff and satisfactory glenoid anatomy, ATSA typically offers the most favourable outcomes, stemless components potentially favourable for any future procedures. Conversely, patients with complex glenoid wear and multiple torn rotator cuff tendons are often better candidates for RTSA. However, there remains ongoing debate regarding the management of elderly patients with partial rotator cuff tears or preserved rotator cuff with accompanying degenerative joint disease. Orvets et al.77 report on the all cause revision risk for ATSA and RTSA being equivocal. The most common cause for ATSA revision was cuff failure and the most common cause for RTSA revision being glenoid component loosening. Schaller et al.78 found that ATSA demonstrates a significant improvement in range of movement in comparison to RTSA in matched elderly patient cohorts. However, there was no statistical difference in functional assessment scores between RTSA and ATSA. A large registry and database study79 has provided further support that RTSA is an acceptable alternative to ATSA for patients aged 60 years or older with osteoarthritis and intact rotator cuff tendons. Despite a significant difference in the risk profiles of revision surgery over time, there was no statistically significant nor clinically important differences between RTSA and ATSA in terms of long-term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.80

A recent study compared RTSA outcomes in 2 matched patient cohorts; those under 70 and those over the age 70 (81). The study found that regardless of age patients undergoing RTSA for glenohumeral osteoarthritis have good outcomes which along with the longer survivorship outcome study by Chelli et al.16 does provide strong evidence for choosing RTSA for the index procedure.

As experience with RTSA expands both in the UK and internationally, there is a growing trend towards considering RTSA as the primary surgical option for many patients. Many surgeons are now reserving ATSA for a younger cohort with minimal glenoid deformity and a robustly intact rotator cuff.

9. Future research in shoulder arthroplasty

Future research in shoulder arthroplasty for the elderly focuses on improving surgical outcomes, implant longevity, and patient-specific approaches to address the unique challenges posed by this demographic. One notable ongoing study is the RAPSODI (Randomised controlled trial of Arthroplasty for the Painful Shoulder in Osteoarthritis in patients over 65 years: Decision aid Implementation) trial (ISRCTN12216466),82 which aims to evaluate the effectiveness of different types of shoulder arthroplasty in older patients with osteoarthritis with intact or partial rotator cuff tears.

Although RTSA seems to demonstrate good survivorship16 more needs to be explored about the functional impact for patients and the burden of revision surgery. How we can optimise this through modular components, better materials and equipment will all help reduce the difficulties often faced and thereby hopefully improve outcomes for patients.

CRediT authorship contribution statement

P. Raval: Writing – review & editing. Harvinder Singh: Writing – review & editing.

Patient consent

Consent was not required for this review article

Ethical clearance

Ethical approval was not required for this review article

Source of funding

No funding was received by either author for the production of this manuscript.

Declaration of competing interest

All the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

No further acknowledgments are required beyond the 2 authors of the manuscript

Footnotes

This article is part of a special issue entitled: Shoulder Arthroplasty published in Journal of Clinical Orthopaedics and Trauma.

Contributor Information

P. Raval, Email: parag.raval@uhl-tr.nhs.uk.

Harvinder Singh, Email: harvinder.p.singh@uhl-tr.nhs.uk.

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