Osteoarthritis with an intact rotator cuff, reverse shoulder arthroplasty, or total shoulder arthroplasty?

Abstract

Aims

The indications for reverse shoulder arthroplasty (RSA) have expanded beyond the primary design philosophy of an implant used to deal with rotator cuff deficiency. Its application in the cuff intact shoulder is growing in clinical practice. Despite this, there is little understanding of how surgeons decide between implants, specifically RSA and total shoulder arthroplasty (TSA) in this clinical scenario.

Methods

Trauma & Orthopaedic Consultants specializing in shoulder surgery were recruited to participate in semistructured interviews by the research team. Using grounded theory methodology, the transcribed interviews were analyzed to generate themes and theories on factors affecting the decision-making between RSA and TSA. Collection and analysis was concluded when data saturation had been reached.

Results

Patients characteristics, specifically ‘physiological age’, a term incorporating age, comorbid status, and preoperative function played a key role in decision-making. Anatomical factors specifically glenoid morphology and retroversion angle significantly contributed to implant choice; however, specific cut-offs for determining implants were not universal. Other themes identified included revision profiles of the implants, functional outcomes, and surgical training and experience.

Conclusion

The decision-making between RSA and TSA for osteoarthritis and cuff intact patients is complex and multifactorial. The main factors surgeons consider are physiological age, patient anatomy, and functional outcomes. Within these factors however, there is no uniform agreement on which implant is best for which patients.

Cite this article: Bone Jt Open 2026;7(3):433–441.

Introduction

Reverse shoulder arthroplasty (RSA) was originally designed for cuff tear arthropathy; however, its use has now expanded to a broad range of indications such as glenohumeral osteoarthritis (GHOA) with an intact rotator cuff.¹ RSA for GHOA with an intact cuff is a key research priority highlighted by National Institute for Health and Care Excellence (NICE)² and the James Lind Alliance.³ A recent National Joint Registry (NJR) study⁴ found RSA was an acceptable alternative to total shoulder arthroplasty (TSA) in terms of clinical outcomes and cost effectiveness, though patient-reported outcome measures (PROMs) data were limited and further research was required. The Reverse or Anatomical (replacement) for Painful Shoulder Osteoarthritis (RAPSODI) trial a current randomized controlled trial,⁵ is comparing clinical and patient outcomes between RSA and TSA in the cuff intact patients. In the trial’s initial design, 34 surgeons were surveyed: 87% already used or would consider RSA, and if evidence suggested benefit, 74% would change practice.⁵

This study uses qualitative methods to examine which patient and surgical factors influence choice between TSA and RSA in GHOA with an intact cuff. Findings, alongside the RAPSODI trial, may help us understand surgeons’ decisions, support the development of evidence-based decision tools that may aid shared decision-making, highlight areas for surgeon education, and inform implant design.

Methods

The study was conducted according to the consolidated criteria for reporting qualitative research (COREQ).⁶ The study team included Trauma & Orthopaedic (T&O) surgeons specializing in shoulder and elbow surgery as well as a foundation doctor and T&O registrars with previous experience of qualitative research methods (OOM, AA, JC, HB, SS, PR). The interviews were carried out by the primary author (OOM). Ethical approval was not required according to NHS Health Research Authority guidance, as the study involved interviews with clinicians recruited solely in their professional capacity, with no patient data and no impact on patient care. Participation was voluntary, informed consent was obtained, and all data were anonymized and stored securely.

Study design

Grounded-theory methodology underpins this study.⁷ An inductive approach was used with semistructured interviews, with open-ended questions on broad topics such as surgical and patient factors, which generated themes and theories on decision-making in RSA compared with TSA (see Supplementary Material).

Participant recruitment and inclusion

Participants were selected through purposive sampling to identify individuals with specialist knowledge, maximizing efficiency and validity of the findings.⁸ Consultant T&O surgeons specializing in shoulder and elbow who completed ≥ 12 primary shoulder arthroplasties per year (the 2023 UK median) were contacted by SS or OOM.⁹ Sample size was determined by data saturation. In line with grounded-theory methodology, we defined saturation as the point at which further interviews ceased to add new conceptual categories or significantly refine existing ones. Currently, approximately 7% of orthopaedic surgeons are female; we aimed for 10% female representation to reflect the current and future consultant population.^10,11 We aimed to include surgeons with a range of years in practice and annual case volumes.

Interviews

Interviews followed a structured guide developed by the research team. If a range was reported for annual shoulder arthroplasty cases, the midpoint was recorded and rounded to the nearest whole number. If participants were unsure or unclear, data were verified using the NJR database with the three-year mean recorded.

Statistical analysis

OOM reviewed transcriptions alongside recordings to ensure accuracy. Lumivero NVIVO v. 14 (Lumivero, USA) was used for thematic analysis.¹² An evolved grounded-theory was used to systematically code the data, using open coding, axial coding, and selective coding.⁷ Themes were discussed and revised by the research team, with constant comparison as new data were collected to refine them. Quotes were used to illustrate the identified themes. Analysis commenced during interviews and continued until saturation.

Results

Interviews were completed between April and July 2025 and lasted from 15 to 35 minutes. Data saturation was reached following ten interviews. Table I summarizes the participants demographic details. The mean participant age was 45 years (40 to 53) with a mean of eight years in consultant practice (4 to 14). All were fellowship trained. The mean case load was 32 (13 to 90) arthroplasty cases per year (all implants), and in nine out of ten participants, the practice was predominantly RSA (70% to 95%). One participant reported a majority TSA caseload (66%).

Table I.

Participant demographic details.

Participant number	Age, yrs	Sex	Years as a consultant	Fellowship trained (Y/N)	Average shoulder arthroplasty cases per annum	Approximate split RSA:TSA
1	53	Male	12	Y	25	90:10
2	40	Male	4	Y	13	70:30
3	51	Male	14	Y	90	70:30
4	42	Female	4	Y	18	33:66
5	44	Male	5	Y	45	95:5
6	43	Male	8	Y	25	90:10
7	45	Male	8	Y	30	90:10
8	48	Male	10	Y	19	90/95:10
9	40	Male	3	Y	18	90:10
10	44	Male	11	Y	40	90:10

RSA, reverse shoulder arthroplasty; TSA, total shoulder arthroplasty.

Five themes emerged during the interviews, each with multiple interlinked sub themes. Figure 1 illustrates these themes and their associations. Line thickness reflects the frequency of occurrence within the interviews.

Fig. 1.

Schematic of themes and subthemes in surgeon decision-making.

Patient characteristics

All participants noted patient characteristics as crucial to decision-making (Table II), with ‘physiological age’ emerging as a recurrent theme. Multiple participants noted the interlinking between age, comorbid status, and preoperative function. No participant described an absolute age cut-off, rather, most noted a general trend towards RSA in older and TSA in younger patients. In younger patients (generally aged < 65 years), there were concerns about RSA which centred on revision. Borderline cases were often discussed in a multidisciplinary team environment. For older patients, participants generally preferred an RSA to provide a ‘one operation’ solution. Opposing views were observed within the cohort, for example in participants 4 and 5 (Table II).

Table II.

Patient characteristics influencing decision-making.

Participant	Sub theme	Quote
2	Physiological age	“A 73-year-old who’s playing golf and very fit and active and has got an intact cuff I'd still want to do a primary anatomical, whereas somebody the same age that’s of a lower functional demand with more comorbidities and a bit less active then I would perhaps more likely to go for reverse.”
9	Age	“I don’t have a hard and fast cut-off. Broadly speaking, over 70 probably be thinking more towards a reverse, if they're under 70, probably have, an open discussion with them about the different options.”
7	Age and revision	“It’s physiological thing… But it’s also the fact that you're active, you still do the load of stuff and things like that. So I'm thinking more revision, but we still don't know long-term outcomes, do we.”
1	Age and revision	“If you're younger, probably an anatomical is easier to revise and so there’s a better chance it would be easily revisable.”
5	‘One operation’	“If I have an older patient, I think I’m going to give you one operation. I don't want to come back here and if I’ve got an 80 year old, they only need one shoulder arthroplasty and I know that a reverse with intact cuff does very well.”
4	‘One operation’	Referring to an older patient receiving a TSA - “I think there’s enough evidence now that these patients will do really well and I think the revision rate is actually much lower. So the older idea that maybe you want to do a single operation in somebody who’s 70 or above I don't think in my mind looking at the evidence that’s really worn out.”
4	Comorbidities	“Medically poor had lots of medical comorbidities I just wanted a single operation, then I might think about giving them a reverse.”
10	Patient choice	“Montgomery ruling says that you have to discuss every option with them, which is what I do.”
6	Patient choice	“The majority of patients are asked what would you rather have, one operation? The function might not quite be as good or potentially 2 operations. They all choose the reverse.”
6	Occupation	“If they are working, particularly any manual work, I'd probably rather do an anatomical, so I've got an easier revision option.”
1	Support/social status	“But then are they coping on their own because that’s difficult in the first six weeks if you've got an anatomical because we really don't want them doing too much. And I would be concerned about rupture and you know that’s part of the reasoning for me as well.”

TSA, total shoulder arthroplasty.

Specific comorbidities, such as inflammatory arthropathy, diabetes, cardiorespiratory disease, and smoking, were factors specified as key indicators for RSA over TSA again for ‘one operation’ in higher-risk patients.

Another frequently mentioned theme was patient choice. Most participants discussed how they counsel particularly borderline patients where they felt either implant may be appropriate. A persistent theme was that a TSA may provide better functional outcome; however, an RSA would likely give a lower likelihood of revision.

Finally, two smaller themes that were deemed important were occupation and social status. Manual handling or high-intensity jobs were deemed more suitable for TSA. Also given the importance of the subscapularis repair in TSA, there was concern if a participant lived alone, they may be at higher risk of rupture due to carrying out activities independently in the early stages postoperatively.

Anatomy and physiology

The second major theme was patient’s anatomy (Table III). Glenoid morphology was a key decision factor and participants referred to the Walch classification when describing the glenoid.¹³ For a patient with a B2 glenoid, surgeons preferentially choose a RSA. There were differences in cut-offs for retroversion angles deemed correctable for a TSA. Most participants had a maximum cut-off of 15° retroversion for a TSA; however, there was a range. Superior wear of the glenoid was also a factor reported. Similarly to retroversion cut-offs, there was differing acceptable limits for TSA suitability. Humeral head positioning, both retroversion and subluxation, were factors considered by participants.

Table III.

Anatomical factors affecting decision-making.

Participant	Sub theme	Quote
3	Retroversion	“So you could have a patient with a with a bone loss, say a 15° bone loss in a 75 year old, I would happily do an anatomical, you take it to 20° and I'm thinking maybe a reverse and if you take it to 30° then oh yeah, it’s a reverse.”
6	Retroversion	“I do use wedges to correct some posterior subluxation. But the ones we've got allow up to 8° correction. Any more than that? Then I'd do a reverse.”
7	Superior glenoid wear	“…no superior wear or no significant superior wear, so anything more than that to me goes to a reverse.”
9	Superior glenoid wear	“Referring to choosing an RSA - if I've got a glenoid that has sort of more than 15° of superior inclination.”
7	Humeral head	“…and then the amount of translation of the humeral head and whether you can correct that ideally without an augment or changing the head rotation. If you can't, then I'm looking at reverse.”
9	Humeral head	“…if you've got more than 85% subluxation or if you've got a B2 glenoid, massive retroversion, you're heading towards a reverse.”
5	Rotator cuff	“… if the MRI scan shows that you know there’s not significant thinning or fatty atrophy, then you know I will do an anatomical up to 85.”
3	Rotator cuff	“Attenuated cuff in younger people I’m still doing an anatomical, attenuated cuff in older people, I'm a reverse.”
10	Rotator cuff repair	“I'd be frightened that the cuff would give up in anyone who’s had a cuff repair previously so they would get a reverse as well.”
1	Rotator cuff repair	“It depends on the nature of the cuff tear. So if you have an acute cuff when you're windsurfing in your 20 s or 30 s, that’s a different kettle of fish to something when you're 50/60/70. So is it an acute traumatic cuff tear or not?”

Another anatomical factor reported was the quality of the intact rotator cuff. As with glenoid morphology there was not a clear consensus on acceptable quality for TSA with uncertainty highlighted. In general, if a patient had a previous cuff repair, participants would choose RSA, however, there were caveats to this. Previous surgeries, such as proximal humeral fracture fixation or stablization, were also cited as factors influencing preference for RSA over TSA.

Outcomes

Many participants considered outcomes such as function, PROMs, and revision and research outcomes following shoulder arthroplasty important when choosing implants (Table IV).

Table IV.

Outcomes affecting decision-making.

Participant	Sub theme	Quote
9	Function/ROM	“I generally feel that probably a good anatomical gives patients slightly better function at least in their short to intermediate term.”
2	Function/ROM	“My senior physios feedback to me that in a well done anatomical, they can still get back to better range and function than a well done reverse.”
5	Revision	“The modern reverse implants with the fixation methods we have for the glenoid, I think they are going to be more long lasting.”
9	Revision	“You know, if you have an anatomical, you might do well for five, seven however many years and then suddenly functional drop off and actually sort of in my experience, most people say well, actually I'd prefer just, you know what? one operation that gives me a bit more certainty about the future.”
8	Revision	“I am not just thinking about first implant, I am thinking about second implant, the third implant et cetera, revising a total as long as you don't get the glenoid massively loose, a total to reverse is easier than a reverse to reverse if that makes sense. So that’s a factor.”
6	NJR	“I think probably another factor that I’ve not mentioned is NJR surveillance. So it is less likely to have any early revisions if you do reverses.”
8	Research	“So RAPSODI, we've started doing more anatomics by the nature of the trial.”
7	Research	“But the complications that we're seeing with both are similar. So, we know that we can apply reverse like would apply an anatomical without causing any significant problems going forward… It may change with RAPSODI you know, because we might get forced into doing more anatomics.”

NJR, National Joint Registry; RAPSODI, Reverse or Anatomical (replacement) for Painful Shoulder Osteoarthritis; ROM, range of motion.

Regarding patient’s function and range of motion (ROM), the consensus among participants was that TSA was superior to RSA. Despite uniform consensus regarding revision outcomes, participants expressed concerns about higher TSA revision rates with the theme of a ‘one operation’ solution remaining prevalent.

In addition to primary revision rates, complexity of revision procedure was considered. Participants reported revising a TSA to an RSA as less complex and therefore considered when completing the primary procedure.

NJR surveillance was an influential factor mentioned by some. In the UK, a surgeon’s revision rates are monitored and freely available to the public. As RSA tends to have fewer early revisions, some participants felt this may influence surgeons to choose RSA over TSA.

NJR data for revision rates, Orthopaedic Data Evaluation Panel (ODEP) ratings of implants,¹⁴ and current literature were influential. At some centres, participants had recently performed more TSAs due to the RAPSODI trial allocation, and several felt its results may influence future practice.

Surgeon factors

Participant-related factors, such as workplace, training, and experience and financial considerations, also influenced decision-making (Table V). The most common theme mentioned in this category was training and experience. It was noted by many participants the trend towards RSA in recent years and concerns were raised about limited TSA exposure in training which may further drive the increasing use of RSA.

Table V.

Surgeon factors affecting decision-making.

Participant	Sub theme	Quote
5	Training and experience	“I think it’s undeniable that reverses are coming up and anatomics are coming down. So when I was a registrar in 2015/16, I think we were doing 50/50… that number came down as a fellow in 2019 where in nine months I did 2 anatomics and 40 reverses. And now as a consultant from 2020 I’ve done two anatomics and 100 reverses.”
9	Training and experience	“The major thing that swayed me, is training and in fellowship really, I do think we're better at reverses now, probably certainly I think the function we get is probably a bit better for trying to understand the deformity a bit more and correcting that.”
6	Training and experience	“Well when I started my training… you didn’t do reverse for anyone under 80 and now there are people that only do reverses.”
3	Training	“When you see no anatomicals in your six years of rotation or five after a fellowship, you know, you're not going to feel comfortable doing anatomical… It is a bit of bit of a problem really if we're getting trainees through the system at a senior level and they've not been exposed to a certain operation.”
8	Procurement	“Yeah, because, there’s procurement, does your, you know what your department uses, the cost of implants, all of that, your caseloads, your referral patterns make a difference too.”

Departmental factors played a role in decision-making. Procurement of implants, colleagues experience, and implant philosophies were highlighted factors.

Implant factors

The final theme related to implant factors, including design developments and preoperative planning capabilities (Table VI). Participants felt both implants had improved over time particularly glenoid fixation methods in TSA and advances in deformity correction. Improvements in implant design did not necessarily affect decision-making between implants. Some participants felt advances in surgical planning and imaging improved appreciation of deformity, potentially favouring RSA over TSA.

Table VI.

Implant factors affecting decision-making.

Participant	Sub theme	Quote
5	Implant design development	“We have great anatomical stemless stuff; the glenoid component fixation options have changed. You know you went from peg to keel. You now have Trilock stuff. You've got hybrid glenoid implants. We've got trabecular metal as well to improve those fixation methods and reduce the loosening rates. So I think industry has advanced.”
1	Implant design development	“…the increasing options for reverse shoulder arthroplasty with augments, the ability to correct much more sole defects has certainly helped. As to influence me from to do one from the other I'm not sure.”
5	Planning software	“Having a 3D view of the glenoid, you see things that you didn't appreciate before… So I think the software as well is starting to sway people away from an anatomical.”

Discussion

This qualitative study has revealed that decision-making in shoulder arthroplasty is informed by a complex interplay of factors. Despite ongoing research, such as the RAPSODI trial, evidence remains limited and no consensus exists on optimal implant choice for patients with GHOA and an intact rotator cuff.

Our findings illustrate how surgeons navigate uncertainty using a combination of experiential knowledge, professional heuristics, and risk management strategies. Many participants quoted a ‘one operation’ concept aversion to perform revisions in these patients, and the belief that RSA had a better revision profile; this belief, however, was not universal. This form of precautionary reasoning has been shown in qualitative research in hip arthroplasty, where surgeons balanced evidence, infrastructure, and their own expertise in the face of uncertainty when deciding between one or two stage revision for prosthetic hip infection.¹⁵ Similar to in lower limb arthroplasty, many of our participants relied on tacit knowledge and rules of thumb acquired through training and prior cases, rather than strictly formal guidelines.¹⁵ This reflects the broader, unavoidable role of clinical intuition and professional norms in surgical judgement.

System-level influences also played a notable role. Many surgeons described how registry data, departmental factors, and outcome-reporting frameworks shaped their views of implant risk and performance. While direct evidence of institutional habits in shoulder arthroplasty is limited, this parallels other qualitative studies showing how organizational structures and performance metrics influence clinical judgement, sometimes reinforcing the use of implants that are familiar, have predictable outcomes, or are viewed favourably in institutional data.^16,17

Participants widely agreed TSA provides superior ROM. Evidence is mixed: matched cohorts show no PROMs difference between TSA and RSA, although TSA demonstrates better internal rotation at short-term follow-up. Longer-term studies suggest TSA initially outperforms RSA in PROMs and ROM, but differences diminish or reverse by seven years.^18-20 Anatomical factors, such as B2 glenoids or retroversion, strongly influenced decision-making, though consensus on cut-offs was lacking. A recent study²¹ looking at specific cut-offs surgeons use found that on average surgeons would perform a TSA rather than RSA at retroversion angle of < 20° (IQR 10° to 20.75°), subluxation of < 70% (IQR 60% to 80%), and up to a median age of 70 years (IQR 65 to 75) yet overall consistency was low when presented with varying case scenarios. Furthermore, while some studies find similar functional outcomes between TSA and RSA even in challenging glenoid morphologies, others suggest trade-offs in revision risk.^21-25

Cuff quality also presented a dilemma; some surgeons were cautious about using TSA in attenuated cuffs, while others proceeded if other factors (age, anatomy) were favourable. This aligns with the limited and sometimes conflicting quantitative literature about how muscle quality, fatty infiltration, and minor tears predict function.^22,26-28 This absence of rigid, evidence-based anatomical cutoffs provides surgeons with necessary clinical flexibility but simultaneously creates a channel through which experiential bias is introduced. A surgeon is likely to push the perceived envelope for the procedure they perform most frequently and confidently, leading to decision variability rooted in personal comfort rather than established thresholds.

An important sub-theme that emerged was the influence of evolving surgical experience and training. In the UK, the proportion of shoulder arthroplasties that were RSAs increased significantly, from 26.8% in 2012 to 57.8% by 2022, a trend that is being reflected in training exposure.²⁹ Participants noted that trainees had little experience of TSA. Surgeon volume has been shown to affect clinical outcomes.³⁰ While TSA may provide superior outcomes in some patient groups, these benefits may not be realized if performed infrequently or without adequate experience. This has implications for training and service delivery: if exposure to TSA continues to decline, its outcomes may worsen through reduced surgeon familiarity, creating a self-perpetuating cycle favouring RSA. Addressing this will require deliberate training strategies and possibly centralization of TSA expertise, to ensure that patient care reflects both the evidence base and real-world practice patterns.

Taken together, our data suggest that decision-making about shoulder arthroplasty implants cannot be understood simply in terms of anatomy or patient characteristics alone. Rather, surgeons’ choices emerge from a dynamic negotiation among evidence gaps, experiential reasoning, institutional forces, and risk perceptions.

This study aimed to develop a comprehensive understanding of how surgeons make decisions regarding implant choice for patients with GHOA and an intact cuff. However, limitations should be acknowledged. Although our sampling strategy was designed to capture a representative group of T&O practising in England, the resulting sample reflects the current sex imbalance within the profession, and is restricted to a single national context. As such, the perspectives captured may not fully reflect decision-making practices in countries with different demographic characteristics or healthcare systems, which may limit transferability.

The research team was predominantly composed of practising orthopaedic surgeons. While this supported rapport and a nuanced understanding of the clinical context, it also carries the risk of reinforcing shared assumptions. To mitigate this, we undertook duplicate coding, held regular team discussions to explore divergent interpretations, and engaged in reflexive consideration throughout the analytical process. These steps were taken to enhance the credibility and trustworthiness of the findings.

In conclusion, the decision-making process between RSA and TSA in patients with GHOA and an intact cuff is complex and multifactorial, extending beyond mere clinical data. The main factors that surgeons actively balance are physiological age, patient anatomy, and anticipated functional outcomes. However, within these broad categories, our findings underscore a lack of uniform agreement on which implant is optimal for which specific patient profile. This variability is largely attributed to the current gap in a strong, comparative evidence base for these two implants in this patient group. While the RAPSODI trial aims to address a large aspect of this clinical question, further long-term comparative studies or targeted sub-group analyses in National Joint Registries should be prioritized targets for future research to establish consensus guidance.

Take home message

- This study highlights that implant selection between reverse shoulder arthroplasty (RSA) and total shoulder arthroplasty in cuff-intact osteoarthritis is not standardized and is influenced by a combination of patient-, anatomical-, and surgeon-related factors.

- The lack of consensus underscores ongoing uncertainty despite increasing RSA use, with potential implications for patient outcomes and variation in care.

- These findings emphasize the need for high-quality comparative evidence and decision support tools to guide more consistent, evidence-based practice.

Data Availability

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.