One reason for success after anatomic total shoulder arthroplasty (TSA) survival rate is a well-functioning rotator cuff. Concerns regarding risk of subscapularis (SC) failure in older patients may shift surgeons toward performing reverse arthroplasty. This study aimed to report the rate of clinically relevant SC failure after TSA in elderly patients.
Methods
We retrospectively reviewed 282 patients greater than 70 years who underwent TSA for osteoarthritis with a minimum of 6-month follow-up (mean 1.8 years). Clinically relevant SC failure was defined as either: (1) American Shoulder and Elbow Score (ASES) below a threshold score with a positive abdominal compression or anterior subluxation or (2) reoperation for SC deficiency.
Results
Of 282 patients, 23 patients demonstrated possible SC failure. Five patients had confirmed SC failure, but only four patients (1.4%) were clinically symptomatic. Three patients (1.06%) underwent revision surgery for SC deficiency. Symptomatic SC failure patients had higher body mass index, higher comorbidity burden, lower ASES scores, and higher pain scores prior to revision surgery (mean 1.5 years). Anterior subluxation on radiographs was prevalent in 100% of the failure group.
Discussion
Clinically symptomatic SC failure after TSA is rare (1.4%). Older age should not represent a contraindication to TSA due to the perceived risk of SC failure.
JensenARTangtiphaiboontanaJMarigiE, et al.Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly. J Shoulder Elbow Surg2021; 30: S131–S139.
2.
SuFNuthalapatiPFeeleyBT, et al.Outcomes of anatomic and reverse total shoulder arthroplasty in patients over the age of 70: a systematic review. JSES Rev Rep Tech2023; 3: 181–188.
3.
PiperCCHorneffJG. Management of subscapularis insufficiency after total shoulder arthroplasty. J Am Acad Orthop Surg2022; 30: 933–940.
4.
CofieldRHEdgertonBC. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect1990; 39: 449–462.
5.
MillerSLHazratiYKleppsS, et al.Loss of subscapularis function after total shoulder replacement: a seldom recognized problem. J Shoulder Elbow Surg2003; 12: 29–34.
6.
ParadaSAFlurinP-HWrightTW, et al.Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty. J Shoulder Elbow Surg2021; 30: 811–818.
7.
AchakriHBen-ShlomoYBlomA, et al.The National Joint Registry 20th Annual Report 2023. London: National Joint Registry 2022 http://www.ncbi.nlm.nih.gov/books/NBK601075/ (accessed 4 August 2025).
8.
Australian Orthopaedic Association National Joint Replacement Registry. Smith PN, Australian National University Medical School, et al. Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Australian Orthopaedic Association. 2023:1-478. DOI: 10.25310/YWQZ9375.
9.
AtwanYWaltonMJWattsAC, et al.Anatomic or reverse shoulder arthroplasty for cuff intact glenohumeral osteoarthritis. Shoulder Elbow2025; 17: 697–702.
10.
PolisettyTSColleyRLevyJC. Value analysis of anatomic and reverse shoulder arthroplasty for glenohumeral osteoarthritis with an intact rotator cuff. J Bone Joint Surg Am2021; 103: 913–920.
11.
PolisettyTSSwansonDPHartP-AJ, et al.Anatomic and reverse shoulder arthroplasty for management of type B2 and B3 glenoids: a matched-cohort analysis. J Shoulder Elbow Surg2023; 32: 1629–1637.
12.
SchochBSKingJJZuckermanJ, et al.Anatomic versus reverse shoulder arthroplasty: a mid-term follow-up comparison. Shoulder Elbow2021; 13: 518–526.
13.
RichardsRRAnKNBiglianiLU, et al.A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg1994; 3: 347–352.
14.
DelgadoDALambertBSBoutrisN, et al.Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. JAAOS Glob Res Rev2018; 2: e088.
15.
HawkinsRJBoesNThigpenCA, et al.Measure what matters: Single Assessment Numeric Evaluation (SANE) score as the critical measure for shoulder outcomes. J Shoulder Elbow Surg2024; 33: 1397–1403.
16.
SciasciaADMorrisBJJacobsCA, et al.Responsiveness and internal validity of common patient-reported outcome measures following total shoulder arthroplasty. Orthopedics2017; 40: e513–e519.
17.
SimovitchRWElwellJColasantiCA, et al.Stratification of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex. J Shoulder Elbow Surg2024; 33: e492–e506.
18.
WernerBCChangBNguyenJT, et al.What change in American shoulder and elbow surgeons score represents a clinically important change after shoulder arthroplasty?Clin Orthop Relat Res2016; 474: 2672–2681.
19.
BerglundDDDamodarDVakhariaRM, et al.Predicting outstanding results after anatomic total shoulder arthroplasty using percentage of maximal outcome improvement. J Shoulder Elbow Surg2019; 28: 349–356.
20.
JacobsCAMorrisBJSciasciaAD, et al.Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty. J Shoulder Elbow Surg2016; 25: 1128–1132.
21.
ArmstrongALashgariCTeefeyS, et al.Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty. J Shoulder Elbow Surg2006; 15: 541–548.
22.
JacksonJDCilASmithJ, et al.Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg2010; 19: 1085–1090.
23.
LiemDKleeschulteKDedyN, et al.Subscapularis function after transosseous repair in shoulder arthroplasty: transosseous subscapularis repair in shoulder arthroplasty. J Shoulder Elbow Surg2012; 21: 1322–1327.
24.
BeleckasCMSchodlbauerDFMousadAD, et al.Evaluation of new normal after shoulder arthroplasty: comparison of anatomic vs. Reverse total shoulder arthroplasty. J Shoulder Elbow Surg2025; 34: S43–S49.
25.
TripletJJEverdingNGLevyJC, et al.Anatomic and reverse total shoulder arthroplasty in patients older than 80 years. Orthopedics2025; 38.
26.
MowbrayJVan NiekerkMFramptonC, et al.The outcomes of shoulder arthroplasty in those aged ≥70 years with glenohumeral arthritis: a New Zealand joint registry study. J Shoulder Elbow Surg2022; 31: 799–805.
27.
BestMJAzizKTWilckensJH, et al.Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg2021; 30: 1159–1166.
28.
HeifnerJJKumarADWagnerER. Glenohumeral osteoarthritis with intact rotator cuff treated with reverse shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg2021; 30: 2895–2903.
29.
ASES Complications of RSA Research Group, LohreRSwansonDP, et al.Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES complications of reverse shoulder arthroplasty multicenter research group. J Shoulder Elbow Surg2023; 32: 2483–2492.
30.
LopezRGoltzDCoxR, et al.Comparison of anterior shoulder pain and internal rotation dysfunction after anatomic and reverse shoulder arthroplasty for osteoarthritis. J Shoulder Elbow Surg2025; 34: 2130–2137.
31.
SimonMCoghlanJBellS. Shoulder replacement in the elderly with anatomic versus reverse total prosthesis? A prospective 2-year follow-up study. J Clin Med2022; 11: 540.
32.
ForuriaAMSperlingJWAnkemHK, et al.Total shoulder replacement for osteoarthritis in patients 80 years of age and older. J Bone Joint Surg Br2010; 92-B: 970–974.
33.
EvansJPBattenTBirdJ, et al.Survival of the Aequalis total shoulder replacement at a minimum 20-year follow-up: a clinical and radiographic study. J Shoulder Elbow Surg2021; 30: 2355–2360.
