Courtesy: Mr Shahbaz Malik FRCS Orth, West Midlands, UK

Stemless Anatomic Total Shoulder Arthroplasty in Elderly Patients

Overview

Anatomic Total Shoulder Arthroplasty (aTSA) is a highly effective treatment for primary glenohumeral osteoarthritis, consistently providing excellent pain relief, improved shoulder function, and enhanced quality of life. While reverse shoulder arthroplasty (RSA) has become increasingly popular in elderly patients, emerging evidence suggests that chronological age alone should not dictate implant selection. In patients with an intact rotator cuff, anatomic TSA—and particularly stemless anatomic TSA—can provide excellent clinical outcomes, even in patients over 70 or 80 years of age.

The Increasing Demand for Shoulder Arthroplasty

An Aging, Active Population

Advances in healthcare have resulted in an older population that remains active well into later life.

Key demographic trends include:

Increased life expectancy
Greater participation in recreational and occupational activities
Higher expectations regarding function and independence

Studies predict:

The number of individuals aged 85 years and older will double by 2035.
The demand for shoulder arthroplasty in this age group is expected to increase by approximately 344% by 2040.

These trends emphasize the need for durable, functional shoulder replacement solutions in elderly patients.

Clinical Decision-Making in Elderly Patients

Choosing between anatomic and reverse shoulder arthroplasty requires careful patient assessment rather than relying solely on chronological age.

Typical Clinical Scenario

Patients commonly present with:

Primary glenohumeral osteoarthritis
Preserved rotator cuff function
Variable glenoid retroversion
Good muscle bulk with minimal fatty infiltration

Examples include:

An 80-year-old patient with intact supraspinatus, infraspinatus, and subscapularis tendons
A healthy, active 75-year-old retiree with symptomatic osteoarthritis
A physically active 72-year-old patient with preserved rotator cuff function

These patients may all be appropriate candidates for anatomic shoulder arthroplasty despite their age.

Reverse Shoulder Arthroplasty: Current Trends

Reverse shoulder arthroplasty has expanded rapidly over the past decade owing to its versatility and predictable outcomes in selected patients.

Factors Influencing Reverse Shoulder Arthroplasty

Modern RSA involves numerous implant design considerations, including:

Glenoid Factors

Glenoid lateralization
BIO-RSA versus augmented baseplates
Inferior overhang
Inferior tilt
Glenosphere diameter

Humeral Factors

Neck-shaft angle (135° vs 155°)
Humeral retroversion
Offset
Stemless versus stemmed implants
Cemented versus cementless fixation
Polyethylene liner design and constraint

Because multiple implant philosophies exist, no single design is ideal for every patient. Successful outcomes depend on selecting the most appropriate implant combination for the patient’s specific anatomy and pathology.

Should Patients Over 70 Receive Reverse Shoulder Arthroplasty?

Increasing age alone should not automatically lead to reverse shoulder arthroplasty.

Current literature demonstrates that elderly patients with:

Primary osteoarthritis
Intact rotator cuff
Good bone quality

continue to achieve excellent outcomes following anatomic total shoulder arthroplasty.

Evidence Supporting Anatomic Shoulder Arthroplasty

Comparable Outcomes Across Age Groups

Studies comparing younger and older patients undergoing anatomic TSA demonstrate:

Similar pain relief
Comparable functional improvement
Equivalent patient satisfaction
No significant difference in clinical outcomes

Patients over 70 years perform as well as younger patients following anatomic shoulder replacement.

Lower Revision Rates

Comparative studies have demonstrated:

Revision rate following anatomic TSA: approximately 4%
Revision rate following RSA: approximately 8%

These findings suggest that anatomic TSA remains a durable solution for elderly patients with an intact rotator cuff.

Faster Functional Recovery

Patients undergoing anatomic TSA typically experience:

More rapid pain relief
Earlier recovery of function
Better restoration of internal and external rotation

By six months following surgery:

Anatomic TSA patients achieve approximately 90–100% of functional recovery.
Reverse shoulder arthroplasty patients achieve 72–91% recovery.

The greatest advantages of anatomic TSA are observed in rotational movements and overall functional recovery.

Registry Evidence

Large national registry data support the continued use of anatomic TSA.

Key findings include:

Higher Oxford Shoulder Scores at five years
Similar revision rates compared with RSA
Excellent medium-term survivorship

For patients aged 70 years and older with primary osteoarthritis and an intact rotator cuff, anatomic TSA continues to be regarded as the preferred treatment option.

Shoulder Arthroplasty in Patients Over 80 Years

Age alone should not be considered a contraindication for shoulder replacement surgery.

Reverse Shoulder Arthroplasty

Studies have shown that RSA is:

Safe
Effective
Associated with relatively low complication rates

when performed in carefully selected patients over 80 years of age.

Anatomic Total Shoulder Arthroplasty

Similarly, studies evaluating anatomic TSA in patients over 80 years demonstrate:

Good to excellent clinical outcomes
Durable pain relief
Excellent long-term shoulder function

These findings reinforce that implant selection should depend on pathology rather than age.

Stemless Anatomic Total Shoulder Arthroplasty

Rationale

Stemless implants preserve proximal humeral bone while avoiding complications associated with traditional humeral stems.

Potential advantages include:

Bone preservation
Easier future revision surgery
Less invasive humeral preparation
Reduced operative time
Elimination of stem-related complications

Is Age a Contraindication?

Multiple clinical studies have shown that patients older than 70 years undergoing stemless anatomic TSA achieve:

Similar patient-reported outcomes
Equivalent shoulder function
Comparable range of motion
High rates of clinically meaningful improvement

Therefore, age alone is not a contraindication to stemless anatomic shoulder arthroplasty.

Systematic Review of Stemless Anatomic TSA

A review of eight published studies involving more than 450 elderly patients undergoing stemless anatomic TSA demonstrated significant postoperative improvements.

Functional Outcomes

Patients showed significant improvement in:

Forward elevation
Abduction
Internal rotation
External rotation

Patient-Reported Outcome Measures

Marked improvements were observed in:

American Shoulder and Elbow Surgeons (ASES) score
Constant-Murley Score
Visual Analogue Scale (VAS)
Other validated shoulder outcome measures

Complications

Overall complication rate:

Most common complications included:

Rotator cuff failure (2.7%)
Periprosthetic humeral fracture
Glenoid fracture
Temporary postoperative neuropathy

Importantly:

No cases required revision because of humeral implant loosening or failure.
Most fractures occurred following postoperative trauma rather than implant-related failure.

Stemless Anatomic TSA vs Stemless Reverse TSA

Comparative reviews suggest that stemless anatomic TSA demonstrates:

Lower overall complication rates
Fewer implant-related failures
No reported humeral component loosening
Excellent functional outcomes

In contrast, reported complications following stemless reverse arthroplasty include:

Periprosthetic fractures
Glenoid loosening
Shoulder instability

Overall complication rates reported for stemless RSA are approximately 12%, compared with 6% for stemless anatomic TSA.

Clinical Outcomes

Representative clinical cases demonstrated excellent postoperative function following stemless anatomic TSA.

Patients consistently achieved:

Pain-free shoulders
Excellent forward elevation
Good shoulder abduction
Functional internal rotation
Satisfactory external rotation
High patient satisfaction

These outcomes were observed in patients aged 72–80 years with intact rotator cuffs.

Factors Influencing Reverse Shoulder Arthroplasty Outcomes

Functional outcomes following RSA are influenced by several factors.

Risk factors for poor postoperative internal rotation include:

Poor preoperative internal rotation
Smoking
Male sex
Limited postoperative distalization
Thin humeral inserts
Higher body mass index

Many of these variables are modifiable and should be considered during surgical planning.

Surgical Considerations

Successful patient selection requires careful assessment of:

Rotator Cuff Integrity

Evaluation should include:

Clinical examination
MRI assessment
Fatty infiltration
Muscle bulk

MRI provides valuable information beyond tendon integrity by evaluating muscle quality and degeneration.

Bone Quality

Stemless fixation requires adequate metaphyseal bone stock.

Assessment includes:

Preoperative imaging
Intraoperative evaluation
Thumb press test of cancellous bone quality

Patients with significant proximal humeral cysts or poor bone quality may require conversion to a stemmed implant.

Patient Counselling

Patients should be informed about:

Expected functional outcomes
Recovery timeline
Risk of future rotator cuff failure
Potential need for revision surgery if cuff degeneration develops

Clinical Pearls

Assess the patient, not simply their chronological age.
Physiological age and functional status are more important than calendar age.
Always evaluate rotator cuff integrity with MRI when considering anatomic TSA.
Carefully assess muscle quality and fatty infiltration.
Confirm adequate bone quality before selecting a stemless implant.
If uncertainty exists, use the implant and surgical technique with which you have the greatest experience.

Key Takeaways

Anatomic total shoulder arthroplasty remains the preferred treatment for primary glenohumeral osteoarthritis with an intact rotator cuff, even in patients older than 70 years.
Stemless anatomic TSA provides excellent pain relief, restoration of function, and durable outcomes in appropriately selected elderly patients.
Current evidence demonstrates similar or superior outcomes compared with reverse shoulder arthroplasty in patients with an intact rotator cuff.
Reverse shoulder arthroplasty remains an excellent option when indicated, but age alone should not determine implant selection.
Careful assessment of rotator cuff integrity, muscle quality, bone stock, and patient physiology is essential to achieving optimal outcomes.

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