Quick answer: There are three main types of shoulder replacement: anatomic total shoulder replacement, reverse total shoulder replacement, and partial replacement (hemiarthroplasty). The single most important factor in choosing between them is whether your rotator cuff is healthy. If the cuff is intact, an anatomic replacement is usually preferred for arthritis; if the cuff is torn or not working, a reverse replacement is usually the better choice [1, 2]. Partial replacement is used much less often today.
The Three Main Types
| Anatomic total shoulder | Reverse total shoulder | Hemiarthroplasty (partial) | |
|---|---|---|---|
| What is replaced | Ball and socket, in their natural positions | Ball and socket, with positions switched | Ball only |
| Relies on | A healthy rotator cuff | The deltoid muscle | A healthy rotator cuff and socket |
| Typical candidates | Arthritis with an intact rotator cuff | Rotator cuff tear arthropathy, massive irreparable tears, complex fractures, failed prior replacement | Selected cases with a healthy socket |
| 10-year implant survival | About 92–95% [3] | About 94% [3] | About 85–90% [3] |
Anatomic Total Shoulder Replacement
An anatomic replacement recreates the normal shoulder: a polished metal ball replaces the top of the arm bone, and a plastic socket lines the shoulder blade [1]. Patients with bone-on-bone osteoarthritis and an intact rotator cuff are generally good candidates [1].
For osteoarthritis, the AAOS clinical practice guideline favors total shoulder replacement over replacing the ball alone [4]. In a meta-analysis of randomized trials, total shoulder replacement produced better function, pain relief, and overhead motion than hemiarthroplasty at two years [5].
Reverse Total Shoulder Replacement
In a reverse replacement, the ball and socket are switched: the metal ball is fixed to the shoulder blade and a plastic cup to the arm bone. This lets the large deltoid muscle lift the arm when the rotator cuff can no longer do its job [2].
Reverse replacement is used for [2]:
- Arthritis combined with a large, irreparable rotator cuff tear (cuff tear arthropathy)
- A massive rotator cuff tear that can't be repaired, with pain and weakness
- Complex fractures of the upper arm bone, particularly in older adults
- A previous shoulder replacement that has failed
- Severe bone loss or chronic dislocation
Its use has grown rapidly. Between 2012 and 2017, the number of reverse replacements performed in the U.S. nearly tripled, and reverse replacements now outnumber anatomic ones [6]. For older adults with complex fractures, a randomized trial found that reverse replacement produced better function and fewer revisions than hemiarthroplasty [7].
The main trade-off is rotation. Reverse replacement reliably restores the ability to raise the arm, but rotating the arm outward and reaching behind the back are often not fully restored [8].
Hemiarthroplasty (Partial Replacement)
A hemiarthroplasty replaces only the ball. It may be considered when the socket cartilage is healthy, when glenoid bone is too deficient to hold a socket component, or in some younger patients [1]. Because total and reverse replacements generally give more predictable results for arthritis and fractures, hemiarthroplasty use has declined substantially [6].
How Is the Choice Made?
Your surgeon will weigh:
- Rotator cuff function, the most important single factor [1, 2]
- The shape and bone stock of the socket, often assessed with a CT scan
- The underlying diagnosis: osteoarthritis, cuff tear arthropathy, fracture, or a failed prior surgery
- Your age, activity goals, and overall health
Activity goals matter. In a review of older patients, about 90% returned to sport after anatomic replacement compared with about 77% after reverse replacement [9]. That difference partly reflects the different conditions each implant treats, but it is a fair point to discuss with your surgeon.
Frequently Asked Questions
Is a reverse shoulder replacement "worse" than an anatomic one?
No. They solve different problems. A reverse replacement is often the best option when the rotator cuff is torn, and it has excellent long-term survival [3]. Using an anatomic replacement in a shoulder without a working rotator cuff can leave patients with pain and an inability to lift the arm [1].
How long do shoulder replacements last?
About 90% of shoulder replacements are still functioning more than 10 years after surgery, and patients' reported benefits are sustained over that time [3].
Can I choose which type I get?
Your preferences and goals are a central part of the decision, but the condition of your rotator cuff and bone usually determines which implant will work best. Ask your surgeon to explain why a particular type is recommended for you.
Can a reverse replacement be done if I've had prior surgery?
Yes. Reverse replacement is commonly used after failed rotator cuff repairs and failed earlier replacements [2]. See When Does a Shoulder Replacement Need Revision?
Related Reading
- Understanding Reverse Shoulder Replacement
- What to Expect After Shoulder Replacement
- Shoulder Replacement / Arthroplasty
Dr. Tej Joshi performs anatomic, reverse, and revision shoulder replacement and sees patients at NYU Langone offices in Manhattan, Lake Success, and Bay Ridge, Brooklyn.
References
- American Academy of Orthopaedic Surgeons. Shoulder Joint Replacement. OrthoInfo. orthoinfo.org
- American Academy of Orthopaedic Surgeons. Reverse Total Shoulder Replacement. OrthoInfo. orthoinfo.org
- Evans JP, Evans JT, Craig RS, et al. How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up. Lancet Rheumatol. 2020;2(9):e539-e548. PubMed 38273618 · doi:10.1016/S2665-9913(20)30226-5
- American Academy of Orthopaedic Surgeons. Management of Glenohumeral Joint Osteoarthritis: Evidence-Based Clinical Practice Guideline. Published March 23, 2020. aaos.org
- Bryant D, Litchfield R, Sandow M, et al. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(9):1947-1956. PubMed 16140808 · doi:10.2106/JBJS.D.02854
- Best MJ, Aziz KT, Wilckens JH, McFarland EG, Srikumaran U. Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2021;30(5):1159-1166. PubMed 32858194 · doi:10.1016/j.jse.2020.08.010
- Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014;23(10):1419-1426. PubMed 25086490 · doi:10.1016/j.jse.2014.06.035
- Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S):147S-161S. PubMed 15726075 · doi:10.1016/j.jse.2004.10.006
- Papalia R, Ciuffreda M, Albo E, et al. Return to sport after anatomic and reverse total shoulder arthroplasty in elderly patients: a systematic review and meta-analysis. J Clin Med. 2020;9(5):1576. PubMed 32456117 · doi:10.3390/jcm9051576