Primary reverse total shoulder arthroplasty in patients aged ≤65 years: a systematic review and meta-analysis

Reverse total shoulder arthroplasty (rTSA), once reserved for elderly low-demand patients, is increasingly used in younger adults despite concerns regarding complication rates and longevity. This systematic review and meta-analysis evaluate contemporary evidence on primary rTSA in patients aged ≤65 years.

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, PubMed, Scopus, and CENTRAL databases were searched to October 2025. Studies reporting outcomes of primary rTSA in patients ≤65 years with ≥2 years of follow-up were included. Data on indications, functional outcomes, range of motion (ROM), patient-reported outcome measures (PROMs), complications, revisions, and implant survival were recorded and synthesized. Subgroup analyses based on patients' age and comparisons with older rTSA cohorts were also performed.

Thirteen studies met our inclusion criteria. Cuff tear arthropathy (27.29%), massive cuff tears (23.39%), and glenohumeral osteoarthritis (22.34%) accounted for most indications. rTSA resulted in significant improvements in ROM and all major PROMs. The overall complication rate was 14.23%, and the revision rate was 2.92%, with instability and infection responsible for 64.2% of revisions. Mid- to long-term implant survival exceeded 85%. When compared with older patients, younger adults demonstrated equivalent ROM outcomes. Concerning PROMs younger patients demonstrated inferior American Shoulder and Elbow Surgeons (mean difference [MD] = -6.43, P = .01), visual analog scale (MD = 0.93, P < .01), Constant score (MD = -4.98, P < .01), University of California Los Angeles (MD = -2.07, P < .01), and Shoulder Pain and Disability Index (MD = 13.56, P < .01), whereas Simple Shoulder Test (MD = -0.7, P = .19) did not differ between the 2 groups. Moreover, younger patients presented a higher revision risk (risk ratio [RR] = 2.21, P < .01).

Primary rTSA provides substantial and predictable improvements in pain and shoulder function among young adults, with acceptable early- to mid-term durability. Nevertheless, younger age remains associated with higher revision risk and modestly lower subjective outcomes, likely reflecting greater functional demands and post-operative expectations. These findings highlight the importance of nuanced surgical decision-making and patient counseling as rTSA use continues to expand in this demographic.