Under-reporting of sex-specific outcomes in reverse shoulder arthroplasty: a systematic review

Reverse shoulder arthroplasty (rTSA) has become a foundational procedure in shoulder surgery, with utilization expanding across all age groups. As case volumes have risen, attention has shifted toward patient-specific factors that may influence outcomes and complication rates. Sex-based differences are increasingly recognized in orthopedics, yet the extent to which rTSA literature reports and analyzes outcomes by sex remains unclear. As surgical care moves toward more personalized care, understanding the influence of sex on rTSA outcomes and revision risk is critical. This review aims to assess the extent of sex-specific reporting in rTSA studies and identify trends and gaps in the analysis of outcomes and complications by sex.

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Scopus were searched for English-language studies from 2007 to 2024 involving patients undergoing rTSA. Eligible studies reported sex-disaggregated baseline characteristics, outcomes, or complications. Extracted data included study design, demographics, procedure type, and sex-specific reporting of functional outcomes, complications, and revision rates.

Of 10,805 studies screened, 356 met inclusion criteria, comprising 345,154 patients (63% female). Only 10 studies (2.8%) reported sex-disaggregated outcomes, covering 14,694 patients (9,338 females; 5,354 males). Females presented with lower preoperative scores but showed similar improvements postoperatively, while males showed greater postoperative external rotation and abduction. No significant difference was found between final American Shoulder and Elbow Surgeons scores. Females had a significantly increased risk of acromial stress fractures (odds ratio 2.32, 95% confidence interval: 1.26-4.28, P < .05).

rTSA benefits both male and female patients; our review underscores persistent disparities in outcomes and a critical underreporting of sex-disaggregated data. Female patients exhibited a significantly higher risk of acromial stress fractures, consistent with trends previously described in the rTSA literature. With only 2.8% of studies reporting sex-specific outcomes, a substantial evidence gap remains. Surgeons should consider potential sex-based differences during preoperative planning, and future research must prioritize comprehensive, sex-disaggregated analyses to guide equitable, personalized care.