Reverse Shoulder Arthroplasty - Rethinking the Shoulder in Modern Orthopaedics

Reverse shoulder arthroplasty (RSA) has transformed significantly over the past forty years, progressing from a salvage intervention for cuff tear arthropathy to a fundamental component of contemporary shoulder reconstruction. The initial design, pioneered by Grammont, fundamentally reconfigured shoulder biomechanics through the medialisation and distalisation of the centre of rotation, thereby engaging the deltoid as the primary mover in cases of cuff deficiency. This biomechanical advancement has facilitated dependable pain alleviation and functional restoration in patients for whom traditional arthroplasty procedures have historically been inadequate or failed. The clinical indications for RSA have significantly expanded. Historically restricted to elderly patients with extensive cuff tears. Its current applications include complex proximal humeral fractures, failed anatomical arthroplasty, inflammatory arthritis, tumour reconstruction and even select younger patients when joint preservation is unfeasible. Long-term studies demonstrate consistent improvements in pain and function, with implant survivorship exceeding 85% at ten years. Nevertheless, the rates of complications remain a concern, with scapular notching, instability, acromial and scapular fractures, and peri-prosthetic joint infections constituting the most significant issues challenges. Recent years have witnessed significant technological advancements in RSA, including three-dimensional preoperative planning, patient-specific instrumentation, augmented baseplates, 3D printing, navigation and robotic-assisted implantation. These innovations improve precision, broaden indications, and have the potential to enhance long-term outcomes. However, the use of these technologies is largely limited to institutions with high financial capacity. In low- and middle-income countries, obstacles such as high implant costs, limited availability, delayed presentation, and inadequate surgical expertise persistently impede widespread adoption. Nonetheless, evidence indicates that, with appropriate patient selection and tailored strategies, outcomes in resource-limited settings can approach those achieved in high-income countries. RSA now constitutes one of the most substantial advancements in shoulder surgery, providing durable outcomes across various pathologies. The future of RSA involves enhancing implant longevity, minimising complications, and ensuring equitable global access to this transformative technology procedure.