Decreased clinical and functional outcomes following reverse total shoulder arthroplasty for proximal humerus fractures compared to rotator cuff arthropathy: a systematic review and meta-analysis

Background Comparative studies of reverse total shoulder arthroplasty (rTSA) for proximal humerus fractures (PHFs) versus rotator cuff arthropathy (RCA) have yielded conflicting findings and lack comprehensive synthesis to guide perioperative counseling. This study aimed to systematically compare clinical and functional outcomes between patients undergoing rTSA for PHFs and RCA. Methods A PROSPERO-pre-registered systematic review and meta-analysis queried PubMed, CINAHL, MEDLINE, and Web of Science on July 25, 2025, for studies comparing PHF- versus RCA-indicated rTSA. Study quality was assessed using the Methodological Index for Non-Randomized Studies scale. Extracted variables included patient demographics, survey scores, range of motion, and revisions. Patient-reported outcome measures and functional outcomes were compared between patients undergoing rTSA for PHFs and RCA. Results Eleven observational studies encompassing 6,698 patients (1,832 PHF; 4,866 RCA) met criteria; overall evidence quality was moderate. Compared with RCA, PHF patients had lower American Shoulder and Elbow Surgeons scores (mean difference −5 points; P = .045) and reduced forward flexion (−14°; P < .001) and abduction (−17°; P < .001). Pain scores were similar (visual analog scale; P = .62). Overall revision risk did not differ, but PHF patients had a higher revision risk from dislocation (risk ratio 1.59; P = .04). Implant survivorship appeared similar across groups. Conclusion RTSA for PHF yields slightly lower shoulder function, range of motion, and a higher dislocation-related revision risk compared with RCA; though, absolute differences were modest. These findings support nuanced preoperative counseling, highlighting opportunities to optimize PHF-specific surgical strategies.