Massive irreparable posterosuperior rotator cuff tears (MRCTs) pose clinical and surgical challenges due to tendon retraction, fatty infiltration, muscle atrophy, and poor tissue quality. Nonarthroplasty options have emerged as alternatives to shoulder arthroplasty.
Methods
We conducted a systematic review and meta-analysis of comparative studies evaluating nonarthroplasty surgical treatments for MRCTs. We searched PubMed, LILACS, Scopus, and Google Scholar, including studies with at least 12 months of follow up. Functional outcomes, range of motion, and complication rates were extracted. Risk of bias was assessed using ROBINS-I.
Results
Twenty-one studies (n = 1036 patients) were included, evaluating partial repair, tendon transfers, superior capsular reconstruction (SCR), debridement, augmentation, and subacromial balloon spacers. All techniques showed functional improvement and pain reduction. Partial repair showed better external rotation than augmentation. Tendon transfers and SCR yielded similar functional outcomes. Augmentations had the highest complication rate (33%), while debridement the lowest (10%). These findings may reflect differences in baseline pathology severity and the relative complexity of the surgical techniques.
Conclusion
Nonarthroplasty surgical options for MRCTs provide significant functional gains and pain relief. No technique demonstrated clear superiority. Overall evidence quality was low, highlighting the need for future high-quality comparative studies to optimize treatment strategies.
KovacevicDSurianiRJGraweBM, et al.Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response. J Shoulder Elbow Surg2020; 29: 2459–2475.
2.
KimIBJungDWSuhKT. Prediction of the irreparability of rotator cuff tears. Arthroscopy2018; 34: 2076–2084.
3.
NeriBRChanKWKwonYW. Management of massive and irreparable rotator cuff tears. J Shoulder Elbow Surg2009; 18: 808–818.
4.
MicallefJPandyaJLowAK. Management of rotator cuff tears in the elderly population. Maturitas2019; 123: 9–14.
5.
DinesDMMoynihanDPDinesJS, et al.Irreparable rotator cuff tears: what to do and when to do it; the surgeon’s dilemma. J Bone Joint Surg Am2007; 88: 13–22.
6.
CastagnaAGarofaloRCesariE. No prosthetic management of massive and irreparable rotator cuff tears. Shoulder Elbow2014; 6: 147–155.
7.
DelaneyRALinAWarnerJJP. Nonarthroplasty options for the management of massive and irreparable rotator cuff tears. Clin Sports Med2012; 31: 727–748.
8.
BediADinesJWarrenRF, et al.Massive tears of the rotator cuff. J Bone Joint Surg Am2010; 92: 1894–1908.
9.
CarverTJKraeutlerMJSmithJR, et al.Nonarthroplasty surgical treatment options for massive, irreparable rotator cuff tears. Orthop J Sports Med2018; 6: 1–13.
10.
GreenspoonJAPetriMWarthRJ, et al.Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes. J Shoulder Elbow Surg2015; 24: 1493–1505.
11.
PierrePSMillettPJAbboudJA, et al.Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg2021; 30: 1977–1989.
12.
MoherDShamseerLClarkeM, et al.Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev2015; 4: 1–9.
13.
CiapponiA. ROBINS Tools for assessing the risk of bias in non-randomized studies. Evidencia2022; 25: e007024.
14.
HarbourRMillerJ. A new system for grading recommendations in evidence based guidelines. Br Med J2001; 323: 334–336.
15.
PetrieJCGrimshawJMBrysonA. The Scottish Intercollegiate Guidelines Network Initiative: getting validated guidelines into local practice. Health Bull (Edinb)1995; 53: 345–348.
16.
Collaboration TC. Review Manager (RevMan) [Computer program]. Version 5.4. 2020.
17.
BariliFParolariAKappeteinPA, et al.Statistical primer: heterogeneity, random- or fixed-effects model analyses?Interact Cardiovasc Thorac Surg2018; 27: 317–321.
18.
BorensteinM. In a meta-analysis, the I-squared statistic does not tell us how much the effect size varies. J Clin Epidemiol2022; 152: 281–284.
19.
HolmgrenTÖbergBAdolfssonL, et al.Minimal important changes in the Constant-Murley score in patients with subacromial pain. J Shoulder Elbow Surg2014; 23: 1083–1090.
20.
GagnierJJRobbinsCBediA, et al.Establishing minimally important differences for the American Shoulder and Elbow Surgeons score and the Western Ontario Rotator Cuff Index in patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg2018; 27: e160–e166.
21.
LichtenbergSMagoschPHabermeyerP. Are there advantages of the combined Latissimus dorsi transfer according to L’Episcopo compared to the isolated Latissimus dorsi transfer according to Herzberg after a mean follow-up of 6 years? A matched-pair analysis. J Shoulder Elbow Surg2012; 21: 1499–1507.
22.
MoriDFunakoshiNYamashitaF. Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure. Arthroscopy2013; 29: 1911–1921.
23.
BerthANeumannWAwiszusF, et al.Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair. J Orthop Traumatol2010; 11: 13–20.
24.
ParibelliGBoschiSRandelliP, et al.Clinical outcome of Latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear. Musculoskelet Surg2015; 99: 127–132.
25.
KolkAHenselerJFOveresFJ, et al.Teres major tendon transfer in the treatment of irreparable posterosuperior rotator cuff tears. Bone Joint J2018; 100B: 309–317.
26.
BlankeFSachserJMajewskiM. Operative techniques for treatment of chronic massive rotator cuff lesions: deltoid flap transfer versus arthroscopic debridement. Acta Orthop Belg2017; 83: 428–432.
27.
KlingerHMSpahnGBaumsMH, et al.Arthroscopic debridement of irreparable massive rotator cuff tears: a comparison of debridement alone and combined procedure with biceps tenotomy. Acta Chir Belg2005; 105: 297–301.
28.
PandeyRTafazalSShyamsundarS, et al.Outcome of partial repair of massive rotator cuff tears with and without human tissue allograft bridging repair. Shoulder Elbow2017; 9: 23–30.
29.
GreinerSKaeaebMVossA, et al.Comparison of superior capsular reconstruction and partial infraspinatus repair: a matched-pair analysis of irreparable rotator cuff tears. Orthop J Sports Med2021; 9: 2325967120984264.
30.
KadowTRMeredithSJGarciaD, et al.Latissimus dorsi tendon transfer and superior capsular reconstruction for irreparable, posterosuperior rotator cuff tears. Arch Bone Jt Surg2021; 9: 44–49.
31.
BaverelLPBonnevialleNJoudetT, et al.Short-term outcomes of arthroscopic partial repair vs. Latissimus dorsi tendon transfer in patients with massive and partially repairable rotator cuff tears. J Shoulder Elbow Surg2021; 30: 282–289.
32.
MoriDKizakiKFunakoshiN, et al.Irreparable large to massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus tendon: minimum 7-year follow-up of fascia autograft patch procedure and partial repair. Am J Sports Med2021; 49: 3656–3668.
33.
BilselKAliyevOAltintasB, et al.Subacromial spacer implantation during arthroscopic partial repair in patients with massive irreparable rotator cuff tears provides satisfactory clinical and radiographic outcomes: a retrospective comparative study. Arthrosc Sports Med Rehabil2022; 4: e1051–e1057.
34.
OzturkBYAkSGultekinO, et al.Prospective, randomized evaluation of Latissimus dorsi transfer and superior capsular reconstruction in massive, irreparable rotator cuff tears. J Shoulder Elbow Surg2021; 30: 1561–1571.
35.
BaekCHLimCKimJG. Superior capsular reconstruction versus lower trapezius transfer for posterosuperior irreparable rotator cuff tears with high-grade fatty infiltration in the infraspinatus. Am J Sports Med2022; 50: 1938–1947.
36.
BaekCHLeeDHKimJG. Latissimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears. J Shoulder Elbow Surg2022; 31: 1810–1822.
37.
LädermannADenardPJBarthJ, et al.Superior capsular reconstruction for irreparable rotator cuff tears: autografts versus allografts. Orthop Traumatol Surg Res2021; 107: 103059.
38.
WoodmassJMWagnerERChangMJ, et al.Arthroscopic lower trapezius tendon transfer provides equivalent outcomes to Latissimus dorsi transfer in the treatment of massive posterosuperior rotator cuff tears. J ISAKOS2020; 5: 269–274.
39.
KocaogluBFiratliGUlkuTK. Partial rotator cuff repair with superior capsular reconstruction using the biceps tendon is as effective as superior capsular reconstruction using a tensor fasciae latae autograft in the treatment of irreparable massive rotator cuff tears. Orthop J Sports Med2020; 8: 2325967120922526.
40.
ValentiPReinaresFMarounC, et al.Comparison of arthroscopically assisted transfer of the Latissimus dorsi with or without partial cuff repair for irreparable postero-superior rotator cuff tear. Int Orthop2019; 43: 387–394.
41.
ParkSRSunDHKimJ, et al.Is augmentation with the long head of the biceps tendon helpful in arthroscopic treatment of irreparable rotator cuff tears?J Shoulder Elbow Surg2018; 27: 1969–1977.
42.
JeonYSLeeJKimRG, et al.Does additional biceps augmentation improve rotator cuff healing and clinical outcomes in anterior L-shaped rotator cuff tears? Clinical comparisons with arthroscopic partial repair. Am J Sports Med2017; 45: 2982–2988.
43.
BiASAnilUColasantiCA, et al.Comparison of multiple surgical treatments for massive irreparable rotator cuff tears in patients younger than 70 years of age: a systematic review and network meta-analysis. Am J Sports Med2024; 52: 2919–2930.
44.
KovacevicDSurianiRJGraweBM, et al.Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response. J Shoulder Elbow Surg2020; 29: 2459–2475.
45.
HughesJDDavisBWhickerE, et al.Nonarthroplasty options for massive, irreparable rotator cuff tears have improvement in range of motion and patient-reported outcomes at short-term follow-up: a systematic review. Knee Surg Sports Traumatol Arthrosc2023; 31: 1883–1902.
46.
GerberCRahmSACatanzaroS, et al.Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears. J Bone Joint Surg Am2013; 95: 1920–1926.
47.
ShonMSKohKHLimTK, et al.Arthroscopic partial repair of irreparable rotator cuff tears: preoperative factors associated with outcome deterioration over 2 years. Am J Sports Med2015; 43: 1965–1975.
48.
YooJCShonMSKohKH, et al.Clinical and radiographic results of arthroscopic partial repairs for massive irreparable rotator cuff tears: deterioration of the results at minimum two year follow-up. J Shoulder Elbow Surg2013; 22: e23–e24.
49.
PogorzelskiJRuppMCScheidererB, et al.Management of irreparable posterosuperior rotator cuff tears—a current concepts review and proposed treatment algorithm by the AGA shoulder committee. J Pers Med2023; 13: 191.
50.
VoglerTAndreouDGoshegerG, et al.Long-term outcome of arthroscopic debridement of massive irreparable rotator cuff tears. PLoS One2020; 15: e0241277.
51.
SoderlundMBorenMO’ReillyA, et al.Arthroscopic debridement for management of massive, irreparable rotator cuff tears: a systematic review of outcomes. JSES Rev Rep Tech2021; 2: 1–7.
52.
MandaliaKMousadAWelbornB, et al.Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022. J Shoulder Elbow Surg2023; 32: 1784–1800.
53.
SommerMCWagnerEZhuS, et al.Complications of superior capsule reconstruction for the treatment of functionally irreparable rotator cuff tears: a systematic review. Arthroscopy2021; 37: 2960–2972.
54.
KholinneESunYKwakJM, et al.Failure rate after superior capsular reconstruction with achilles tendon–bone allograft for irreparable rotator cuff tears. Orthop J Sports Med2021; 9: 23259671211002280.
55.
GilatRHaunschildEDWilliamsBT, et al.Patient factors associated with clinical failure following arthroscopic superior capsular reconstruction. Arthroscopy2021; 37: 460–467.
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