1 Introduction

Rotator cuff arthropathy (RCA) occurs when a chronic, full-thickness, irreparable tear of one or more of the rotator cuff muscles leads to secondary, degenerative, pathoanatomical findings within the shoulder joint.¹ An initial rotator cuff injury, which may result from overuse, aging, or trauma, impairs the rotator cuff's ability to properly align the humeral head within the glenohumeral joint. In the case of RCA, this causes the humeral head to migrate superiorly against the glenoid fossa, leading to erosion of the acromion.²

Radiographically, RCA is characterized by degenerative changes of the glenohumeral joint, namely femoralization, acetabularization, and superior migration of the humeral head. The severity of the cuff arthropathy is classified using the Hamada and Seebauer systems, although other classification metrics exist. The Hamada system categorizes joint deterioration from rotator cuff tears based on the status of the acromiohumeral space, the glenohumeral joint, complete tear of rotator cuff, and tear of long head of biceps.³ The Seebauer system, in contrast, categorizes arthropathy by medial and/or proximal displacement of the humeral head due to disease progression, describing arthropathy as centered or uncentered, and as stable, medialized, or unstable.⁴

Rotator cuff tears are initially managed conservatively with activity modification, NSAIDs, subacromial corticosteroid injection, and/or physical therapy. If symptoms fail to improve, surgical intervention can be considered.⁵ When radiographic imaging determines that irreparable cuff tears have led to RCA, patients are often indicated to receive a form of arthroplasty.⁶

Reverse total shoulder arthroplasty (RTSA) aims to re-center the humeral head within the joint space by increasing deltoid tension and reducing the ratio of shear to compressive forces within the replaced joint.⁷ Patients undergoing RTSA may also require concurrent tendon repair if degeneration of the teres minor and infraspinatus has led to loss of external rotation. In more severe cases, a combined loss of external rotation and active elevation is an indication for tendon transfer. Although tendon transfer is often associated with improved subjective and functional outcome scores, it may also increase the incidence of complications.⁸

RTSA with or without tendon repair or transfer may confer differing biomechanical advantages. This review aims to provide a detailed comparison of all three variations of reverse total shoulder arthroplasty. Recent literature lacks a focused comparison of these surgical techniques; thus, this paper provides an up-to-date analysis of surgical outcomes and complications associated with each procedure. In comparing tendon augmentation metrics, this review seeks to clarify current evidence supporting the utilization of RTSA with or without tendon repair or transfer for the treatment of rotator cuff arthropathy.

2 Methods

2.1

2.1 Search strategy

A systematic review of the current literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. Databases including PubMed, Embase, MEDLINE, and Cochrane were used to compile articles focused on surgical interventions to fix RCA. Keywords including “reverse total shoulder arthroplasty” and “rotator cuff arthropathy” were used in conjunction with “functional outcomes” and “cuff repair” or “tendon transfer” to find relevant literature. After screening articles using inclusion and exclusion criteria, the authors read each article in its entirety to ensure the collected data would be relevant and easily analyzable (Fig. 1).

Close

Fig. 1 PRISMA 2020 flow diagram of study selection.

Export to PPT

3 Results

A total of 15 studies including 1404 patients were analyzed. There were 513 males and 829 females, with a mean age of 71.0 years. Most studies were retrospective in design, comprising retrospective comparative (5) and retrospective cohort (2) studies, followed by case series (4), randomized controlled trials (3 total: one Level I and two Level II), one prospective (Level II), and one observational study. The different approaches to RTSA that were compared were no cuff repair, subscapularis repair, transfer of the latissimus dorsi and teres minor, and transfer of the pectoralis major (Table 1).^10–24 Outcomes that were compared were functional scores and range of motion.

In the RTSA without repair cohort, results demonstrated a mean constant score of 61.9 ± 10.2, VAS pain score of 1.54 ± 1.36, and ASES score of 79.01 ± 19.73. For range of motion, patients had mean forward elevation and abduction scores of 144.8 ± 21.5° and 127.1 ± 28.1°, respectively. External rotation in these patients was 39.2 ± 12.8°. In the cohort that was treated with subscapularis repair, the Constant score had a weighted average of 65. The mean VAS score was 1.0 ± 1.5 and ASES score was 74.0 ± 22.3. These patients demonstrated a forward elevation and abduction score of 141.8 ± 27.9° and 131.2 ± 29.0°, respectively, and external rotation was 39.1 ± 18.6°. The latissimus dorsi and teres minor transfer cohort had a Constant score of 62.0 ± 9.4, VAS of 1.3 ± 0.9, and ASES of 76.1 ± 10.0. These patients demonstrated 145.7 ± 25.0° of forward elevation, 131° of abduction, and 33.8 ± 7.7° of external rotation. Patients who underwent pectoralis major transfer displayed a Constant score of 65.2 ± 7.6, VAS of 1.6 ± 0.9, and ASES of 74.8 ± 10.1. Forward elevation, abduction, and external rotation were 155 ± 16°, 131 ± 24°, and 41 ± 11°, respectively (Table 2).

Overall, the pectoralis major transfer cohort demonstrated the highest forward elevation and abduction, while VAS scores were lowest in the subscapularis repair group. External rotation was the highest in the pectoralis major transfer and no repair groups, and lowest in the latissimus dorsi and teres minor transfer groups despite similar forward elevation to the other cohorts.

The rate of complications was low across both groups; however, patterns varied by repair status. In the group treated without cuff repair augmentation, scapular notching was the most common complication, observed in 55.45 % of cases. This was followed by dislocation (2.14 %), revision (3.87 %), and fracture (1.19 %). Conversely, the cohort who underwent RTSA with cuff repair had a lower incidence of notching (3.9 %) and had a higher rate of dislocation (7.7 %), revision (8.1 %), and humeral osteolysis (80 %). The rate of infection was similar between both groups (0.7 % vs 0.8 %), and there were no cases of complex regional pain syndrome or rotator cuff failure reported (Table 3).

4 Discussion

Rotator cuff arthropathy (RCA) is a well-established cause of shoulder dysfunction with typical presentations including chronic pain, reduced range of motion, and decline in functionality. Multiple surgical options are considered for treating RCA; however, RTSA is reflected across current literature as the most utilized approach. The design of the reverse prosthesis is favorable as it allows the deltoid to compensate for a deficient rotator cuff by shifting the center of rotation medially and inferiorly, thereby increasing deltoid tension and torque.²⁵

Despite continuing advances in shoulder arthroplasty, a lack of consensus in the literature regarding whether there is a benefit to tendon repair in the setting of RTSA remains. Some studies suggest that partial cuff repair with RTSA can improve forward elevation and abduction, potentially enhancing deltoid efficiency and joint stability. For example, Bethell et al. reported mild but statistically significant improvements in forward flexion, internal rotation, ASES, and Constant scores when RTSA was performed in conjunction with subscapularis repair compared to no repair.²⁶ However, other authors have found no significant long-term functional advantage of cuff repair, specifically when there is poor tendon quality or when repair integrity is not maintained. This study evaluates how concomitant cuff repair or tendon transfer influences functional recovery in modern lateralized RTSA, addressing a current gap in implant-era literature. We found that regardless of all cohorts, patients demonstrated improvements in both pain relief and range of motion on the shoulder. These results support the consistency of RTSA to restore shoulder function through deltoid-mediated mechanics, even in the absence of an intact rotator cuff.²⁷

Similarly, repair of the subscapularis has been discussed to improve anterior stability, increase joint compression forces, and reduce dislocation risk. This type of repair is particularly useful in medialized implants. However, advances in prosthesis design such as lateralized glenospheres, which enhance deltoid wrapping and joint compression, have diminished the role of subscapularis repair for postoperative stability. These prostheses allow for consistent motion and stability of the shoulder joint without depending on the repair of the anterior soft tissue. The functional outcomes and pain scores observed between the subscapularis repair and no repair cohorts were comparable, consistent with current literature reporting no significant differences in functionality following subscapularis repair after RTSA.²⁸

Tendon transfers such as the latissimus dorsi, teres minor, and pectoralis major remain useful adjuncts to RTSA in patients with rotator cuff deficiencies or combined loss of external and internal rotation. Even though tendon transfers can restore range of motion in specific planes, their overall benefit on shoulder function is limited, likely reflecting the patient's population in which they are applied. These challenging cohorts are faced with long-standing muscular atrophy, neurologic deficits, and severe preoperative stiffness among other attributes. These restrictions limit the patient's potential for full recovery despite successful reconstruction. Furthermore, altering the tension of the muscle as well as scarring that may present postoperatively may limit the expected biomechanical benefit of the tendon transfers.²⁹

Similar improvement observed across all repair strategies emphasizes the stability and predictability of reverse total shoulder arthroplasty, supporting the idea that cuff repair serves as an adjunct rather than prerequisite. The decision to incorporate cuff repair should be guided by anatomy, implant design, and patient goals. When suitable tendons are available, selective repair or transfer may help improve rotation or soft-tissue balance; however, excessive or unnecessary repair can contribute to increased stiffness and operative time without demonstrable long-term benefit.³⁰

Recent studies continue to expand our understanding of postoperative outcomes. A study conducted by Endell et al. investigated radiographic outcomes and return to sports after RTSA. Their findings demonstrate that with proper rehabilitation, many patients can return to sports successfully.³¹ This study suggests that lower-income patients may experience longer recovery times and a higher rate of postoperative complications. This highlights the importance of patient-catered follow-up in vulnerable populations.

Several limitations exist in this study, including modest subgroup sizes that may have reduced statistical power to detect small differences among repair strategies. Additionally, there was heterogeneity in surgeon experience, implant selection, and rehabilitation protocols, which may have influenced outcomes. However, while these limitations were present, the consistent result from our study offers a valuable perspective on the effect of various repair choices on postoperative function following RTSA.

Our analysis highlights the need for future prospective, comparative studies that incorporate uniform rehabilitation pathways and controlled comparisons across implant lateralization, tendon quality, and patient demographics. Further evidence could delineate the contribution of residual cuff activity to stability and motion following RTSA, allowing for precise surgical indications and optimizing functional recovery.

5 Conclusions

Reverse total shoulder arthroplasty (RTSA) has become the standard practice for treating rotator cuff arthropathy. While subscapularis repair and tendon transfers have been proposed to improve post-operative range of motion, this study found no significant improvements with these additional procedures. These data also suggest that augmentation provides similar patient satisfaction and functional outcomes to those of RTSA.

Ethics approval and consent to participate

Not applicable. This article is a systematic review of previously published studies.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Authors’ contributions

All authors contributed to the conception and design of the study. DJH and BTB performed the literature search and data extraction. DGD conducted the data analysis, drafted the initial manuscript, and revised the manuscript. BTB and DJH prepared the Introduction. JMB drafted the manuscript, conducted data analysis, and critically revised the manuscript for important intellectual content. JL supervised the study, provided guidance throughout, and finalized the manuscript. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Ethical statement

We confirm that all authors have read and approved the manuscript, and no other individuals meet the authorship criteria but are not listed. We have also agreed upon the order of authorship as presented. Furthermore, we assure you that this manuscript has not been submitted elsewhere.

Guardian Patient's consent

NA.

Funding information

This research was conducted independently and did not receive specific funding from public, commercial, or not-for-profit agencies.