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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Patients with irreparable massive rotator cuff tears without osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after reverse shoulder arthroplasty [1].
• Reverse shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff [2].
• Subacromial balloon spacers for massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures in the short term [3].
• Arthroscopic repairs of chronic, massive rotator cuff tears, whether complete or partial, are associated with significant improvements in pain, function, and objective outcome scores with a low rate of re-tear [5].
• Differences in postoperative patient-reported outcomes and improvement from baseline show a trend toward lower outcomes in patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty, but these differences may be below the minimal clinically important difference [7].
• Superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion irrespective of tissue source [8].
• For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains [10].
• Nonarthroplasty treatment options for irreparable rotator cuff tears result in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty [14].
• Anatomic total shoulder arthroplasty displays equal functional results and postoperative complications compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear [17].
• Higher revision rates were identified following anatomic total shoulder arthroplasty compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear, although this finding is within retrospective studies [17].
• Complications for primary reverse shoulder arthroplasty using augmented baseplates are within an acceptable range, with a low rate of revision [18].
• Patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure [24].
• The rate of satisfaction is highest in patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis [24].

Anatomy & Pathophysiology

• Reverse total shoulder arthroplasty (RTSA) is indicated for patients with irreparable massive rotator cuff tears who do not have osteoarthritis [1].
• RTSA is indicated for patients with rotator cuff arthropathy (RCA) [40].
• RTSA yields slightly lower shoulder function, range of motion, and a higher dislocation-related revision risk compared to its use for proximal humerus fractures (PHF) [40].
• RTSA results in an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation compared to asymptomatic shoulders [30].
• RTSA is associated with no significant deterioration in shoulder function and outcome scores between 5 and 20 years of follow-up [15].
• Shoulder scores may decline at mid- to long-term follow-up for patients with large and massive irreparable rotator cuff tears treated with soft tissue reconstruction techniques [4].
• Soft tissue reconstruction for irreparable anterosuperior rotator cuff tears is associated with improved clinical outcomes [19].
• For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains [10].
• Subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure in cadaveric studies [36].
• Subacromial balloon spacer implantation results in improved shoulder function and decreased pain at 24 months post-procedure [44].
• The majority of painful complications after RTSA, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [20].
• There are no differences in abduction, internal rotation, or external rotation strength after RTSA with or without subscapularis repair [37].
• There appears to be a trend suggesting improved postoperative clinical outcomes and active range of motion for patients with a subscapularis repair versus without a repair after primary RTSA [45].
• Studies analyzing the impact of subscapularis repair on internal rotation following RTSA report conflicting results [41].
• Measures and reporting of shoulder internal rotation after RTSA vary widely, making it difficult to assess associations between postoperative internal rotation limitation and functional abilities [38].
• The anterosuperior approach for RTSA offers better forward flexion, while the deltopectoral approach is associated with a lower glenoid loosening rate [35].
• Changes in humeral stem inclination in RTSA are accompanied by less scapular notching and dislocations, with no clear impact on functional outcome measures [32].

Classification

• Reverse shoulder arthroplasty is indicated for patients with irreparable massive rotator cuff tears without the presence of osteoarthritis [1].
• Reverse shoulder arthroplasty provides optimal outcomes with low complication rates for glenohumeral osteoarthritis with an intact rotator cuff [2].
• Subacromial balloon spacer implantation is an alternative for patients with massive irreparable rotator cuff tears [3].
• Primary arthroscopic repair is a treatment option for massive rotator cuff tears [5].
• Osteoporosis is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Rheumatoid arthritis is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Female sex is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Rotator cuff arthropathy is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Graft interposition repair techniques are a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
• Superior capsular reconstruction using the long head of the biceps tendon is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
• Arthroscopic debridement is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
• Balloon arthroplasty is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
• Inflammatory arthritis is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Female gender is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Previous rotator cuff repair is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Reverse total shoulder arthroplasty may be required to recover a functional shoulder in cases of complications or revision [12].
• Patients with previous rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair [13].
• Nonarthroplasty options for massive, irreparable rotator cuff tears include treatments that result in improvements in range of motion and patient-reported outcomes at short-term follow-up [14].
• Anatomic total shoulder arthroplasty is a treatment option for patients aged over 70 without a full-thickness rotator cuff tear [17].
• Reverse total shoulder arthroplasty is a treatment option for patients aged over 70 without a full-thickness rotator cuff tear [17].
• Failed rotator cuff repair prior to reverse shoulder arthroplasty is associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair [21].
• Subscapularis repair techniques are relevant for reverse total shoulder arthroplasty [22].
• The humeral neck-shaft angle is an important variable in choosing the reverse shoulder arthroplasty implant design for patients with rotator cuff arthropathy [42].
• Bridging grafts are a treatment option for large to massive rotator cuff tears [43].

Clinical Presentation

• Shoulder scores may decline at mid- to long-term follow-up for interventions such as superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
• Arthroscopic repairs of chronic, massive rotator cuff tears, whether complete or partial, are associated with significant improvements in pain, function, and objective outcome scores [5].
• Osteoporosis is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Rheumatoid arthritis is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Female sex is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Rotator cuff arthropathy is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
• Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty, but these differences may be below the minimal clinically important difference [7].
• Superior capsule reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion irrespective of tissue source [8].
• Better evidence from reports with greater detail is necessary to show that patients are realizing progressively better outcomes from shoulder arthroplasty [9].
• Osteoporosis is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Inflammatory arthritis is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Female gender is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Previous rotator cuff repair is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
• Although patients may require multiple procedures, it is often possible to conserve or replace the reverse total shoulder arthroplasty to recover a functional shoulder [12].
• Patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair [13].
• Shoulder function and outcome scores showed no significant deterioration between 5 and 20 years of follow-up for reverse total shoulder arthroplasty in patients with rotator cuff dysfunction [15].
• The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after reverse total shoulder arthroplasty [16].
• Reverse total shoulder arthroplasty remains a safe and effective treatment option for patients with os acromiale [16].
• The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [20].
• Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement [26].
• Patients undergoing primary reverse shoulder arthroplasty demonstrated clinically significant improvements in both range of motion and clinical outcome scores [27].
• Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function [28].
• Tuberosity healing may be a major contributing factor to the difference in clinical outcomes between elective indications and acute 3- and 4-part proximal humeral fractures treated with reverse total shoulder arthroplasty [34].

Investigations

• Reverse total shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff [2].
• The most commonly cited risk factors for acromial stress fractures following reverse total shoulder arthroplasty include osteoporosis, rheumatoid arthritis, female sex, and rotator cuff arthropathy [6].
• Other risk factors for acromial and scapular fractures following reverse shoulder arthroplasty include osteoporosis, inflammatory arthritis, female gender, and previous rotator cuff repair [11].

Treatment

Reverse Shoulder Arthroplasty (rTSA)

• Reverse shoulder arthroplasty provides a high likelihood of achieving a painless shoulder and functional improvements in patients with irreparable massive rotator cuff tears who do not have osteoarthritis [1].
• Reverse shoulder arthroplasty provides optimal outcomes with low complication rates in the short term for glenohumeral osteoarthritis with an intact rotator cuff [2].
• Patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with satisfaction rates being highest in glenohumeral osteoarthritis [24].
• Differences in postoperative patient-reported outcomes and improvement from baseline show a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference [7].
• The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty, which remains a safe and effective treatment option [16].

Non-Arthroplasty Options for Massive Irreparable Rotator Cuff Tears

• Subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrates clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures in the short term [3].
• Subacromial balloon spacer implantation achieves satisfactory clinical outcomes in the short and middle term (between 3 months and 3 years) for massive irreparable rotator cuff tears [31].
• Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure associated with favorable patient-reported outcomes at limited short-term follow-up [33].
• Patients undergoing subacromial spacer implantation for massive irreparable rotator cuff tears have satisfactory outcomes at 2- to 3-year follow-up with a low rate of complications [23].
• All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year or more, with low rates of revision and conversion to arthroplasty [14].
• Arthroscopic debridement with subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow-up for low-demand patients greater than 65 years of age seeking pain relief over substantial increase in function [28].
• Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with a low rate of re-tear [5].
• Superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion [8].
• Superior capsular reconstruction is associated with significantly improved functional outcome scores and preserved or increased mean acromiohumeral distance [46].

Proximal Humerus Fractures (Elderly Population)

• Reverse shoulder arthroplasty is a better option than hemiarthroplasty for proximal humerus fractures in the elderly [39].
• Clinical decision for reverse shoulder arthroplasty in proximal humerus fractures should be preferred on the condition that the patient's medical conditions are indicated [39].
• Consideration may be given to an initial trial of nonoperative treatment for acute proximal humeral fractures in the elderly, saving reverse total shoulder arthroplasty for those in whom nonoperative treatment fails without compromising the ultimate outcome [47].

Complications

Complications

• Complications are within an acceptable range for primary reverse shoulder arthroplasty using augmented baseplates, with a low rate of revision [18].
• Complications do not appear to be appreciably higher in the reverse shoulder arthroplasty group compared to other treatments for proximal humeral fractures in older adults in existing follow-up [51].
• Shoulder scores may decline at mid- to long-term follow-up for treatments including superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
• Patients undergoing subacromial spacer implantation for massive irreparable rotator cuff tears have a low rate of complications at 2- to 3-year follow-up [23].
• Anatomic total shoulder arthroplasty displayed equal postoperative complications compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear [17].
• Failed rotator cuff repair prior to reverse shoulder arthroplasty was associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair [21].
• Further long-term studies are needed to assess the durability of stemless versus stemmed reverse total shoulder arthroplasty as primary treatment in the elderly [25].

Recovery

• Shoulder scores may decline at mid- to long-term follow-up for procedures such as superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
• Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference [7].
• Irrespective of tissue source, superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion [8].
• There was no radiological evidence of humeral loosening at the latest follow-up for stemless reverse total shoulder arthroplasty in short- and mid-term results [29].
• Although early results for arthroscopic superior capsular reconstruction are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure [52].

Key Evidence

• [L1] Patients with irreparable massive rotator cuff tears without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after reverse shoulder arthroplasty. [1] (10.1016/j.jse.2017.03.039)
• [L4] Reverse shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff. [2] (10.1016/j.jse.2021.06.010)
• [L4] The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. [3] (10.1016/j.arthro.2023.05.028)
• [L1] Shoulder scores may decline at mid- to long-term follow-up. [4] (10.1186/s13018-022-03411-y)
• [L2] Arthroscopic repairs of chronic, massive RCTs, whether complete or partial, are associated with significant improvements in pain, function and objective outcome scores. [5] (10.1007/s00167-020-06190-3)
• [L4] The most commonly cited risk factors for ASFs following rTSA include osteoporosis, rheumatoid arthritis, female sex, and rotator cuff arthropathy. [6] (10.1016/j.jse.2025.02.032)
• [L4] Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference. [7] (10.1177/17585732241268712)
• [L1] Irrespective of tissue source, SCR serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion. [8] (10.1016/j.asmr.2020.09.002)
• [L2] Better evidence from reports with greater detail will be necessary to show that patients are realizing progressively better outcomes from shoulder arthroplasty. [9] (10.1007/s00264-017-3443-0)
• [L3] For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains. [10] (10.1177/03635465231204623)
• [L1] Other risk factors identified included osteoporosis, inflammatory arthritis, female gender, and previous rotator cuff repair. [11] (10.1016/j.xrrt.2025.08.015)
• [L4] Although patients may require multiple procedures, it is often possible to conserve or replace the RTSA to recover a functional shoulder. [12] (10.1016/j.otsr.2015.06.031)
• [L1] Patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair. [13] (10.1016/j.xrrt.2023.01.006)
• [L4] All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. [14] (10.1007/s00167-022-07099-9)
• [L1] Shoulder function and outcome scores also showed no significant deterioration between 5 and 20 years of follow-up. [15] (10.1016/j.jse.2018.10.005)
• [L4] The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after surgery and rTSA remains a safe and effective treatment option. [16] (10.1016/j.xrrt.2025.01.002)
• [L1] Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. [17] (10.1177/24715492231206685)
• [L4] Complications are within an acceptable range for primary reverse shoulder arthroplasty, with a low rate of revision. [18] (10.1016/j.xrrt.2022.08.008)
• [Paper] Soft tissue reconstruction for irreparable AS rotator cuff tears is associated with improved clinical outcomes. [19] (10.1177/17585732261431826)
• [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [20] (10.1177/1758573217702333)
• [L1] Failed rotator cuff repair prior to reverse shoulder arthroplasty was associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair. [21] (10.1177/17585732231194785)
• [L3] This information can help guide future studies in this area and highlights the need for high quality studies comparing different subscapularis repair techniques. [22] (10.1016/j.jisako.2022.05.001)
• [L1] Patients undergoing subacromial spacer implantation for the treatment of massive irreparable rotator cuff tears have satisfactory outcomes at the 2- to 3-year follow-up with a low rate of complications. [23] (10.1016/j.arthro.2018.08.006)
• [L4] This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. [24] (10.1016/j.jse.2024.03.036)
• [L1] Further long-term studies are needed to assess durability. [25] (10.1177/17585732251388447)
• [L4] Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. [26] (10.1016/j.jse.2020.10.003)
• [L1] Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores. [27] (10.1016/j.jse.2022.06.005)
• [L1] Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function. [28] (10.1016/j.xrrt.2021.08.012)
• [L1] There was no radiological evidence of humeral loosening at the latest follow-up. [29] (10.1177/17585732211013356)
• [L1] There is an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation following TSA compared to asymptomatic shoulders. [30] (10.1016/j.jse.2025.08.010)
• [L1] Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. [31] (10.1007/s00167-019-05834-3)
• [L1] This change in range of motion is accompanied by less scapular notching and dislocations, with no clear impact on functional outcome measures. [32] (10.1016/j.xrrt.2021.02.002)
• [L4] Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure with favorable patient-reported outcomes at limited short-term follow-up. [33] (10.1177/2325967119875717)
• [L1] Tuberosity healing may be a major contributing factor to the difference in clinical outcomes. [34] (10.1016/j.jse.2021.07.014)
• [L1] One of the two approaches did not bring a better result than the other; one has strength for better forward flexion and the other for a lower glenoid loosening rate. [35] (10.1186/s13018-022-03414-9)
• [L1] In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. [36] (10.1016/j.asmr.2020.06.011)
• [L4] There were no differences in abduction, internal rotation, or external rotation strength after rTSA with or without subscapularis repair. [37] (10.1016/j.xrrt.2021.11.004)
• [L4] Measures and reporting of shoulder internal rotation after reverse total shoulder arthroplasty varied widely, making it difficult to assess associations between postoperative internal rotation limitation and functional abilities. [38] (10.1016/j.jses.2019.10.109)
• [L1] Clinical decision should be preferred to RSA on the condition that patients ' medical conditions are indicated. [39] (10.1007/s00264-015-2811-x)
• [L2] 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. [40] (10.1016/j.xrrt.2026.100691)
• [L4] Studies that analyzed the impact of subscapularis repair reported conflicting results. [41] (10.1016/j.jse.2023.10.006)
• [L2] The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. [42] (10.3390/jcm11133641)
• [L4] Bridging grafts may be considered for this difficult patient population with large to massive rotator cuff tears. [43] (10.1016/j.arthro.2016.08.030)
• [L1] Despite overall fair MCMS scores, at 24‐m post‐SBSI, shoulder function improved and pain decreased. [44] (10.1002/ksa.12331)
• [L1] However, there appears to be a trend suggesting improved postoperative clinical outcomes and active range of motion for patients with a subscapularis repair vs. without a repair. [45] (10.1016/j.xrrt.2022.01.003)
• [L1] This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears, associated with significantly improved functional outcome scores and preserved or increased mean AHD. [46] (10.1016/j.otsr.2019.07.022)
• [L1] Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome. [47] (10.1016/j.jse.2018.10.004)
• [L4] Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. [51] (10.1016/j.jse.2013.08.021)
• [L1] Although early results are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure in this population. [52] (10.1016/j.arthro.2018.09.033)

References

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[2] Glenohumeral osteoarthritis with intact rotator cuff treated with reverse shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.06.010

[3] Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.05.028

[4] Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03411-y

[5] Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re‐tear. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06190-3

[6] Inconsistent reporting of risk factors for acromial stress fractures following reverse total shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.032

[7] Is the impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty clinically relevant? A systematic review of 2879 shoulders. Shoulder & Elbow. 2024. DOI: 10.1177/17585732241268712

[8] Clinical Outcomes of Superior Capsular Reconstruction for Massive, Irreparable Rotator Cuff Tears: A Systematic Review Comparing Acellular Dermal Allograft and Autograft Fascia Lata. Arthroscopy, Sports Medicine, and Rehabilitation. 2020. DOI: 10.1016/j.asmr.2020.09.002

[9] Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better?. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3443-0

[10] 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. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465231204623

[11] Risk factors for acromial and scapular fractures following reverse shoulder arthroplasty: a meta-analysis of over 100,000 shoulders. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.08.015

[12] Complications and revision of reverse total shoulder arthroplasty. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2015.06.031

[13] Outcomes of reverse shoulder arthroplasty in patients with previous rotator cuff repair: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.01.006

[14] 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 Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07099-9

[15] Long-term results of reverse total shoulder arthroplasty for rotator cuff dysfunction: a systematic review of longitudinal outcomes. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.10.005

[16] Clinical implications of reverse total shoulder arthroplasty with an os acromiale: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.01.002

[17] Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis. Journal of Shoulder and Elbow Arthroplasty. 2023. DOI: 10.1177/24715492231206685

[18] Augmented baseplates in reverse shoulder arthroplasty: a systematic review of outcomes and complications. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2022.08.008

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