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J Shoulder Elbow Surg. Author manuscript; available in PMC 2021 December 01.
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Published in final edited form as:

J Shoulder Elbow Surg. 2020 December ; 29(12): 2459–2475. doi:10.1016/j.jse.2020.07.030.

Address Correspondence to: David Kovacevic, MD, Chief of Shoulder, Elbow, and Sports Medicine, NewYork-Presbyterian
Lawrence Hospital, Head Team Physician Columbia Rugby, Head Team Physician Old Blue Rugby, Assistant Professor, Chief of
Informatics, Department of Orthopedic Surgery, NewYork-Presbyterian / Columbia University Medical Center, 622 West 168th Street,
PH-11, New York, NY 10032, USA, Phone: (914) 787-3286, Fax: (914) 787-2246, [email protected].
Publisher's Disclaimer: This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a
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Study Group Name: American Shoulder & Elbow Surgeons Massive cuff Evaluation and Research IniTiative Investigators (ASES
MERIT Investigators)
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Ethical Committee approval: The study was exempt from local institutional review board approval because of study type (i.e.,
systematic review and meta-analysis).
Conflicts of interest/Disclosures:
David Kovacevic, MD: This author is a committee member of American Shoulder and Elbow Surgeons and Orthopaedic Research
Society, and serves on the editorial or governing board for Journal of Bone and Joint Surgery.
Robert J. Suriani Jr, BA: This author, their immediate family, and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Brian M. Grawe, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive
any financial payments or other benefits from any commercial entity related to the subject of this article.
Edward H. Yian, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive
any financial payments or other benefits from any commercial entity related to the subject of this article.
Mohit N. Gilotra, MD: This author is a paid presenter / speaker for Arthrex Inc.
S. Ashfaq Hasan, MD: This author is a board / committee member of AAOS.
Umasuthan Srikumaran, MD MBA: This author receives financial or material support from Arthrex, DePuy, Smith & Nephew,
Stryker, Thieme, and Wright Medical Technology; is a paid consultant for Conventus and Fx Shoulder; holds stock or stock options
with Quantum OPS and Tigon Medical; receives research support from Stryker; has a family member who is an employee for Abbott;
is a paid presenter / speaker for Fx Shoulder; and receives publishing royalties from Thieme.
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Samer S. Hasan, MD PhD: This author receives financial or material support from Arthrex, DePuy, and DJ Orthopaedics; is a board /
committee member for AAOS, American Shoulder and Elbow Surgeons; serves on the editorial / governing board for Arthroscopy and
Orthopedics Today; receives research support from DJ Orthopaedics and OrthoSpace; is a paid presenter / speaker for Arthrex; is a
paid consultant for DJ Orthopaedics and OrthoSpace; receives IP royalties from DJ Orthopaedics; holds stock of stock options with
ROM3.
Frances Cuomo, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive
any financial payments or other benefits from any commercial entity related to the subject of this article.
Robert T. Burks, MD: This author is a board or committee member of American Orthopaedic Society for Sports Medicine; paid
consultant for DePuy Mitek; receives IP royalties and is an unpaid consultant for Arthrex; is a paid presenter / speaker for DePuy
Mitek; and holds stock or stock options with KATOR.
Andrew G. Green, MD: This author receives financial / material support from Arthrex, JBJS, and Smith & Nephew; is a board /
committee member of AAOS and American Shoulder and Elbow Surgeons; is a paid consultant for DJ Orthopaedics; holds stock or
stock options with IlluminOss Medical and Pfizer; serves on the editorial / governing board for JBJS and Techniques in Shoulder and
Elbow Surgery; is a paid presenter / speaker and receives research support from DJ Orthopaedics; receives publishing royalties from
JBJS, and receives IP royalties from Wright Medical Technology.
Wesley M. Nottage, MD: This author is a board / committee member for the American Orthopaedic Society for Sports Medicine, the
American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America; holds stock or stock options with Johnson
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& Johnson.
Sai Theja, MSc: This author, their immediate family, and any research foundation with which they are affiliated did not receive any
financial payments or other benefits from any commercial entity related to the subject of this article.
Hafiz F. Kassam, MD: This author serves on the editorial / governing board for the Journal of Shoulder and Elbow Arthroplasty.
Maarouf A. Saad, BS: This author, their immediate family, and any research foundation with which they are affiliated did not receive
any financial payments or other benefits from any commercial entity related to the subject of this article.
Miguel A. Ramirez, MD: This author serves on the editorial / governing board for the Journal of Shoulder and Elbow Surgery, is a
paid consultant and paid presenter / speaker for Stryker.
Rodney J. Stanley, MD: This author is a board / committee member for the American Shoulder and Elbow Surgeons.
Matthew D. Williams, MD: This author, their immediate family, and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Vidushan Nadarajah, BA: This author, their immediate family, and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Alexis C. Konja, MPH: This author, their immediate family, and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any commercial entity related to the subject of this article.
 Kovacevic et al. Page 2
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Management of irreparable massive rotator cuff tears: a

systematic review and meta-analysis of patient-reported
outcomes, reoperation rates and treatment response
David Kovacevic, MDa, Robert J. Suriani Jr, BAa, Brian M. Grawe, MDb, Edward H. Yian,
MDc, Mohit N. Gilotra, MDd, S. Ashfaq Hasan, MDd, Umasuthan Srikumaran, MD, MBAe,
Samer S. Hasan, MD, PhDf, Frances Cuomo, MDg, Robert T. Burks, MDh, Andrew G. Green,
MDi, Wesley M. Nottage, MDj, Sai Theja, MSca, Hafiz F. Kassam, MDa, Maarouf A. Saad, BSa,
Miguel A. Ramirez, MDk, Rodney J. Stanley, MDl, Matthew D. Williams, MDm, Vidushan
Nadarajah, BAd, Alexis C. Konja, MPHa, Jason L. Koh, MDn, Andrew S. Rokito, MDo,
Charles M. Jobin, MDa, William N. Levine, MDa, Christopher C. Schmidt, MDp, ASES MERIT
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Investigators
aDepartment of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
bDepartment of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, OH,
USA
cKaiser Permanente Southern California, Anaheim, CA, USA
dDepartment of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
eDepartment of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
fMercyHealth/Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH, USA
gDepartment of Orthopaedic Surgery, Montefiore Medical Center, New York, NY, USA
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hDepartment of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City, UT,
USA
iDepartment of Orthopaedic Surgery, Warren Alpert Medical School at Brown University/Rhode
Island Hospital, Providence, RI, USA

Jason L. Koh, MD: This author is a board / committee member for American Academy of Orthopaedic Surgeons, ACL Study Group,
American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North
America, Herodicus Society, Illinois Association of Orthopaedic Surgeons, International Patellofemoral Study Group, International
Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and the Patellofemoral Foundation; is a paid consultant for
Flexion; holds stock or stock options with Acuitive and Marrow Access Technologies; is an employee of Marrow Access
Technologies; and serves on the editorial or governing board for Orthopaedic Journal of Sports Medicine.
Andrew S. Rokito, MD: This author, their immediate family, and any research foundation with which they are affiliated did not
Author Manuscript

receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Charles M. Jobin, MD: This author is a paid consultant for Acumed LLC, Consortium of Focused Orthopedists LLC, DePuy, Wright
Medical Technology, and Zimmer Biomet; is a paid presenter / speaker for Acumed LLC, Wright Medical Technology, and Zimmer
Biomet; is a board / committee member for the American Shoulder and Elbow Surgeons and American Board of Orthopaedic Surgery;
receives research support from Acumed LLC; and serves on the editorial / governing board for the Journal of the American Academy
of Orthopaedic Surgeons.
William N. Levine, MD: This author is a board / committee member of the American Shoulder and Elbow Surgeons; serves on the
editorial / governing board for the Journal of the American Academy of Orthopaedic Surgeons; is an unpaid design team member for
Zimmer.
Christopher C. Schmidt: This author is a board / committee member of the American Shoulder and Elbow Surgeons; is a paid
consultant for Arthrex.

J Shoulder Elbow Surg. Author manuscript; available in PMC 2021 December 01.
 Kovacevic et al. Page 3

jThe Sports Clinic Orthopaedic Medical Associates, Laguna Hills, CA, USA
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kOSF Saint Francis Medical Center, Peoria, IL, USA

lOrthoCarolina, Mooresville, NC, USA
mLouisiana Orthopaedic Specialists, Lafayette, LA, USA
nNorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, IL, USA
oDepartment of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
pDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA

Abstract
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Background: There is no consensus on treatment of irreparable massive rotator cuff tears

(MRCT). The goal of this systematic review and meta-analysis was to (1) compare patient-
reported outcome (PRO) scores, (2) define failure and reoperation rates, and (3) quantify
magnitude of patient response across treatment strategies.

Methods: MEDLINE, Embase, CENTRAL, and Scopus databases were searched for studies
including physical therapy and operative treatment of MRCT. The criteria of the Methodological
Index for Nonrandomized Studies were used to assess study quality. Primary outcome measures
were PRO scores as well as failure, complication and reoperation rates. To quantify patient
response to treatment, we compared changes in the Constant-Murley (CMS) and American
Shoulder and Elbow Surgeons (ASES) score to previously reported minimum clinically important
difference (MCID) thresholds.

Results: No level I or II studies were found that met the inclusion / exclusion criteria. Physical
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therapy was associated with a 30% failure rate and another 30% went on to have surgery. Partial
repair was associated with a 45% re-tear rate and 10% reoperation rate. Only graft interposition
was associated with a weighted average change that exceeded the MCID for both CMS and ASES
score. Latissimus tendon transfer techniques utilizing humeral bone tunnel fixation were
associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was
associated with a weighted average change that exceeded the MCID for ASES score. Reverse
arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate.

Conclusion: There is a lack of high-quality comparative studies to guide treatment

recommendations. Physical therapy compared to surgery is associated with a lower improvement
in perceived functional outcome and higher clinical failure rate.

Level of Evidence: Level IV; Systematic Review

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Keywords
Irreparable massive rotator cuff tear; systematic review; meta-analysis; patient-reported outcomes;
response to treatment; survival; failure rate; reoperation; complications

As the most common upper extremity condition in people over 50 years old,54 rotator cuff
tears represent a significant clinical challenge in our aging population. The overall incidence

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of rotator cuff tears ranges from 5–40%,52, 53 with approximately 54% of individuals over
the age of 60 having a partial or complete rotator cuff tear.63 Massive rotator cuff tears
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(MRCT), commonly defined as involving a full-thickness tear of at least two tendons10 or

measuring greater than five centimeters in the coronal plane,23 are estimated to comprise
approximately 20% of all rotator cuff tears and 80% of recurrent tears.5, 43

Increasing rotator cuff tear size is associated with poor outcomes and high structural failure
rates following surgical repair.37, 58 A review of 18 studies reporting outcomes after repair of
massive tears found a re-tear rate of 78%. Despite the high rate of structural failure, much of
the published literature supports an attempt at primary repair.4 However, a number of these
MRCT are retracted or lack tendon length so that they cannot be re-attached to their
footprint and thus are irreparable. Numerous treatment strategies, such as physical therapy,
débridement, partial repair, graft interposition, tendon transfer, superior capsular
reconstruction, balloon arthroplasty, and reverse shoulder arthroplasty, have been proposed
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to treat irreparable MRCT. The comparative efficacy of these treatments remains unclear.

The purpose of this systematic review and meta-analysis was to evaluate the highest quality
clinical evidence currently available to recommend either for or against the various treatment
options for irreparable MRCT. This was accomplished by (1) comparing patient-reported
outcome (PRO) scores across treatment strategies, (2) reporting failure and reoperation rates,
and (3) quantitatively evaluating the magnitude of patient response to treatment. We
hypothesized that (1) there is a lack of a consistent definition of irreparable MRCT, (2)
operative treatment of the irreparable tear leads to greater improvement in PRO scores when
compared with nonoperative treatment, and (3) there is no single superior operative
treatment strategy due to a lack of high-quality evidence.
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Materials and Methods

Search Rationale
This systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) statement guidelines. MEDLINE, Embase,
CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were
searched in November 2019 for studies addressing eight treatment methods for irreparable
MRCT: physical therapy, débridement, partial repair, graft interposition, tendon transfer,
superior capsular reconstruction, balloon arthroplasty, and reverse shoulder arthroplasty.
Separate searches were carried out for each treatment. Search terms included “massive
rotator cuff tear” AND terms associated with each treatment: (“physical therapy OR
rehabilitation”) / “debridement” / “partial repair” / (“scaffold OR patch OR graft
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interposition OR platelet rich plasma OR augmentation OR stem cell”) / (“tendon transfer

OR latissimus dorsi tendon transfer OR lower trapezius tendon transfer”) / (“superior
capsular reconstruction OR superior capsule reconstruction”) / (“(subacromial OR sub-
acromial) AND (balloon OR spacer)) OR balloon arthroplasty”) / (“reverse total shoulder
arthroplasty OR reverse shoulder arthroplasty OR reverse shoulder prosthesis”). Titles,
abstracts, and full texts were screened to identify potentially relevant studies.

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Study Eligibility
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Eligibility criteria were determined a priori. Inclusion criteria included studies of any level
of evidence with a minimum two-year clinical follow-up with criteria defining MRCT and
reporting of validated PROs and/or range of motion data. Exclusion criteria included studies
that included patients with a repairable rotator cuff tear, rotator cuff tear arthropathy with
Hamada stage ≥ 3 (glenohumeral arthritis),28 fractures, rheumatoid arthritis, or instability, as
well as case reports, biomechanical studies, reviews, surgical techniques, or studies written
in a language other than English. Studies that included patients with or without
glenohumeral arthritis were included if data for patients without glenohumeral arthritis were
reported separately.

Data Abstraction
Extrapolated data were recorded using a standardized data collection spreadsheet for all
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sections. This included study design and patient demographics (Supplemental Tables 1a–9a),
MRCT diagnosis criteria (Supplemental Tables 1b–9b), clinical outcomes before and after
treatment intervention, including VAS pain scores (range 0–10), range of motion, PRO
scores, radiographic analysis, failure and revision rates, and complications (Supplemental
Tables 1c–9c). All continuous variables were reported as a mean ± standard deviation, unless
the standard deviation was unavailable, in which case range was reported, if available.

Assessment of Study Quality

Two reviewers (R.J.S. and D.K.) independently assessed the methodologic quality of all
included studies with the Methodological Index for Nonrandomized Studies (MINORS)
scoring system.64 Studies with a MINORS score <75% were excluded.
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Response to Treatment
To determine variation in magnitude of response to treatment of the Constant-Murley Score
(CMS) and the American Shoulder and Elbow Surgeons (ASES) score, we compared pre-to-
post-treatment score changes to the minimally clinical important difference (MCID)
thresholds determined by previous rotator cuff studies.21, 32 The CMS and ASES were
chosen because they were the most frequently reported PROs among included studies. The
change in ASES and CMS for each study reporting either PRO as well as the weighted
average change in score for each treatment modality were graphically compared to
previously reported MCID thresholds. The weighted average change in PRO score was
influenced by sample size. For CMS, we used an MCID of 15 for nonoperative treatment
and an MCID of 30 for operative management.31 For ASES, we used an MCID of 17 for
nonoperative and 39 for operative management.20 All selected MCID threshold values were
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calculated by prior studies via an anchor-based approach, in which the change in PRO score
is anchored to a separate global rating of change questionnaire that determines overall
patient improvement with their treatment outcome at final follow-up.

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Results
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Search Strategy and Data Aggregation

We identified 120 relevant studies with 77 not meeting the inclusion criteria, leaving 43
studies included in this review (Figure 1). All 43 studies were included in the qualitative
synthesis and 37 studies were included in the quantitative synthesis. The most common
reasons for exclusion were insufficient follow-up, inclusion of rotator cuff tear sizes other
than massive (without a subgroup analysis of massive tears), and failure to define the criteria
for MRCT. For each treatment strategy, the data were aggregated and pooled where
appropriate, such that Table I provides a summary of study design and demographics, Table
II includes criteria for defining MRCT, and Table III outlines clinical outcomes, failure rates,
and reoperation rates.

Physical Therapy
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Study Design and Patient Demographics—All three studies were of level III or IV
evidence with two prospective and one retrospective study and an average follow-up of 32
months.11, 69, 70 Patients lost to follow-up ranged from 0% to 35%. The number of patients
ranged from 19 to 45 (total 94). Nonoperative treatment strategies varied between studies.
One study used a home-based three-month anterior deltoid rehabilitation program,69 a
second restored passive range of motion and strength without a described duration,70 and a
third focused on periscapular and intact rotator cuff muscles and described deltoid muscle
coaptation only when the arm was elevated.11

Definition of a MRCT—All three studies defined MRCT as two or more tendon

involvement and defined irreparable as fatty muscle infiltration of grade ≥ 3.11, 69, 70
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Clinical Outcomes—Complete PRO scores were available for two studies with +13-point
and +23-point mean change in CMS and ASES scores, respectively.9;69 Pain scores
improved 3 points after physical therapy.69 Complete range of motion data were available
from two studies,11, 69, 70 with forward elevation improving by 25°. Meanwhile, Collin et al
demonstrated that 53% of patients (24/45) achieved more than 160° forward elevation after
treatment.11 Those with subscapularis involvement performed worse than postero-superior
rotator cuff tears. Strength improved from 1.1kg to 1.9 kg.69

Survival and Complications—For patients treated with anterior deltoid rehabilitation,

40% (12/30) had a successful outcome, 30% (9/30) chose surgery, and 30% (9/30) did not
improve with the rehabilitation program.69 In another study, 18% (7/40) of patients elected
to undergo surgery after failing nonoperative treatment.70
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Débridement
Study Design and Patient Demographics—All seven articles were of level III or IV
evidence with five retrospective22, 30, 35, 38, 41 and two prospective studies.36, 48 All articles
had minimal loss to follow-up. The number of patients ranged from 23 to 57 (total 256) with
an average age of 65.7 years. Average follow-up was 48 months with two studies reporting
follow-up of at least 5 years.22, 38

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Definition of a MRCT—There was variability in the criteria used for defining MRCT. The
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most common were ≥2-tendon involvement or >5 cm anterior-posterior width size. One
study referenced either two tendons torn or retraction past the glenoid.41

Clinical Outcomes—Five studies used the CMS with +26-point mean change in scores
before and after surgery,22, 30, 35, 36, 41 while two studies used the ASES with +37-point
mean change in scores.22, 41 Three studies reported pain scores with an average
improvement of 4.5 points.22, 30, 41 Range of motion data were available from five studies,
22, 30, 35, 36, 41 but only two measured motion both before and after surgery,22, 30 with

forward elevation increasing by 32°.

Survival and Complications—Complications were seldom reported. One study reported

4.9% of patients (2/41) developing complex regional pain syndrome type 135 while another
study reported 6.1% (2/33) and 3.0% (1/33) developed seromas and infections, respectively.
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22

Partial Repair
Study Design and Patient Demographics—All seven articles were of level III55 or IV
evidence.30, 48, 559, 12, 16, 21 Study sample size ranged from 11 to 90 (total 226) with an
average age of 62.7 years. Two studies had greater than 5% loss to follow-up.12, 21 Average
follow-up was 45.2 months with two studies reporting follow-up of at least 5 years.12, 21

Definition of a MRCT—All studies defined MRCT by number of tendons torn (two torn
tendons in five studies12, 16, 21, 48, 55 and three torn tendons in two studies.9, 30 Three studies
included tear size (≥ 5 cm) as an additional criterion.16, 48, 55 Three studies reported
preoperative fatty infiltration,9, 30, 55 three the acromiohumeral interval,9, 16, 21 and two the
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Hamada classification,9, 12 demonstrating variability in criteria used for defining MRCT.

Clinical Outcomes—Six studies reported PROs both before and after surgery. The mean
change in scores with CMS30;21;55 and ASES16;48;9 was +32 points and +35 points,
respectively. Pain scores improved by about 4.5 points.16; 9;12;30 Three studies reported
motion both before and after surgery, with forward elevation and external rotation improving
on average by 30° and 11°, respectively.12, 16, 30

Survival and Complications—Pooled rates for re-tear defined as re-rupture on

postoperative MRI or ultrasound,9, 30 unsatisfactory outcomes,12, 21 and revision
surgery16;48;30;21 were 45% (25/55), 14% (16/111), and 9.7% (16/165), respectively.
Reasons for revision surgery included re-tear (12/16), infection (2/16), anchor loosening
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(1/16), or AC joint cyst (1/16).

Graft Interposition
Study Design and Patient Demographics—The three articles were of level IV
evidence with one prospective study and two retrospective studies.2, 44, 51 (Supplemental
Table 5d) The number of patients ranged from five to 41 (total 67) with an average age of
68.2 years and an average follow-up of 34.3 months.

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Definition of MRCT—There was variability in the criteria used for defining MRCT with ≥
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two tendon involvement reported in two articles.2, 44, 51 All three articles quantified tear size
with two reporting > 5cm44, 51 and one > 4cm2 tear size for the diagnosis of MRCT.

Clinical Outcomes—Two of three studies used the CMS with +42-point mean change in
scores before and after surgery,2, 51 while one study used the ASES with +45-point mean
change in scores.44 Two studies reported pain scores with an average improvement of 5
points.44, 51 Range of motion before and after surgery was reported for two studies,2, 51 with
forward elevation and external rotation improving on average by 61° and 12°, respectively.
2, 51

Survival and Complications—Pooled rates for re-tear2, 51 and revision surgery2, 51 were
20% (1/5) and 20% (1/5), respectively.
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Tendon Transfer
Study Design and Patient Demographics—All eleven articles were of level III49 or
IV evidence.8, 14, 17, 18, 24, 25, 27, 32–34, 49 Study sample size ranged from 14 to 86 (total 506)
with an average of 59 years. Average follow-up was 57.7 months with two studies reporting
follow-up of at least 9 years.17, 25 It is worth noting that there was overlap in the cohorts of
patients reported by two separate pairs of studies,25, 27, 34;24 (Supplemental Table 6a) which
slightly skews conclusions drawn from analysis of all patients between the eleven studies.

All studies utilized the latissimus dorsi tendon8, 14, 17, 24, 25, 27, 32–34, 49 except for Elhassan
et al who transferred the lower trapezius.18 The latissimus transfer surgeries were performed
either using the open two-incision technique popularized by Gerber26 or an arthroscopic-
assisted approach.14, 27, 33, 34 Operative technique details are outlined in Supplemental Table
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6d.

Definition of MRCT—All studies defined MRCT as either involving ≥ 2 tendons (i.e.,

supraspinatus and infraspinatus),17, 18, 24, 25, 33, 34, 49 or measuring ≥ 5 cm,8, 24, 32, 34, 49 with
two studies24, 49 requiring both criteria. Nine of eleven articles reported tendon retraction to
at least the level of the glenoid or medial to it5; 11;17, 18, 27, 33, 34; 44 and all studies observed
fatty infiltration of Goutallier grade ≥ 3.8, 14, 17, 18, 24, 25, 27, 32–34, 49

Clinical Outcomes—All but one study18 reported CMS, with a mean change of +28
points (+30 points for arthroscopic treatment and +26 points for open treatment). The mean
change in ASES was +33 points.17, 49 Pain scores improved by about 5.1 points.17, 33 All
studies reported motion both before and after surgery, with forward elevation and external
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rotation improving on average by 43° and 15°, respectively.

Survival and Complications—Pooled rates for tendon transfer re-tear,14, 17, 18, 25, 27, 34
rotator cuff tear,24, 25, 34 deltoid deficiency,17, 24, 25 and revision surgery17, 18, 24, 25, 27, 34
were 14.6% (35/239), 6.6% (8/122), 1.6% (2/122), 6.7% (24/356), respectively. Twenty-
seven of the 35 tendon transfer failures (77%) occurred secondary to humeral bone tunnel
fixation with tendon tubularization compared to eight failures with greater tuberosity
footprint fixation (23%).27, 34 Postoperative complications included hematoma (8%;

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 Kovacevic et al. Page 9

23/286),17, 18, 27, 32, 34 greater tuberosity fracture (7.3%; 4/55),27 deep infection (3.3%;
7/214),14, 18, 27, 32, 34 stiffness (3.1%; 6/193),17, 25, 32 and nerve dysesthesias (2.1%; 9/431).
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14, 17, 24, 25, 27, 32, 34, 49

Superior Capsular Reconstruction

Study Design and Patient Demographics—All four retrospective articles were of
level IV evidence including 177 patients with an average age of 64.7 years and an average
follow-up of 44.5 months.45–47, 57 There was overlap in the cohorts reported by three
studies,45–47 which slightly skews conclusions drawn from analysis of patients receiving
fascia lata autograft. There was variability noted concerning graft characteristics (i.e., type,
size, thickness) and glenoid fixation. (Supplemental Table 7d).

Definition of MRCT—Pennington et al defined MRCT using tear size ≥ 5 cm and further

characterized muscle quality with the Goutallier grading classification,57 while Mihata et al
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defined MRCT by two or more tendon invlovement.45–47 All studies reported preoperative
fatty infiltration and average changes in the acromiohumeral interval (AHI) ranging from 3.4
mm preoperatively to 9.6 mm postoperatively.45–47, 57

Clinical Outcomes—All studies used the ASES score with +57-point mean change in
scores before and after surgery (+36 points for human dermal allograft and +64 points for
tensor fascia lata autograft). Two studies reported pain scores with an average improvement
of 3.9 points.45, 57 Range of motion before and after surgery was reported for all studies,
with forward elevation improving on average by 57°.

Survival and Complications—Pooled rates for structural failure and revision surgery
were 6.1% (11/180) and 4.8% (6/126), respectively. Rates of graft tear and revision surgery
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were 7.9% (3/38) and 2.6% (1/38) with use of human dermal allograft, respectively.57. Rates
of infraspinatus re-tear, graft tear, and revision surgery were 12.5% (3/24), 5.6% (8/142),
and 5.7% (5/88) with use of tensor fascia lata autograft, respectively.45–47

Balloon Arthroplasty
Study Design and Patient Demographics—Two articles, one retrospective case series
and one prospective case series, were included and both were of level IV evidence including
25 patients with an average age of 68.8 years and an average follow-up of 42 months.59, 62

Definition of MRCT—Both studies defined MRCT using tear size ≥ 5 cm. Ricci et al59
also required ≥ two tendons to be torn and Goutallier grade ≥ 3, while Senekovic noted the
presence of substantial fatty infiltration deemed unsuitable for repair in all patients without
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qualitatively assessing its severity.62

Clinical Outcomes—Both studies used the CMS with +29-point mean change in scores
before and after surgery. One study reported pain scores with an average improvement of 3.8
points.59 Range of motion before and after surgery was reported for one study, with forward
elevation improving on average by 58°.62

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Survival and Complications—No complications were noted and one patient (5%; 1/20)
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needed eventual conversion to RSA within the five-year follow-up period.62

Reverse Shoulder Arthroplasty

Study Design and Patient Demographics—All six articles were retrospective case
series of level IV evidence.3, 19, 29, 50, 65, 67 The number of patients included ranged from 17
to 64 (total 247) with an average age of 67.5 years and an average follow-up of 39.4 months.
Age data were available from only three studies.19, 29, 50

Definition of MRCT—Tendon number was the most commonly referenced criterion, with
a minimum two tendon tear.29, 50, 67;3, 65;15 All studies referenced either the acromiohumeral
interval3, 19 or the Hamada classification,27, 29, 50, 67; 60 but the Hamada classification was
primarily used to exclude arthritis and not to diagnose MRCT. Of the three studies that
assessed tendon retraction,3, 19, 65 a common value for the degree of retraction was not
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identified. Three studies used the Goutallier classification and considered grade ≥ 3 to be
consistent with MRCT.3, 19, 67

Clinical Outcomes—Three studies reported the CMS with +32-point mean change in
scores before and after surgery,3;67;19 while two studies reported the ASES score with +37-
point mean change in scores.29;50 Two studies reported pain scores with an average
improvement of 3.9 points.29;50 Range of motion before and after surgery was reported for
three studies, with forward elevation improving on average by 64°.27, 29, 50, 67

Survival and Complications—Pooled rates for prosthesis failure,3, 19, 29, 50, 65, 67
fracture,3, 19, 29, 50, 65, 67 instability,3, 19, 29, 50, 65, 67 and revision surgery3, 19, 29, 50, 65, 67
were 10.1% (16/159), 6.1% (14/231), 1.9% (4/206), and 8.2% (19/231), respectively. One
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study provided an estimated 90.7% survival at 52 months, with the end-point defined as
component revision, removal, loosening, or a worsening ASES score.50

Response to Treatment
The magnitude of change in CMS and ASES score for each treatment strategy compared to
the MCID threshold for nonoperative and operative treatment are provided in Figures 2 and
3. Twenty-six studies reported sufficient data for CMS score comparison to MCID. The
weighted average change in CMS was greater than MCID for partial repair, graft
interposition, balloon arthroplasty, and reverse shoulder arthroplasty. Fifteen studies reported
sufficient data for ASES score comparison to MCID. The weighted average change in ASES
score was greater than MCID for physical therapy, graft interposition, and superior capsular
reconstruction with tensor fascia lata autograft.
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Discussion
Our study findings clearly show the absence of high-quality literature on irreparable MRCT.
Of all 43 studies, only 9.3% (4/43) were of level III evidence with the remaining of level IV
evidence. As such, it is difficult to definitively recommend either for or against one
treatment strategy over another for the management of irreparable MRCT. These findings

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 Kovacevic et al. Page 11

agree with the recommendations provided by the American Academy of Orthopaedic

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Surgeons 2019 clinical practice guideline on management of rotator cuff injuries. The
authors found insufficient evidence to support the efficacy of physical therapy, partial repair,
tendon transfer, superior capsular reconstruction (SCR), débridement, allograft
augmentation, or RSA in the treatment of irreparable tears, instead concluding based on
consensus clinical opinion alone that these treatments may improve patient reported
outcomes.1

Treatment decisions when the rotator cuff cannot be repaired will have to be made with
professional judgement, surgeon experience, patient expectations, ability to complete
postoperative rehabilitation, and a shared decision making process between the surgeon and
the patient. In such scenarios, appropriate use criteria (AUC) can provide guidance by
considering clinical experience, patient factors (smoking status, worker’s compensation,
etc.), and disease type (tear size and fatty infiltration) to indicate the appropriateness of a
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given intervention for a specific clinical scenario.56, 60

Our current study suggests that physical therapy compared to surgery may lead to high
failure rates and inferior clinical outcomes for irreparable MRCT. Physical therapy is
promoted to be the first line of treatment when a patient is medically unfit, does not wish to
proceed with surgery, or demonstrates a positive response to non-operative care.60 However,
with the numbers available, 60% of the patients (18/30) in this review did not respond to
physical therapy or went on to have surgery.

Débridement and partial repair showed improvements in VAS pain scores, functional range
of motion and PRO scores with lower reoperation rates compared to physical therapy. The
majority of débridement studies did not meet the MCID threshold, and as such, débridement
may not be a successful treatment strategy. However, Walch et al66 investigated débridement
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with concomitant biceps tenotomy in 307 patients with full-thickness rotator cuff tears,
finding that this combination of procedures led to significant clinical improvement. While
this study did not exclusively investigate MRCT, this treatment strategy may be considered
in the appropriate patient. A drawback to partial repair was the high re-tear rate (45%;
25/55) and the majority of studies did not meet the MCID threshold.

Surgical reconstruction (graft interposition / tendon transfer) compared to physical therapy

showed superior improvements in pain scores, forward elevation, and mean change in CMS
and ASES scores. All three graft interposition studies exceeded the MCID threshold, and as
such, graft interposition should be investigated further. Arthroscopic-assisted tendon transfer
utilizing greater tuberosity fixation techniques are favored over humeral bone tunnel fixation
techniques as the latter are associated with a high failure rate (77%; 27/35). Based on the
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available evidence, open tendon transfer may not be a successful treatment strategy as the
majority of studies did not meet the MCID for either ASES or CMS.

SCR and balloon arthroplasty are relatively new procedures with a paucity of data reporting
clinical outcomes and rates of failure, revision surgery, and complications. With the numbers
available, both SCR and balloon arthroplasty led to an improvement in pain scores, forward
elevation, and PRO scores. However, of concern is the high structural failure rate of SCR

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 Kovacevic et al. Page 12

using human dermal allograft, which has been reported to range from 15–
75%6, 7, 15, 39, 57, 68, compared to SCR using tensor fascia lata autograft, with failure rates
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reported to range from 5–36%13, 40, 42, 45–47 (Table IV). Based on the available evidence,
SCR may be considered using fascia lata autograft, and further studies are needed to
determine success of SCR with human dermal allograft and efficacy of balloon arthroplasty.

Reverse shoulder arthroplasty was found to improve pain scores, functional motion and PRO
scores compared to physical therapy. However, this treatment strategy has an 8.2% (19/231)
reoperation rate and a 10.1% (16/159) prosthesis failure rate. In light of this, we agree with
the AUC that reverse arthroplasty should be considered only in a healthy elderly patient with
pseudoparalysis from a chronic irreparable massive tear.56, 60

We found considerable variability in the definition of MRCT. Thirty-two studies required a

minimum tear size for diagnosis (i.e., ≥ 5cm), and twenty-three studies required a minimum
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number of involved tendons (i.e., two). Meanwhile, thirteen studies required both a
minimum tear size and a minimum number of involved tendons, and two studies required
either a minimum tendon retraction length or a minimum amount of fatty infiltration.
Clearly, there is inconsistent reporting on what defines MRCT. How to define MRCT may
depend on treatment strategy and patient expectations (i.e., pain relief, restore motion, limit
progression of radiographic changes). A recent study using the Delphi method determined
with 90% agreement that MRCT should be defined as either axial or coronal tendon
retraction to the glenoid rim and/or a tear with ≥67% of the tuberosity exposed in the sagittal
plane.61

The major limitation of this review is the lack of high-quality evidence available on the
treatment of irreparable MRCT. There were only three comparative studies, all of which
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compared débridement to partial repair, while the majority were case series (72%; 31/43).
Without better quality studies, it is difficult to make evidence-based recommendations for
clinical care. Second, we observed an inconsistent reporting of PROs, pain scores, range of
motion, strength, failure rates, revision surgery, and complication rates across all treatment
strategies. There were twelve different PROs used, with CMS (27 studies) and ASES (17
studies) scores most commonly reported. Similarly, six of 43 studies (14%) reported motion
data in four planes (forward flexion, internal rotation, external rotation, and abduction)
before and after surgery. Third, we were unable to perform a comprehensive quantitative
synthesis due to inconsistent outcome instrument selection. Standardized data collection and
reporting are keys to data transparency, and instituting a minimum data set requirement
could improve the quality of future studies. Fourth, the results of our quantitative analysis
are highly dependent on MCID values selected from prior studies. While separate MCIDs
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were chosen for operative and nonoperative treatments, the operative MCID available was
calculated using data from patients undergoing complete rotator cuff repair only. It is highly
likely that each treatment strategy will have a unique MCID threshold if separately
determined by anchor-based methodology.

Further limitations of our quantitative analysis are those inherent to anchor-based MCID
methods. First, MCID values are highly impacted by the patient population being studied,
with less healthy cohorts having lower baseline scores and more opportunity for score

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 Kovacevic et al. Page 13

improvement. This is particularly relevant when considering the functional impairment seen
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in patients with irreparable MRCT. Second, anchor-based approaches are subject to recall
bias. Results of the global rating of change questionnaire administered to patients at final
follow-up are likely influenced by recent developments in each patient’s health status and
therefore may reflect a single time-point snapshot of health status rather than magnitude of
change from baseline. Third, the timing of MCID determination influences the magnitude of
recall bias, with a longer follow-up duration introducing more susceptibility to bias. Lastly,
many studies determining MCID are limited by small subject numbers and wide confidence
intervals. Gagnier et al evaluated 222 patients with full-thickness rotator cuff tears, but only
22 patients had a minimal clinical improvement. This small subset was further evaluated to
determine the ASES MCID for surgical treatment, which was found to have a fragile
confidence interval of −7.57 to 85.57.20 Robust MCID values for each treatment strategy
matched for age, gender, and racial differences need to be determined through studies with
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larger sample sizes utilizing a combination of anchor- and distribution-based approaches.

Conclusions
Due to the paucity of high-quality clinical studies available for guiding management of
irreparable MRCT, it is currently not possible to recommend for or against any specific
treatment strategy. Rather, clinical experience, patient factors, patient expectations, and
rotator cuff tear characteristics should guide clinical decision-making. Physical therapy
compared to surgical treatments may have inferior outcomes. Standardized data collection,
reporting, and terminology are key to enhancing the quality of evidence-based medicine.
There is a need to unequivocally define the MCID for various MRCT treatment strategies
that will lead to improved interpretation of outcomes. Significant opportunities exist for
multi-center research groups to embark on high-quality comparative clinical studies to
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improve our understanding and management of MRCT.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Sources of Support / Funding:

Research reported in this publication was partially supported by the National Institute of Arthritis and
Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number K08AR072092
(D.K.). The content is solely the responsibility of the authors and does not necessarily represent official views of the
National Institutes of Health.

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56. Pappou IP, Schmidt CC, Jarrett CD, Steen BM, Frankle MA. AAOS appropriate use criteria:
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 Kovacevic et al. Page 18
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Figure 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow
diagram representing search and screen process of studies reporting on nonoperative and
operative treatment of irreparable massive rotator cuff tears. CENTRAL, Cochrane Central
Register of Controlled Trials; PT, Physical therapy; D, Débridement; PR, Partial repair; GI,
Author Manuscript

Graft interposition; TT, Tendon transfer; SCR, Superior capsular reconstruction; BA,
Balloon arthroplasty; RSA, Reverse shoulder arthroplasty; FU, Follow-up; MRCT, Massive
rotator cuff tear; RA, Rheumatoid arthritis.
Author Manuscript

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 Kovacevic et al. Page 19
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Figure 2.
Author Manuscript

Change in CMS for each treatment strategy compared to MCID threshold for either
nonoperative or operative intervention. Sample size is directly proportional to the size of the
circle (or triangle for arthroscopic tendon transfer). Influenced by the sample size, the red
“x” denotes the weighted average change in CMS for all treatment strategies except tendon
transfer. The “T” denotes the weighted average change in CMS for all tendon transfers. The
blue “a” represents the weighted average change in CMS for arthroscopic tendon transfer.
The green “o” represents the weighted average change in CMS for open tendon transfer. PT,
Physical therapy; D, Débridement; PR, Partial repair; GI, Graft interposition; TTA,
Arthroscopic tendon transfer; TTO, Open tendon transfer; SCR-HDA, Superior capsular
reconstruction—human dermal allograft; SCR-TFL, Superior capsular reconstruction—
tensor fascia lata autograft; BA, Balloon arthroplasty; RSA, Reverse shoulder arthroplasty;
MCID, Minimum clinically important difference.
Author Manuscript

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 Kovacevic et al. Page 20
Author Manuscript
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Figure 3.
Author Manuscript

Change in ASES score for each treatment strategy compared to MCID threshold for either
nonoperative or operative intervention. Sample size is directly proportional to the size of the
circle. The red “x” denotes the weighted average change in CMS for all treatment strategies,
which is influenced by sample size. PT, Physical therapy; D, Débridement; PR, Partial
repair; GI, Graft interposition; TTA, Arthroscopic tendon transfer; TTO, Open tendon
transfer; SCR-HDA, Superior capsular reconstruction—human dermal allograft; SCR-TFL,
Superior capsular reconstruction—tensor fascia lata autograft; BA, Balloon arthroplasty;
RSA, Reverse shoulder arthroplasty; MCID, Minimum clinically important difference.
Author Manuscript

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 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Table I

Study design and patient demographics

Treatment No. Papers LOE MINORS Score N (M/F) Age (y) Follow-up (months)
Physical Therapy 3 III (1); IV (2) 89.6% 94 (59/35) 68.3 (54–89) 32 (24–65)
Kovacevic et al.

Debridement 7 III (1); IV (6) 88.8% 256 (160/96) 65.7 (33–82) 48 (24–120)

Partial Repair 7 III (1); IV (6) 89.0% 226 (122/93)* 62.7 (33–81) 45.2 (24–90)

Graft Interposition 3 IV (3) 85.4% 67 (39/28) 68.2 (51–85) 34.3 (24–86)

Tendon Transfer 11 III (1); IV (10) 88.1% 506 (319/187) 59.2 (53–64.2) 57.7 (24–147)
Arthroscopic-Assisted 4 IV (4) 89.1% 144 (68/76) 61.7 (59–64.2) 70.2 (24–147)
Open 7 III (1); IV (6) 87.5% 362 (251/111) 57.7 (53–61) 35.8 (24–77)

SCR 4 IV (4) 81.3% 179 (12/11)* 64.7 (43–82) 44.5 (24–60+)

HDA 1 IV 87.5% 38 59.4 24

TFL 3 IV (3) 79.2% 141 (12/11)* 66.4 (65.1–68.0) 51.4 (24–110)

Balloon 2 IV (2) 93.8% 25 68.8 (54–85) 42 (24–60)

RSA 6 IV (6) 85.4% 247 (48/74)* 67.5 (34–86) 39.4 (24–118)

MINORS score represented as weighted average for each treatment strategy.

N=Total number of patients per treatment group reported; M=male; F=female.

Age and follow-up reported as mean (range) in years and months, respectively.

LOE Level of evidence

SCR Superior Capsular Reconstruction

RSA Reverse Shoulder Arthroplasty

AA Arthroscopic-Assisted

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HDA Human Dermal Allograft

TFL Tensor Fascia Lata Autograft

*
Incomplete reporting of number of patients based on gender
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Table II

Massive rotator cuff tear criteria

Treatment No. Papers Tear Size Tendon No. Tendon Retraction (Patte) Goutallier Fatty Infiltration (SITS) AHI (mm) or Hamada Classification
Physical Therapy 3 NR ≥2 (3) Stage 3(1) Grade 4(1) AHI Preop 8.2 (1), Postop 5.6 (1)
Kovacevic et al.

Grade 3–4 (2) Hamada Stage 1–2 (1)

Debridement 7 ≥5cm (5) ≥2 (5) Stage 2 (1) Grade 3–4 (1) 19 (1) AHI Preop <5 (1), Preop 5.1 (1)
Stage 3 (1)
4–5cm (1)
“Unable to Reattach” (1)
Partial Repair 7 ≥5cm (3) ≥2 (5) Stage 2(1) Grade 3–4 (1) AHI Preop <7 (1)
≥3 (2) Grade 1.9 (1.5–2.2) (2) AHI Preop 8.8 (1)
Hamada Stage 1 (1)
Hamada Stage 1–2 (1)
Graft Interposition 3 ≥5cm (2) ≥2 (2) NR Grade 3.75 (1) AHI Preop 7.7 (1), Postop 8.6 (1)
≥4cm (1)
Tendon Transfer 11 ≥5cm (5) ≥2 (7) Stage 2–3 (2) Grade 3–4 (11) AHI Preop 4.2 (2.3–5.9) (4), Postop 5.1 (4.7–5.7) (3)
Stage 3 (5) AHI Preop <5 (1)
“Excessive” (2) AHI Preop <7 (1)
AHI decreased by 1.5 (1)
Hamada Preop 1.7 (0–2) (2), Postop 2.2 (1–5) (2)
Hamada Preop Grade 1–2 (1)
Hamada Postop Grade 2–3 (1)
AA 4 ≥5cm (1) ≥2 (2) Stage 2–3 (2) Grade 3–4 (4) AHI Preop 3.13 (1), Postop 5.7 (1)
Stage 3(1) AHI Preop <5 (1)
Hamada Preop Grade 1–3 (1)
Open 7 ≥5cm (4) ≥2 (5) Stage 3 (4) Grade 3–4 (7) AHI Preop 4.6 (2.3–5.9) (3), Postop 4.8 (4.7–4.9) (2)
“Excessive” (2) AHI Preop <7 (1)
AHI decreased by 1.5 (1)
Hamada Preop 1.7 (0–2) (3), Postop 2.2 (1–5) (3)
Hamada Preop Grade 1–2 (1)
Hamada Postop Grade 2–3 (1)
SCR 4 ≥5cm (1) ≥2 (3) ≥5cm (1) Grade 3–4 (1) AHI Preop 4.9 (4.6–7.3) (4), Postop 9.1 (8.1–9.9) (4)
Grade 2.6 (2.0–3.7) (3)

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HDA 1 ≥5cm - ≥5cm Grade 3–4 AHI Preop 7.3, Postop 9.9
TFL 3 - >2 (3) - Grade 2.6 (2.0–3.7) (3) AHI Preop 4.1 (3.4–4.6) (3), Postop 8.8 (8.1–9.7) (3)
Balloon 2 ≥5cm (2) ≥2 (1) NR Grade 3–4 (1) AHI Preop 6.7 (1), Postop 8.0 (1)
“Unsuitable for Repair” (1)
RSA 6 ≥5cm (1) ≥2 (6) Stage 2(1) Grade 3–4 (3) AHI Preop <6 (1)
Stage 3(1) AHI Preop <7 (1)
Hamada Preop <4 (4)

SCR Superior Capsular Reconstruction

RSA Reverse Shoulder Arthroplasty

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SITS Supraspinatus, Infraspinatus, Teres Minor, Subscapularis

AHI Acromiohumeral Interval

AA Arthroscopic-Assisted

HDA Human Dermal Allograft

TFL Tensor Fascia Lata Autograft

Kovacevic et al.

NR Not Recorded

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Table III

Clinical outcomes, failure, and reoperation rates

Treatment No. VAS VAS ROM Initial ROM Final PRO Initial PRO Final Failure / Survival Revision/
Papers Initial Final Reoperation
Kovacevic et al.

Physical 3 6.7 (1) 3.7 (1) FF 97 (76–115) (3) FF 133 (129–136) (2) CMS 43 (1) CMS 62.4 (56–69) (2) 12/30 (40%) Success 9/30 (30%)
Therapy Abd 118 (1) Abd 136 (1) ASES 39 (1) ASES 62 (1) 9/30 (30%) Failed PT Surgery
ER 44 (1) ER 39 (1) SSV 45 (1) SSV 64 (60–68) (2)
IR 76 (1) IR 66 (1)
Debridement 7 7.6 (7– 3.1 (2– FF 106 (96–115) FF 137 (118–155) (2) CMS 42.7 (31–72.2) CMS 63.9 (42.3–89) (6) NR 1/23 (4.2%) (1)
7.9) (3) 4.3) (3) (2) Abd 118 (85–150) (2) (5) ASES 62.4 (55–69.8)
Abd 74 (57–90) (2) ER 42 (1) ASES 25.5 (24–27) (2)
ER 20 (1) IR T12 (1) (2) UCLA 21 (1)
Scaption 111 (1) UCLA 11.5 (1) SSV 73.2 (1)
SSV 35.2 (1) DASH 41.3 (1)
qDASH 63.4 (1) qDASH 24.1 (1)
SPADI 38.4 (1)
Partial Repair 7 6.3 (5.6– 1.8 (1.5– FF 126 (95–168) FF 160 (154–172) (4) CMS 39.6 (36.6– CMS 71.5 (67.5–76.3) 16/111 (14.4%) 16/165 (9.7%)
7) (4) 2) (4) (3) Abd 150 (120–169) (3) 43.1) (3) (3) unsatisfactory (4)
Abd 90 (1) ER 39 (27–54) (5) ASES 44.5 (41–46.6) ASES 79.3 (78.6–80.1) outcome (2)
ER 34 (20–44) (3) IR T9 (2) (3) (3) 25/55 (45.4%) re-
IR 84% (1) SSV 34.7 (1) SSV 74.0 (1) rupture (2)
SST 5.6 (1) SST 9.1 (1) qDASH
qDASH 52.5 (1) 55.8 (1)
Oxford 17.8 (1) Oxford 37.1 (1)
SANE 96 (1)
SPADI 29.5 (1)
Graft 3 6.9 (6.8– 1.9 (1– FF 67 (65–69) (2) FF 128 (120–136) (2) CMS 36.2 (25.7– CMS 78.3 (72.1–84.5) 1/5 (20%) re-rupture 1/5 (20%) (1)
Interposition 7) (2) 2.8) (2) Abd 64 (60–68) (2) Abd 127 (120–134) (2) 46.7) (2) (2) (1)
ER 36 (32–39) (2) ER 48 (38–57) (2) ASES 29 (1) ASES 74 (1)
IR 3.8/10 (3.4–4.2) IR 8.0/10 (7.5–8.4) (2) UCLA 10.2 (1) UCLA 29.4 (1)
(2) SST 2.4 (1) SST 7.8 (1)
Tendon 11 7.7 (7.5– 2.6 (2.4– FF 95 (58–134) FF 137 (120–157) (11) CMS 35.9 (21–47.3) CMS 63.5 (58–69.5) 29/184 (15.8%) LD 24/356 (6.7%)
Transfer 7.8) (2) 2.8) (3) (11) Abd 123 (90– 154) (10) (10) re-rupture (4) (6)
Abd 84 (40–112) (11) ASES 39.2 (30.1– ASES 71.7 (66.7–73.2) 8/122 (6.6%) SSC
(11) ER 33 (23–50) (11) 48.3) (2) (3) insufficiency (2)
ER 18 (12–29) (11) IR L3 (1) UCLA 6.5 (1) UCLA 27.5 (1) 2/122 (1.6%) deltoid

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IR L3 (1) SSV 31.3 (19.3–54) SSV 66.8 (48.9–78) (5) avulsion (2)
(5) SST 7 (1) 2/55 (3.6%) stiffness
DASH 52 (1) DASH 18 (1) (1)
6/55 (10.9%) LD
insufficiency (1)
AA 4 7.5±1.0 2.7 (2.5– FF 97 (58–134) (4) FF 140 (130–157) (4) CMS 30.1 (21–37) (4) CMS 60.5 (58–65.4) (4) 28/129 (21.7%) LD 10/115 (8.7%)
(1) 2.8) (2) Abd 64 (51–80) (4) Abd 115 (93–130) (4) UCLA 6.5 (1) ASES 66.7 (1) re-rupture (3) (2)
ER 19 (13–29) (4) ER 33 (28–42) (4) SSV 22.7 (19.3–26) UCLA 27.5 (1)
(2) SSV 60.0 (48.9–71.1)
(2) SST 7 (1)
Open 7 7.8±1.5 2.4±1.9 FF 93 (70–118) (7) FF 136 (120–151) (7) CMS 39.8 (32–47.3) CMS 65.4 (60–69.5) (6) 1/55 (1.8%) LD re- 14/241 (5.8%)
(1) (1) Abd 87 (40–112) Abd 128 (90–154) (7) (6) ASES 71.7 (70.2–73.2) rupture(1) (4)
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Treatment No. VAS VAS ROM Initial ROM Final PRO Initial PRO Final Failure / Survival Revision/
Papers Initial Final Reoperation
(7) ER 33 (23–50) (7) ASES 39.2 (30.1– (2) 8/122 (6.6%) SSC
ER 19 (14–23) (7) IR L3 (1) 48.3) (2) SSV 71.4 (60–78) (3) insufficiency (2)
IR L3 (1) SSV 37.0 (28–54) (3) DASH 18 (1) 2/122 (1.6%) deltoid
DASH 52 (1) avulsion (2)
2/55 (3.6%) stiffness
(1)
Kovacevic et al.

6/55 (10.9%) LD
insufficiency (1)
SCR 4 5.6 (4.3– 1.1 (0.9– FF 97 (84–123) (4) FF 154 (148–162) (4) ASES 34.3 (23.5– ASES 91.2 (85.3–94.3) 11/180 (6.1%) graft 6/126 (4.8%)
6.9) 1.2) Abd 106 (1) Abd 160 (1) 49.5) (4) (4) failure (4) (2)
(2) (2) ER 27 (26–27) (3) ER 41 (40–43) (3) UCLA 9.9 (1) UCLA 32.4 (1) 3/24 (12.5%) retear
IR L3 (1) IR L1 (1) JOA 50.9 (48.3–53.0) JOA 92.4 (91.4–93.2) of ISP (1)
(3) (3)
HDA 1 FF 123 FF 162 3/38 (7.9%) graft
4.3 1.2 ASES 49.5 ASES 85.3 1/38 (2.6%)
Abd 106 Abd 160 failure
TFL 3 6.9 (1) 0.9 (1) FF 89 (84–123) (3) FF 152 (148–156) (3) ASES 29.2 (23.5–35) ASES 93.2 (92.3–94.3) 8/142 (5.6%) graft 5/88 (5.7%)
ER 27 (26–27) (3) ER 41.4 (40–43) (3) (3) (3) failure (3)
IR L3 (1) IR L1 (1) UCLA 9.9 (1) UCLA 32.4 (1) 3/24 (12.5%) retear
JOA 50.9 (48.3–52) JOA 92.4 (91.4–93.2) of ISP (1)
(3) (3)
Balloon 2 6.6 (1) 2.8 (1) FF 71 (1) FF 129 (1) CMS 38.0 (34.2– CMS 67.1 (66.8–67.4) NR 1/20 (5%) (1)
Abd 65 (1) Abd 125 (1) 41.8) (2) (2)
SAS 6.7 (1) SAS 8.0 (1)
RSA 6 5.9 (5.5– 2.0 (1.9– FF 69 (53–94) (3) FF 133 (122–143) (3) CMS 26.5 (23–27.8 CMS 59.4 (55–63.4) (3) 16/159 (10.1%) 19/231 (8.2%)
6.3) (2) 2.0) (2) ER 29 (21–40) (3) ER 40.2 (29–51) (3) (3) 74.7 (74–75.4) (2) prosthesis failure (3) (4)
ASES 37.5 (33.3– SST 7.1 (6.5–7.6) (2) 14/231 (6.1%)
41.6) (2) fracture (4)
SST 1.0 (1.6–2.2) (2) 4/206 (1.9%)
instability (3)

AA Arthroscopic-Assisted

SCR Superior Capsular Reconstruction

HDA Human Dermal Allograft

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TFL Tensor Fascia Lata Autograft

RSA Reverse Shoulder Arthroplasty

VAS Visual Analogue Scale

PRO Patient-Reported Outcome

CMS Constant-Murley Score

ASES American Shoulder and Elbow Surgeons

UCLA University of California Los Angeles

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SSV Subjective Shoulder Value

SST Simple Shoulder Test

SANE Single Assessment Numeric Evaluation

SPADI Shoulder Pain and Disability Index

SAS Shoulder Activity Scale

Kovacevic et al.

DASH Disabilities of Arm, Shoulder, and Hand

qDASH Quick Disabilities of Arm, Shoulder, and Hand

JOA Orthopedic Association

ROM Range of Motion

FF Forward Flexion

Abd Abduction

ER External Rotation

IR Internal Rotation

NR Not Reported

PT Physical Therapy

LD Latissimus Dorsi

SSC Subscapularis

ISP Infraspinatus

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Table IV.

Superior capsular reconstruction graft failure rates

Author (Year) Graft Type N n with Post-Op MRI Timing of Imaging (years) Graft Failure Rate
Hirihara (2017) HDA 8 5 2 1/5 (20%)
Kovacevic et al.

Denard (2018) HDA 59 20 1 11/20 (55%)

Pennington (2018) HDA 88 4 2 3/4 (75%)
Burkhart (2019) HDA 10 10 1 3/10 (30%)

Woodmass (2019) HDA 34 Not Reported Not Reported 22/34 (65%)*

Burkhart (2020) HDA 41 26 1 4/26 (15%)
Lacheta (2020) HDA 22 21 0.2 9/21 (43%)

HDA Total 262 86 32/86 (37%)

Mihata (2013) TFL 24 24 3 4/24 (17%)
De Campos Azevedo (2018) TFL 22 22 0.5 2/22 (9%)
Lee (2018) TFL 36 36 1 13/36 (36%)
Lim (2018) TFL 31 31 1 9/31 (29%)
Mihata (2018) TFL 88 88 5 4/88 (5%)
Mihata (2019) TFL 30 30 2.5 3/30 (10%)

TFL Total 231 231 35/231 (15%)

SCR: Superior Capsule Reconstruction

HDA: Human Dermal Allograft

TFL: Tensor Fascia Lata Autograft

N=Total number of patients

*

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Graft failure rate determined by clinical examination rather than advanced imaging
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