JSES - 2026-05-23 - Journal Article; Review
Subscapularis Repair in Reverse Shoulder Arthroplasty: A Systematic Review and Meta-Analysis with a Sub-analysis by Implant Lateralization and Repair Techniques.
Daher M, Boufadel P, Fiandeiro M, Parmar T, Kane L, Satalich JR, Klifto CS, Abboud JA
Topics
Key Takeaway
Subscapularis repair reduces instability risk by 74% overall (OR=0.26) in rTSA, but this benefit is largely confined to medialized implants (OR=0.06), with no IR improvement advantage demonstrated in lateralized designs.
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Summary
This meta-analysis compared outcomes of subscapularis repair versus non-repair in rTSA across 18 cohorts (n=2,982), with sub-analyses by implant lateralization and repair technique. Repair reduced instability (OR=0.26, p<0.001) and improved pain and IR overall, but in the lateralized subgroup, IR improvement was equivalent between repair and non-repair groups. Trans-osseous repair yielded superior PROMs (ASES MD=5.22, p<0.001), while tendon-to-tendon repair produced better IR improvement (SMD=0.52, p<0.001).
Key Limitation
The underlying studies are predominantly retrospective cohorts with inconsistent definitions of subscapularis repair integrity and healing, making it impossible to determine whether functional repair—rather than attempted repair—drives the observed outcome differences.
Original Abstract
BACKGROUND
The debate about repairing the subscapularis in the setting of reverse shoulder arthroplasty (rTSA) is ongoing. Some reported benefits of the subscapularis repair are a reduced rate of instability, more internal rotation (IR) improvement, and better functional outcomes. However, with the popularization of lateralized implants, these benefits are becoming more limited. Therefore, this meta-analysis compared outcomes of rTSA depending on whether or not the subscapularis was repaired with a sub-analysis by rTSA design (lateralized vs medialized) and subscapularis repair technique.
METHODS
PubMed, Cochrane, and Google Scholar were queried through January 2026. Inclusion criteria consisted of studies comparing the outcomes of rTSA based on whether the subscapularis was repaired or not. Extracted data included adverse events, improvement in patient reported outcome measures (PROMs), and improvement in range of motion (ROM). A sub-analysis was done by whether or not the rTSA was lateralized or medialized, and by subscapularis repair techniques (trans-osseous (TO), tendon to tendon (TT), or both).
RESULTS
Nineteen articles based on 18 cohorts met the inclusion criteria with 1698 patients in the subscapularis repair group (R) and 1284 in the non-repair group (NR). Patients in the R group had a lower rate of instability (Odds-Ratio=0.26, p<.001), better pain improvement (Mean difference=0.47, p=0.01), and better IR improvement (Standardized mean difference=0.17, p=0.04). When sub-analyzing by rTSA design the R group in the medialized rTSA subgroup had a lower rate of complications (Odds-Ratio=0.10, p<.001) and instability (Odds-Ratio=0.06, p<.001), as well as better ASES improvement (Mean difference=7.01, p<.001) compared to the NR group. The R group had better pain improvement in both the medialized and lateralized subgroups. Of note, there was no difference in IR improvement between the two groups in the lateralized subgroup. When sub-analyzing by subscapularis repair technique, the R group had a lower rate of complications and instability (Odds-Ratio=0.06, p<.001, both) in the TT+TO subgroup, and better ASES (Mean difference=5.22, p<.001), and pain improvement (Mean difference=0.62, p<.001) in the TO subgroup, and better IR improvement (Standardized mean difference=0.52, p<.001) in the TT subgroup.
CONCLUSION
While subscapularis repair is shown to be beneficial in medialized rTSA implants, minimal benefits are reported in lateralized rTSA implants. However, repair techniques were shown to affect outcomes with TO repair resulting in better PROMs improvement, and TT in better IR improvement. Future studies are needed to assess different tendon repair techniques in the setting of lateralized rTSA implants.