Rotator Cuff Tears Part II: Subscapularis Repair, Augmentation, and Tendon Transfer—An International Expert Consensus Statement

Abstract

PURPOSE: To establish updated international consensus statements on subscapularis repair, graft/patch augmentation and superior capsular reconstruction, and tendon transfers for rotator cuff tears, reflecting new evidence, evolving techniques, and ongoing areas of controversy. METHODS: A consensus process on the treatment of rotator cuff tears was conducted, with 97 shoulder/sports surgeons from 15 countries participating. There were 9 specific subtopics: (1) Diagnosis, (2) Nonoperative Management, (3) Repair of Posterosuperior Tears, (4) Subscapularis Repair, (5) Graft/Patch Augmentation and Superior Capsular Reconstruction, (6) Tendon Transfers, (7) Reverse Total Shoulder Arthroplasty, (8) Revision Surgery, and (9) Rehabilitation, Return to Play, and Follow-up. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Of the 48 consensus statements, 1 achieved unanimous consensus, 21 achieved strong consensus, 10 achieved consensus, and 16 did not achieve any level of consensus. CONCLUSIONS: All statements regarding subscapularis repair reached a strong consensus, underscoring broad agreement on surgical approach, number of anchors, intraoperative assessment strategies, and key principles such as tension-free repair, adequate mobilization, and protection of neurovascular structures. In contrast, augmentation and superior capsular reconstruction showed substantial variability, with most statements failing to reach consensus, with no agreement regarding the optimal graft type, augmentation configuration, or ideal indications for balloons, tuberoplasty, or acromial patching. For tendon transfer, a strong consensus was achieved across core indications, contraindications, and technical principles. Experts agreed that tendon transfer is appropriate for younger, active patients with irreparable tears, preserved passive motion, minimal arthritis, and intact deltoid function. Lower trapezius transfer was preferred over latissimus dorsi for posterosuperior tears, whereas pectoralis major transfer for irreparable subscapularis tears did not reach consensus. LEVEL OF EVIDENCE: Level V, expert opinion.