Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for Massive, Irreparable Rotator Cuff Tears Without Arthritis: A Systematic Review and Meta-Analysis

Massive, irreparable rotator cuff tears with glenohumeral deficiency present a significant surgical challenge. While hemiarthroplasty was historically the treatment of choice, reverse total shoulder arthroplasty (rTSA) has gained popularity due to its biomechanical ability to restore active elevation. However, high-quality comparative evidence remains scarce. The purpose of this systematic review and meta-analysis was to compare the clinical outcomes and revision rates of rTSA versus hemiarthroplasty for massive rotator cuff deficiency. A systematic literature search was conducted to identify comparative studies evaluating rTSA versus hemiarthroplasty for cuff tear arthropathy or massive cuff tears without significant arthritis. Methodological quality was assessed using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool for non-randomized studies. Data were pooled using a random-effects model. Functional outcomes were analysed using standardized mean differences (SMD), and revision rates were analysed using odds ratios (OR). The overall certainty of evidence was graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Two retrospective cohort studies meeting the inclusion criteria were identified, comprising 158 shoulders (87 rTSA, 71 hemiarthroplasty). Risk of bias ranged from moderate to serious due to confounding factors. rTSA demonstrated superior functional outcomes compared to hemiarthroplasty (SMD=0.64; 95% CI: 0.32-0.97; P<.001). Patients undergoing rTSA achieved significantly greater active forward elevation (113° vs. 58°). There was no statistically significant difference in revision rates between the two procedures (OR=0.58; 95% CI: 0.21-1.57; P=.28), though the trend favoured rTSA. It was found that rTSA provides superior functional recovery compared to hemiarthroplasty for patients with massive rotator cuff deficiency, with a comparable safety profile at short- to-mid-term follow-up. Despite the "very low" certainty of evidence due to the observational nature of available studies, the consistent functional benefits support rTSA as the preferred surgical intervention for this condition.