Rotator cuff tears represent one of the most prevalent musculoskeletal conditions worldwide, with massive irreparable tears comprising approximately 10-40% of all rotator cuff pathology [1]. The global burden of rotator cuff disease continues to escalate with demographic aging, with prevalence rates exceeding 50% in individuals over 70 years of age [2]. In India, rotator cuff tears affect 15-25% of the general population, with significantly higher rates observed among manual laborers, agricultural workers, and individuals engaged in repetitive overhead activities [2].

The definition of an "irreparable" rotator cuff tear lacks universal consensus among orthopedic surgeons, though generally encompasses massive tears involving two or more tendons with significant retraction beyond the glenoid rim, advanced fatty infiltration (Goutallier grade 3-4), and poor tissue quality that precludes direct anatomical repair [3]. These tears are characterized by superior humeral head migration, loss of acromiohumeral distance, and often present with pseudoparalysis of shoulder elevation [4]. The pathophysiology involves progressive muscle atrophy, fatty infiltration, and biomechanical alterations that fundamentally compromise the force-couple mechanism essential for normal shoulder function [3].

Traditional surgical approaches for irreparable rotator cuff tears have historically included arthroscopic debridement, partial repair techniques, and margin convergence procedures [5]. However, these interventions often fail to restore normal shoulder biomechanics and may result in persistent pain, functional limitation, and progressive degenerative changes [5]. The recognition that irreparable tears require fundamentally different treatment paradigms compared to reparable tears has driven the development of alternative surgical strategies over the past two decades [6].

Contemporary surgical management options for irreparable rotator cuff tears encompass a broad spectrum of procedures, including superior capsular reconstruction (SCR), tendon transfers, reverse total shoulder arthroplasty (RTSA), and biological augmentation techniques [6]. Each approach addresses different aspects of the complex pathophysiology and is associated with specific indications, contraindications, and expected outcomes [6]. The selection of optimal treatment requires comprehensive evaluation of patient age, functional demands, tear characteristics, remaining muscle function, presence of glenohumeral arthritis, and patient expectations [9].

Recent advances in understanding rotator cuff biomechanics have significantly influenced surgical decision-making and technique development [7]. The concept of the superior capsule as a critical stabilizer preventing superior humeral head translation has revolutionized treatment approaches for younger patients with preserved joint space [7]. Similarly, recognition of the importance of the rotator cable and its role in load distribution has influenced the development of new reconstructive techniques [1]. The emergence of arthroscopic techniques for traditionally open procedures has reduced surgical morbidity while maintaining clinical efficacy [8].

The evolution of patient selection criteria represents another critical advancement in the field [9]. Modern classification systems incorporate magnetic resonance imaging findings, including the extent of fatty infiltration, tendon retraction patterns, and muscle quality assessment [9]. The Hamada radiographic classification system remains widely utilized for grading acromiohumeral distance and presence of arthritis, directly influencing surgical planning [10]. Understanding these classification systems and their prognostic implications is essential for optimizing treatment outcomes [10].

The purpose of this review is to examine the current evidence regarding surgical management options for irreparable rotator cuff tears, analyze the outcomes of different techniques, and provide guidance for optimal patient selection [6]. This analysis focuses on high-quality evidence published within the last decade to present the most current understanding of this challenging clinical problem [6].

METHODOLOGY OF THE REVIEW

A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane databases for articles published between January 2014 and December 2024. Search terms included "irreparable rotator cuff tear," "massive rotator cuff tear," "superior capsular reconstruction," "tendon transfer," "reverse total shoulder arthroplasty," and "biological augmentation." Inclusion criteria encompassed systematic reviews, meta-analyses, randomized controlled trials, and high-quality cohort studies with minimum 2-year follow-up. Articles were included if they reported clinical outcomes, complications, or comparative effectiveness of surgical interventions for irreparable rotator cuff tears. Exclusion criteria included case reports with fewer than 20 patients, technical notes, non-English publications, and studies focusing primarily on reparable tears. A total of 147 articles were initially identified, with 45 studies meeting inclusion criteria for detailed analysis and synthesis.

Classification Systems and Biomechanical Considerations in Irreparable Rotator Cuff Tears

The classification of irreparable rotator cuff tears has evolved to incorporate both anatomical and functional parameters that directly influence surgical decision-making algorithms [10]. The Hamada classification system remains the most widely utilized radiographic assessment tool, correlating acromiohumeral distance with functional outcomes and treatment selection [10]. This system grades tears from 1 (normal acromiohumeral distance >7mm) to 5 (glenohumeral arthritis with superior humeral head migration), with grades 4-5 typically indicating advanced disease requiring arthroplasty consideration [10].

Contemporary classification systems have increasingly incorporated magnetic resonance imaging findings, particularly the extent of fatty infiltration as quantified by the Goutallier classification system [9]. This system grades fatty infiltration from 0 (normal muscle) to 4 (more fat than muscle), with grades 3-4 generally indicating irreversible changes and poor prognosis for healing after repair attempts [9]. The Thomazeau retraction index, measuring tendon retraction relative to glenoid anatomy, provides additional prognostic information regarding repairability and surgical planning [9].

Recent studies have demonstrated that tears with retraction beyond the medial border of the glenoid and Goutallier grade 3-4 fatty infiltration have consistently poor outcomes with attempted direct repair and should be classified as irreparable [9]. The critical shoulder angle, measured on anteroposterior radiographs, has emerged as an additional prognostic factor, with angles greater than 35 degrees associated with increased risk of repair failure and progression to arthropathy [9].

The biomechanical implications of massive rotator cuff tears extend far beyond simple loss of specific muscle function [11]. The disruption of the force-couple mechanism between the rotator cuff and deltoid muscle results in superior migration of the humeral head, loss of glenohumeral stability, and altered kinematics affecting the entire shoulder girdle [11]. The intact subscapularis and remaining posterior rotator cuff muscles become critically important for maintaining glenohumeral stability and compensatory function [11].

Superior capsular reconstruction represents a paradigm shift based on enhanced understanding of the biomechanical role of the superior capsule in preventing superior humeral head translation [7]. Cadaveric biomechanical studies have demonstrated that reconstruction of the superior capsule can restore near-normal glenohumeral contact pressures, improve subacromial space maintenance, and enhance abduction biomechanics in the setting of massive rotator cuff deficiency [7]. The selection of appropriate graft material, including autograft fascia lata, dermal allograft, and synthetic materials, continues to evolve based on biomechanical testing and clinical outcome studies [12].

Superior Capsular Reconstruction: Current Evidence and Clinical Outcomes

Superior capsular reconstruction has emerged as a revolutionary technique for treating irreparable rotator cuff tears in younger patients with preserved glenohumeral joint space and adequate bone stock [13]. The procedure involves reconstruction of the superior joint capsule using autograft or allograft tissue, spanning from the superior glenoid to the greater tuberosity insertion site [13]. Initial clinical studies by Mihata and colleagues demonstrated significant improvements in shoulder elevation and pain scores in patients with pseudoparalytic shoulders, establishing SCR as a viable alternative to arthroplasty in appropriate candidates [14].

Patient selection criteria for SCR have been refined through clinical experience and outcome studies, with optimal candidates typically being younger than 65-70 years, having absence of glenohumeral arthritis (Hamada grade 1-3), intact or repairable subscapularis function, and adequate bone stock for secure graft fixation [15]. Contraindications include advanced fatty infiltration of the infraspinatus (Goutallier grade 4), deltoid dysfunction, active infection, and previous failed rotator cuff surgery with compromised tissue quality [15]. The presence of pseudoparalysis is not an absolute contraindication but may indicate more advanced disease requiring careful evaluation [4].

The surgical technique requires meticulous attention to graft preparation, tensioning, and fixation to optimize clinical outcomes [13]. Arthroscopic SCR can be performed using various graft materials, with autograft fascia lata providing biological integration advantages but requiring additional surgical time and donor site morbidity [16]. Dermal allograft offers convenience and eliminates donor site complications but may have different mechanical properties and integration characteristics [16]. Recent technical modifications include partial SCR for smaller defects and augmentation with biceps tendon autograft for enhanced biological healing [17].

Clinical outcomes following SCR have been encouraging across multiple studies and systematic reviews [18]. A comprehensive systematic review analyzing outcomes in patients with irreparable rotator cuff tears demonstrated mean improvements in forward elevation of 65 degrees and American Shoulder and Elbow Surgeons scores increasing by 35 points at minimum 2-year follow-up [18]. Patient satisfaction rates consistently exceed 85%, with significant improvements in pain scores and quality of life measures [18]. However, failure rates ranging from 15-30% have been reported, with graft failure typically occurring within the first postoperative year [18].

Comparative studies between SCR and alternative treatments have provided valuable insights into optimal patient selection and expected outcomes [19]. A recent propensity score-matched study comparing arthroscopic SCR versus primary rotator cuff repair in massive tears demonstrated superior clinical outcomes, including improved postoperative range of motion, lower pain scores, and higher healing rates with SCR [19]. Similarly, systematic reviews comparing SCR to latissimus dorsi tendon transfer have suggested better functional outcomes and lower infection rates with SCR for appropriate candidates [20].

The choice of graft material for SCR remains an area of active investigation and clinical debate [12]. Autograft fascia lata provides the theoretical advantage of biological integration and mechanical strength but requires additional operative time and creates donor site morbidity [16]. Clinical studies comparing autograft and allograft materials have shown similar functional improvements but potentially different failure patterns and healing characteristics [21]. A recent study evaluating SCR using tensor fascia lata allograft demonstrated reliable clinical outcomes despite early infection risks, particularly when multiple graft layers were utilized [21].

Long-term outcome data for SCR continues to mature, with recent studies providing 10-year follow-up results [14]. Mihata and colleagues reported sustained improvements in clinical outcomes and shoulder function at 10-year follow-up, though some patients required conversion to reverse arthroplasty for progressive arthritis [14]. These long-term studies provide valuable insights into the durability of SCR and help refine patient selection criteria for optimal outcomes [14].

Recovery patterns following SCR have been systematically studied, with muscle strength showing progressive improvement over time [22]. At 2 years after surgery, patients demonstrate 61% recovery in scaption strength, 63% in external rotation, and 103% in internal rotation relative to the uninvolved side [22]. Functional improvements plateau around 1-2 years postoperatively, with peak benefits maintained at long-term follow-up [22].

Tendon Transfer Procedures: Evidence-Based Approaches and Comparative Outcomes

Tendon transfer procedures represent well-established surgical options for irreparable rotator cuff tears, particularly in younger patients with specific functional deficits and preserved glenohumeral joint space [23]. The latissimus dorsi transfer, originally described by Gerber and colleagues, has demonstrated reliable long-term outcomes for posterosuperior rotator cuff tears with intact subscapularis function [23]. This procedure addresses external rotation weakness by transferring the latissimus dorsi tendon to the greater tuberosity, effectively replacing the function of the infraspinatus and teres minor muscles [23].

Patient selection for latissimus dorsi transfer requires careful evaluation of tear pattern, remaining muscle function, and patient factors including age and activity level [24]. Ideal candidates typically have posterosuperior tears involving the infraspinatus and supraspinatus with intact subscapularis function, absence of glenohumeral arthritis, and functional latissimus dorsi muscle [24]. Contraindications include advanced fatty infiltration of the teres minor (Goutallier grade 3-4), subscapularis dysfunction, and significant glenohumeral arthritis [24].

Technical aspects of latissimus dorsi transfer have been refined to optimize clinical outcomes and reduce complications [25]. Traditional open techniques have been supplemented by arthroscopic-assisted approaches that reduce surgical morbidity while maintaining clinical efficacy [25]. Augmentation with Achilles tendon allograft has been reported to improve tendon transfer integrity and clinical outcomes compared to conventional techniques [26]. The use of interference screw fixation and transosseous tunnels has enhanced fixation strength and reduced failure rates [27].

Clinical outcomes following latissimus dorsi transfer have been consistently favorable across multiple studies and systematic reviews [24]. A recent systematic review and meta-analysis analyzing mid- to long-term outcomes demonstrated significant improvements in Constant scores, external rotation range of motion, and patient satisfaction rates exceeding 80% [24]. The mean Constant score increased from 29 to 51 points, forward elevation improved from 89 to 135 degrees, and external rotation increased from 12 to 24 degrees at final follow-up [28]. However, complications including deltoid dysfunction, infection, and graft failure occur in approximately 15-20% of cases [24].

Lower trapezius transfer has gained popularity as an alternative to latissimus dorsi transfer, particularly for patients with combined external rotation and elevation deficits [29]. Biomechanical studies have demonstrated superior restoration of the force vector for shoulder elevation compared to latissimus dorsi transfer, with the native line of pull more closely approximating that of the infraspinatus muscle [29]. Clinical studies report functional improvements comparable to latissimus dorsi transfer, with the advantage of avoiding posterior axillary dissection and potential neurovascular complications [29].

Comparative studies between different tendon transfer options have provided insights into optimal patient selection and expected outcomes [30]. A prospective randomized trial comparing latissimus dorsi transfer and superior capsular reconstruction demonstrated equivalent clinical outcomes at 2-year follow-up, with SCR showing slightly better functional scores and lower infection rates [30]. However, patient selection criteria differed between groups, highlighting the importance of individualized treatment algorithms [30].

Recent studies have evaluated the comparison of anterior versus posterior latissimus dorsi transfer techniques for different tear patterns [31]. A prospective clinical trial demonstrated that both anterior and posterior transfer approaches provide significant improvements in pain and function, with posterior transfer showing superior improvements in shoulder elevation and abduction [31]. The anterior transfer approach was found to be as safe as posterior transfer regarding nerve injury complications [31].

Arthroscopic-assisted tendon transfer techniques have evolved to reduce surgical morbidity while maintaining clinical efficacy [25]. A study evaluating arthroscopic-assisted latissimus dorsi transfer in patients with pseudoparalysis demonstrated significant improvements in UCLA and Constant-Murley scores, with mean UCLA scores increasing from 6.5 to 27.5 points at 26-month follow-up [25]. The minimally invasive approach reduces surgical trauma while providing reliable clinical outcomes [25].

Reverse Total Shoulder Arthroplasty: Current Evidence and Long-Term Outcomes

Reverse total shoulder arthroplasty has established itself as the preferred treatment for irreparable rotator cuff tears in elderly patients, particularly those with rotator cuff arthropathy and pseudoparalysis [32]. The prosthetic design compensates for rotator cuff deficiency by medializing the center of rotation and allowing the deltoid muscle to provide both elevation and stability [32]. Multiple studies have demonstrated excellent pain relief and functional improvement with RTSA, making it the most predictable surgical option for appropriately selected candidates [32].

Indications for RTSA in irreparable rotator cuff tears have expanded over time but generally include age greater than 65-70 years, presence of glenohumeral arthritis (Hamada grade 4-5), failed previous surgery, and functional deltoid muscle [33]. The procedure is particularly beneficial for patients with pseudoparalytic shoulders who cannot elevate the arm above 90 degrees and those with combined rotator cuff and subscapularis deficiency [33]. Modern implant designs have improved range of motion outcomes and reduced complications compared to earlier generations [32].

Clinical outcomes following RTSA for rotator cuff arthropathy are consistently favorable across multiple studies and registries [34]. Long-term follow-up studies have demonstrated sustained functional improvements and high patient satisfaction rates [34]. A longitudinal study evaluating patients at minimum 7-year follow-up showed excellent clinical outcomes, with final ASES scores of 82 points and Constant scores of 68 points [34]. Pain relief is typically excellent, with visual analog scale scores improving dramatically from preoperative levels [34].

Long-term survival data for RTSA continues to mature, with 10-year implant survival rates exceeding 90% in most series [35]. A comprehensive study evaluating long-term results of primary reverse shoulder arthroplasty for massive irreparable rotator cuff tears without arthritis demonstrated sustained improvements at mean 9.4-year follow-up, though some decline in outcomes was observed after 10 years [35]. Revision rates remain low, with most revisions related to infection, instability, or mechanical complications rather than implant loosening [35].

Complications following RTSA include scapular notching, infection, instability, and periprosthetic fracture, occurring in approximately 15-25% of cases overall [32]. Scapular notching, while radiographically common in up to 90% of cases with certain implant designs, rarely affects clinical outcomes or implant survival [32]. Modern implant designs with lateralized centers of rotation and improved metallurgy have reduced complication rates compared to earlier systems [32].

The expanding indications for RTSA have included younger patients and those without arthritis, though long-term outcomes in these populations require careful evaluation [36]. A study evaluating RTSA in patients younger than 60 years demonstrated good functional outcomes at long-term follow-up, with mean Constant scores improving from 24 to 59 points at 11.7-year follow-up [36]. However, the decision to perform RTSA in younger patients should carefully weigh the benefits of predictable functional improvement against the risks of future revision surgery [36].

Comparative studies between RTSA and other treatment modalities have demonstrated equivalent or superior outcomes for appropriately selected patients [37]. A systematic review evaluating RTSA versus non-arthroplasty options for irreparable rotator cuff tears without arthritis found that while functional improvements were similar, complication profiles differed significantly between treatment approaches [37]. The decision between RTSA and joint-preserving procedures depends on patient age, activity level, presence of arthritis, and individual risk factors [37].

Arthroscopic Debridement and Emerging Treatment Modalities

Arthroscopic debridement with subacromial decompression represents a palliative treatment option for irreparable rotator cuff tears, particularly in elderly patients with limited functional demands who are not candidates for more extensive reconstructive procedures [8]. The procedure typically includes removal of inflamed bursal tissue, biceps tenotomy or tenodesis, subacromial decompression, and debridement of degenerative tissue [8]. While not addressing the underlying rotator cuff deficiency, debridement can provide significant pain relief and functional improvement in appropriately selected patients [8].

A systematic review evaluating arthroscopic debridement for massive irreparable rotator cuff tears demonstrated good functional outcomes and pain improvement at mid- to long-term follow-up [8]. The procedure produced good functional outcomes and improvement in pain for the low-demand population greater than 65 years of age looking for pain relief over substantial functional improvement [8]. Biceps tenotomy as part of the debridement procedure has been shown to provide additional pain relief benefits [8].

Patient selection for arthroscopic debridement requires careful consideration of functional expectations and alternative treatment options [8]. Ideal candidates include elderly patients with significant medical comorbidities, those unwilling to undergo more extensive surgery, and patients with predominantly nocturnal pain symptoms [8]. The procedure should not be considered in patients with pseudoparalysis or those expecting significant functional improvement [8].

Biological augmentation techniques have gained attention as adjunctive treatments for irreparable rotator cuff tears, aimed at improving healing potential and reducing re-tear rates [38]. These approaches include the use of platelet-rich plasma, mesenchymal stem cells, growth factors, and biological scaffolds [38]. While preclinical studies have shown promising results, clinical evidence remains limited and techniques lack standardization [38].

Recent innovations in SCR technique include biological augmentation approaches, such as the "biological superior capsular reconstruction" technique using biceps transposition without tenotomy [17]. A study evaluating this approach demonstrated significant improvements in clinical outcomes, with mean ASES scores improving from 35 to 91 points and satisfaction rates exceeding 90% [17]. This technique offers the advantage of using autologous tissue while avoiding donor site morbidity [17].

Patch augmentation using various graft materials has been investigated as an alternative approach for bridging irreparable defects [39]. Studies evaluating dermal allograft augmentation for large and massive rotator cuff tears have shown promising results, though long-term outcomes require further investigation [39]. The optimal indication for patch augmentation remains to be defined through additional research [39].

Bioinductive Patch Augmentation: Evidence for Enhanced Healing

Bioinductive patch augmentation has emerged as a promising biological enhancement technique for rotator cuff repair, particularly in cases of large and massive tears where healing rates remain suboptimal [41]. The bioinductive patch, composed of highly purified type I collagen, is designed to stimulate new tissue formation and enhance the biological healing environment at the repair site [41]. Unlike traditional patch grafts that serve primarily as mechanical scaffolds, bioinductive patches promote cellular infiltration and vascularization, potentially improving tendon quality and repair integrity [41].

A recent systematic review and meta-analysis evaluating bioinductive patch augmentation for rotator cuff repair demonstrated encouraging clinical and structural outcomes [41]. The analysis included multiple studies comparing standard rotator cuff repair with and without bioinductive patch augmentation, revealing significant improvements in healing rates and patient-reported outcomes [41]. Patients treated with bioinductive patch augmentation showed reduced re-tear rates compared to standard repair alone, with particularly notable benefits observed in larger tears [41].

The surgical technique for bioinductive patch application involves placement of the patch over the bursal surface of the repaired tendon, secured with absorbable sutures [41]. The patch gradually resorbs over approximately six months while promoting new tissue formation and maturation [41]. Magnetic resonance imaging studies have demonstrated increased tendon thickness and improved tissue quality at the repair site following bioinductive patch augmentation [41].

Clinical outcomes following bioinductive patch augmentation have shown consistent improvements in functional scores and pain relief [41]. The meta-analysis reported significant improvements in American Shoulder and Elbow Surgeons scores and Constant scores compared to control groups, with benefits maintained at minimum two-year follow-up [41]. Importantly, the complication profile remained favorable, with no significant increase in adverse events compared to standard repair techniques [41].

Patient selection for bioinductive patch augmentation requires consideration of tear size, tissue quality, and healing potential [41]. The technique appears most beneficial for large and massive tears where traditional repair techniques have historically shown high failure rates [41]. While the current evidence is promising, longer-term studies are needed to fully establish the role of bioinductive patches in the treatment algorithm for challenging rotator cuff tears [41].

Clinical Decision-Making and Future Directions

The optimal management of irreparable rotator cuff tears requires a systematic approach to patient evaluation and treatment selection based on multiple patient and tear-specific factors [6]. A comprehensive assessment should include patient age, functional demands, activity level, medical comorbidities, expectations, tear characteristics, remaining muscle function, and presence of arthritis [6]. Modern imaging evaluation with magnetic resonance imaging is essential to assess tear size, retraction pattern, fatty infiltration, and bone quality [9].

For patients over 70 years with rotator cuff arthropathy and pseudoparalysis, RTSA provides the most predictable outcomes with excellent pain relief and functional improvement [33]. Younger patients (under 65) with preserved joint space and intact subscapularis function may be candidates for superior capsular reconstruction or tendon transfer procedures [15,24]. The specific pattern of rotator cuff deficiency influences the choice between different reconstructive options [6].

Recent comparative studies have provided valuable insights into treatment selection algorithms [40]. A network meta-analysis comparing multiple surgical treatment options for irreparable rotator cuff tears found that while all interventions provided functional improvement, reverse arthroplasty demonstrated the most predictable outcomes for elderly patients with arthritis [40]. For younger patients without arthritis, both SCR and tendon transfer procedures showed comparable functional improvements with different risk profiles [40].

Future research directions should focus on optimizing patient selection criteria, standardizing surgical techniques, and establishing long-term comparative effectiveness among treatment modalities [6]. The development of predictive models incorporating patient factors, imaging findings, and biomechanical parameters may improve treatment selection accuracy [6]. Additionally, advances in biological therapies and tissue engineering may provide new treatment options for younger patients seeking joint preservation [38].

CONCLUSION

The surgical management of irreparable rotator cuff tears has evolved significantly over the past decade, with multiple evidence-based treatment options now available for different patient populations. Current literature supports a personalized approach to treatment selection based on patient age, functional demands, tear characteristics, presence of arthritis, and individual risk factors. This comprehensive review of contemporary evidence demonstrates that no single treatment approach is optimal for all patients with irreparable rotator cuff tears.

Reverse total shoulder arthroplasty remains the gold standard for elderly patients with rotator cuff arthropathy, providing predictable pain relief and functional improvement with acceptable complication rates and excellent long-term implant survival. The procedure is particularly effective for patients with pseudoparalysis and those who have failed previous surgical interventions. Modern implant designs have improved outcomes and reduced complications compared to earlier generations.

Superior capsular reconstruction has emerged as a valuable joint-preserving option for younger patients with preserved glenohumeral joint space and intact subscapularis function. Clinical outcomes have been encouraging, with significant improvements in pain and function reported across multiple studies. However, graft failure rates of 15-30% necessitate careful patient selection and counseling regarding expected outcomes and potential need for future revision surgery.

Tendon transfer procedures, particularly latissimus dorsi and lower trapezius transfers, continue to provide reliable functional restoration for specific tear patterns in appropriately selected patients. These procedures offer the advantage of joint preservation while addressing specific functional deficits. Arthroscopic-assisted techniques have reduced surgical morbidity while maintaining clinical efficacy.

Arthroscopic debridement remains a valuable palliative option for elderly patients with limited functional demands who are not candidates for more extensive reconstructive procedures. While not addressing the underlying rotator cuff deficiency, the procedure can provide significant pain relief with minimal surgical morbidity.

The future of irreparable rotator cuff tear management will likely involve continued refinement of existing techniques, development of new biological therapies, and improved patient selection algorithms. Standardization of outcome measures and long-term follow-up studies will be essential for advancing the field and optimizing patient care. The ultimate goal remains providing each patient with the most appropriate treatment option to maximize functional improvement while minimizing complications and the need for revision surgery.

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