Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making

BACKGROUND: Several classifications have been proposed for subscapularis tendon tearing (SCTs); however, there remains a poor agreement between orthopedic surgeons regarding the diagnosis and management of these lesions. Distinguishing the various tear patterns and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment. PURPOSE: The purpose of this study was to outline the current literature regarding SCT classification and treatment and conduct a survey among shoulder and elbow surgeons to identify the approaches regarding surgical decision-making for these injuries. METHODS: In this systematic review, we analyzed 12 articles regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. In addition, 4 international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1161 ASES members. One hundred sixty five surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in 4 parts including indications/contraindications, treatment plan, and the factors affecting outcomes in the survey. RESULTS: Classification criteria were extremely variable with differing recommendations and descriptions of tear morphology; most were based on tear size, associated shoulder pathology, or lesser tuberosity footprint exposure. Considering the multiple classification systems and the overall poor agreement regarding SCT management, our study found that the most widely agreed upon (more than 80%) statements included early surgery is advised for traumatic SCT, chronic degenerative SCT (without fatty infiltration) associated with acute supraspinatus tear is a candidate for repair, and rotator cuff arthropathy is a contraindication for SCT repair. CONCLUSION: Our study was able to identify both patient and tear characteristics that are well agreed upon among surgeons in the treatment of these injuries. Lafosse classification is generally widely accepted; however, it needs to be improved by some additions. Continued collaboration among surgeons is needed to establish an acceptable and broadly applicable classification system for the management of these injuries.