The Effect of Rotator Cuff Repair on Natural History

Abstract

Background:Rotator cuff disease can have a progressive natural history of increasing tear size and worsening function. It remains unknown whether rotator cuff repair alters this natural history.Methods:A systematic review of the intermediate to long-term (minimum 5-year) results of operative rotator cuff repair and no repair of rotator cuff injuries was performed to compare (1) patient-based outcomes, (2) future surgical intervention, (3) future tear progression or recurrence, and (4) tear size. The no-repair group included both conservative treatment and surgical treatment without repair. After the application of selection criteria, 29 studies with 1,583 patients remained. Meta-regression was conducted to adjust for baseline age, sex, tear size, and duration of follow-up.Results:Comparison of the repair and no-repair groups revealed no significant differences in terms of age (p = 0.36), sex (p = 0.88), study level of evidence (p = 0.86), or Coleman methodology score (p = 0.8). The duration of follow-up was significantly longer for the no-repair group (p = 0.004), whereas baseline tear size was significantly larger in the repair group (p = 0.014). The percentage of patients requiring additional surgery was significantly higher in the no-repair group after adjustment for age, sex, duration of follow-up, and tear size (9.5% higher in estimated means between groups [95% confidence interval, 2.1% to 17%]; p = 0.012). The likelihood of a recurrent defect (repair group) or extension of the prior tear (no-repair group) was not different between groups after adjustment for age, sex, duration of follow-up, and tear size (p = 0.4). There were no differences between the repair and no-repair groups in terms of the Constant score after adjustment for age, sex, duration of follow-up, and tear size (p = 0.31). The final tear size was significantly larger in the no-repair group than the repair group (967 mm2 higher in estimated means between groups [95% confidence interval, 771 to 1,164 mm2]; p < 0.001).Conclusions:At intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased need for future surgery after adjusting for age, sex, duration of follow-up, and tear size. The likelihood of a recurrent defect after rotator cuff repair did not differ from that of tear extension after nonoperative treatment. Thus, rotator cuff repair may not alter natural history.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do We have Arguments in Decision Making: Conservative or Surgical Treatment in Painful Degenerative Large Rotator Cuff Tears?

“…However, the current literature does not seem to indicate clearly any signi cant clinical difference in terms of improvement of pain and functional disability between the two types of care (13). A recent systematic review showed that outcomes were similar for both treatment approaches (14). However, all these reviewed studies, except two randomized controlled clinical trials, were cohort studies without external control groups, and the studies consisting of conservatively treated patients generally included patients with small or medium sized tears, whereas the surgically treated patients typically presented with large or massive tears.…”

Rotator Cuff Tears : Short- and long-term aspects on treatment outcome

“…The mean Constant score in those with arthropathy was 47, and mean 65 in those with full-thickness tear without arthropathy. A recent review by Chalmers et al from 2018 found a total of 289 patients with mid to longterm results for unrepaired rotator cuff tears (including those from paper I) and the mean duration of follow-up was 14.9 years (95% CI, 11.5-18.3 years) 39 . Paper I therefore seems to have the longest follow-up of unrepaired tears published until now.…”

“…Paper I therefore seems to have the longest follow-up of unrepaired tears published until now. In this review, 1 294 patients from 23 studies with outcome after repair were compared to 289 patients with unrepaired tears from 8 studies 39 . The repair group had a larger tear size at inclusion and the duration of follow-up was longer in the unrepaired group.…”

Editorial Commentary: Does a Medialized Repair Allow Single-Row to Outperform Double-Row Rotator Cuff Repair?

“…R otator cuff repair remains an imperfect treatment for a rotator cuff tear, with retears remaining a common issue, especially with large tears. [1][2][3][4][5] To combat this issue, there has been a great deal of research into the repair technique, with much of this effort focused on the placement pattern and number of suture anchors relative to the tendon footprint. 2,4 Specifically, much of this debate has focused on whether 2 rows of anchors provide sufficiently better outcomes or better tendon healing to justify their increased cost and surgical time.…”

“…These results suggest that footprint coverage may be less important than previously thought regarding restoration of a full tendon attachment. Anatomic restoration is likely going to be important if our goal is for repair to interrupt the natural history of rotator cuff tears, 3 which is not benign. 24,25 Yamakado 20 has focused this study on medium-sized tears, which typically have high healing rates.…”