These authors point out that rotator cuff disease has a progressive natural history of increasing tear size and worsening function, but that it is uncertain whether rotator cuff repair alters this natural history.
They conducted 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.
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 having 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 (967mm2 higher in estimated means between groups [95% confidence interval, 771 to 1,164mm2]; p < 0.001).
The authors concluded that at intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased having 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 the natural history of cuff disease.
The authors suggest that a “recurrent defect” after rotator cuff repair may be understood not as a surgical failure but instead as a continuation of the underlying, unaltered, biological degeneration that leads to rotator cuff pathology.
Comment: In that most cuff 'tears' are the result of chronic tendon degeneration, the tissue available for attempted repair is of quality inferior to normal tissue so that the surgery is at risk for failure as the sutures cut through the tendon edge. This risk is heightened because chronic tears are often associated with loss of the length of the tendon, so that increased tension is applied to the tendon edge as the surgeon attempts to approximate the tendon edge to the bone at the insertion site. To protect this vulnerable approximation, the surgeon tries to unload the repair attempt for months until she or he assumes healing is completed. When the shoulder is returned to being loaded, the strength of the attempted reattachment is challenged (see this link).
Against this background, careful analysis is needed to determine the relative risk and benefits to the patient of (1) non-operative management, (2) non-repair surgery, and (3) attempted cuff repair for patients with chronic rotator cuff defects. We are impressed by the millions of individuals in the U.S. with minimally symptomatic or asymptomatic cuff tears, by the effectiveness of a gentle rehab program in improving the comfort and function of individuals with chronic cuff tears, and by the effectiveness of non-repair surgery in this context (see this link).
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