Irreparable massive rotator cuff tears – systematic review & meta-analysis
These authors conducted a systematic review and meta-analysis to (1) compare patient reported outcome (PRO) scores, (2) define failure and reoperation rates, and (3) quantify magnitude of patient response across treatment strategies.
Physical therapy was associated with a 13 point gain in the Constant score and and 23 point gain in the ASES score. There were no complications. 30% went on to have surgery.
Debridement was associated with a 26 point gain in the Constant score and a 37 point gain in the ASES score. Complications were seldom reported. One study reported 4.9% of patients developing complex regional pain syndrome type while another study reported 6.1% and 3.0% developed seromas and infections
Partial repair was associated with a change in Constant score of 32 and a change in the ASES score of 35 and with a 45% re-tear rate and 10% reoperation rate.
Graft interposition was associated with a 42 point gain in Constant score and a 45 point gain in the ASES score. The pooled rates for re-tear, and revision surgery were 20% and 20% respectively.
Tendon transfers were associated with a change of 28 points in the Constant score and a 33 point change in the ASES score. Pooled rates for tendon transfer re-tear, rotator cuff tear, deltoid deficiency, and revision surgery were 14.6%, 6.6%, 1.6%, 6.7%, respectively. Twenty-seven of the 35 tendon transfer failures (77%) occurred secondary to humeral bone tunnel fixation with tendon tubularization compared to eight failures with greater tuberosity footprint fixation (23%). Postoperative complications included hematoma (8%) greater tuberosity fracture (7.3%) deep infection (3.3%) stiffness (3.1%), and nerve dysesthesias (2.1%). Latissimus tendon transfer techniques utilizing humeral bone tunnel fixation were associated with a 77% failure rate.
Superior capsular rconstruction was associated with a 57 point gain in the ASES score (+36 points for human dermal allograft and +64 points for tensor fascia lata autograft). Pooled rates for structural failure and revision surgery were 6.1% and 4.8%, respectively. Rates of graft tear and revision surgery were 7.9% (3/38) and 2.6% with use of human dermal allograft, respectively. Rates of infraspinatus re-tear, graft tear, and revision surgery were 12.5%, 5.6%, and 5.7% with use of tensor fascia lata
autograft, respectively.
Reverse total shoulder was associated with a 32 gain in the Constant score and and 37 point gain in the ASES score. Pooled rates for prosthesis failure, fracture, instability, and revision surgery were 10.1%, 6.1%, 1.9% and 8.2%, respectively.
Comment: While limited by the lack of high level quality studies, these authors characterized the effectiveness and the downsides of different approaches to the management of massive irreparable cuff tears.
Our approach is as follows:
In chronic irreparable cuff tears, a course of gentle stretching and strengthening exercises is the initial treatment; see this link.
For irreparable cuff tears with preserved active elevation, we use the smooth and move procedure; see this link.
For irreparable cuff tears with pseudo paralysis we use a reverse total shoulder arthroplasty; see this link.
