The management of patients with rotator cuff tears presents a significant clinical and economic challenge. With annual costs of rotator cuff surgery exceeding $3 billion in the United States alone, and increasing evidence that structural repair does not always correlate with functional outcomes, a critical reassessment of the cost-effectiveness of different management options seems warranted.
Let's start with a case example
A 70 year old active skier, cyclist, climber and practicing orthopaedic surgeon presented with the progressive onset of pain in the right shoulder. Physical examination revealed weakness of resisted elevation, but a good range of active motion. Plain radiographs showed no evidence of arthritis. The MRI findings are shown below.
Surgical repair was offered but declined in favor of a home exercise program. A decade later the shoulder has a full painless range of range of motion and strength sufficient for sports and surgical practice.
Non-operative treatment represents the most cost-effective strategy for many patients with symptomatic rotator cuff tears.
Jed Kuhn and the MOON (Multicenter Orthopaedic Outcomes Network) Shoulder Group that he leads published Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study, a multicenter prospective cohort study of 452 patients with atraumatic full-thickness rotator cuff tears treated with a standardized physical therapy protocol. The study found that 75% of patients achieved successful outcomes with physical therapy alone at 2-year follow-up, with "failure" defined as patients electing to undergo surgery.
The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time: Ten-Year Outcomes of the MOON Shoulder Prospective Cohort, a follow-up study tracked the original cohort for 10 years and found that physical therapy remained successful in over 70% of patients, with only 27% ultimately requiring surgery. Importantly, patient-reported outcomes improved with physical therapy and did not decline over the 10-year period. This study won the 2024 Kappa Delta Ann Doner Vaughan Award and demonstrated the long-term durability of non-operative treatment.
EXERCISE THERAPY IN THE NON-OPERATIVE TREATMENT OF FULL-THICKNESS ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW Of the non-operatively treated cohorts 78% improved in pain, 81% improved in range of motion, 85% improved in strength, 84% improved in functional outcomes. Dissatisfied outcomes occurred in 15% of patients, who then transitioned to surgery.
The cost differential is substantial. Home exercises are inexpensive and often effective. While comprehensive physical therapy may cost $1,500-3,000 over several months, surgical repair typically ranges from $15,000-25,000, creating a 10-fold cost difference for initial treatment. Given that many patients achieve acceptable outcomes with therapy alone, this represents a significant opportunity for cost savings without compromising patient outcomes.
Patient selection for non-operative management should prioritize older individuals (typically >65 years), those with maintained active forward elevation without pseudoparalysis, reasonable functional demands, and chronic rather than acute tears.
Symptoms of cuff tears do not correlate strongly with the magnitude of the defect.
Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear, A cross-sectional study of 393 patients with symptomatic atraumatic full-thickness rotator cuff tears demonstrated that pain severity does not correlate with tear size or other anatomic features. This finding challenged the assumption that larger tears necessarily cause more symptoms and require more aggressive treatment.
Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity found that cuff integrity was not strongly associated with the shoulder's comfort or function.Failure with continuity in rotator cuff repair "healing" found that all rotator cuff repairs retracted substantially away from their position of initial fixation during the first year after surgery (mean 16.1 ± 5.3 mm; range, 5.7-23.2 mm), yet only 30% of patients showed a defect on MRI. This study is important because it indicates that an "intact" tendon repair on MRI may not indicate healing of the tendon to the insertion site. This finding may be especially relevant to the assessment of repair integrity after the use of patches and grafts.
The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears reported arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects.
Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome found that the mean re-tear rate was 26.6% at a mean of 23.7 months after surgery. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. In spite of a dramatic increase in the number of publications per year and the advent of biologic augmentation there was little evidence that the clinical results of rotator cuff repair were improving with time.
Structural Integrity After Rotator Cuff Repair Does Not Correlate with Patient Function and Pain The differences in validated functional outcome scores and pain were not clinically significant for intact and failed repairs.
Non-repair surgery - the underutilized "smooth and move" procedure / debridement.
Smoothing the humeroscapular motion interface without acromioplasty is a quick, safe procedure for painful cuff tears in shoulders with preserved active elevation. It allows the patient immediate return to use of the shoulder without postoperative "down time". It does not involve use of a more costly "subacromial balloon" or a "biological tuberoplasty". The cost-effectiveness advantages of debridement are substantial. Operative time is typically 30-45 minutes compared to 2-3 hours for complex repairs, resulting in lower facility and anesthesia costs. Recovery is faster, allowing quicker return to activities and reduced rehabilitation expenses. Complication rates are lower due to the less invasive nature of the procedure.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty. In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 to 8.5. Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 to 7.5. Fifty-four patients (73%) improved by the MCID. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
Comparing outcomes between debridement and attempted repair of large/massive tears reveals only modest functional differences, yet the repair costs more and carries higher complication risks.
Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair Both treatment groups had similar pain relief and satisfaction, reflected in equal values of disabilities of the arm, shoulder and hand (DASH) score. Ultrasonography revealed structural failure of the partial rotator cuff repair in 52% at final follow-up.
Partial rotator cuff repair versus debridement for irreparable rotator cuff tears: A systematic review 709 shoulders from 706 patients were reviewed, with 380 patients receiving a partial repair and 329 shoulders receiving debridement. Pre- and post-operative mean VAS scores were the same for both treatments. Patient satisfaction with partial repair was reported as 75 %; for patients treated with debridement, post-operative satisfaction was 80.7 %.This systematic review study demonstrates that both partial repair and debridement alone can result in acceptable clinical outcomes with no significant differences noted for patients with irreparable rotator cuff tears in short to mid-term follow up.
Standard Rotator Cuff Repair
Standard surgical repair remains the gold standard of treatment for cuff tears when the quantity and quality of the tendon is adequate. The outcomes of cuff repair surgery are strongly influenced by the patient's nutrition. See: The "Secret Sauce" for Optimizing Rotator Cuff Outcomes: Biologics or nutrition?
Biologics, patches, PRP, and augmentation
While these interventions are associated with reduced retear rates there is currently insufficient evidence that their significantly increased costs result in clinically meaningful improvement in clinical outcomes for patients. Structural healing on imaging does not reliably translate to better clinical outcomes for patients. This disconnect persists despite 25+ years of rotator cuff biological augmentation research.
Platelet-Rich Plasma (PRP)
Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: a systematic review and meta-analysis with bias assessment Improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences
Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: a meta-analysis and meta-regression. A meta-analysis of Level I and II studies found no statistically significant differences in overall outcome scores or retear rates between PRP-treated and control groups.
Evaluating the longitudinal efficacy of platelet-rich plasma in rotator cuff surgery: a systematic review and meta-analysis While PRP reduced pain (VAS) in the early postoperative period, the improvement was not clinically significant.
Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial found that despite better structural healing in the PRP group, there was no clinically significant difference in outcomes between groups.
Cost: Approximate per-procedure expense of PRP: preparation kits: $600 per case; 15 min additional OR time for preparation ($600), processing equipment ($3,000-15,000). The Cost-Effectiveness of Using Platelet-Rich Plasma During Rotator Cuff Repair: A Markov Model Analysis This cost-utility analysis shows that, currently, the use of PRP to augment rotator cuff repair is not cost-effective.
Scaffold and Patch Augmentation
The clinical adoption of these technologies raises questions about their actual effectiveness in improving patient outcomes, their cost-effectiveness in real-world practice, and their safety profile.
A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair found the change in ASES, Constant, and UCLA scores were not clinically signficantly better (did not exceed MCID) for the matrix augmentation group than for the controls.
A pilot randomised controlled trial assessing standard versus dermal patch-augmented rotator cuff repair found no adverse effects and suggest future trials need a minimum of 150 patient Among 40 patients randomized to augmented repair versus standard repair there was no difference between groups with respect to clinical outcomes.
Clinical and anatomical outcomes of arthroscopic repair of large rotator cuff tears with allograft patch augmentation: a prospective, single-blinded, randomized controlled trial with a long-term follow-up This prospective, single-blinded RCT compared arthroscopic repair of large rotator cuff tears with vs. without allograft dermal patch augmentation at mean 7.3-year follow-up. Clinical outcomes (Patch vs. Control at final follow-up): VAS pain: 1.3 vs. 1.5 (difference 0.2 - clinically insignificant) ASES: 87.9 vs. 86.1 (difference 1.8 points - well below MCID of 6.4) Constant: 82.6 vs. 79.5 (difference 3.1 points - well below MCID of 10.4)UCLA: 32.0 vs. 31.0 (difference 1.0 point - below MCID) SST: 10.2 vs. 9.6 (difference 0.6 - below MCID of ~2 points). None of these differences were clinically significant.
Outcome of Large to Massive Rotator Cuff Tears Repaired With and Without Extracellular Matrix Augmentation: A Prospective Comparative Study Uniquely, this study showed a clinically significant difference in ASES score with matrix augmentation.
Cost: Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears Average cost of treatment $32,213 without Regeneten, $54,459 with Regeneten (additional cost 69%). The authors did not assess patient reported outcomes or revision rates for patients without or with the patch. While using "healing" as the study endpoint, the authors point out that there is lack of agreement on what constitutes healing or re-tearing after a cuff repair based on magnetic resonance imaging, ultrasound, or arthrogram. Evidence was not presented that "healing" by imaging correlated with better clinical outcomes .
Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy. Average cost of treatment €4650 without Regeneten, €7828 with Regeneten (additional cost 68%). Study limitations the same as those for the report above.
Complications:
Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial found that postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the Regeneten patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group. All 6 reoperations in the patch group were performed to address stiffness. The authors concluded that patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required.
Severe subacromial-subdeltoid inflammation with rice bodies associated with implantation of a bio-inductive collagen scaffold afterrotator cuff repair The potential for an acute, significant painful phase in a patient’s recovery should be part of the informed-consent process when using the Regeneten implant.
These findings suggest that reactive bursitis may be an under-recognized complication of biological patch augmentation, potentially contributing to the increased stiffness rates observed in larger series. What makes these complication rates concerning is their infrequency in control groups. In the propensity-matched study, zero patients in the standard repair group required reoperation, while 19% of patch-augmented patients did experience this novel category of complications associated with the augmentation material itself.
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Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
