Rotator cuff repair - does failure matter?

Outcomes of arthroscopic rotator cuff repair with muscle advancement for massive rotator cuff tears

In patients of average age of 67 years with retained elevation (average >120 degrees), these authors performed arthroscopic rotator cuff repair combined with mini-open supraspinatus and infraspinatus muscle advancement for massive rotator cuff tears (RCTs) in an effort to decrease tension at the repair site. 

They evaluated the clinical outcomes and failure rates after this procedure.

Their study included 47 patients diagnosed with chronic massive RCTs, of these, 21 had transosseous equivalent repair only (control group), and 26 underwent transosseous equivalent repair with muscle advancement (study group).  

There was substantial down time after these surgeries: the affected arm was immobilized for 6 weeks in an abduction brace. Passive range of motion exercise commenced from 1 week, active ROM exercise commenced from 4 weeks, and rotator cuff and deltoid muscle strengthening exercises commenced from 12 weeks.

Failure rates were determined by postoperative magnetic resonance imaging. The failure rates were high in in both groups, but lower in the study group than in the control group (23.1% and 52.4%; P = .03).  In spite of the observation that the failure rate was twice as high in the control group, there was no difference in the clinical outcomes between the two groups as reflected by the Constant and UCLA scores. Leading one to ask, "does failure matter"?

Comment: The failure rate of repair of massive cuff tears remains high.

In our practice, we discuss the possibility of a smooth and move procedure with patients who have retained elevation and massive tears. This procedure is short, safe and avoids the need for protracted down time after surgery, as described below.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

The typical pathology in these cases is shown in the figure below.

The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.

The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.

The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable. 

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test

In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). 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 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities

They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.

These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.

Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.

While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.

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Large to massive cuff tears - what can we learn from this study?

Surgical repair of large-to-massive rotator cuff tears seems to be a better option than patch augmentation or débridement and biceps tenotomy: a prospective comparative study 

In this small case study the authors compared the outcomes after 3 different treatments for large and massive rotator cuff tears: 12 in which the surgeon was able to perform an arthroscopic repair, 11 in which the surgeon elected open repair and xenograft

and 9 in which the surgeon decided that neither repair or patch was advisable and performed a debridement only.

The mean Constant-Murley scores were significantly improved for the patients in each group

Five complications occurred in 11 patients in the patch group (1 deep infection required the removal of the patch and antibiotic treatment, and postoperative stiffness developed in 4 patients. The stiffness regressed at the 1-year follow-up in 3 patients, and the remaining patient was treated with arthroscopic capsular release 9 months after the repair,

One complication occurred in the repair group (a superficial wound infection)

No complications occurred in the débridement group.

Comment: It would seem that patients in the three groups did not have comparable pathology (one group had reparable tears, one group had arthroscopically reparable tears in which the surgeon felt the need for graft supplementation at open surgery, and one group in which the surgeon could not repair the tear).

As we know, tears that can be robustly repaired do better than those that cannot.

The authors do not provide data on the postoperative integrity of the repair attempts or the patch grafts, so the anatomic effectiveness of these surgeries is unknown.

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Massive rotator cuff tears

Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears A Critical Analysis Review

After their review of the available data, these authors concluded that

(1) Massive rotator cuff tears that are treated nonoperatively demonstrate increases in tear size, fatty infiltration, muscular atrophy, and arthritis.

(2) The pooled retear rate following complete repair of massive rotator cuff tears is 79%.

(3) Absorbable and nonabsorbable graft augmentation following rotator cuff repair can reduce the retear rate and improve functional outcomes.

(4) Irreparable tears can be predicted preoperatively by evaluating the degree of fatty infiltration, muscular atrophy, and tendon length.

(5) Latissimus dorsi transfer, lower trapezius transfer, and superior capsular reconstruction provide improvements in terms of pain, range of motion, and function in patients with irreparable tears.

Comment: This is an impressively comprehensive article. The authors carefully differentiate options for treating a reparable massive tear:

from the options for treating a massive irreparable cuff tear:

They point out that nonoperative treatment of a massive rotator cuff tear can be effective for patients who present with pain and preserved range of motion with an emphasis on strengthening the remaining rotator cuff, deltoid, and periscapular muscles. While tear progression has been observed in association with the nonoperative treatment, its not clear whether the clinical outcomes of operative management of these tears is superior to that of non-operative management. The bottom line, of course, is that these tears are degenerative so that all methods of treatment (non-operative and operative) are destined to suffer from progressive deterioration with time of the tissue surrounding the humeral head (see chart above).

Thus it seems important to focus on the symptoms of the patient at present because it is unclear whether we can change the natural history of this disease.

Finally we need to recall that selected patients with massive irreparable cuff tears can be successfully treated by methods that do not attempt to restore the integrity of the rotator cuff, such as rehabilitation (see this link), the smooth and move procedure (see link,  link, link), the CTA athroplasty (see this link) and the reverse total shoulder (see this link).

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Large/massive cuff tears: Reverse total shoulder or arthroscopic repair?

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears.

The authors compared the cost-effectiveness of attempted arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.

The input variables to their model are shown in the figure below. Note the retear rate after attempted arthroscopic repair is estimated at 68.5%

It is very interesting to look at the clinical states modeled, for example, the ASES scores assigned to cuff repair with and without retear are essentially the same.

They concluded that both attempted arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an incremental cost-effectiveness ratio (ICER) of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Attempted arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes even though over two thirds of these repair attempts would fail to re-establish the rotator cuff attachment to bone.

In their analysis arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.

The authors concluded that attempted arthroscopic rotator cuff repair may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty despite high rates of tendon retearing for patients with large and massive rotator cuff tears.

Comment: As the readers of this blog know, we have found a secure place in our practice for the 'smooth and move' procedure for large and massive cuff tears - avoiding the cost and the rehabilitation of a cuff repair. See this link. This approach seems particularly attractive in light of the observation that less than 1/3 of attempted repairs of these tears are successful, so the effort to 'repair' the tear may not be worth it.

Readers will be interested in a prior relevant post (see this link).

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massive irreparable rotator cuff tear - management with arthroscopic-assisted latissimus dorsi transfer

Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears.

These authors reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer for treatment of irreparable, posterosuperior massive rotator cuff tears at 36.4 ± 9 months after surgery. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff retear after a prior arthroscopic rotator cuff repair. 

The Constant scores improved. A lower preoperative Constant score and a previous failed rotator cuff repair resulted in lower postoperative range of motion, Constant score, and patient satisfaction.

Comment: This article can be compared to another recent publication that used a lower trapezius transfer for similar indications (see this link).

The management of a patient with an irreparable cuff tear needs to be highly individualized based on the patients health and expectations as well as the condition of the shoulder before shoulder surgery. We use a range of approaches including the smooth and move procedure, CTA arthroplasty, and reverse total shoulder arthroplasty. We have not found a role for tendon transfers in our practice, but will observe with interest the attempts of others to explore other approaches.

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Rotator cuff tears - what to do if they are irreparable?

Long-term outcome of tuberoplasty for irreparable massive rotator cuff tears: is tuberoplasty really applicable?

These authors report on 16 patients who underwent arthroscopic tuberoplasty for symptomatic irreparable massive RCT without pseudoparalysis. Patients were a mean age of 64 years (range, 43-80 years) at the time of the operation, and the mean duration of follow-up was 98 months (range, 84-126 months).

At the last follow-up, the visual analog scale score for pain during motion had decreased to 2.3 from a preoperative mean of 6.9 (P < .001). The mean University of California at Los Angeles and Constant scores improved from 10.3 and 37.9 preoperatively to 27.2 and 59.2, respectively, at the last follow-up (P < .001 for both). 

The mean acromiohumeral interval changed from 5 mm preoperatively to 4 mm at the last follow-up. Only 1 patient underwent revision surgery.

The authors concluded that arthroscopic tuberoplasty is a good option for relieving pain and improving functionality in nonpseudoparalytic patients with painful irreparable massive RCT.

Comment: Currently there is enthusiasm for treating massive irreparable cuff tears with marginal convergence, superior capsular reconstructions, patch grafts, and reverse total shoulders. These authors demonstrate that some patients may be substantially improved with a simpler option that does not require prolonged periods of rehabilitation after surgery.

As Codman pointed out many years ago, the shoulder is a joint with two concentric spheres sharing a common center of rotation: (1) the humeral head articulating in the glenoid socket and (2) the proximal humeral convexity articulating within the coracoacromial arch. The radius of the second is equal to the radius of the first plus the thickness of the cuff and tuberosity. Here is an illustration from his book:

When the cuff is absent, the uncovered tuberosity extends beyond the extended curvature of the humeral surface, disrupting the normally smooth surface of the proximal humeral convexity. As the figure below from Steve Lippitt shows, smoothing of the tuberosity can restore the smoothness of the proximal humeral convexity that articulates with the undersurface of the (hopefully) intact coracoacromial arch.

Our favored procedure for the painful, stiff and crepitant irreparable cuff tear without pseudoparalysis is the smooth and move procedure, which includes tuberoplasty along with a bursectomy, lysis of adhesions, and a gentle manipulation under muscle relaxation.See this link and this link.

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Reverse total shoulder - what patients with massive cuff tears tend to poorly? What is the value?

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

These authors conducted a retrospective case-control analysis to determine the risk factors for poor outcomes after reverse shoulder arthroplasty (RSA) for massive rotator cuff tear without glenohumeral arthritis. Cases (n=13) were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls (n=61) had improved SST score ≥2.

Neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (7 or more) (P = .03) were independently associated with poor functional improvement.

Hospital costs were used as a proxy measure for the overall cost of the procedure. Direct hospital costs averaged $18,367 for cases vs. $16,585 for controls, and the indirect hospital costs averaged $6470 for cases vs. $5870 for controls. The total hospital costs for cases averaged $24,837 vs. $22,456 for controls.

The benefit of the procedure was characterized as the change in the ASES score. The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001). Thus the value of RSA was > 20 times higher for control patients than for cases.

Nine patients (12%) experienced a major complication:instability requiring multiple closed reductions with eventual resolution (n . 1), instability requiring revision (n . 1), and acromial fracture (n . 7). Four patients (5%) experienced a minor complication: lower extremity deep venous thrombosis (n . 1), reflex sympathetic dystrophy in the operative extremity that resolved (n . 1), wound dehiscence treated successfully with oral antibiotics only (n . 1), and postoperative aspiration requiring a longer hospital stay and temporary nasogastric tube insertion (n . 1). The total complication rate was 17%, with a 1.4% revision rate at minimum 2-year follow-up.

Comment: These data from a high volume RSA practice are helpful in guiding patient selection this procedure. While improvement of only 2 SST functions is a relatively low threshold for defining improvement, it is important that the authors used a patient self-assessment metric, such as the SST, in quantitating improvement in the preoperative comfort and function. The finding that individuals with high preoperative SST scores have on average less improvement is consistent with our observation with other types of arthroplasty and provides easy to obtain information that is useful in deciding whether or not surgery is appropriate in individual cases.

The data on value are of great interest. We want to spend health care dollars where they will do the most good. The value equation of change in comfort and function divided by the cost. If instead of the ASES score the authors use the SST, the Δ SST for the cases was be -1 and the Δ SST for the controls was 6.6. Using the total hospital costs for cases as $24,837 vs. $22,456 for controls, the value of the cases would be -0.4 SST/$10,000 for the cases and +2.96 SST/$10,000 for the controls.

Makes one think!

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Rotator cuff tears involving two or more tendons - what to do about them?

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.

These authors review the management options for two tendon ("massive") rotator cuff tears. We've highlighted a few quotes from the article:

Repair fails in ~ 40% of the cases: "In an effort to identify factors associated with healing, Chung et al investigated 108 patients who underwent arthroscopic repair of massive cuff tears at a minimum of 1 year of follow-up. Anatomic failures occurred in 39.8% of patients. This is a comparable retear rate to that reported by Zumstein et al (57%), Miller et al (41%), Kim et al (42.4%), and Park et al (25%). "

The healing time for a repair is longer than what we have been led to believe: "The optimal postoperative rehabilitation strategy to promote healing has yet to be determined. The ideal protocol protects the repair construct during the healing process while minimizing the risk of postoperative stiffness. A study conducted by Iannotti et al investigated the time to failure after rotator cuff repair of full-thickness tears ranging from 1 to 4 cm. The investigators found that the majority of retears occurred between 6 and 26 weeks postoperatively, suggesting that rehabilitation should focus on protecting the repair for a longer time."

In view of the above two observations, why not try non-operative management?: "A study conducted by Zingg et al evaluated the clinical and structural midterm outcomes in 19 patients with nonoperatively managed massive rotator cuff tears, defined as full-thickness complete tears of at least 2 tendons. After a mean follow-up duration of 48 months, the mean relative Constant score was 83%."

Comment: This article prompted us to resurface some of the content of three previous posts:

(1) Rotator cuff tear and rotator cuff wear.
 "The rotator cuff is the only tendon structure situated between two bones. Compressed between the acromion and the humerus by every motion of the shoulder, it succumbs to the ravages of attrition long before most other tendons. In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle age, it has worn thin and often becomes so weak and brittle that it ruptures with ease." McLaughlin 1962

Detachment of the rotator cuff tendons from the greater tuberosity is often described as a rotator cuff tear. The word 'tear' suggests an acute process, such as tear in otherwise great blue jeans that can be easily repaired.

On the other hand, most cuff defects arise in tendons of suboptimal quality without an acute traumatic episode and may be better referred to as cuff wear, similar to defects in worn jeans that defy repair.

We emphasize the distinction in an article on rotator cuff failure in the New England Journal as well as in the text, The Shoulder, where we quote McLauhglin's admonition regarding 'rotten cloth to sew' in an Instructional Course Lecture: "The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis. [There was complete agreement of the Panel on this point.]" See his 1962 article.


(2) Some of our most distinguished colleagues set out to model the societal and economic value of rotator cuff repair.

As they point out rotator cuff tears are common in the United States, but the effect of cuff tears on earnings, missed workdays, and disability payments has not been well defined. As they point out in the introduction, long-term clinical studies of cost effectiveness 'do not exist'. This is a sad commentary on the state of clinical research in that hundreds of thousands of cuff repairs are performed each year, providing a huge opportunity for long term studies of the actual costs of cuff tears as well as the effectiveness of operative and non-operative management of different types of cuff tears in different types of patients using different techniques by different providers (see the 4Ps).

In the absence of real data, the authors' goal was to estimate the value of surgical treatment for full-thickness rotator cuff tears from a societal perspective using a Markov decision model of the lifetime direct and indirect costs (e.g. inability to work, lower wages, missed workdays, disability payments) associated with surgical and continued nonoperative treatment for symptomatic full-thickness rotator cuff tears. Patients with a symptomatic full-thickness rotator cuff tear 'underwent' either open or arthroscopic rotator cuff repair or continued to receive nonoperative treatment. After one year, all rotator cuff repairs resulted in either (1) healed rotator cuff repair (symptomatic and asymptomatic), (2) asymptomatic retear, (3) symptomatic retear, or (4) death; shoulders treated without surgery resulted in either (1) symptomatic tear, (2) asymptomatic tear, or (3) death.

The model indicated that surgical treatment results in an average improvement of 0.62 QALY. The model suggested that the age-weighted mean total societal savings from rotator cuff repair compared with nonoperative treatment was $13,771 over the lifetime of the patient. Savings ranged from + $77,662 for patients who are thirty to thirty-nine years old to - $11,997 for those who are seventy to seventy-nine years old.

The model concluded that "rotator cuff repair is cost-effective for all populations" and "The estimated lifetime societal savings of the approximately 250,000 rotator cuff repairs performed in the U.S. each year was $3.44 billion." This is a staggering figure.

Because actual data were not available for many of the key elements in the model, values were based on Level V assumptions. As the authors point out 'evidence to support some of the model assumptions is limited.'These assumptions had a strong influence on the results. Here are some considerations of the assumptions used:

(1) It was assumed that all symptomatic full-thickness rotator cuff tears assigned to the repair group were repairable, whereas this does not seem to be the common experience

(2) The model recognizes that healed repairs can be symptomatic or asymptomatic, but does not assume any disability if the healed repair is symptomatic, whereas we have all seen patients who are unable to return to work after a symptomatic "successful" cuff repair.

(3) The long term retear rate after cuff repair was assumed to be 2%, whereas a recent post found retear rates after one year approximating 10%.
(4) Patient outcomes for all repairs were assumed to be the same as those of seventy-three patients who underwent surgery at a large orthopaedic surgery group; presumably those cases represented careful selection of patients, of reparable cuff tears, and excellent surgical technique by a well trained shoulder surgeon, whereas many patients with cuff tears are not prime surgical candidates, have irreparable cuff tears and may be cared for by surgeons who are not specialized in shoulder (see the 4Ps: problem, patient, procedure, physician).
(5) It was assumed that workers lost an average of twenty-eight additional days as a result of rotator cuff repair compared with those undergoing non-operative treatments, whereas recent data suggests that repairs should be protected from loading for up to six months after surgery. In that many cuff tears occur in those with physical laboring jobs, the 28 days seems like a short interval for return to work. Furthermore, it is not clear that cuff tears treated with non-operative management need to miss work at all.
(6) The model assumed complication rates of stiffness (2.5%) and of infection (0.1%) following rotator cuff repair, whereas some studies have reported a complication rate of 10.6% of which the most common was persistent stiffness.
(7) The model used an expensive approach to non-operative management costing $1802, whereas there is substantial evidence that an inexpensive home program provides an effective method for non-operative management.
(8) The model assumes that only 5% of asymptomatic retears following repair become symptomatic annually, whereas it assumes that 8.8% of asymptomatic tears managed non-operatively become symptomatic per year.

These and other assumptions led the model to conclude that "rotator cuff repair produces societal cost savings for patients under the age of sixty-one years and is cost-effective for all patients". However, it is easy to see that different assumptions might have led to a different answer. 

It may be worthwhile to reflect on whether this model addresses the right question. No one would doubt that a successful rotator cuff repair that returns a worker to work is a good thing for that person and for society. On the other hand non-operative management can be of value to many patients. The real question is 'how do we decide which rotator cuff tears in which patients will benefit from rotator cuff repair and the critical post-operative rehabilitation period that must follow?'. The model's conclusion that 'rotator cuff repair is cost-saving across all patients' does not change the fact that many cuff tears are not reparable and that many patients with cuff tears are not good candidates for cuff repair. 

In terms of guidance, the model leaves us with the quizzical statement "Although rotator cuff repair is cost-saving across all patients, nonoperative treatment is the preferred strategy for a large number of patients. "

(3) Rotator Cuff Repair Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome

Rotator cuff tears are common, and rotator cuff surgery represents a major health care expense.  Rotator cuff repairs are commonly performed: well over 200,000 per year in the U.S. The direct costs of these repairs are estimated a $3 to 12 billion per year in direct costs alone. While patients often benefit from rotator cuff surgery, anatomic failure of the repair is not unusual. These authors sought to identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.

They identified 2383 articles on rotator cuff repairs published between 1980 and 2012. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. From these articles they extracted data relating to the patients, their shoulders, the procedures, and the results.

One of the most interesting findings in this paper is that while the number of articles meeting the inclusion criteria per year increased ten fold from the 1990s to 2012, the retear rates and clinical outcomes did not change significantly over this time interval (see the figure below).

The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery - an annualized failure rate of over 13% per year. Retears were associated with more fatty infiltration, larger tear size, and advanced age.

Clinical improvement averaged 72% of the maximum possible improvement.

Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff.

Unfortunately, the inconsistent and incomplete data in the published articles limited the opportunity to conduct a meta-analysis of the influence of factors such as repair technique on the clinical outcome of rotator cuff repair.

The authors concluded that in spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. They suggest that in order to accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must make available the important data relating to each patient’s condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function. These data, will, in turn, enable meaningful meta-analyses of the influence of the details of the cuff pathology (size, chronicity, nature of injury), patient factors (age, gender, co-morbidities) and repair and rehabilitation approaches on the clinical and anatomic outcome. of cuff repair surgery.

This paper again surfaces the question of why anatomically unsuccessful cuff repairs can be associated with clinical improvement after surgery. In that retears were associated with more fatty infiltration, larger tear size, and advanced age, patients with these characteristics may want to consider non-repair options for managing their cuff tears.

Comment: So where does that leave us?
(1) In degenerative two tendon tears, there's plenty of time to implement a non-operative program of gentle stretching exercises and activity modification.
(2) For many patients with degenerative "massive" tears and symptoms refractory to non-operative management, the best rotator cuff surgery may not be a repair, but rather a 'smooth and move' procedure that avoids the prolonged period of protection required after a repair attempt for such a tear and avoids the risk of repair failure.

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