Abstract
We sought to compare success and re-tear rates of surgically treated full-thickness tears of the rotator cuff in men and women older than 18 years of age to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and superior capsular reconstruction (SCR); and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking surgical intervention of full thickness rotator cuff tears by improving counselling on surgical treatment options and outcomes. It will also benefit surgical providers by expanding their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.
Double-row fixation in arthroscopic rotator cuff repair, although superior in some objective outcomes (e.g., healing rates), is similar to single-row fixation for subjective outcomes in the short to medium term.
There are many options for the treatment of massive tears of the rotator cuff.
The subjective functional and pain outcomes in the treatment of massive tears of the rotator cuff with latissimus dorsi tendon transfer are similar to those of other surgical treatment options, including partial rotator cuff repair, lower trapezius tendon transfer and superior capsular reconstruction.
Patients should be counselled that there are limited existing data, including poor evidence regarding functional outcomes and pain, regarding the treatment of massive rotator cuff tears.
Patients should be counselled that there are limited existing data, including poor evidence regarding functional outcomes and pain, regarding the timing of treatment of traumatic rotator cuff tears; in the absence of high-quality data, the current best practice recommendation is to treat traumatic tears within 12 weeks of injury.
Objective outcomes often differ from subjective outcomes, and an exploration of patient expectations is essential before every rotator cuff operation.
There is a lack of data on the long-term durability of all soft tissue surgical options.
Degenerative tearing of the rotator cuff is one of the most common disorders of the shoulder.1,2 Rotator cuff tears may result in considerable pain, typically experienced over the lateral aspect of the shoulder, although patients may describe pain in other areas.3 Pain may be worsened when there is degeneration of the long head of the biceps tendon.3 Pain associated with the rotator cuff is typically exacerbated with forward elevation of the arm and is often accompanied by nocturnal pain and the inability to sleep on the affected side.3 Dysfunction of the affected arm is common and, as a consequence, patients frequently report difficulty with activities of daily living, limitations with overhead use of the arm, and lack of strength, particularly above shoulder level.3 Loss of strength on external rotation is common with larger posterosuperior tears involving the infraspinatus, and loss of strength on internal rotation is associated with subscapularis tears and may limit using the arm behind the back.4
First-line management of rotator cuff tears includes conservative options, such as physiotherapy directed at regaining range of motion and dynamic rotator cuff strength, nonsteroidal anti-inflammatory agents, and corticosteroid injections.5 When conservative measures fail or are not acceptable to individual patients, surgical treatments may be offered. Of all the symptoms associated with rotator cuff tears, pain is the most amenable to improvement with surgery, although functional improvement also typically occurs.6
Both open and arthroscopic approaches are standard for the treatment of rotator cuff tears, and either approach may be used based on surgeon experience and training.7 Arthroscopic approaches offer the benefit of being minimally invasive, but both open and arthroscopic techniques are commonly used. The most common arthroscopic techniques are the single-row and double-row techniques, and suture-bridge configurations using suture anchors.8 There is a lack of clear evidence regarding which of these techniques is superior in terms of clinical outcomes and healing rates.
There is continued controversy surrounding the optimal treatment of massive rotator cuff tears. Historically, a rotator cuff tear was defined as massive if the tear was greater than 5 cm or if 2 or more tendons were detached.9,10 Recently, a Delphi consensus study on the definition of massive cuff tears concluded with 90% agreement that a massive cuff tear should be defined as tendon retraction to the glenoid rim in the coronal or axial plane and/or a tear with more than 67% of the greater tuberosity footprint exposed, as measured in the sagittal plane.11
Surgical intervention may be considered when non-operative management of massive cuff tears fails. Denard and colleagues12 reported a 91% success rate for repair in a study of 126 massive rotator cuff tears.12 However, a recent systematic review identified a re-tear rate of 79% following repair of massive rotator cuff repairs.13 The review identified 9 studies including 448 patients who were assessed with ultrasonography, magnetic resonance imaging, or computed tomography angiography at a minimum of 6 months following repair of a massive rotator cuff repair.
An unusual phenomenon has been observed with failed repairs of massive rotator cuff tears, which is that postoperative outcomes are still commonly improved (i.e., pain levels) in patients with structural failure of the repaired tendon.14 However, it has also been observed that functional outcomes are typically superior if the repair remains intact.15 Rotator cuff deficiency has also been shown to result in abnormal positioning of the humeral head in the glenoid fossa, typically with superior translation of the humeral head, resulting in eccentric loads across the glenohumeral joint.16 This can lead to abnormal wear patterns and subsequent arthritic changes.17–19
Owing to the high structural failure rates after arthroscopic repair of massive posterosuperior rotator cuff tears, several alternatives to repair have been proposed. Currently, the most common alternate options include partial repair of the rotator cuff, tendon transfers of the latissimus dorsi or lower trapezius,18 and superior capsular reconstruction (SCR).20 Additional surgical options, such as reverse shoulder arthroplasty,21 exist with long-term outcome data, and newer techniques, such as the subacromial balloon spacer,22 remain under investigation.
The incidence of acute traumatic rotator cuff tears ranges from 2.3% to 17.7% of all rotator cuff tears.23 These tears are often massive in size. It has been observed that over time, rotator cuff tears may increase in size and, if large enough, will gradually develop unwanted changes to the muscle quality, including atrophy and fatty infiltration.24 Fatty degeneration is irreversible and is associated with significantly higher tendon re-tear rates following surgical repair.24–26 Therefore, early surgical repair may result in higher rates of success in achieving complete tendon healing, and has the potential to prevent or arrest progressive fatty infiltration of the rotator cuff. However, there is a lack of consensus regarding optimal timing and level of improvement.
This position statement provides recommendations for selection of single-row versus double-row fixation in arthroscopic cuff repair based on objective and imaging outcomes, reviews soft-tissue treatment options for massive rotator cuff tears, and provides recommendations regarding optimal timing of surgical intervention in traumatic rotator cuff tears.
Methodology
A systematic review and meta-analysis was conducted.27 We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and SCR; and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach (Table 1 and Table 2).
Key to Grading of Recommendations, Assessment, Development and Evaluating Quality of Evidence
Implications of strong and conditional recommendations, by guideline user
Recommendations
Patients with full-thickness tears of the rotator cuff seeking surgical intervention should be counselled about the higher risk of objective failure regarding healing, but similar patient-reported outcomes with single-row compared to double-row fixation in arthroscopic rotator cuff repair (Strong, moderate).
Appropriately trained surgeons may consider a number of treatment options for massive tears of the rotator cuff, including partial arthroscopic cuff repair, LDT, LTT, and SCR, considering the similar overall patient-reported outcome measures in the short and medium term (Conditional, very low).
In the absence of reliable evidence regarding the optimal timing of surgical intervention for traumatic rotator cuff tears, current best practice is to treat traumatic rotator cuff tears within 12 weeks of injury, or as soon as reasonably possible (Conditional, very low). All summary statements refer to repair of the rotator cuff or other surgical options in the short-term (up to 2 yr), except when specified otherwise.
Single-row versus double-row fixation
We included the following procedures: arthroscopic single-row repair, arthroscopic double-row repair and suture-bridge repair. Fifteen randomized controlled trials were included in the meta-analysis6,28–41; only 1 of them evaluated the outcomes of suture-bridge repair.41
Single-row repair results in similar functional outcomes as double-row repair (standardized mean difference 0.08, 95% confidence interval [CI] −0.09 to 0.24). Similarly, postintervention pain as determined using a visual analogue scale (VAS) did not differ between single-row and double-row techniques (standardized mean difference −0.01, 95% CI −0.52 to 0.49) (Box 1 and Box 2). Healing of the tendon was more likely with double-row repair than with single-row repair; the relative risk of re-tear with single-row compared to double-row fixation was 1.56 (95% CI 1.06 to 2.29).
Summary statement 1, recommendation 1
Single-row fixation was similar to double-row fixation in arthroscopic cuff repair for the outcomes of:
Overall patient-reported outcome measures for function (moderate level of evidence)
Overall patient-rated pain measures (moderate level of evidence)
Summary statement 2, recommendation 1
Double-row fixation was superior to single-row fixation for the outcome of:
Objective measures of healing by ultrasonography or magnetic resonace imaging (moderate level of evidence)
Massive rotator cuff tears
We identified only 1 randomized trial comparing LDT with SCR.42 There was a statistically nonsignificant trend toward superiority in American Shoulder and Elbow Surgeons (ASES) functional scores in favour of SCR. The VAS scores did not differ significantly between treatments. We did not identify any randomized trials comparing LDT with LTTor partial repair. Three prospective comparative studies were included,43–45 and data were pooled from 2 studies comparing LTD with partial repair.43,44 Both studies reported minimum 12-month outcomes in 45 patients43 and in 40 patients,44 respectively, undergoing either LDT or partial repair. The functional outcome scores and pain scores were similar between groups (Box 3). Woodmass and colleagues45 compared arthroscopy-assisted LDT (n = 16) with arthroscopy-assisted LTT (n = 8) at 24-month follow-up. Functional and pain scores did not differ significantly between groups, although there was a trend toward higher functional scores in the LTT group.
Summary statement 3, recommendation 2
Latissimus dorsi transfer was similar to partial rotator cuff repair, lower trapezius transfer and superior capsular reconstruction for the outcomes of:
Overall patient-reported outcome measures for function (very low level of evidence)
Overall patient-rated pain measures (very low level of evidence)
Early versus late repair of traumatic rotator cuff tears
In the few studies that compared functional and pain outcomes in patients with traumatic rotator cuff tears, the timing of treatment varied considerably among the studies.46–49 In 3 of the 4 comparative studies, follow-up times were short (4, 9 and 14 mo, respectively), and 3 of the 4 studies did not show any significant differences in functional or pain outcomes between early and late intervention (Box 4).
Summary statement 4, recommendation 3
Current data are inconclusive for the outcomes regarding the optimal timing of treatment of traumatic tears of the rotator cuff; the available data indicate that “sooner is better,” but “how soon” is not accurately known at this time (very low level of evidence).
Discussion
Our systematic review included comparative studies of surgical procedures in the operative management of rotator cuff tears. Following a rigorous methodology, experts in shoulder surgery reviewed the available literature. Patient-reported outcomes and VAS pain scores were used to compare treatments.
Limitations
No clear conclusions could be drawn regarding the treatment of massive rotator cuff tears given the paucity of comparative data. We were unable to make any evidence-based recommendations regarding the optimal timing of surgical treatment for massive rotator cuff tears. However, we recommend treatment of traumatic large to massive rotator cuff tears within 3 months, given the possibility of progression of fatty infiltration and tendon retraction that may worsen with time.
Other than in the comparison between single- and double-row fixation, few randomized trials were found, and the grading of outcomes was generally low to moderate owing to small numbers of patients and the possibility of bias.
Conclusion
Surgeons counselling patients on operative options for rotator cuff repair should be aware that there are similar subjective outcomes in the medium term for single- and double-row fixation, but there are differences in objective tendon healing and structural failure between the 2 techniques. There is limited literature directly comparing functional outcomes or pain after the various surgical procedures for the treatment of massive rotator cuff tears. The level of comparative evidence for these procedures is low. Consequently, partial repair, SCR, LDT or LTT may be considered when surgery is indicated.
Footnotes
↵* This position statement was prepared by the authors and overseen by the CSES Guideline Management and Oversight Committee and the CSES Executive Committees.
Competing interests: George Athwal reports royalties or licences, and patents planned, issued or pending from ConMed Linvatec. No other competing interests were declared.
Contributors: P. Lapner and G. Athwal designed the study. P. Henry, J. Moktar, D. McNeil and P. MacDonald acquired the data. P. Lapner, J. Moktar, D. McNeil and P. MacDonald wrote the manuscript, which all authors critically revised. All authors gave final approval of the article to be published.
Disclaimer: This position statement was prepared by the authors and overseen by the Canadian Shoulder and Elbow Society (CSES) Guideline Management and Oversight Committee and the CSES Executive Committee. The summary statements in this document are opinions and/or consensus-based statements/recommendations; they may not necessarily consider physician or patient values and/or preferences. None of the statements are meant to serve as official guideline recommendations or exclusive course of treatment or procedure recommendations endorsed by the Canadian Orthopaedic Association.
- Accepted July 27, 2022.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
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