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Meta-Analysis
. 2020 Dec;29(12):2459-2475.
doi: 10.1016/j.jse.2020.07.030. Epub 2020 Aug 4.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response

David Kovacevic  1 , Robert J Suriani Jr  2 , Brian M Grawe  3 , Edward H Yian  4 , Mohit N Gilotra  5 , S Ashfaq Hasan  5 , Umasuthan Srikumaran  6 , Samer S Hasan  7 , Frances Cuomo  8 , Robert T Burks  9 , Andrew G Green  10 , Wesley M Nottage  11 , Sai Theja  2 , Hafiz F Kassam  2 , Maarouf A Saad  2 , Miguel A Ramirez  12 , Rodney J Stanley  13 , Matthew D Williams  14 , Vidushan Nadarajah  5 , Alexis C Konja  2 , Jason L Koh  15 , Andrew S Rokito  16 , Charles M Jobin  2 , William N Levine  2 , Christopher C Schmidt  17 ; American Shoulder and Elbow Surgeons Massive Cuff Evaluation and Research Initiative (ASES MERIT) Investigators
Affiliations
Meta-Analysis

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response

David Kovacevic et al. J Shoulder Elbow Surg. 2020 Dec.

Abstract

Background: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies.

Methods: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds.

Results: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate.

Conclusion: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Keywords: Irreparable massive rotator cuff tear; complications; failure rate; meta-analysis; patient-reported outcomes; reoperation; response to treatment; systematic review.

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Conflict of interest statement

Conflicts of interest/Disclosures:

David Kovacevic, MD: This author is a committee member of American Shoulder and Elbow Surgeons and Orthopaedic Research Society, and serves on the editorial or governing board for Journal of Bone and Joint Surgery.

Robert J. Suriani Jr, BA: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Brian M. Grawe, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Edward H. Yian, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Mohit N. Gilotra, MD: This author is a paid presenter / speaker for Arthrex Inc.

S. Ashfaq Hasan, MD: This author is a board / committee member of AAOS.

Umasuthan Srikumaran, MD MBA: This author receives financial or material support from Arthrex, DePuy, Smith & Nephew, Stryker, Thieme, and Wright Medical Technology; is a paid consultant for Conventus and Fx Shoulder; holds stock or stock options with Quantum OPS and Tigon Medical; receives research support from Stryker; has a family member who is an employee for Abbott; is a paid presenter / speaker for Fx Shoulder; and receives publishing royalties from Thieme.

Samer S. Hasan, MD PhD: This author receives financial or material support from Arthrex, DePuy, and DJ Orthopaedics; is a board / committee member for AAOS, American Shoulder and Elbow Surgeons; serves on the editorial / governing board for Arthroscopy and Orthopedics Today; receives research support from DJ Orthopaedics and OrthoSpace; is a paid presenter / speaker for Arthrex; is a paid consultant for DJ Orthopaedics and OrthoSpace; receives IP royalties from DJ Orthopaedics; holds stock of stock options with ROM3.

Frances Cuomo, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Robert T. Burks, MD: This author is a board or committee member of American Orthopaedic Society for Sports Medicine; paid consultant for DePuy Mitek; receives IP royalties and is an unpaid consultant for Arthrex; is a paid presenter / speaker for DePuy Mitek; and holds stock or stock options with KATOR.

Andrew G. Green, MD: This author receives financial / material support from Arthrex, JBJS, and Smith & Nephew; is a board / committee member of AAOS and American Shoulder and Elbow Surgeons; is a paid consultant for DJ Orthopaedics; holds stock or stock options with IlluminOss Medical and Pfizer; serves on the editorial / governing board for JBJS and Techniques in Shoulder and Elbow Surgery; is a paid presenter / speaker and receives research support from DJ Orthopaedics; receives publishing royalties from JBJS, and receives IP royalties from Wright Medical Technology.

Wesley M. Nottage, MD: This author is a board / committee member for the American Orthopaedic Society for Sports Medicine, the American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America; holds stock or stock options with Johnson & Johnson.

Sai Theja, MSc: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Hafiz F. Kassam, MD: This author serves on the editorial / governing board for the Journal of Shoulder and Elbow Arthroplasty.

Maarouf A. Saad, BS: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Miguel A. Ramirez, MD: This author serves on the editorial / governing board for the Journal of Shoulder and Elbow Surgery, is a paid consultant and paid presenter / speaker for Stryker.

Rodney J. Stanley, MD: This author is a board / committee member for the American Shoulder and Elbow Surgeons.

Matthew D. Williams, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Vidushan Nadarajah, BA: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Alexis C. Konja, MPH: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Jason L. Koh, MD: This author is a board / committee member for American Academy of Orthopaedic Surgeons, ACL Study Group, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, Herodicus Society, Illinois Association of Orthopaedic Surgeons, International Patellofemoral Study Group, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and the Patellofemoral Foundation; is a paid consultant for Flexion; holds stock or stock options with Acuitive and Marrow Access Technologies; is an employee of Marrow Access Technologies; and serves on the editorial or governing board for Orthopaedic Journal of Sports Medicine.

Andrew S. Rokito, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Charles M. Jobin, MD: This author is a paid consultant for Acumed LLC, Consortium of Focused Orthopedists LLC, DePuy, Wright Medical Technology, and Zimmer Biomet; is a paid presenter / speaker for Acumed LLC, Wright Medical Technology, and Zimmer Biomet; is a board / committee member for the American Shoulder and Elbow Surgeons and American Board of Orthopaedic Surgery; receives research support from Acumed LLC; and serves on the editorial / governing board for the Journal of the American Academy of Orthopaedic Surgeons.

William N. Levine, MD: This author is a board / committee member of the American Shoulder and Elbow Surgeons; serves on the editorial / governing board for the Journal of the American Academy of Orthopaedic Surgeons; is an unpaid design team member for Zimmer.

Christopher C. Schmidt: This author is a board / committee member of the American Shoulder and Elbow Surgeons; is a paid consultant for Arthrex.

Figures

Figure 1
Figure 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram representing search and screen process of studies reporting on nonoperative and operative treatment of irreparable massive rotator cuff tears. CENTRAL, Cochrane Central Register of Controlled Trials; PT, Physical therapy; D, Débridement; PR, Partial repair; GI, Graft interposition; TT, Tendon transfer; SCR, Superior capsular reconstruction; BA, Balloon arthroplasty; RSA, Reverse shoulder arthroplasty; FU, Follow-up; MRCT, Massive rotator cuff tear; RA, Rheumatoid arthritis.
Figure 2
Figure 2
Change in CMS for each treatment strategy compared to MCID threshold for either nonoperative or operative intervention. Sample size is directly proportional to the size of the circle (or triangle for arthroscopic tendon transfer). Influenced by the sample size, the red “x” denotes the weighted average change in CMS for all treatment strategies except tendon transfer. The “T” denotes the weighted average change in CMS for all tendon transfers. The blue “a” represents the weighted average change in CMS for arthroscopic tendon transfer. The green “o” represents the weighted average change in CMS for open tendon transfer. PT, Physical therapy; D, Débridement; PR, Partial repair; GI, Graft interposition; TTA, Arthroscopic tendon transfer; TTO, Open tendon transfer; SCR-HDA, Superior capsular reconstruction—human dermal allograft; SCR-TFL, Superior capsular reconstruction—tensor fascia lata autograft; BA, Balloon arthroplasty; RSA, Reverse shoulder arthroplasty; MCID, Minimum clinically important difference.
Figure 3
Figure 3
Change in ASES score for each treatment strategy compared to MCID threshold for either nonoperative or operative intervention. Sample size is directly proportional to the size of the circle. The red “x” denotes the weighted average change in CMS for all treatment strategies, which is influenced by sample size. PT, Physical therapy; D, Débridement; PR, Partial repair; GI, Graft interposition; TTA, Arthroscopic tendon transfer; TTO, Open tendon transfer; SCR-HDA, Superior capsular reconstruction—human dermal allograft; SCR-TFL, Superior capsular reconstruction—tensor fascia lata autograft; BA, Balloon arthroplasty; RSA, Reverse shoulder arthroplasty; MCID, Minimum clinically important difference.
See this image and copyright information in PMC

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