Surgical and Non-Surgical Interventions in Complete Rotator Cuff Tears

Abstract

Background: This systematic review compares the efficacy and safety of surgical and non-surgical interventions for full- thickness rotator cuff tears.

Methods: A systematic literature search was conducted in five databases. Randomized (RCTs) and non-randomized controlled trials of interventions (non-RCTs) for the surgical or non-surgical treatment of patients with traumatic or atraumatic full-thickness rotator cuff tears were included. The review protocol was published in the PROSPERO registry (CRD42018100343).

Results: Ten studies (three RCTs with 332 participants; seven non-RCTs with 650 participants) met the inclusion criteria. One year after treatment, shoulder function, measured with the 100-point Constant score, had improved by 6.7 points (95% confidence interval [2.3; 11.0]) and pain, measured with the 10-cm visual analog scale, by 1.1 cm (0.5; 1.7] in the full-thickness rotator cuff tears treated surgically compared with non-surgical treatment. In one study the difference in favor of surgery persisted after 10 years' follow-up. For other outcomes, such as range of motion, muscle strength, quality of life, and adverse events, the data were sparse and the group differences were similar. The findings of the non-RCTs were comparable with those of the RCTs.

Conclusion: With regard to functional improvement and pain reduction, surgical treatment of full-thickness rotator cuff tears was superior to non-surgical treatment in the short and the long term. Whether the differences between the groups are relevant for individual cases is uncertain, as the measured results were distributed below and above the threshold of clinical relevance. The conclusions may not be applicable to rotator cuff tears over 3 cm in size or to young persons.

Figure 1

PRISMA flow chart of study selection PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2a

Shoulder function (Constant score. 0–100 points. 100 = best outcome). Forest plots (based on data from RCTs) (A) Random sequence generation (selection bias) (B) Allocation concealment (selection bias) (C) Blinding of participants and personnel (performance bias) (D) Blinding of outcome assessment (detection bias) (E) Incomplete outcome data (attrition bias) (F) Selective reporting (reporting bias) (G) Other forms of bias not covered by A–F * Studies (– 20) Chi². Chi-squared test; CI. confidence interval; fixed. fixed-effects model analysis; IV. inverse variance; I². Higgins and Thompson heterogeneity test; mean difference. difference between baseline and follow-up measurements; SD. standard deviation; +. low risk of bias; -. high risk of bias; ?. unclear risk of bias

Figure 2b

Shoulder pain (visual analog scale. 0–10 cm. 0 cm = best outcome). NB: The algebraic sign of the mean differences were inverted so as to match the other scores. for which higher numbers show better outcomes (e.g.. the Constant score). (A) Random sequence generation (selection bias) (B) Allocation concealment (selection bias) (C) Blinding of participants and personnel (performance bias) (D) Blinding of outcome assessment (detection bias) (E) Incomplete outcome data (attrition bias) (F) Selective reporting (reporting bias) (G) Other forms of bias not covered by A–F * Studies (– 20) Chi². Chi-squared test; CI. confidence interval; fixed. fixed-effects model analysis; IV. inverse variance; I². Higgins and Thompson heterogeneity test; mean difference. difference between baseline and follow-up measurements; SD. standard deviation; +. low risk of bias; -. high risk of bias; ?. unclear risk of bias

Figure 2c

Muscle strength (Constant score. 0–25 points. 25 = best outcome) (A) Random sequence generation (selection bias) (B) Allocation concealment (selection bias) (C) Blinding of participants and personnel (performance bias) (D) Blinding of outcome assessment (detection bias) (E) Incomplete outcome data (attrition bias) (F) Selective reporting (reporting bias) (G) Other forms of bias not covered by A–F * Studies (– 20) Chi². Chi-squared test; CI. confidence interval; fixed. fixed-effects model analysis; IV. inverse variance; I². Higgins and Thompson heterogeneity test; mean difference. difference between baseline and follow-up measurements; SD. standard deviation; +. low risk of bias; -. high risk of bias; ?. unclear risk of bias

eFigure

Adverse events (longest follow-up) (A) Random sequence generation (selection bias) (B) Allocation concealment (selection bias) (C) Blinding of participants and personnel (performance bias) (D) Blinding of outcome assessment (detection bias) (E) Incomplete outcome data (attrition bias) (F) Selective reporting (reporting bias) (G) Other forms of bias not covered by A–F * Studies (– 20) Chi². Chi-squared test; CI. confidence interval; fixed. fixed-effects model analysis; I². Higgins and Thompson heterogeneity test; M-H. Mantel–Haenszel procedure; SD. standard deviation; ?+. low risk of bias; -. high risk of bias; ?. unclear risk of bias