Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis

Abstract

Objective: To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs).

Design: Systematic review and meta-analysis.

Data sources: MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020.

Eligibility criteria: All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions.

Data extraction and synthesis: Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane).

Results: We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%).

Conclusions: While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations.

Prospero registration number: CRD42017057908.

Keywords: adverse events; biotechnology & bioinformatics; orthopaedic & trauma surgery.

Figure 1

PRISMA flow chart of study selection. N, number; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SR, systematic review.

Figure 2

Forest plots comparing shoulder-specific functional outcomes scores at final follow-up for (A) Autografts, (B) Allografts, (C) Xenografts (non-SIS) or (D) Synthetic patches against standard repair alone. SIS, small intestine submucosa; IV, Random, a random-effects meta-analysis is applied, with weights based on inverse variances.

Figure 3

Forest plots comparing re-tear rates at final follow-up for (A) Autografts, (B) Allografts, (C) Xenografts (SIS) (D) Xenografts (non-SIS) or (E) Synthetic patches against standard repair alone. SIS, small intestine submucosa; MH, Random, a random-effects meta-analysis is applied, with weights based on the Mantel-Haenszel method.

Figure 4

Forest plots comparing postoperative pain at final follow-up for (A) Autografts, (B) Allografts, (C) Xenografts (non-SIS) or (D) Synthetic patches against standard repair alone. SIS, small intestine submucosa; IV, Random, a random-effects meta-analysis is applied, with weights based on inverse variances.