The provided PDF is a systematic review and meta-analysis titled “Management of Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Comparative Studies.“ The study aims to evaluate the effectiveness of various treatment strategies for irreparable massive rotator cuff tears (MRCTs).
Definition of MRCT
The definition of MRCT varies across studies. Some require a minimum tear size for diagnosis (i.e., ≥ 5cm), and others require a minimum number of involved tendons (i.e., two). Some studies require both a minimum tear size and a minimum number of involved tendons. The inconsistency in defining MRCT can affect treatment strategy and patient expectations.
The study evaluates several treatment strategies, including physical therapy, débridement, partial repair, graft interposition, tendon transfer, superior capsular reconstruction (SCR), balloon arthroplasty, and reverse shoulder arthroplasty (RSA).
Physical therapy, compared to surgical treatments, may have inferior outcomes. In the review, 60% of the patients did not respond to physical therapy or went on to have surgery.
Débridement and Partial Repair
Débridement and partial repair showed improvements in pain scores, functional range of motion, and patient-reported outcome (PRO) scores with lower reoperation rates compared to physical therapy. However, a drawback to partial repair was the high re-tear rate (45%).
Graft Interposition and Tendon Transfer
Graft interposition and tendon transfer showed superior improvements in pain scores, forward elevation, and mean change in CMS and ASES scores compared to physical therapy. However, arthroscopic-assisted tendon transfer utilizing greater tuberosity fixation techniques are favored over humeral bone tunnel fixation techniques due to high failure rates associated with the latter.
Superior Capsular Reconstruction (SCR) and Balloon Arthroplasty
SCR and balloon arthroplasty are relatively new procedures. Both led to an improvement in pain scores, forward elevation, and PRO scores. However, there is a high structural failure rate of SCR using human dermal allograft.
Reverse Shoulder Arthroplasty (RSA)
RSA was found to improve pain scores, functional motion, and PRO scores compared to physical therapy. However, this treatment strategy has an 8.2% reoperation rate and a 10.1% prosthesis failure rate.
Due to the paucity of high-quality clinical studies available for guiding management of irreparable MRCT, it is currently not possible to recommend for or against any specific treatment strategy. Rather, clinical experience, patient factors, patient expectations, and rotator cuff tear characteristics should guide clinical decision-making. There is a need to unequivocally define the MCID for various MRCT treatment strategies that will lead to improved interpretation of outcomes. Significant opportunities exist for multi-center research groups to embark on high-quality comparative clinical studies to improve our understanding and management of MRCT.
In a study titled “Comparative Effectiveness of Operative and Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis of a Nationwide Prospective Cohort from the Swedish Shoulder Arthroscopy Registry,“ the authors found that operative treatment for rotator cuff tears was associated with better patient-reported outcomes compared to nonoperative treatment. This finding aligns with the conclusion of the provided PDF that surgical treatments may have superior outcomes compared to physical therapy for irreparable MRCT.