Low level of evidence for all treatment modalities for irreparable posterosuperior rotator cuff tears
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This systematic review assesses evidence for improvements in outcome for all reported types of treatment modalities [physical therapy, tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis. The primary aim was to be able to inform patients about expectations of the amount of clinical improvement after these treatments.
A systematic search was conducted in MEDLINE, EMBASE, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral osteoarthritis, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of cuff tear irreparability were included. We defined the non-adjusted Constant Score as the primary outcome.
Sixty studies (2000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of ‘irreparable’ were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean preoperative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and physical therapy (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4–5-year) follow-up. Treatments deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8–10-year) follow-up and showed similar improvements in Constant Score at this time point.
The variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without osteoarthritis complicates sound comparison of treatments. Clinically important treatment effects were seen for all 11 different treatment modalities.
Level of evidence
KeywordsIrreparable rotator cuff tear Reversed shoulder arthroplasty Balloon spacer Graft Muscle transfer Superior capsular reconstruction Biceps Partial repair Tuberoplasty Deltoid flap
Magnetic resonance imaging
Superior capsular reconstruction
Reversed shoulder arthroplasty
Modified Coleman Methodology Score
Minimal clinically important difference
American Shoulder and Elbow Surgeons Score
University of California at Los Angeles score
Visual Analogue Scale
BK designed the study, performed the literature search, performed the analysis, and wrote the manuscript. NG performed the literature search and helped to draft the manuscript. AW participated in study design and helped to draft the manuscript. MB participated in study design and coordination and helped to draft the manuscript. DD participated in study design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
No funding was received for the present study.
Compliance with ethical standards
Conflict of interest
The authors have no conflicts of interest.
No ethical approval was sought, as this was a review study.
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