Treatment of Chronic Rotator Cuff Tears
Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears.
Rationale
Our systematic review identified one Level III study46 that compared conservative to surgical treatment of rotator cuff tears. In this study, sixty patients treated without surgery were compared to seventy-seven with rotator cuff repair. Per this study, in group A, tears were non-traumatic in 73% of cases and traumatic in 27% of cases. In group B, tears were non-traumatic in 32% of cases and traumatic in 68% of cases. Statistically significant less pain on shoulder range of motion and at night was seen in those patients who had surgery as compared to those with conservative treatment. Eighty-one percent of the surgical patients reported excellent results as compared to thirty-seven percent with conservative treatment although the authors did not report statistical significance in this comparison. Because there was only one Level III study to support this recommendation, we also examined Level IV articles.
We identified multiple Level IV articles47-52 on the influence of advanced muscle disease on rotator cuff repair. Six studies47-52 assessed MRI tear characteristics of fatty infiltration and/or muscle atrophy on outcome. One study47 reported that patients undergoing open, mini-open or arthroscopic repairs of full thickness tears had fatty atrophy or infiltration of the infraspinatus that led to lower ASES scores. Atrophy and infiltration of the supraspinatus did not correlate with ASES scores. Another study51 reported that the degree of preoperative supraspinatus atrophy correlated with postoperative Constant-Murley scores. Constant-Murley scores in patients with greater atrophy were associated with poorer outcome. Another study48 did not show a statistically significant correlation between preoperative fatty infiltration and postoperative Constant-Murley score. A final study50 showed positive correlation between decreasing postoperative UCLA scores and greater preoperative muscle degeneration as assessed by MRI. While these studies in total suggest that greater post operative functional deficits may occur in the presence of more significant muscle disease, the overall positive outcome of the surgery still suggests that operative treatment of chronic rotator cuff tears is an option.
Because this recommendation is supported by a single Level III article and several Level IV articles, the strength of the evidence that supports it is limited.
We identified multiple Level IV articles47-52 on the influence of advanced muscle disease on rotator cuff repair. Six studies47-52 assessed MRI tear characteristics of fatty infiltration and/or muscle atrophy on outcome. One study47 reported that patients undergoing open, mini-open or arthroscopic repairs of full thickness tears had fatty atrophy or infiltration of the infraspinatus that led to lower ASES scores. Atrophy and infiltration of the supraspinatus did not correlate with ASES scores. Another study51 reported that the degree of preoperative supraspinatus atrophy correlated with postoperative Constant-Murley scores. Constant-Murley scores in patients with greater atrophy were associated with poorer outcome. Another study48 did not show a statistically significant correlation between preoperative fatty infiltration and postoperative Constant-Murley score. A final study50 showed positive correlation between decreasing postoperative UCLA scores and greater preoperative muscle degeneration as assessed by MRI. While these studies in total suggest that greater post operative functional deficits may occur in the presence of more significant muscle disease, the overall positive outcome of the surgery still suggests that operative treatment of chronic rotator cuff tears is an option.
Because this recommendation is supported by a single Level III article and several Level IV articles, the strength of the evidence that supports it is limited.
- (46) Tabata S, Kida H, Takahara M, Yamaguchi S, Masuda K. A comparative study of non-surgical treatment and surgical treatment of complete tears of the rotator cuff. 241-244. 1987. Tokyo: Professional Postgraduate Service. Ref Type: Generic
- (47) Shen PH, Lien SB, Shen HC, Lee CH, Wu SS, Lin LC. Long-term functional outcomes after repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images. J Shoulder Elbow Surg 2008;17(1 Suppl):1S-7S.
- (48) Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med 2007;35(5):719-728.
- (49) Gerber C, Schneeberger AG, Hoppeler H, Meyer DC. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients. J Shoulder Elbow Surg 2007;16(6):691-696.
- (50) Mellado JM, Calmet J, Olona M et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. AJR Am J Roentgenol 2005;184(5):1456-1463.
- (51) Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair. J Bone Joint Surg Am 2007;89(8):1770-1776.
- (52) Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop Relat Res 1997;(344):275-283.