UNREPAIRABLE TEARS WITHOUT ARTHROPATHY (NON-REVERSE ARTHROPLASTY)

The recommendation was downgraded for heterogeneity, and generalizability. There are three high quality studies (Metcalfe, 2022; Ono, 2022; Wong, 2021) and two moderate quality studies (Ozturk, 2021; Verma, 2022) from the exhaustive research that the AAOS team performed on this PICO. Studies of high and moderate quality comparing specific treatments as below demonstrated conflicting results such as ballon spacer placement. Two studies suggest dermal allograft augmentation may provide benefit in patients with MIRCTs. One study indicated a better pain score with improved motion with SCR versus tendon transfer. The remaining studies are all low quality, and do not allow for definitive recommendations regarding management of MIRCTs without arthropathy.

Metcalfe et al (high quality) demonstrated worse outcomes (CM, function) despite improved WORC when comparing balloon spacer placement versus debridement.

Verma et al (moderate quality) concluded better WORC and forward elevation with balloon spacer placement versus partial repair and improved WORC versus debridement; other studies regarding this technique are of low quality.

Wong et al (high quality) demonstrated comparatively better WORC, DASH, AHD, forward elevation, and abduction with dermal allograft augmentation after “maximal rotator cuff repair with debridement.” Ono et al (high quality) demonstrated superior ASES scores in patients that underwent inter-positional human dermal allograft versus SCR at one year. This finding became nonsignificant at two-year follow-up. Ozturk et al (moderate quality) demonstrated improved pseudoparalysis and VAS pain scores with SCR versus tendon transfer with nonsignificant improvement in all other outcome measures.

Risks and Harms of Implementing this Recommendation
Nonsurgical and surgical options remain available to patients with MIRCTs without arthropathy. Those patients who are directed towards the nonsurgical path may not experience appreciable improvement in pain relief and/or function impacting his/her quality of life including independence with ADLs. Each surgical option has distinct risks and potential outcomes which may not be acceptable to the patient, thus requiring additional surgical intervention/revision.

Future Research
Future research is required to evaluate long term outcomes comparing non-surgical versus surgical and surgical versus surgical modalities in this clinical setting.