Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis.
Russell RD, Knight JR, Mulligan E, Khazzam MS. J Bone Joint Surg Am. 2014 Feb 19;96(4):265-71. doi: 10.2106/JBJS.M.00265.
Take Home Message: Patients who underwent rotator cuff repair have improved function and reduced pain, regardless of the structural integrity of the repair. Patients with an intact repair have greater strength than those with retears.
Rotator cuff repairs decrease pain and improve shoulder function. Despite these improvements, recurrent cuff tears and repair failures are common (20-94% of patients). After a rotator cuff repair, there may be discordance between the structural integrity of the rotator cuff and clinical outcomes. If this is true, it could influence our treatment strategies (e.g., do we need post-op imaging of the rotator cuff, are there other causes of shoulder symptoms). Therefore, Russell and colleagues conducted a meta-analysis to assess the relationship between functional outcomes and structural integrity of rotator cuff repairs. The authors performed a systematic review and a meta-analysis of Level-I and Level-II studies (randomized trials or prospective comparative studies) that reported outcome measures (minimum of 1 year follow-up) and an imaging assessments of the structural integrity of the repair (using magnetic resonance imaging, computed tomography, or ultrasound). Fourteen studies met inclusion criteria (861 patients combined). The authors extracted patient demographics, tear size, repair type, clinical outcome measures, and repair integrity. The average patient age was 58.5 years and the average follow-up was 30 months. Overall, 674 patients (78.3%) had intact repairs at the time of latest follow-up. There was no difference in tear size between patients with intact repairs and those with failed repairs. Patient-reported outcomes and pain scores improved (including UCLA, Constant, ASES, and Visual Analog Scale scores), regardless of structural integrity of the repair. Participants with intact repairs had better UCLA, Constant, and VAS scores than participants with failed repairs (retears), but the groups had similar ASES score. Additionally, participants with intact repairs had better strength in forward elevation (5.29 lbs) and had a trend toward greater strength in external rotation compared with participants with failed repairs. Despite statistical differences between participants with intact and failed repairs, the small magnitude of the differences in patient-reported outcomes and pain scores failed to meet a level of clinical importance, which the authors defined based on existing research.
The authors demonstrated that there is not a clinically-important difference in functional outcome scores or pain among participants with or without intact rotator cuffs following cuff repairs. Therefore, even when a rotator cuff repair does not heal, the patient will likely have good outcomes. This may suggest that routine imaging to evaluate repair integrity provides little to no benefit. Despite a lack of difference in patient-reported outcomes between groups, patients with intact repairs had better strength compared with those who had failed repairs. This finding is important, particularly with athletes, who may consider regaining strength a priority. Findings from this study raise additional questions in our understanding of rotator cuff disease and rotator cuff tendon healing and repair. For example, what makes a rotator cuff repair successful and what are possible causes of pain? Future studies should work to identify predictors of outcomes following surgical intervention in order to improve pre- and post-operative treatment strategies. In the meantime, this study provides us with important information to discuss with our patients and may lend credence for us to avoid routine imaging, which may help us reduce the financial and time burden on our patient.
Questions for Discussion: Based on results from this study, do you see any added benefit to using routine imaging to assess cuff repair integrity? Are you able to identify failed repairs in the clinic based on patient progress and strength?
Written by: Katie Reuther
Reviewed by: Jeffrey Driban
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