integrity after rotator cuff repair does not correlate with patient function
and pain: a meta-analysis.
Mulligan E, Khazzam MS. J Bone Joint Surg Am. 2014 Feb 19;96(4):265-71. doi:
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.
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.
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.
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?
Russell RD, Knight JR, Mulligan E, & Khazzam MS (2014). Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis. The Journal of Bone and Joint Surgery. American Volume, 96 (4), 265-71 PMID: 24553881