Knee Surg Sports Traumatol Arthrosc (2015) 23:523–529 DOI 10.1007/s00167-014-3234-8

SHOULDER

Long‑term outcome after arthroscopic rotator cuff treatment Pietro Spennacchio · Giuseppe Banfi · Davide Cucchi · Riccardo D’Ambrosi · Paolo Cabitza · Pietro Randelli 

Received: 23 May 2014 / Accepted: 11 August 2014 / Published online: 22 August 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Abstract  Purpose  Arthroscopic techniques have become the gold standard in the operative management of several pathologic conditions of the shoulder. The purpose of this systematic review was to present the long-term outcomes following arthroscopic treatment of rotator cuff pathology. Methods  A comprehensive literature review was performed to identify studies reporting clinical or structural results of arthroscopic rotator cuff repairs (ARCRs) at least 5 years after surgery. Results  Ten articles were selected, which described 483 procedures. Study type, surgical approaches, complications, evidences of structural integrity of the repaired lesions, preoperative and postoperative functional scores are identified, analyzed and discussed. Satisfactory results are presented by all authors, and significant postoperative improvement is reported by all the studies with available preoperative data; 16 of 483 cases were re-operated. Conclusion  Although high-level evidences are lacking, ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. Current evidences are insufficient to clearly define the relationship between structural integrity of repaired cuffs and long-term clinical outcome. The P. Spennacchio (*) · D. Cucchi · R. D’Ambrosi  IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato, Milan, Italy e-mail: [email protected] G. Banfi  IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy P. Cabitza · P. Randelli  IRCCS Policlinico San Donato, Università degli Studi di Milano, San Donato, Milan, Italy

available data do not allow to draw conclusions regarding the long-term superiority of double-row versus single-row repairs. Level of evidence  Review of level II, III and IV studies, Level IV. Keywords  Rotator cuff tear · Arthroscopic repair · Long term · Clinical outcomes · Structural outcomes

Introduction Surgical management of rotator cuff tears (RCTs) is evolving rapidly, and the number of publications regarding arthroscopic rotator cuff repair (ARCR) increases dramatically every year [26]. Arthroscopic techniques are now considered the gold standard for treatment of most RCTs, providing similar functional results to open and mini-open surgery, with a decrease in postoperative complications [9, 27, 32]. A wide variety of different treatment modalities can be performed arthroscopically, and most publications report satisfactory results at short-term follow-up evaluation. However, no consensus exists on the duration of results over time. The goal of this study was to review systematically the literature and present the long-term results associated with the arthroscopic treatments of RCTs, in order to provide clinicians and researchers with an updated standpoint about the arthroscopic rotator cuff management.

Materials and methods Search strategy This study did not require ethic committee approval. A methodical review of the literature was performed to

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Knee Surg Sports Traumatol Arthrosc (2015) 23:523–529

Fig. 1  A flowchart shows the selection process of studies included in the review

identify all studies reporting a long-term follow-up after arthroscopic treatment of rotator cuff pathology. MEDLINE (1950 to January 2014) was searched by two independent investigators (RD and DC). The search terms used were “rotator cuff” AND [“tear” OR “repair” OR “healing”] and “shoulder arthroscopy”; MeSH terms were used for “tear”, “repair”, “healing” and “arthroscopy.” The references of relevant review papers were also searched. The initial search strategy revealed 7,778 articles for consideration. After a first screening-based exclusion criteria, 246 records remained; of these, 236 were excluded after abstract and full-text review on the basis of eligibility criteria. Ten studies were included in the review (Fig. 1). Eligibility and exclusion criteria Types of studies All randomized controlled trials and prospective cohort studies (level I and II studies) were included, as well as retrospective comparative trials (level III studies) and therapeutic case series (level IV studies). Reviews, meta-analyses, expert opinions and editorial pieces were excluded. Animal studies, in vitro studies and biomechanical studies on human cadaver specimens were also excluded.

different therapeutical approaches were excluded unless it was possible to identify and isolate data from the subgroup of patients who underwent all-ARCR. The minimum follow-up for inclusion was 5 years. Studies reporting longer average follow-up but in which the minimum follow-up was shorter or not specified were excluded unless it was possible to identify and isolate data from the subgroup with follow-up greater than 5 years. Therefore, all patients considered underwent not less than 5-year follow-up. Study selection and data collection Two independent reviewers (RD and DC), non-blinded to the author of the study or the journal in which they were published, performed a full-text review of the selected studies. Information regarding author, data and journal of publication, study design and level of evidence, patient demographics, modality for diagnosis, treatment intervention, follow-up duration, outcomes, complications and failure rates and evidence of tendon healing (either obtained from clinical tests, from histological findings or from imaging techniques) were extracted and entered into a spreadsheet for analysis.

Subjects, interventions and follow‑up Results Studies enrolling human subjects of all ages with RCTs who underwent arthroscopic rotator cuff lesion treatment (repair or debridement) were eligible for inclusion. No studies describing treatment options for shoulder instability, glenohumeral osteoarthritis or other pathologies different from RCTs were included. Studies investigating open or mini-open (arthroscopically assisted) procedures, diagnostic arthroscopies without either tendon repair or debridement, isolated arthroscopic biceps tenotomy and medical, injective or physical therapies for shoulder pain were excluded as well. Studies presenting results of

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Specific data from each of the ten articles that met the inclusion criteria are reported in Table 1 [2, 7, 8, 12, 13, 18, 24, 29, 30, 34]. Two level II (prospective cohort studies), one level III (retrospective comparative study) and seven level IV (therapeutic case series) studies were selected. The two level II articles actually refer to the same cohort, for which two different sets of outcomes were considered. The majority of the selected studies report outcomes generically associated with heterogeneous groups of rotator cuff lesions with no

II

II

IV

IV

III

IV

IV

IV

IV

IV

Gulotta et al. [12]

Gulotta et al. [13]

Marrero et al. [24]

Denard et al. [7]

Denard et al. [8]

Porcellini et al. [30]

Stuart et al. [34]

Budoff et al. [2]

Kartus et al. [18]

Paxton et al. [29]

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26

60

15

67

115

79

24

106

106

Patients

127.2 (120–NA)

101 (60–128)

114 (NA–NA)

162 (144–180)

NA (60–NA)

98.9 (62–149)

104.8 (84–NA)

151.7 (108–NA)

60 (NA–NA)

60 (NA–NA)

Follow-up, months [mean (range)]

Recurrent RCT after arthroscopic repair of large or massive tears, single-row repair

Partial-thickness RCTs, debridement and acromioplasty

Partial-thickness RCTs, debridement

PASTA lesion, transtendon repair

Irreparable supraspinatus tendon tear, functional repair

Massive RCTs, single-row or doublerow suture anchors

subscapularis tendon tears (isolated or part of massive RCT), subscapularis repair

Any RCT, single-row suture anchors

Any RCT, various techniques

Any RCT, various techniques

Type of lesion and surgical technique

Progression to full-thickness RCT (ultrasonography): 34.6 % Proximal migration of the humeral head (radiography): 91.6 % FF: 143.6° ER: 46.3° VAS: 2.2 ASES: 79.4 Constant score: 73.2 SST: 9.2 FF: 92° ER: 44° VAS: 5.2 ASES: 48.3

NA

NA

VAS: 2.0 Constant score: 65 Active FF: 150° Strength abduction: 4.7 kg

UCLA excellent or good: 79 %

UCLA: 32.5* SF-36: significant improvement in physical functioning, role-physical, bodily pain NA

NA

UCLA: 17.9 SF-36

Constant score: 44 SST: 4.6

AHD (radiography): 9.1 mm*

NA FF: 167.8°* VAS: 1.3* UCLA: 30*. ASES: 81.6* Constant score: 73* SST: 9.0*

NA

FF: 172°* UCLA: 30.1* ASES: 88.5* VAS: 1.5* SANE: 89.8

FF: 139° UCLA: 16.5 ASES: 40.8 VAS: 6.3 SANE: NA FF: 132.5° VAS: 6.3 UCLA: 15.8 ASES: 41.7

NA

NA

NA

UCLA: 31.8 Strength abduction grade 5: 76 % FF>150°: 94 %

Healing rate (ultrasonography): 81.2 %

ASES: 93.4* Passive ER: 70.0° Passive FF: 168.6°* Strength FF (MRC): 4.8* Strength ER (MRC): 4.8*

Postoperative

Structural postoperative outcome

NA

ASES: 52.6 Passive ER: 60.5° Passive FF: 151.9° Strength FF (MRC): 3.8 Strength ER (MRC): 4.0

ASES: 52.6 Passive ER: 60.5° Passive FF: 151.9° Strength FF (MRC): 3.8 Strength ER (MRC): 4.0

Preoperative

Functional scores

* values that changed significantly related to the preoperative values

LOE level of evidence, SST simple shoulder test, AHD acromion–humeral distance, NA not available, RCT rotator cuff tear, ASES American Shoulder and Elbow Surgeons score, ER external rotation, FF forward flexion, MRC Medical Research Council, VAS visual analog scale, UCLA University of California, Los Angeles score, PASTA partial articular-sided supraspinatus tendon avulsion, SF-36 Short Form 36 score, SANE single assessment numeric evaluation

LOE

Reference

Table 1  Specific data from the ten articles included in the review

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stratification of the clinical results for the different patterns of RCTs (Table 1). Altogether, 483 procedures were considered; all results were published between 2005 and 2013. Gulotta et al. designed the only prospective study (level II) with the goal of defining prognostic factors associated with long-term outcomes following ARCR [12, 13]. Younger age and single-tendon tears were reported as predictive factors of radiographic healing, with no correlation between resolution of a radiographic defect and clinical results at the 5-year follow-up. The authors also described [12, 13] the ability of some defects to heal spontaneously, referring a statistically significant increase in the ultrasound-documented healing rates from 64.3 to 81.2 % at 1and 5-year follow-up, respectively. The published results of arthroscopic repair of full-thickness tears with the longest follow-up are that from Marrero et al. [24], who reported, the clinical outcomes of 33 RCTs of any size, all repaired with a single-row technique. University of California, Los Angeles (UCLA) score revealed excellent and good results in 87.7 % of the cases. Denard et al. [7] were the only who analyzed long-term outcomes associated with subscapularis tendon repair. The authors observed that the size of the subscapularis lesion did not affect long-term clinical results, with a rate of patient satisfaction over 90 % at a mean follow-up of nearly 9 years. Isolated subscapularis tendon repairs represented 11 of the 79 arthroscopically repaired RCTs. However, the associated outcomes were not reported separately, avoiding a comparison between isolated subscapularis lesions and other RCTs patterns. Denard et al. [8] compared in another paper the outcomes associated with single-row and double-row fixation of massive rotator cuff lesions. In their series, a double-row repair was 4.9 times more likely to lead to a good or excellent functional outcome by UCLA score. Porcellini et al. [30] also dealt with massive RCTs and evaluated the clinical results and the radiological measurement of the acromion–humeral distance (AHD) associated with partial repair of irreparable supraspinatus tendon tears. Statistically significant improvement in all the analyzed outcomes was reported. Authors also described a not statistically significant positive trend between best preoperative Constant scores and best increases in AHD. For what concerns treatment of partial RCTs, Stuart et al. [34] published the long-term results following arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion (PASTA) lesions, reporting significant improvements in the outcome scores at a minimum follow-up of 12 years. In this study, the majority of the patients underwent concomitant procedures. Other than Stuart’s report [34] two other studies focused on arthroscopic treatment of partial RCTs [2, 18]. Budoff et al. [2] reported 79 % excellent or good results after

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Knee Surg Sports Traumatol Arthrosc (2015) 23:523–529

arthroscopic rotator cuff debridement of partial-thickness RCTs, describing a significant association between the success rate and the thickness of the lesion. In cases of partialthickness tears of 50 % thickness or greater, good or excellent results were 54 %, whereas arthroscopic debridement of tears of