Evidence on the pros and cons of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive, a comparative effectiveness review concludes.
The bottom line from the researchers: the data are sparse, but patients improved substantially with all interventions; there were few clinically important differences between approaches, and complications were rare.
Most patients try to resolve their pain and disability with a course of physical therapy before attempting surgery, but the study found "very little good quality research to guide the choice of nonoperative treatment, the timing of treatment, and who would most benefit from various forms of treatment," senior researcher Dr. David M. Sheps from Canada's University of Alberta (in Edmonton) told Reuters Health by e-mail.
Dr. Sheps, a surgeon, added that "there is limited evidence to guide some of the surgical decision making."
He and his colleagues analyzed 137 randomized and nonrandomized trials, cohort studies, and case series in their review, which appeared online July 5th in the Annals of Internal Medicine. The number of study participants ranged from 12 to 224, with a median of 55 and an interquartile range of 33 to 93. Patients' average age ranged from 41 to 80 years.
Four out of five studies comparing surgical and nonsurgical management favored operative repair, but "the evidence was too limited to make conclusions regarding comparative effectiveness," the researchers said.
One randomized trial comparing early vs late surgical repair after failed nonoperative management found that mean functional outcome scores were better after early repair, but the trial investigators didn't report the statistical significance.
One hundred thirteen studies comparing various operations found no differences in functional outcomes between open vs mini-open repair, mini-open vs arthroscopic repair, arthroscopic repairs with vs without acromioplasty, and single-row vs double-row fixation.
Patients who had mini-open repair returned to work about a month earlier than patients who had open repair. On the other hand, functional improvement was better after open repair compared with arthroscopic debridement.
With regard to adding continuous passive motion to postoperative physical therapy, eleven trials yielded moderate evidence for no difference in function or pain. One study found no difference in range of motion or strength, while another suggested that adding continuous passive motion shortened the time until return to work and the time to 90 degrees abduction.
For other postoperative rehabilitation strategies, one study showed that standardized physical therapy produced better improvements in function than nonstandardized therapy, and progressive loading reduced pain compared to traditional loading. In general, though, most studies found no difference in health-related quality of life, function, pain, range of motion, and strength with one approach versus another (e.g., with or without aquatics, individualized vs at home alone, videotape vs therapist-based, etc.).
Complications were uncommon in the 64 studies that reported on them, and few were clinically important. Twenty-one studies reported no complications during follow-up.
In the 72 studies that assessed prognostic factors, older age, increasing tear size, and greater preoperative symptoms were consistently associated with recurrent tears, whereas gender, worker's compensation board status, and duration of symptoms usually did not predict poorer outcomes.
All the randomized controlled trials and controlled clinical trials contained sources of potential bias, such as inadequate blinding, inadequate allocation concealment, and incomplete outcome data. The methodological quality of the cohort and uncontrolled studies was moderate.
"It is crucial moving forward, that those health care professionals involved in the care of these patients continue to work toward the development and completion of higher quality trials to evaluate the various aspects of care mentioned in the article," Dr. Sheps said. "This would allow us as clinicians to practice in an evidence-based fashion and make more informed decisions regarding treatment options for our patients."
This comparative effectiveness review was commissioned by the Agency for Healthcare Research and Quality (AHRQ), lead author Jennifer C. Seida, also from the University of Alberta, told Reuters Health.
Ann Intern Med 2010.
Will Boggs, MD • Reuters Health Information © 2010