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Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears

Slides: 25–36 of 38
Comparative Effectiveness of Operative Repair for Rotator Cuff Tears (2)
In general, the studies showed few differences in function between interventions. However, outcomes differed in these comparisons. There was a moderate level of evidence that patients may return to work or sports approximately 1 month earlier if they have a mini-open repair vs. open repair (p < 0.00001). For the comparison of open repair vs. open or arthroscopic debridement, there is a moderate level of evidence that open repair results in greater improvement in functional outcomes than does debridement alone (p ? 0.03).

Comparative Effectiveness of Operative Repair for Rotator Cuff Tears (2)

Comparative Effectiveness of Operative Techniques for Rotator Cuff Tears
Operative techniques were examined in 15 comparative studies (6 randomized controlled trials, 1 controlled clinical trial, 8 cohort studies). The most frequently studied techniques were single-row vs. double-row suture anchor fixation (six studies). Overall the methodological quality of the studies was modest.

Comparative Effectiveness of Operative Techniques for Rotator Cuff Tears

Comparative Effectiveness of Operative Techniques for Rotator Cuff Tears
For all patient groups, regardless of technique, there were significant improvements in the postoperative functional, pain, and range-of-motion outcome measures when compared to preoperative scores. However, few of the techniques demonstrated clinically important differences between their respective groups on any of the postoperative measures; six studies comparing single-row vs. double-row repairs documented moderate evidence for statistical equivalence in function and cuff integrity. There was moderate evidence for no difference in cuff integrity between mattress locking and simple stitch. The evidence was too limited to make conclusions about the other techniques.

Comparative Effectiveness of Operative Techniques for Rotator Cuff Tears

Comparative Effectiveness of Postoperative Rehabilitation for Rotator Cuff Tears
Eleven studies evaluated postoperative rehabilitation protocols following surgery (10 comparative, 1 uncontrolled). Three compared continuous passive motion with physical therapy vs. physical therapy alone. For postoperative rehabilitation, studies included a median of 61 participants (interquartile range [IQR]: 36 to 79.5) with a median age of 58.0 years (IQR: 56.3 to 60.8). Males comprised an average of 58.9 percent of study participants.

Comparative Effectiveness of Postoperative Rehabilitation for Rotator Cuff Tears

Postoperative Rehabilitation Options for Rotator Cuff Tears
The postoperative rehabilitation comparisons studied in the 11 postoperative rehabilitation studies (10 comparative, 1 uncontrolled) are as follows: 
Physical therapy with or without continuous passive motion
Land-based therapy with or without aquatic therapy
Inpatient vs. day-patient rehabilitation
Home exercise program with or without individualized physical therapy programs
Early progressive activation and then resistive exercises vs. early immobilization followed by delayed progressive resistive exercise
Standardized vs. nonstandardized physical therapy programs
Videotape vs. physical therapy home-exercise instruction

Postoperative Rehabilitation Options for Rotator Cuff Tears

Comparative Effectiveness of Postoperative Rehabilitation for Rotator Cuff Tears
Three studies compared continuous passive motion with physical therapy vs. physical therapy alone. These three studies provided moderate evidence of no clinically important or statistically significant difference in function, but there was some evidence for earlier return to work with continuous passive motion. Overall, there was not enough quality evidence to determine the optimal postoperative rehabilitation protocol.

Comparative Effectiveness of Postoperative Rehabilitation for Rotator Cuff Tears

Additional Issues
Three small comparative studies assessed augmentation, such as grafts or patches, in the repair of a rotator cuff tear. However, evidence was too limited to permit conclusions. Although older age, increasing tear size, and extent of preoperative symptoms were associated with recurrent tears in several studies, evidence regarding the relationship of patient or disease characteristics to prognosis was too limited to permit definitive conclusions.
Complication Rates for Rotator Cuff Tear Interventions
A total of 85 studies provided data on 34 different complications of nonoperative, operative, and postoperative rehabilitation interventions. Complications were poorly reported, with studies providing limited information on how complications were defined and assessed. In 21 studies, it was reported that no complications occurred during the course of the study. In general, the rates of complications were low and most complications were not deemed to be clinically important or were reported only in a few studies. Throughout, “rate” referred to the number of patients who experienced complications during the study period. Study lengths varied, so no standardized time period was used. The rates of some of the most clinically important operative complications were as follows: retears ?10%, infection ?5%, stiffness ?8%, reflex sympathetic dystrophy ?2%, and neurological injury ?6%.

Complication Rates for Rotator Cuff Tear Interventions

Summary of Conclusions
Timing of Operative Intervention: Evidence was too limited to permit conclusions about the comparative effectiveness of early surgical repair when compared to late surgical repair following nonoperative interventions.  Operative vs. Nonoperative Interventions: Significant improvements were seen in all study groups, regardless of the intervention. Although there was a trend for better outcomes with surgery, results were too limited to permit conclusions. Nonoperative Interventions: The variety of interventions and the low quality of studies precludes any conclusions about the most effective nonoperative patient-management strategy.

Summary of Conclusions

Summary of Conclusions (2)
There was moderate evidence that functional outcomes were similar for open vs. mini-open repair; mini-open vs. arthroscopic repair; open or mini-open vs. arthroscopic repair; and arthroscopic repair with or without acromioplasty. However, exceptions were: Mini-open vs. open repair: Patients may return to work or sports approximately 1 month earlier if they have a mini-open repair (p < 0.00001); Open repair vs. open or arthroscopic debridement: Open repair results in greater improvement in functional outcomes than does arthroscopic or open debridement (p ? 0.03).
Summary of Conclusions (3)
Postoperative Rehabilitation: Overall, patients improved over the course of postoperative followup. However, there was not enough quality evidence to determine the optimal postoperative rehabilitation protocol. Adverse Events: In general, complication rates were low. The most commonly reported postoperative complications were infection and retears.
What To Discuss With Your Patients
Whether or not the symptoms of their rotator cuff (RC) tear can be addressed by nonoperative or operative interventions or both, and their values and preferences regarding these options. 
The patient’s role in adhering to a therapeutic plan whether it is nonoperative or operative, as well as in postoperative rehabilitation.
The types of surgery available if surgery is needed.
How postoperative rehabilitation will affect their overall clinical outcomes.
How long it may take before they will be able to return to their normal daily activities, depending on the required intervention.
Any other medical conditions or concerns they may have that will influence the decision to address the RC tear with nonoperative or operative interventions or both.

What To Discuss With Your Patients

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