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To study the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following arthroscopic rotator cuff repair (ARCR) at a minimum of 10-years follow-up.
Methods
Two independent reviewers performed a literature search of PubMed, Embase, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only studies reporting on outcomes of ARCR with a minimum 10-year follow-up were considered for inclusion. Patient demographics, satisfaction, and clinical, radiologic, and surgical outcomes were evaluated.
Results
Our search found 9 studies including 455 shoulders in 448 patients (51.6% male patients), with age at time of surgery ranging from 45 to 90 years met our inclusion criteria. Overall follow-up ranged from 10 to 18 years. At final follow-up, the ranges of American Shoulder & Elbow Surgeons, age- and sex-adjusted Constant–Morley, and University of California Los Angeles scores were reported in 5, 6, and 3 studies, respectively, as 79.4 to 93.2, 73.2 to 94, and 26.5 to 33, respectively. Of the included studies, satisfaction rates varied in 6 studies from 85.7% to 100% in the long-term. Additionally, the overall radiologic retear rate ranged from 9.5% to 63.2%. The overall surgical revision rates ranged in 6 studies from 3.8% to 15.4%, with from 0% to 6.7% requiring revision ARCR and from 1.0% to 3.6% requiring revision subacromial decompression in 6 and 2 studies, respectively, at minimum 10-years’ follow-up.
Conclusions
In this study, we found that ARCR results in high rates of patient satisfaction, satisfactory clinical outcomes with respect to patient-reported functional outcomes and range of motion, and low revision rates at minimum 10-years’ follow-up. However, an overall 30% retear rate was observed in asymptomatic patients.
Level of Evidence
Level IV, systematic review of Level II-IV studies.
Rotator cuff tears (RCTs) represent a common cause of shoulder pain for patients globally, with more than two-thirds of patients older than the age of 70 years in the general population suffering RCTs in the absence of trauma.
In the first instance, many RCTs may be managed conservatively with acceptable functional outcomes in the medium-term, particularly in the elderly patient with lower functional demands.
However, surgical repair is often indicated in degenerative cases refractory to initial conservative management as well as acute traumatic tears in active patients.
Until recently, the majority of literature with respect to the management of RCTs focused primarily on outcomes following open rotator cuff repair (ORCR), with low retear rates reported in the long-term.
However, arthroscopic rotator cuff repair (ARCR) has emerged as the gold standard treatment option for such patients in recent years, with shorter length of hospital stay, lower postoperative pain levels, shortened recovery times, and improved cosmesis.
A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: Disease-specific quality of life outcome at an average 2-year follow-up.
our understanding of longer-term outcomes after arthroscopic RCR is limited.
The purpose of this study was to evaluate the functional outcomes, radiologic outcomes, and revision rates following ARCR at a minimum of 10-years’ follow-up. Our hypothesis was that ARCR would result in satisfactory clinical outcomes (including excellent patient-reported functional outcomes and excellent range of motion), with modest revision rates for retears at minimum 10-years follow-up.
Methods
Search Strategy
Two independent reviewers (M.S.D. and P.J.C.) performed a systematic review of the literature with reference to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. In September 2021, the following search terms were used for our literature search of the PubMed, Embase, and Scopus databases: ((long-term or long term or 10 year or ten year) and (follow-up or follow up) and (arcr or arthroscopic rotator cuff repair)). It was predetermined that no time limit would be applied to the search. Following the removal of duplicate studies, manual screening of the titles and abstracts of all studies from the initial search was performed by both reviewers independently while applying our exclusion criteria, with the senior author acting independently as an arbitrator in cases of disagreement. Following this, the same 2 reviewers independently evaluated the full texts of all potentially eligible studies using predetermined inclusion criteria.
Eligibility Criteria
Before commencement of the search, all authors discussed and agreed on the predetermined inclusion, exclusion criteria, and data-collection sheet for this study. The inclusion criteria for this study included the following parameters: (1) any clinical study evaluating outcomes of ARCR with a minimum of 10-years’ follow-up, (2) published in English, and (3) full text available following publication in a peer-reviewed journal. The exclusion criteria included (1) any clinical study evaluating outcomes of ORCR or mini-ORCR alone, (2) studies evaluating revision procedures, (3) biomechanical studies, (4) cadaveric studies, (5) abstract-only studies, and (6) case reports. It was predetermined that studies that pooled results of studies with ARCR and ORCR and did not delineate and report results of each procedure independently would be excluded.
Data Extraction & Outcomes of Interest
Two reviewers (M.S.D. and P.J.C.) independently evaluated each of the published manuscripts of the included studies with a focus of gathering all relevant data. Study characteristics and patient demographics of interest included (1) minimum and mean follow-up, (2) study design, (3) Level of Evidence as described by Wright et al.
Studies of surgical outcome after patellar tendin-opathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group.
(5) number of included shoulders, (6) mean patient age at time of follow-up, (7) patient sex, and (8) ARCR technique/implants used. Outcomes of interest included (1) reported pain levels using visual analog scale scores; (2) Constant–Morley (CM) scores, including (a) age/sex-adjusted scoring, (b) pain, (c) activity, (d) mobility, and (e) strength; (3) American Shoulder and Elbow Surgeons (ASES) scores; (4) Quick Disabilities of Arm, Shoulder and Hand scores; (5) University of California Los Angeles (UCLA) scores; (6) subjective shoulder values; (7) Simple Shoulder Test; (8) Single Assessment Numeric Evaluation; and (9) satisfaction rates, with those reported in the included studies as “very satisfied” or “satisfied” being pooled into a single “satisfied” group for the purpose of this study; (10) tangent sign positive; (11) range of motion including flexion, abduction, internal rotation, and external rotation; (12) radiologic outcomes at time of latest follow-up, including (a) retear rates as depicted on ultrasound assessment, (b) retear rates as depicted on magnetic resonance imaging (MRI) assessment, (c) osteoarthritis staging of the glenohumeral joint as reported on plain film radiographs using the criteria described by Hamada et al., (d) fatty infiltration of the supraspinatus (SS) and infraspinatus (IF) tendons (defined as Goutallier classification III or IV) as depicted on MRI; and (13) subsequent revision surgeries rates including (a) revision ARCR, (b) removal of metal/implant, (c) subacromial depressions (SADs), (d) arthroscopic washout and debridement, and (e) arthroplasty surgeries, among others by final follow-up.
Statistics
Quantitative statistical analysis of data, stored in a password-protected worksheet, was performed using SPSS, version 22.0 (IBM Corp., Armonk, NY). A P-value of less than .05 was deemed to be statistically significant.
Results
Literature Search
In total, the initial literature search resulted in 843 studies. There were 234 duplicate studies overall, which, following manual removal, resulted in 609 studies remaining, which were screened using our exclusion criteria. Thereafter, our inclusion criteria were applied to the full texts of the remaining 56 studies to screen for eligibility. Using our predetermined eligibility criteria, a total of 9 clinical studies including 455 shoulders were included in this review (Fig 1).
Fig 1Preferred Reporting Items for Systematic Reviews and Meta-analyses flow chart.
The 9 included studies (including 1 Level II study, 2 Level III studies, and 6 Level IV studies) composed of 455 shoulders that underwent ARCR with a minimum of 10-years follow-up.
Long-term outcomes after arthroscopic transosseous-equivalent repair: Clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.
Long-term results of arthroscopic rotator cuff repair: initial tear size matters: A prospective study on clinical and radiological results at a minimum follow-up of 10 years.
There were 3 studies from the United States, and one from each of Austria, Brazil, France, Italy, Switzerland, and Turkey. Risk of bias assessment using the Methodological Quality of Evidence varied from 43 to 75 for the included studies. This review included a total of 448 patients (51.6% males) aging from 45 to 90 years of age at time of surgery. The overall follow-up was 120 to 216 months. None of the included studies reported outcomes of control group at minimum 10-years follow-up. A summary of study characteristics and patient demographics are further illustrated in Tables 1 and 2, respectively.
Long-term outcomes after arthroscopic transosseous-equivalent repair: Clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.
Long-term results of arthroscopic rotator cuff repair: initial tear size matters: A prospective study on clinical and radiological results at a minimum follow-up of 10 years.
Long-term outcomes after arthroscopic transosseous-equivalent repair: Clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.
Long-term results of arthroscopic rotator cuff repair: initial tear size matters: A prospective study on clinical and radiological results at a minimum follow-up of 10 years.
The most commonly used functional outcome score was ASES, reported in 343 patients in 5 studies post-ARCR. The ASES scores reported in 343 patients varied from 79.4 to 93.2. In addition, the mean CM scores (adjusted for age and sex), which were reported in 6 studies in 247 patients, varied from 73.2 to 94. Satisfaction was reported in a total of 5 studies including 257 patients, varying from 85.7% to 100% at minimum 10-years follow-up.
Forward flexion and external rotation were in combination the most commonly reported range of motion angles measured, with only 3 studies including 92 patients reporting mean forward flexion varying from 142.4° to 170° and mean external rotation from 22.9° to 64° at minimum 10-years’ follow-up post-ARCR. Mean abduction varied from 116.2° to 166° at final follow-up, as reported in 77 patients from 2 studies, with no studies reporting on internal rotation. A summary of clinical outcomes is further illustrated in Table 3.
Table 3Clinical Outcomes
Outcome ± SD
No. Studies
Total (%)
Range
Shoulder, n
9
455
–
Patients, n
9
448
–
Males (%)
6
206/399 (51.6%)
–
Mean age, y
9
70.7 ± 3.7
45-90
Mean F/U, mo
9
146.9 ± 21.8
120-216
ASES
5
89.9 ± 6.1
50-100
CM Adjusted
6
86.5 ± 7.4
20-129
CM Standard
4
75 ± 7.9
14-97
CM - Pain
3
10.2 ± 5.7
6-15
CM - Activity
3
17.9 ± 8.6
5-20
CM - Mobility
3
36.4 ± 4.3
6-40
CM - Strength
3
7.1 ± 1.2
2-25
SANE
2
80.6 ± 4.8
NR
Satisfaction (%)
5
251/257 (97.7%)
–
SST
2
10.2 ± 0.8
6-12
SSV
2
89.8 ± 2.8
30-100
Tangent positive (%)
2
8/76 (10.5%)
–
UCLA
3
29.9 ± 3.6
4-35
VAS
4
1.2 ± 0.8
0-7
Abduction
2
152° ± 35
80-160
External rotation
3
52° ± 21
5-75
Flexion
3
159° ± 15
70-170
ASES, American Shoulder and Elbow Surgeons; CM, Constant–Morley; F/U, follow-up; N, Number, NR; not reported, SANE, Single Assessment Numeric Evaluation; SD, standard deviation; SST, simple shoulder test; SSV, subjective shoulder value; UCLA, University of California Los Angeles; VAS, visual analog scale
The overall radiologic retear rate varied from 9.5% to 63.2% among included studies. In 3 studies, the retear rate was found to be from 9.5% to 27.3% using MRI at 10-years’ minimum follow-up. In addition, in 2 studies, the retear rate ranged from 46.5% to 63.2% using ultrasound at latest follow-up.
A total of 4 studies reported fatty infiltration rates on MRI, with rates varying from 23.1% to 83.3% having Grade 3 or 4 fatty infiltration of either the SS and/or IF tendons. Of these, 23.4% (39/167) and 9.6% (16/167) of patients had Grade 3 or 4 fatty infiltration in isolation of either the SS or IF tendons, respectively, with 8.3% (14/167) of patients having both.
Surgical Revisions
The reoperation rate was reported in 6 studies ranging from 3.8% to 15.4% at minimum 10-years’ follow-up. The rate of revision ARCR and revision SAD was reported in 6 and 2 studies, respectively, as varying from 0.0% to 6.7% and 1.0% to 3.6% post-ARCR at final follow-up, respectively. The other subsequent surgeries in the absence of revision ARCR consisted of 2 patients (1.9%) who required manipulation under anesthesia with capsulotomy for shoulder stiffness, whereas 2 other patients (1.4%) in isolation underwent debridement and revision SAD for persistent pain and impingement of the ipsilateral shoulder. Of note, only 1 patient who required revision ARCR also subsequently underwent hemiarthroplasty of the ipsilateral shoulder following the development of severe rotator cuff arthropathy. A summary of radiologic findings and surgical revisions is further illustrated in Table 4.
Table 4Radiologic Findings and Surgical Revisions
Outcome
No. Studies
Total
Percentage
Retears
Overall
5
87/295
29.5%
Detected on MRI
2
59/120
49.2%
Detected on US
3
28/175
16.0%
Retear, medium
2
7/74
9.5%
Retear, large
2
9/40
22.5%
Retear, massive
2
12/31
38.7%
Fatty infiltrates (Goutallier Grade 3+)
IF
4
53/167
31.7%
SS
4
30/167
18.0%
SS and IF
4
69/167
41.3%
Osteoarthritis (Hamada classification)
Stage 1
2
10/31
32.3%
Stage 2
2
7/31
22.6%
Stage 3
2
5/31
16.1%
Stage 4a
3
18/133
13.5%
Stage 4b
3
22/133
16.5%
Stage 5
1
2/102
2.0%
Stage 4a, 4b, and 5
3
42/133
31.6%
Surgical revisions
Total reoperations
6
18/272
6.6%
Revision ARCR
6
14/272
5.2%
MUA + capsulotomy
2
2/104
1.9%
Debride and revision SAD
2
2/147
1.4%
Concomitant revisions with revision ARCR
ACJ resection
1
1/13
7.7%
Adhesiolysis
2
1/91
2.2%
Hemiarthroplasty
1
1/18
5.6%
Irrigation and debride
1
1/91
1.1%
MUA + capsulotomy
2
2/104
1.9%
Revision SAD
2
1/147
0.7%
ACJ, acromioclavicular joint; ARCR, arthroscopic rotator cuff repair; debride, debridement; IF, infraspinatus; MRI, magnetic resonance imaging; MUA, manipulation under anesthesia; SAD, subacromial decompression; SS, supraspinatus; US, ultrasound.
The most important finding in this study is that ARCR results in favorable functional outcomes with low revision rates at minimum 10-years follow-up. Patients reported high satisfaction rates, despite radiologic evidence of retear in almost one-third of asymptomatic patients who underwent imaging as part of their long-term follow-up.
ARCR has emerged in recent years as the gold standard procedure for patients with RCTs that warrant surgical intervention. Although reported long-term functional outcomes of ORCR in the literature are acceptable to patients and surgeons alike, the less-invasive nature of ARCR has resulted in significantly lower postoperative pain levels, shortened recovery times, and improved cosmesis in the short-term postoperatively.
reported that ARCR represents a safe and effective option to treat symptomatic RCTs, which provides acceptable functional outcomes at minimum 5-years follow-up. In our study, we found that patients had satisfactory functional outcomes, including mean ASES, CM, and UCLA scores of approximately 90, 87, and 30, respectively, at 10-years’ minimum follow-up. In addition, the authors acknowledge the findings of the study by Marrero et al.
; although their study did not meet the strict inclusion criteria of minimum 10-years’ follow-up for all included patients, the authors reported good functional outcomes at a mean 12.6-years’ follow-up (range, 9.2 to 19.4 years), with UCLA scores of 31.8. Therefore, the results of our study suggest that ARCR represents a viable treatment option for patients with symptomatic RCTs that results in durable functional outcomes well into the second postoperative decade, with high rates of patient reported-satisfaction.
Although satisfactory functional outcomes have been reported post-ARCR at long-term follow-up across all included studies in this review, previous literature has raised concerns in relation to significantly greater revision rates following ARCR when compared with ORCR in the medium-term.
previously reported a 3.3% revision rate at medium-term follow-up post-ARCR. The authors also acknowledge the requirement of further manipulation under anesthesia in patients with adhesive capsulitis following ARCR, with rates of 3% reported in the short-term.
Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: A comparative study.
However, our study demonstrates that there does not appear to be a substantial rate of further interventions in the medium- to long-term follow-up, with a rate of 6% reported in our study after at least 10-years follow-up. In addition, it is noteworthy that approximately 80% of such repairs included revision ARCR, with three-quarters of such patients requiring an additional concomitant procedure at the time of revision ARCR. These findings reflect the results of Marrero et al.,
with a revision surgery rate of 6.1% in their 33 patient series at 12-years mean follow-up post-ARCR. Therefore, although the rate of surgical revisions varies from 0% to 15% at long-term follow-up among the included studies in this review, it is likely that a steady rise in revisions may be expected following ARCR at minimum 10-years’ follow-up, when compared with those reported in the medium-term.
The low rate of symptomatic retear seen in this systematic review is reassuring, and we note that further arthroscopic soft-tissue surgery is generally feasible with a relatively low rate of revision to prosthesis.
Limitations
This study is not without limitations. The most obvious limitation in this study is that there is a variety of surgical techniques employed for various types of RCTs, with heterogeneity in results reported among the included studies. In addition, no analysis of specific anchor usage, type of anesthesia, or postoperative rehabilitation protocols has been carried out, which may vary greatly among the included studies. Furthermore, this study is a systematic review of all levels of evidence, it inherently suffers from the innate limitations of these studies. All except one of the included studies in this review are retrospective in nature and therefore represent studies of lower Level of Evidence. In addition, a number of the included studies in this systematic review failed to report results that represent the outcomes of interest outlined in this study, and therefore although this has been highlighted in the manuscript, the pooled analyses of outcomes are not truly reflective of all studies reporting outcomes of ARCR at minimum 10-years’ follow-up. There also is a lack of randomization among the included studies, which may potentially represent a source of selection bias.
Conclusions
In this study, we found that ARCR results in high rates of patient satisfaction, satisfactory clinical outcomes with respect to patient reported functional outcomes and range of motion, and low revision rates at minimum 10-years’ follow-up. However, an overall 30% retear rate was observed in asymptomatic patients.
A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: Disease-specific quality of life outcome at an average 2-year follow-up.
Studies of surgical outcome after patellar tendin-opathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group.
Long-term outcomes after arthroscopic transosseous-equivalent repair: Clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.
Long-term results of arthroscopic rotator cuff repair: initial tear size matters: A prospective study on clinical and radiological results at a minimum follow-up of 10 years.
Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: A comparative study.
The authors report that they have no conflicts of interest in the authorship and publication of this article. ICMJE author disclosure forms are available for this article online, as supplementary material.
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