Systematic Review With Video Illustration An Evidenced-Based Examination of the Epidemiology and Outcomes of Traumatic Rotator Cuff Tears Nathan A. Mall, M.D., Andrew S. Lee, B.S., Jaskarndip Chahal, M.D., F.R.C.S.C., Seth L. Sherman, M.D., Anthony A. Romeo, M.D., Nikhil N. Verma, M.D., and Brian J. Cole, M.D., M.B.A. Purpose: The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears. Methods: An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data. Results: Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to 5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81?to 150?postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77. Conclusions: Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the sub- scapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair. Level of Evidence: Level IV, systematic review Levels III and IV studies. R patients regardless of symptoms discovered that those with ultrasound-proven rotator cuff tears had worse Simple Shoulder Test (SST) and Constant scores than those with an intact cuff.2Another recent study of the natural history of rotator cuff tears found that outcome scores were significantly lower for symptomatic tears than asymptomatic tears.3When rotator cuff tears occur in the younger, working population, these injuries can cause significant lost wages or time lost from work. Recently, information morphology and natural history of chronic or atrau- matic rotator cuff tears has been reported.3,4Several studies have revealed that the prevalence of these injuries increases with age.5-7Also, tears appear to begin in an area posterior to the biceps and propagate in both directions.4Although many of these tears begin asymptomatically, at least 20% progress to symptom- atic tears in only a few years.3Unfortunately, very little has been published on the epidemiology, prevalence, or natural history of traumatic, acute rotator cuff tears. In many cases, a trial of nonoperative management prior to surgical repair is indicated for patients with atraumatic but symptomatic rotator cuff tears. However, the short- and long-term success rates after conservative care remain poorly defined. Contemporary literature suggests that irreversible fatty atrophy and ultrastruc- tural changes occur after rotator cuff discontinuity.8-10 As a result, there is a need to delineate the indications and timing for surgical intervention to avoid any controversy and to establish the direction for treatment. otator cuff tears are a source of significant morbidity for patients.1A study examining 200 regarding the From the Sports Medicine Program (N.A.M., A.S.L., J.C., A.A.R., N.N.V., B.J.C.), Department of Orthopaedic Surgery (A.A.R., N.N.V., B.J.C.), Hand, Elbow, and Shoulder Surgery Program (A.A.R.), Department of Anatomy and Cell Biology (B.J.C.), and Cartilage Restoration Center (B.J.C.), Rush University Medical Center, Chicago, Illinois; and Department of Orthopaedic Surgery (S.L.S.) and Sports Medicine Program (S.L.S.), University of Missouri School of Medicine, Columbia, Missouri, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 17, 2012; accepted June 25, 2012. Address correspondence to Brian J. Cole, M.D., M.B.A., Department of Orthopaedics, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612, U.S.A. E-mail: firstname.lastname@example.org Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America 0749-8063/12331/$00.00 http://dx.doi.org/10.1016/j.arthro.2012.06.024 366 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 2 (February), 2013: pp 366-376
367 TRAUMATIC ROTATOR CUFF TEARS Table 1. Inclusion and Exclusion Criteria of Search After traumatic rotator cuff tear, early surgery may be indicated to preserve tissue quality and mobility while minimizing tear retraction to maximize structural healing and functional outcomes. However, reported outcomes after rotator cuff repair often combine trau- matic and atraumatic tears, resulting in a loss of specific outcomes after repair of isolated traumatic tears; for this, further clarification is required between the different categories. The goal of this Systematic Review was to better delineate the epidemiology, mechanism of injury, tear anatomy, and outcomes of traumatic rotator cuff tears to determine if the literature supports the early repair of traumatic rotator cuff tears. The hypothesis was that traumatic rotator cuff tears would occur in a younger patient population, be more likely to include the sub- scapularis tendon, and exhibit significant improvement in pain, range of motion, and clinical outcome scores, with concomitant high rates of structural integrity after repair. Nonetheless, we believe the evidence supporting acute repair of traumatic rotator cuff tears will not be sufficient to recommend for or against early repair. Inclusion Criteria Exclusion Criteria English language Evidence Levels I-IV Results of studies describing rotator cuff repair Studies with no pre-existing shoulder malfunction Studies investigating acute symptoms or pain onset, functional impairment of limb Studies with minimum time to repair of 1.5 years Caseecontrol studies, case series, expert opinions, commentaries, surgical technique articles, letters to editors Basic science or animal studies Evidence Level V Results for which validated clinical outcome measures were not used Results of studies with no follow-up Evaluation of joints other than the shoulder eligibility was resolved with the senior author (B.J.C.). Bibliographiesof all reviewed articleswerereferencedto assess for potentially inclusive articles that were missed by the initial search. Data Extraction Data were extracted from investigations that satisfied the eligibility criteria. Details of study design, sample size, and patient demographics, including sex, age, indication, and length of follow-up, were recorded. Surgical factors such as mechanism of injury, tendons involved, tear size, and surgical technique were abstracted. Additionally, timing of the repair, follow-up time, healing rates, and outcome variables were tabu- lated. Patient-based and functional outcomes scores were grouped by test used in each study. The Constant,11 University of California, Los Angeles (UCLA),12,13Western Ontario Rotator Cuff (WORC),14 American Shoulder and Elbow Surgeons (ASES),15 visual analog scale (VAS),16Disabilities of the Arm, Shoulder, and Hand (DASH),17and Japanese Ortho- paedic Association (JOA)18scores were variably iden- tified in the studies included for this review. Methods Search Strategy An independent systematic review of the literature was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted using traumatic rotator cuff tear or acute rotator cuff tear. The terms were individually queried, Boolean terms were not incorporated, and no limits were set on the dates of studies. The references to each article were also reviewed for possible study inclusion. Studies consid- ered for evaluation were acute or traumatic rotator cuff tears and follow-up periods longer than 6 months (Table 1). Studies must have ensured all patients were asymptomatic with respect to the affected shoulder prior to the injury or specific date of pain onset. Potentially inclusive papers were discussed and deci- sions were made regarding inclusion. A hand search for studies meeting the inclusion criteria was performed using relevant review articles. Case reports on fewer than 10 patients, technique articles, editorials, guide- lines, animal and cadaver studies, and review articles were excluded (Table 1). A CONSORT diagram illus- trates the study selection algorithm (Fig 1). Results Initial literature search of rotator cuff tear resulted in 2,687 studies, for which the search was narrowed by including rotator cuff repair, decreasing the results to 257 studies. The limit of English language was applied, decreasing the number of studies to 205. Traumatic rotator cuff tear and acute rotator cuff tear further decreased the results respectively to 106 and 211 pub- lished studies. In total, the 3 latter search terms combined allowed for a total of 522 abstracts to be reviewed. Three of the authors appraised abstracts and selected any potentially eligible study for further review and analysis. Basic sciences and cadaveric studies were excluded and references were reviewed leading to a potential pool of 52 studies (Fig 1). Several studies without proper follow-up or those that contained chronic rotator cuff repairs were excluded, resulting in 9 studies identified for this report.3,5,7,15,16,20,27,30,34,38 Study Selection Full articles of citations adhering to the inclusion criteria and those that were uncertain were down- loaded. Three authors (N.A.M., J.C., A.S.L.) indepen- dently reviewed all titles and abstracts of pertinent citations. Reference lists of all full articles were reviewed against the inclusion criteria, and any disagreement on
368 N. A. MALL ET AL. Fig 1. Search strategy results. patients in the study by Bjornsson et al.21and 2 patients in the study by Namdari et al.20had rotator cuff tears as a result of glenohumeral dislocation. Both Braune et al.19and Hantes et al.25followed recommendations for diagnosis and legal assessment of traumatic rotator cuff tears from the German Association of Shoulder and Elbow Surgery as inclusion criteria, but failed to mention specific injury mechanisms. Two studies did not mention any specific injury mechanism.26,27 Patient Demographics The weighted average age of patients with acute rotator cuff tears in this review was 54.7 years (average range, 34 to 61) (Table 2). Seventy-seven percent of the patients were male. The study by Braune et al.19was the only included study that evaluated the difference between traumatic and nontraumatic tears, and for this group, age was significantly younger (34.2 years) in the traumatic group than in the atraumatic group (54.1 years). Both groups had few women, and thus, there was no difference in gender between the groups.19The weighted percentile of men in the included studies was 76.7%. Surgical Timing The weighted average for the 7 studies that reported mean time to surgical intervention was 66 days (3 weeks to 12 months) from the time of injury. Braune et al.19and Gerber et al.22did not provide mean time from injury to surgery; however, in their study, Gerber et al. reported more improved outcomes in the 13 patients who underwent surgery within 20 months of injury as than the 3 patients whose surgeries were delayed more than 36 months after injury. Of the other studies that evaluated time to surgery as a variable, Petersen and Murphy,27Bassett and Cofield,24and Hantes et al.25found that early treatment improved outcomes, whereas Bjornsson et al.21found no differ- ence in healing, Constant score, DASH score, or WORC index with respect to time to repair. Petersen and Murphy27noted that when compared with those per- formed longer than 16 weeks after injury, repairs per- formed prior to 16 weeks from injury were associated Injury Mechanism Five studies reported that an injury mechanism20-24 such as a fall, most often onto an outstretched arm, was the most common injury pattern (Table 3). Ide et al.23 noted 12 patients were injured in a fall, 7 had a forceful external rotation moment with an abducted arm, and 1 was injured in a motor vehicle accident. Gerber et al.22 described a forceful external rotation of an adducted extremity in 9 patients, 1 glenohumeral dislocation, and 6 unknown injury mechanisms. Bassett and Cofield24reported that 22 (59%) of their patients fell onto an outstretched arm, 6 were injured by lifting a heavy object, 4 were injured during sporting activities, 3 reached out to grab a rail to prevent falling, and 1 was injured after a motor vehicle accident. Seventeen
369 TRAUMATIC ROTATOR CUFF TEARS Table 2. Characteristics of Selected Studies Level of Study Number of Patients Follow-up (mo) Average Patient Age (yr) Author Time to Repair Bassett and Cofield (1983)24 III 37 84 56 <3 weeks (12) 3-6 weeks (6) 6-12 weeks (19) NR NR Gerber et al. (1996)22 Braune et al. (2003)19 IV III 16 46 43 41 50 Traumatic: 34 Atraumatic: 54 53 57 Lahteenmaki et al. (2006)26 Namdari (2008)20 IV IV 246 33 73 56 NR 4.5 ? 3.5 months >3 months: 15 6-12 months: 6 2.7 months Group I (early, <3 weeks: 15 Average ¼ 12 days Group II (late, >3 weeks: 20 Average ¼ 131 days 38 days 0-8 weeks: 15 9-16 weeks: 15 >16 weeks: 6 Average ¼ 11 weeks Ide et al. (2007)23 Hantes et al. (2011)25 IV III 20 35 36 36 61 Group I: 54 Group II: 56 Bjornsson et al. (2011)21 Petersen and Murphy (2011)27 IV III 42 36 39 31 62 57 comparedwiththesizesreportedbyBassettandCofield24 if the first 2 sizes are combined in each system (Bateman class I and II and Post small and medium both represent tears <3 cm).Hantes et al.25classified 4 tears as medium, 16 as large, and 15 as massive tears. Braune et al.19 classified7tears inthetraumaticgroupasBatemanIorII and 3 tears as Bateman 3. Interestingly, this group re- ported 10 partial-thickness tears in their traumatic group and only 1 partial-thickness tear in their nontraumatic group.Lahteenmakietal.26reported6medium,10large, and 10 massive tears using the Post classification. Bassett and Cofield24noted 7 small (<3 cm), 10 medium (3 to 5 cm), and 20 large (>5 cm) tears. When these studies are combined,22%were<3cm,36%3to5cm,and42%>5 cm. Petersen and Murphy27used a classification system reported by Galatz29that is based on area rather than longitudinal dimension and noted 5 small, 15 medium/ large, and 15 massive tears (Table 3) with significantly improved active elevation (140?v 100?), ASES score (81 v 65), and UCLA score (30 v 25). Bassett and Cofield24determined that those repaired within 3 weeks had significantly better forward eleva- tion and showed a trend toward better strength in both abduction and external rotation than those repaired after 3 weeks. Hantes et al.25reported significantly higher mean postoperative Constant (82) and UCLA (31) scores in the acute repair (<3 weeks) group than in the delayed repair group (70 and 26, respectively). Tear Characteristics and Tendon Involvement The studies included in this review varied widely in terms of tear characteristics. Tendon involvement was part of the inclusion criteria for 3 of the studies: both Namdari et al.20and Ide et al.23required full-thickness tears of both subscapularis and supraspinatus tears, whereas Gerber et al.22restricted inclusion to those with isolated subscapularis tears. Namdari et al.20found that 53% of their patients also had an infraspinatus tear, whereas Ide et al.23reported 35% involvement of the infraspinatus. Bjornsson et al.21included only full-thick- ness tears, noting 15 of 42 (36%) with single-tendon tears, of which 14 involved the supraspinatus and 1 the subscapularis.Combinedsupraspinatusandsubscapularis tears were present in 8 patients, and combined supra- spinatus and infraspinatus tears also occurred in 8 patients. Three-tendon tears were present in 12 patients. If these 4 studies are combined, supraspinatus tears were present in 84% of tears, infraspinatus tears in 39% of tears, and subscapularis tears in 78% of tears. The remaining 5 studies evaluated tear characteristics by size, using various classification systems. The Bate- man28and Post et al.13classification systems can be Concomitant Pathology Namdari et al.20found that 77% of patients had biceps tendon pathology; however, 1 of their inclusion criteria was a >50% subscapularis tear. Gerber et al.22 also had a subscapularis tear as an inclusion criterion, and reported 63% of their patients had biceps pathology, including 5 thickened biceps tendons, 4 dislocated tendons, and 1 with a prior tenodesis. The other study that had subscapularis tear as an inclusion criterion did not report concomitant pathology. Gle- nohumeral dislocations occurred in 7 of 20 (35%) traumatic tears in 1 study and 17 of 42 (40%) in another study. The latter study, by Bjornsson et al.,21 also had 2 greater tuberosity fractures, 4 transient axillary nerve palsies, and 1 small glenoid fracture.
Table 3. Surgical Parameters 370 Author Inclusion Exclusion Mechanism of Injury Tendon Repair Bassett and Cofield (1983)24 Significant acute injury and FT RCR; repair within 3 months Chronic tear, defined as repair >3 months Fall on shoulder or outstretched hand (59%), stress lifting (16%), other (25%) RC Primary tendon suture, 9 patients: side-to-side tendon suture and suturing of healthy tendon to cancellous bone of humeral tuberosities Open TO tendon suture Gerber et al. (1996)22 Acute onset of pain, functional impairment of limb; severity resulting in temporary work disability; SS tear No pre-existing shoulder pain or malfunction; complete, sudden loss of shoulder function; sharp trauma-related pain with correlated dead arm sign Avulsion of lesser tuberosity; concomitant rupture of SSp or ISp; postop avulsion of SS tending during surgery Chronic shoulder pain; pre-existing shoulder malfunction; mechanical outlet impingement signs; ?50 years excluded for traumatic origin but included for nontraumatic origin Forceful external rotation of abducted upper extremity (56%), 1 traumatic anterior dislocation, others could not be precisely defined Group 1: 7 traumatic shoulder dislocations (35%); complete RCTs in 10 patients (50%); 10 partial tears, either on acromial or articular surface Group 2: 25 patients (96.2%) sustained complete RCT Acute traumatic SS Braune et al. (2003)19 RC Tendon-to-bone refixation with TO suture in McLaughlin’s technique or tendon-to-tendon repair FT tear; acute symptoms, trauma; <90?of abduction and forward flexion Massive tear <5 cm in diameter; concomitant shoulder dislocation; fracture; nerve injury; chronic symptoms Partial-thickness tear; FT tear of SS that involved <50% insertion; prior failed RCR, symptoms <12 months; atraumatic mechanism; symptoms in contralateral shoulder Irreparable RCT; partial RCR; stage 3/4 fatty infiltration of RC muscles; cuff tear arthropathy; failed prior cuff repair; Worker’s Compensation claim Chronic shoulder pain with onset irrelevant to trauma; pre-existing shoulder malfunction; acromioclavicular joint arthritis; acromion osteophytes RC NR Lahteenmaki et al. (2006)26 N. A. MALL ET AL. Namdari et al. (2008)20 Traumatic RCT that involved SS in addition to SSp, <12 months in duration, treatment with open repair NR RC TO technique and suture anchors Ide et al. (2007)23 Arthroscopic repair of FT tear of SS with SSp or ISp; MRI scans preop and postop, minimum 2-year follow-up NR RC Arthroscopic repair, TO technique, and suture anchors Hantes et al. (2011)25 No pre-existing shoulder pain or malfunction; complete, sudden loss of shoulder function; sharp trauma-related pain with correlated dead arm sign in combination with adequate trauma mechanism Trauma to shoulder; sudden onset; asymptomatic before trauma; pseudoparalysis; FT RCT of at least one tendon with acute appearance when sutured; no signs of previous cuff tearing Acute, traumatic, FT RCT; inability >90?of active abduction Fall on shoulder/ hand; shoulder dislocation; motor vehicle accident RC Mini-open arthroscopic technique Bjornsson et al. (2011)21 Previous or gradual onset of symptoms in injured shoulder, partial cuff tear, displaced fracture NR RC Open technique, osteostructures and suture anchors in all patients, one arthroscopic procedure NR Work related RC Open approach, suture and tendon to greater tuberosity by TO tunnels; all procedures included anterior acromioplasty Petersen and Murphy (2011)27 FT, full-thickness; RCR, rotator cuff repair; RCT, rotator cuff tear; RC, rotator cuff; SS, subscapularis; TO, transosseous; SSp, supraspinatus; ISp, infraspinatus; preop, preoperation; postop, postoperation; NR, not reported.
371 TRAUMATIC ROTATOR CUFF TEARS Bassett and Cofield24reported 6 patients who required a distal clavicle excision and 2 with biceps pathology requiring tenodesis. Lahteenmaki et al.26also noted biceps pathology in 2 of 26 patients. The remaining 2 studies do not mention associated pathology.19,27 repair groups had significantly better forward elevation (137?and 142?) than their delayed repair group (100?). This study also showed a more significant improvement in forward elevation in those with small and medium/ large tears than with those with massive tears. Pain Scores Three studies did not report pain scores as a separate outcome measure.19,21,25Two studies used a standard VAS pain score, with Namdari et al.20revealing an improvement from 6.2 pre-operatively to 1.2 post- operatively, and Petersen and Murphy27reporting a similar improvement from 7 preoperatively to 1.4 postoperatively. Ide et al.23used the pain component of the JOA score, which ranged from 0 to 30, with 0 being severe pain. This group also reported a significant reduction in pain scores from pre- to postoperatively (11.2 to 24.8, respectively). Lahteenmaki et al.26used the pain component of the UCLA score and noted a significant improvement from 2.1 preoperatively to 9.3 postoperatively. Gerber et al.22used the pain component of the Constant score and reported post- operative pain scores of 10.4 to 15, with a score of 15 denoting no pain. Finally, Bassett and Cofield24used a scale that allowed patients to rate their pain as none, slight, moderate, or severe. All patients scored their pain as moderate or severe preoperatively, whereas postoperatively 13 reported no pain and the remaining 24 reported only slight pain (Table 3). Healing Rates Rotator cuff healing was evaluated in only 3 of the 9 studies, 2 using MRI23,25and the other using ultra- sound21to evaluate cuff integrity. Ide et al.23divided patients into 2 groups on the basis of MRI healing. The group with an intact repair (13 of 20 patients, 65%) was significantly younger (58 years) than the failed repair group (68 years) and had significantly better JOA scores (93 v 87). Of note, 6 of the 7 tears that failed involved the entire tendinous portion of the sub- scapularis and retraction was to the level of the glenoid. Hantes et al.25observed healing on MRI in 23 of 35 (66%) patients, but found no difference in healing based on time to surgery. In the early repair group, there was no difference in outcomes based on presence of healing; however, in the delayed repair groups, UCLA and Constant scores were significantly better for those that healed. Bjornsson et al.,21using ultrasound at follow-up, found that 29 of 42 (69%) had an intact cuff, and 9 of 42 (21%) had partial-thickness tears. This study reported a significantly lower age (60 years) in the intact group than in the defect group (68 years). The other studies did not report rotator cuff healing as an outcome variable.19,20,22,24,26,27 Strength/Motion The preoperative forward elevation was reported in 4 studies with a weighted average of 80.9?(59?to 95?).20,23,26,27These improved to a weighted average of 149.9?(88?to 142?) postoperatively, as measured in 6 studies.19,20,23,24,26,27Preoperative and postoperative external rotation was reported in 4 studies,23,26and averaged 42.4?preoperatively to 49.1?at final follow- up. Internal rotation was reported by 3 groups20,23,27 and found to improve from a weighted average of L-1 (T-10 to gluteal level) preoperatively to T-10 (T-9 to T-12) postoperatively. Postoperative abduction was measured in only 2 studies, and the weighted average was 165.7?(<90?to 173.1?).19,26Gerber et al.22did not report actual degrees of motion, but stated that flexion was reduced in 4 of 16, abduction was reduced in 5 of 16, and external rotation was reduced in 6 of 16. Braune et al.19reported a significant difference in improvement in postoperative forward flexion and abduction between the traumatic rotator cuff group and the nontraumatic group, with mean differences of 10?in forward elevation and 26?in abduction. Bassett and Cofield24reported approximately 40? forward elevation in their acute (<3 weeks) repair group compared with later repairs; this difference was signifi- cant.PetersenandMurphy27alsofoundthattheir2acute Outcome Scores The UCLA23,25-27and Constant19,21,22,25scores were the most frequently used outcome scores, each being used in 4 of the 9 studies. One study did not report specific outcome scores and reported only functional results.24All showed a significant improvement from preoperative to postoperative values for the respective outcomes measures used. The weighted average post- operative UCLA score was 30.1 (9 to 31), and the weighted average Constant score was 76.6 (39 to 95) for all patients with traumatic tears. One study compared traumatic and atraumatic tears, and thus, the scores for the atraumatic group were not used in this calculation. Several studies compared outcomes with respect to tear size,26time to repair,27or healing,21and 1 study compared outcomes by both healing and time to repair.25However, these scores incorporate all patients with traumatic tears, regardless of time to surgery, healing, or tear size (Table 4). Namdari et al.20reported postoperative SST and DASH scores of 82.8 and 12.2. Ide et al.,23using the JOA score, reported an improvement to 91.0 post- operatively. Hantes et al.25reported significantly better Constant and UCLA scores in the acute repair group than in the delayed repair group (P < .05). Petersen and of improved
372 Table 4. Clinical Outcomes Study Constant Score VAS Score UCLA Score Active Forward Flexion Active External Rotation Other Gerber et al. (1996)22 Braune et al. (2003)19 59 (preop) to 95 Group 1: 94.1 (acute repair) Group 2: 75.3 (delayed repair) NR NR NR NR NR NR NR NR Group 1: 20 (7-10) Group 2: 13 (7-10), 7 (5-6), 6 (<5) Group I: 166 Group II: 156 Group 1: 56 Group 2: 38 Lahteenmaki et al. (2006)26 NR Pain: 1.8 (preop) to 8.3 Function: 1.8-8.6 Strength: 2.7-4.4 Satisfied 239/unsatisfied 7 Overall score: 30.6 NR Small tear: 130-160 Medium tear: 112-153 Large tear: 115-151 Small tear: 62-61 Medium tear: 60-54 Large tear: 59-54 Overall satisfaction rating: 38% excellent, 38% good, 38% fair, 9% poor 93.4 6.2-1.2 81-97 93-109 DASH: 41.7-12.2 SST: 36.4-82.8 SF-36: 54.99-84.26 (Pain); 88.55-99.24 (Physical functioning) JOA score: 55.7-91.0 Pain: 11.2-24.8 Function: 9.4-18.7 External rotation: 5.5-6.9 Internal rotation: 3.6-5.9 NR Namdari et al. (2008)20 (internal rotation: 3 to <1) N. A. MALL ET AL. Ide et al. (2007)23 NR NR 14.9-31.1 97-162 30-43 (internal rotation: L-2 to T-10) Group 1: 39-82 Group 2: 40-70 73 (repaired) 83 (contralateral shoulder) NR NR Group I: 10-31 Group 2: 12-27 NR NR NR Hantes et al. (2011)25 Bjornsson et al. (2011)21 NR NR NR DASH: 17 (intact) to 31 (defect) WORC: 79 (intact) to 65 (defect) Petersen and Murphy (2011)27 7-1.4 Group 1: 6-30 Group 2: 9-30 Group 3: 9-25 Group 1: 54-137 Group 2: 52-142 Group 3: 66-100 39-49 Strength of SST: 2.7-4.1 Strength of infraspinatus: 3.7-4.2 ASES Group 1: 28-82 Group 2: 31-79 Group 3: 24-65 VAS, visual analog scale; UCLA, University of California, Los Angeles; DASH, Disabilities of the Arm, Shoulder, and Hand score; SST, supraspinatus; SF-36, Short Form-36; JOA, Japanese Orthopaedic Association; WORC, Western Ontario Rotator Cuff score; ASES, American Shoulder and Elbow Surgeons score.
373 TRAUMATIC ROTATOR CUFF TEARS Murphy27also reported more improved results in early repair groups than with delayed repair groups, but found no difference in tear size. Bjornsson et al.,21 however, found no difference in Constant, DASH, or WORC scores with respect to time from injury, but did report a significant difference in these scores with respect to healing of the rotator cuff tear. The mean DASH score was 17 in intact cuffs and 31 in those with a defect. The mean WORC score was 79 in the intact group and 65 in the defect group. The mean Constant score was 73 with an intact repair and 55 with a failed repair (Table 4). experience a nontraumatic attritional type of tear, which can also produce acute symptoms. The average age in this study (54.7 years) is nearly 10 years younger than the average age in a recent publication of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group’s demographics for atraumatic rotator cuff tears (62.6 years).30Braune et al.19used an exclusion criterion of age 50 to differentiate between true traumatic tears and acutely symptomatic attritional tears. However, this same study found more partial- thickness tears in the traumatic group.19Traumatic tears are thought to stem from more violent mecha- nisms and cause full-thickness tears, whereas the natural history of attritional tears is that they originate as partial-thickness tears and perhaps progress to full- thickness tears.3Also, traumatic tears may be larger and more likely to involve the subscapularis muscle. Three of the studies required subscapularis involvement as an inclusion criterion in their study.22In this review, only 22% of the patients had small tears <3 cm in size and more than 50% of patients had 2 or more tendons involved. These tears are much larger than atraumatic tears, with more than 71% of the single-tendon supraspinatus tears in the MOON Shoulder Group being classified as atraumatic30(Table 5). However, it is difficult to ensure that all patients in the included studies did not have acute on chronic tears as several studies included older patient populations with acute symptoms. Healing continues to be a major focus in rotator cuff surgery, with surgeons and researchers attempting to determine the best milieu to allow tendon to bone healing. Healing has been consistently shown to dramatically affect outcomes.31-39Patient age36,37,40 and tear size18,38,41are routinely quoted as the 2 biggest factors in rotator cuff healing. Recently, studies have evaluated type of repair and healing rates, showing that transosseous equivalent techniques have improved healing in tears larger than 1 cm.42The video shows an example of the authors’ approach in repairing an acute traumatic tear (Video 1, available at www .arthroscopyjournal.org). Healing rates for traumatic tears should theoretically be improved when repaired early because they occur in younger patients, may have less retraction or muscle atrophy, and may present a favorable biological environment for tendon healing with ongoing inflammatory response. The 3 studies reporting healing in traumatic tears were consistent with 65% to 69% healing. A systematic review of rotator cuff healing showed failure rates as low as 7% in small tears <1 cm and upward of 69% retears in larger tears. These authors also found that the method of repair may play a role in healing, with double-row repairs performing better than single-row or trans- osseous repairs for all tears greater than 1 cm. In this systematic review, Bjornosson et al.5and Ide et al.23 Bias All studies were retrospective in nature, which inherently introduces selection described enrolling consecutive patients who met inclusion criteria, which may minimize this bias. Inde- pendent examiners were not used or not mentioned in 5studies,20,24-27whichintroducesdetectionbiasinthese studies. All studies had relatively small numbers of patients, and no study mentioned an a priori power analysis. Hantes et al.25used 2 different surgeons, 1 of whom used an open technique, and the other an arthroscopic technique. Also, in this study the delayed repair group had a large time range from 45 to 303 days postinjury. The level of evidence of the included studies was Level III or IV, which introduces additional selection and detection bias compared with Level I and II studies. Bjornsson et al.21used 3 different surgeons and divided patients by age above or below 65, which likely introduces some bias as those over the age of 65 likely have poorer tissue. Bassett and Cofield24used multiple examiners, which introduces inconsistency with results, which is compounded by not using standardized outcomes scores. Petersen and Murphy27only had a 9-month minimum follow-up, and different rehabil- itation was prescribed based on tear size and integrity of repair. Concomitant pathology was not discussed in several studies, which can be a factor in postoperative outcome scores and can introduce performance bias. bias. Ide et al.23 Discussion Traumatic rotator cuff tears are often discussed as a separate entity compared with nontraumatic, attri- tional rotator cuff tears. Prior studies of rotator cuff tears have found that age and tear size are significant factors in outcome and healing. However, there has been relatively little literature examining the difference between traumatic and nontraumatic tears. The goal of this systematic review was to better delineate the epidemiology, anatomy, and outcome of traumatic rotator cuff tears and determine if there is evidence to support the acute repair of these injuries. Patients who incur a traumatic rotator cuff tear are thought to be categorically different from those who
374 N. A. MALL ET AL. Table 5. Differences Between Traumatic and Nontraumatic Rotator Cuff Tears Traumatic Tears Attritional Tears Epidemiology Mechanism of injury Younger (mean, 54.7 years) Fall onto outstretched arm Forceful extended rotation on abducted arm Supraspinatus (84%) Infraspinatus (39%) Subscapularis (78%) Size: 42% large/massive Forward elevation: 81 preop to 150 postop UCLA: 30.1 Constant: 76.6 Significant pain improvement Age and size related Older: prevalence increases with age Attritional, nontraumatic Slow progression of symptoms Likely start as small supraspinatus tear and progress in size Fewer subscapularis tears Tear characteristics Outcomes Forward elevation improved UCLA: 28.6-33.3 Constant: 74.4-82.7 Significant pain improvement Age and size related Healing UCLA, University of California, Los Angeles score. found no difference in healing with respect to tear size or number of tendons involved, but the numbers were too small to prevent beta error. Two of the three studies that reported healing used single-row repairs,16,20and the other performed all-open repairs.5Two21,23of these studies reported better healing in the younger pop- ulation. The third study evaluated healing as it related to time to surgery and found no difference in acute versus delayed repair25(Table 5). Again, no power analysis was performed to ensure this result was not caused by beta error. Because of the heterogeneity of these studies in terms of inclusion criteria, length of time to repair, repair type, age, and size of tears, as well as the fact that only 3 studies totaling less than 100 patients reported healing rates, it is inappropriate to comment on time to surgery or healing rates in trau- matic rotator cuff tears based on the available literature. The UCLA scores after repair of nontraumatic rotator cuff tears ranged from 28.6 to 33.3 in a recent systematic review; Constant scores in this same study ranged from 74.4 to 82.7.43The weighted average of the UCLA scores (30.7) and Constant scores (76.6) from this traumatic group fall within these ranges despite likely representing larger tears (Table 5). Lahteenmaki et al. also published their results of the opposite pop- ulation of chronic tears repaired after 3 weeks from the onset of symptoms.28UCLA scores averaged 30.6, although this study excluded massive tears (>5 cm). Mean strength was 4.4 of 5, forward elevation was 154?, abduction was 148?, and age did not influence results. The only factor that consistently affected results was the size of the tear, with much better results in small tears than medium or large tears.44Other studies have also reported that the size of the tear (or number of tendons involved) has been shown to affect clinical outcome after repair.45-48 required the arm to be pain free prior to a specific, identifiable injury. Some studies had age restrictions. However, the ability to distinguish between an acute tear and a degenerative tear with an acute worsening is admittedly difficult24,27,44,49if not impossible without some screening examination of all patients prior to the injury to ensure no cuff tear was present. Some authors believe that traumatic tears occur mostly in diseased or aged tendons.42,49-51Another limitation of this study is the heterogeneity in the studies with several requiring subscapularis tears, which are more likely to involve biceps pathology, and this concomitant pathology can affect pain and outcome scores. All of these studies were Level III or lower, and many did not use inde- pendent examiners. Also, at most, 4 studies used the same outcome tools, which prevented meaningful pooling of results and meta-analysis. The studies included in this review do not fully evaluate the role tear size and tear chronicity have in rotator cuff healing nor overall results. With the current available literature, there is no indication that acute repair in traumatic injuries produces better outcomes; however, this may be related to the difficulty in differentiating an acute on chronic tear from a definitively acute, traumatic tear. Further research is needed to directly compare the results of acute intervention for patients who present with traumatic rotator cuff tears. Conclusions Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommen- dation for early surgical repair. Limitations There are several limitations to this study, which were determined by the studies included. The definition of acute tears was similar among the groups: each References 1. Longo UG, Berton A, Papapietro N, Maffulli N, Denaro V. Epidemiology, genetics and biological factors of rotator cuff tears. Med Sport Sci 2012;57:1-9.
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