Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis

Abstract

Background: There is no consensus about the best choice between all the options available for large and massive rotator cuff tear (mRCTs) management. Objective: To determine the comparative effectiveness of current treatment options for management of large and mRCTs. Design: Network meta-analysis. Setting: We searched the Cochrane systematic reviews, MEDLINE and EMBASE databases for all trials of adults with large and mRCTs that report preoperative and postoperative functional scores after an intervention option. Patients: The network meta-analysis included 20 trials with 1233 patients with 37.24 months follow-up. Interventions: Eight treatment options for management of large and mRCTs were compared. Main Outcome Measures: The primary effectiveness outcome was the functional score. Results: This meta-analysis did not show statistically significant differences between conservative, partial repair, patch or platelet rich plasma (PRP) augmentation, reverse total shoulder arthroplasty, and complete repair. Latissimus dorsi (LD) transfer was ranked first for effectiveness [standardized mean difference (SMD): 2.17, 0.28-4.07] and debridement ranked last (SMD: −2.15, −3.13 to −1.17). Conclusions: Latissimus dorsi transfer seems to be most effective for management of large and mRCTs, although some heterogeneity was observed in this network meta-analysis of full text reports. The choice of the operating technique depends on the patient's general health status and his expectations. When a decision has been reached to perform surgery, a repair, even if partial, should be attempted. Procedures involving biologic augmentation (eg, PRP) seem to convey no additional benefit while introducing more risk. Debridement alone should be avoided.

Resultado clínico do reparo parcial nas roturas irreparáveis do manguito rotador

“…Entretanto, este estudo inclui tanto pacientes com roturas irreparáveis como aqueles com artropatia do manguito rotador, além de utilizar uma amostra de pacientes com idade mais avançada. Maillot et al, 8 em uma metanálise envolvendo 20 estudos e 1.233 pacientes, compararam as diferentes formas de tratamento para as roturas grandes ou extensas do manguito rotador (tratamento conservador, desbridamento, reparo parcial, reparo completo, transferência do grande dorsal, uso de "patches", plasma rico em plaquetas e artroplastia reversa). Observaram que o único tratamento que demonstrou superioridade frente aos demais foi a transferência do grande dorsal.…”

“…However, this review included patients with irreparable tears and rotator cuff arthropathy, who were also older when compared to our subjects. Maillot et al, 8 in a meta-analysis involving 20 studies and 1,233 patients, compared different forms of treatment for large or extensive rotator cuff tears (conservative treatment, debridement, partial repair, complete repair, latissimus dorsi transfer, patches, platelet-rich plasma, and reverse arthroplasty). Latissimus dorsi transfer was the only treatment showing superiority over the others.…”

“…In a systematic review, Malahias et al 7 demonstrated that the partial repair significantly improves strength and functional scores. Maillot et al, 8 in a meta-analysis, found no difference between partial repair, complete repair, and reverse arthroplasty.…”

“…Malahias et al, 7 numa revisão sistemática, demonstraram que o reparo parcial melhora significativamente a força e a pontuação das escalas funcionais. Maillot et al, 8 numa metanálise, não observaram diferença entre o reparo parcial, reparo completo e artroplastia reversa.…”

Arthroscopic Superior Capsule Reconstruction and Rotator Cuff Repair to Restore Static and Dynamic Stability of the Shoulder

“…A recent systematic review identified that 42% of RCT can be classified as irreparable tears 5 . Although various surgical techniques have been developed and applied, postoperative complications and uncertain outcomes often trouble both clinicians and patients 6 . Galatz et al 7 report that the re-tear rate of massive irreparable RCT could be up to 94%.…”