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<h5 class="title" id="d342611e183">Background</h5>
<p id="d342611e185">This review is one in a series of Cochrane Reviews of interventions
for shoulder disorders.</p>
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<h5 class="title" id="d342611e188">Objectives</h5>
<p id="d342611e190">To synthesise the available evidence regarding the benefits and
harms of rotator cuff
repair with or without subacromial decompression in the treatment of rotator cuff
tears of the shoulder.
</p>
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<h5 class="title" id="d342611e193">Search methods</h5>
<p id="d342611e195">We searched the CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and
WHO ICRTP registry
unrestricted by date or language until 8 January 2019.
</p>
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<h5 class="title" id="d342611e198">Selection criteria</h5>
<p id="d342611e200">Randomised controlled trials (RCTs) including adults with full‐thickness
rotator cuff
tears and assessing the effect of rotator cuff repair compared to placebo, no treatment,
or any other treatment were included. As there were no trials comparing surgery with
placebo, the primary comparison was rotator cuff repair with or without subacromial
decompression versus non‐operative treatment (exercises with or without glucocorticoid
injection). Other comparisons were rotator cuff repair and acromioplasty versus rotator
cuff repair alone, and rotator cuff repair and subacromial decompression versus subacromial
decompression alone. Major outcomes were mean pain, shoulder function, quality of
life, participant‐rated global assessment of treatment success, adverse events and
serious adverse events. The primary endpoint for this review was one year.
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<h5 class="title" id="d342611e203">Data collection and analysis</h5>
<p id="d342611e205">We used standard methodologic procedures expected by Cochrane.</p>
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<h5 class="title" id="d342611e208">Main results</h5>
<p id="d342611e210">We included nine trials with 1007 participants. Three trials compared
rotator cuff
repair with subacromial decompression followed by exercises with exercise alone. These
trials included 339 participants with full‐thickness rotator cuff tears diagnosed
with magnetic resonance imaging (MRI) or ultrasound examination. One of the three
trials also provided up to three glucocorticoid injections in the exercise group.
All surgery groups received tendon repair with subacromial decompression and the postoperative
exercises were similar to the exercises provided for the non‐operative groups. Five
trials (526 participants) compared repair with acromioplasty versus repair alone;
and one trial (142 participants) compared repair with subacromial decompression versus
subacromial decompression alone.
</p>
<p id="d342611e212">The mean age of trial participants ranged between 56 and 68 years,
and females comprised
29% to 56% of the participants. Symptom duration varied from a mean of 10 months up
to 28 months. Two trials excluded tears with traumatic onset of symptoms. One trial
defined a minimum duration of symptoms of six months and required a trial of conservative
therapy before inclusion. The trials included mainly repairable full‐thickness supraspinatus
tears, six trials specifically excluded tears involving the subscapularis tendon.
</p>
<p id="d342611e214">All trials were at risk of bias for several criteria, most notably
due to lack of
participant and personnel blinding, but also for other reasons such as unclearly reported
methods of random sequence generation or allocation concealment (six trials), incomplete
outcome data (three trials), selective reporting (six trials), and other biases (six
trials).
</p>
<p id="d342611e216">Our main comparison was rotator cuff repair with or without subacromial
decompression
versus non‐operative treatment. We identified three trials for this comparison, that
compared rotator cuff repair with subacromial decompression followed by exercises
with exercise alone with or without glucocorticoid injections, and results are reported
here for the 12 month follow up.
</p>
<p id="d342611e218">At one year, moderate‐certainty evidence (downgraded for bias)
from 3 trials with
258 participants indicates that surgery probably provides little or no improvement
in pain; mean pain (range 0 to 10, higher scores indicate more pain) was 1.6 points
with non‐operative treatment and 0.87 points better (0.43 better to 1.30 better) with
surgery. Mean function (zero to 100, higher score indicating better outcome) was 72
points with non‐operative treatment and 6 points better (2.43 better to 9.54 better)
with surgery (3 trials; 269 participants), low‐certainty evidence (downgraded for
bias and imprecision). Participant‐rated global success rate was 48/55 after non‐operative
treatment and 52/55 after surgery corresponding to risk ratio (RR) 1.08, 95% confidence
interval (CI) 0.96 to 1.22; low‐certainty evidence (downgraded for bias and imprecision).
Health‐related quality of life was 57.5 points (SF‐36 mental component score, 0 to
100, higher score indicating better quality of life) with non‐operative treatment
and 1.3 points worse (4.5 worse to 1.9 better) with surgery (1 trial; 103 participants),
low‐certainty evidence (downgraded for bias and imprecision).
</p>
<p id="d342611e220">We were unable to estimate the risk of adverse events and serious
adverse events as
only one event was reported across the trials (very low‐certainty evidence; downgraded
once due to bias and twice due to very serious imprecision).
</p>
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<h5 class="title" id="d342611e223">Authors' conclusions</h5>
<p id="d342611e225">At the moment, we are uncertain whether rotator cuff repair surgery
provides clinically
meaningful benefits to people with symptomatic tears; it may provide little or no
clinically important benefits with respect to pain, function, overall quality of life
or participant‐rated global assessment of treatment success when compared with non‐operative
treatment. Surgery may not improve shoulder pain or function compared with exercises,
with or without glucocorticoid injections.
</p>
<p id="d342611e227">The trials included have methodology concerns and none included
a placebo control.
They included participants with mostly small degenerative tears involving the supraspinatus
tendon and the conclusions of this review may not be applicable to traumatic tears,
large tears involving the subscapularis tendon or young people. Furthermore, the trials
did not assess if surgery could prevent arthritic changes in long‐term follow‐up.
Further well‐designed trials in this area that include a placebo‐surgery control group
and long follow‐up are needed to further increase certainty about the effects of surgery
for rotator cuff tears.
</p>
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<b>Does repair of torn rotator cuff tendons work?</b>
</p><p id="d342611e238">
<b>Review question</b>
</p><p id="d342611e243">To assess the effect of surgical repair of rotator cuff tendons
on shoulder pain,
function and other outcomes in adults with full‐thickness rotator cuff tears compared
with non‐surgical management.
</p><p id="d342611e245">
<b>Background</b>
</p><p id="d342611e250">The rotator cuff is a group of tendons that move the shoulder
joint. Some people have
pain in their shoulder related to wear and tear of the rotator cuff tendons. The weakening
of the tendon is thought to be caused by aging and mechanical wear. Eventually, the
process may result in a tear of the tendons.
</p><p id="d342611e252">Rotator cuff tears can cause pain and impair arm function
but asymptomatic tears also
occur. For people with symptomatic tears, non‐operative management including pain
medicines (simple analgesia and anti‐inflammatories), glucocorticoid injections and
physical therapies do not always result in satisfactory outcomes.
</p><p id="d342611e254">Surgery is usually considered when other treatments fail.
Surgery includes removing
part of the bone to broaden the tendon passage (subacromial decompression) and repair
of the torn tendons. Sometimes the surgeons cannot repair the tendon due to the size
of the tear or degeneration of the muscle, and in these cases only subacromial decompression
may be performed. Most rotator cuff surgery is now performed arthroscopically (surgical
instruments are inserted through small key holes to perform surgery) or through small
incisions (mini‐open approach).
</p><p id="d342611e256">
<b>Study characteristics</b>
</p><p id="d342611e261">This Cochrane Review is current to January 2019. We found
nine trials with 1007 participants.
Participants mean age was 56 to 68 years, and females comprised 29% to 56% of the
participants. The participants had symptoms for several months or years and were diagnosed
with a full‐thickness tear with magnetic resonance imaging or ultrasound examination.
Studies were conducted in Finland, Norway, Canada, USA, France, the Netherlands, Italy
and South Korea. Our primary analysis included three trials with 339 participants
who received either surgery (tendon repair and removal of bone from undersurface of
acromion) or non‐operative therapy (exercises with or without glucocorticoid injection).
Three studies received funding however none of them reported using the funds directly
for these trials.
</p><p id="d342611e263">
<b>Key results</b>
</p><p id="d342611e269">Compared with non‐operative treatment, surgery resulted in
little or no benefit in
people with rotator cuff tears for up to one year.
</p><p id="d342611e271">
<i>Pain (lower scores mean less pain)</i>

Improved by 9% (4% better to 13% better) or 0.9 points on a zero to 10 scale

• People who had non‐operative treatment rated their pain as 1.6 points

• People who had surgery rated their pain as 0.7 points.



<i>Function (0 to 100; higher scores mean better function)</i>Improved by 6% (2% better
to 10% better) or 6 points on a zero to 100 scale

• People who had non‐operative treatment scored 72 points

• People who had surgery scored 78 points
</p><p id="d342611e279">
<i>Participant‐rate global treatment success (participants satisfied with the outcome)</i>

7% more people rated their treatment a success (4% fewer to 13% more), or seven more
people out of 100.

• 48/55 (873/1000) of people considered treatment as successful with non‐operative
treatment

• 51/54 (943/1000) of people considered treatment as successful with surgery
</p><p id="d342611e284">
<i>Overall quality of life (higher scores mean better quality of life)</i>Worsened
1% (4% worse to 2% better) or 1.3 points on a zero to 100 scale

• People who had non‐operative treatment rated their quality of life 58

• People who had surgery (subacromial decompression) rated their quality of life 57
</p><p id="d342611e289">
<i>Adverse events</i>

• One adverse event (frozen shoulder) was reported in the trials in exercise group.
Thus, we are unable to estimate comparative risk.
</p><p id="d342611e294">
<i>Serious adverse events</i>

• No serious adverse events were reported in the trials.
</p><p id="d342611e299">
<b>Quality of the evidence</b>
</p><p id="d342611e304">As compared with non‐operative treatment, moderate‐certainty
evidence (downgraded
due to risk of bias) indicates that surgery (rotator cuff repair with or without subacromial
decompression) probably provides little or no benefit in pain and low‐certainty evidence
indicates that it may provide little or no improvement in function, participant‐rated
global treatment success or overall quality of life (downgraded due to bias and imprecision)
in people with rotator cuff tears. Due to only one reported adverse event across the
trials, we cannot estimate if there is higher risk for adverse events after either
treatment (very low‐certainty evidence).
</p>