Outcomes of rotator cuff surgery: what does the evidence tell us?

Rotator cuff disease accounts for more than 4.5 million annual visits to a physician, and more than 75,000 surgical repairs are performed a year. Surgical techniques have evolved from all open repairs to all arthroscopic repairs being the most commonly used. The purpose of this article is to review the current evidence regarding the outcomes of surgical techniques in rotator cuff surgery. Reported outcomes have been favorable with open, mini-open, and arthroscopic repairs. Recently, a committee sponsored by the AAOS published a clinical practice guideline summary regarding the management of rotator cuff tears. The guidelines touched aspects of both nonoperative and operative repair. In regard to operative repair, the committee could not recommend a modality of surgical repair (eg, arthroscopic vs open) as a superior method, citing a lack of comparative studies. The theoretical advantage of arthroscopic surgery lies in smaller soft tissue dissection and the ability to evaluate and treat the glenohumeral joint. However, no study using patient-based outcomes has shown superiority compared with open or mini-open repairs. With the method of surgical repair not changing outcomes, investigation has recently focused on optimizing bone-tendon healing in rotator cuff repair. Double-row fixation allows for a more anatomic reapproximation of the rotator cuff footprint on the greater tuberosity versus single-row and has been shown to be biomechanically superior. Despite this, no clinical studies have shown superiority of one type of repair versus the other. The AAOS committee citing similar evidence gave a weak recommendation for the use of achieving tendon-to-bone healing with double-row fixation. Transosseous-equivalent repair, which provides a high compressive force on the tendon-to-bone interface of repair, is the newest fixation method under investigation to optimize healing. The use of collagen and biologic augmentation has gained interest as researchers are attempting to optimize rotator cuff healing. There is moderate evidence against the use of porcine small intestine submucosa xenograft patches. Other commercially available collagen augments have yet to be proven as either beneficial or detrimental. Other than PRP, which has not shown to have any benefit augmenting repair, no biologic augment has been investigated clinically. Overall, rotator cuff surgery portends a good outcome for appropriately selected patients. However, there is not much high-quality evidence-based research that can be used to conclude what surgical treatments are superior or appropriate for a given patient. Future research should be aimed at identifying whether and in whom rotator cuff healing is appropriate to better identify surgical candidates as well as to determine the best surgical repair strategy.