Surgery Versus Conservative Strategies In Patients With Rotator Cuff Tear Of The Shoulder: A Systematic Review With Meta-Analysis

Shoulder pain (SP) is one of the most common musculoskeletal complaints 1 and it can negatively affect the correct movement of the upper limb, night rest, daily life activity, work and sports performances and autonomy 2-4. Rotator cuff (RC) disease represents the most common cause of SP and it is responsible for up to 70% of all shoulder related visits to clinicians 5. RC tears are generally considered to be a normal imaging result and a age related disorder 6, when we consider patients over 5th decade. Infact, RC tears are present between 20% to 54% of subjects aged between 60 and 80 years 7; moreover full-thickness RC tears can be evident in approximately 20% of patients over 65 years old 8. RC tears have been widely studied and a lot of management strategies of patients with RC tears are actually available in literature 9,10; even if successful results have been achieved for both conservative and surgical treatment of RC tears, optimal management and best choice treatments for patient with RC tears are still unknown and debated 11,12. Generally, conservative treatments were often administered in partial thickness RC tear, while surgery was judged as better option for massive tear 13. Furthermore, conservative treatment has often been advocated for older patients with comorbidities, while surgery is suggested for younger people 14,15. Lastly, physiotherapy did not reach structural healing of the tear, however successful rate was reported also after conservative treatment of massive tears: nevertheless, some concerns persist about the enlargement of the anatomical lesion and following loss of strength and pain persistence 7. In the USA, in 2006, the annual incidence of surgery for RC tear was 98 procedures per 100,000 inhabitants and the incidence was increased form the application of the arthroscopic strategies 16,17, moreover, despite being considered as a successful treatment option, surgical treatment is estimated to cause from 20 to 90% rate of re-tear after surgery 18,19. In such a framework of uncertainty on optimal management, several randomized controlled trials (RCTs) have been structured to compare the efficacy of surgical and conservative treatments for patient with any type of RC tears; results coming from different studies are often contradictory and substantially influenced by the recruited sample characteristics. The aim of this systematic review is to analyze the results of randomized controlled trials which compare surgical and conservative treatments for patient with any type of RC tear through meta-analysis. Furthermore, this study also aims to know which are the most common indication to surgery: authors would like to understand if the presence of structural failure at the imaging assessment, the presence of pain refractory to conservative treatment, the presence of strength deficit or the combination of this mentioned elements are considered as decision criteria for choosing a surgery approach.