Insufficient evidence to confirm benefit of adjuvant distal clavicle resection during rotator cuff repair: a systematic review and meta-analysis

in EFORT Open Reviews
Authors:
Johannes Barth Clinique des Cèdres, 21 Avenue Albert Londres, 38130 Échirolles, France

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Jerôme Garret Clinique du parc, 155, Boulevard Stalingrad, Lyon, France

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Luca Nover ReSurg SA, Rue Saint Jean 22, Nyon, Switzerland

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Floris van Rooij ReSurg SA, Rue Saint Jean 22, Nyon, Switzerland

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Philippe Clavert Service de Chirurgie du Membre Supérieur, Haut Pierre 2, CHRU Strasbourg, avenue Molière, Strasbourg, France

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The Société Francophone d'Arthroscopie*
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The Société Francophone d'Arthroscopie

Correspondence should be addressed to F van Rooij; Email: journals@resurg.com

*(Collaborators: David Gallinet, Ludovic Labattut, Philippe Collin, Pierre Métais, Nicolas Bonnevialle, Arnaud Godeneche)

DOI:
https://doi.org/10.1530/EOR-22-0101
Volume/Issue:
Volume 8: Issue 8
Page Range:
615–625
Article Type:
Systematic Review
Online Publication Date:
01 Aug 2023
Copyright:
© the author(s) 2023
Category:
Shoulder & Elbow
Open access

  • The aim of this study is to determine whether adjuvant Distal Clavicle Resection (DCR) improves outcomes of Rotator Cuff Repair (RCR) in terms of ROM, clinical scores as well as reducing complications and/or reoperations.

  • This systematic review conforms to the PRISMA guidelines. Studies were included if they compared outcomes of RCR with and without adjuvant DCR and reported on postoperative ROM, clinical scores, complications, and/or reoperations.

  • Seven studies that comprised 1572 shoulders which underwent RCR at a follow-up ranged 8-54 months: 398 with adjuvant DCR and 1174 without DCR. No significant differences were found between patients that had DCR versus those that did not have DCR, in terms of postoperative clinical scores (ASES, Constant, pVAS), postoperative ROM (AFE, external and internal rotation), retear rate and reoperation rate.

  • There were no significant differences in ROM, clinical scores, or rates of retears and reoperations between patients that underwent RCR with or without adjuvant DCR.

  • There is insufficient evidence to support routine DCR during RCR; the incidence of new or residual acromioclavicular joint (ACJ) pain after RCR with adjuvant DCR is higher than following isolated RCR, which could in fact induce iatrogenic morbidity and therefore does not justify the additional surgery time and costs of routine adjuvant DCR.

Abstract

  • The aim of this study is to determine whether adjuvant Distal Clavicle Resection (DCR) improves outcomes of Rotator Cuff Repair (RCR) in terms of ROM, clinical scores as well as reducing complications and/or reoperations.

  • This systematic review conforms to the PRISMA guidelines. Studies were included if they compared outcomes of RCR with and without adjuvant DCR and reported on postoperative ROM, clinical scores, complications, and/or reoperations.

  • Seven studies that comprised 1572 shoulders which underwent RCR at a follow-up ranged 8-54 months: 398 with adjuvant DCR and 1174 without DCR. No significant differences were found between patients that had DCR versus those that did not have DCR, in terms of postoperative clinical scores (ASES, Constant, pVAS), postoperative ROM (AFE, external and internal rotation), retear rate and reoperation rate.

  • There were no significant differences in ROM, clinical scores, or rates of retears and reoperations between patients that underwent RCR with or without adjuvant DCR.

  • There is insufficient evidence to support routine DCR during RCR; the incidence of new or residual acromioclavicular joint (ACJ) pain after RCR with adjuvant DCR is higher than following isolated RCR, which could in fact induce iatrogenic morbidity and therefore does not justify the additional surgery time and costs of routine adjuvant DCR.

Keywords: shoulder; tendon tear; rotator cuff repair; clavicle resection; clinical scores; range of motion

Introduction

Rotator cuff tears (RCT) are among the most common shoulder pathologies and can result in considerable pain and functional impairment (1). RCTs can be caused by overall degeneration or trauma and are often concomitant with other pathologies such as acromioclavicular joint (ACJ) arthropathy, glenohumeral degeneration and biceps or labral tears (2). ACJ arthropathy may lead to impingement and pain due to inferiorly directed osteophytes (3, 4), and can be challenging to diagnose and treat.

Patients undergoing rotator cuff repair (RCR) may require adjuvant distal clavicle resection (DCR) if they have signs of ACJ arthropathy (5, 6, 7), but DCR is not always recommended as it can cause pain, stiffness, instability, and infection (3, 8, 9, 10, 11). Recent meta-analyses (12, 13) advised against DCR as an adjuvant procedure during RCR, whether it is performed systematically (13) or in shoulders diagnosed with ACJ arthropathy (12), concluding that DCR does not improve outcomes for patients in the first 2 years after RCR. As both meta-analyses included the same three randomized controlled trials, which had low statistical power, the risks and benefits of routine DCR during RCR remains a matter of debate. Therefore, an updated meta-analysis including newer studies as well as older non-randomized comparative studies seems necessary to help reach consensus.

The purpose of this systematic review and meta-analysis was to determine whether adjuvant DCR improves outcomes of RCR in terms of range of motion (ROM), clinical scores as well as reducing complications and/or reoperations. The hypothesis was that adjuvant DCR does not improve clinical scores nor ROM.

Materials and methods

The protocol for this systematic review was submitted to PROSPERO prior to commencement (registration number: CRD42021286668) and conforms to the principles outlined in the Handbook of the Cochrane Collaboration (14), along with the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) (15).

Search strategy

The authors conducted a structured electronic literature search on November 15, 2021, using the PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases, applying the keywords presented in Appendix 1. The search was limited to articles published between January 1, 2001, and November 15, 2021, to ensure a contemporary systematic review, in consideration of modernization of surgical techniques. After removal of duplicate records, each of two researchers (LN, FVR) screened the titles and abstracts to determine the suitability for the review using the following predefined eligibility criteria:

Inclusion criteria

  • Studies of level I to III (16) that compare outcomes of RCR with and without adjuvant DCR, with no limits to sample sizes or prevalence in the included studies.

  • Studies that report postoperative ROM, clinical scores, complications and/or reoperations.

Exclusion criteria

  • Studies that do not compare outcomes of RCR with and without adjuvant DCR.

  • Narrative or systematic reviews, non-comparative case series, case reports, expert opinions, editorials, or letters to editors.

  • Articles published in languages other than English, French, German, Italian, or Spanish will be excluded due to a lack of confidence of the researchers' in analysis in other languages,

  • In cases of duplicate patient population between two studies, the most complete dataset will be used,

Study selection

Full-text review of studies meeting the eligibility criteria in the initial screening was carried out by two researchers (LN, FVR) and any disagreement was first discussed between the researchers, and, if required, a third researcher (BLINDED) resolved any disagreement. The reference lists of studies for full text review were searched, and an expert was consulted to identify further relevant studies that may not have been captured by the database searches.

Data extraction and quality assessment

Data extraction was performed by two researchers (LN, FVR) independently and their results were compared to ensure accuracy. Where there was disagreement in the documented value, the correct value was ascertained by simultaneous review of the data in question by both researchers. The following data were extracted from the included studies: author(s), journal, year of publication, level of evidence, country where study was performed, conflicts of interest, and funding declaration. Patient characteristics were retrieved, including number of patients in each group, sex, and age. Furthermore, patient-reported outcome measures (PROMs) were extracted, including the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and pain on visual analogue scale (pVAS). ROM was also extracted, notably active forward elevation (AFE), external rotation (ER), and internal rotation (IR). Finally, ACJ pain or tenderness, ACJ instability, residual ACJ pain, and reoperation rates were noted. Methodological quality of the eligible studies was assessed by two researchers (LN, FVR) according to the Joanna Briggs Institute (JBI) checklist (17) to appraise the reporting quality (10 items). Where there was disagreement between the researchers, consensus was achieved by discussion and review.

Statistical analysis

When studies were not sufficiently comparable to pool, results were displayed in a forest plot without the summary estimate (18). Heterogeneity was evaluated by visual inspection of the forest plots and quantified using the I2 statistic to provide a measure of the degree of inconsistency across the studies (14). Where possible, summary pooled estimates of proportions and mean differences with 95% confidence intervals were estimated using random-effects models. Between-study variance was quantified using the I2 statistic, estimated using the restricted maximum-likelihood (REML) approach. Statistical analyses were performed using R version 3.5.0 (R Foundation for Statistical Computing, Vienna, Austria) using the meta package (19).

Results

The systematic search returned 228 records, of which 40 were duplicates, leaving 188 for screening (Fig. 1). A total of 170 studies were excluded by examining their titles and/or abstracts, and a further 11 studies were excluded after full-text review. This left 7 (Table 1) eligible studies (3, 8, 9, 10, 11, 20, 21) which reported on a total of 1572 shoulders that underwent RCR at a follow-up ranging from 8 to 54 months: 398 with adjuvant DCR and 1174 without DCR (Tables 2 and 3). Of the seven included studies, three case controls (8, 20, 21) and four were randomized controlled trials (RCTs) (3, 9, 10, 11). In two studies, DCR was systematically performed, regardless of ACJ status (9, 20), while in the other five studies, DCR was only performed in patients with signs of ACJ arthritis (3, 8, 10, 11, 21).

Figure 1
Figure 1

Flowchart.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Table 1

Studies included and declarations.
Study Country Indication LOE Declarations
COI Funding
Gallinet et al. (9) France Distal or middle SSP tear I Yes* No
Chalmers et al. (20) USA Arthroscopic RCR (with or without DCR) performed within a 9-month period III Yes† NA
Razmjou et al. (21) Canada RCT + ACJ–OA Collins Grade 1-4 II NA NA
Park et al. (3) S Korea RCT + ACJ–OA Petersson Grades II–III + positive ‘lidocaine injection test in the ACJ’ I Yes‡ Yes§
Oh et al. (11) S Korea RCT with asymptomatic ACJ–OA I Yes‡ NA
Blasiak et al. (8) Poland 1- or 2-tendon RCT + symptomatic ACJ degeneration III NA NA
Kim et al. (10) S Korea RCT 1–3 cm + asymptomatic + dominant + ACJ–OA Stein Grade 4 I Yes‡ NA

*Royalties from Move-Up, Aston Medical, Wright Medical; Consulting fees from Move-Up, Arthrex, SBM, Aston Medical, Wright Medical, General Secretary of SECEC, Johnson and Johnson, Smith & Nephew, Lima, Conmed, FH Orthopedics, Zimmer Biomet; Deputy Editor for OTSR and Surg Radiol Anat; †paid consultant and/or presenter/speaker for DePuy Mitek, DePuy, Cayenne Medical, Zimmer Biomet; hospitality payments from Tornier; royalties from Arthrex; stock in KATOR; educational support from Pinnacle; ‡none; §funding from Smith & Nephew.

ACJ–OA, Acromio Clavicular Joint OA; LOE, level of evidence; NA, not available; SSP, supraspinatus.

Table 2

Cohort demographics.
Study/Groups Shoulders, n Males, % Females, % Dominant, n (%) Age*
Gallinet et al. (9)
 RCR + DCR 97 45 55 82 (85%) 58 (42–69)
 Isolated RCR 103 49 51 76 (74%) 57 (45–69)
Chalmers et al. (20)
 RCR + DCR 46 54 46 21 (46%) 52 ± 11
 Isolated RCR 894 65 35 386 (43%) 58 ± 10
Razmjou et al. (21) 61* 39* 62 ± 9
 RCR + DCR 144
 Isolated RCR 40
Park et al. (3)
 RCR + DCR 21 19 81 21 (100%) 63 ± 9
 Isolated RCR 26 19 81 25 (96%) 62 ± 6
Oh et al. (11)
 RCR + DCR 39 54 46 34 (87%) 64 ± 7
 Isolated RCR 39 59 41 30 (77%) 64 ± 8
Blasiak et al. (8) 55* 45
 RCR + DCR 20 55 ± 15
 Isolated RCR 20 51 ± 11
Kim et al. (10)
 RCR + DCR 31 52 48 31 (100%) 60 ± 5
 Isolated RCR 52 46 54 52 (100%) 55 ± 6

*Mean ± s.d values in parentheses are range; †values refer to the entire cohort as opposed to comparative and control groups

DCR, distale clavicle resection; RCR, rotator cuff repair.

Table 3

Tear location, tear size, and repair techniques using surgery in the cohorts included.
Study/ Groups Tear location Tear size Surgery Biceps
SSP SSC ISP SSP+ SSC SSP+ ISP SM MO LA MA PA Repair technique UN TT TD
Gallinet et al. (9)
 RCR + DCR  97 Double-row repairs
 Isolated RCR 103 Double-row repairs
Chalmers et al. (20)
 RCR + DCR Single-row anchor with double sutures
 Isolated RCR Single-row anchor with double sutures
Razmjou et al. (21)
 RCR + DCR 96 48 27 Partial repairs
 Isolated RCR 26 14 10 Partial repairs
Park et al. (3)
 RCR + DCR 5 11 4 1 Single row with suture anchor
 Isolated RCR 1 12 9 4 Single row with suture anchor
Oh et al. (11)
 RCR + DCR  36 2 1 6 17 2 11 3 15 Single row; 24 suture bridge 14 18 7
 Isolated RCR  36 1 2 4 26 2 4 3 13 Single row; 26 suture bridge 12 21 6
Blasiak et al., (8)
 RCR + DCR  10 5 5 Single row anchor with double sutures
 Isolated RCR  9 1 5 5
Kim et al. (10)
 RCR + DCR 27.2 ± 3.7 mm (10–30) DCR 5.2 ± 1.1 mm; double-row fixation using susure anchors 1 1
 Isolated RCR 24.7 ± 3.1 mm (10–30) DCR 5.4 ± 1.4mm; double-row fixation using susure anchors 1 1

DCR, distale clavicle resection; ISP, infraspinatus; LA, large; MA, massive; MO, moderate; RCR, rotator cuff repair; SSP, supraspinatus; SSC, subscapularis; SM, smallPA, partial; TD, tenodesis; TT, tenotomy; UN, untouched.

Quality assessment

Of the three case control studies, 2 did not match cases and controls appropriately, as there were statistically significant differences between patient characteristics and did not state strategies to deal with confounding factors (Fig. 2). Of the four randomized controlled trials, none clarified whether clinicians, patients, or assessors were blinded to treatment (Fig. 3).

Figure 2
Figure 2

JBI checklist for case–control studies.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Figure 3
Figure 3

JBI checklist for randomized controlled trials.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Clinical scores

Five studies reported postoperative PROMs (Table 4). Compared to patients that did not have DCR, those that had adjuvant DCR reported similar ASES scores (range: 77–95 vs 81–93) and similar Constant scores (range: 72–96 vs 75–96), but slightly lower pain on VAS (range: 0.6–2.3 vs. 0.6–1.8). No significant differences were found between patients that had RCR than for those that did not have DCR, in terms of postoperative ASES scores (MD: −1.9; CI: −7.2 to 3.5; P = 0.490), Constant scores (MD: −0.2; CI: −1.9 to 1.5; P = 0.820), and pVAS (MD: 0.1; CI: −0.2 to 0.5; P = 0.520) (Fig. 4). Of the seven studies, five reported on residual or new ACJ pain following surgery and found that there was residual pain in 0−37% of patients that had adjuvant DCR vs 0−22% of patients that did not have DCR.

Figure 4
Figure 4

Forest plots for ASES, constant score, and pain on VAS.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Table 4

Clinical outcomes. Data are presented as mean ± s.d. or n (%).
Study/groups

 Follow-up

 ASES Constant score Pain on VAS
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Residual/new pain
Gallinet et al. (9)
 RCR + DCR 12 54 ± 13 79 ± 13 6.9 ± 1.8 1.8 ± 2.4 36 (37%)
 Isolated RCR 12 53 ± 14 81 ± 11 6.9 ± 1.8 1.3 ± 2.2 23 (22%)
Chalmers et al. (20) 8 ± 10*
 RCR + DCR 41 ± 22 6.2 ± 2.1 0 (0%)
 Isolated RCR 45 ± 19 5.5 ± 2.4 10 (1.1%)
Razmjou et al. (21)
 RCR + DCR 24 49 86 51 96
 Isolated RCR 24 44 77 47 85
Park et al. (3)
 RCR + DCR 44 ± 9.8 40 ± 17 81 ±14 45 ± 17 75 ± 12 5.3 ± 2.1 1.8 ± 1.3 7 (33%)
 Isolated RCR 44 ± 9.5 39 ± 17 79 ± 24 45 ± 16 72 ± 21 6.1 ± 1.9 2.0 ± 2.5 5 (20%)
Oh et al. (11)
 RCR + DCR 28 ± 6.7 47 ± 10 92 ±16 74 ± 6 96 ± 6 7.2 ± 1.8 0.6 ± 1.8
 Isolated RCR 31 ± 7.2 51 ± 14 95 ±12 74 ± 8 96 ± 5 6.1 ± 1.9 0.6 ± 0.9
Blasiak et al. (8) 54 ± 6*
 RCR + DCR 55 ± 10.9 95 ± 8 8.2 ± 1.6 0.7 ± 1.0 1 (5%)
 Isolated RCR 64 ± 12.8 96 ± 7 8.0 ± 1.3 0.7 ± 1.3 0 (0%)
Kim et al. (10)
 RCR + DCR 33 ± 4.1 57 93 7.2 1.7 0 (0%)
 Isolated RCR 32 ± 4.9 57 89 7.2 2.3 2 (3.8%)

*Value refers to the entire cohort as opposed to comparative and control.

Range of motion

Three studies reported postoperative ROM (Table 5). Compared to patients that did not have DCR, those that had adjuvant DCR reported similar AFE (range: 142–172 vs 141–170) and similar ER (range: 34–74 vs 36–76), but slightly better IR (range: T7.9–T8 vs T8–T9.4). The three studies were eligible for meta-analysis, which revealed no significant differences between patients that had RCR with or without DCR, in terms of postoperative AFE (MD: −2.0; CI: −5.0 to 1.0; P =0.190) (Fig. 5), ER (MD: −1.0; CI: −7.0 to 5.1; P = 0.750), and IR (MD: 0.7; CI: −0.9 to 2.2; P = 0.410).

Figure 5
Figure 5

Forest plots for active forward elevation, external rotation, and internal rotation.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Table 5

ROM complications and reoperations. Data are presented as mean ± s.d. or n (%).
Study/groups Complications AFE External rotation Internal rotation
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
Gallinet et al. (9)
 RCR + DCR 0% 7% 0% 116 ± 32 169 ± 16 32 ± 24 53 ± 16 3.6 ± 2.0 8.6 ± 1.9
 Isolated RCR 1% 5% 0% 124 ± 29 171 ± 14 29 ± 23 59 ± 23 4.0 ± 2.0 8.7 ± 1.5
Chalmers et al. (20)
 RCR + DCR 4% 2%
 Isolated RCR 7% 4%
Razmjou et al. (21)
 RCR + DCR 0%
 Isolated RCR 0%
Park et al. (3)
 RCR + DCR 5% 10% 142 ± 30 141 ± 17 37 ± 18 36 ± 13 T11* T8
 Isolated RCR 4% 15% 142 ± 22 142 ± 22 44 ± 20 34 ± 17 T10 T8
Oh et al. (11)
 RCR + DCR 0% 23% 5% 160 ± 11 170 ± 11 56 ± 17 76 ± 17 T10.2 ± 3 T9.4 ± 2.4
 Isolated RCR 0% 26% 0% 160 ± 16 172 ± 9 61 ± 14 74 ± 16 T8.0 ± 3 T7.9 ± 1.4
Blasiak et al. (8)
 RCR + DCR 0% 0% 0%
 Isolated RCR 0% 0% 0%
Kim et al. (10)
 RCR + DCR 0% 0% 0%
 Isolated RCR 2% 0% 0%

*Internal rotation was measured as the highest spinal level achieved when the patient reached behind the back with the ‘hitch-hiking thumb’.

AFE, anterior forward elevation.

Retears, reoperations, and ACJ instability

The reoperation rates were similar for patients that had DCR (range: 0–5%) as for those that did not have DCR (range: 0–7%) (Table 5). The retear rates were similar for patients that had DCR (range: 0–23%) as for those that did not have DCR (range: 0–26%). The ACJ instability rates were greater for patients that had DCR (range: 0–5%) than for those that did not have DCR (range: 0–0%). No significant differences were found between patients that had RCR vs those that did not have DCR, in terms of retear rate (OR: 0.9; CI: 0.5–1.8; P = 0.830) (Fig. 6) and reoperation rate (OR: 0.6; CI: 0.2–1.8; P = 0.370).

Figure 6
Figure 6

Forest plots for retear rate and reoperation rate.

Citation: EFORT Open Reviews 8, 8; 10.1530/EOR-22-0101

Discussion

The most important finding of this systematic review and meta-analysis is that there was insufficient evidence to detect benefits of DCR during RCR, in terms of ROM, clinical scores, or rates of retears and reoperations.

Performing adjuvant DCR during RCR could increase morbidity risk or severity of complications, as insufficient resection may lead to residual impingement, while excessive resection may cause AC joint instability, heterotopic ossification, fracture, or suprascapular nerve lesion (9, 22). Furthermore, as adjuvant DCR increases both the operation time and consequently the cost of surgery (23, 24), the procedure should provide significant improvement in the expected result, to offset potential drawbacks. In the present meta-analysis, there was greater incidence of residual pain following adjuvant DCR during RCR than isolated RCR, possibly due to iatrogenic morbidity, though it is important to note that pain at the ACJ may not necessarily originate therefrom and that specific tests or imaging are necessary to ascertain the source of pain (25).

The present meta-analysis found no benefit in performing adjuvant DCR during RCR, even in patients that have radiological signs of ACJ arthropathy; thus performing DCR as a secondary procedure may be sufficient in patients that present with persistent ACJ pain following RCR, as it is a relatively quick and simple procedure and may only be required in 1–2% of cases (26). A recent study found that DCR could be effective as a secondary procedure in a small subset of patients that developed symptomatic ACJ arthropathy following isolated RCR. Even so, patients should be informed about the potential for residual pain and/or functional impairment, which could be associated with other intrinsic or extrinsic factors that may be unrelated to the rotator cuff or the ACJ.

A recent study by Yiannakopoulos et al. (26) evaluated clinical progression of ACJ osteoarthritis in patients who underwent isolated arthroscopic RCR regardless of the presence of ACJ arthropathy. The authors found that only 1% of patients had persistent ACJ pain following arthroscopic RCR, and that there was no difference in clinical outcomes between patients who had or did not have ACJ symptoms prior to the procedure. Yiannakopoulos et al. (26) therefore did not recommend DCR during RCR in patients with ACJ arthropathy, which corroborate our findings. ACJ arthropathy could be a different and unrelated disease to rotator cuff pathology; in fact, Shubin Stein et al. (27) found that in patients aged >30, scheduled for MRI of extremities unrelated to the shoulder, 93% had radiographic signs of ACJ arthritis.

When conservative management of ACJ arthropathy fails, surgical intervention is the treatment of choice, but the criterion defining failure of conservative management and the best practice evidence for existing nonpharmacological interventions is a matter of debate (28, 29). Furthermore, as the prevalence of patients that would require DCR following RCR is very low, Farrell et al. (29) recommends that patients should undergo 4–6 months of both nonpharmacological and pharmacological treatments to treat ACJ arthropathy, such as activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular steroid injections, and physiotherapy. Only after following such a treatment plan, conservative management is deemed to have failed and surgical intervention is indicated.

The results of the present meta-analysis should be interpreted with the following limitations in mind. There was heterogeneity in the indications for DCR (in two studies, DCR was systematically performed, regardless of ACJ status, while in the other five studies, DCR was performed in patients with signs of ACJ arthritis) which makes quantitative comparisons between cohorts difficult. Of the three case–control studies, two did not perform adequate matching and did not state strategies to deal with confounding factors. Of the four randomized controlled trials, none clarified whether clinicians, patients, or assessors were blinded to treatment. Finally, it is worth noting that few additional studies have been published in recent years highlighting the need for new trials.

Conclusion

In this systematic review and meta-analysis, there were no significant differences in ROM, clinical scores, or rates of retears and reoperations between patients that underwent RCR with or without adjuvant DCR. There is insufficient evidence to support routine DCR during RCR; the incidence of new or residual ACJ pain after RCR with adjuvant DCR is higher than following isolated RCR, which could in fact induce iatrogenic morbidity and therefore does not justify the additional surgery time and costs of routine adjuvant DCR.

ICMJE conflict of interest statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding statement

This work was supported by ‘Clinique des Cèdres’, which provided funding for data extraction and manuscript preparation.

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    • Search Google Scholar
    • Export Citation
  • 11.↑

    Oh JH, Kim JY, Choi JH, & Park SM. Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study. American Journal of Sports Medicine 2014 42 2567–2573. (https://doi.org/10.1177/0363546514547254)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.↑

    Wang J, Ma JX, Zhu SW, Jia HB, & Ma XL. Does distal clavicle resection decrease pain or improve shoulder function in patients with acromioclavicular joint arthritis and rotator cuff tears? A meta-analysis. Clinical Orthopaedics and Related Research 2018 476 2402–2414. (https://doi.org/10.1097/CORR.0000000000000424)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.↑

    Livingstone A, Asaid R, & Moaveni AK. Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis. Shoulder and Elbow 2019 11(1) 39–45. (https://doi.org/10.1177/1758573217741124)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.↑

    Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011 343 d5928. (https://doi.org/10.1136/bmj.d5928)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.↑

    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372 n71. (https://doi.org/10.1136/bmj.n71)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.↑

    Burns PB, Rohrich RJ, & Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and Reconstructive Surgery 2011 128 305–310. (https://doi.org/10.1097/PRS.0b013e318219c171)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.↑

    Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, Stephenson M, & Aromataris E. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evidence Synthesis 2020 18 2127–2133. (https://doi.org/10.11124/JBISRIR-D-19-00099)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.↑

    Faber T, Ravaud P, Riveros C, Perrodeau E, & Dechartres A. Meta-analyses including non-randomized studies of therapeutic interventions: a methodological review. BMC Medical Research Methodology 2016 16 35. (https://doi.org/10.1186/s12874-016-0136-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.↑

    Balduzzi S, Rucker G, & Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evidence-Based Mental Health 2019 22 153–160. (https://doi.org/10.1136/ebmental-2019-300117)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.↑

    Chalmers PN, Granger E, Ross H, Burks RT, & Tashjian RZ. Preoperative factors associated with subsequent distal clavicle resection after rotator cuff repair. Orthopaedic Journal of Sports Medicine 2019 7 2325967119844295. (https://doi.org/10.1177/2325967119844295)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.↑

    Razmjou H, ElMaraghy A, Dwyer T, Fournier-Gosselin S, Devereaux M, & Holtby R. Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear. Knee Surgery, Sports Traumatology, Arthroscopy 2015 23 585–590. (https://doi.org/10.1007/s00167-014-3114-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.↑

    Aliberti GM, Kraeutler MJ, Trojan JD, & Mulcahey MK. Horizontal instability of the acromioclavicular joint: a systematic review. American Journal of Sports Medicine 2020 48 504–510. (https://doi.org/10.1177/0363546519831013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.↑

    Morris JH, Malik AT, Hatef S, Neviaser AS, Bishop JY, & Cvetanovich GL. Cost of arthroscopic rotator cuff repairs is primarily driven by procedure-level factors: a single-institution analysis of an ambulatory surgery center. Arthroscopy 2021 37 1075–1083. (https://doi.org/10.1016/j.arthro.2020.11.033)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.↑

    Sabesan VJ, Shahriar R, Chatha K, Malone DL, Sherwood A, Peaguda CF, & Whaley JD. Factors affecting the cost and profitability of arthroscopic rotator cuff repair. Arthroscopy 2019 35 38–42. (https://doi.org/10.1016/j.arthro.2018.07.034)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.↑

    Aly AR, Rajasekaran S, & Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British Journal of Sports Medicine 2015 49 1042–1049. (https://doi.org/10.1136/bjsports-2014-093573)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.↑

    Yiannakopoulos CK, Vlastos I, Theotokatos G, & Galanis N. Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy 2021 29 2090–2095. (https://doi.org/10.1007/s00167-020-06098-y)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.↑

    Shubin Stein BE, Wiater JM, Pfaff HC, Bigliani LU, & Levine WN. Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. Journal of Shoulder and Elbow Surgery 2001 10 204–208. (https://doi.org/10.1067/mse.2001.113498)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.↑

    Soler F, Mocini F, Djemeto DT, Cattaneo S, Saccomanno MF, & Milano G. No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review. Knee Surgery, Sports Traumatology, Arthroscopy 2021 29 2194–2201. (https://doi.org/10.1007/s00167-020-06377-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.↑

    Farrell G, Watson L, & Devan H. Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: a systematic review. Shoulder and Elbow 2019 11 395–410. (https://doi.org/10.1177/1758573219840673)

    • PubMed
    • Search Google Scholar
    • Export Citation

EFORT Open Reviews is committed to supporting researchers in demonstrating the impact of their articles published in the journal.

As an open-access journal, EFORT Open Reviews articles are immediately available to read on publication, without restriction. The two types of article metrics we measure are (i) more traditional full-text views and pdf downloads, and (ii) Altmetric data, which shows the wider impact of articles in a range of non-traditional sources, such as social media.

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Online ISSN:
2058-5241
Copyright:
© the author(s) 2023
Article Type:
Systematic Review
Page Range:
615–625
Published Online:
01 Aug 2023
Keywords:
shoulder; tendon tear; rotator cuff repair; clavicle resection; clinical scores; range of motion
Figure 1

Flowchart.
Figure 2

JBI checklist for case–control studies.
Figure 3

JBI checklist for randomized controlled trials.
Figure 4

Forest plots for ASES, constant score, and pain on VAS.
Figure 5

Forest plots for active forward elevation, external rotation, and internal rotation.
Figure 6

Forest plots for retear rate and reoperation rate.
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    Blasiak A, Mojzesz M, Brzoska R, Solecki W, & Binkowska A. Results of arthroscopic treatment of rotator cuff tear with the resection of symptomatic acromioclavicular joint with degenerative changes. Polish Orthopedics and Traumatology 2013 78 229–234.

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    Gallinet D, Barth J, Labattut L, Collin P, Metais P, Bonnevialle N, Godeneche A, Garret J, Clavert P & Francophone Arthroscopy Society (SFA). Benefits of distal clavicle resection during rotator cuff repair: prospective randomized single-blind study. Orthopaedics and Traumatology, Surgery and Research 2020 106 S207–S211. (https://doi.org/10.1016/j.otsr.2020.08.006)

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    Kim J, Chung J, & Ok H. Asymptomatic acromioclavicular joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study. Archives of Orthopaedic and Trauma Surgery 2011 131 363–369. (https://doi.org/10.1007/s00402-010-1216-y)

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  • 11.

    Oh JH, Kim JY, Choi JH, & Park SM. Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study. American Journal of Sports Medicine 2014 42 2567–2573. (https://doi.org/10.1177/0363546514547254)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Wang J, Ma JX, Zhu SW, Jia HB, & Ma XL. Does distal clavicle resection decrease pain or improve shoulder function in patients with acromioclavicular joint arthritis and rotator cuff tears? A meta-analysis. Clinical Orthopaedics and Related Research 2018 476 2402–2414. (https://doi.org/10.1097/CORR.0000000000000424)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Livingstone A, Asaid R, & Moaveni AK. Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis. Shoulder and Elbow 2019 11(1) 39–45. (https://doi.org/10.1177/1758573217741124)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011 343 d5928. (https://doi.org/10.1136/bmj.d5928)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372 n71. (https://doi.org/10.1136/bmj.n71)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Burns PB, Rohrich RJ, & Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and Reconstructive Surgery 2011 128 305–310. (https://doi.org/10.1097/PRS.0b013e318219c171)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, Stephenson M, & Aromataris E. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evidence Synthesis 2020 18 2127–2133. (https://doi.org/10.11124/JBISRIR-D-19-00099)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Faber T, Ravaud P, Riveros C, Perrodeau E, & Dechartres A. Meta-analyses including non-randomized studies of therapeutic interventions: a methodological review. BMC Medical Research Methodology 2016 16 35. (https://doi.org/10.1186/s12874-016-0136-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Balduzzi S, Rucker G, & Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evidence-Based Mental Health 2019 22 153–160. (https://doi.org/10.1136/ebmental-2019-300117)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Chalmers PN, Granger E, Ross H, Burks RT, & Tashjian RZ. Preoperative factors associated with subsequent distal clavicle resection after rotator cuff repair. Orthopaedic Journal of Sports Medicine 2019 7 2325967119844295. (https://doi.org/10.1177/2325967119844295)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Razmjou H, ElMaraghy A, Dwyer T, Fournier-Gosselin S, Devereaux M, & Holtby R. Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear. Knee Surgery, Sports Traumatology, Arthroscopy 2015 23 585–590. (https://doi.org/10.1007/s00167-014-3114-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Aliberti GM, Kraeutler MJ, Trojan JD, & Mulcahey MK. Horizontal instability of the acromioclavicular joint: a systematic review. American Journal of Sports Medicine 2020 48 504–510. (https://doi.org/10.1177/0363546519831013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Morris JH, Malik AT, Hatef S, Neviaser AS, Bishop JY, & Cvetanovich GL. Cost of arthroscopic rotator cuff repairs is primarily driven by procedure-level factors: a single-institution analysis of an ambulatory surgery center. Arthroscopy 2021 37 1075–1083. (https://doi.org/10.1016/j.arthro.2020.11.033)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Sabesan VJ, Shahriar R, Chatha K, Malone DL, Sherwood A, Peaguda CF, & Whaley JD. Factors affecting the cost and profitability of arthroscopic rotator cuff repair. Arthroscopy 2019 35 38–42. (https://doi.org/10.1016/j.arthro.2018.07.034)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Aly AR, Rajasekaran S, & Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British Journal of Sports Medicine 2015 49 1042–1049. (https://doi.org/10.1136/bjsports-2014-093573)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Yiannakopoulos CK, Vlastos I, Theotokatos G, & Galanis N. Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy 2021 29 2090–2095. (https://doi.org/10.1007/s00167-020-06098-y)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Shubin Stein BE, Wiater JM, Pfaff HC, Bigliani LU, & Levine WN. Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. Journal of Shoulder and Elbow Surgery 2001 10 204–208. (https://doi.org/10.1067/mse.2001.113498)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Soler F, Mocini F, Djemeto DT, Cattaneo S, Saccomanno MF, & Milano G. No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review. Knee Surgery, Sports Traumatology, Arthroscopy 2021 29 2194–2201. (https://doi.org/10.1007/s00167-020-06377-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Farrell G, Watson L, & Devan H. Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: a systematic review. Shoulder and Elbow 2019 11 395–410. (https://doi.org/10.1177/1758573219840673)

    • PubMed
    • Search Google Scholar
    • Export Citation