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Commentary and Perspective

No Sling After Rotator Cuff Repair: Balancing Short-Term Benefit with Long-Term Health of Shoulder

Commentary on an article by Jérôme Tirefort, MD, et al.: “Postoperative Mobilization After Superior Rotator Cuff Repair: Sling Versus No Sling. A Randomized Prospective Study”

Neviaser, Andrew S. MD

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The Journal of Bone and Joint Surgery: March 20, 2019 - Volume 101 - Issue 6 - p e24
doi: 10.2106/JBJS.18.01424
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Commentary

From the time of Codman through today, every aspect of rotator cuff disease has been debated. In the past 2 decades, improved standards of research have helped to erase unsupported dogma but have also brought about many unanswered questions. In their report on sling use following repair of small to medium-sized tears of the superior aspect of the rotator cuff, Tirefort et al. question another pillar of treatment following rotator cuff repair. Their premise was that sling use is associated with several deleterious effects, including stiffness, atrophy, and balance problems, while its benefits are unproven. Given that sling use is nearly universal following shoulder surgery, the authors assumed a substantial scientific burden in questioning it.

The study is a well-designed, randomized controlled trial. Eighty consecutive patients undergoing arthroscopic rotator cuff repair were randomized to use a sling for 4 weeks following surgery (40 patients) or to not use a sling (40 patients). All repairs were done arthroscopically using a double row of suture anchors. All patients began passive range-of-motion exercises following surgery. Patients in the no-sling group were instructed by the surgeon not to perform active abduction-elevation for 4 weeks. The instructions for sling use were not described. Clinical evaluation was done by a blinded physician up to 6 months postoperatively. Visual analog scale (VAS) pain scores, American Shoulder and Elbow Surgeons (ASES) scores, and Single Assessment Numeric Evaluation (SANE) scores were collected. At the 6-month time point, patients also underwent an ultrasound examination of the repaired rotator cuff by an experienced radiologist.

The VAS pain scores at 10 days following surgery were identical in the sling and no-sling groups. At 1.5 months, the no-sling group showed significantly greater external rotation and active elevation. These differences were small, however, and likely clinically unimportant (8° and nearly 14°, respectively). At 3 months, the no-sling group again demonstrated better active elevation (139° compared with 126°), and a higher percentage of patients could reach up the back to T12 or above. At 6 months, the no-sling group reported better SANE scores (85.8 compared with 79.4) and lower VAS pain scores (0.8 compared with 1.5). These differences were significant. On ultrasound examination, 1 patient was seen to have a Sugaya type-III repair (insufficient thickness) and 1 patient, a Sugaya type-IV repair (minor discontinuity). Both of them were in the no-sling group. All patients in the sling group had a Sugaya type-I or II repair. These differences did not reach significance. Reduced SANE and increased VAS scores significantly correlated with immobilization in the sling. The authors concluded that no immobilization after surgery was associated with reduced pain and improved function at 6 months without a significant reduction in rotator cuff healing.

This is a scientifically sound study, and the authors should be congratulated. These results must be interpreted with some caution, however. The long-term health of the shoulder should be the primary concern after shoulder surgery, and this is likely best achieved through rotator cuff healing. For optimal recovery, interventions to prevent stiffness must be balanced with mechanical protection of healing repairs. If short-term improvement were the primary treatment goal, this could be achieved equally with either nonoperative therapy or surgery1. There are obvious benefits to a more rapid return of function following surgery, but this does not predict long-term outcome. In fact, there is some evidence suggesting higher levels of pain in the early postoperative period correlate with higher rates of healing after repair of small tears2. The current study was sufficiently powered to detect the minimal clinically important difference in ASES score, but the number of subjects remains small and the follow-up short. There was a trend toward less robust healing of repairs in the no-sling group and this may produce longer-term results that differ from those at 6 months. The study is valuable for questioning an important routine aspect of treatment that is accepted a priori. The data published here may not be sufficient to warrant changes in practice but they should inspire further investigation. I look forward to follow-up publications on the long-term outcomes in these patients.

References

1. Piper CC, Hughes AJ, Ma Y, Wang H, Neviaser AS. Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2018 Mar;27(3):572-6. Epub 2017 Nov 21.
2. Yeo DY, Walton JR, Lam P, Murrell GA. The relationship between intraoperative tear dimensions and postoperative pain in 1624 consecutive arthroscopic rotator cuff repairs. Am J Sports Med. 2017 Mar;45(4):788-93. Epub 2016 Dec 19.

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