Patients with unilateral rotator cuff tears usually choose to have surgical treatment, and rotator cuff repair is a routine surgery[18–21]. Bilateral rotator cuff tears have become more and more common, and most of the patients receive staged surgery in clinical practice[2, 10]. However, single-stage surgery is now gradually being implemented, and the effect of single-stage surgery requires further exploration. Postoperative outcomes are evaluated to compare single-stage bilateral rotator cuff repair and staged bilateral rotator cuff repair.
Liem et al. have pointed out that the prevalence of contralateral supraspinatus tears is significantly higher in the surgery group (67.3%). These findings suggest that patients with rotator cuff tears undergoing surgery have a higher risk of developing a rotator cuff tear on the contralateral side. Yoo et al. have performed a comparison between the patients with surgical and non-surgical treatments after the suggestion of operative treatment for symptomatic rotator cuff tear. Out of the 137 patients, 104 patients (75.9%) ultimately undergo operative treatment. Deterioration of function and symptom with non-surgical treatment is a primary reason for surgery. The primary reasons for not undergoing surgery in the remaining 33 (24.1%) patients include improvement of function and symptom in 18 patients (55%), economic pressure in four patients (12%), and worry for long-term rehabilitation in three patients (9%). There are many reasons that prompt patients to decide to undergo surgery or not. The probability of bilateral rotator cuff tears is likely to happen while one side tear occurs. Patients with rotator cuff tears are prone to require surgical treatment, and the opposite side has to undergo surgery after receiving surgery on one side. Nowadays, patients are prone to accept staged surgery, and single-stage surgery remains uncommon. Therefore, we focused on the outcomes of the two surgical methods.
For patients with bilateral rotator cuff tears undergoing staged surgery, a large number of studies have shown that the final result of the second operation is equivalent to the first operation. Rhee et al. have reported that patients with bilateral rotator cuff tears undergoing staged surgery prefer to repair the more severely symptomatic side. Compared with the first operation, the VAS pain score in the second operation was significantly worse at 6 months postoperatively. However, there was no significant difference in the VAS score between the two groups at the final follow-up. When all these clinical outcomes from the final follow-up were combined, both sides of shoulders undergoing staged bilateral arthroscopic rotator cuff repairs would get a similarly good result. Because a large number of studies have investigated the impact of staged surgery on both shoulders, our study did not compare these values. However, we compared single-stage surgery and staged surgery, and observed the results of postoperative functional scores to study whether single-stage surgery could be a good substitute.
Gerber et al. have demonstrated that single-stage bilateral total joint arthroplasty is considered an alternative to staged bilateral surgery. The authors have compared six patients receiving single-stage bilateral total shoulder arthroplasty with eight patients receiving staged bilateral total shoulder arthroplasty. Compared with the staged group, the postoperative outcomes of the single-stage group are significantly improved, and there are no extra complications in the single-stage group. Similarly, Pak et al. have focused on the results of a single-stage bilateral rotator cuff repair, including 10 patients receiving single-stage bilateral surgery and 17 patients receiving unilateral surgery. The operation time of the single-stage group is longer, while there is no difference in the postoperative rehabilitation time. The single-stage bilateral repair offers similar results with no additional complications. Compared with unilateral repair, this process does not require more hospitalization and rehabilitation work. They suggest that for patients who can tolerate both shoulder fixation, single-stage bilateral arthroscopic rotator cuff repair is a viable option. Patients with unilateral rotator cuff tears have to accept surgical treatment after inefficient conservative treatment, while patients with bilateral rotator cuff tears can choose single-stage or staged bilateral arthroscopic rotator cuff repair. Our results provided important clinical guidance for patients with bilateral rotator cuff tears when choosing the appropriate surgical method.
The VAS and functional scores are effective methods to assess postoperative clinical outcomes[24–28]. In our study, at 6 months postoperatively, VAS pain and functional scores after the single-staged operation were worse compared with the staged operation. However, there was no significant difference in VAS pain and functional scores between the two groups at the 12-month follow-up. Because the bilateral rotator cuff tears were repaired at the same time during the single-stage operation with bilateral trauma, the patients needed time to overcome early pain and underwent difficult functional recovery. It demonstrated that patients who accepted single-stage bilateral rotator cuff repair would undergo a more painful experience and more difficult functional rehabilitation, while the difference at 6 months would disappear at subsequent follow-up without special treatment. Both surgical methods could achieve good functional rehabilitation postoperatively, and there was no difference at the final follow-up. After the two operations, the ROM was significantly improved during the follow-up, and the two surgical methods achieved similarly good results. MRI has comparable accuracy in measuring the tear size of rotator cuff tears. Similarly, it has high accuracy for the detection of rotator cuff healing[29–33]. The repaired tendons were intact, and no obvious postoperative symptoms were observed in our study.
Due to strict restrictions on both shoulders after the single-stage surgery, it was generally considered that they could not perform daily life or early rehabilitation activities. Patients who underwent single-stage operation tended to protect their repaired shoulders rather than performing high-intensity exercises. Although patients undergoing single-stage repair needed help with shoulder pad replacement and passive exercise, and some patients slept uncomfortably throughout the night in the early postoperative period, they could adapt and overcome difficulties gradually. Compared with the staged operation, patients receiving single-stage operation saved hospitalization costs and avoided the second operation. If patients could adapt to the early difficult rehabilitation period and did not require much daily work, we would advise that patients with bilateral rotator cuff tears could consider single-stage bilateral rotator cuff repair. Compared with the staged bilateral rotator cuff repair, good results would also be achieved.
Besides, our operation used a lateral position for a single-stage operation. It is generally believed that although the first operation side is protected by thick gauze and shoulder pad, it would be compressed to some extent when patients receiving surgery on the contralateral side. Currently, no research has reported whether the compression of the first operation side in single-stage rotator cuff respire has an impact on postoperative pain, functional scores, and ROM. Our study compared the postoperative outcomes of bilateral shoulders in the single-stage operation. During the follow-up, there was no significant difference in pain scores, functional scores, and ROM. It showed that a short period of intraoperative compression would not affect postoperative functional rehabilitation. Under good protection and short-time operation, short-term compression might not have adverse effects on the first operation side. However, we should try to shorten the operation time under the premise of ensuring the quality of operation. A longer operation time would increase the operation risk.
This study has several limitations. Because of the strict inclusion criteria, the sample size was relatively small, and the follow-up duration was short. The results of this study need to be validated by large clinical samples and prospective randomized controlled studies.