1100 THE BONE & JOINT JOURNAL Rotator cuff tears are a common cause of pain and impairment of shoulder function. They affect more than 30% of the population aged 60 years or older, 1-5 and the incidence appears to be increas- ing as the population ages. 6-8 While it is generally agreed upon that acute, traumatic tears in young patients should be managed with surgical repair, the optimal treatment for managing sympto- matic chronic/degenerative tears in older patients remains controversial. 1,9,10 Both surgical repair and conservative treatment have shown satisfactory results in this setting, 2,10-13 and significant improve- ments in the Constant–Murley Score (CMS) have been reported for both operative and conserva- tive treatment of rotator cuff tears. 3 Three recent prospective randomized controlled trials (RCTs) have compared operative repair to nonoperative treatment in older patients with chronic, degen- erative tears of the rotator cuff. 2,3,10 These studies have generally shown small, nonsignificant differ- ences in favour of surgical repair, and have been unable to provide clear conclusions regarding the preferred treatment. A further four recent RCTs have compared surgical repair to subacromial decompression alone. 2,9,14,15 Three of these studies showed a small difference favouring repair over decompression alone, 9,14,15 while the other study showed no difference. 2 These conflicting results can make decision making regarding the optimal treatment for rotator cuff tears difficult. To our knowledge, there has not been a meta-analysis of randomized trials comparing the  SHOULDER & ELBOW Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears A META-ANALYSIS OF RANDOMIZED TRIALS C. Schemitsch, J. Chahal, M. Vicente, L. Nowak, P-H. Flurin, F. Lambers Heerspink, P. Henry, A. Nauth From St. Michael’s Hospital, Toronto, Canada Correspondence should be sent to A. Nauth; email: nautha@smh.ca ©2019 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.101B9. BJJ-2018-1591.R1 $2.00 Bone Joint J 2019;101-B:1100–1106. Aims The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/ degenerative tears of the rotator cuff. Materials and Methods PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results Six studies were included. Surgical repair resulted in a statistically significantly better Constant–Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair. Conclusion The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the ‘success rate’ of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100–1106.