Monday, April 16, 2012

Long-term follow-up of cases of rotator cuff tear treated conservatively JSES

JSES published a study on the Long-term follow-up of cases of rotator cuff tear treated conservatively. Between 1996 and 1999, the authors offered non-operative treatment to 104 consecutive patients (107 shoulders) diagnosed by MRI or arthrogram as having rotator cuff tears. Patients were informed that they could have surgery if their symptoms continued. Non-operative management included injections, medications and physical therapy continued until the patient was satisfied. Three patients had cuff repair for persistent limiting symptoms. Long term followup was available in 2009 on 43 shoulders, of which 56% had no pain, 33% had slight pain, and 12% had pain during activities of daily living. Patients with poorer results tended to be younger than those with better results.

This article was highlighted in a recent email from an orthopaedic surgeon colleague: "As you may recall, I have a irreparable rotator cuff tear (RCT). I followed your advice and now my right shoulder is essentially asymptomatic. Yesterday I skied 19000 vertical feet—19 Xs up and down XXX —with no shoulder probs. Several months ago J. Shoulder Elbow had a commentary on Dr. Codman, publishing his first 2 rotator cuff repair op. reports. I was fascinated to read that Codman concluded that the massive tears he found in the hod carrier and Irish washerwoman had been present for years without significant functional impairment. A recent article from Japan (J. Shoulder Elbow (2012), 491-494 indicates that the great majority of pts they followed had no significant sx or impairment with unrepaired RCTs. I have done lots of Independent Medical Evaluations on workers who had rotator cuff tears of various severity who had open or arthroscopic repairs—the result is usually the same—some residual pain which limits them with overhead work and a ratable impairment in the range of 10% to 25% of the upper extremity due to postoperative stiffness. My question is why, especially in the worker’s comp setting, does a MRA showing a tear automatically result in an attempted surgical repair? Am I missing something? Are there good reasons to repair RCTs surgically? What are the indications other than a positive MRA?"

The principal value of this article is that it demonstrates that rotator cuff tear in and of itself need not be an indication for surgery. While the Journal listed this as a Level II prognostic study, we really don't have enough data to use the data prognostically. What would have been most helpful would be to know more about the size and acuity of the cuff tears as well as the shoulder function at the time they presented. It would also be important to know more about the fate of the 50+ shoulders that were not included in the follow-up for a variety of reasons. 

It seems important that several elements need to be included in any study of rotator cuff treatment:
(1) patient age
(2) whether the tear is acute or chronic
(3) the comfort and function of the shoulder

As we've posted before, other factors are important in determining if the rotator cuff is repairable.
Whether or not the patient should have a repair depends not only on the repairability of the tear, but also on the nature and severity of the problems the patient is having with their shoulder. In many cases, when non-operative management of chronic cuff tears is insufficiently effective, we have found that a 'smooth and move procedure' is helpful, without the need for the extensive recovery perior necessary to protect a repaired cuff tear.

In summary, we encourage young, non-smoking individuals with symptomatic, repairable acute rotator cuff tears to consider a prompt cuff repair so that they have the optimal chance of regaining their strength. Individuals with chronic tears have time to try non-operative management, including stretching, strengthening of the deltoid and residual cuff muscles, and mild anti-inflammatory analgesics. If this non-operative program fails to give the desired improvement, the pros and cons of repair vs. smooth and move are reviewed with the patient.


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