Saturday, September 29, 2012

Treatment of rotator cuff tears in older individuals: a systematic review. JSES

JSES just published a most interesting article: Treatment of rotator cuff tears in older individuals: a systematic review.

The authors define "older" as over the age of 60 (yikes, that includes me!).

Referring to Figure 1-1 in our book, Practical Evaluation and Management of the Shoulder, we see that indeed full thickness cuff tears are particularly common in individuals of the age of 60.

Thus, it is quite disappointing that only eight publications of Levels of Evidence I-III were available bearing on the treatment of cuff tears in the over 60 age group. It is even more disappointing that the analysis of these articles yielded no "valid consensus on the best treatment approach" for these patients. Furthermore they state "There is insufficient evidence to support efficacy of operative vs. nonoperative treatment in patients aged 60 years and older." Perhaps some patients are better candidates for repair surgery than others.

These findings sound very similar to the conclusions of the Cochrane review on the evidence informing treatment of cuff tears for all ages: Surgery for rotator cuff disease, which concludes: "Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease."

Now none of this means that patients over 60 with cuff tears cannot be helped or that surgery may not be beneficial or even that an attempt at repair may be indicated in selected patients. What it does mean is that we need to get busy and document the effectiveness of different treatments for these patients, such as range of motion exercises for those with stiff shoulders, surgical repair especially for those with acute, traumatic tears, and the 'smooth and move' procedure for those with refractory functional limitations in association with irreparable tears.

In this regard we should be particularly mindful of studies such as: Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study that found that only 24% of arthroscopic repairs of tears greater than 3 cm in size (a common finding in older patients) remained intact at one year.


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