Monday, May 13, 2013

When to repair the rotator cuff - well known surgeons disagree

In April 2013 the 12th International Congress of Shoulder and Elbow Surgery took place in Nagoya, Japan.

This meeting gathered well known surgeons from around the world. We were especially interested in the recommendations for treatment of rotator cuff defects. Two highly respected surgeons each presented their thoughts.

Christian Gerber from Zurich presented the Neer Lecture on Rotator Cuff Tendon Tears. We quote here from his abstract in the Congress Program: "Surgical repair of small, non-retracted tears yields excellent and durable results, which, however, have not been proven to be superior to subacromial debridement, biceps tenotomy or even the natural history [i.e. non surgical management]. There are no cost-effectiveness studies indicating that small tears justify operative intervention. Surgical treatment of disabling large tears, however, has proven to improve quality of life, pain, function and work capacity relatively reliably and durably."

Ken Yamaguchi from St. Louis presented an instructional course lecture on Natural History of Rotator Cuff Tears: Implications for Treatment. We quote here from his abstract in the Congress Program: “Early surgery is recommended for rotator cuff tears in younger patients (less than 60 years old), patients with small to medium sized tears, especially if the anterior supraspinatus is intact and thus, at risk for rupturing, large, degenerative partial tears, acute tears of any size, new or sudden pain in any risk age group, and tears that are bordering on 1.5 cm of transverse dimension. Patients with chronic large tears or elderly patients, greater than the age of 65 are much better candidates for conservative [i.e. non surgical] management." 

Our approach is rather simple as explained in this patient handout. As repeated observed in this blog, repairs of large atraumatic tears often do not hold up and may not merit the cost and downtime associated with a surgical repair. We have been impressed by the results of the 'smooth and move' procedure when such cuff defects do not respond to gentle stretching and strengthening exercises.

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