Saturday, September 21, 2013

Rotator cuff tear, when to repair and when not to repair

Rotator cuff tears are not all equal!

Our post yesterday on the AAOS 'appropriate use criteria' for rotator cuff tears has given rise to some thoughtful responses, such as "I read your blog every week. As a shoulder surgeon and app developer, I think AAOS had a nice idea. Of course our decision is made by our experience, but this can be a tool to encourage people to perform/not perform surgery. Like instability index, it will not substitute our judgment, but was a nice constructed tool. "

We thought about this a bit, appreciating the feedback given. We continue to opine that the AAOS AUC app is oversimplified and can be used to encourage surgery by some gentle 'tweeking' of the responses without consideration of the full picture.

Keeping in mind that 'repair' is not the only surgery that can be offered to a patient with a bothersome cuff tear, see here, there are two questions that need to be considered before embarking on REPAIR surgery:
(1) can the cuff tear be durably repaired?
(2) is it in the best interests of the patient to have a repair recognizing the need to protect the shoulder from normal use for 3-6 months after surgery, in other words, are the improvement in comfort and function from an attempted repair likely to be sufficiently superior to that of non-operative management or a 'smooth and move' to justify the time away from work and play? While some justify a repair attempt by noting that patients are 'better' even if the rotator cuff repair fails to reattach the tendon to the bone, the key difference between a repair and a smooth and move is the need for protecting the arm for months in the former.

Below are listed findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without advanced testing. We first published these guidelines in 1994 and have found them as useful to day as back then. Note that the decision is not based on choosing one of two bubbles in an app, but in considering the patient as well as the shoulder (two of the 4Ps the other two are, of course, who should do the surgery and how it should be done).

ENCOURAGING                                    DISCOURAGING

Age less than 55                                        Age over 65
Acute traumatic onset                                Insidious, atraumatic onset
No relation to work                                   Attribution of tear to work
Short duration of weakness                       Weakness over 6 weeks
No history of smoking                               Many smoking pack-years
No steroid injections                                  Repeated steroid injections
No major medications                                Steroids/antimetabolites
No concurrent disease                                Inflammatory joint disease
No infections                                              History of previous infection
No previous shoulder surgery                     Previous cuff surgery
Benign surgical history                               History of failed tissue repairs

Physical Examination
Good nutrition                                             Poor nutrition/obesity
Mild weakness                                            Severe weakness
No spinatus atrophy                                    Severe spinatus atrophy
Stable shoulder                                           Anterior superior instability
Intact acromion                                           Previous acromioplasty
No stiffness                                                 Stiffness

Normal radiographs                                    Upwards head displacement
                                                                    Cuff tear arthropathy

MRI or Ultrasound
Good tendon quality                                   Thin tendon
One tendon tear                                          Multiple tendon involvement
Small gap to close                                       Severe retraction

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