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?
and
and
(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
History
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
Radiographs
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
===
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
History
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
Radiographs
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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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
