Sunday, October 6, 2013

Rotator cuff repair - is change in supraspinatus area a useful outcome measure?

Cross-Sectional Area of the Supraspinatus Muscle After Rotator Cuff Repair An Anatomic Measure of Outcome

These authors recorded the cross sectional area (by MRI) of the supraspinatus three days after arthroscopic repair of full-thickness cuff tears and one year later in eight-eight patients. Patients were classified into two groups according to whether the area of the supraspinatus increased or decreased between these two time points.

The area of the supraspinatus muscle decreased in two thirds of the shoulders, indicating that the repair surgery failed to achieve a positive result in this ‘anatomic measure of outcome’ in 59 of the 88 patients.

Predictors of an increase in supraspinatus area included a lower preoperative Simple Shoulder Test (SST) score, better gross visual grade of the tendon at surgery, and greater strength of the supraspinatus at six months postoperatively. No retear or Sugaya grade of 3 was found in any patient in whom the area increased, whereas 34% of the patients in whom the area decreased had a retear (p < 0.001).

There are some unexplained aspects in this study that lead us to question the clinical value of the proposed outcome measure.

(1) The immediate post operative cross sectional area of the supraspinatus was about 25% greater than the preoperative area – what does this mean?

(2) The change in supraspinatus area did not correlate with the measured muscle strength at one year, the pain score, or the ASES, UCLA, DASH or SPADI scores. Of what use is a method that does not correlate with any of the established outcome measures?

(3) Massive amounts of data appear to have been collected on each of these patients – would it not have been more important to determine which of the preoperative, intraoperative and post operative findings (including anatomic integrity of the repair) were most predictive of an improved patient reported outcome?

Each of the patients in this study had at least 3 MRIs that would cost hundreds of thousands of dollars in the U.S.. In this era of emphasis on value, we must ask what benefit is added by this expense?

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