Saturday, November 30, 2013

Treatment of rotator cuff tears in patients over the age of 70 years

Rotator cuff tears after 70 years of age: A prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients.

The incidence of cuff tears in asymptomatic shoulders increases with age.

Thus discussion of management of cuff tears in older individuals is complicated by the observation that many are asymptomatic and probably chronic and atraumatic.

These authors report the results of a prospective, comparative, multicenter study of 154 patients 70 years of age or older in which treatment was randomize to arthroscopic repair or decompression. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 75 years. Inclusion criteria were:

patient 70 years of age or older (no upper limit);
complete supraspinatus tear that can be reduced without tendon release;
extension limited to the upper-third of the infraspinatus,
no significant subscapularis involvement;
fatty infiltration ≤ 3;
stage 1 or 2 retraction, according to the Patte classification;
flexible shoulder, with no subacromial or glenohumeralimpingement.

The exclusion criteria were :
massive tears requiring intra-operative arthrolysis;
non-reducible tear without excessive tension;
partial rotator cuff tear;
instability associated with the cuff tear.

This was not actually a randomized study; rather the authors used a comparative design because they felt that random allocation by drawing lots was "overly restrictive and hard for patients to accept". Instead they "indirectly randomized" consecutive cohorts to simplify the decision-making and explanations during patient care, and also to allow inclusion or every patient 70 years or older. The protocol attempted to recruit two consecutive 6-month cohorts. In half the centers, every patient of at least 70 years of age seen during the first 6 months was treated with surgical repair, while every patient seen in the next 6 months received palliative decompression. In the other half of the centers, the decompression cohort was recruited in the first 6 months and the repair cohort during the second 6 months. The patients in the two groups had similar ages, preoperative scores, severity of cuff tears and ease of tendon reduction. Nevertheless a more robust experimental design would be to randomize the treatment at surgery after the arthroscopic findings were documented; proper randomization avoids the risk of selection bias.

All patients had an acromioplasty; 92% had biceps tenotomy or tenodesis. The repair technique was single or double row according to surgeon preference. Apparently the decompression group received only an acromioplasty. Shoulders having only decompression were immobilized for 10 days and those having repair for six weeks.

Overall, patients were improved: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001).
Patients having repair faired better than those having decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.

No data on the integrity of the repairs is available. It has been reported that a high percentage of arthroscopic repairs may retear, even though the patients experienced excellent pain relief at one year.

So without the data on the integrity of the repairs, we do not know the relationship of the success of the repair in re-establishing the attachment of the tendon to bone to the success of improving the clinical outcome and do not understand the benefit of attempting a repair if it is not durable.

A final comment is that there is a risk in performing an acromioplasty in shoulders with a cuff defect: 'decompression' of a shoulder with a significant cuff defect may lead to anterosuperior escape and pseudo paralysis.

So, the bottom line is that careful thought needs to go into the decision of when to repair and when not to repair a cuff defect, especially atraumatic chronic tears in older individuals.

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