Friday, December 27, 2013

Management of rotator cuff tears

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Optimizing the Management of Full-Thickness Rotator Cuff Tears

This article proposes a formula for determining the appropriateness of different approaches to the patient with a rotator cuff defect using "appropriate use criteria".

Importantly the authors emphasize some of the 4Ps.

The problem is characterized in terms of the tear size, retraction, and atrophy/fatty infiltration as well as the severity of pain
The patient is characterized in terms of
 - the American Society of Anesthesiologist classification of the amount of systemic disease,
 -  factors that negatively affect healing (for example: diabetes, obesity, osteoporosis, prior infection, advanced age, smoking, multiple cortisone injections, use of predisone or immunosupressive drugs, and Parkinson's disease)
 - factors that negatively affect outcome (for example: worker's compensation, litigation, substance abuse, psychiatric disorders)
The procedures are characterized as nonsurgical, non-repair surgery, repair surgery, reconstruction with a patch or tendon transfer, and arthroplasty.

What is missing from these recipes is (1) consideration of the degree of trauma that caused the tear, (2) the chronicity of the tear, and (3) the recognition that cuff defects often present as weakness rather than pain. A 40 year old with acute shoulder weakness after a major fall within the last week resulting in a supraspinatus and infraspinatus tear usually deserves acute repair, whereas a 70 year old with chronic shoulder symptoms associated with the same size tear without a history of trauma deserves a good try at non-operative management, recognizing that attempted repair is not likely to durably restore the integrity of the cuff. If non-operative management is unsuccessful, the surgical options are determined by the degree of active motion, the stability of the joint, the presence or absence of arthritis, and the functional needs of the patient along with risk factors.

The companion article, AAOS Appropriate Use Criteria: Optimizing the Management of Full-Thickness Rotator Cuff Tears, further demonstrates the difficulty of applying the 'appropriate use criteria. Case 2 example 3 is a 66 woman with diabetes with chronic refractory pain, active motion limited to 45 degrees, and a large supra+infraspinatus tear retracted to the level of the glenoid and fatty infiltration, who smokes a pack of cigarettes per day. The AUC recommends 'reconstruction', defined as 'an augmented repair with a patch or tendon transfer'.   The evidence is that neither a patch or a tendon transfer would yield a satisfactory result for this woman: individuals who smoke and who have diabetes are likely to have difficulty healing a patch or tendon transfer.

For our approach see "when to repair". and more about when to repair. It is important to distinguish cuff wear from cuff tear: not all cuff defects have the same quality of surrounding tissue.

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