Friday, February 28, 2014

Does it matter if the patient is compliant with restrictions after cuff repair?

Patient adherence with postoperative restrictions after rotator cuff repair

Many surgeons believe that the position and activity of shoulders needs to be restricted after cuff repair, perhaps for months after surgery. Abduction braces are used in the hope that the repair is protected from tension that may result in a retear. However, the amount of abduction necessary to unload the repair is substantial.

This study aimed to measure self-reported patient adherence to postoperative restrictions after rotator cuff repair, to evaluate correlations between adherence and functional outcome in 50 consecutive patients undergoing repair for rotator cuff tears. Patients were instructed to wear an abduction brace for 6 weeks after surgery.

Patient-reported adherence to the recommendation average 88% (range, 59.2-100). There were no significant correlations between adherence and improvement in American Shoulder and Elbow Surgeons, University of California–Los Angeles, or Simple Shoulder Test scores after rotator cuff repair. Of the patient demographics analyzed, only smoking status had a positive effect on adherence All other demographics, including hand dominance, mechanism of injury, repair complexity, comorbidities, living status, employment status, and age, had no significant effect on self-measured adherence to postoperative restrictions.

Unfortunately, the authors did not present data on the effect of adherence on the integrity of the repair at followup. 

Comment: One of the major 'costs' of cuff repair surgery is the amount of time the shoulder is 'out of use' after surgery. If it is shown that abduction bracing after repair has no effect on either cuff integrity or shoulder function after repair, one must question whether it is reasonable to subject the patient to this major inconvenience. There are other questions evident from the picture below.

How does one get the brace on and off to bathe or dress without loading the cuff? To what degree does the patient actively abduct the shoulder to move the brace around?

Our thought is that if abduction is required to help close a gap in the cuff, the chances of failure are increased and it is unlikely that abduction will matter. The evidence of the benefit of abduction bracing appears inconclusive.

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