Monday, March 17, 2014

Degenerative (atraumatic) rotator cuff tears are usually bilateral and continue to degenerate with age.

Prospective Longitudinal Analysis of the Risk of Tear Progression for Asymptomatic Degenerative Rotator Cuff Tears

These authors identified that of 224 subjects with a painful rotator cuff tear in one shoulder were often found to have an asymptomatic tear on the opposite side:  118 had full-thickness and 56 had partial thickness asymptomatic tears.

These subjects were followed annually with shoulder ultrasonography, radiographs and clinical evaluations. The study also included 50 control subjects.  The mean age of the control subjects (60.7 +/- 10 yrs) and those with partial-thickness (59.4 +/- 10 yrs) was less than those with full-thickness tears (63.8 +/- 9 yrs, p=0.01).

38% of control subjects developed a tear and 46% of partial-thickness and 53% of full-thickness tears demonstrated tear enlargement.

Age was associated with enlargement for partial-thickness tears (62.5 +/-10 yrs enlarged vs. 55.8 +/- 10 yrs stable, p=0.01) but not for controls (p=0.52) or full-thickness tears (p=0.70).

Twenty percent of controls, 36% of partial-thickness and 42% of full-thickness tears developed pain regardless of tear enlargement. Interestingly the development of pain did not correlate with tear enlargement for the controls (p=0.47), partial-thickness (p=0.69) or full-thickness tears (p=0.80).

Survivorship analysis for the entire cohort with tear progression as the end point was 96% at one year, 74% at three years and 59% at five years.

Comment: This study documents well that the issue with atraumatic cuff tears is the progressive loss of the quality of the tendon. This progressive degeneration was observed in over 1/3 of the control subjects as well as in those individuals with existing cuff tears. Pain is not a reliable indicator of the progressive deterioration of the cuff tendon.

This study helps explain the high failure rate of rotator cuff repair that has remained constant despite many different approaches used in an attempt to reattach the degenerated tendon to bone.

As H.L.McLaughlin stated in 1962, "the wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis."
It has yet to be demonstrated that suturing degenerated tendon results in improvement in the quality of the tendon.
Bottom line: it matters if the cuff fails because of tear or wear

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