Sunday, March 16, 2014

Rotator cuff repair: anatomic and clinical outcomes, are we getting better?

This paper, presented at the 2014 meeting of the American Academy of Orthopaedics Surgeons noted that rotator cuff repairs are commonly performed: well over 200,000 per year in the U.S. The direct costs of these repairs are estimated a $3 to 12 billion per year in direct costs alone. In spite of this expenditure, the published failure rates of cuff repair are substantial.

These authors reviewed 108 articles presenting the post operative clinical integrity of the repair and clinical outcomes in over 8,000 patients having cuff repair surgery.

The key finding was that in spite of an essentially exponential rise in the number of publications meeting the inclusion criteria per year and the use of more advanced repair methods, the failure rate and clinical outcomes have not improved over the last two decades. The overall retear rate was 27%. Risk factors for retear included larger tears, increased fatty infiltration and older age. The clinical improvement (expressed as a percent of maximal possible improvement) was 72%. Most studies found that the integrity of the repair did not have a substantial relation to the clinical outcome.

Most of the studies had incomplete data, so that the effect of repair technique and other key variables could not be determined.

The authors suggest that future clinical studies of cuff repairs need to include the following minimal dataset on each patient in an accessible appendix so that the data can be used in further systematic reviews and meta analyses:

•Patient (age, gender, smoking)
•Shoulder (tear size, fatty infiltration, preoperative clinical scores)
•Procedure (treatment method, rehabilitation protocol)
•Results (repair integrity, postoperative clinical scores, duration of followup)

Comment: This study again calls attention to the observation that factors other than repair integrity determine the outcome of rotator cuff surgery. Furthermore, larger tears, with fatty infiltration, in older individuals are at increased risk for failure of surgical repair and may be candidates for other types of treatment.

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