Sunday, October 19, 2014

Rotator cuff disease - what evidence supports what treatment?

Cochrane in CORR: Surgery for Rotator Cuff Disease (Review)

While rotator cuff conditions are the most common shoulder condition to bring a patient to medical attention, and while cuff problems have a negative impact on the quality of life, and while there are many non-operative and surgical treatments available there is a lack of solid evidence to guide treatment. Theses authors present the results of a Cochrane review of all randomized and quasirandomized trials of nonoperative and operative treatments for rotator cuff disease. They found that 11 of 14 trials failed to perform or report intention-to-treat analyses (in which the results are analyzed according to the treatment group to which they were randomized, regardless of whether the assigned intervention was actually carried out), and one of the trials reported that a significant number of crossovers were not analyzed in their original group.

When intention-to-treat analysis is not used, the benefits of treatment may be inflated. These authors concluded that in the studies reviewed, the benefits of surgery and other invasive treatments have been overestimated because the authors did not rigorously apply an intention-to-treat approach.

The authors also present the issue of surgical expertise, which can be a feature of surgical randomized trials. As an example, a surgeon who is expert in arthroscopic repairs may perform a study comparing arthroscopic repairs to open repairs (in which the surgeon is not an expert). The results of open repair are inferior - is that because open repair is worse or because the surgeon is less apt at performing it? As we are fond of saying, 'the surgeon is the method!'

They found that six of the included trials did not assess described surgeon expertise. Published studies tended to lump younger and older patients together, in spite of the different mechanisms of injury, different types of pathology, and different priorities in outcome (i.e. pain relief vs improved function).

The Cochrane review found no difference in either functional outcome scores or pain relief between surgical and active nonoperative treatment for cuff disorders. Firm conclusions could not be made regarding the effectiveness of open versus arthroscopic surgical approaches and conservative management for rotator cuff disease. 

Comment: This article should be considered along with that covered in a recent post. The bottom line is that in view of the prevalence of cuff disease and the frequency and cost of surgery for cuff disorders, and the failure of one-quarter of cuff repair repairs to achieve anatomic integrity, better studies are needed to define the appropriate treatment for acute and chronic rotator cuff tears in different age groups. In our practice we continue to see failed 'heroic' attempts to repair substantial chronic cuff defects in individuals over the age of 60. We have been impressed with the success of the 'smooth and move' approach for managing irreparable cuff tears or failed attempts at cuff repair. 

Our approach to rotator cuff disease can be seen on this post.