Saturday, December 6, 2014

'Better functional outcomes were noted in patients who had re-torn their cuffs' - how's that again?

The influence of intraoperative factors and postoperative rehabilitation compliance on the integrity of the rotator cuff after arthroscopic repair.

These authors sought to determine when cuff re-tear commonly occurs in the postoperative period and to investigate the clinical factors that might predispose to an early cuff re-tear. They reviewed 127 cases having arthroscopic repair for supraspinatus ± infraspinatus tears with serial ultrasound examinations at 6 weeks, 12 weeks, and 26 weeks postoperatively.

The mean age of patients was 60 years. The overall re-tear rate was 29.1%, most occurring in the first 12 weeks postoperatively (25.2%) but continuing into the second 12 weeks (3.9%).

The patient's postoperative compliance, primary tear size, tendon quality, repair tension, cuff retraction, and footprint coverage were significant prognostic factor for re-tearing. The patients were questioned by a nurse to determine their compliance with the postoperative rehabilitation protocol.

There was a significant association between the rate of cuff re-tears and patients’ compliance at each time period after surgery:

Poor compliance of patients was highest (17.3%) during the second 6 weeks postoperatively.

There was a trend of increasing percentage of cuff re-tear with increasing tear size, retraction, and repair tension. An increasing percentage of cuff re-tear was also noted with decreasing tendon quality and footprint coverage. However, in the  multinomial logistic regression analysis, only the postoperative compliance was significantly associated with the rate of retear.

In contrast to the patients with good compliance, the relative risk ratio of retear in poorly compliant patients was 152 times higher at 6 weeks, 7 times higher at 12 weeks, and 39 times higher at 26 weeks.

At 12 weeks the Oxford score demonstrated a statistically significant increase in the patients with re-tears than in those with intact cuffs. There were no other differences in functional outcome between the shoulders with intact or failed repairs.

The authors concluded that "Better functional outcomes were noted in patients who had re-torn their cuffs at the 12-week period (Oxford mean scores, P 04)."  and "an early significant improvement of the clinical outcome should be a warning sign to a surgeon that the patient's compliance may be suboptimal, resulting in an increased risk of the cuff's re-tearing."

Comment: Their 29% retear rate is consistent with that in our recent review of the literature.
The fact that repairs are continuing to fail at 26 weeks after surgery brings into question the assumption made in an article on the economics of cuff repair that folks return to work 6 weeks after cuff repair.

While the focus of this article is on the relationship between compliance and cuff integrity, it seems that the real message is that there the clinical outcome as reflected by the Oxford Score is no better for intact than for retorn rotator cuff repairs. This makes us reflect on the clinical value of repair and of compliance with the postoperative rehabilitation program.

The improved clinical scores at 12 weeks in retorn repairs may be due to stress relaxation.


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