Monday, July 27, 2015

Rotator cuff repair - what is an 'early repair' of an "acute" rotator cuff tear?

Surgery within 6 months of an acute rotator cuff tear significantly improves outcome

These authors performed a retrospective analysis of patients having sustained an acute full-thickness rotator cuff tear defined as a sudden episode of shoulder pain precipitated by a traumatic episode resulting in a deterioration in shoulder function with self-reported normal shoulder function before injury. 

 Twenty had rotator cuff repair within 6 months of injury - these were compared to 20 age- and sex-matched patients who had undergone delayed repair (6-18 months after injury; mean age, 60 years; age range, 40-78 years). The mean follow-up period was 10 months for the early repair group versus 11 months for the delayed repair group. Both groups had clinically significant improvements in their Oxford scores, although the early repair group had an improvement that was nearly double that of the delayed repair group (20.3 for early vs 10.4 for delayed, P = .0014). Postoperative Oxford scores were significantly higher in the early repair group (mean of 43.8 for early vs 35.8 for delayed, P = .0057). There were 2 symptomatic retears in the early repair group versus 5 in the delayed repair group.

Comment: A few comments about this study:
(1) patients with 'self-reported normal shoulder function' can have asymptomatic tears - many of the 60 year old patients in this study are likely to have had some degree of degenerative tearing, so it is difficult to distinguish an acute tear from an acute extension of a chronic tear
(2) the definition of a 'traumatic episode' can vary substantially from lifting a suitcase to falling off a ski lift
(3) one cannot use the rate of 'symptomatic retears' as an indication of the success rate of repair - many retears are asymptomatic so that the the retear rate can only be known if a standardized imaging protocol is applied.
(4) 'matching' groups of patients is tenuous unless we know the degree of trauma, the surgeons, techniques, and other factors such as smoking history for both groups.
(5) repair at 6 months is not really an 'early repair. 

Nevertheless it makes sense that tendon ruptures are more amenable to successful reconstitution if the repair is performed immediately after the injury. What surgeon would wait 6 months, or even one month to repair the rupture of a quadriceps tendon? Why is the shoulder different?

Our practice is to treat the acute onset of weakness after a substantial injury in a healthy individual as an indication for urgent imaging of the rotator cuff using MRI or sonography. By urgent we mean within a week - it is intuitive that the quality of the tendon, muscle and bone as well as the degree of retraction will worsen progressively from the time of injury.  If the history, physical examination and cuff imaging together suggest an acute reparable rotator cuff tear, our goal is to discuss with the patient an expeditious attempt at repair within a month of the injury.

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