Friday, July 31, 2015

"Rotator cuff repair" "You keep using that word. I do not think it means what you think it means."

One of my colleagues loves this quote of Inigo Montoya in the Princess Bride: "You keep using that word. I do not think it means what you think it means."

Inigo was referring to the word "Inconceivable", but this quote may also apply to arthroscopic rotator cuff repair.

According to a recent article, Characteristics of clinical shoulder research over the last decade: a review of shoulder articles in The Journal of Bone & Joint Surgery from 2004 to 2014, the most cited article on clinical shoulder research was "The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears"

The authors of this most cited article evaluated 18 patients who had complete arthroscopic repair of a tear measuring >2 cm in the transverse dimension at a minimum of twelve months after surgery and again at two years after surgery. The evaluation consisted of a standardized history and physical examination as well as calculation of the preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons. The strength of both shoulders was quantitated postoperatively with use of a portable dynamometer. Ultrasound studies were performed with use of an established and validated protocol at a minimum of twelve months after surgery.

Recurrent tears were seen in seventeen of the eighteen patients. Despite the absence of healing at twelve months after surgery, thirteen patients had an American Shoulder and Elbow Surgeons score of >/=90 points. Sixteen patients had an improvement in the functional outcome score, which increased from an average of 48.3 to 84.6 points. Sixteen patients had a decrease in pain, and twelve had no pain. Although eight patients had preoperative forward elevation to <95 degrees, all eighteen regained motion above shoulder level and had an average of 152 degrees of elevation. At the second evaluation, a minimum of twenty-four months after surgery, the average score, according to the system of the American Shoulder and Elbow Surgeons, had decreased to 79.9 points; only nine patients had a score of >/=90 points, and six patients had a score of </=79 points. The average forward elevation decreased to 142 degrees.

They concluded that arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects; however, at a minimum follow-up of two years, the results deteriorated with only twelve patients who had an American Shoulder and Elbow Surgeons score of >/=80.

Comment: This sentinel article taught us that "repair" doesn't always mean what we think it does. Durable rotator cuff repair did not occur in many of these patients despite improvement in clinical outcome. Thus, improved clinical outcome cannot be used to judge the success of a surgical attempt to reattach the torn tendon to the tuberosity. This fact is echoed in many other articles, as shown in this post.


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