Saturday, October 31, 2015

Rotator cuff tear and repair outcomes.

Outcomes assessment in rotator cuff pathology: what are we measuring?

These authors reviewed 156 studies assessing rotator cuff tear and repair outcomes in 6 orthopedic journals with a high impact factor from January 2010 to December 2014 were reviewed.

Of the 156 included studies,
63% documented range of motion measurements, with 18% reporting range of motion in all 4 planes. 38% of studies reported quantitative strength measurements. 
65% of studies, tendon integrity was documented with imaging (38% magnetic resonance imaging/magnetic resonance anrhrogram, 31% ultrasound, and 8% computed tomography arthrogram). 
Functional score reporting varied significantly, with the 5 most frequently reported scores ranging from 16% to 61% in studies.

The authors suggest that creating a uniformly accepted, validated outcomes tool that assesses pain, function, patient satisfaction, and anatomic integrity would enable consistent outcomes assessment after operative and nonoperative management and allow comparisons across the literature.

Comment: In a recent paper, Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome. we have made sense out of the heterogenous literature on cuff repairs, using a method for comparing results obtained with different outcome scores. The abstract of this paper is reproduced here:

Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.
To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.

Systematic review and meta-analysis of articles with evidence levels 1-4.

A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.

While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. The inconsistent and incomplete data in the published articles limited the meta-analysis of factors affecting the outcome of rotator cuff repair.

In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient. To accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patient's condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function."


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