Wednesday, November 11, 2015

Is rotator cuff repair of value in the treatment of atraumatic rotator cuff tears?

Treatment of Nontraumatic Rotator Cuff Tears - A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up

The authors of this Level I study randomized 180 shoulders (patient age > 55 years, average age 65 ± 6 years) with symptomatic, nontraumatic, isolated supraspinatus tears that had been symptomatic for > 2 years into one of three intervention groups:
*a physiotherapy (PT)-only group (Group 1),
*an acromioplasty, debridement and PT group (Group 2), and
*a rotator cuff repair, acromioplasty, and PT group (Group 3).

The repair technique was arthroscopic single row for tears of ≤10 mm and double row for larger tears followed by sling immobilization for three weeks.

167 shoulders were available for analysis at two years. The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity by MRI.

Direct cost data were obtained including cost related to transportation, health-care center, hospital, outpatient clinics, physiotherapist visits, laboratory and imaging services, the surgical procedure, length of hospital stay, medications, and lost income during sick leave.

The mean changes in the Constant score were not significantly different among the three groups: 18.4 points for Group 1, 20.5 for Group 2, and 22.6 points for Group 3. The recovery time for Group 3 patients was the slowest. There were no significant differences in visual analog scale for pain scores or patient satisfaction.

In comparison to baseline, at two years, the mean sagittal size of the tendon tear on MRI for Group 1 changed from 9.6 to 10.4 mm, for Group 2 from 9.1 to 11.7 mm and for Group 3 from 8.4 to 4.2 mm (i.e. the average patient having attempted cuff repair had a 4 mm tendon defect at two years in comparison to the average 8 mm defect preoperatively).

At two years, the mean Constant score was 78.4 points in patients with a full-thickness supraspinatus tendon defect and 79.0 points in patients with a healed supraspinatus tendon in all shoulders (Groups 1, 2, and 3). Only 3% of cuff defects randomized to the non-operative group crossed over to having surgery.

The range of motion and the strength for the three groups were virtually identical.

The costs of treatment were € 5,104 for Group 1, € 6,915 for Group 2 and € 9,185 for Group 3.

The costs for the patient were € 2,915 for Group 1, € 2,434 for Group 2 and € 3,674 for Group 3.

The costs for society were € 2,348 for Group 1, € 4,691 for Group 2 and € 5,646 for Group 3.

Considering the value of the different treatments, the treatment cost for a single point increase in the Constant score was € 277.39 for physical therapy, € 337.32 for debridement and € 406.42 for repair.

Comment: The key point about this study is that it concerns atraumatic cuff defects (i.e. the result of cuff wear in contrast to traumatic cuff tears) - see this link. This is the commonest type of cuff defect - the cuff tissue had degenerated to the point where it failed without a specific injury. Attempting to reattach degenerated tendon tissue to bone is expensive on one hand, has a substantial risk of failure on the second hand, and that the clinical results are essentially the same whether the repair attempt heals or not on the third hand.

One might critique this study based on surgical method or period of immobilization after surgery, but until other evidence comes along supporting the surgical treatment of non-traumatic cuff defects, we should strongly consider the authors’ recommendation of: “conservative treatment as the primary initial treatment for nontraumatic, isolated, supraspinatus tears”. As they state, “The wave of operative treatment of nontraumatic rotator cuff tears may cause increasing health-care expenses at no benefit over conservative treatment.”

The results of this study should be compared to that of another Level I study (see this link) with the caveat that the prior study included both traumatic and atraumatic cuff tears.

This article also calls to mind one of the most curious of all publications on rotator cuff surgery which came to a seemingly hyperinflated estimate of the value of cuff surgery (see this link).

We continue to consider the 'smooth and move' procedure (see link) in the management of atraumatic tears.