Friday, April 22, 2016

Over a 40% rotator cuff repair failure rate - is it the fault of the patient's parents?

Identification of a genetic variant associated with rotator cuff repair healing.

These authors studied 72 patients undergoing arthroscopic rotator cuff repair for a full-thickness posterosuperior tear. The surgeon performed arthroscopic single row repairs using triple-loaded suture anchors and simple stitches as well as double-row repairs using a suture bridge construct. There were 46 small/ medium-sized tears and 26 large/massive tears. The average preoperative muscle quality as graded by the Goutallier classification was 1.2 (range, 0-3). Of the 72 patients, 30 patients (42%) reported a positive family history of rotator cuff tear.

Typically, small tears (< 1 cm) had a single-row repair performed with triple-loaded anchors. Easily mobilized tears > 1 cm that could completely cover the footprint without significant tension had either a single-row repair with triple-loaded anchors or a double-row transosseous-equivalent repair based on the discretion of the surgeon. Large, retracted tears that could not completely cover the footprint without significant tension after mobilization had a single-row repair with triple-loaded anchors at a more medialized location on the footprint. There were 24 double-row transosseous-equivalent repairs and 44 singlerow triple-loaded anchor repairs performed.

After surgery the arm was immobilized in a sling for the first 6 weeks postoperatively for all patients. For small and mediumsized tears, passive supine forward elevation in the scapular plane to 130° and external rotation at the side to 30° were allowed starting at 2 weeks postoperatively. For large and massive tears, only pendulums were allowed for the first 6 weeks postoperatively. Passive and active assisted motion in all planes, except internal rotation and extension, was allowed at 6 weeks postoperatively for all patients. Isometric and resistive shoulder strengthening exercises as well as internal rotation and extension stretching were started at 3 months postoperatively. Patients were allowed to return to all activities without restriction at 6 months postoperatively.

Magnetic resonance imaging studies were performed at a minimum of 1 year postoperatively (average, 2.6 years). 

Of 72 rotator cuff repairs, 42 (58%) healed and 30 (42%) failed to heal; 28 of 46 (61%) small and medium-sized tears healed; 14 of 26 (54%) large and massive tears healed; 13 of 30 (43%) failures were Cho type I lateral failures; and 17 of 30 (57%) failures were Cho type II medial failures. Significantly more patients with lateral failures (Cho type I) reported a family history of rotator cuff tearing than those that healed (77% vs. 33%; P = .009). 

Multivariate regression analysis showed a significant association between familiality and overall healing failure (medial and lateral failures) (P = .036) and lateral failures independently (P = .006). An increased risk for the presence of a rare allele for SNP rs17583842 was present in lateral failures compared with those that healed (P = .005).

The authors concluded that individuals with a family history of rotator cuff tearing were more likely to have repair failures. Significant association of a SNP variant in the ESRRB gene was also observed with lateral failure.

Comment: This is a most important contribution, calling attention to potential genetic influence on cuff integrity and reparability. The high repair rate in the hands of experienced surgeons forces us to consider more closely the indications for repair, including a good family history and possibly including genetic screening. Perhaps we can shed some additional light to McLaughlin's observations over 50 years ago:

"The rotator cuff is the only tendon structure situated between two bones. Compressed between the acromion and the humerus by every motion of the shoulder, it succumbs to the ravages of attrition long before most other tendons. In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle age, it has worn thin and often becomes so weak and brittle that it ruptures with ease." McLaughlin 1962

We observe that detachment of the rotator cuff tendons from the greater tuberosity is often described as a rotator cuff tear. The word 'tear' suggests an acute process, such as tear in otherwise great blue jeans that can be easily repaired.

On the other hand, most cuff defects arise in tendons of suboptimal quality without an acute traumatic episode and may be better referred to as cuff wear, similar to defects in worn jeans that defy repair.

We emphasize the distinction in an article on rotator cuff failure in the New England Journal as well as in the text, The Shoulder, where we quote McLauhglin's admonition regarding 'rotten cloth to sew' in an Instructional Course Lecture: "The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis. [There was complete agreement of the Panel on this point.]" See his 1962 article.

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