Thursday, October 6, 2016

Rotator cuff tears - what evidence is available to guide our treatment?

Rotator cuff repair: a review of surgical techniques, animal models, and new technologies under development

These authors review some of the many approaches advocated for the management of cuff treats. They point out that rotator cuff tears are the most common musculoskeletal injury occurring in the shoulder. Current surgical repair fails to heal in 20% to 95% of patients, depending on age, size of the tear, smoking, time of repair, tendon quality, muscle quality, healing response, and surgical treatments. These problems are worsened by the limited healing potential of injured tendons attributed to the presence of degenerative changes and relatively poor vascularity of the cuff tendons. Most chronic tendon tears occur in the supraspinatus and ultimately lead to structural change such as fatty accumulation, loss of volume, muscle remodeling, subtraction of sarcomeres, and sometimes profound muscle weakness.

The latest generation techniques involve the use of different suture configurations. Double-row configuration seems to increase the rate of tendon healing, but this has generally not translated into improved clinical and functional outcomes.

ECM patches have shown some promising findings in some animal studies, but not in randomized clinical trials. Scaffolds and cells are becoming more popular in tissue engineering as a structural support and as a cellular delivery aid, but further clinical studies are still needed. Growth factors have been shown to improve healing, but there is still no study on rotator cuff repair using growth factors in humans.  PRP use in orthopedics is still controversial and under investigation for now, and data on its effectiveness are still limited. None of these strategies is perfectly suited for rotator cuff tear repair.

They summarize: "several repair strategies are available, but further clinical trials are needed to find the optimal treatment for rotator cuff repair.

Comment:  In the search for evidence, we often turn to the Cochrane reviews. With respect to rotator cuff tears, their reviews state, " This summary of a Cochrane review presents what we know from research about the effect of surgery for rotator cuff disease. The review shows that surgery: may not lead to any difference in pain compared with different exercise programs. The review shows that arthroscopic surgery: may not lead to any difference in outcome in the long run compared with open surgery but people might recover sooner.

There was not enough information in the included studies to tell whether surgery would make a difference in the ability to use your shoulder normally, your quality of life, your shoulder's range of motion, your strength, the chance that your symptoms might come back, the time it takes to return to work or sports and whether people are satisfied with surgery.

Side effects that occurred in the studies included pain, infection, difficulty moving the shoulder after the operation, wasting of the shoulder muscle, and the need to have another surgical procedure. There were no differences in side effects in the people who had arthroscopic surgery compared with those who had open surgery.

Another source of information is the AAOS practice guidelinesThis resource presents our Academy's findings on the evidence supporting different treatments:

In addition we have the results of a large study indicating that "patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention." See: Predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears

So, it appears that we're still looking for good evidence to guide our management of the most common condition of the shoulder.