Saturday, January 21, 2017

What happens if a rotator cuff tear is not repaired?

The natural course of nonoperatively treated rotator cuff tears: an 8.8-year follow-up of tear anatomy and clinical outcome in 49 patients

From May 2001 through November 2006, 1 orthopedic surgeon referred to physiotherapy 89 consecutive patients who were diagnosed sonographically and by MRI with an isolated full-thickness tear of the rotator cuff with a tear size of no more than 3 cm, no involvement of the subscapularis tendon, a negative tangent sign for muscle atrophy and a fatty degeneration of no more than stage 2 according to Goutallier.

It is unclear why surgery was not performed on these shoulders and what percent of similar tears were operated on by this surgeon during the same time period? Were these patients too ill (of note 11 could not participate in followup because of serious medical conditions unrelated to the shoulder and 4 had died)? Were they poor candidates for surgery for other reasons? Did they decline surgery because of minimal symptomatology? Or was this surgeon very conservative with the indications for surgery?

Twenty-three had surgical treatment later on but we do not know if this surgery improved the function of these shoulders.  The remaining 49 still unrepaired tears were re- examined after 8.8 (8.2-11.0) years with sonography.

The mean tear size increased by 8.3 mm in the anterior-posterior plane (P = .001) and by 4.5 mm in the medial-lateral plane (P = .001). Increase of tear size was −5 to +9.9 mm in 33 patients, 10 to 19.9 mm in 8 patients, and ≥20 mm in 8 patients. The Constant Score was 81 points for tear increases <20 mm and 58.5 points for increases ≥20 mm (P = .008). Muscle atrophy and fatty degeneration progressed in 18 and 15 of the 37 patients, respectively. In tears with no progression of atrophy, the CS was 82 points compared with 75.5 points in tears with progression (P = .04). 

Comment: This study again demonstrates the uncertain indictions for the different types of management for the different types of cuff tears. 

It is surely of interest that the average Constant scores improved with non operative management

A key question is the relationship of cuff integrity to shoulder function. In that light, it would have been interesting to see a plot of the final Constant score as a function of final tear size and to see a plot of the change in Constant score as a function of change in tear size.

While it may be tempting to use these results as justification for surgical intervention in an attempt to prevent tear enlargement, we do not have evidence that the anatomic or functional outcomes would have been better had these shoulders been operated on.

The bottom line is that, even in spite of some tear enlargement with time, the shoulder comfort and function for these shoulders as reflected by the Constant Score improved over 9 years with non operative management (p<.0001).


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