Monday, February 12, 2018

Rotator cuff tears - why not try non-operative treatment?

What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears 

These authors examined the 5-year outcomes in a prospective cohort of patients aged 40-85 years referred to shoulder surgeons because of chronically symptomatic  (>3 months), full-thickness rotator cuff tears of the supraspinatus or infraspinatus, confirmed on ultrasound or magnetic resonance imaging.

These patients were initially managed with a comprehensive, nonoperative, home-based treatment program. 

After 3 months, the outcome in these patients was defined as “successful” if they were essentially asymptomatic and as "failed" if they were symptomatic and consented to undergo surgical repair. 

At 5 or more years, all patients were contacted for follow-up; the response rate was 84%.

Approximately 75% of patients remained successfully treated with nonoperative treatment at 5 years and reported a mean rotator cuff quality-of-life index score of 83 of 100. 

Those in whom nonoperative treatment had failed and who underwent surgical repair had a mean rotator cuff quality-of-life index score of 89  at 5-year follow-up. 

The operative and nonoperative groups were not significantly different at 5-year follow-up  (P = .11).

The authors concluded that nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. 

Comment: It is recognized that most patients with chronic rotator cuff tears are minimally symptomatic. A small subset of all patients with chronic rotator cuff tears present to surgeons because of symptoms of pain, weakness or crepitus. 

This study suggests a cost-effective approach to these patients: start with a 3 month non operative program and reserve surgery for those who do not improve.

The results of this study are consistent with those of

Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.

Those authors compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34).

These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

See also: Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis

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