Sunday, July 8, 2018

Failed and healed cuff repairs: is there a clinically important difference in outcome?

What Influence Does Progression of a Nonhealing Rotator Cuff Tear Have on Shoulder Pain and Function?

These authors asked (1) Do patients with healed arthroscopic rotator cuff repairs have better outcomes, less pain, and more strength than patients whose repair did not heal? (2) In patients with nonhealed rotator cuff tendons, does tear size progression (increase or decrease) affect outcomes, pain, and strength? (3) Is there continued improvement beyond 6 months in outcomes, pain, and strength; and how do the improvements differ based on whether the tear size has increased or decreased?

They investigated 442 of 647 patients underwent arthroscopic rotator cuff repair for fullthickness tears who had all MRI and clinical information at a minimum of 2 years followup.

Eighty-two of 442 tears (19%) were not healed. The patients with failed repairs were older with a relatively higher percentage of large to massive tears.

Of the nonhealed tears, 45 (55%) had a decrease and 37 (45%) had an increase in tear size. Shoulder function outcomes using the American Shoulder and Elbow Surgeon (ASES) and Constant scores and pain severity using VAS scores were evaluated preoperatively, at 6 months postoperatively, and at the latest followup. Some preoperative (A) and postoperative (B) images are shown below.

Compared with patients with nonhealed tendons after arthroscopic rotator cuff repair, patients with healed repairs had improved ASES scores (healed, 93 ± 5; nonhealed, 89 ± 8; mean difference, 4; 95% CI, 3–5; p< 0.001), better Constant scores (healed, 91 ± 5; nonhealed, 85 ± 8; mean difference, 6; 95% CI, 4–7; p<0.001); however there was no difference in pain level based on VAS scores.

The authors concluded that patients who had healed tendons after arthroscopic rotator cuff repair had better shoulder function than patients who had nonhealed tendons. Among patients with nonhealed rotator cuff tendons after surgery, those with decreased tear size, observed on their 6-month postoperative MRI, compared with their initial tear size, showed better shoulder function and muscle strength than those with increased tear size beyond 6 months.

Comment: It would have been useful to have the preoperative scores for the different patient groups rather than only the postoperative scores so that the reader could compare the amount of improvement and determine the percent of maximum possible improvement for failed and intact repairs. 

For patients having rotator cuff repairs MCID (minimal clinically important difference) for  the ASES score is 12-17 and for the Constant Score is 10. Thus, the patients in this series with intact repairs did not  have clinically significantly better average outcomes than those with failed repairs. 
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