Tuesday, August 13, 2019

Rotator cuff tears - when should surgery be done?

Identifying regional characteristics influencing variation in the utilization of rotator cuff repair in the United States

These authors point out that there is a lack of consensus regarding indications for surgical management of rotator cuff disease. To emphasize this point, they examined the geographic variation in rates of rotator cuff repair (RCR) in the United States over time and to identify regional characteristics associated with utilization. They used Medicare data from 2004-2014 and found wide variability in the rates of rotator cuff repair in different geographical regions - in some patients were more likely to be operated on than in others. In 2014, there was an 8-fold difference in rates of RCR between regions.

They found that the rate of RCR has increased substantially over the past decade.  It is of interest to observe the high rates of cuff repair surgery in individuals over the age of 70 years - an age group known to be associated with poorer results from cuff surgery.
The regional supply of orthopedic surgeons and the rate of other orthopedic procedures, was independently associated with significantly increased utilization (p = 0.002).  A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P <.001). 

These results suggest the lack of generally applied guidelines for the treatment of rotator cuff disorders. Basically they seem to say that the more non-academic surgeons there are in an area, the more rotator cuff surgeries are performed per 1,000 medicare patients.

This lack of useful guides is evident on reviewing the AAOS Guideline on Optimizing the Management of Rotator Cuff Problems, which is summarized below. These guidelines do not suggest which patients should receive rotator cuff surgery.

We have developed a simple set of guidelines for managing the spectrum of cuff disease. We use the guidelines below for discussing treatment options with our patients. We recognize that the presence of a cuff tear is not in and of itself an indication for surgery in that many cuff tears are either asymptomatic or responsive to non operative management.

Acute traumatic reparable rotator cuff tear
   - consider acute rotator cuff repair (see this link)

Chronic cuff tear without arthritis
   - gentle progressive stretching and strengthening (see this link)
   - if unsatisfactory response to non-operative program:
      - if tear is reparable - consider attempting repair (see this link)
       -if tear is irreparable
          -if patient can actively elevate arm above horizontal, consider smooth and move (see this link)
          -if patient is unable to actively raise arm above horizontal, consider reverse total shoulder (see this link)

Chronic rotator cuff tear with arthritis
   - gentle progressive stretching and strengthening (see this link)
   - if unsatisfactory response to non-operative program:
        -if patient can elevate arm above horizontal and if coracoacromial arch is intact, consider CTA arthroplasty (see this link)
        -if patient is unable to actively raise arm above horizontal, consider reverse total shoulder (see this link)


We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

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You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'