These authors retrospectively evaluated a cohort of patients over 18 years of age who had a full-thickness rotator cuff tear seen on magnetic resonance imaging . After clinical evaluation, each patient elected to undergo either rotator cuff repair or nonsurgical treatment. Treatment allocation was determined by agreement between the patient and surgeon after clinical evaluation and thorough discussion of the risks and benefits of surgical and nonsurgical treatment options for full-thickness rotator cuff tears.
Demographic information was collected at enrollment, and self-reported outcome measures (the Normalized Western Ontario Rotator Cuff Index [WORCnorm], American Shoulder and Elbow Surgeons score [ASES], Single Assessment Numerical Evaluation [SANE], and pain score on a visual analog scale [VAS]) were collected at baseline and at 6, 12, and >24 months. The Functional Comorbidity Index (FCI) was used to assess health status at enrollment. The size and degree of atrophy of the rotator cuff tear were classified on MRI. Propensity score analysis was used to create rotator cuff repair and nonsurgical groups matched by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy.
One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics.
For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS.
J
In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair.
They concluded that patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment.
Comment: In that patients make decisions based on the expectations set by their surgeons, this study shows essentially that these surgeons were able to select patients who would benefit from cuff repair. In a sense it is a study of the effectiveness of selection bias in choosing surgical candidates. While they attempted to match patients by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy, surgeons base their recommendations on many other factors that affect outcome, such as the presence or absence of depression, smoking, workers' compensation status, nutrition, narcotic use and socioeconomic factors (see this link). Thus, even though the authors "used propensity score analysis to approximate a randomized controlled trial to minimize the effects of confounding bias while maintaining a realistic method of treatment allocation", this study does not "approximate a RCT" because of the many important variables that could not be accounted for in the matching process.
So we are not left with much generalizable guidance on patient selection except to say that experienced surgeons appear to be able to select good candidates for surgery. That is a good thing!
One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics.
For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS.
J
In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair.
They concluded that patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment.
Comment: In that patients make decisions based on the expectations set by their surgeons, this study shows essentially that these surgeons were able to select patients who would benefit from cuff repair. In a sense it is a study of the effectiveness of selection bias in choosing surgical candidates. While they attempted to match patients by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy, surgeons base their recommendations on many other factors that affect outcome, such as the presence or absence of depression, smoking, workers' compensation status, nutrition, narcotic use and socioeconomic factors (see this link). Thus, even though the authors "used propensity score analysis to approximate a randomized controlled trial to minimize the effects of confounding bias while maintaining a realistic method of treatment allocation", this study does not "approximate a RCT" because of the many important variables that could not be accounted for in the matching process.
So we are not left with much generalizable guidance on patient selection except to say that experienced surgeons appear to be able to select good candidates for surgery. That is a good thing!
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