Wednesday, May 20, 2020

Do cuff tears increase in size with time and does it matter?

The natural course of and risk factors for tear progression in conservatively treated full-thickness rotator cuff tears

These authors conducted a retrospective case series study of 345 patients with full thickness cuff tears treated nonoperatively.. These patients expressed low demand, low activity levels, and a reluctance to undergo surgical treatment and initially underwent conservative treatment. Surgery was recommended when their symptoms had not improved after at least 3 months of conservative treatment. Among the 345 patients who underwent nonoperative treatment, 87 patients underwent surgery before the follow-up period of a year, 159 patients were lost to follow-up, and 23 patients refused to take follow-up MRI for financial reasons. 76 patients had a followup MRI performed. Of these, 28 patients were excluded: 17 had poorquality  MR images, 4 had follow-up MRI at less than 12 months  after the initial MRI, 5 had prior surgery on the shoulder, and 2 had inflammatory arthritis. Thus, 48 patients were finally enrolled in the study, mean age 69 years.

The mean MRI follow-up duration was 22 months. 26 (54%) showed progression in the medial-lateral (M-L) direction and 20 (41%) showed progression in the anterior-posterior (A-P) tear direction.

The main progression was in the involvement of the infraspinatus. The average amount of increase in the AP dimension of the tear was 4 mm. The amount of retraction increased by 5 mm.

 On multivariate analysis, follow-up duration, diabetes mellitus, and infraspinatus muscle atrophy were independently associated with tear progression in the A-P plane. A high critical shoulder angle and supraspinatus and infraspinatus muscle atrophy were associated with M-L tear progression. While the difference in "critical shoulder angle" between the "no change" and the "progressed" group was statistically significant, the difference in the average angles was only 5 degrees; thus it seems unlikely that this difference could be used to support the idea that a higher angle causes cuff progression.

Comment: Unfortunately this article does not present the clinical status of the shoulder. Specifically, it seems essential to know whether the 5 mm "progression" in tear size was of any clinical significance.

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