Does attempted arthroscopic cuff repair improve shoulder activity?

Does arthroscopic rotator cuff repair improve patients’ activity levels?

These authors asked whether attempted arthroscopic cuff repair led to improvements in patients' activity level. For 281 shoulders from 273 patients with a mean follow-up of 3.7 years. Scores included the Simple Shoulder Test, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, as well as the Shoulder Activity Level:

The Simple Shoulder Test improved from 4 to 11. Other scores improved similarly except for the Shoulder Activity Level score which decreased from the preoperative score (12 vs. 11; P < .0001).

Comment: This study introduces yet another shoulder outcome scale, the Shoulder Activity Level. The value of this scale and the clinical significance of the differences noted is unclear. Perhaps most importantly, the paper does not relate the success of the repair (i.e. achieving durable cuff integrity) with the clinical outcome. Specifically, did patients with failed cuff repairs have different clinical outcomes than those with intact repairs?
=====

Use the "Search" box to the right to find other topics of interest to you. 

How you can support progress in shoulder surgery

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

Rotator cuff repair. Does technique matter? Does integrity matter?

Advantages of Arthroscopic Rotator Cuff Repair With a Transosseous Suture Technique. A Prospective Randomized Controlled Trial

These authors conducted a randomized controlled trial of two rotator cuff repair techniques: (a) single-row anchor fixation and (b) transosseous hardware-free suture repair. Sixty-nine patients with rotator cuff tears were enrolled: 35 patients were operated with metal anchors and 34 with standardized transosseous repair. 

Patients operated with the transosseous technique had significantly less pain, especially from the 15th postoperative day, however no differences in functional outcome were noted between the 2 groups at the final evaluation. In the evaluation of rotator cuff repair integrity, based on Sugaya magnetic resonance imaging classification, no significant difference was found between the 2 techniques in terms of retear rate.

Comment: In this randomized study, repair technique did not have a significant effect on outcome. Furthermore, at followup the 88% of the repairs that were intact (Sugaya classes I, II, III) had similar outcomes to the 12% that were retorn ( Sugaya classes IV and V = retorn).

===
Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

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

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff repair - does repair integrity matter?

Rotator cuff surgery in patients older than 75 years with large and massive tears

These authors reviewed 121 patients aged ≥75 years who underwent rotator cuff repair for large and massive rotator cuff tears. However, only 64 patients were enrolled in this study.

Open cuff repairs were performed by an individual surgeon. The mobilized, the mobilized rotator cuff was repaired with multiple tendon-totendon repair sutures and tendon-to-bone repair to the prepared greater tuberosity using transosseous rotator cuff repair with a double mattress suture technique.

After surgery, a shoulder abduction brace was applied for 7 to 8 weeks. The patients started passive forward elevation on the first postoperative day. On the third postoperative day, stretching exercises including pendulum exercises and passive external rotation were started. The average hospital stay was 4.6 days. After 4 weeks, pulley exercises to gain full forward elevation were started. Strengthening of the rotator cuff and periscapular muscle and wall pushups were started immediately after removal of the shoulder abduction brace at postoperative week 8. Posteriocapsular stretching exercises and internal rotation stretching were initiated after approximately 3 months of strengthening exercise.

MRI revealed retears at or before one year in 26% of patients.

While the scores and motion of the patients were improved for those patients without and with retears, there was no difference in functional outcomes between the retear and the non-retear groups as shown in the chart below.

Comment: This is one of a growing number of papers showing that cuff integrity after surgery may not have a major influence on the patient's perception of the outcome: failed repairs have similar patient-reported results to successful repairs.

Here are some related posts:

What happens if a rotator cuff tear is not repaired?

Rotator cuff repair, does integrity matter?

=

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

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

See from which cities our patients come.

See the countries from which our readers come on this post.

Assessing rotator cuff integrity - MRI and Ultrasound

Assessment of rotator cuff repair integrity using ultrasound and magnetic resonance imaging in a multicenter study.

These authors sought to compare ultrasound and magnetic resonance imaging (MRI) evaluation of the repaired rotator cuff to determine concordance between these imaging studies in 113 shoulders having repair with the suture bridge technique for rotator cuff tears that were between 1 and 4 cm wide.

They concluded that there was a good degree of  concordance between MRI and ultrasound readings if the individual reading the sonogram was experienced.

Comment: Unfortunately, this study does not provide data on the integrity of the cuff repairs. It would have been most interesting to see how many of the 113 cuff repairs were intact at the different time points.

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

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

See from which cities our patients come.

See the countries from which our readers come on this post.

To see other similar posts, click on the label of interest below.

Rotator cuff repair: anatomic and clinical outcomes, are we getting better?

Rotator cuff repair: What predicts anatomic and clinical outcomes.

This paper, presented at the 2014 meeting of the American Academy of Orthopaedics Surgeons noted that rotator cuff repairs are commonly performed: well over 200,000 per year in the U.S. The direct costs of these repairs are estimated a $3 to 12 billion per year in direct costs alone. In spite of this expenditure, the published failure rates of cuff repair are substantial.

These authors reviewed 108 articles presenting the post operative clinical integrity of the repair and clinical outcomes in over 8,000 patients having cuff repair surgery.

The key finding was that in spite of an essentially exponential rise in the number of publications meeting the inclusion criteria per year and the use of more advanced repair methods, the failure rate and clinical outcomes have not improved over the last two decades. The overall retear rate was 27%. Risk factors for retear included larger tears, increased fatty infiltration and older age. The clinical improvement (expressed as a percent of maximal possible improvement) was 72%. Most studies found that the integrity of the repair did not have a substantial relation to the clinical outcome.

Most of the studies had incomplete data, so that the effect of repair technique and other key variables could not be determined.

The authors suggest that future clinical studies of cuff repairs need to include the following minimal dataset on each patient in an accessible appendix so that the data can be used in further systematic reviews and meta analyses:

•Patient (age, gender, smoking)
•Shoulder (tear size, fatty infiltration, preoperative clinical scores)
•Procedure (treatment method, rehabilitation protocol)
•Results (repair integrity, postoperative clinical scores, duration of followup)

Comment: This study again calls attention to the observation that factors other than repair integrity determine the outcome of rotator cuff surgery. Furthermore, larger tears, with fatty infiltration, in older individuals are at increased risk for failure of surgical repair and may be candidates for other types of treatment.

===
Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Use the "Search" box to the right to find other topics of interest to you.

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

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff repair - does it matter if it works?

Structural Integrity After Rotator Cuff Repair Does Not Correlate with Patient Function and Pain: A Meta-Analysis

This article comes to a conclusion similar to that of an article by Doug Harryman published two decades ago and discussed in previous posts, such as this one. Other similar posts on the discordance between clinical outcome and retear can be found here.

The authors conducted a systematic review and a meta-analysis of studies that compared the clinical outcome with the structural integrity of the repair. 

They found only 14 studies that met their inclusion criteria. Of 861 patients in the included studies, 187 (>20%)  had failure of healing or retear of the rotator cuff repair. The size of the repaired cuff tear did not appear to affect the rate of retearing. 

Clinical outcome (as reflected by the University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score  and the visual analog scale score) were improved whether the repair was intact or not.

The authors concluded that " The results of this meta-analysis demonstrate that the structural integrity
does not correlate with a clinically important difference in patient function and pain relief after rotator cuff repair." and " data from this meta-analysis demonstrated that, on the basis of validated shoulder outcome measures after rotator cuff repair, no difference exists in patient pain or function regardless of the structural integrity of the repair."

Comment: It is of interest that the average patient in this series was relatively young (58.5 years) and the average tear size was relatively small (2.68 cm). Thus one might expect that the post operative retear rates would be greater in older patients with larger tears. The minimum time from repair to postoperative imaging was 6 months; it seems likely that the retear rate would increase with time after repair. Thus the rates of retear may be underestimated.

This paper presented the results in terms of the scores and strength after surgery. Patients have surgery to improve their comfort and function; thus would have been more informative to see the results expressed as the amount of improvement in function and strength in the intact and retorn shoulders. In this way one can include the preoperative as well as the postoperative status so that the benefit of treatment is apparent, assuring that those patients with better scores after treatment did not have better scores before treatment. For measuring improvement, we prefer to assess the amount of improvement as a percent of the maximal possible improvement or the  IMPI as shown here.

The observation, made repeatedly by many authors, that shoulders with cuff tears are improved whether or not a surgical repair attempt is successful makes us question the value of rotator cuff repair surgery and prolonged restricted activity after repair in larger chronic cuff tears. When a durable repair seems unlikely we consider a smooth and move surgery that avoids the prolonged postoperative protection required after a cuff repair.

It also makes one wonder about the assumptions that went in to the paper concluding that across the board rotator cuff repairs save the country money.

Finally, in view of these results it is apparent that studies comparing methods of cuff repair need to be done very carefully in order to determine the value of one technique in comparison to another.

In this context, readers will be interested in this recent randomized study comparing non-operative management, acromioplasty and cuff repair in the treatment of non-traumatic cuff tears.

===
Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

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

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff repair healing and clinical result of rotator cuff 'repair' - is there a relationship?

Arthroscopic Repair of Massive Contracted Rotator Cuff Tears: Aggressive Release with Anterior and Posterior Interval Slides Do Not Improve Cuff Healing and Integrity

This is a non-randomized study of forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. 22 patients underwent arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge and 19 patients had a partial repair with margin convergence. (nineteen patients; Group M).

No significant differences were detected between groups. At the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. The mean preoperative SST scores (and standard deviation) were 4.9 ± 1.3 in Group P and 4.7 ± 1.4 in Group M. The mean postoperative SST scores improved to 8.6 ± 1.6 in the posterior slide group (p < 0.001) and 8.8 ± 1.8 in the margin convergence group (p < 0.001) at the time of the two-year follow-up

91% of the patients with the posterior interval slide had a retear by MRI. 

So, once again, we are impressed with yet another article showing discordance: patients are improved clinically after rotator cuff surgery even when anatomical integrity is not achieved. It makes us wonder what is it about the surgery and aftercare that leads to the improvement, in that it is obviously not the integrity of the 'repair'. Perhaps a lesser surgery without postoperative immobilization could achieve the same result (see here)

====
To see the table of contents of this Blog with links, click here

Use the "Search" box to the right to find other topics of interest to you.

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


See from which cities our patients come.


See the countries from which our readers come on this post.

Failure of rotator cuff repair, when does it happen and what difference does it make?

Time to Failure After Rotator Cuff Repair: A Prospective Imaging Study

The goal of the surgical repair of a rotator cuff tear is to re-establish the integrity of the tendon attachment to the humeral tuberosity. Failure of tendon healing can be demonstrated as a fluid-filled defect within the tendon on magnetic resonance imaging.

These authors followed 113 patients (age range 12 (!) to 75 years) having a standardized arthroscopic repair of a full-thickness tear of 1 to 4 cm with sequential MRI studies from 2 to 52 weeks after repair. Interestingly, the authors state that "At the time of enrollment, patients had a nearly normal active range of motion—i.e., at least 140° of lateral elevation (abduction), forward flexion (elevation), and scapular elevation (abduction in the scapular plane)." All tears were repaired with the suture bridge technique (double-row transosseous equivalent) with use of metal anchors medially (average # 2) and knotless anchors laterally (average # 2).

The postoperative protocol included the use of a shoulder immobilizer or abduction pillow for six weeks after surgery. A passive range of motion was allowed within the first six weeks after surgery, and lifting, reaching, pushing, and pulling were avoided for the first twelve weeks after surgery. Progression of the exercise program to include strengthening was started twelve weeks after surgery.

A recurrent tear was noted in nineteen (17%) of the 113 patients within one year after surgery. Interestingly, this retear rate at 1 year using 'modern' repair techniques is not different than that reported for the the open repair of similar tears at 5 years reported previously by Harryman et al. The mean time to the retear was 19.2 weeks, with most retears noted between six and twenty-six weeks after arthroscopic rotator cuff repair. Half of the retears occurred between twelve and twenty-six weeks after surgery. The authors did not identify significant risk factors for re-tear.

As has been the case in previous studies, the presence of a retear was not correlated with a difference in shoulder outcome scores, including the normalized Constant-Murley Shoulder Score, VAS pain score, or Penn Shoulder Score at the time of final follow-up.

Based on their data, the authors conclude that rotator cuff repairs should be protected for at least six months.  This is important because this recommendation for 'down time' adds substantially to the cost of rotator cuff repair.

===
Use the "Search" box to the right to find other topics of interest to you.

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


See from which cities our patients come.


See the countries from which our readers come on this post.

Rotator cuff repair: integrity and functional outcomes (guess what?)

Repair integrity and functional outcomes for arthroscopic margin convergence of rotator cuff tears.

The authors studied 24 consecutive patients with full-thickness rotator cuff tears, in which the free tendon edge could not be reduced to the footprint after the release and mobilization of the rotator cuff tendon. Rotator cuff repair integrity was determined by magnetic resonance imaging or ultrasonography after the operation. The mean age and follow-up period for the patients were 60 years and 31 months.

Half of the repairs were found to be retorn at followup. While the clinical outcomes were improved for the entire group, the VAS, ASES, UCLA and Constant scores were not different between the healed and the unhealed shoulders. 

The authors make the somewhat quizzical statement: "Although the functional scores were not significantly different between the healed and unhealed groups after margin convergence, it does not mean that margin convergence would be better than not fully reducing the cuff or not repairing the cuff at all."

It would have been informative had the authors analyzed the effects of age and tear size on the functional result.

===
Use the "Search" box to the right to find other topics of interest to you.

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


See from which cities our patients come.


See the countries from which our readers come on this post.

Failed Repairs of Large or Massive Rotator Cuff Tears

Clinical and Radiographic Outcomes of Failed Repairs of Large or Massive Rotator Cuff Tears: Minimum Ten-Year Follow-up - E. Scott Paxton, MD; Sharlene A. Teefey, MD; Nirvikar Dahiya, MD; Jay D. Keener, MD; Ken Yamaguchi, MD; Leesa M. Galatz, MD
J Bone Joint Surg Am, 2013 Apr 3;95(7):627-632.


This is a long term followup of fifteen of eighteen patients average age 61 years having had attempted arthroscopic repair of massive rotator cuff tears (at least two tendons torn) at a minimum of 10 years. The rotator cuff repair was attempted with use of a single-row construct with 5-mm bioabsorbable corkscrew anchors. Two to five anchors were used, depending on tear size and configuration.  After surgery the arm was immobilized in a sling.The rehabilitation protocol began on the first postoperative day with passive shoulder range-of-motion exercises. Active-assisted motion was initiated at six weeks. A return to recreational activity with heavy demands on the shoulder or to manual labor was delayed for six months.

The functional results as measured by the ASES score are shown here

The average SST score was 9.2 out of 12 points (range, 6 to 12 points). Of these patients with structurally failed repairs, all but one had radiographic signs of proximal humeral migration or cuff tear arthropathy. Ultrasound confirmed the persistence of all tears that had been seen at two years.

The authors concluded that clinical improvements and pain relief after a failed attempt at arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (ten-year) follow-up in spite of a high rate of progression of radiographic signs associated with large rotator cuff tears.

These results showing durable clinical improvement after failed attempts to achieve arthroscopic integrity of the rotator cuff once again cause us to question what it was about the surgery and postoperative rehabilitation that led to this improvement, in that it obviously was not the reestablishment of cuff integrity.  Did these patients achieve any value from the placement of 2 to 5 suture anchors? Might it be true that 60+ year olds with chronic massive cuff tears might be equally well treated without attempting to repair cuff tendons lacking in quantity and quality?

===
Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.


See from which cities our patients come.


See the countries from which our readers come on this post.

Rotator cuff repair outcomes

Long-Term Longitudinal Follow-up of Mini-Open Rotator Cuff Repair

This is an average 16 yr followup of 49 of 79 who had mini-open rotator cuff repair from 1993 to 1996. Outcomes were reviewed in 1997, 2002, and 2010. Eight were large tears, forty medium tears, and one small tear. 34 had good or excellent results and 41 were were satisfied with the final outcome of the procedure. Interestingly patient satisfaction at the final evaluation did not necessarily correspond with a good or an excellent UCLA score.

This study demonstrates the challenges of a long term followup study, specifically the patients lost to followup (20%) and the 18% percent that were lost because of death or dementia.

The authors did not determine the integrity of the repairs in those shoulders with good and poor results. They state that "there are studies that demonstrate that the functional outcome following shoulder surgery is not determined by the integrity of the cuff". Does this mean we shouldn't care about integrity?

The lack of this information makes it difficult to know how much surgical and rehabilitative effort should be put into achieving cuff integrity in the treatment of rotator cuff tears. What matters?

We are interested in finding out the predictors of achieving integrity in managing cuff tears so we can learn when to repair and when to smooth and move. In other words, if the functional outcome is indeed unrelated to integrity, why do the repair at all?

===
Use the "Search" box to the right to find other topics of interest to you.

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


See from which cities our patients come.


See the countries from which our readers come on this post.