Rethinking rotator cuff tear management - how do we want to spend the money?

The management of patients with rotator cuff tears presents a significant clinical and economic challenge. With annual costs of rotator cuff surgery exceeding $3 billion in the United States alone, and increasing evidence that structural repair does not always correlate with functional outcomes, a critical reassessment of the cost-effectiveness of different management options seems warranted. 

Let's start with a case example

A 70 year old active skier, cyclist, climber and practicing orthopaedic surgeon presented with the progressive onset of pain in the right shoulder. Physical examination revealed weakness of resisted elevation, but a good range of active motion. Plain radiographs showed no evidence of arthritis. The MRI findings are shown below.  

Surgical repair was offered but declined in favor of a home exercise program. A decade later the shoulder has a full painless range of range of motion and strength sufficient for sports and surgical practice. 

An Overview

Prevalence, Natural History, and Nonoperative Treatment of Rotator Cuff Disease

Rotator cuff disease is extremely common, affecting up to 25% of the population over age 40. Tear prevalence, size, likelihood of progression, and retear rates after surgical repair are all related to increasing age. Fewer than 5% of people with rotator cuff tears come to surgery, the great majority of rotator cuff tears are either asymptomatic or mildly symptomatic. 

However, Over a half million cuff surgeries are performed each year and this number is increasing

Non-operative treatment represents the most cost-effective strategy for many patients with symptomatic rotator cuff tears.

Jed Kuhn and the MOON (Multicenter Orthopaedic Outcomes Network) Shoulder Group that he leads published Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study, a multicenter prospective cohort study of 452 patients with atraumatic full-thickness rotator cuff tears treated with a standardized physical therapy protocol. The study found that 75% of patients achieved successful outcomes with physical therapy alone at 2-year follow-up, with "failure" defined as patients electing to undergo surgery. 

The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time: Ten-Year Outcomes of the MOON Shoulder Prospective Cohort, a follow-up study tracked the original cohort for 10 years and found that physical therapy remained successful in over 70% of patients, with only 27% ultimately requiring surgery. Importantly, patient-reported outcomes improved with physical therapy and did not decline over the 10-year period. This study won the 2024 Kappa Delta Ann Doner Vaughan Award and demonstrated the long-term durability of non-operative treatment.

EXERCISE THERAPY IN THE NON-OPERATIVE TREATMENT OF FULL-THICKNESS ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW Of the non-operatively treated cohorts 78% improved in pain, 81% improved in range of motion, 85% improved in strength, 84% improved in functional outcomes. Dissatisfied outcomes occurred in 15% of patients, who then transitioned to surgery.

The cost differential is substantial. Home exercises are inexpensive and often effective. While comprehensive physical therapy may cost $1,500-3,000 over several months, surgical repair typically ranges from $15,000-25,000, creating a 10-fold cost difference for initial treatment. Given that many patients achieve acceptable outcomes with therapy alone, this represents a significant opportunity for cost savings without compromising patient outcomes.

Patient selection for non-operative management should prioritize older individuals (typically >65 years), those with maintained active forward elevation without pseudoparalysis, reasonable functional demands, and chronic rather than acute tears. 

Symptoms of cuff tears do not correlate strongly with the magnitude of the defect.

Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear, A cross-sectional study of 393 patients with symptomatic atraumatic full-thickness rotator cuff tears demonstrated that pain severity does not correlate with tear size or other anatomic features. This finding challenged the assumption that larger tears necessarily cause more symptoms and require more aggressive treatment.

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity found that cuff integrity was not strongly associated with the shoulder's comfort or function. 

Repair attempts often lead to failure of anatomic healing of the tendon to bone; clinical outcomes are largely independent of repair integrity.

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? Only 43% of patients over the age of sixty-five years had completely healed tendons.

Failure with continuity in rotator cuff repair "healing" found that all rotator cuff repairs retracted substantially away from their position of initial fixation during the first year after surgery (mean 16.1 ± 5.3 mm; range, 5.7-23.2 mm), yet only 30% of patients showed a defect on MRI. This study is important because it indicates that an "intact" tendon repair on MRI may not indicate healing of the tendon to the insertion site. This finding may be especially relevant to the assessment of repair integrity after the use of patches and grafts.

The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears reported arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects.

Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome found that the mean re-tear rate was 26.6% at a mean of 23.7 months after surgery.  Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff.  In spite of a dramatic increase in the number of publications per year and the advent of biologic augmentation there was little evidence that the clinical results of rotator cuff repair were improving with time. 

Structural Integrity After Rotator Cuff Repair Does Not Correlate with Patient Function and Pain The differences in validated functional outcome scores and pain were not clinically significant for intact and failed repairs.

Non-repair surgery - the underutilized "smooth and move" procedure / debridement (see this link)

Smoothing the humeroscapular motion interface without acromioplasty is a quick, safe procedure for painful cuff tears in shoulders with preserved active elevation. It allows the patient immediate return to use of the shoulder without postoperative "down time". It does not involve use of a more costly "subacromial balloon" or a "biological tuberoplasty". The cost-effectiveness advantages of debridement are substantial. Operative time is typically 30-45 minutes compared to 2-3 hours for complex repairs, resulting in lower facility and anesthesia costs. Recovery is faster, allowing quicker return to activities and reduced rehabilitation expenses. Complication rates are lower due to the less invasive nature of the procedure.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty.  In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 to 8.5. Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 to 7.5. Fifty-four patients (73%) improved by the MCID. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID). The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus. In addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.

Comparing outcomes between debridement and attempted repair of large/massive tears reveals only modest functional differences, yet the repair costs more and carries higher complication risks.

Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair Both treatment groups had similar pain relief and satisfaction, reflected in equal values of disabilities of the arm, shoulder and hand (DASH) score. Ultrasonography revealed structural failure of the partial rotator cuff repair in 52% at final follow-up.

Partial rotator cuff repair versus debridement for irreparable rotator cuff tears: A systematic review 709 shoulders from 706 patients were reviewed, with 380 patients receiving a partial repair and 329 shoulders receiving debridement.  Pre- and post-operative mean VAS scores were the same for both treatments. Patient satisfaction with partial repair was reported as 75 %; for patients treated with debridement, post-operative satisfaction was 80.7 %.This systematic review study demonstrates that both partial repair and debridement alone can result in acceptable clinical outcomes with no significant differences noted for patients with irreparable rotator cuff tears in short to mid-term follow up.

Standard Rotator Cuff Repair

Standard surgical repair remains the gold standard of treatment for cuff tears when the quantity and quality of the tendon is adequate. The outcomes of cuff repair surgery are strongly influenced by the patient's nutrition. See: The "Secret Sauce" for Optimizing Rotator Cuff Outcomes: Biologics or nutrition?

Biologics, patches, PRP, and augmentation 

While these interventions are associated with reduced retear rates there is currently insufficient evidence that their significantly increased costs result in clinically meaningful improvement in clinical outcomes for patients. Structural healing on imaging does not reliably translate to better clinical outcomes for patients. This disconnect persists despite 25+ years of rotator cuff biological augmentation research.

Platelet-Rich Plasma (PRP)

Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: a systematic review and meta-analysis with bias assessment Improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences

Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: a meta-analysis and meta-regression. A meta-analysis of Level I and II studies found no statistically significant differences in overall outcome scores or retear rates between PRP-treated and control groups.

Evaluating the longitudinal efficacy of platelet-rich plasma in rotator cuff surgery: a systematic review and meta-analysis While PRP reduced pain (VAS) in the early postoperative period, the improvement was not clinically significant.

Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial found that despite better structural healing in the PRP group, there was no clinically significant difference in outcomes between groups.

Cost: Approximate per-procedure expense of PRP:  preparation kits: $600 per case; 15 min additional OR time for preparation ($600), processing equipment ($3,000-15,000). The Cost-Effectiveness of Using Platelet-Rich Plasma During Rotator Cuff Repair: A Markov Model Analysis This cost-utility analysis shows that, currently, the use of PRP to augment rotator cuff repair is not cost-effective.

Scaffold and Patch Augmentation

The clinical adoption of these technologies raises questions about their actual effectiveness in improving patient outcomes, their cost-effectiveness in real-world practice, and their safety profile. 

A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair found the change in ASES, Constant, and UCLA scores were not clinically signficantly better (did not exceed MCID) for the matrix augmentation group than for the controls.

A pilot randomised controlled trial assessing standard versus dermal patch-augmented rotator cuff repair found no adverse effects and suggest future trials need a minimum of 150 patient Among 40 patients randomized to augmented repair versus standard repair there was no difference between groups with respect to clinical outcomes.

Clinical and anatomical outcomes of arthroscopic repair of large rotator cuff tears with allograft patch augmentation: a prospective, single-blinded, randomized controlled trial with a long-term follow-up This prospective, single-blinded RCT compared arthroscopic repair of large rotator cuff tears with vs. without allograft dermal patch augmentation at mean 7.3-year follow-up. Clinical outcomes (Patch vs. Control at final follow-up): VAS pain: 1.3 vs. 1.5 (difference 0.2 - clinically insignificant) ASES: 87.9 vs. 86.1 (difference 1.8 points - well below MCID of 6.4) Constant: 82.6 vs. 79.5 (difference 3.1 points - well below MCID of 10.4)UCLA: 32.0 vs. 31.0 (difference 1.0 point - below MCID) SST: 10.2 vs. 9.6 (difference 0.6 - below MCID of ~2 points). None of these differences were clinically significant.

Outcome of Large to Massive Rotator Cuff Tears Repaired With and Without Extracellular Matrix Augmentation: A Prospective Comparative Study Uniquely, this study showed a clinically significant difference in ASES score with matrix augmentation.

Cost: Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears Average cost of treatment $32,213 without Regeneten, $54,459 with Regeneten (additional cost 69%). The authors did not assess patient reported outcomes or revision rates for patients without or with the patch. While using "healing" as the study endpoint, the authors point out that there is lack of agreement on what constitutes healing or re-tearing after a cuff repair based on magnetic resonance imaging, ultrasound, or arthrogram. Evidence was not presented that "healing" by imaging correlated with better clinical outcomes .

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy. Average cost of treatment €4650 without Regeneten, €7828 with Regeneten (additional cost 68%). Study limitations the same as those for the report above.

Complications: 

Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial found that postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the Regeneten patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group. All 6 reoperations in the patch group were performed to address stiffness. The authors concluded that patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required. 

Subacromial-Subdeltoid Bursitis With Rice Bodies After Rotator Cuff Repair With a Collagen Scaffold Implant: A Case Report. reported a case of subacromial-subdeltoid bursitis with rice bodies after rotator cuff repair with a Smith + Nephew REGENETEN bovine-derived bioinductive collagen scaffold implant. After debridement, the patient recovered well and made a full return to work and recreational activities.

Revision arthroscopic surgery after rotator cuff repair with a collagen graft: histologic evaluation of biopsy specimens from two patients. Patients undergoing collagen scaffold augmentation should be warned of the possibility of reactive bursitis. Cases of reactive bursitis may need to be managed with surgical débridement to treat symptoms and structural failure and to rule out infection. 

Restore orthobiologic implant: not recommended for augmentation of rotator cuff repairs  Years after surgical repair of large rotator cuff defects supplemented with a xenograft, patients had persisting deficits and no recognizable benefit as compared with the results in a control group. In view of these findings, together with the unsatisfactorily high proportion of patients with a severe inflammatory reaction to the xenograft, the authors do not recommend use of the Restore Orthobiologic Implant.

Subacromial-Subdeltoid Bursitis With Rice Bodies After Rotator Cuff Repair With a Collagen Scaffold Implant: A Case Report This case demonstrates persistent pain, swelling and decreased range of motion for several months after rotator cuff repair with the use of a collagen implant

Severe subacromial-subdeltoid inflammation with rice bodies associated with implantation of a bio-inductive collagen scaffold afterrotator cuff repair  The potential for an acute, significant painful phase in a patient’s recovery should be part of the informed-consent process when using the Regeneten implant.

These findings suggest that reactive bursitis may be an under-recognized complication of biological patch augmentation, potentially contributing to the increased stiffness rates observed in larger series. What makes these complication rates concerning is their infrequency in control groups. In the propensity-matched study, zero patients in the standard repair group required reoperation, while 19% of patch-augmented patients did experience this novel category of complications associated with the augmentation material itself.

Conclusions:

(1) Age-relared rotator cuff failure is common and very often minimally symptomatic.

(2) Physical therapy can be cost-effective in improving comfort and function for the majority of patients with these tears.

(3) Non-repair surgery (smooth and move/debridement) can be cost-effective for patients with retained active elevation

(4) Surgical repair can be cost-effective when there is adequate quantity and quality of cuff tendon.

(5) PRP and "biologic" patches have not been shown to be cost-effective in improving patient reported outcomes. Sponsored 'cost-effectiveness' studies measuring surrogate endpoints (e.g. healing by imaging) rather than patient-centered outcomes may be misleading by not considering patient outcomes and complications.

Looking the problem in the eye.

Red-faced Warbler

Tucson

Spring 2020

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)

Shoulder rehabilitation exercises (see this link). 

Treating shoulder arthritis without surgery - non-operative management

Arthritis is a chronic condition - there is usually no rush in pursuing a surgical approach. The quality of life of a person with shoulder arthritis can often be improved by optimizing the person's overall health:
  1. regular aerobic exercise for an hour a day (walking, running, cycling, treadmill, stationary cycling, elliptical, swimming, etc).
  2. stopping smoking and alcohol consumption
  3. eliminating narcotic and sleeping medications
  4. healthy diet
  5. positive social interactions (dancing, volunteer work, church)
  6. getting outdoors (hiking, fishing)
  7. keeping the BMI under 25

In addition to these general health measures, there are some shoulder-specific therapies

A. Exercises
   1. Range of motion - In that stiffness is a prominent feature of arthritis, gentle range of motion exercises may be helpful in improving comfort and function. Each stretch needs to be held with gentle pressure for a full two minutes while the patient focuses on relaxation. How to stretch and how not to stretch
      a. Flexion
         i. Supine stretch
         ii. Pulley
         iii. Forward lean
      b. External rotation
      c. Cross body adduction
      d. Internal rotation
         i. Sleeper stretch
         ii. Up the back

2. Strengthening exercises – In that weakness from disuse may compromise the comfort and function of the shoulder, gentle progressive strengthening exercises may be helpful as long as they do not cause increased discomfort. A useful guideline is the ‘rule of 20’ i.e. exercises are likely to be helpful if they can be repeated comfortably for 20 repetitions. This performance level should be achieved before advancing the resistance of the exercises.
         i. Supine press
         ii. Latissimus pull
         iii. Rowing

B. Medications –Acetaminophen and non-steroidal anti-inflammatory medications may offer some symptomatic relief. However, these medications can have serious side-effects and patients need to be advised to follow the manufacturer’s dosing instructions on the bottle and to be made aware of potential hepatic, renal, marrow, cardiac and gastrointestinal complications. Here's a post about drugs for arthritis. Here are two posts about non-steroidal antiinflammatory medications (NSAIDS1)(NSAIDS2).

C. Injections
         i. Steroids + local anesthetic – these injections may be used to achieve temporary relief of symptoms. In some studies these injections have not been more effective than injection with saline alone. Repeated injection may damage cartilage and rotator cuff tendons.
         ii. Hyaluronic acid – while there have been some reports that these injections provide substantial relief; most data suggest they are no more effective than saline.

D. Arthroscopy
         Arthroscopy may be helpful in the management of early arthritis. See also here.
     
For more on things to be considered in the management of arthritis, click on this link.

When is the right time for shoulder joint replacement arthroplasty? Click on this link.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link)

Scapular spine and acromial fractures after reverse total shoulder - which ones might best be left alone?

Nonoperative Treatment of Acromial Fractures Following Reverse Shoulder Arthroplasty: Clinical and Radiographic Outcomes

These authors reported on clinical and radiographic outcomes of nonoperative treatment of acromial and scapular spine fractures (ASF) after reverse total shoulder arthroplasty. 

44 patients diagnosed with ASF following RSA were matched 1:3 to a control group based upon gender, age, and preoperative function. 

ASF were identified at a median of 2 months and were followed for a median of 37 months. All ASF patients were treated nonoperatively.

Overall, patients with ASF had inferior clinical outcomes with a higher rate of dissatisfaction when compared to controls. 

Lateral fracture subtypes (I and IIA) were similar to controls and had little impact on outcomes. 

Medial fracture subtypes (Type-IIB, IIC, and III) demonstrated inferior outcomes when compared to controls, with Type-III fracture patients demonstrating no improvement from baseline. 

The overall non-union rate was 61.4%, with high rates of scapular rotation and osteolysis in medial fracture subtypes. Nonunion was associated with a higher incidence of secondary radiographic findings, including scapular rotation, progressive notching, and osteolysis.

The authors concluded that fractures which occur at or medial to the glenoid face demonstrated high rates of unsatisfactory results and worse clinical outcomes as well as increased rates of scapular tilt, progressive scapular notching and osteolysis

Comment: For good reason, there has been substantial interest in the prevention, diagnosis and treatment of acromial and spine fractures after reverse total shoulder arthroplasty. It seems that the symptoms from these fractures are related both to the location of the fracture and the amount of displacement.

Here's a case: a middle aged man had a reverse total shoulder after multiple failed cuff repairs of the left shoulder. At the six week checkup, all was well clinically and radiographically.

He started gentle assisted flexion exercises. Two days after the office visit while reaching up he had sudden pain in the shoulder and heard a 'crack'. He returned to the office at which time tenderness was noted at the posterior acromion. The AP view was not remarkable.

However, the axillary view showed a non-displaced crack in the acromion.

This case reveals the potential of fracture of an acromion that is not used to being loaded.

Here's another case:
An 85 year old lady presented with severe cuff tear arthropathy as shown below.

She had a reverse total shoulder in early 2012. Two years after surgery she had excellent comfort and function. An axillary x-ray at that point is shown below.

Three and a half years after her procedure she developed the atraumatic onset of posterior shoulder pain. Her axillary x-ray shows a fatigue fracture of the scapular spine (to the left of the red line).

These minimally displaced fractures healed with non operative management.

Research is ongoing to determine the effect of prosthesis type and position that influence the risk of these fractures.

However, the type of patient at greatest risk is becoming clearer:

Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study

These authors investigated the incidence of acromial stress fractures (ASFs) after reverse total shoulder and and sought to identify preoperative patient characteristics associated with their occurrence.

They identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). 

Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex, rheumatoid arthritis, osteoporosis, a diagnosis of degenerative joint disease with rotator cuff tear, and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05).

This is an interesting study, although the followup time is short. Many acromial fractures occur more than 3 months after surgery.

The article below dives a bit deeper into the local changes in scapular bone density associated with age and sex.

Changes in Scapular Bone Density Vary by Region and are Associated with Age and Sex

They studied 97 three-dimensional models of the scapula that were segmented from routine clinical computed tomography (CT) scans, and obtained detailed calibrated bone density measurements for each bone model. The effects of age and sex on cortical and trabecular bone density were assessed for the entire scapula.

They found that cortical bone loss averaged to 1.0 mg/cc and 0.3 mg/cc per year. 

Trabecular bone loss was 1.6 mg/cc and 1.2 mg/cc for female and males respectively. 

Areas that were significantly affected by age included the acromion, the scapular spine, the base of the coracoid, the inferior glenoid neck as well as the glenoid vault. 

Areas that were significantly affected by sex were the scapular spine and body. These findings are consistent with the risk factors for acromial and scapular spine fractures after reverse total shoulder.

Here are some other links relating to acromial and scapular spine fractures after reverse total shoulder: link 1, link 2, link 3, link 4, link 5 and this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Rotator cuff tears - repair versus non-operative treatment

Rotator cuff repair versus nonoperative treatment: a systematic review with metaanalysis

These authors conducted a systematic review to analyze randomized controlled trials (RCTs) comparing rotator cuff repair to non-operative treatment for patients with any type of RC tear.

Six RCTs met the inclusion criteria. 

At 6 months, pooled results showed improvement in favor of the repair group with respect to the Constant score (mean difference 1.26 [CI 95% -2.34 to 4.85, p=0.49) and pain perception  (0.59 [95% CI -0.84 to -0.33, p< 0.00001).

At 12 months pooled results showed improvement in favor of the repair group with respect to the Constant score (mean difference 5.25 [CI 22 95% 1.55 to 8.95, p= 0.005) and pain perception(mean difference -0.41 [CI 95% -0.70 to -0.12,  p=0.006]).

At 24 months pooled results showed improvement in favor of the repair group with respect to the Constant score  (mean difference 5.57 [CI 95% 1.86 to 9.29 p= 0.003] and for pain perception (mean difference -0.92 [CI 95% -1.31 to -0.52 p<0.00001]).

However, these differences did not reach the minimum clinically important difference for the Constant score (10.4) or the VAS pain score (2.17). 

The certainty of evidence ranged from low to moderate due to imprecision in the studies included. The authors question whether these statistically significant effects are clinically significant.

The authors concluded that this systematic review with meta-analysis on repair versus conservative treatment for patients with rotator cuff tears showed statistically, but not clinically, meaningful difference between repair and conservative treatment in terms of improvement in pain and Constant score.

Comment: These findings can be compared to the 2019 Evidence Based Practice Guidelines from the American Academy of Orthpaedic Surgeons 

In which there are two strong recommendations:

and a moderate recommendation:

Rotator cuff failure is the most commonly treated shoulder disorder. More data are needed directly comparing the outcomes of operative and non-operative management for different types of cuff defects in different types of patients.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Does the patient over the age of 55 benefit from attempting a repair of small atraumatic cuff tears?

OPERATIVE VS. CONSERVATIVE TREATMENT OF SMALL NON-TRAUMATIC SUPRASPINATUS TEARS IN PATIENTS OVER 55 YEARS: OVER 5-YEAR FOLLOW-UP OF A RANDOMIZED CONTROLLED TRIAL

A previous post (see this link) discussed the management of traumatic rotator cuff tears in individuals with an average age of 60 years. By contrast this study discusses the management of atraumatic rotator cuff tears in individuals with an average age of 71.

180 shoulders with symptomatic, non-traumatic supraspinatus tears were randomly assigned to one of the three treatment groups: physiotherapy (Group 1), acromioplasty and physiotherapy (Group 2) and rotator cuff repair,  acromioplasty and physiotherapy (Group 3). 

150 shoulders (mean age 71) were available for analysis after a mean follow-up of 6.2 years. 

The mean sagittal tear size of the supraspinatus tendon tear was at baseline 10 mm in all groups.

Eight shoulders in Group 1 and two shoulders in Group 2 crossed over to rotator cuff repair during the follow-up. 

There were no significant differences in the mean change of the Constant score.

There were also no statistically significant differences in the change of visual analog scale for pain and patient satisfaction. 

Preoperatively there was no or mild radiographic evidence of osteoarthritis  At follow-up moderate or severe osteoarthritis was detected in 7 (19%), 14 (40%), and 13 (35%) shoulders in Groups 1, 2, and 3 respectively (p=0.124). Despite non-significant between group differences, there was a statistically significant mean progression in the grading of osteoarthritis from baseline to follow-up in the overall study group.

From this study, the authors concluded that 

(1) operative treatment was not better than non-operative treatment of small non-traumatic single tendon supraspinatus tears in patients over 55 years of age. 

(2) operative treatment did not protect against degeneration of the glenohumeral joint or cuff tear arthropathy. 

(3) non-operative treatment is a reasonable option for the primary initial treatment for these tears.

Readers may be interested in a recent Cochrane analysis, Does repair of torn rotator cuff tendons work?, that concluded, "As compared with non-operative treatment, moderate-certainty evidence (downgraded due to risk of bias) indicates that surgery (rotator cuff repair with or without subacromial decompression) probably provides little or no benefit in pain and low-certainty evidence indicates that it may provide little or no improvement in function, participant-rated global treatment success or overall quality of life (downgraded due to bias and imprecision) in people with rotator cuff tears." The AAOS practice guidelines for the management of cuff tears can be found at this link.

Comment: Rotator cuff repair is a surgical procedure that can be associated with increased costs,  substantial postoperative discomfort and a prolonged "down time" to protect the repair during the time of anticipated healing. In this light, surgical repair should be reserved for cases in which the procedure offers a definite benefit to the patient in comparison to non-operative treatment.

An example of "right sizing" treatment is shown in the case below of a degenerative supraspinatus cuff tear.

With a simple stretching and strengthening rehabilitation program (see this link), durable full, comfortable function was achieved.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).