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
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). 

Rotator cuff tears and tendinopathy - Is platelet rich plasma (PRP) helpful? Read this important updated version.

A review of published randomized trials and meta-analyses indicates that non-operative treatment is effective for the majority of patients with conditions of the rotator cuff, including rotator cuff tears.

Local corticosteroid injections are sometimes used in non-operative treatment, however they apparently have no biologic effect in terms of regenerating or reversing the degenerative changes occurring in rotator cuff tendons and their clinical benefit usually wears off quickly.

It has been suggested that local injection of platelet-rich plasma (PRP) may promote stem and progenitor cell proliferation, modulate inflammatory responses, stimulate angiogenesis, enhance the proliferation of tenocytes, stimulate the production of extracellular matrix proteins, protect against oxidative stress, and inhibit inflammation (see Platelet-Rich Plasma in Orthopaedic Surgery: A Critical Analysis Review) and that these effects may benefit patients with rotator cuff tendinopathies before structural failure of the rotator cuff occurs. 

 The authors of Subacromial injection of platelet-rich plasma provides greater improvement in pain and functional outcomes compared to corticosteroids at 1-year follow-up: a double-blinded randomized controlled trial attempted to answer this question in a randomized clinical trial of patients between 18 and 50 years old (mean age 28 years) who had both a clinical and magnetic resonance imaging diagnosis of supraspinatus tendinopathy refractory to conservative treatment. 

A total of 50 patients received a single subacromial injection of PRP, whereas 50 patients received a single subacromial corticosteroid injection. All the patients completed 12 months of clinical follow-up. 

At 12 months, in comparison to the those receiving cortisone, patients in the PRP group showed a significantly greater improvement in 

the VAS score: 1.68 vs. 2.3

the American Shoulder and Elbow Surgeons (ASES) score, 89.8  vs. 78.0 

the Single Assessment Numeric Evaluation (SANE) score, 89.2 vs. 80.5 

and the the Pittsburgh Sleep Quality Index (PSQI) score, 2.72 vs. 4.02 

The overall failure rate was significantly higher in the corticosteroid group (30%) than in the PRP group (12%) (P < .01).

It was particularly interesting to note that the difference in the course of the two groups was not evident until 6 months after the injection. As Michael Pearl pointed out, it is possible that the PRP folks would have gotten better anyway (i.e. the PRP may not have had an effect). We'd need a saline injected control arm to examine that possibility.

It does seem that the corticosteroid injected group tended to do less well with time and their greater failure rate may be related to the adverse effects of cortisone on tendons. As Dr Pearl says "An alternative explanation could be that cortisone is deleterious and the PRP less interfered with the natural history.  " 

It is notable that the ASES score difference between 3 and 12 months (85 to 90) does not exceed the minimal clinically important difference for ASES of 15. 

Comment: This double blinded randomized clinical trial showed that young patients with rotator cuff tendinosis having subacromial injection of PRP did better than comparable patients having subacromial injection of cortisone. It does not show that patients having subacromial injection of PRP would do better than those with no treatment or with a placebo control. Keep in mind that these patients had an average age of 28, folks who have a lot of potential for recovery with time and rehab.

A possible benefit of PRP in cuff tendinosis cannot be extrapolated to the treatment of cuff tendons with structural failure, as demonstrated by the authors of Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy who found that  improvement in the ASES score was significantly greater in the group without tears than in the group with partial cuff tears (PTRCTs) at all follow-up times. 94% of the patients in the isolated tendinopathy group but less than half of patients in the PTRCTs group achieved a substantial clinical benefit at 12 months follow-up. 

Furthermore, a review of published randomized controlled trials and meta-analyses failed to demonstrate a clinically significant benefit to the patient of the use of PRP in conjunction with surgical repair of a torn rotator cuff.

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/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

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). 

Risk factors for glenoid loosening and cuff tears after anatomic shoulder arthroplasty.

The authors of Risk Factors for Rotator Cuff Tears and Aseptic Glenoid Loosening After Anatomic Total Shoulder Arthroplasty reviewed the factors associated with increased risk of cuff tears and glenoid loosening at two years after anatomic total shoulder arthroplasty in 2,699 patients from an international multicenter study who received the Equinoxe platform implants. 

Postoperative cuff tears were reported in 2.5%; 1.3% had revision surgery because of a cuff tear. Patients were more likely to experience postoperative cuff tears if they had prior surgery on the affected side or were treated with a small glenoid component.

Aseptic glenoid loosening was reported in 4.0%; 3.4% had revision surgery because of glenoid loosening. Patients were more likely to experience glenoid loosening if they were ≤62 years of age at the time of surgery, treated with a small glenoid component, or treated with smooth pegged or keeled glenoid components (as opposed to hybrid glenoid components) 

Comment: a few thoughts about these risk factors

Patient factors:

(1) Patient age ≤62 years - this once more brings up the issue of "how do we choose the treatment of osteoarthritis in younger patients?".

(2) Prior surgery - the nature of the prior surgery is not reported. It seems likely that some of these prior surgeries may have been rotator cuff related, which could account for the observed increase in post-arthroplasty cuff tears.

Surgeon controlled factors:

(1) Small glenoid component - it is not clear whether the increased risk associated with the use of a small glenoid component is related to the size of the native glenoid, to less bony support of the component,  to lesser experience of the surgeon or to other factors.

(2) Non-ingrowth pegged or keeled glenoid components - many surgeons currently prefer glenoid components that provide the opportunity for bony ingrowth instead of smooth pegs or keels.

We've still got a lot to learn.

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

Follow on twitter: https://twitter.com/RickMatsen or 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).

Rotator cuff tears and their management - news and commentary

Rotator cuff failure is the most common disorder of the shoulder.

The 2020 American Academy of Orthopaedic Surgeons Orthoguidelines on the Management of Rotator Cuff Injuries (see this link) provides the AAOS-suggested appropriate use criteria for the diagnosis and management of cuff disorder along with an assessment of the strength of data supporting each recommendation. The link to the complete "Management of Rotator Cuff Injuries Evidence-Based Clinical Practice Guidelines" can be found here. Against that background, some recent publications are of interest.


Natural History of Cuff Failure

The great majority of cuff failures are degenerative, rather than traumatic in nature; biologic rather than mechanical.

The authors of Evaluation of survivorship of asymptomatic degenerative rotator cuff tears in patients 65 years and younger: a prospective analysis with long-term follow-up described the natural history of untreated asymptomatic degenerative rotator cuff tears. At a median followup of seven years, 60% of 229 patients ((mean age 57.1 years) demonstrated enlargement of the cuff defect. Full-thickness tears were at greater risk for enlargement compared with partial-thickness tears and had earlier tear progression. Tears in the dominant shoulder were associated with greater enlargement, but patient age and sex were not. The 2-, 5-, and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42%, and 20%, respectively. Pain development was associated with tear enlargement and was more common in full-thickness tears. Tear enlargement and the integrity of the anterior cable were significantly associated with progression of muscle fatty degeneration.

While this study helps identify shoulders at risk for progression of a rotator cuff defect, it is not clear whether it helps refine the indications for surgical intervention and whether surgery alters the natural history of the condition.

The article states: "We believe the asymptomatic tear is an ideal cohort to study tear progression as there is no need for treatment interventions, which may alter the natural history of the disease." and "When considering surgical indications, full thickness rotator cuff tears with either a recent enlargement event, with disruption of the anterior rotator cable, or that are >20-25 mm in size possess a different natural history than stable, smaller degenerative tears."

This information needs to be considered in light of the recent Cochrane review of Surgery for Rotator Cuff Tears that found "no clinically important benefit to surgery in the treatment of symptomatic, atraumatic rotator cuff tears. This is at odds with common surgical practice, and we need to take this difference seriously. This does not mean that surgery is always ineffective; rather, it suggests that we need to refine our indications to see whether there are certain subpopulations in whom surgery is more effective. For instance, the studies included in this Cochrane review focused largely on atraumatic rotator cuff tears in older patients, and the recommendations of this review do not pertain to acute tears in younger patients."


Postoperative management

Most surgeons use immobilization for 4-6 weeks after cuff repair. Theoretically, immobilization in abduction reduces tension on the repair. 

In practice, however, abduction braces are uncomfortable and difficult for the patient to manage while sleeping, bathing and dressing. A recent study, Effectiveness of abduction brace versus simple sling rehabilitation following rotator cuff repair: systematic review and meta-analyses found that wearing abduction braces after rotator cuff repair neither improved the Constant score, VAS, and WORC scores, and ROM of the shoulder joint, nor did it reduce the risk of re-tearing. A simple sling may be a better option in terms of cost effectiveness. 

Risk of retear after rotator cuff repair.

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning reported a retrospective case-control study of 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. The authors included the analysis the classification of the tendon stump MRI signal intensity relative to that of the deltoid.

The rates of the different factors in the re-tear and non re-tear groups are shown below. Diabetes, stump type 3, large/massive tears, and grades 3 and 4 fatty degeneration were prominent features in the 15% of the repairs that failed. 

Frequency of characteristics in the re-tear and no re-tear groups

Frequency of failure in patients with different characteristics

These data may help surgeons and patients consider the indications for rotator cuff repair on a case by case basis.

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).

Rotator cuff tears and repair - the basics

Rotator cuff lesions are the most common afflictions of the shoulder.

While some of these lesions result from acute injury to previously healthy cuff tendons, the great majority result from age related wear and degeneration. Often this degeneration occurs unnoticed by the patient - the shoulder progressively accommodates to the loss of normal tendon integrity resulting in an asymptomatic cuff tear.

Acute injury to a previously well-functioning shoulder deserves acute evaluation by radiographs and MRI. If an acute rotator cuff tear is identified, consideration is given to an expeditious rotator cuff repair with the goal of preventing further deterioration of the cuff tendon and muscle. 

Patients with chronic cuff defects often continue to function well because their shoulder adapts to the tendon degeneration. These patients are commonly unnoticed by the medical community (how would we know if a person without symptoms would have an abnormal rotator cuff?), but the available data suggest that most individuals over the age of 60 have rotator cuff lesions ranging from tendon thinning to massive full-thickness tears. Several scenarios may cause chronic cuff lesions to come to medical attention:

    1. They may become symptomatic by sudden extension of the tear, i.e. acute injury superimposed on chronic degeneration.

    2. Progressive loss of functioning tendon may result in noticeable weakness and/or pain.

As pointed out in a previous post (see this link), the patient's threshold for seeking medical evaluation can be influenced by factors such as depression, anxiety and on the job injury. 

Because chronic cuff tears are not acute, decisions regarding surgery are not urgent. There is time to try to improve the shoulder comfort and function through gentle progressive mobility and strengthening exercises as shown in this link. 

By definition, chronic, minimally traumatic cuff tears occur in tendons of inferior quality so that attempts at surgical repair are less likely to be as successful in contrast to the acute, traumatic tear. In considering the prospect of surgical repair, the surgeon and the patient should be aware of Harrison McLaughlin's admonition from 1951, "The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis". Thus the surgeon and the patient need to know the likelihood of a successful outcome before attempting a repair for a chronic rotator cuff defect. The best prognosis for a durable repair is for tendons with only small amounts of tendon retraction away from the normal attachment on the greater tuberosity as seen on an MRI (below left - moderate retraction, below right - severe retraction)

and with minimal degeneration of the quality of the cuff tendon and muscle as seen on the MRI. Cuff tendon degeneration and fatty degeneration of the cuff muscles are correlated with patient age, tear chronicity, and size of the cuff defect. 

The Goutallier classification is commonly used to characterize the status of the cuff muscles:

(a) Stage 0, no fatty deposits, (b) Stage 1, some fatty streaks, (c) Stage 2, more muscle than fat, (d) Stage 3, as much muscle as fat, (e) Stage 4, less muscle than fat.

A recent article, The Relationship between Preoperative Goutallier Stage and Retear Rates following Posterosuperior Rotator Cuff Repair: A Systematic Review,  points out the high percentage of retears after rotator cuff repair attempts. In a systematic review of articles on primary cuff repairs, they correlated the retear rate after cuff repair with the preoperative fatty degeneration of the supraspinatus and infraspinatus muscles as characterized by the Goutallier Stage.

In the plot of their data below, it can be seen that retears are common for all Goutallier stages, ranging from 20% to 100%. 

Thus an MRI can inform the patient and the surgeon about the degree of retraction and the quality of the tendon, both of which are predictive of the chance of a successful repair. If the tendon is retracted and of poor quality, the chances of failure of the repair are high. 

Patients with irreparable rotator cuff tears with retained active elevation above the horizontal may benefit from a smooth and move procedure (see this link).

Other options for the management of irreparable rotator cuff tears with severe weakness include tendon transfers (see this link) and reverse total shoulder arthroplasty (see this link)

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

To add this blog to your reading list in Google Chrome, click on the reading list icon

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).