Saturday, October 29, 2011

Rotator cuff papers at the 2011 closed meeting of the ASES - do cuff repairs work?

Two papers caught my attention:

MacDonald et al conducted a randomized control trial comparing single row with double row fixation in arthroscopic rotator cuff repair. The outcome was evaluated in terms of clinical scoring as well as healing assessment by MRI or ultrasound. While both groups were improved from their pre-surgical status, there was no significant difference in the outcome scores. Interestingly, the rotator cuff imaging showed that between 23 and 35% of the repairs were not intact at 2 years after surgery.

McCarron et al did a most interesting study where they used the 'suture bridge' technique for cuff repair, a method that has been reported to be associated with a high rate of failure. The authors placed metal markers (1.6 mm tantalum beads) placed 2 centimeters medial to the lateral edge of the tendon. CT scans were obtained on the day of surgery and at four intervals up to 1 year after surgery as were ultrasound examinations of the cuff. They found that the tendon edge pulled away from the repair site by an average of 1.6 centimeters over the first 26 weeks after repair, even though ultrasound showed recurrent defects in only 2 of the 13 shoulders. Clinical outcome scores were improved for these shoulders in spite of the failure of the repair to remain fast to the bone.

These two studies again bring into question the degree to which arthroscopic rotator cuff repair can anatomically restore the attachment of the rotator cuff tendon to bone. As originally pointed out by my late partner, Doug Harryman, clinical improvement commonly occurs after rotator cuff surgery even if the repair of tendon to bone is not successful. This is why we consider a 'smooth and move' procedure when conditions are not optimal for cuff healing, thereby avoiding the need to protect a repair after surgery.


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