Wednesday, January 8, 2014

Is surgery better than non-operative treatment for non-traumatic rotator cuff tears?

Treatment of non-traumatic rotator cuff tears

This article was pointed out to us by one of our readers - thanks!

It is an extremely well done bit of clinical research.

The authors compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age.

Inclusion criteria: 
 Age > 55 years
 Atraumatic symptomatic supraspinatus tendon tear comprising < 75% of the tendon insertion and documented with MRI
 Full range of motion of the shoulder
 Written informed consent

Exclusion criteria 
 Age < 55 years
 History of trauma relating to the onset of symptoms
 A massive tendon tear involving the whole supraspinatus tendon and/or combined tear of two to three tendons
 Stiffness of the glenohumeral joint (passive external rotation < 30° ± elevation < 120°)
 Glenohumeral osteoarthritis with present osteophytes in radiographs
 Systemic corticosteroid or antimetabolite medication
 Significant malignant, hematological, endocrine, metabolic, rheumatoid or gastrointestinal disease
 History of alcoholism, drug abuse, psychological or other emotional problems that are likely to invalidate informed consent
 Previous surgery of same shoulder
 Patient refusal

They randomized 180 shoulders with supraspinatus tendon tears into one of three equal sized groups: physical therapy, acromioplasty and physiotherapy, and rotator cuff repair, acromioplasty and physiotherapy. The outcomes were analyzed by intention to treat. There were no significant differences in the patient or cuff characteristics of those assigned to the three groups.

An independent observer found no between-group differences in the Constant score at final follow-up or in the mean change in the Constant score. They concluded that at one-year follow-up, operative treatment was no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition. It is of interest that at 3 months, the rotator cuff repair group had lower constant scores than the other two groups.

The cost of each unit improvement in the Costant Score was 142 € in the PT group, 271 € in the acromioplasty and PT group and 288 € in the cuff repair and acromioplasty and PT group.

Patient satisfaction at one year of follow-up was 87% in the PT group, 96% in the acromioplasty and PT group, and 95% in the cuff repair and acromioplasty and PT group.


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