Monday, January 20, 2014

"Patients treated with rotator cuff repair do well regardless of the integrity of the repair" - what does this tell us?

Factors Affecting Satisfaction and Shoulder Function in Patients with a Recurrent Rotator Cuff Tear

The authors of this article open with the statement that "It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair." This statement again makes us question whether the anatomic success of cuff repair is important to the quality of the clinical outcome.  The purpose of this cross-sectional study was to reexamine this concept and identify the factors affecting the outcomes of patients with a recurrent tear. This study is similar to that which was the subject of yesterday's post.

Reestablishing cuff integrity is challenging. As pointed out in a prior post (which includes a Robert Frost poem), we have to thank the late Doug Harryman for first showing that cuff repair integrity was not essential to a good outcome from cuff repair surgery and showing us that it may not be in the best interest of the patient to perform a cuff repair and implement a prolonged period of restricted activity to protect the repair unless the conditions are optimal for healing of the repair. "When to repair and when to do a smooth and move?", that is the question.

The authors reviewed 180 patients who had cuff repair from 2007 to 2011 who met inclusion criteria among which there were 47 (26%) patients with full thickness retear. Functional outcomes were poorer for those having full thickness retears, but not those having attenuated or partial thickness defects. In patients with retears, clinical outcomes were better in patients over 65 years of age, whereas age did not significantly correlate with the clinical outcome in the patients with no retear.

Patient factors had a strong influence on the clinical outcomes in the patients with retears. Multiple regression analysis of the retear group showed that
(1) lower education level and a Workers’ Compensation claim were independent predictors of a poorer satisfaction score;
(2) lower education level, younger age, and a Workers’ Compensation claim were independent predictors of a poorer ASES score; and
(3) lower education level was an independent predictor of a poorer SST score
Furthermore, those patients who had retired for reasons other than illness demonstrated better clinical outcomes than those who were unemployed or disabled.

When we discuss the 4 Ps that influence the outcome of treatment (problem, patient, physician, and procedure), age, Workers' Compensation and lower education levels are great examples of the 'patient' factors that are known to influence the clinical outcome of treatment. It is desirable to include each of the 4 Ps in studies of clinical outcome (e.g. did the size of the tear or the type of repair affect clinical outcome in this series?). It would have been really interesting if the authors had performed a multiple regression analysis to determine how important cuff integrity was to the clinical outcome so that we could be sure that poor outcomes were not related to lower education level, Workers' Compensation claim and young age rather than to retear.

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