Sunday, January 19, 2014

Structural failure of 33% of 212 arthroscopic repairs of full thickness rotator cuff tears - half of which had 'successful' outcomes

Factors Affecting Outcome After Structural Failure of Repaired Rotator Cuff Tears

Recognizing the high rate of retear after cuff repair, these authors retrospectively studied factors associated with clinical outcome in patients with known failure of cuff repair. The preoperative size of tear and type of repair were not presented. 33 patients (54%) had American Shoulder and Elbow Surgeons scores of 80 points or more and were deemed to have had 'successful' outcomes.

Interestingly, 15 (54%) of the patients with unsuccessful outcomes reported a labor-intensive occupation compared with only two patients in the successful group. In addition to occupation, a low preoperative simple shoulder test score was associated with an unsuccessful clinical outcome.

Age and other demographic variables, including sex, dominant-sided surgery, and medical comorbidities, were similar for the successful and unsuccessful groups.

Comment: This is a well done study. It brings to light several questions:  (1) How many of these patients had 'retears' and how many had 'unhealed' repairs? (2) Why did half of these patients get better even though the surgery failed to reestablish cuff integrity (even those in the clinically unsuccessful group had on average improved clinical scores)? (3) What is the appropriate management of a cuff tear in a patient with a labor-intensive occupation and a low simple shoulder test score? (4) If this same definition of 'successful' clinical outcome were applied to patients with intact repairs, what percent would be found to have achieved the threshold of 80 or more points on the ASES scale? (5) Why was the preoperative simple shoulder test a better predictor than the preoperative ASES score? (6) How is it that the postoperative retear size was not different between the successful and unsuccessful groups?

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.

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