Tuesday, February 25, 2014

Rotator cuff repair - does it matter if it works?

Structural Integrity After Rotator Cuff Repair Does Not Correlate with Patient Function and Pain: A Meta-Analysis

This article comes to a conclusion similar to that of an article by Doug Harryman published two decades ago and discussed in previous posts, such as this one. Other similar posts on the discordance between clinical outcome and retear can be found here.

The authors conducted a systematic review and a meta-analysis of studies that compared the clinical outcome with the structural integrity of the repair. 

They found only 14 studies that met their inclusion criteria. Of 861 patients in the included studies, 187 (>20%)  had failure of healing or retear of the rotator cuff repair. The size of the repaired cuff tear did not appear to affect the rate of retearing. 

Clinical outcome (as reflected by the University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score  and the visual analog scale score) were improved whether the repair was intact or not.

The authors concluded that " The results of this meta-analysis demonstrate that the structural integrity
does not correlate with a clinically important difference in patient function and pain relief after rotator cuff repair." and " data from this meta-analysis demonstrated that, on the basis of validated shoulder outcome measures after rotator cuff repair, no difference exists in patient pain or function regardless of the structural integrity of the repair."

Comment: It is of interest that the average patient in this series was relatively young (58.5 years) and the average tear size was relatively small (2.68 cm). Thus one might expect that the post operative retear rates would be greater in older patients with larger tears. The minimum time from repair to postoperative imaging was 6 months; it seems likely that the retear rate would increase with time after repair. Thus the rates of retear may be underestimated.

This paper presented the results in terms of the scores and strength after surgery. Patients have surgery to improve their comfort and function; thus would have been more informative to see the results expressed as the amount of improvement in function and strength in the intact and retorn shoulders. In this way one can include the preoperative as well as the postoperative status so that the benefit of treatment is apparent, assuring that those patients with better scores after treatment did not have better scores before treatment. For measuring improvement, we prefer to assess the amount of improvement as a percent of the maximal possible improvement or the  IMPI as shown here.

The observation, made repeatedly by many authors, that shoulders with cuff tears are improved whether or not a surgical repair attempt is successful makes us question the value of rotator cuff repair surgery and prolonged restricted activity after repair in larger chronic cuff tears. When a durable repair seems unlikely we consider a smooth and move surgery that avoids the prolonged postoperative protection required after a cuff repair.

It also makes one wonder about the assumptions that went in to the paper concluding that across the board rotator cuff repairs save the country money.

Finally, in view of these results it is apparent that studies comparing methods of cuff repair need to be done very carefully in order to determine the value of one technique in comparison to another.

In this context, readers will be interested in this recent randomized study comparing non-operative management, acromioplasty and cuff repair in the treatment of non-traumatic cuff tears.

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