Friday, April 25, 2014

Rotator cuff repair - retears and clinical outcomes

Rotator Cuff Repair Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome

Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual. These authors sought to identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.

They identified 2383 articles on rotator cuff repairs published between 1980 and 2012. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. From these articles they extracted data relating to the patients, their shoulders, the procedures, and the results.

One of the most interesting findings in this paper is that while the number of articles meeting the inclusion criteria per year increased ten fold from the 1990s to 2012, the retear rates and clinical outcomes did not change significantly over this time interval.

The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery - an annualized failure rate of over 13% per year. Retears were associated with more fatty infiltration, larger tear size, and advanced age.

Clinical improvement averaged 72% of the maximum possible improvement.

Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff.

Unfortunately, the inconsistent and incomplete data in the published articles limited the opportunity to conduct a meta-analysis of the influence of factors such as repair technique on the clinical outcome of rotator cuff repair.

The authors concluded that in spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. They suggest that in order to accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must make available the important data relating to each patient’s condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function. These data, will, in turn, enable meaningful meta-analyses of the influence of the details of the cuff pathology (size, chronicity, nature of injury), patient factors (age, gender, co-morbidities) and repair and rehabilitation approaches on the clinical and anatomic outcome. of cuff repair surgery.

This paper again surfaces the question of why anatomically unsuccessful cuff repairs can be associated with clinical improvement after surgery. In that retears were associated with more fatty infiltration, larger tear size, and advanced age, patients with these characteristics may want to consider non-repair options for managing their cuff tears.



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