The 2020 American Academy of Orthopaedic Surgeons Orthoguidelines on the Management of Rotator Cuff Injuries (see this link) provides the AAOS-suggested appropriate use criteria for the diagnosis and management of cuff disorder along with an assessment of the strength of data supporting each recommendation. The link to the complete "Management of Rotator Cuff Injuries Evidence-Based Clinical Practice Guidelines" can be found here. Against that background, some recent publications are of interest.
Natural History of Cuff Failure
The great majority of cuff failures are degenerative, rather than traumatic in nature; biologic rather than mechanical.
The authors of Evaluation of survivorship of asymptomatic degenerative rotator cuff tears in patients 65 years and younger: a prospective analysis with long-term follow-up described the natural history of untreated asymptomatic degenerative rotator cuff tears. At a median followup of seven years, 60% of 229 patients ((mean age 57.1 years) demonstrated enlargement of the cuff defect. Full-thickness tears were at greater risk for enlargement compared with partial-thickness tears and had earlier tear progression. Tears in the dominant shoulder were associated with greater enlargement, but patient age and sex were not. The 2-, 5-, and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42%, and 20%, respectively. Pain development was associated with tear enlargement and was more common in full-thickness tears. Tear enlargement and the integrity of the anterior cable were significantly associated with progression of muscle fatty degeneration.
While this study helps identify shoulders at risk for progression of a rotator cuff defect, it is not clear whether it helps refine the indications for surgical intervention and whether surgery alters the natural history of the condition.
The article states: "We believe the asymptomatic tear is an ideal cohort to study tear progression as there is no need for treatment interventions, which may alter the natural history of the disease." and "When considering surgical indications, full thickness rotator cuff tears with either a recent enlargement event, with disruption of the anterior rotator cable, or that are >20-25 mm in size possess a different natural history than stable, smaller degenerative tears."
This information needs to be considered in light of the recent Cochrane review of Surgery for Rotator Cuff Tears that found "no clinically important benefit to surgery in the treatment of symptomatic, atraumatic rotator cuff tears. This is at odds with common surgical practice, and we need to take this difference seriously. This does not mean that surgery is always ineffective; rather, it suggests that we need to refine our indications to see whether there are certain subpopulations in whom surgery is more effective. For instance, the studies included in this Cochrane review focused largely on atraumatic rotator cuff tears in older patients, and the recommendations of this review do not pertain to acute tears in younger patients."
Postoperative management
Most surgeons use immobilization for 4-6 weeks after cuff repair. Theoretically, immobilization in abduction reduces tension on the repair.
In practice, however, abduction braces are uncomfortable and difficult for the patient to manage while sleeping, bathing and dressing. A recent study, Effectiveness of abduction brace versus simple sling rehabilitation following rotator cuff repair: systematic review and meta-analyses found that wearing abduction braces after rotator cuff repair neither improved the Constant score, VAS, and WORC scores, and ROM of the shoulder joint, nor did it reduce the risk of re-tearing. A simple sling may be a better option in terms of cost effectiveness.
Risk of retear after rotator cuff repair.
Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning reported a retrospective case-control study of 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. The authors included the analysis the classification of the tendon stump MRI signal intensity relative to that of the deltoid.
The rates of the different factors in the re-tear and non re-tear groups are shown below. Diabetes, stump type 3, large/massive tears, and grades 3 and 4 fatty degeneration were prominent features in the 15% of the repairs that failed.
Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning reported a retrospective case-control study of 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. The authors included the analysis the classification of the tendon stump MRI signal intensity relative to that of the deltoid.
Frequency of characteristics in the re-tear and no re-tear groups
Frequency of failure in patients with different characteristics
These data may help surgeons and patients consider the indications for rotator cuff repair on a case by case basis.
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
