Does it matter to the patient whether a rotator cuff repair heals or not?

A bit of context.

In large part, rotator cuff tears are a consequence of aging, increasing in prevalence in older individuals. A high percentage of these tears are asymptomatic (link, link, link). Some studies comparing non-operative and surgical treatment of cuff tears have found similar outcomes for each (link, link, link).

In 1962 McLaughlin wrote about the rotator cuff: “In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle-age it has worn thin and often becomes so weak and brittle that it ruptures with ease”. On surgical management, he added “The wise surgeon, realising that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis”. 

Primary Cuff Repairs

Surgeons in the United States perform over 400,000 rotator cuff repair surgeries annually, with each procedure costing between $8,400 and $56,200.  Thus the total annual expenditure on rotator cuff repair surgeries in the U.S. ranges from approximately $3.36 billion to $22.48 billion. It is important to note that these figures represent direct surgical costs and do not account for additional expenses such as preoperative evaluations, postoperative rehabilitation, or potential costs associated with surgical complications. Therefore, the overall economic impact of rotator cuff injuries and their treatment is likely higher. The rate of rotator cuff repairs per 100,000 citizens is increasing steadily (link, link, link). Rotator cuff repair remains the most commonly performed shoulder surgery.

As pointed out in Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome,  innovations in surgical technique, instrumentation, augmentation or biologics do not appear to be leading to improved clinical outcomes perceived by the patient.

New, more expensive innovations for cuff repair are being used; for some of these there is questionable evidence of improved benefit/cost.

Editorial Commentary: Bioinductive Collagen Implants Reduce Rotator Cuff Retear, yet Cost-Effectiveness and Improvement in Clinical Outcomes Are Unclear"Unfortunately, retear rates do not appear to have improved significantly since the 1980s, despite advances in surgical technology and the biomechanics of repair."

No Short-term Clinical Benefit to Bovine Collagen Implant Augmentation in Primary Rotator Cuff Repair: A Matched Retrospective Study

Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis "The facility cost of subacromial balloon spacer was significantly higher than that of partial cuff repair"

Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis "The largest cost drivers of aRCR are the use of biologic adjuncts, augments, the use of multiple suture anchors, and certain anchor brands."

Arthroscopic Transosseous Rotator Cuff Repair may be more cost effective than suture anchor repairs.

Use of intraoperative platelet-rich plasma during rotator cuff repair is correlated with increased patient-level charges across multiple categories

Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care "There was a poor correlation between the clinical outcome and the cost of care."

The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases"Surgeon-controllable factors significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and the number of suture anchors.

Failed Cuff Repairs 

Healthcare costs of failed rotator cuff repairs are approaching one half billion dollars.

A recent article,The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis assessed the published data on the consequences for the patient of a retear after surgical repair of a torn rotator cuff. The authors reviewed 43 studies including  3350 patients. The average age of the participants was 62 years (range, 52-78 years). 

At a median of 18 months' follow-up  844 repairs (25%) were described as retorn on imaging. 

The differences in patient assessed outcome between healed repairs and retears at follow-up were statistically significant, but the differences in pain, function, or quality of life were not clinically significantly different for healed and retorn cuff repairs.

In light of the foregoing, there is an opportunity to reconsider the approach to the patients with cuff tears, making sure that they are aware of 

(1) the factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes as pointed in Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

(2) the complications that can be associated with cuff repair. The authors of Complications Within 6 Months After Arthroscopic Rotator Cuff Repair: Registry-Based Evaluation According to a Core Event Set and Severity Grading found that the cumulative risk for adverse events at 6 months after rotator cuff repair was 18.5% (21.8% for partial tears, 15.8% for full-thickness single-tendon tears, 18.0% for tears with 2 ruptured tendons, and 25.6% for tears with 3 ruptured tendons). These adverse events included shoulder stiffness, persistent or worsening pain, rotator cuff defects, neurologic lesions, surgical-site infection, device failure, and others.

(3) the recovery or "down time" period. In Functional Recovery Period after Arthroscopic Rotator Cuff Repair: Is it Predictable Before Surgery? 31% took less than 3 months, 40% took between 3 and 6 months, and 28% took greater than 6 months to achieve a score greater than 80%. Age, shoulder stiffness, and rotator cuff tear size influenced functional recovery time.

What about non-repair surgery?

The observation in  The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis that shoulders with anatomically failed (retorn) and anatomically successful cuff (not retorn) repairs both have similar clinical outcomes makes us wonder what leads to the clinical improvement if the repair is retorn. What might happen if patients at high risk for retear, those concerned about complications and those not wishing to experience the protracted period of recovery were treated with a non-repair surgery (that is, a smooth and move / debridement). 

Smooth and Move in the Treatment of Irreparable Cuff Tears - Technique and Case Example

One of the major advantages of the smooth and move is that the patient can go back to active use of their shoulder immediately post surgery - because nothing is repaired there is no repair to protect. This is in marked contrast to the postoperative restrictions on motion during the healing period recommended for the balloon, patches, augments, partial repairs and superior capsular reconstruction. This is illustrated in the examples shown below,

The smooth and move in the management of irreparable tears or failed rotator cuff repairs

Can a subacromial balloon do this?

Massive rotator cuff tear and the smooth and move

Irreparable cuff tear in a 62 year old woman.

A 61 year old women with an irreparable cuff tear

Irreparable rotator cuff tear in an active man

Massive irreparable rotator cuff tears - how to treat them

Irreparable rotator cuff tear after failed rotator cuff repair

The Superior Capsular Reconstruction - what is its place?

Rotator cuff tears - the benefits of non-repair surgery

Treatment of irreparable cuff tears with retained active elevation

Here are some relevant articles from the literature on the effectiveness of the smooth and move

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation.The smooth and move procedure provided clinically significant improvement as early as 6 weeks after surgery.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty In 77 shoulders with irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0-12) to 8.5 (range 1-12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.

Partial rotator cuff repair versus debridement for irreparable rotator cuff tears: A systematic review In 153 shoulders treated with debridement, post-operative satisfaction was 80.7 %.

Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age found that most studies did not evaluate treatment with simple debridement in comparison to more complex procedures. However for studies that did, debridement had the highest P-score (probability of achieving the desired outcome), as shown below.

Forrest plot for Constant Score:

Forrest plot for range of active forward flexion:

This network meta-analysis found that simple debridement was the most effective procedure in significantly improving Constant score and active flexion for individuals with massive irreparable cuff tears when it was compared to other more complex surgical modalities. 

Comment

Of course we know that many thousands of patients benefit from rotator cuff repair surgery each year. For the majority, the procedure improves shoulder comfort and function. This is especially the case for acute tears in healthy patients with good quality cuff tendon and muscle.

For chronic cuff tears, a trial of non-operative management, including gentle stretching and strengthening can often be helpful and does not preclude surgical intervention if it becomes necessary.

For patients with large, chronic, atraumatic cuff tears, there may be a downside of attempting a rotator cuff repair with the risks of retear, complications, dissatisfaction, prolonged recovery, and cost. Evidence is currently lacking that these downsides can be eliminated by new innovative surgical approaches. Against this background a non-repair alternative, such as smooth and move/debridement, may be a cost-effective and safe consideration for selected patients with retained preoperative active elevation. Furthermore, the smooth and move does not burn bridges for other more complex procedures should they become indicated.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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). 

A B2 glenoid in a 67 year old man - 12 year followup after a basic arthroplasty

 An active man in his mid 60s presented with pain and stiffness of his left shoulder. His radiographs at presentation showed an arthritic shoulder with the humeral head posteriorly decentered on a retroverted biconcave glenoid.

After discussion of the option of a reverse total shoulder, he elected to proceed with an anatomic total shoulder.

The procedure was performed without preoperative CT scanning or preoperative 3D planning. General anesthesia was used without a nerve block. The shoulder was exposed with a subscapularis peel preserving the long head of the biceps. The glenoid was conservatively reamed without attempting to alter version. A standard non-augmented all polyethylene glenoid with an ingrowth central peg was used. The standard length smooth humeral stem was fixed with impaction autografting. 

At the age of 80, he returned for routine followup. His 12 year x-rays (shown below) reveal no evidence of stress shielding, component loosening, or instability.

 He reported excellent comfort and function. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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). 

Using humeral head geometry to establish immediate postoperative mobility and stability in a B2 glenoid

A man in his 50s from another state presented with a grinding and aching pain in his left shoulder after prior arthroscopic surgery and cortisone injections. 

On his Simple Shoulder Test he reported the inability to tuck in his shirt behind his back, to place his hand behind his head with his elbow out to the side, to lift a gallon of milk, to toss under hand, to throw overhand, and had difficulty doing his work as a general contractor.  He was previously a competitive archer, however he was currently unable to hold his bow properly given the range of motion deficits and pain in his left shoulder.

His examination revealed 140 degrees of humerothoracic motion of which only 80 degrees was humeroscapular. External rotation was limited to 0 degrees at the side and 10 degrees with the arm in abduction. Internal rotation with the arm abducted was 10 degrees. Reach up the back was to the gluteal area. 

His preoperative x-rays are shown below. The axillary truth view showed severe posterior decentering of the humeral head on a biconcave glenoid. 

After discussion of the options of an anatomic and a reverse total shoulder, the patient elected a ream and run procedure. 

The surgical challenge was to manage the posterior instability while loosening this tight shoulder (avoiding overstuffing).  Without using a preoperative CT or 3D planning, it was anticipated that the posterior decentering would require the use of an anteriorly eccentric humeral head component with a short stem to provide secure fixation that would resist eccentric loading.

At surgery, the stiffness of the shoulder was confirmed on examination under general anesthesia, no nerve block was used. The shoulder was approached through a deltopectoral incision and a subscapularis peel. The long head of the biceps was preserved. 

The humeral head was deformed as anticipated.

Extensive subscapularis and anterior / inferior capsular releases were performed as shown in these diagrams from Steve Lippitt.

The glenoid was conservatively reamed to a single concavity without attempting to "correct" glenoid retroversion.

The sizing of the humeral head component was determined by trialing, paying attention to the 40, 50, 60 rules and assuring that easy flexion to at least 150 degrees could be achieved.

Implant manufacturers typically describe the size of their humeral head components in terms of diameter of curvature and height.

It is useful to recognize that the humeral head component is a spherical cap (shown in blue below) with a height of h and a radius of r (half the diameter of curvature).

The volume of the humeral head is an important factor in determining the degree of stuffing of the joint. The humeral head volume is determined by 

The effect of changing the diameter curvature and the height of the humeral component are show in diagrams below. As pointed out by Jason Hsu, increasing the height has a greater effect on humeral head volume than increasing the diameter of curvature.

This effect is quantitatively demonstrated in the table below showing the humeral head volume for a commonly used range of prosthetic humeral head diameters and radii. The different component geometries are arranged in order of decreasing head volume. Note that it is the head height that is the primary driver of joint volume.

In this case a 54 20 head provided the necessary stability and mobility as demonstrated by this photo taken after wound closure.

His immediate postoperative x-rays show the impaction grafted humeral stem with an anteriorly eccentric humeral head centered in the conservatively reamed glenoid. 

Four days after his surgery he reported that he was taking only Tylenol for his shoulder and sent this report:

 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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). 

Can Computer Vision/AI solve a challenge in clinical shoulder arthroplasty research?

Shoulder surgeons are trying to understand the clinical importance of preoperative shoulder pathoanatomy and its modification by arthroplasty. Large-scale multicenter studies are necessary for investigating the relationship between standardized preoperative and sequential postoperative anatomical measurements and the outcome realized by the patient. 

The validity of such studies will depend on (1) standardization of the measurement methods across different centers, (2) human-observer independency avoiding the risk of inter-observer variation and observer bias, and (3) highly efficient methods that enable the evaluation of very large numbers of images. While CT scans are commonly used for characterizing preoperative shoulder anatomy, they are impractical for evaluating the postoperative anatomy and changes over time.  Standardized anteroposterior and axillary radiographs provide a practical and cost-effective approach for making preoperative and postoperative measurements using the same imaging method.

A recent study, Can computer vision / artificial intelligence locate key reference points and make clinically relevant measurements on axillary radiographs? demonstrated the potential of artificial intelligence in assessing clinically important relationships on standardized axillary x-rays. Standardized pre and post arthroplasty axillary radiographs were manually annotated by shoulder surgeons locating six reference points as shown the figure below:

The anterior and posterior edges of the glenoid face are indicated by the green dots.

The center of the glenoid face by the blue dot.

The base of the glenoid vault by the yellow dot. 

The spinoglenoid notch by black dot at tip of arrow.

The circle fitting the humerus articular surface by the blue circle.

These points were then used to measure glenoid version and humeroglenoid alignment (HGA-AP). Version was measured as the angle between the red and green lines. HGA-AP was measured as the perpendicular distance (double headed arrow) between the centre of the circle (star) and the perpendicular bisector (yellow line) of the glenoid face line (red line) divided by the diameter of the circle (dotted white line)

These annotated images were used to train a computer vision model that could identify these reference points and determine humeroglenoid alignment in the anterior to posterior direction and glenoid version without human guidance. 

The model's accuracy was tested on a separate test set of 52 axillary images that were not used in training the model, comparing the model's reference point locations, humero-glenoid alignment and glenoid version to the corresponding values assessed by the two surgeons. 

The model performed efficiently, allowing the rapid uploading of images and analysis of reference points, glenoid version, and humeroglenoid alignment (HGA-AP) without human participation. The model was able to produce the measurements in a matter of seconds compared to approximately two hours required for surgeon assessment of the relatively small set of 52 images.

The model was able to rapidly identify all six reference point locations to within a mean of 2 mm of the surgeon-assessed points. The mean variation in alignment and version measurements between the surgeon assessors and the model was similar to the variation between the two surgeon assessors.

The average differences between the surgeon- and the model-assessed reference points for the test set are shown below

The mean differences in glenoid version and HGA-AP between the surgeon assessors, between each surgeon assessor and the model, and between the average of the two surgeon assessors the model is shown below

The inter-observer variability between the two surgeons was similar to that between the average of the two surgeons and model 

While it will require substantial further refinement before it is ready for broad scale application, this proof-of-principle study does demonstrate the development and validation of a computer vision/artificial intelligence model that can independently identify key landmarks and determine the glenohumeral relationship and glenoid version on axillary radiographs. This observer-independent approach has the potential to enable efficient assessment of shoulder radiographs, substantially lessening the burden of manual x-ray interpretation and enabling scaling of these measurements across large numbers of patients from multiple centers so that pre- and postoperative anatomy can be correlated with patient reported clinical outcomes. 

Other studies have reported the use of artificial intelligence to classify shoulder implants 

Classifying shoulder implants in X-ray images using deep learning "In a data set containing X-ray images of shoulder implants from 4 manufacturers and 16 different models, deep learning is able to identify the correct manufacturer with an accuracy of approximately 80% in 10-fold cross validation, while other classifiers achieve an accuracy of 56% or less"

Development of a machine learning algorithm to identify total and reverse shoulder arthroplasty implants from X-ray images. "This proof of concept study demonstrates that machine learning can assist with preoperative planning and improve cost-efficiency in shoulder surgery."

A novel hybrid machine learning based system to classify shoulder implant manufacturers. "The proposed hybrid machine learning algorithms achieve the goal of low cost and high performance compared to other studies in the literature."

Deep learning to automatically classify very large sets of preoperative and postoperative shoulder arthroplasty radiographs. "We developed an efficient, accurate, and reliable AI algorithm to automatically identify key imaging features of laterality, imaging view, and implant type in shoulder radiographs. This algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries."

Artificial intelligence for automated identification of total shoulder arthroplasty implants. "A DL model demonstrated excellent accuracy in identifying 22 unique TSA implants from 8 manufacturers. "

EFFICACY OF ARTIFICIAL INTELLIGENCE-BASED MODELS FOR SHOULDER ARTHROPLASTY IMPLANT DETECTION AND CLASSIFICATION USING UPPER LIMB RADIOGRAPHS: A SYSTEMATIC REVIEW AND META-ANALYSIS "AI-based classification of shoulder implant types can be considered a sensitive method."

Artificial intelligence in shoulder arthroplasty

Other studies have explored the use of artificial intelligence to make measurements on x-ray images

The Development of a Yolov8-Based Model for the Measurement of Critical Shoulder Angle (CSA), Lateral Acromion Angle (LAA), and Acromion Index (AI) from Shoulder X-ray Images. "The results indicated that automatic measurement methods align with manual measurements with high accuracy and offer an effective alternative for clinical applications".

The acetabularization index: a novel measure of acromial bone loss prior to reverse shoulder arthroplasty. "AI is a reliably measurable tool on radiographs and 2D CT scans"

While others have used artificial intelligence to assess humeral fractures

Clinical validation of artificial intelligence-based preoperative virtual reduction for Neer 3- or 4-part proximal humerus fractures "The AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times."

Artificial intelligence versus radiologist in the accuracy of fracture detection based on computed tomography images: a multi-dimensional, multi-region analysis "The optimized AI model improves the diagnostic efficacy in detecting extremity fractures on radiographs, and the optimized AI model is significantly better than radiologists in detecting avulsion fractures, "

From the foregoing it is evident that we are on the forefront of the application of computer vision/artificial intelligence to enhance clinically important shoulder research. 

Stay tuned!

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).