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

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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). 

What is the value of total shoulder arthroplasty - how can it be improved?

The value of a procedure to patients can be defined as quality of care divided by the costs associated with the procedure. Measures of quality include improvements in patient reported outcomes along with intra- and postoperative complications.

The authors of Measuring Patient Value after Total Shoulder Arthroplasty sought calculate the patient value delivered by total shoulder arthroplasty (TSA) for 116 consecutive TSAs.

Patient value was defined as quality of care divided by direct costs of surgery; the preoperative costs (i.e. imaging, planning) and postoperative costs (i.e. physical therapy) were not assessed.

Compared to a reference threshold of 1.0, ninety patients (78%) had a quality of care ≥1.0 and 61 patients (53%) had direct costs related to surgery ≤1.0. 

The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function.

43% of the patients were in the highest value (green) rectangle below, while 13% were in the lowest value (red) rectangle.

19% of the patients had intraoperative or postoperative complications. 

 

Comment: The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function. While not discussed in this publication, it seems likely that patients having complications would be likely to have both higher costs and poorer outcomes. If having a complication resulted in patients being in the red rectangle, avoiding complications might be a most effective means of optimizing value.

As suggested in Innovations in the Realm of Shoulder Arthroplasty the incremental preoperative, intraoperative and postoperative costs associated with preoperative planning, navigation, artificial intelligence, augmented reality, new prosthetic designs, custom augments, and three dimensional printing might be justified by actual improved outcomes in selected patients with certain complex pathologies......but perhaps not in shoulders with routine arthritic anatomy

Careful clinical research will be necessary to identify which patients are likely to achieve better outcomes with which of these technologies leading to the establishment of what the American Academy of Orthopaedic Surgeons refers to as clinical practice guidelines and appropriate use criteria.

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: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
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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).

The negative impact of alcohol use disorder on total shoulder outcomes

 The Association of Alcohol Use Disorder on Perioperative Outcomes Following Primary Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis: A Retrospective Matched-Cohort Study

Alcohol use disorder (AUD) refers to a pattern of alcohol use leading to clinically significant impairment or distress, for example continued consumption despite knowledge of physical or psychological problems due to alcohol, consumption of alcohol in excess of initial intention, persistent desire or failure to reduce consumption, cravings, failure to fulfill major roles due to alcohol use, continued use despite recurrent social problems, development of tolerance, or withdrawal with a time interval of 12 months. Approximately 14.4 million individuals over the age of 18 met these criteria for diagnosis with AUD in 2018. The national rate of AUD is rising.

These authors sought to determine whether patients who have alcohol use disorder (AUD) have higher in hospital lengths of stay (LOS), medical complications, and healthcare expenditures after total shoulder arthroplasty (TSA).

They queried the Medicare Claims Database identifying 5,479 patients who underwent primary TSA for glenohumeral OA and had AUD. These patients were 1:5 ratio to a comparison cohort of 27,367 patients matched by age, sex, and various comorbid conditions. 

Patients with AUD had significantly longer in-hospital length of stay (4- vs. 2-days), addition to higher rates  of 90-day complications (30.44% vs. 7.94%) such as surgical site infections (1.15 vs. 0.24%), cerebrovascular accidents (5.06 vs. 1.23%), respiratory failures (5.79 vs. 1.52%), myocardial infarctions (1.53 vs. 0.43%), acute kidney injuries (6.55 vs. 1.34%), and other complications.

Patients with AUD incurred significantly higher day of surgery ($12,160.60 vs. $11,308.48) and 90-day episode of care costs ($14,493.13 vs. $13,087).

Comment: Total shoulder arthroplasty in patients with alcohol use disorder is more risky and more costly. 

A number of mechanisms may contribute to the adverse effects of AUD:

(1) AUD may simply increase the amount of patient care which is required for these patients, prolonging their in-hospital course prior to discharge.

(2) Patients who have AUD may have other psychiatric comorbidities, and the synergestic effects of AUD coupled with these mental health conditions could increase in-hospital LOS.

(3) Alcohol may impair dermal fibroblast function by decreasing the threshold for dermal wound-breaking strength for immature wounds increasing the risk of infection and failure of wound healing.

(4) Chronic alcohol use is thought to disrupt the function of alveolar macrophages with a decrease in phagocytic activity when they are exposed to bacteria.

(5) Alcohol-related inhibition of fibrinolysis and induction of an inflammatory state may predispose to cerebrovascular accidents.

(6) AUD may be associated with poor nutrition, less preventative health care, inferior social support, and lower self-esteem.

(7) AUD is likely to increase the risk of falling after a TSA, injuring the shoulder.

This brings up some important, yet currently unanswered questions: 

(1) How treatable is alcohol use disorder? 

(2) Can the negative effects of AUD be prevented by prospective management? 

(3) How should the presence of AUD change the tipping point (see this link) for elective shoulder arthroplasty? 

(4) Are alcohol use biomarkers (see this link) useful in managing the patient with AUD.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

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

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

How modifying risk factors may increase the value of shoulder arthroplasty

 Modifiable risk factors increase length of stay and 90-day cost of care after shoulder arthroplasty

These authors queried the electronic medical record (EPIC) for 1317  houlder arthroplasty cases under DRG 483 within a regional 7-hospital system to calculate mean length of stay (LOS), total 90-day charges, related emergency department (ED) visits and charges, and related hospital readmissions after shoulder arthroplasty. 

Data for patients who had 1 or more predefined modifiable risk factors (MRFs), defined as 

anemia (hemoglobin < 10 g/dL), 

malnutrition (albumin < 3.4 g/dL), 

obesity (BMI > 40), 

uncontrolled diabetes

(random glucose > 180 mg/dL or glycated hemoglobin > 8.0%), 

tobacco use (International Classification of Diseases, Tenth Revision, code indicating patient is a smoker), 

and opioid use (opioid prescription within 90 days of surgery), 

were evaluated as potential covariates to assess the relationship between MRFs and total encounter charges, LOS, ED visits, ED charges, and hospital readmissions.

The prevalence of these risk factors is shown below

Multivariable analysis demonstrated that anemia ($19,847), malnutrition ($5850), and obesity ($2762) independently contributed to higher charges after shoulder arthroplasty as shown in the graph below.

Mean LOS was higher in patients with anemia (5.0 days), malnutrition (3.7), and uncontrolled diabetes (2.8). 

Comment: The value of shoulder arthroplasty can be defined as the benefit to the patient divided by the cost of care.  While this study did not assess the numerator (i.e. the benefit of arthroplasty in terms of patient assessed measures of comfort and function) it did demonstrate the increased costs care related to anemia, malnutrition and obesity.

While these three risk factors are - in theory - modifiable, how to most effectively modify them needs further study. For example, while anemia may be amenable to management preoperatively by iron supplementation, treatment with medication such as epoetin alpha, transfusion, and/or identification and correction of the underlying cause, it is uncertain how effective these approaches are in reducing cost: is a transfusion of two units the day prior to surgery likely to result in earlier discharge - might transfusion increase the risk of infection? Malnutrition exists for a reason (malabsorption, poverty, alcoholism) how effective is nutritional supplementation in increasing the serum albumin to the point of reducing cost?  Obesity can be addressed by bariatric surgery which creates a relative starvation: does such a surgery reduce the cost of arthroplasty?

The purpose in asking these questions is a practical one: what should a surgeon tell the patient with painful arthritis who also has anemia, malnutrition, or obesity: "I'm not operating on you until you've corrected your hemoglobin, albumin, or BMI" or "We can do your surgery, but it is likely to cost (someone) more or to be associated with a longer length of stay in the hospital"?

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

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

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

 

Increasing the value of shoulder arthroplasty by reducing cost - are "modifiable" risk factors modifiable?

 Modifiable Risk Factors Increase Length of Stay and 90-Day Cost of Care After Shoulder Arthroplasty

These authors sought to determine the impact of pre-defined modifiable risk factors (MRF) on total encounter charges, hospital length of stay (LOS), related emergency department (ED) visits and charges, and related hospital readmissions within 90 days after shoulder arthroplasty.

They queried the electronic medical record (EPIC) for 1317 shoulder arthroplasty cases under DRG 483 within a regional seven-hospital system between October 2015 and December 2019. Data for patients who had one or more modifiable risk factors, defined as anemia (Hg<10g/dL), malnutrition (albumin<3.4g/dL), obesity (BMI body mass index>40kg/m2), uncontrolled diabetes (random glucose >180mg/dL or HgA1C>8.0%), tobacco use (ICD 10 code indicating patient is a smoker) and opioid use (opioid prescription within 90 days of surgery), were evaluated as potential covariates to assess the relationship between MRF and total encounter charges, LOS, ED visits, ED charges, and hospital readmissions.

  

Multivariable analysis demonstrated that anemia (+$19,847), malnutrition (+$5,850), and obesity (+$2,762) independently contributed to higher charges after shoulder arthroplasty. Mean LOS was higher in patients with anemia (5.0 days vs. 2.2 days, malnutrition (3.7 days vs. 2.2 days) and uncontrolled diabetes (2.8 vs. 2.3).

Univariate risk factors associated with a significant increase in total 90-day encounter charges included anemia (+$19,345), malnutrition (+$6,971), obesity (+$2,615), and uncontrolled diabetes (+$4,377). Univariate risk for readmission within 90 days was higher in patients with malnutrition.

Comment: This is a valuable study in that it highlights the effect of certain risk factors on the cost of arthroplasty, which, of course, is a critical element in determining the value of the procedure: the benefit to the patient divided by the cost of the arthroplasty, including complications (see this link). Since new technical innovations have yet to be shown to substantially increase the benefit of arthroplasty (see this link), the greatest opportunity for improving the value of the procedure may lie in reducing its cost.

Certain risk factors for expensive adverse outcomes, such as age, sex, severity of the pathology and untreatable medical co-morbidities are not modifiable.The question then becomes, "which risk factors are modifiable?". 

Of the risk factors identified in this study, some are apparently modifiable as indicated in the references below.

Anesthesia preoperative clinic referral for elevated HbA1C reduces complication rate in diabetic patients undergoing total joint arthroplasty.

The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty.

Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty.

A promising area for future clinical research is the study of the effectiveness of risk factor modification on the cost and outcomes of shoulder arthroplasty. This combined with minimizing the costs of imaging, implants, medications and therapy may go a long way toward improving the value of shoulder arthroplasty.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

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

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).