• DOI:10.3928/01477447-20091020-01
• Corpus ID: 27800906

Should we repair rotator cuff tears earlier?

@article{Schneider2009ShouldWR,
  title={Should we repair rotator cuff tears earlier?},
  author={Marc C Schneider},
  journal={Orthopedics},
  year={2009},
  volume={32 12},
  pages={
          879
        }
}

• Marc C Schneider
• Published 1 December 2009
• Medicine
• Orthopedics

According to the American Academy of Orthopaedic Surgeons,1 between 1998 and 2004, !5 million physician visits were attributed to rotator cuff disease. Many of these problems are self-limited and include sprains, strains, and overuse. On the other end of the spectrum are degenerative large and massive full-thickness rotator cuff tears. These tears are especially prevalent in the general population older than 50 years and are associated with signifi cant costs to society and the health care system. Historically, many of these tears have been considered to be asymptomatic because patients often demonstrate subtle signs and symptoms. More recently, Kim et al2 found that asymptomatic large and massive full-thickness tears are associated with decreased abduction strength. A multicenter prospective study by Harryman et al3 determined that the typical patient with a rotator cuff tear was only able to perform 4.4 of 12 Simple Shoulder Tests compared to normal controls. If the defi nition of asymptomatic is “having no evidence of disease,” how can a weak shoulder really be considered asymptomatic? How many patients have modifi ed their activities, work, or recreation to accommodate shoulder weakness or to avoid pain? How often have patients given a history of recurrent but only episodic shoulder symptoms and simply attributed this to the aging process? Natural history studies of rotator cuff disease have revealed that many small tears become larger over time. Larger tears are typically associated with increased symptoms. Although conservative treatment can initially improve pain, unsatisfactory outcomes with nonoperative treatment of chronic rotator cuff tears have been reported in up to 50% of patients with results deteriorating over time.4 Full-thickness tears rarely heal spontaneously with nonoperative treatment. Although a rotator cuff tear isn’t a life-threatening problem, it can signifi cantly impact an individual’s quality of life and work productivity. McKee and Yoo5 found a signifi cant improvement in patients’ general health status after rotator cuff repair. Vitale et al6 reported increases in “health-related quality of life” measures postoperatively. Based on the Health Utility Index and the European Quality of Life Measure, it was determined that rotator cuff repair is a highly cost-effective intervention, comparing favorably to other medical interventions including coronary artery bypass graft, medical treatment of hypertension, and hemodialysis. Evidence-based data have consistently shown that the surgical repair of small full-thickness tears is associated with better healing, lower re-tear rates, improved patient function, and better strength in comparison to repairs of large and massive tears. With current surgical principles, postoperative imaging demonstrates an 11% to 94% rate of structural failure, with the highest percentage of failures affecting repairs of large and massive tears.7,8 These rates have persisted irrespective of surgical approach (eg, open, mini-open, or all arthroscopic). Techniques to augment the biology and biomechanics of the repair through growth factors, structural scaffolds, tendon transfers, and tissue engineering continue to be researched. However, the most technically profi cient surgeon cannot return a fatty, atrophic, inelastic musculotendinous unit back to its normal condition. Without surgical treatment, some of these tears can become irreparable, and in the worst case scenario, the shoulder progresses to a pattern of rotator cuff arthropathy. Several studies suggest this can be prevented by surgically repairing a torn rotator cuff. Dr Schneider is from Cincinnati Bone and Joint Institute, Cincinnati, Ohio. Dr Schneider has no relevant fi nancial relationships to disclose. Correspondence should be addressed to: Marc C. Schneider, MD, Cincinnati Bone and Joint Institute, 2123 Auburn Ave, Ste 231, Cincinnati, OH 45219 ([e-mail]). doi: 10.3928/01477447-20091020-01