Article 2: Degenerative RTC Repair, or not Repair

Intro:

• Increasing demand in aging population = what?

• Research studies have raised doubts about the benefits of ____ ____ ____ compared to ___ ___ ___ in the management of ____ ____ RTC repair

• Aging Population = Increased Financial Burdens

  • NOTE: Within the last 15 years a significant number of rotator cuff repairs. 

    • In England cost for RTC repair was excess of 60 million 

    • In US the annual cost for RTC repair between $1.2-1.6 billion

• Rotator Cuff Repair; Non-Operative Tx; Non-Traumatic RTC Repair I

Intro:

• In 2018, an RCT concluded that Subacromial Decompression (DID OR DID NOT) offer extra benefit over arthroscopy alone for Subacromial Shoulder Pain

• DID NOT

Intro: Topic Question

• The cost effectiveness of RTC repair, esp compared with __ __ __ for Non Traumatic/Degenerative RTC Tears

• Non-Operative Options

Intro:

• What are different treatment options for MASSIVE RTC TEARS discussed in this article?

• Debridement/subacromial decompression 

• Partial repair

• Transfer of subscap tendon 

• Transfer of teres major muscle

• Deltoid flap reconstruction

• Transfer of lats dorsi/ pec major 

• Superior capsule reconstruction (using synthetic, auto, or allograft to replace torn tendon)

• Augmented cuff repair (using synthetic, auto, or allograft to augment repaired tendon)

• Subacromial balloon (balloon inserted and inflated under acromion to prevent prox migration of humeral head)

• Reverse total shoulder replacements

Purpose:

• The purpose of this study was ___ ___ to consider when counseling pts with Non Traumatic RTC Tears on which route to take.

• These Factors include what 3 things?

• T/F: Clinicians treating pts with RTC should be mindful of financial burden and implications of the two management strategies

• Important Factors

• 3 Factors:

  • Clinical outcomes of surgical and non-surgical procedures

  • Tendon healing rates w/ surgery 

  • Natural healing of tendons if treated non operatively 

• True

Specific Findings: Effects on Sleep

• What is common in patients with RTC Tears?

  • Clinically present in how many pts?

• What usually drives the pt to opt for surgery?

• What procedure provided significant improvement in sleep quality?

• Sleep Disturbances

  • 85% of such pts (Degenerative)

• Symptoms

• Post Arthroscopic RTC Repair

Specific Findings: Clinical Outcome in Older Pop

• T/F: Clinical Outcomes are POOR in older populations?

• In one study involving 40 pts younger than 50 years and 40 pts older than 70 years, what was reported?

• FALSE

  • Common disbelief of decreased outcomes in elderly pop (NOT SUPPORTED BY RESEARCH)

• Functional gains were reported to be EQUIVALENT in both groups

Specific Findings: Physiotherapy vs. Surgery

• Are there many high level studies comparing Physiotherapy with Surgery?

• Most studies involved what type of tears?

• NAUR (Limited)

• Small tears

  • NOT medium or large tears

Specific Findings: Heal Repairs Have Better Outcomes than those Without?

• Patients with ___ ___ have BETTER RTC strength than those with repeat tears

• Healed Tendon

Specific Findings: Natural Hx of RTC Tears

• What type of RTC Tear DO NOT heal without surgery?

• 4 Main Factors:

• Full Thickness Tears

• 4

  • Progression of Tear Size

  • Rate related to tear size

  • Degree of Fatty Infiltration

  • Pt age

Specific Findings: Financial Burden

• Factors that increases cost were found to be what?

• Most factors that improved outcomes were found to be what?

  • Do procedural costs appear to necessarily related to better outcome?

• Outcome Neutral

• Cost Neutral

  • NAUR

Conclusion:

• What has a role in management of Degenerative RTC Tears?

• It is fair to conclude that RTC repair has good clinical outcome regarding significant improvement in what 5 ways?

• Non Surgical Route with Appropriate Physiolotherapy Program

• 5:

  • Pain

  • ROM

  • Strength

  • QOL

  • Sleep Patterns

Conclusions:

• What does NOT have a good clinical outcome?

• Full Thickness tears are treated how?

  • Particularly what type of tear and pop?

  • What do they appear to do?

• Surgeons treating pts with RTC Tear MUST be aware of what?

• Radiological Outcome

• Non Operatively

  • Large tears with fatty degeneration in elderly pop

  • Increase in size that they may NOT be repairable

• Cost effectiveness of their chosen strategy 

Quiz Question:

T/F: Surgery is considered ineffective in pts over 75 yrs old d/t decreased bone density and reduced blood supply.

FALSE

Quiz Question:

1. What type of ailment affects 85% of pts with degenerative RTC tears?

   1. Getting dressed 

   2. Sitting in chair for prolonged periods 

   3. Walking 

   4. Sleep disturbances 

Sleep Disturbances

Quiz Question:

1. Which of the following statements best reflects the current understanding of managing degenerative RTC tears?

   1. Surgery should be avoided entirely d/t financial pressures and lack of long term studies 

   2. Non-surgical tx is always preferred d/t its superior radiological outcomes 

   3. Surgical repair of RTC consistently leads to  better radiological and clinical outcomes in all pts 

   4. Nonsurgical tx has a role, esp in certain pts, but surgery can offer significant clinical benefits despite mixed radiological results 

1. Nonsurgical tx has a role, esp in certain pts, but surgery can offer significant clinical benefits despite mixed radiological results 

Quiz Question:

1. T/F. Patients over the age of 76 experiences poorer outcomes following RTC repair. 

FALSE