Why Do Rotator Cuff Repairs Fail?

[mtomaino]

The above article was emailed to me by one of the Physical therapists that I am privileged to have treat my patients with shoulder issues. The abstract can be read at this link:
http://www.ncbi.nlm.nih.gov/pubmed/21737833

Here's a summary---and then I will provide a commentary.

Rotator cuff tears occur frequently and this occurrence increases with an increase in age. Arthroscopic repair is presently the best option to improve shoulder function and decreasing pain. However, large and massive tears have been reported to have a high retear rate (13% to 94%). To better optimize the surgical repair and rehabilitation of these patients we need a better understanding of when these repairs fail. Therefore, the objective of this study was to define the timing of structural failure and to examine the association between failures and clinical outcome variables. Twenty-two patients with rotator cuff tears larger than 3 mm in size were recruited. All patients underwent arthroscopic rotator cuff repairs and rotator cuff integrity was evaluated at 2 days, 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months post surgery with diagnostic ultrasound. Western Ontario Rotator Cuff (WORC) Index scores, which assess symptoms, function, and quality of life, were also collected at each time point. All patients were immobilized for three months following surgery and then standard rehabilitation was initiated starting with gentle passive motion. They found that nine (41%) of the 22 patients developed a recurrent tear. Seven of the nine occurred within 3 months post-surgery and the remaining two occurred between 3 and 6 months. At the 24-month follow-up there was a trend when comparing group WORC scores (p = 0.07) suggesting that the intact group had better shoulder function that the patients with recurrent tears.

And here's my commentary:
Large (2-tendon) and Massive tears cannot be evaluated ---in terms of outcome after repair--without considering patient age, chronicity, MRI evidence of muscle atrophy, operative technique, tension at repair site etc.Each of these factors has an impact on not only healing rates, but also reparibility in the first place. This paper is not equipt to answer the question of whether repair is advisable, because certain data is not provided. That having been said, the paper does provide some interesting data worth noting.

1. 40% of repairs did not heal, and the majority of "failures" were noted within the first 3 months.
2. All patients were immobilized for 3 months before any PT was started.
3.Western Ontario Rotator Cuff (WORC) Index scores, which assess symptoms, function, and quality of life--were better if structural healing occured.

Clearly, getting a cuff tear to heal results in better functional scores. Indeed, although pain relief may accompany a failed repair, strength is better if tendon healing occurs. The fact that some tears did not heal despite 3 months of immobilization shows that "failure of biology" is a very real entity----that having been said, tension at the repair site and muscle atrophy are risk factors for poor tendon healing. In the final analysis, 60% of large and massive tears may heal, so if there is no significant arthritis or alteration in shoulder mechanics (ie superior elevation), an attempt at a repair is reasonable if pain and poor function exist. Also---even if a tear cannot be repaired, we know that a simple debridement with biceps tenotomy may provide pain relief. When repairs fail or are not possible, Reversed shoulder arthroplasty becomes an option particularly in one's 60's and 70's.