Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Thomas J. Gill, MD*,
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Posted September 2007
Surgical repair of rotator cuff tears has been shown to
result in good-to-excellent clinical outcomes, even when postoperative imaging
has demonstrated that up to 90% of repaired massive tears are not fully intact.
Thus, when reporting "outcomes" of rotator cuff repair, it is important to
differentiate between "objective" and "subjective" assessments.
There are certain variables that are traditionally believed
to influence the clinical outcome of rotator cuff repairs. Perhaps the most
important of these are the size of the tear, the chronicity of the tear, and
the degree of fatty atrophy in the muscle belly of the torn tendon. Although
larger tears can be surgically repaired, the function of the cuff itself will
not always improve if there is greater than 50% fatty atrophy of the muscle
belly. Nevertheless, even without objective improvements in motion and
strength, patients will often report improvements in subjective clinical
outcome following repair.
In addition to the anatomic factors, other aspects, such as
the demographic and psychosocial attributes of patients with torn rotator cuffs,
are predictive of outcome. These include age, Workers' Compensation status,
occupation, comorbidities such as diabetes mellitus, and a history of smoking. The
tendon quality and bone density of older patients generally are not as strong
as those of younger patients, which may predispose the repair to failure even
following a technically sound procedure. The healing rate in smokers is lower
than that in matched nonsmoking cohorts, and patients with diabetes may
struggle to regain motion following repair and have a higher incidence of
adhesive capsulitis. The measured clinical outcome of rotator cuff repair in
patients with active Workers' Compensation claims is also inferior to that in control
groups1.
This study by Henn et al. is among the first to study the
effect of patients' preoperative expectations on the clinical outcome following
rotator cuff repair. The authors describe a strong correlation between the preoperative
expectations of patients and their actual self-assessed outcome scores on the Simple
Shoulder Test (SST), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire,
the Short Form-36 (SF-36), and visual analog scales for pain, shoulder
function, and quality of life. Unfortunately, postoperative patient
satisfaction was not measured in this study; it would have been interesting to
know if there was a correlation between preoperative expectations and the final
result. The authors concluded that, at a mean follow-up of fourteen months
(range, eight to twenty-two months), preoperative expectations are the single
most important predictor of both one-year performance and improvement from
baseline after rotator cuff repair. However, they do acknowledge that anatomic
factors such as tendon quality and repair integrity were not taken into account
in their multivariate analysis.
Preoperative counseling has a major effect on the
establishment of the patient-doctor relationship. Taking time to properly
counsel patients on the natural history of their diagnosis, their treatment
options (including nonoperative options), and the risks and benefits of
potential surgical interventions will help to ensure that proper treatment plans
are designed and implemented.
Preoperative counseling can also help the patient to set realistic
expectations. For example, if a sixty-three-year-old laborer with a massive,
chronic, retracted rotator cuff tear and high-riding humeral head expects to
return to heavy lifting and construction work, then he will not typically
report a favorable outcome. The same is true for a professional baseball
pitcher with a torn supraspinatus, frayed infraspinatus, and nondisplaced
labral tear who expects an easy return to professional baseball without any
losses in velocity, control, or endurance. For the laborer, realistic
expectations include relief of pain and improvement of function with the arm by
the side. The baseball player should be counseled that realistic expectations
include the ability to perform all activities of daily living, elimination of
pain at night and with overhead reaching, and the ability to return to
throwing. However, the player must not expect a "guarantee" that he or she can
return to pitching at the same level or with the same velocity. In fact, the
player should understand that ending his or her career might be a realistic
expectation after surgical repair.
For patients with torn rotator cuffs, there are multiple
predictors of surgical outcome. In considering "subjective outcomes," preoperative
patient expectations do play a central role. Patients must be forewarned that
they may not be able to have unlimited overhead motion and/or function or "full
strength" postoperatively, especially if they are being treated for larger,
chronic tears. Otherwise, even if pain is completely eliminated but motion not
fully restored, their subjective outcomes will be poor. In contrast, when considering
"objective" outcomes, strength, function, and range of motion are the primary
outcome measures, and anatomic factors such as tendon quality, tear size,
chronicity of symptoms, and fatty atrophy remain more predictive of objective
outcome. Setting realistic expectations for the patient will help to ensure
that objective and subjective outcomes are similar.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
Reference
1. Watson EM, Sonnabend DH. Outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11:201-11.
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