Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Keith M. Baumgarten, MD*,
Orthopedic Institute, Sioux Falls, South Dakota
Posted August 2009
Nonoperative management of rotator cuff tears is an accepted mode of treatment. Several Level-IV evidence studies suggest good-to-excellent results in 56% to 89% of patients who are managed nonoperatively1-3. These studies were limited by selection bias, and at least one study was limited by detection bias3. The durability of the success of nonoperative management of rotator cuff tears (and of full-thickness tears, in particular) remains unproven3.
Yamaguchi et al. examined tear progression in asymptomatic patients who received nonoperative treatment for a torn rotator cuff4. All asymptomatic shoulders examined in their study were in patients with a symptomatic contralateral shoulder. Nine of twenty-three patients had tear progression. More than half of the asymptomatic shoulders became symptomatic over the course of approximately three years. No patients had tear recession or healing. A trend was found between tear-size progression and the onset of symptoms. The authors recommended repeat imaging at six months and then at yearly intervals for rotator cuffs that are managed nonoperatively5.
Zingg et al. assessed the nonoperative management of massive rotator cuff tears6. They demonstrated that, although the clinical status remained stable, the acromiohumeral distance decreased and the staging of osteoarthritis increased. The mean rotator cuff tear size increased from 5.6 to 6.0 cm in the sagittal plane and from 4.2 to 4.7 cm in the coronal plane. Fatty infiltration increased significantly. Four of eight reparable tears had become irreparable at the time of the final follow-up.
Maman et al. found that more than 50% of full-thickness rotator cuff tears that had been treated nonoperatively progressed over time. In addition, tear progression was associated with a patient age of greater than sixty years and the finding of fatty infiltration of the rotator cuff on initial magnetic resonance imaging. The authors found that, when compared with patients who were followed for a shorter interval, patients who were followed for more than eighteen months had a significantly increased risk for progression in tear size.
The utility of a diagnostic test depends on the accuracy and reliability of that test. Although it has been suggested that magnetic resonance imaging is accurate in measuring the area of a rotator cuff tear7,8, the accuracy of magnetic resonance imaging in measuring the width and retraction of a tear in millimeters may be limited. In this study, the size of the rotator cuff tears was measured in millimeters and interpreted by experienced musculoskeletal radiologists.
Toyoda et al. found that magnetic resonance imaging underestimates tear-size estimation transversely by a mean (and standard deviation) of 2.2 ± 9.9 mm and longitudinally by 7.5 ± 13.4 mm9. Bryant et al. demonstrated that magnetic resonance imaging underestimated the size of a rotator cuff tear by 30%10. Teefey et al. demonstrated that magnetic resonance imaging correctly predicted the width of full-thickness tears in 80% of shoulders and the degree of retraction in 63%11. Magnetic resonance arthrography has been shown to be more accurate than magnetic resonance imaging in estimating the size of a rotator cuff tear9,12. Spencer et al. demonstrated questionable reliability with only fair interobserver agreement in the assessment of the size of a rotator cuff tear in both the sagittal and the coronal directions13.
One potential limitation of this study is that magnetic resonance imaging may not be accurate or reliable enough to measure the small changes in tear size that were demonstrated in this study and therefore may not be able to substantiate tear progression or recession. The results and conclusions need to be interpreted in light of this potential limitation.
I congratulate Maman and colleagues on their interesting and timely study that assesses rotator cuff tear progression associated with nonoperative treatment. This study suggests that patients with full-thickness tears, fatty infiltration of the muscle, and an age older than sixty years should be monitored at close and regular intervals for evidence of tear progression. However, even with identification of the risk group, the dilemma remains with regard to how to address asymptomatic tear progression if found during a follow-up examination. We encourage the authors of this study to continue to follow this patient cohort and to assess further tear progression, symptom progression, numbers of patients converting to surgical intervention, maintenance of anatomic acromiohumeral distances, and development of rotator cuff tear arthropathy.
*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.
References
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