A bit of context.
In large part, rotator cuff tears are a consequence of aging, increasing in prevalence in older individuals. A high percentage of these tears are asymptomatic (link, link, link). Some studies comparing non-operative and surgical treatment of cuff tears have found similar outcomes for each (link, link, link).
In 1962 McLaughlin wrote about the rotator cuff: “In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle-age it has worn thin and often becomes so weak and brittle that it ruptures with ease”. On surgical management, he added “The wise surgeon, realising that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis”.
Primary Cuff Repairs
Surgeons in the United States perform over 400,000 rotator cuff repair surgeries annually, with each procedure costing between $8,400 and $56,200. Thus the total annual expenditure on rotator cuff repair surgeries in the U.S. ranges from approximately $3.36 billion to $22.48 billion. It is important to note that these figures represent direct surgical costs and do not account for additional expenses such as preoperative evaluations, postoperative rehabilitation, or potential costs associated with surgical complications. Therefore, the overall economic impact of rotator cuff injuries and their treatment is likely higher. The rate of rotator cuff repairs per 100,000 citizens is increasing steadily (link, link, link). Rotator cuff repair remains the most commonly performed shoulder surgery.
As pointed out in Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome, innovations in surgical technique, instrumentation, augmentation or biologics do not appear to be leading to improved clinical outcomes perceived by the patient.
New, more expensive innovations for cuff repair are being used; for some of these there is questionable evidence of improved benefit/cost.
Editorial Commentary: Bioinductive Collagen Implants Reduce Rotator Cuff Retear, yet Cost-Effectiveness and Improvement in Clinical Outcomes Are Unclear“Unfortunately, retear rates do not appear to have improved significantly since the 1980s, despite advances in surgical technology and the biomechanics of repair.”
No Short-term Clinical Benefit to Bovine Collagen Implant Augmentation in Primary Rotator Cuff Repair: A Matched Retrospective Study
Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers
Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis “The facility cost of subacromial balloon spacer was significantly higher than that of partial cuff repair”
Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis “The largest cost drivers of aRCR are the use of biologic adjuncts, augments, the use of multiple suture anchors, and certain anchor brands.”
Arthroscopic Transosseous Rotator Cuff Repair may be more cost effective than suture anchor repairs.
Use of intraoperative platelet-rich plasma during rotator cuff repair is correlated with increased patient-level charges across multiple categories
Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care “There was a poor correlation between the clinical outcome and the cost of care.”
The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases“Surgeon-controllable factors significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and the number of suture anchors.
Failed Cuff Repairs
Healthcare costs of failed rotator cuff repairs are approaching one half billion dollars.
A recent article,The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis assessed the published data on the consequences for the patient of a retear after surgical repair of a torn rotator cuff. The authors reviewed 43 studies including 3350 patients. The average age of the participants was 62 years (range, 52-78 years).
At a median of 18 months’ follow-up 844 repairs (25%) were described as retorn on imaging.
The differences in patient assessed outcome between healed repairs and retears at follow-up were statistically significant, but the differences in pain, function, or quality of life were not clinically significantly different for healed and retorn cuff repairs.
In light of the foregoing, there is an opportunity to reconsider the approach to the patients with cuff tears, making sure that they are aware of
(1) the factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes as pointed in Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data
(2) the complications that can be associated with cuff repair. The authors of Complications Within 6 Months After Arthroscopic Rotator Cuff Repair: Registry-Based Evaluation According to a Core Event Set and Severity Grading found that the cumulative risk for adverse events at 6 months after rotator cuff repair was 18.5% (21.8% for partial tears, 15.8% for full-thickness single-tendon tears, 18.0% for tears with 2 ruptured tendons, and 25.6% for tears with 3 ruptured tendons). These adverse events included shoulder stiffness, persistent or worsening pain, rotator cuff defects, neurologic lesions, surgical-site infection, device failure, and others.
(3) the recovery or “down time” period. In Functional Recovery Period after Arthroscopic Rotator Cuff Repair: Is it Predictable Before Surgery? 31% took less than 3 months, 40% took between 3 and 6 months, and 28% took greater than 6 months to achieve a score greater than 80%. Age, shoulder stiffness, and rotator cuff tear size influenced functional recovery time.
What about non-repair surgery?
The observation in The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis that shoulders with anatomically failed (retorn) and anatomically successful cuff (not retorn) repairs both have similar clinical outcomes makes us wonder what leads to the clinical improvement if the repair is retorn. What might happen if patients at high risk for retear, those concerned about complications and those not wishing to experience the protracted period of recovery were treated with a non-repair surgery (that is, a smooth and move / debridement).
See:
Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation.The smooth and move procedure provided clinically significant improvement as early as 6 weeks after surgery.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty In 77 shoulders with irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0-12) to 8.5 (range 1-12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.
Forrest plot for Constant Score:
This network meta-analysis found that simple debridement was the most effective procedure in significantly improving Constant score and active flexion for individuals with massive irreparable cuff tears when it was compared to other more complex surgical modalities.
Comment
For patients with large, chronic, atraumatic cuff tears, there may be a downside of attempting a rotator cuff repair with the risks of retear, complications, dissatisfaction, prolonged recovery, and cost. Evidence is currently lacking that these downsides can be eliminated by new innovative surgical approaches. Against this background a non-repair alternative, such as smooth and move/debridement, may be a cost-effective and safe consideration for selected patients with retained preoperative active elevation. Furthermore, the smooth and move does not burn bridges for other more complex procedures should they become indicated.
Here are some videos that are of shoulder interest
Shoulder arthritis – what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
