Long-term followup of shoulder procedures is of great interest to patients and surgeons. Rotator cuff repair (RCR) is perhaps the commonest of shoulder surgeries, therefore extended followup is also of great interest to the payers of health care. Yet getting reliable and relevant data is difficult because of patients lost to followup and evolution of surgical techniques.
The authors of Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair point out that while studies have shown considerable symptomatic relief in the short term following surgery, a relatively high rate of recurrent defects has led surgeons to question the long-term durability of this operation.
193 patients had all-arthroscopic rotator cuff repair by one of 12 surgeons between 2003 and 2005 and thus were potentially eligible for 15 year followup. Rotator cuff integrity was classified according to the method described by Harryman et al (Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff). In this classification scheme, type 0 indicates intact; type 1A, partial tear of the supraspinatus; type 1B, full-thickness tear of the supraspinatus; type 2, full-thickness tear involving the supraspinatus and infraspinatus; and type 3, full thickness tear involving the supraspinatus, infraspinatus, and subscapularis.
They collected patient-reported outcomes preoperatively and at 1, 2, 5, and 15 years postoperatively. 60 patients (31% of the initial cohort) had a mean follow-up period of 16.5 years. For these patients, the mean ASES score improved from 60 preoperatively to 93 at 15 years.
There were no factors significantly associated with the final ASES score. Specifically neither the tear size or the integrity of the repair at 5 years correlated with the final ASES score.
Comment: While a 31% fifteen year followup rate is impressive, the lack of data on the missing 69% leaves us without a full understanding of the long term effectiveness of RCR. The lack of correlation of the available outcomes with the integrity of the repair leaves us without information regarding the importance of a durable repair.
Substantial resources are being poured into innovations for improving the healing rates and clinical outcomes of cuff repair, such as different repair methods (double row, transosseous equivalent, etc), grafts, stem cells, platelet rich plasma, and growth factors. This study shows that accessing the longterm value of these efforts to the patient will be difficult.
Furthermore, the ASES score for the patients in this study with 15+ years of followup averaged 93. According to Establishing minimal clinically important difference for the UCLA and ASES scores after rotator cuff repair The mean MCID value for the ASES score was 15.2 points. Thus, since the maximum ASES score is 100, it is not mathematically possible for any innovation to make a clinically significant improvement in the outcome of rotator cuff repair.
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