Therapeutics

In rotator cuff tears, primary tendon repair was better than physiotherapy for some measures of function at 5 years 多多多多多多夞

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Moosmayer S, Lund G, Seljom US, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. J Bone Joint Surg Am. 2014;96:1504-14.

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Question In patients with rotator cuff tears, what is the relative efficacy of primary tendon repair and physiotherapy with optional secondary tendon repair for long-term outcomes?

Shoulder and Elbow Surgeons self-report score, Short-Form 36 Health Survey physical score, and strength. Patient follow-up: 98% (intention-to-treat analysis).

Main results

Methods Design: Randomized controlled trial. ClinicalTrials.gov NCT00852657.

24% of patients in the physiotherapy group had secondary tendon repair at 2 years. The main results are in the Table.

Conclusion

Allocation: Concealed.*

In patients with rotator cuff tears, primary tendon repair improved pain and some measures of function at 5 years compared with physiotherapy and optional secondary tendon repair.

Blinding: Blinded* (outcome assessors). Follow-up period: 5 years. Setting: Secondary care center in Norway. Patients: 103 patients ≥ 18 years of age (mean age 60 y, 71% men) who were referred for treatment of rotator cuff tears and had lateral shoulder pain at rest or exercise, painful motion arc, passive shoulder motion ≥ 140° for abduction and flexion, positive impingement sign, and a full-thickness tear with muscle atrophy ≤ stage 2 on magnetic resonance imaging and size ≤ 3 cm on ultrasonography. Exclusion criteria included tears > 25% of subscapularis tendon width, previous surgery on affected shoulder, or local or systemic diseases that affect shoulder function. Intervention: Primary tendon repair using an open or miniopen approach and a modified Mason-Allen technique, followed by postoperative passive range-of-motion exercises and referral for supervised physiotherapy and home exercises after discharge (n = 52); or individually tailored, outpatient physiotherapy, based on a set of 52 exercises given in 40-minute sessions twice weekly for 12 weeks and less frequently for the next 6 to 12 weeks, plus patient education and optional secondary tendon repair if the condition persisted after ≥ 15 physiotherapy sessions (n = 51). Outcomes: Primary outcome was the Constant score. Other outcomes included pain, pain-free shoulder mobility, American Primary tendon repair vs physiotherapy in patients with rotator cuff tears† Outcomes

Mean values at 5 y Primary Physiotherapy tendon repair

Mean difference (95% CI) at 5 y‡

Constant score

80

74

6.5 (⫺0.7 to 14)

Pain, cm (10-cm visual analogue scale)

0.6

1.6

1.0 (0.2 to 1.8)

Pain-free abduction, degrees

167

155

15 (0.1 to 29)§

Pain-free flexion, degrees

171

164

8.3 (⫺4.4 to 21)

ASES self-report score

93

85

8.3 (1.2 to 15)

Short-Form 36 physical summary score

50

48

1.9 (⫺2.3 to 6.2)

Strength, kg

12

11

0.8 (⫺1.1 to 2.7)||

*See Glossary. Source of funding: South-Eastern Norway Regional Health Authority. For correspondence: Dr. S. Moosmayer, Martina Hansens Hospital, Sandvika, Norway. E-mail [email protected] 

Commentary The role of surgery in management of rotator cuff tears has become increasingly uncertain (1), and the trial by Moosmayer and colleagues adds further fuel to the debate. The study had appropriate randomization and allocation concealment, blinded outcome assessors, intention-to-treat analysis, 98% follow-up at 5 years, and adherence to the CONSORT guidelines for reporting trial results. Patients treated conservatively and those treated with either open or mini-open rotator cuff repair did not differ for final functional outcome as assessed by the Constant score. However, several issues deserve attention. First, this was a “pragmatic trial.” Although it tries to imitate real life, the lack of intervention standardization allows for confounding of treatment effect by surgical or physiotherapy techniques. Second, 24% of the physiotherapy patients were not satisfied and had surgery within the first 2 years, so the results may underestimate the true benefit of surgery. Comparing as-treated groups, patients treated surgically did slightly better at 5 years, but early vs late surgery did not differ for Constant scores. Finally, ultrasound assessment of rotator cuff integrity at 5 years showed that tear sizes increased by 5 to 24 mm in 37% of patients in the physiotherapy-only group, and these patients had worse outcomes than those with tears that remained relatively stable in size. Although Moosmayer and colleagues found no difference in Constant scores after early surgical cuff repair compared with physiotherapy, it is unclear how best to apply these results to clinical practice because of the number of crossover patients and the observed deterioration of some tears treated nonoperatively. Nonetheless, the results will allow surgeons to better educate their patients on the potential course of surgical or nonsurgical management. Patrick Henry, MD Sunnybrook Health Sciences Centre Toronto, Ontario, Canada

†ASES = American Shoulder and Elbow Surgeons; CI defined in Glossary. ‡Adjusted for baseline values and patient age. Positive values indicate benefits with primary tendon repair. Results are consistent with linear mixed models using repeated measurements unless stated otherwise. §P = 0.15 with linear mixed model. ||Treatment by time interaction, P < 0.001: mean difference at 6 months ⫺2.5 kg, CI ⫺4.2 to ⫺0.7 favoring physiotherapy; differences at 1, 2, and 5 y were not significant.

Reference 1. Kuhn JE, Dunn WR, Sanders R, et al; MOON Shoulder Group. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22: 1371-9.

17 March 2015 Annals of Internal Medicine ACP Journal Club Downloaded From: http://annals.org/ by a Western Michigan University User on 05/06/2015

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姝 2015 American College of Physicians

ACP journal club. In rotator cuff tears, primary tendon repair was better than physiotherapy for some measures of function at 5 y.

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