Impact of Postoperative Management on Outcomes and Healing of Rotator Cuff Repairs
| Status: | Active, not recruiting |
|---|---|
| Conditions: | Orthopedic |
| Therapuetic Areas: | Orthopedics / Podiatry |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 4/21/2016 |
| Start Date: | September 2011 |
| End Date: | July 2016 |
Rotator cuff tears are seen in 40% of subjects over age 50 57, with a prevalence known to
increase with each decade of life 51. Each year rotator cuff disorders lead to 4.5 million
physician visits, 40,000 inpatient surgeries, and 250,000 outpatient surgeries with costs of
$17,427 per patient in 2004. As the population ages, the number of rotator cuff repair
surgeries is increasing; in New York State, rotator cuff repairs increased by 50% over a 5
years span 48. Unfortunately, surgically repaired rotator cuff tears fail in at least 20%
and up to 94% of individuals 3, 9, 13, 20, 28, 40, 52, 58. While many non-modifiable
variables have been associated with failure of repair, postoperative rehabilitation is a
modifiable variable that has received little attention. The investigators propose a
multicenter randomized controlled trial to study one important strategy for postoperative
rehabilitation: early versus delayed onset of physical therapy. This pilot study will enroll
patients with isolated supraspinatus tears who undergo a standard surgical repair technique.
The investigators hypothesize that delaying the onset of physical therapy will improve
healing and patient outcomes. Our primary outcome variable is the Western Ontario Rotator
Cuff (WORC) Index (a disease specific validated outcome measure). Because outcome measures
may not always correlate with healing of rotator cuff repairs 50, our secondary outcome
measure will be healing based on MRI scans 12 months after surgery.
increase with each decade of life 51. Each year rotator cuff disorders lead to 4.5 million
physician visits, 40,000 inpatient surgeries, and 250,000 outpatient surgeries with costs of
$17,427 per patient in 2004. As the population ages, the number of rotator cuff repair
surgeries is increasing; in New York State, rotator cuff repairs increased by 50% over a 5
years span 48. Unfortunately, surgically repaired rotator cuff tears fail in at least 20%
and up to 94% of individuals 3, 9, 13, 20, 28, 40, 52, 58. While many non-modifiable
variables have been associated with failure of repair, postoperative rehabilitation is a
modifiable variable that has received little attention. The investigators propose a
multicenter randomized controlled trial to study one important strategy for postoperative
rehabilitation: early versus delayed onset of physical therapy. This pilot study will enroll
patients with isolated supraspinatus tears who undergo a standard surgical repair technique.
The investigators hypothesize that delaying the onset of physical therapy will improve
healing and patient outcomes. Our primary outcome variable is the Western Ontario Rotator
Cuff (WORC) Index (a disease specific validated outcome measure). Because outcome measures
may not always correlate with healing of rotator cuff repairs 50, our secondary outcome
measure will be healing based on MRI scans 12 months after surgery.
Surgically repaired rotator cuff tears fail at surprisingly high rates, approaching 20-94%
as determined by MRI 3, 9, 13, 20, 28, 40, 52, 58. Non-modifiable variables associated with
rotator cuff repair failure include: duration of symptoms 9, 19, 39, fatty infiltration of
the atrophied muscle 6, 15, 17, larger rotator cuff tears 6, 9, 19, 20, 21, 26, 39, 47,
older age 9, 20, 22, 48, 55, co-morbidities 48, and workers compensation claims 2, 22, 23.
Potentially modifiable variables include: tobacco use 11, 38, limited preoperative range of
motion 45, and surgeon volume 48.
Two other modifiable variables are surgical technique and postoperative management. As
advances in arthroscopic techniques have evolved, a variety of studies have evaluated
different surgical techniques in clinical series and trials 3, 4, 20, 12, 18, 31, 36. In
2006, Park et al described the "transosseous equivalent" repair technique characterized by
sutures secured medially, passed through and over the top of the rotator cuff, and then
secured laterally 44. This method of repair has been shown to have better biomechanical
properties and produce superior healing rates compared to other techniques in randomized
clinical trials 5, 12. These data suggest this technique is currently the best available
method to repair rotator cuff tears.
Postoperative management of patients who have had rotator cuff repair has received little
attention in the literature, yet is likely one of the most important modifiable variables
that can influence rotator cuff repair integrity. It has been argued that early physical
therapy may increase failure rates of rotator cuff repair 1, 14. This has led some to
recommend delaying therapy for up to 6 weeks after surgery.
Three groups have studied delaying the onset of physiotherapy in patients with full
thickness rotator cuff tears. Klintberg et al 29 performed a randomized trial on patients
who underwent open rotator cuff repair comparing two postoperative physical therapy
protocols: a "Progressive Therapy Group" ¬ (started the day after surgery with passive range
of motion and dynamic muscle activation of the rotator cuff, a sling was removed after 4
weeks and rotator cuff loading was progressive through the rehabilitation), and a
"Traditional Group" (passive range of motion the day after surgery with immobilization in a
sling for 6 weeks during which time no rotator cuff loading was applied). In this trial no
significant differences in outcome were detected.
In contrast to this, Deutsch et al 7 reported on 70 patients who had a single row
arthroscopic rotator cuff repair with simple suture configuration randomized to one of two
physical therapy protocols that were different only in that the "Standard" protocol began
passive forward elevation on postoperative day 7 (N=37), whereas the "Delayed" protocol
began passive forward elevation after 4 weeks (N=33). At 6 months range of motion was not
different, however ultrasound examination demonstrated 19% of the repairs failed in the
"Standard" group, whereas only 9% failed in the "Delayed" group (p<0.05).
In a prospective cohort study presented by Accousti et al 1, 56 patients were all managed by
6 weeks of immobilization following rotator cuff repair. When immobilization was removed, 13
patients were considered "stiff" with limited motion, and 43 had "good" passive motion. By
one year none of the patients were considered stiff. In the "stiff" group rotator cuff
repairs failed in 30%, whereas in the group with "good" motion at six weeks 62% of repairs
failed.
These data, while limited, suggest that some period of immobilization may improve healing of
rotator cuff repairs. The effect of immobilization on other measures of outcome is unclear.
Unfortunately none of these studies used the transosseous equivalent repair technique.
The purpose of this study is to compare two different strategies of postoperative management
in patients with isolated supraspinatus rotator cuff tears repaired with a standardized
"SpeedBridge" arthroscopic transosseous equivalent technique, using a disease specific
validated measure of outcome (WORC index) as the primary outcome variable. The design will
be a multicenter randomized trial comparing immediate to delayed physical therapy. As
patient oriented outcomes frequently do not correlate with rotator cuff repair healing 50,
the second aim is to study the effect of these rehabilitation paradigms on rotator cuff
healing by MRI.
as determined by MRI 3, 9, 13, 20, 28, 40, 52, 58. Non-modifiable variables associated with
rotator cuff repair failure include: duration of symptoms 9, 19, 39, fatty infiltration of
the atrophied muscle 6, 15, 17, larger rotator cuff tears 6, 9, 19, 20, 21, 26, 39, 47,
older age 9, 20, 22, 48, 55, co-morbidities 48, and workers compensation claims 2, 22, 23.
Potentially modifiable variables include: tobacco use 11, 38, limited preoperative range of
motion 45, and surgeon volume 48.
Two other modifiable variables are surgical technique and postoperative management. As
advances in arthroscopic techniques have evolved, a variety of studies have evaluated
different surgical techniques in clinical series and trials 3, 4, 20, 12, 18, 31, 36. In
2006, Park et al described the "transosseous equivalent" repair technique characterized by
sutures secured medially, passed through and over the top of the rotator cuff, and then
secured laterally 44. This method of repair has been shown to have better biomechanical
properties and produce superior healing rates compared to other techniques in randomized
clinical trials 5, 12. These data suggest this technique is currently the best available
method to repair rotator cuff tears.
Postoperative management of patients who have had rotator cuff repair has received little
attention in the literature, yet is likely one of the most important modifiable variables
that can influence rotator cuff repair integrity. It has been argued that early physical
therapy may increase failure rates of rotator cuff repair 1, 14. This has led some to
recommend delaying therapy for up to 6 weeks after surgery.
Three groups have studied delaying the onset of physiotherapy in patients with full
thickness rotator cuff tears. Klintberg et al 29 performed a randomized trial on patients
who underwent open rotator cuff repair comparing two postoperative physical therapy
protocols: a "Progressive Therapy Group" ¬ (started the day after surgery with passive range
of motion and dynamic muscle activation of the rotator cuff, a sling was removed after 4
weeks and rotator cuff loading was progressive through the rehabilitation), and a
"Traditional Group" (passive range of motion the day after surgery with immobilization in a
sling for 6 weeks during which time no rotator cuff loading was applied). In this trial no
significant differences in outcome were detected.
In contrast to this, Deutsch et al 7 reported on 70 patients who had a single row
arthroscopic rotator cuff repair with simple suture configuration randomized to one of two
physical therapy protocols that were different only in that the "Standard" protocol began
passive forward elevation on postoperative day 7 (N=37), whereas the "Delayed" protocol
began passive forward elevation after 4 weeks (N=33). At 6 months range of motion was not
different, however ultrasound examination demonstrated 19% of the repairs failed in the
"Standard" group, whereas only 9% failed in the "Delayed" group (p<0.05).
In a prospective cohort study presented by Accousti et al 1, 56 patients were all managed by
6 weeks of immobilization following rotator cuff repair. When immobilization was removed, 13
patients were considered "stiff" with limited motion, and 43 had "good" passive motion. By
one year none of the patients were considered stiff. In the "stiff" group rotator cuff
repairs failed in 30%, whereas in the group with "good" motion at six weeks 62% of repairs
failed.
These data, while limited, suggest that some period of immobilization may improve healing of
rotator cuff repairs. The effect of immobilization on other measures of outcome is unclear.
Unfortunately none of these studies used the transosseous equivalent repair technique.
The purpose of this study is to compare two different strategies of postoperative management
in patients with isolated supraspinatus rotator cuff tears repaired with a standardized
"SpeedBridge" arthroscopic transosseous equivalent technique, using a disease specific
validated measure of outcome (WORC index) as the primary outcome variable. The design will
be a multicenter randomized trial comparing immediate to delayed physical therapy. As
patient oriented outcomes frequently do not correlate with rotator cuff repair healing 50,
the second aim is to study the effect of these rehabilitation paradigms on rotator cuff
healing by MRI.
Inclusion Criteria:
- Patients for inclusion based on MRI documented full thickness supraspoinatus tear
with acute tears, or chronic tears that fail non-operative therapy.
- Tears that involve the supraspinatus and are minimally displaced (Grade I) or
displaced to the humeral head (Grade II) will be included
Exclusion Criteria:
1. Age < 18 years
2. Evidence of major joint trauma, infection, avascular necrosis, chronic dislocation,
inflammatory or degenerative glenohumeral arthropathy, frozen shoulder, or previous
surgery of the affected shoulder,
3. Evidence of significant cuff arthropathy with superior humeral translation and
acromial erosion diagnosed by x-ray or other investigations,
4. Major medical illness (life expectancy < 2 years or unacceptably high operative
risk),
5. Unable to speak or read English,
6. Psychiatric illness that precludes informed consent,
7. Unwilling to be followed for 2 years,
8. Large, massive, or irreparable cuff tears extending into the subscapularis or teres
minor,
9. Inelastic and immobile tendon which cannot be advanced to articular margin,
10. Co-existing labral pathologies requiring repair (SLAP II-IV), Bankart lesions
requiring repair, partial tears of biceps (more than 60% of thickness) requiring
surgical treatment,
11. Acromioclavicular pathology requiring a distal clavicle excision.
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University of Iowa With just over 30,000 students, the University of Iowa is one of...
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