The American Academy of Orthopedic Surgeons released working group guidelines for rotator cuff injuries and repair. There were some very surprising recommendations that tend to follow the recent blog posts here on the evidence that shoulder surgery for a torn rotator cuff is not much better than no surgery. I have to applaud the working group for what appears to be a very thorough and candid assessment of the efficacy research to date on surgery for shoulder rotator cuff tears. Here are the real bombshells (my comments in italics):
-Full thickness tears and symptomatic patients. Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears. Surprising that the recommendation is lukewarm as we still see that surgery for patients with full thickness, symptomatic rotator cuff tears is the norm.
–Rotator cuff-related symptoms. The workgroup suggests patients who have rotator cuff-related symptoms without a full thickness tear are treated initially nonoperatively using exercise and/or non-steriodal anti-inflammatory drugs. My comments on NSAID complications and side effects in the earlier post today.
–Acute traumatic rotator cuff tears and surgery. Early surgical repair after an acute injury is an option for patients with rotator cuff tears, but the recommendation from the group is weak. Again, we still see these being operated early, but the working group appears to be making a recommendation here that’s very wise-wait and see if it heals.
–Surgery. The group suggests routine acromioplasty isn’t required at the time of rotator cuff repair. There is a weak recommendation for performing partial rotator cuff repair, debridement or muscle transfer for patients with irreparable rotator cuff tears. We still see routine acromioplasty with many rotator cuff repairs as well as partial rotator cuff repair. Acromioplasty means cutting out bone and important ligaments that may be causing impingement on the rotator cuff.
There are still some patients that will likely benefit from shoulder rotator cuff surgery, but for many, it’s likely not going to help. While there seems to be a way to go before these AAOS recommendations filter down to routine orthopedic practice, they will likely start adversely affecting insurance reimbursement for many of these rotator cuff repair surgeries, so that may have it’s own impacts on utilization.