Abstract
INTRODUCTION
The aim of this study was to characterise current rotator cuff repair activity in the UK with emphasis on the management of rotator cuff tears in the elderly population (over 70s).
METHODS
A one-page web-based survey was created. All British Elbow and Shoulder Society (BESS) members and surgeons who listed the shoulder as an area of specialist interest on the website http://www.specialistInfo.com/ were invited to complete this.
RESULTS
A total of 103 surgeons completed the survey; most (n=89, 86%) were BESS members. They had spent a median of 10 years (range: 9 months — 30 years) in consultant practice and performed an annual median of 200 (range: 0—1,000) arthroscopic shoulder procedures. For rotator cuff repair the favoured method was arthroscopic for 47 consultants (46.5%), open or mini-open for 41 (40.6%) and both for 13 (12.9%). The annual median number of arthroscopic and open cuff repairs was 20 (range: 0—250) and 12 (range: 0—100) respectively.
The longer the time in practice, the fewer the reported number of arthroscopic cuff repairs (rs=-0.22, p=0.027) and the greater the number of open and mini-open cuff repairs (rs=0.33, p=0.001). In the management of a full-thickness rotator cuff tear in a patient over 70 years of age, 27 (26.7%) would perform an open or mini-open repair, 43 (42.6%) an arthroscopic repair and 22 (21.8%) would not attempt a repair.
CONCLUSIONS
Surgeons performing a higher volume of arthroscopic cuff repairs annually were more likely to repair cuff tears and they predicted significantly better outcomes of cuff repair for both pain and shoulder movement. Our results reflect the existing conflicting evidence regarding the indications for and methods of treatment of rotator cuff disease.
Keywords: Rotator cuff, Tendon, Arthroscopy
The management of rotator cuff tears is a challenging problem. In the US the rates of rotator cuff repair vary greatly between geographical regions1 and a survey of members of the American Academy of Orthopaedic Surgeons (AAOS) highlighted a significant variation in management.2 Moreover, the indications for repair and best form of repair are not clear.3
In patients who are over 70 years of age the incidence of asymptomatic full-thickness rotator cuff tears is around 38%.4 However, elderly patients often have poorer soft tissue and bone quality. Some surgeons may therefore be less aggressive in their treatment.
The aim of this study was to survey current practices with emphasis on rotator cuff repair, particularly in the elderly population.
Methods
A one page, web-based survey was created using a survey creation tool (http://www.surveymonkey.com/). The survey consisted of three sections: section one contained questions pertaining to the surgeon’s demographic, surgical activity and favoured method of rotator cuff repair, section two contained questions relating to the management of full-thickness rotator cuff tears (Table 1) and section three contained questions about the surgeon’s expectations with regard to the outcomes of repair of a full-thickness rotator cuff tear (Table 2). Approval for the study was gained from the British Elbow and Shoulder Society (BESS) research committee. The survey was carried out in two phases.
Table 1.
Clinical scenarios
| Clinical scenario 1 |
| Preferred method of managing a full-thickness rotator cuff tear resulting in pain and poor function in a patient aged 70 years or over (presuming the patient is active, self caring and medically fit) |
| Clinical scenario 2 |
| Preferred method of managing a full-thickness rotator cuff tear resulting in pain and poor function in a patient aged 60—69 years |
| Clinical scenario 3 |
| Preferred method of managing a full-thickness rotator cuff tear resulting in pain and poor function in a patient aged less than 60 years |
Table 2.
Clinical questions
| Question 1 |
When fully recovered from surgery to repair a full-thickness tear, what percentage of your patients do you expect to be:
|
| Question 2 |
When fully recovered from surgery to repair a full-thickness tear, what percentage of your patients do you expect to have:
|
Phase 1: An electronic link to the survey was sent by BESS to all members on their mailing database.
Phase 2: We compiled a list of orthopaedic surgeons in the UK offering shoulder surgery using the website http://www.specialistinfo.com/. Any surgeons who had replied to phase 1 of the survey were excluded.
The results were analysed by a statistician (HAD) using Excel® 2007 (Microsoft, Redmond, WA, US) and SPSS® v15.0 (SPSS Inc, Chicago, IL, US). Medians were compared using the Mann—Whitney U test (M—W). Associations between continuous variables were assessed using the Spearman’s correlation coefficient (rs). For categorical variables the chi-square (X2) statistic was used. Statistical significance was taken at the 5% level.
Results
Characteristics of responding surgeons
The survey link was sent via email to all 308 consultant members of BESS and also other orthopaedic surgeons in the UK offering shoulder surgery. We received 103 responses. Two respondents were excluded due to not having completed the survey fully. Most of the respondents (89/103, 86%) were BESS members. We used a post hoc calculation to determine the accuracy of our sample using a survey sample size calculator (http://www.custominsight.com/). Our results had an error rate of 6.6% at the 90% confidence level.
Responding surgeons had been in consultant practice for a median of 10 years (range: 9 months — 30 years). More than a third (n=36, 35.6%) had been in practice for ≤5 years while 20 had practised between 6 and 10 years, 22 between 11 and 15 years, and 22 >15 years. The favoured method of rotator cuff repair was arthroscopic in 47 surgeons (46.5%), open or mini-open in 41 (40.6%) and both in 13 (12.9%). The median annual number of arthroscopic shoulder procedures performed was 200 (range: 0—1,000). For arthroscopic cuff repairs it was 20 (range: 0—250) and for open cuff repairs 12 (range: 0—100). The 47 surgeons who listed arthroscopic repair as their preferred method performed a median of 50 (range: 10—250) arthroscopic cuff repairs per year. The 41 surgeons who listed open or mini-open as their preferred method performed a median of 25 (range: 3—90) open/mini-open repairs annually.
Characteristics associated with procedure preference and volume
While there was no statistically significant relationship between years in practice and annual arthroscopic shoulder procedure volume (rs=-0.12, p=0.25), the longer the time in practice the fewer the reported number of arthroscopic cuff repairs (rs=-0.22, p=0.027) and the greater the number of open and mini-open cuff repairs (rs=0.33, p=0.001). Thus, those consultants who had been in practice for fewer than 10 years preferred arthroscopic cuff repair (n=35, 62.5%), whereas consultants who had been practising for more than 10 years preferred open/mini-open cuff repair (n=32, 72.7%; X2=10.9, df=1, p=0.001). A linear trend for increased likelihood of preferring open/mini-open repair with increased time spent practising was also observed (X2=11.7, df=1, p=0.001). There was a strong linear trend for arthroscopic rotator cuff repair being the preferred method the greater the number of arthroscopic shoulder procedures performed per year (X2=27.2, df=1, p<0.001).
Management of full-thickness rotator cuff tears
The preferred methods of surgeons for managing a full-thickness rotator cuff tear resulting in pain and poor function in patients of varying age are given in Table 3. In patients aged 70 and over, almost half of the surgeons (n=49, 48.5%) would undertake a period of conservative treatment followed by operative repair if there was no improvement. This approach was favoured by only 16 (15.8%) for patients under 60 years of age. For the oldest patients, 22 surgeons (21.8%) responded that they would not attempt repair of the cuff tear. Overall, 33 (32.7%) stated they would use physiotherapy or injections as part of their management. For the youngest patients, 54 surgeons (53.5%) opted for an arthroscopic repair, 45 (44.6%) opted for an open/mini-open repair and 6 (5.9%) opted for both modalities. None of the surgeons chose to treat this cuff tear solely non-operatively.
Table 3.
Preferred method of managing a full-thickness rotator cuff tear resulting in pain and poor function in patients of varying age (Scenarios 1 to 3)
| Management* | ≥70 years (Scenario 1) | 60—69 years (Scenario 2) | <60 years (Scenario 3) |
| Physiotherapy/injections | 33 (32.7%) | 11 (10.9%) | 9 (8.9%) |
| Reverse shoulder prosthesis | 9 (8.9%) | 1 (1.0%) | 0 (0.0%) |
| Open/mini-open cuff repair | 27 (26.7%) | 36 (35.6%) | 45 (44.6%) |
| Arthroscopic cuff repair | 43 (42.6%) | 47 (46.5%) | 54 (53.5%) |
| Period of conservative treatment followed by operative repair if no improvement | 49 (48.5%) | 40 (39.6%) | 16 (15.8%) |
| Other | 43 (42.6%) | 23 (22.8%) | 13 (12.9%) |
Surgeon characteristics associated with preferred management
Table 4 shows the annual number of arthroscopic shoulder procedures and cuff repairs performed and the years spent in consultant practice by the chosen method of treatment for each scenario. Across all scenarios, surgeons opting for arthroscopic repair reported that they perform more arthroscopic shoulder procedures annually than those opting for either open/mini-open or no repair. In patients aged ≥70 years (Scenario 1), median procedure frequencies were 200 for those surgeons who would repair arthroscopically and 120 for those who would not attempt a repair (M—W p<0.001). Surgeons opting for arthroscopic repair had also spent less time in consultant practice than those who would not attempt a repair (for Scenario 1: median 5.0 vs 11.0 years; M—W p=0.014).
Table 4.
Annual number of arthroscopic shoulder procedures and cuff repairs performed and years spent in consultant practice by chosen method of treatment for each scenario. Data are shown as median (range).
| Chosen method of treatment | Annual number of procedures performed | Years spent in consultant practice | ||
| Arthroscopic shoulder procedures | Arthroscopic cuff repairs | Open/mini-open cuff repairs | ||
| Scenario 1 | ||||
| No attempt at repair (n=15) | 120 (5—450) | 0 (0—95) | 17.5 (3—50) | 11.0 (2.0—18.0) |
| Open/mini-open (n=27) | 100 (0—1,000) | 5 (0—100) | 27.5 (3—100) | 14.5 (1.5—30.0) |
| Arthroscopic (n=43) | 200 (20—1,000) | 50 (0—250) | 4.5 (0—100) | 5.0 (0.75—29.0) |
| Scenario 2 | ||||
| No attempt at repair (n=5) | 120 (75—250) | 12 (0—95) | 12.0 (5—35) | 14.0 (10.0—18.0) |
| Open/mini-open (n=36) | 120 (0—1,000) | 0 (0—100) | 22.5 (3—100) | 13.0 (1.5—30.0) |
| Arthroscopic (n=47) | 200 (20—1,000) | 50 (5—250) | 5.0 (0—100) | 6.0 (0.75—29.0) |
| Scenario 3 | ||||
| No attempt at repair (n=0) | — | — | — | — |
| Open/mini-open (n=45) | 100 (0—1,000) | 0 (0—100) | 20.0 (3—100) | 11.5 (1.5—30.0) |
| Arthroscopic (n=54) | 225 (20—700) | 50 (0—250) | 5.0 (0—100) | 6.0 (0.75—29.0) |
Surgeons who elected to perform an arthroscopic rotator cuff repair in all three scenarios performed a median of 50 (range: 0—250) arthroscopic cuff repairs per year. This was a much larger number of rotator cuff repairs per year than for those surgeons who said that they would not attempt arthroscopic repair (Scenario 1: M—W p<0.0005). Similarly, for open and mini-open cuff repairs, surgeons who would not undertake this procedure performed fewer open/mini-open cuff repairs annually (Scenario 1: median 5.0 vs 27.5; M—W p<0.0005).
Predicted outcome of surgery
The predicted outcome of surgery in the surgeons’ own patients after repair of a full-thickness rotator cuff tear is illustrated in Table 5. In response to the clinical questions, surgeons performing more arthroscopic cuff repairs reported significantly better outcomes for both pain and shoulder movement. The median percentage of patients expected to be pain free was 80% for those surgeons performing more arthroscopic repairs compared to 70% in those performing fewer (p=0.026). The median percentage of patients expected to have no improvement in pain was greater for those surgeons performing fewer repairs (10% vs 5%, p=0.001). In terms of having a normal range of shoulder movement, 60% vs 30% (p=0.007) of surgeons in the higher and lower arthroscopic volume groups expected this compared to 35% and 60% in the higher and lower frequency open/mini-open groups respectively (p=0.057). After adjusting for years spent in practice, these relationships generally remained statistically significant.
Table 5.
Predicted outcome of surgery in the surgeons’ own patients after repair of a full-thickness rotator cuff tear (%). Data are shown as median (range).
| Outcome | Outcome | |||||
| Annual frequency of cuff repairs* | Pain free | In some pain | Pain not improved | Normal range of shoulder movement | Improved range of shoulder movement | Range of movement not improved |
| Arthroscopic | ||||||
| ≤20 (n=54) | 70 (0—99) | 20 (0—80) | 10 (0—50) | 30 (0—90) | 50 (5—100) | 15 (0—50) |
| >20 (n=47) | 80 (25—95) | 15 (0—70) | 5 (0—20) | 60 (0—95) | 30 (5—95) | 10 (0—40) |
| M—W p-value (adjusted)# | 0.026 (0.067) | 0.21 (0.45) | 0.001 (0.002) | 0.007 (0.012) | 0.061 (0.10) | 0.009 (0.019) |
| Open/mini-open | ||||||
| ≤12 (n=51) | 80 (0—95) | 15 (0—80) | 5 (0—50) | 60 (0—95) | 35 (5—90) | 10 (0—50) |
| >12 (n=50) | 75 (15—99) | 17.5 (0—80) | 10 (0—25) | 35 (0—80) | 50 (10—100) | 10 (0—40) |
| M—W p-value (adjusted)# | 0.310 (0.860) | 0.550 (0.880) | 0.100 (0.820) | 0.057 (0.0840) | 0.058 (0.098) | 0.140 (0.660) |
Discussion
There was a large variation in the rates of arthroscopic shoulder procedures and all forms of rotator cuff repairs being performed. Notably, there was a statistically significant relationship between preference for arthroscopic cuff repair and the surgeons’ annual arthroscopic procedure workload. This finding supports the results of a similar study in the US.2
Surgeons who had been in consultant practice for a shorter period of time were more likely to prefer arthroscopic rotator cuff repair to open techniques. This trend was also noted by Dunn et al.2 This may reflect the relatively recent development of arthroscopic shoulder surgery and the availability of training in this area. However, there is no conclusive evidence that arthroscopic cuff repair is better although it is less invasive. In the field of distal radius fracture treatment, other authors have observed that younger surgeons may be more likely to adopt newer techniques without evidence of superior results.5 There is certainly an intrinsic attraction towards newer technologies or techniques and surgeons may perceive certain pressures to offer these.
Overall, the favoured method of rotator cuff repair was arthroscopic (46.5%). In the study by Dunn et al only 14.5% of surgeons preferred arthroscopic cuff repair, with 46.2% and 36.6% preferring mini-open and open methods respectively.2 This difference may be accounted for by several factors. Our study concentrated solely on shoulder specialists whereas the former randomly surveyed members of the AAOS. There is approximately four years’ time difference between the two studies, during which arthroscopic shoulder surgery has further developed.
In the clinical scenarios, those surgeons who opted to repair the cuff tear in an elderly patient performed a significantly higher volume of cuff repairs in their own practice than those who opted not to repair. The reasons behind this are probably multifactorial. Those surgeons with a higher procedure volume may have better results and therefore be more likely to offer a patient surgical repair. The patients may also be more likely to agree to this. Alternatively, the higher procedure volume may be accounted for by the fact that these surgeons are more aggressive with regard to repairing cuff tears.
It has been reported that surgeons performing a higher volume of rotator cuff surgery estimated the results to be better.2 Similarly, we found that surgeons performing more arthroscopic cuff repairs reported significantly better outcomes for both pain and shoulder movement compared to those performing fewer arthroscopic repairs. There was a tendency for surgeons performing more open/mini-open cuff repairs to report a poorer outcome compared to those performing smaller numbers of these repairs.
We cannot account for this difference between the arthroscopic and open/mini-open surgeons. Nevertheless, we do know that surgeons who had been in consultant practice for longer performed more open/mini-open cuff repairs. Their greater experience could mean that they are correct to be less optimistic about the results of cuff repairs. Conversely, surgeons performing higher volumes of arthroscopic repairs may be more enthusiastic about the procedure and therefore estimate better outcomes. This would lead to further increased numbers of cuff repairs being performed. An alternative explanation is that higher volume surgeons have better outcomes. Trends for better results and lower complication rates in larger volume centres have been reported in arthroplasty of the shoulder, hip and knee.6–10
There were clear trends in the preferred management across age groups: the older the patient, the greater the likelihood of the surgeon preferring non-surgical options and the lower the likelihood of a surgical approach.
There is currently no clear evidence to say either arthroscopic, open or mini-open repair is better.11—17 One of the strengths of our study was that we were able to sample the practices of a large number of specialist shoulder surgeons. While we accept that this does not represent the practices of all shoulder surgeons in the UK, it does allow us to reflect on current trends within the consultant body.
Our study has several limitations. We were unable to confirm how many clinicians actually received the survey link and our response rates were low, which potentially limits generalisability. Selection bias towards those most likely to respond to this voluntary internet-based questionnaire means that respondents may not be representative of the entire population of shoulder surgeons. In addition, there may be inaccuracies in recalling the exact numbers of procedures.
The questionnaire was deliberately designed as a simple one-page survey in an attempt to increase response rates. A subject such as rotator cuff disease cannot be summed up in such a simplified way.
Conclusions
The management of rotator cuff tears varies greatly among shoulder surgeons in the UK. The reasons for this variation are not clearly explained by our results; however, the variation is understandable in the context of our current knowledge about rotator cuff pathology.
References
- 1.Vitale MG, Krant JJ, Gelijns AC, et al. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. J Bone Joint Surg Am. 1999;81:763–772. doi: 10.2106/00004623-199906000-00003. [DOI] [PubMed] [Google Scholar]
- 2.Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87:1,978–1,984. doi: 10.2106/JBJS.D.02944. [DOI] [PubMed] [Google Scholar]
- 3.Oh LS, Wolf BR, Hall MP, et al. Indications for rotator cuff repair: a systematic review. Clin Orthop Relat Res. 2007;455:52–63. doi: 10.1097/BLO.0b013e31802fc175. [DOI] [PubMed] [Google Scholar]
- 4.Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8:296–299. doi: 10.1016/s1058-2746(99)90148-9. [DOI] [PubMed] [Google Scholar]
- 5.Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence? J Bone Joint Surg Am. 2008;90:1,855–1,861. doi: 10.2106/JBJS.G.01569. [DOI] [PubMed] [Google Scholar]
- 6.Jain N, Pietrobon R, Hocker S, et al. The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2004;86:496–505. doi: 10.2106/00004623-200403000-00006. [DOI] [PubMed] [Google Scholar]
- 7.Hammond JW, Queale WS, Kim TK, McFarland EG. Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2003;85:2,318–2,324. doi: 10.2106/00004623-200312000-00008. [DOI] [PubMed] [Google Scholar]
- 8.Norton EC, Garfinkel SA, McQuay LJ, et al. The effect of hospital volume on the in-hospital complication rate in knee replacement patients. Health Serv Res. 1998;33:1,191–1,210. [PMC free article] [PubMed] [Google Scholar]
- 9.Lavernia CJ, Guzman JF. Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty. 1995;10:133–140. doi: 10.1016/s0883-5403(05)80119-6. [DOI] [PubMed] [Google Scholar]
- 10.Katz JN, Losina E, Barrett J, et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2001;83:1,622–1,629. doi: 10.2106/00004623-200111000-00002. [DOI] [PubMed] [Google Scholar]
- 11.Baysal D, Balyk R, Otto D, et al. Functional outcome and health-related quality of life after surgical repair of full-thickness rotator cuff tear using a mini-open technique. Am J Sports Med. 2005;33:1,346–1,355. doi: 10.1177/0363546505275130. [DOI] [PubMed] [Google Scholar]
- 12.Klepps S, Bishop J, Lin J, et al. Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med. 2004;32:1,716–1,722. doi: 10.1177/0363546504265262. [DOI] [PubMed] [Google Scholar]
- 13.Bishop J, Klepps S, Lo IK, et al. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15:290–299. doi: 10.1016/j.jse.2005.09.017. [DOI] [PubMed] [Google Scholar]
- 14.Galatz LM, Griggs S, Cameron BD, Iannotti JP. Prospective longitudinal analysis of postoperative shoulder function: a ten-year follow-up study of full-thickness rotator cuff tears. J Bone Joint Surg Am. 2001;83:1,052–1,056. [PubMed] [Google Scholar]
- 15.Sauerbrey AM, Getz CL, Piancastelli M, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. Arthroscopy. 2005;21:1,415–1,420. doi: 10.1016/j.arthro.2005.09.008. [DOI] [PubMed] [Google Scholar]
- 16.Youm T, Murray DH, Kubiak EN, et al. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcomes and patient satisfaction. J Shoulder Elbow Surg. 2005;14:455–459. doi: 10.1016/j.jse.2005.02.002. [DOI] [PubMed] [Google Scholar]
- 17.Severud EL, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus mini-open rotator cuff repair: a long-term retrospective outcome comparison. Arthroscopy. 2003;19:234–238. doi: 10.1053/jars.2003.50036. [DOI] [PubMed] [Google Scholar]