The rotator cuff dilemma – revisited

A black-shouldered kite with prey. The image is CC by Tariq Sani.
A black-shouldered kite with prey. The image is CC by Tariq Sani.

Is Kukkonen et. al.’s RCT the end of our love for the rotator cuff tear? The industry surrounding rotator cuff tears costs in the US alone about $3 billion every year, earning a top position among common orthopaedic procedures. I have previously written about my doubts concerning this procedure and it is with some satisfaction that I dive in to this recent study by Kukkonen et. al.

It is better to have loved and lost, than never to have loved at all.

Alfred Lord Tennyson

Summary

They did a three-armed randomized controlled trial of 180 shoulders (173 patients). The groups being compared were:

  • Physiotherapy
  • Acromioplasty and physiotherapy
  • Repair, acromioplasty and physiotherapy

They managed to follow 93 % and the results indicated no difference between any of the treatment groups one year later. The repair group was remarkably similar to the acromioplasty group while the physiotherapy did slightly worse, especially regarding pain and ADL.

My view

This is an impressive study and I’m a little surprised that the surgical placebo effect wasn’t more pronounced. The study also provides little support for doing anything more than a acromiplasty and this makes intuitive sense: repairing an old tendon rupture makes little sense as muscles without tension become fat. At the same time, an impingement syndrome should respond to acromioplasty.

A few random thoughts:

  • A longer follow-up would be appreciated – what happens after 4-5 years?
  • 2/3 were included from the screened population, only 5 % declined study participation – this is an astonishingly good inclusion rate!
  • Blinding with sham surgery would be nice although it could be argued that the physiotherapy protocol needs to differ between the groups
  • Note that this study is not an non-inferiority trial, i.e. it does not exclude a certain effect.

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