Tendon Repair Is Superior to Physiotherapy

At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatmentof Small and Medium-Sized Rotator Cuff Tears

Moosmayer, Stefan MD, PhD; et alt.

Departments of Orthopaedic Surgery (S.M.), Physiotherapy (G.L., U.S.S., B.H., and I.C.S.), and Occupational Therapy (T.H.), Martina Hansen’s Hospital, Sandvika, Norway

JBJS: June 19, 2019 - Volume 101 - Issue 12 - p 1050-1060
doi: 10.2106/JBJS.18.01373

"apa prenem nota i comencem a mirar les ruptures del manegot diferentment..."

Background: Tendon repair and physiotherapy are frequently used treatment methods for small and medium-sized rotator cuff tears. In 2 previous publications of the 1 and 5-year results of this study, we reported significant but small between-group differences in favor of tendon repair. Long-term results are needed to assess whether the results in both groups remain stable over time.

Methods: In this study, 103 patients with a rotator cuff tear not exceeding 3 cm were randomly assigned to primary tendon repair or physiotherapy with optional secondary repair. Blinded follow-up was performed after 6 months and 1, 2, 5, and 10 years. Outcome measures included the Constant score; the self-report section of the American Shoulder and Elbow Surgeons score; the measurement of shoulder pain, motion, and strength; and patient satisfaction. Magnetic resonance imaging (MRI) was performed on surgically treated shoulders after 1 year, and ultrasound was performed on all shoulders after 5 and 10 years. The main analysis was by 1-way analysis of covariance and by intention to treat.

Results: Ninety-one of 103 patients attended the last follow-up. After 10 years, the results were better for primary tendon repair, by 9.6 points on the Constant score (p = 0.002), 15.7 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), 19.6° for pain-free abduction (p = 0.007), and 14.3° for pain-free flexion (p = 0.01). Fourteen patients had crossed over from physiotherapy to secondary surgery and had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (p = 0.03).

Conclusions: At 10 years, the differences in outcome between primary tendon repair and physiotherapy for small and medium-sized rotator cuff tears had increased, with better results for primary tendon repair.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Superior Capsular Reconstruction for Massive Rotator Cuff Tears
A Critical Analysis Review
Galvin, Joseph W., DO1; Kenney, Raymond, MD2; Curry, Emily J., BA3; Parada, Stephen A., MD4; Eichinger, Josef K., MD5; Voloshin, Ilya, MD2; Li, Xinning, MD3
JBJS Reviews: June 04, 2019 - Volume Latest Articles - Issue - p
doi: 10.2106/JBJS.RVW.18.00072

Es actualment un tema controvertit...quan no es tenen mes recursos en ruptures massives. Com tot la indicacio es la clau.
Joves
Massiva ( 2 tendons + 5 cm)
cap signe de artropatia glenohumeral ( cal RM)
Preferible empelt de fascia lata de 8cm de 3mm de gruix.

Al meu criteri, com be diuen esta per veure que resulta mes una protesi o aixó i despres la pròtesi. En fi veurem...

A massive rotator cuff tear is defined as a tear involving >2 tendons or >5 cm of retraction.
Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.
Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.
Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.
Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.
Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.
No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears. However, the potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.
Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.
Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized