Surgery or No Surgery: What’s the Best Option for Rotator Cuff Tears?

    When a patient presents with signs and symptoms of a rotator cuff tear, should a surgical procedure be done right away?

    The answer depends on certain factors, according to Jay D. Keener, MD, from Washington University in St. Louis, Missouri:

    • Is the tear reparable?
    • If it is, what is the healing potential?
    • If it’s reparable and could heal, what are the risks of non-operative treatment?

    Dr. Keener told attendees at ICJR’s 7th Annual Shoulder Course that irreparable tears:

    • Are typically atraumatic and chronic
    • Usually involve 2 tendons, although the size can vary
    • Retract medial to the humeral head
    • Have Grade 3 or Grade 4 Goutallier changes

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    The healing potential of a rotator cuff tear probably matters more in younger patients than in older patients, Dr. Keener said. Patients over age 65 generally have a longer recovery period, lower healing rates, and less predictable clinical outcomes. However, older patients, especially active older patients, often want to undergo rotator cuff repair to relieve pain.

    Research has shown fair to good outcomes and low revision rates in older patients who undergo rotator cuff repair, Dr. Keener said, although the surgeon should consider other options if strength is an issue, as in patients with pseudoparalysis, severe overhead weakness, or rotational weakness.

    Tear size and advanced fatty muscle changes are independent predictors of healing:

    • Healing drops off when the tear is more than 25 to 30 mm.
    • Grade 3 and 4 changes, especially in more than 1 muscle, is thought to be irreversible and an indication for treatment other than rotator cuff repair.

    Retraction, though, may be more important than tear size, Dr. Keener said: Tension is the “kiss of death” for cuff repair.

    So, which tears are appropriate for surgical management and which can be treated non-operatively, at least early on? Non-operative management is successful in 60% to 75% of patients with rotator cuff tears, Dr. Keener said. He avoids early surgery in patients with:

    • Partial-thickness tears
    • Small full-thickness tears with an intact cable
    • Tears with advanced muscle changes

    He is inclined to be more aggressive surgically in patients with:

    • A full-thickness rotator cuff tear that’s more than 15 to 20 mm because of the risk of progression of muscle changes and kinematic disruption
    • A recent enlargement of the tear, indicated by a sudden increase in pain and weakness
    • Anterior cable disruption

    He will also recommend early surgery for younger patients with a full-thickness rotator cuff tear.

    Click the image above to watch Dr. Keener’s presentation from ICJR’s 7th Annual Shoulder Course and learn more about rotator cuff tears.

    Disclosures: Dr. Keener has no disclosures relevant to this presentation.