Nonoperative Management of the Rotator Cuff: Is it Legal? John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics and Rehabilitation Chief of Shoulder Surgery Vanderbilt S ports Medicine
Disclosures • I am a Surgeon • I like fixing rotator cuff tears Vanderbilt S ports Medicine
When I was Young….. Presence of the Condition was the Indication for Surgery Vanderbilt S ports Medicine
WHY? Vanderbilt S ports Medicine
Eminence Based Medicine Vanderbilt S ports Medicine
EVIDENCE Based Medicine DATA DOGMA Vanderbilt S ports Medicine
You take the blue pill—the story ends, you wake up in your bed and believe whatever you want to believe . You take the red pill—…and I show you how deep the rabbit hole goes. Remember: all I'm offering is the truth. Nothing more. Vanderbilt S ports Medicine
DATA Driven Thinking Points • PREVALENCE • SYMPTOMS and CUFF DISEASE • REHABILITATION AS TREATMENT • WHY PATIENTS HAVE SURGERY Vanderbilt S ports Medicine
Prevalence Data How Many Cuff Tears Are There? • US Population in 2010 = 308.4 Million • Over age 60 = 57 Million Vanderbilt S ports Medicine
Prevalence Data • What proportion of people have full thickness rotator cuff tears? Reilly et al. Ann R Coll Surg Engl 88:116-121, 2006 Vanderbilt S ports Medicine
POINT 1: PREVALENCE HOW MANY CUFF TEARS ARE THERE? 5.7 to 22.8 MILLION IN USA Vanderbilt S ports Medicine
Who Has Surgery? • 270,000 rotator cuff surgeries/ year • 270,000/ 5.7 Million = 4 .7 % • 270,000/ 22.8 Million = 1 .2 % 1 .2 % to 4 .7 % of people w ith cuff tears are getting surgery..... Vanderbilt S ports Medicine
THINKING POINT If <5% of People with Rotator Cuff Tears are Having Surgery…. Should I be Operating on Every Rotator Cuff Tear I See? Vanderbilt S ports Medicine
POINT 2: SYMPTOMS Assumption SUBJECTIVE OBJECTIVE Vanderbilt S ports Medicine
QUESTION 1 IS IT POSSIBLE THAT THIS ASSUMPTION IS WRONG? Vanderbilt S ports Medicine
Prevalence >95% of Full Cuff Tears are NOT Getting Surgery Are all these cuff tears painful? Vanderbilt S ports Medicine
MOON COHORT DATA Do Symptoms Correlate with Cuff Tear Severity? Pain Level? NO (Dunn et al JBJS 96(10):793-800, 2014) Duration of Symptoms? NO (Unruh et al JSES 23(13):1052-8, 2014) Activity Level? NO (Brophy et al AJSM 42(5)1150-4, 2014) Symptoms DO NOT Correlate with Cuff Tear Severity Vanderbilt S ports Medicine
FAILED CUFF REPAIRS Approximately 1/3 of Cuff Repairs Fail Patient Satisfaction, Pain and PROs are the Same if your Cuff Repair FAILS If the Cuff Tear was the Source of Pain-Shouldn’t These Hurt?…. Vanderbilt S ports Medicine
THINKING POINT The Relationship between Pain and Rotator Cuff Tears is NOT Robust SUBJECTIVE is NOT related to the OBJECTIVE THE CUFF MAY NOT BE THE SOURCE OF PAIN Vanderbilt S ports Medicine
POINT 3: REHABILITATION IS EFFECTIVE PT does not Fix the Cuff Tear If the Cuff Tear was the Source of Pain PT Should Fail Vanderbilt S ports Medicine
• 452 subjects were enrolled and given an EBM based physical therapy program • Assess patients at 6, 12 weeks, 1, 2, years, 5 years – Are you cured? – Are you better and want to continue with therapy? – Are you no better and want to have it repaired? Vanderbilt S ports Medicine
Effectiveness of Therapy 5 Year Outcomes 5 year outcomes 9 2 8 9 Surgery Cured Deceased Dropped Out Lost 191 85% Follow up at 5 years 3% Died-0% had Reverse TSA 3% died, 16% lost to follow up 24% had Surgery; 76% Did Not Vanderbilt S ports Medicine Those that had Surgery Decided Early
Features NOT Predictors of Surgery Patient Factors Structural Factors: • Age, sex, BMI • Number of tendons torn • Handedness • Forward elevation strength • Education, occupation • Work-compensation status • Comorbidities • Pain level • Duration of symptoms • SANE score Vanderbilt S ports Medicine
What Predicted Surgery? PATIENT EXPECTATIONS • If a patient believed PT would work-It did • If a patient believed PT would not work-they had surgery Vanderbilt S ports Medicine
Relative Strength of Predictors Vanderbilt S ports Medicine
DATA Driven Thinking Points • PREVALENCE – >95% of Cuff Tears are NOT having surgery • SYMPTOMS and CUFF DISEASE – The Cuff Tear may NOT be the Source of Pain • REHABILITATION AS TREATMENT AT 5 YEARS – 75% are NOT Having Surgery – You are more likely to DIE than have a Reverse TSA • WHY SOME PATIENTS HAVE SURGERY – Because they believe they need it, (or worse, we talk them into it.... Vanderbilt S ports Medicine
Nonoperative Management of the Rotator Cuff: Is it Legal? Of course it is Legal….. The Real Quesion: Vanderbilt S ports Medicine
Is it Ethical to do Surgery When: • >95% of people with the condition are fine and not in your office • 1/3 of the repairs fail-this does not effect the outcome • The Anatomy that you fix is NOT related to the patients symptoms! • The decision to have surgery is driven by patient expectations, not the Anatomy! Vanderbilt S ports Medicine
Is it LEGAL to do Surgery without INFORMED Consent? • Dr. Plancher, you have an atraumatic cuff tear, like 6 million other Americans • Less than 5% of Americans with Cuff Tears Have Surgery • If the symptom is PAIN, exercises will get 80% of patients better, it may take 12 weeks, it will last at least 5 years. • If the symptoms is WEAKNESS, you could consider surgery. Vanderbilt S ports Medicine
Is it LEGAL to do Surgery without INFORMED Consent? • Surgery improves pain and weakness, but the repair will fail about 1/3 of the time • If you elect to treat this with exercise, you should contact me if your symptoms worsen so we can monitor your cuff tear as some tears progress • We just can’t predict if your tear will progress, or how rapidly, or to what level of symptoms Vanderbilt S ports Medicine
Remember: all I'm offering is the truth. Nothing more. Vanderbilt S ports Medicine
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