Nonoperative Management of the Rotator Cuff: Is it Legal? John E. - - PowerPoint PPT Presentation

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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

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Disclosures

• I am a Surgeon
• I like fixing rotator cuff tears

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When I was Young…..

Presence of the Condition was the Indication for Surgery

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WHY?

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Eminence Based Medicine

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EVIDENCE Based Medicine

DATA DOGMA

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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.

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DATA Driven Thinking Points

• PREVALENCE
• SYMPTOMS and CUFF DISEASE
• REHABILITATION AS TREATMENT
• WHY PATIENTS HAVE SURGERY

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Prevalence Data How Many Cuff Tears Are There?

• US Population in 2010 = 308.4 Million
• Over age 60 = 57 Million

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Prevalence Data

• What proportion of people have full thickness

rotator cuff tears?

Reilly et al. Ann R Coll Surg Engl 88:116-121, 2006

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POINT 1: PREVALENCE

HOW MANY CUFF TEARS ARE THERE?

5.7 to 22.8 MILLION IN USA

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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.....

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THINKING POINT

If <5% of People with Rotator Cuff Tears are Having Surgery…. Should I be Operating on Every Rotator Cuff Tear I See?

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POINT 2: SYMPTOMS Assumption

SUBJECTIVE OBJECTIVE

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QUESTION 1

IS IT POSSIBLE THAT THIS ASSUMPTION IS WRONG?

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Prevalence

>95% of Full Cuff Tears are NOT Getting Surgery

Are all these cuff tears painful?

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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

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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?….

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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

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POINT 3: REHABILITATION IS EFFECTIVE PT does not Fix the Cuff Tear If the Cuff Tear was the Source of Pain PT Should Fail

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• 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?

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Effectiveness of Therapy

5 Year Outcomes

85% Follow up at 5 years 3% died, 16% lost to follow up 24% had Surgery; 76% Did Not Those that had Surgery Decided Early

9 191 9 2 8

5 year outcomes

Surgery Cured Deceased Dropped Out Lost

3% Died-0% had Reverse TSA

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Features NOT Predictors of Surgery

Patient Factors

• Age, sex, BMI
• Handedness
• Education, occupation
• Work-compensation status
• Comorbidities
• Pain level
• Duration of symptoms
• SANE score

Structural Factors:

• Number of tendons torn
• Forward elevation strength

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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

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Relative Strength of Predictors

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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....

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Nonoperative Management of the Rotator Cuff: Is it Legal? Of course it is Legal….. The Real Quesion:

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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
• utcome
• 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!

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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.

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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

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Remember: all I'm offering is the truth. Nothing more.