Treatment of patients with rotator cuff tears – comparative evidence on the effectiveness of tendon repair and conservative treatment for mainly supraspinatus tendon tears

Rotator cuff tears are a common finding in imaging studies. Tears are usually located at the supraspinatus tendon area, one of the four rotator cuff muscles. The symptoms of tears are frequently reported as shoulder pain and weakness. Physiotherapy, a conservative treatment, can relieve symptoms substantially. However, literature reporting on conservative treatment is scarce. Another well-established treatment modality is rotator cuff repair. According to several observational studies, rotator cuff repair, combined with physiotherapy, yields good to excellent results. Since the introduction of arthroscopic techniques, the incidence of rotator cuff repair has increased substantially despite the lack of clear evidence-based treatment guidelines. Given this, randomized controlled trials are needed to produce low-biased evidence and several randomized controlled trials can be combined in a meta-analysis to provide high-level evidence comparing the effectiveness of different treatment modalities. In this thesis, a systematic review and meta-analysis was conducted to evaluate evidence on the effectiveness of tendon repair compared with the conservative treatment of rotator cuff tear. Furthermore, we investigated, with a randomized controlled trial, the difference in mid-term outcome between physiotherapy, acromioplasty and tendon repair to treat non-traumatic supraspinatus tendon tears. In addition, we investigated the effectiveness of supervised physiotherapy compared with home exercises alone after supraspinatus tendon repair. Finally, we present a protocol for the Acute Cuff Tear Repair Trial (ACCURATE) to investigate the difference in outcomes between placebo surgery and arthroscopic rotator cuff repair in patients with a supraspinatus tendon tear related to trauma. According to the meta-analysis and our randomized controlled trial, tendon repair probably does not provide clinically relevant improvement, in 1- to five-years follow-up compared to conservative treatment, in people with mainly supraspinatus tendon tear. After 1-year of supraspinatus tendon repair, no differences were found in the pain or function of the shoulder between postoperative supervised physiotherapy and home exercises only. At three-month follow-up, the supervised physiotherapy group reported less pain than the home-exercise-only group.Kiertäjäkalvosimen repeämien hoito – korjausleikkauksen ja ilman leikkausta toteutetun hoidon vaikuttavuus pääosin ylemmän lapalihaksen jänteen repeämissä Kiertäjäkalvosimen jännerepeämät ovat yleisiä kuvantamistutkimuksissa näkyviä muutoksia. Yleisimmin repeämä sijaitsee ylemmän lapalihaksen jänteen alueella. Tyypillisiä oireita ovat kipu ja olkavarren nostoheikkous. Repeämien aiheuttamiin oireisiin näyttäisi pelkkä fysioterapia tuovan parannusta, mutta fysioterapian vaikuttavuutta koskevia tutkimuksia on vähäisesti. Korjausleikkaus on yleisesti käytetty hoitomuoto jännerepeämissä ja sillä on useissa havainnoivissa tutkimuksissa saatu hyviä tuloksia. Erityisesti tähystysmenetelmien käyttöönoton myötä leikkausmäärät ovat voimakkaasti nousseet ilman että käytäntö perustuisi näyttöön perustuvaan hoitosuositukseen. Jotta saadaan korkealaatuista tutkimusnäyttöä hoidon vaikuttavuudesta eri hoitovaihtoehtojen välillä, tarvitaan satunnaistettuja kontrolloituja tutkimuksia ja niistä tehtyjä meta-analyysejä tuottamaan mahdollisimman vinoutumatonta tietoa. Tässä väitöskirjatutkimuksessa selvitettiin ensin systemaattisella kirjallisuuskatsauksella ja meta-analyysillä kiertäjäkalvosimen jännerepeämän korjausleikkauksen vaikuttavuutta verrattuna fysioterapiaan. Tutkimme satunnaistetulla kontrolloidulla tutkimusasetelmalla fysioterapian, olkalisäkkeen avarrusleikkauksen ja jännerepeämän korjausleikkauksen välisiä eroja hoitotuloksissa viiden vuoden kohdalla potilailla, joilla oli ylemmän lapalihaksen jänteen ei-tapaturmainen repeämä. Lisäksi tutkimme ylemmän lapalihaksen jänteen repeämän korjausleikkauksen jälkeisen ohjatun fysioterapian vaikuttavuutta verrattuna ei-ohjattuun fysioterapiaan. Lopuksi esittelemme ylemmän lapalihaksen tapaturmaisen jännerepeämän korjausleikkauksen tehotutkimuksen (ACCURATE) protokollan, jossa verrataan tähystyskorjausleikkauksen tulosta olkanivelen tähystystutkimusleikkaukseen (placebo). Meta-analyysin ja satunnaistetun kontrolloidun tutkimuksemme perusteella jännerepeämän korjausleikkauksella ei todennäköisesti saavuteta 1–5 vuoden seurannassa kliinisesti merkitsevää parannusta fysioterapiaan verrattuna. Olkapään kivussa tai toiminnassa vuoden kohdalla korjausleikkauksesta ei todettu merkitsevää eroa ohjatun ja ei-ohjatun fysioterapiaryhmän välillä

Surgery or conservative treatment for rotator cuff tear: a meta-analysis

Purpose: Comparative evidence on treating rotator cuff tear is inconclusive. The objective of this review was to evaluate the evidence on effectiveness of tendon repair in reducing pain and improving function of the shoulder when compared with conservative treatment of symptomatic rotator cuff tear.Method: Search on CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and Pedro databases. Randomised controlled trials (RCT) comparing surgery and conservative treatment of rotator cuff tear. Study selection and extraction based on the Cochrane Handbook for Systematic reviews of Interventions. Random effects meta-analysis.Results: Three identified RCTs involved 252 participants (123 cases and 129 controls). The risk of bias was considered low for all three RCTs. For Constant score, statistically insignificant effect size was 5.6 (95% CI −0.41 to 11.62) points in 1-year follow up favouring surgery and below the level of minimal clinically important difference. The respective difference in pain reduction was −0.93 (95% CI −1.65 to −0.21) cm on a 0–10 pain visual analogue scale favouring surgery. The difference was statistically significant (p = 0.012) in 1-year follow up but below the level of minimal clinically important difference.Conclusion: There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. Thus, a conservative approach is advocated as the initial treatment modality.</p

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial

BackgroundNontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years.Materials and methodsOne hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA).ResultsA total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045).ConclusionsOn the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.Level of evidenceLevel IIRandomized Controlled TrialTreatment StudyKeywordsRotator cuff tearconservative treatmentrotator cuff repairConstant scoreVAS pain scorepatient satisfactionradiographic analysisrandomized controlled trial </div

Mortality and subsequent fractures of patients with olecranon fractures compared to other upper extremity osteoporotic fractures

Background: The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures.Methods: A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016.Results: A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19–3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40–1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22–0.56).Discussion: Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.</p

Complications and reoperations related to tension band wiring and plate osteosynthesis of olecranon fractures

BackgroundOlecranon fractures are common and usually treated operatively either by tension band wiring (TBW) or plate fixation (PF). The aim of this study was to assess early complications and reoperations and their predictive factors related to those operative methods.MethodsA retrospective analysis of all patients with an operatively treated olecranon fracture between 2007 and 2017 at Turku University hospital was performed. Reoperations, postoperative complications, and potential risk factors for these were recorded.ResultsA total of 434 patients (387 TBW and 47 PF) were identified. There was no statistically significant difference in the rate of early complications (49% vs. 62%, P = .262) or reoperations (38% vs. 53%, P = .079) between patients treated with TBW and PF. In the TBW group, the intramedullary placement of Kirschner (K)-wires predisposed patients to complications compared to transcortical placement of the K-wires according to multivariate analysis (odds ratio [OR] 1.94, P = .026). Younger age was associated with the frequency of reoperations, the odds decreasing 24% for every 10 years of age (P P = .002). Also, excellent postoperative reduction was associated with higher reoperation rate than good or fair reduction (OR 0.48, P = .033).ConclusionThere is a high risk of early complications and reoperations associated to both TBW and PF. Transcortical positioning of K-wires may reduce the rate of complications in TBW.Level of EvidenceLevel III; Retrospective Cohort Comparison; Treatment Study</p

Scandinavian Olecranon Research in the Elderly (SCORE) : protocol for a non- inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly

Introduction The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift. The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function. Methods and analysis Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis. Ethics and dissemination The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linkoping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals.Peer reviewe

Scandinavian Olecranon Research in the Elderly (SCORE): protocol for a non- inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly

Introduction The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift.The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function.Methods and analysis Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis.Ethics and dissemination The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linkoping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals.</p

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years : over 5-year follow-up of a randomized controlled trial

Background: Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years. Materials and methods: One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA). Results: A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P =.33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P =.85). There were no significant differences (P =.84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P =.74) and patient satisfaction (P =.83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P =.538) or CTA (P =.485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P =.0045). Conclusions: On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.publishedVersionPeer reviewe