Shoulder and Elbow | Links Medicus Content Curation & Alerts in Medicine

Review: Management of Degenerative Rotator-Cuff Disorders

28 Nov, 2024 | 12:48h | UTC

Introduction: Degenerative rotator-cuff disorders are a leading cause of shoulder pain, especially in adults over 40 years of age, involving tendon degeneration from tendinopathy to full-thickness tears. Recognizing the need for clear clinical guidance, Jain and Khazzam provide a comprehensive review aimed at informing clinicians on evidence-based strategies for the evaluation and management of degenerative rotator-cuff tears to optimize patient outcomes.

Key Recommendations:

First-Line Nonoperative Management: Initiate treatment with nonoperative measures, primarily structured physical therapy. The therapy should focus on strengthening periscapular muscles, correcting scapular posture, and improving rotator-cuff muscle strength and endurance. (Evidence Level: Expert consensus)
Pharmacologic Therapy: Employ topical NSAIDs for pain relief due to their favorable safety profile. Oral NSAIDs may offer modest pain relief but should be used cautiously because of potential adverse effects. Opioids are generally not recommended due to associated risks and lack of superior efficacy. (Evidence Level: Moderate)
Glucocorticoid Injections: Consider a single subacromial glucocorticoid injection to provide short-term pain relief, which may facilitate participation in physical therapy. (Evidence Level: Limited)
Selective Imaging Use: Reserve imaging modalities like ultrasonography or MRI for cases with diagnostic uncertainty, potential surgical candidates, or when detailed assessment of tear extent and muscle degeneration is required. Routine imaging is not recommended in primary care settings. (Evidence Level: Consensus)
Surgical Intervention Criteria: Surgery is not the initial treatment and should be considered for patients not improving with nonoperative measures. Factors favoring surgery include younger age, smaller tear size, and absence of significant psychosocial barriers. The decision should be individualized due to debated surgical indications. (Evidence Level: Observational studies)
Avoidance of Unproven Therapies: Current evidence does not support the use of orthobiologic therapies, such as platelet-rich plasma or stem cells, in treating rotator-cuff disorders. (Evidence Level: Insufficient)

Conclusion: Implementing these recommendations can enhance patient care by emphasizing effective nonoperative strategies and judicious use of surgery for degenerative rotator-cuff disorders. Early initiation of physical therapy and appropriate pain management can lead to significant improvements in pain and function, potentially reducing the need for surgical intervention and improving patients’ quality of life.

Reference: Jain NB, Khazzam MS. Degenerative Rotator-Cuff Disorders. New England Journal of Medicine. 2024;391(21):2027–2034. DOI: http://doi.org/10.1056/NEJMcp1909797

RCT | Arthroscopic capsular shift surgery shows no significant pain or functional improvement in atraumatic shoulder instability

29 Jun, 2023 | 13:45h | UTC

Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial – British Journal of Sports Medicine (link to abstract – $ for full-text)

Cohort Study | Increased revision rates seen in shoulder replacement surgeries by surgeons with less than 10 procedures annually

27 Jun, 2023 | 13:48h | UTC

Summary: This prospective cohort study investigated the correlation between surgeon volume and patient outcomes after elective shoulder replacement surgeries. Utilizing data from 39,281 procedures performed by 638 surgeons in UK public and private hospitals between 2012-20, the study focuses on adults aged 18 years or older.

The results indicate a significant connection between a surgeon’s mean annual volume and risk of adverse patient outcomes. Surgeons performing fewer than 10.4 procedures per year demonstrated a significantly increased risk of revision surgery, with the hazard ratio being almost twice as high as that of the lowest risk surgeons. Higher mean annual surgical volume correlated with lower risks of reoperations, fewer serious adverse events, and shorter hospital stays.

These findings suggest the need for strategic resource planning in surgical services, with considerations given to surgeon’s annual procedure volume to improve patient outcomes after shoulder replacement surgery. It should be noted that the study was limited in scope to surgeries performed within the NHS and private hospitals in England. Furthermore, potential confounding factors like patients’ social circumstances, carer availability, or body mass index were not considered.

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