Rotator cuff disease is one of the common musculoskeletal disorders, and previous cadaveric and epidemiological studies have found that the incidence of rotator cuff injuries exceeds 50% in people over the age of 65, and approximately 600,000 people in the United States have undergone surgery related to rotator cuff disease each year in recent years. As the aging population continues to progress, rotator cuff disease will become an important social health issue in the future.
Over the past decade, a large body of clinical and basic research has recognized the breadth and importance of rotator cuff disease and has attempted to address a number of important questions about rotator cuff treatment that remain unclear, including: 1) the timing and role of non-surgical treatments such as closure and physical therapy; 2) indications for repair of chronic rotator cuff injuries; 3) indications for surgery for acute traumatic tears; 4) the impact of multiple confounding factors such as age, diabetes, or smoking on surgical 5. the most effective or appropriate surgical strategy, such as debridement or rotator cuff repair; and 6. the most effective postoperative rehabilitation program.
As with other orthopedic problems, patients suffering from rotator cuff disease face many different treatment options. However, many of these approaches remain controversial. Orthopaedic surgeons’ preferences for treatment options for rotator cuff injuries vary widely.
Helping Orthopaedic Surgeons Determine the Best Treatment.
The CPG Working Group identified six clinical practice issues covering non-operative treatment, indications for surgery, and postoperative management as follows.
1. Treatment decisions for asymptomatic patients with total laminar tears
2. Indications for non-surgical treatment of symptomatic patients
3. The role of physical therapy, closure, anti-inflammatory drugs and other non-surgical treatments
4. indications for rotator cuff repair surgery
5.The role of prognostic factors
6. Principles of optimal rehabilitation
The CPG working group was composed of several voluntary experts who reviewed more than 4,000 publications and conducted a systematic evaluation, but unfortunately they found that very few of them met the evidence criteria of the AAOS. Therefore none of them could reach the level of a strong recommendation in the guidelines. The working group first gave a draft guideline, which was then discussed by the AAOS expert committee, peer-reviewed, and solicited online. The final guideline was developed with 31 recommendations, of which 4 were generally recommended, 6 were rarely recommended, 19 were inconclusive, and 2 were not supported by reliable evidence, but expert consensus was formed after expert discussion and weighing the pros and cons. The guideline took 2 years from the establishment of the working group to its release on December 4, 2010.
Due to the large amount of controversy surrounding the treatment of rotator cuff disease, the working group strongly recommends that orthopaedic surgeons choose treatment options based on individual patient circumstances and patient-physician communication, in addition to the full guidelines and evidence-based reports.
The process and results of this guideline-based study suggest that there is a paucity of reliable evidence for the clinical management of rotator cuff disease, and given the clinical importance of rotator cuff disease, the lack of good evidence represents a serious knowledge gap. The problem with this evidence is not the quantity but the quality. Although there is an extensive research literature on the treatment of rotator cuff disease, the overall quality is disappointing by modern standards of evidence. Further high level, high quality research is important to improve confidence in specific treatment options and better standardize treatment, as well as being a current imperative, especially in the following areas that need to be urgently addressed.
1. Exploring the risk factors for rotator cuff disease progression. Some rotator cuff injuries including partial and total injuries can rupture and enlarge or degenerate over time. Early treatment is important in these cases, so exploring the risk factors involved is important for constructing treatment indications.
To determine the long-term prognostic effect of commonly used non-surgical treatments such as closure or anti-inflammatory drugs in the conservative management of rotator cuff injuries.
3. To determine the importance of rotator cuff healing and its beneficiary population. Rotator cuff repair and healing is the goal of surgical treatment. However, some patients do have good clinical results even if the tear does not heal. It is important to determine who needs to heal and who does not in order to decide on a surgical approach.
4. Determine the best rehabilitation plan after rotator cuff repair. The timing of initiation of activity (early or delayed) and resistance exercise is controversial, and the correct rehabilitation plan is critical to the patient’s prognosis.
5. Determine the preferred surgical repair strategy. Many surgical approaches, such as double or single row repair, are still controversial. Definitive evidence is needed to better standardize the treatment approach.
6. Raise awareness of the role of comorbid conditions such as age, diabetes, and smoking history in the prognosis of rotator cuff repair. These factors can influence the choice of surgical procedure and the construction of surgical indications.
7. Determine the best surgical approach for chronic large or massive rotator cuff tears that are difficult to heal after repair. Whether these patients may require only a clean-up procedure or a larger reconstructive procedure such as tendon transposition, or the application of biologics still needs further confirmation.
The above aspects of the problem have also provided clinical workers with research ideas, and we hope that our domestic colleagues will actively participate with a high level of quality research to make their contribution to improving the diagnosis and treatment of rotator cuff disease worldwide