Commentary on
"Prospective Longitudinal Analysis of Postoperative Shoulder Function: A Ten-Year Follow-up Study of Full-Thickness Rotator Cuff Tears "
By Leesa M. Galatz, MD et al.

Commentary by Robert H. Cofield, MD*,
Mayo Clinic, Rochester, MN

These comments address five aspects of the study: the modus operandi, the surgical technique used, the structure of the study, the results, and the implications for future patient care and evaluation.

The modus operandi of this study is laudable and deserves replication. The authors have taken a commonly performed musculoskeletal procedure, followed the patients longitudinally after treatment with a standard surgical approach, and assessed the patients over a longer period of time than usual—not only to glean information about the results of the procedure but also to recognize unanticipated complications or the need for reoperation. Last, but not least, this study provides a benchmark for comparison with other investigations.

The generally conservative treatment rationale and the surgical technique applied by Galatz et al. are standard in rotator cuff repair. The surgery involves a standard anterior-superior approach with deltoid splitting. A typical anterior-inferior acromioplasty was performed with resection of the coracoacromial ligament, and no distal clavicle excision was performed in these patients. The rotator cuff repair was performed with tendon suture to corticocancellous bone except for rare modifications dictated by the location or extent of the tear. The postoperative rehabilitation was well formulated, cautious, and slowly progressive. In summary, the technique used is the classical approach that we all recognize and one that seemingly has stood the test of time.

The structure of the study, although formulated many years ago, is still contemporary, and involves selecting a rather small to medium-sized group of patients, collecting basic data, and applying evaluative methodology—including the use of a questionnaire—in a consistent manner over time. The rather small number of patients included is surprising when such a common procedure is being analyzed and much of the data collected was, unfortunately, not reported so that readers themselves might analyze the data, such as pain ratings, measures of range of motion and strength, and radiographic features.

The results are well organized but focus on ratings, the central one being the Constant score which is used quite commonly in Europe but less so in North America. This scoring system does allow correction for changes with aging and so it has distinct value for use in this particular patient group with a mean age of fifty-five years at the time of surgery. The authors quite nicely show with use of this outcome assessment tool that the score remained essentially equivalent over time, as did the reported shoulder function score and the patients' assessments of outcome. Interestingly, the authors documented that the patients' activity levels decreased over time, which was related to a decrease in the disability rating scale. Even with a small cohort of patients, the authors recognized that larger tear size lowered the outcome assessment scores, as all patients with unsatisfactory scores had a large or massive tear. In addition, of the four shoulders that were initially irreparable, three had a poorer outcome.

The implications of this study are that surgeons should plan ahead when considering outcome assessment for patient groups and construct a plan for both initial and continuing evaluation, so that patients undergoing typical treatment as a group could form essentially a prospective longitudinal study population. This type of study is not only useful for the descriptive information and the proof of the stability of this procedure over time that it provides, but it also serves as a benchmark for comparison with newer techniques. The authors have demonstrated that rotator cuff repair using this methodology is a high-quality surgical procedure, that complications and the need for reoperation are indeed quite low, and that modifications chosen to improve the procedure should most notably be directed toward the management of large or massive rotator cuff tears. Hopefully, we will see more and more studies like this in the coming years.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.