Juha Kukkonen

Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.

BACKGROUND The minimal clinically important difference (MCID) is increasingly used to evaluate treatment effectiveness. The MCID for the Constant score has not been previously reported. MATERIALS AND METHODS A prospectively collected cohort of 802 consecutive shoulders with arthroscopically treated partial- or full-thickness rotator cuff tears was analyzed. The Constant score was measured preoperatively and at 3 months and 1 year postoperatively. At follow-up visits, the patients were asked a simple 2-stage question: Is the shoulder better or worse after the operation compared with the preoperative state? This single 2-level question was used as an indicator of patient satisfaction and as an anchor to calculate the MCID for the Constant score. RESULTS At 1 year, 781 (97.4%) patients (474 men, 307 women) were available for follow-up. The preoperative Constant score was 53.1 (SD 17.2) in all patients, 56.2 (SD 17.4) in male patients, and 48.2 (SD 15.6) in female patients. Postoperatively at 3 months, the scores were 61.7 (SD 16.4) in all patients, 65.1 (SD 16.1) in male patients, and 56.8 (SD 15.5) in female patients. At 1 year, the scores were 75.9 (SD 15.2) in all patients, 79.0 (SD 14.9) in male patients, and 71.0 (SD 14.3) in female patients. At 3 months postoperatively, 92.2% of male patients and 87.2% of female patients were satisfied with the outcome (P = .027); at 1 year, the satisfaction was 93.2% and 89.5%, respectively (P = .067). Five different statistical approaches yielded 5 different MCID estimates (range, 2-16). The 3-month mean change estimate of MCID was 10.4 points. CONCLUSION Our study demonstrates an MCID estimate of 10.4 points as the threshold for the Constant score in patients with rotator cuff tear. LEVEL OF EVIDENCE Basic science study, validation of outcomes instruments/classification systems.

Treatment of non-traumatic rotator cuff tears A randomised controlled trial with one-year clinical results

We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up.

BACKGROUND The optimal treatment for symptomatic, nontraumatic rotator cuff tear is unknown. The purpose of this trial was to compare the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for this condition. We hypothesized that rotator cuff repair yields superior results compared with other treatment modalities. METHODS One hundred and eighty shoulders with symptomatic, nontraumatic, supraspinatus tears were randomized into one of three cumulatively designed intervention groups: the physiotherapy-only group (denoted as Group 1), the acromioplasty and physiotherapy group (denoted as Group 2), and the rotator cuff repair, acromioplasty, and physiotherapy group (denoted as Group 3). The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity in a control imaging investigation, and cost of treatment. RESULTS One hundred and sixty-seven shoulders (160 patients) were available for analysis at two years. There were no significant differences (p = 0.38) in the mean change of Constant score: 18.4 points (95% confidence interval, 14.2 to 22.6 points) in Group 1, 20.5 points (95% confidence interval, 16.4 to 24.6 points) in Group 2, and 22.6 points (95% confidence interval, 18.4 to 26.8 points) in Group 3. There were no significant differences in visual analog scale for pain scores (p = 0.45) and patient satisfaction (p = 0.28) between the groups. At two years, the mean sagittal size of the tendon tear was significantly smaller (p < 0.01) in Group 3 (4.2 mm) compared with Groups 1 and 2 (11.0 mm). Rotator cuff repair and acromioplasty were significantly more expensive than physiotherapy only (p < 0.01). CONCLUSIONS There was no significant difference in clinical outcome between the three interventions at the two-year follow-up. The potential progression of the rotator cuff tear, especially in the non-repaired treatment groups, warrants further follow-up. On the basis of our findings, conservative treatment is a reasonable option for the primary initial treatment for isolated, symptomatic, nontraumatic, supraspinatus tears in older patients. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Adverse reaction to metal debris after ReCap-M2A-Magnum large-diameter-head metal-on-metal total hip arthroplasty

Background and purpose The clinical findings of adverse reaction to metal debris (ARMD) following large-diameter-head metal-on-metal total hip arthroplasty (LDH MoM THA) may include periarticular fluid collections, soft tissue masses, and gluteal muscle necrosis. The ReCap-M2a-Magnum LDH MoM THA was the most commonly used hip device at our institution from 2005 to 2012. We assessed the prevalence of and risk factors for ARMD with this device. Methods 74 patients (80 hips) had a ReCap-M2a-Magnum LDH MoM THA during the period August 2005 to December 2006. These patients were studied with hip MRI, serum chromium and cobalt ion measurements, the Oxford hip score questionnaire, and by clinical examination. The prevalence of ARMD was recorded and risk factors for ARMD were assessed using logistic regression models. The mean follow-up time was 6.0 (5.5–6.7) years. Results A revision operation due to ARMD was needed by 3 of 74 patients (3 of 80 hips). 8 additional patients (8 hips) had definite ARMD, but revision was not performed. 29 patients (32 hips) were considered to have a probable or possible ARMD. Altogether, 43 of 80 hips had a definite, probable, or possible ARMD and 34 patients (37 hips) were considered not to have ARMD. In 46 of 78 hips, MRI revealed a soft tissue mass or a collection of fluid (of any size). The symptoms clicking in the hip, local hip swelling, and a feeling of subluxation were associated with ARMD. Interpretation ARMD is common after ReCap-M2a-Magnum total hip arthroplasty, and we discourage the use of this device. Asymptomatic patients with a small fluid collection on MRI may not need instant revision surgery but must be followed up closely.

Smoking and operative treatment of rotator cuff tear

This registry study was set up to evaluate the effect of smoking on the pre‐operative status, intraoperative findings, and post‐operative status after rotator cuff reconstruction. Five hundred seventy‐six consecutive shoulders with primarily arthroscopically repaired penetrating rotator cuff tear were followed up. Tobacco consumption was recorded as pack‐years. Age‐adjusted Constant score was used as an outcome measure. Five hundred sixty‐four patients were available for 1‐year follow‐up (dropout rate 2%). One hundred fourteen (20%) and 450 (80%) patients were pre‐operatively recorded to be smokers and non‐smokers, respectively. The gender distribution did not differ between the groups (P = 0.286). The mean age of all patients was 55 years in smokers (SD 9.1) and 61 years in non‐smokers (SD 9.4) (P < 0.001). There was no statistically significant difference in pre‐operative Constant score (P = 0.075) or mean size of intraoperatively measured tendon tear (P = 0.290) between the groups. At final follow‐up, there was a statistically significant difference in Constant scores between smokers [71 (SE 1.4)] and non‐smokers [75 (SE 0.7)] (P = 0.017). The pack‐years of smoking correlated with neither the Constant score (P = 0.815) nor the size of the tear (P = 0.786). We conclude that operatively treated rotator cuff tear patients who smoked were significantly younger than non‐smokers, and that smoking was associated with lower post‐operative Constant score.