**8. Surgical indications for a transition from non-operative treatment**

Throughout the literature, it has been observed that the presence of certain independent "risk factors" may also serve as indicators for the physician to transfer the patient from non-operative management to operative treatment. Beyond the risks and concerns involved with the non-operative treatment option, there are also independent factors that serve as direct indicators to opt for operative treatment. These factors include the patient's demographics, the mechanism of injury, the degree of severity and depth of the tear, the duration of symptoms and the patient's expectations about whether operative or non-operative treatments are effective. Several studies [2, 82, 86] have shown that patient expectations are potentially one of the strongest indicators when deciding how to treat a patient. Dunn et al. [87] and Fucentese et al. [8] demonstrated a direct correlation between the expectations of the patient and the results of conservative treatment.

II were initially treated conservatively and, if they did not respond, they were transitioned to surgical treatment. Furthermore, group III was concerned with maximising conservative treatment, where the healing of the patient's RCT was unlikely. This group typically included patients over the age of 65, with chronic tears and FTT. Patients in the group were shown to have retracted tendons and advanced muscle degeneration. The goal of conservative treatment was to improve the overall functioning level of the patient. This study demonstrated that although these variables improved, there was also a 50% chance of tear

Several other studies of asymptomatic tears followed by either an ultrasound or a MRI have been reported in the literature [2, 15, 83, 84]. Maman et al. [7] described age as a large determinant of progression, with 54% of the tears in the patients over 60 years of age demonstrating progression, in comparison to 17% of tears in subjects under the age of 60 years. Safran et al. [11] found that FTTs had a higher rate of progression in younger patients, with 49% of the

Tear progression as well as muscle atrophy and fatty infiltration have been directly associated with pain. In a study conducted by Moosmayer et al. [85], these three variables were found to correlate with the presence of symptoms in comparison to an asymptomatic group. The authors compared non-operative to operative treatment for smaller tears of 3 cm in size, and found a progression in tear size and structural deterioration over time, which resulted in the recurrence of symptoms and functional depreciation over time. In the cases in which the patients were asymptomatic, they found that progression of the tear was directly related with

In contrast to these studies, Fucentese et al. [8] found that after a follow-up period of 3.5 years following non-operative treatment, there was no increase in the average tear size and only 25% of the initial tears demonstrated progression. An issue with this study is that the average initial tear size was small, averaging 1.6 cm. This further supports the notion that the likelihood of progression is dependent on the initial size of the tear, with larger tears more likely

**8. Surgical indications for a transition from non-operative treatment**

Throughout the literature, it has been observed that the presence of certain independent "risk factors" may also serve as indicators for the physician to transfer the patient from non-operative management to operative treatment. Beyond the risks and concerns involved with the non-operative treatment option, there are also independent factors that serve as direct indicators to opt for operative treatment. These factors include the patient's demographics, the mechanism of injury, the degree of severity and depth of the tear, the duration of symptoms and the patient's expectations about whether operative or non-operative treatments are effective. Several studies [2, 82, 86] have shown that patient expectations are potentially one of the

progression within 5 years, especially in the FTT [82].

tears increasing in size under ultrasound.

the development of pain [30].

28 Advances in Shoulder Surgery

to develop progression.

The demographics of a patient have also been shown to directly correspond with a transition in treatment. The strongest of these include the patient's age, body mass index (BMI) score, and socioeconomic status. Interestingly, patients with a higher BMI score were shown to be more likely to adopt a nonsurgical option, where those with a lower BMI opted for surgical treatment [88].

Regarding age, patients under the age of 60 years are thought to have better outcomes with operative treatment, because of significant risks of irreversible changes with non-operative treatment and a high likelihood of healing if a repair was performed. It has been generally recommended that surgical repair be performed instead of an initial conservative treatment in active patients with acute tears following trauma [4]. Early operative treatment appears to be warranted in this case and in the case of poor function for the achievement of maximal return of shoulder function. The importance of the timing following the initial patient interview is critical and dependent on the factors associated with the tear as well as how long the tear has been present. In a systematic review, Lazarides et al. [40] reported that the RCTs present in patients younger than age 40 years are more commonly FTTs and of traumatic origin. These patients typically respond well to surgery in terms of pain relief due to the good tendon and muscle quality at the time of the repair. The definition of "early" repair is often unclear.

Bjornsson et al. [89] determined that there was no difference in tendon healing, pain, shoulder elevation, or functional outcomes when an acute tear was fixed within the first 3 months of injury compared to within the first 3 weeks. However, if symptoms have persisted for longer than a year, and functional impairment was observed, the expectation for a successful surgical approach is worse in patients with FTTs [56]. Patients over the age of 60 years were twice as likely to develop a tear that was larger than those under 60 years. With each decade after 60, the odds of tear enlargement increased 2.69-fold [90].

Importantly, the mechanism of injury plays a significant role in decision-making for operative treatment. Schmidt and Morrey [91] described a measurement of the "appropriateness" of the various treatment options available to assist in RCT treatment, which are dependent on the associated benefits and risks of each method. The scale is referred to as the appropriate use criteria (AUC), and it was developed by a voting panel composed of mostly orthopaedic surgeons. This panel determined the 'appropriateness' level of a treatment based on the current literature. The AUC determined that a treatment was deemed 'appropriate' if the benefits outweighed the risks, 'may be appropriate' if the difference was null, and 'rarely Appropriate' when the risks outweighed the benefits. A large indicator favouring nonoperative treatment included the initial response a patient exhibited during their initial trial of conservative treatment. If there was a positive response noted by the patient, then they would continue with non-operative treatment. Conversely, if the initial trial of conservative treatment was ineffective, then operative treatment would be recommended. The indications for surgery were 'may be appropriate' in the instances in which the patient responded positively to the conservative management, were healthy before the injury, were experiencing moderate-to-severe pain, as well as in those who were not responsive to non-operative care methods. The duration of time given to determine whether a conservative treatment option is successful is typically 12 weeks. Beyond this time, there was a concern regarding the risk of tear progression. In addition, the authors showed that in patients with a higher level of pain, they were more likely to recommend surgery.

physiotherapy techniques include anterior deltoid training to allow adequate shoulder elevation without upward migration of the humeral head, as well as teres minor training to allow the greater tuberosity of the humerus to clear the acromion during shoulder elevation. Patients who will benefit the most from conservative treatment include those over the age of 60 years with a chronic degenerative tear that is unlikely to heal and with low functional demand. In this scenario, the goal is to improve the function and ROM. The risks associated with these tears include the potential of the progression of the tear, a diminished healing potential due to age or longer symptom duration, muscle atrophy, and fatty infiltration. In addition, poor outcomes have been noted in this group with surgical treatment. Moreover, the indications for surgery following conservative treatment are becoming more defined, and an outline regarding what scenarios warrant a transition from an initial conservative treatment plan has been developed. If the patient does not respond well within the first 6–12 weeks of the conservative treatment and is younger than 60 years, has a higher activity level, and has a healthy tendon and muscle environment, then early operative treatment is likely. Overall, the patient satisfaction indices, and in particular functional scores such as the RC-QOL score, have shown a consistent level of satisfaction regarding conservative manage-

Complete Rotator Cuff Tear: An Evidence-Based Conservative Management Approach

http://dx.doi.org/10.5772/intechopen.70270

31

Although experiments using injections and biologics to specifically treat RCTs are limited, the literature available is promising in primary treatment, adjunctive care, and to augment surgical procedures. Both CS and HA injections offer modest benefits to the patient in terms of reduced pain and improved function. From an administrative perspective, the injections are practical as they are easily available pharmaceuticals, and are relatively low in prices compared to surgical intervention. These injections have demonstrated effectiveness in ame-

The developing benefits of using MSCs, PRP, and other biologics have the potential to be disruptive to current treatment protocols, both conservative as well as surgical, in the approaches to healing RCTs. With improved imaging modalities, diagnostic accuracy, and sensitivity, practitioners of the future will hopefully be able to intervene earlier in the disease pathogenesis cycle. PRP can possibly be an effective method and strategy in the healing process of tendinopathy or PTTs. With standardised preparations and treatment protocols, only a short window of time is required to assess, prepare, and treat patients with this method (less than 30 minutes). The real benefit, although not fully realised at this time, is that PRP follows fundamental biological principles as it releases several growth hormones to stimulate the healing process. PRP also prompts MSC activation, creating a unique regenerative environment that modulates the immune system response and promotes trophic, anti-scarring, and cellular proliferation that in theory further aid the healing process. Regenerative injection therapy provides patients with specific cells and proteins that their body has produced, thus creating a healing environment at the site of injury and/or degeneration. Further studies in the basic science, translation, as well as with high-quality clinical trials are needed to shed further light on this very exciting and potentially game-changing

ment in patients followed from 2 years.

liorating symptoms following RCT.

technology.

If surgery is needed in case of failed conservative treatment, chances for tendon healing are much lower after the age of 60 years [92]. In selected cases, surgery may be limited to a simple arthroscopic biceps tenotomy while leaving the cuff unrepaired with good pain relief and shoulder function in the elderly [93]. In other cases, despite older age, repairing the cuff may still be an option with high subjective patient satisfaction rates [94].
