Grado subjetivo de necesidad y plazos de demanda

Indications for surgery may vary according to surgeons’ opinion. Dunn et al. (2005) demonstrated that factors such as the annual volume of rotator cuff repairs performed by surgeons can influence their decision on indicating patients for surgical repair; those who have higher volume are more positive about the outcome. Generally, the decision making is based on persistent symptoms that do not resolve with

conservative treatment for at least 3 months. Symptoms such as severe pain, especially during night affecting sleep quality, weakness and low functional capacity are the main reasons for requiring surgical intervention (Carr et al., 2015).

The best time for having surgery is also uncertain and still requires primary high-quality studies for clear guidance; a systematic review has shown no benefit on having the procedure during the early stages of less than 3 months (Kweon et al., 2015). There are three approaches to performing the rotator cuff repair: open, mini-open and arthroscopic. The open is the most intrusive among them, it requires an incision of 3 to 6 cm that runs parallel to the lateral border of the acromion on the anterior superior aspect of the shoulder. After dividing the subcutaneous fat, the deltoid is detached from its acromion insertion posteriorly until the lateral side where it is then split by between 3 to 5 cm. After preparing the bone, the muscle is then reattached (Figure 2.17. A). The mini-open is a mix of techniques where the surgeons arthroscopic portals are extended by 1 to 2 cm and the deltoid is split to allow a secure bone to tendon fixation (Figure 2.17.B). The all-arthroscopic repair is nowadays the most common procedure. It is less

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invasive, does not require such an aggressive approach to the deltoid, and has fewer complications like deltoid avulsion infection (Figure 2.17.C) (Ghodadra et al., 2009).

A B

C

Figure 2.17. A) Landmarks and incision line for an open repair, B) Landmarks and incision line for a mini-open repair, C) Landmarks and incision line for an all-arthroscopic repair. From Ghodadra et al. (2009).

Although the open-repair is described as more invasive, for patients with chronic rotator cuff tears who are older than 50 years, the open-repair in comparison to the all- arthroscopic does not have statistically significant differences for functional scores, retears rates, nor it is less clinical or cost-effective after 2 years follow-up (Carr et al., 2015).

The first step is to choose which approach to use, the second is what method will be applied to reattach the tendon. After examining the tear shape, the surgeon chooses how to connect the tendon, there are three main methods: single-row, double-row or transosseous equivalent (McCormick et al., 2014). By their names, it is possible to understand their main differences; the single-row uses a single row setting where usually two anchors are used. The double-row uses two pairs of sutures that attach to 4 anchors. The transosseous equivalent is performed similar to the single-row, however, the suture configuration requires extra sutures which can have a W or X shape

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Figure 2.18. Techniques for reattaching the tendon to the bone: A) single-row, B) double- row, C) transosseous equivalent W shape, D) transosseous equivalent X shape. From McCormick et al. (2014) and Park et al. (2007)

The techniques have evolved to try to make the footprint stronger and more stable. Based on cadaveric studies, the double-row and transosseous equivalent have been shown to display stronger mechanical properties compared to the single-row (Lee, 2013). However, different fixation methods seem not to translate to better patient outcomes, but may possibly aid rehabilitation allowing earlier mobilisation by offering better footprint stability (Mascarenhas et al., 2014).

In summary, physiotherapy can be as effective as surgery for treating rotator cuff tears; however, some patients do not respond to conservative approaches and will

require surgery. The number of rotator cuff repairs performed every year is increasing in many countries (Colvin et al., 2012; Ensor et al., 2013; Judge et al., 2014; Paloneva et al., 2015; Malavolta et al., 2016). After surgery, physiotherapy is needed to support patients in recovering their movements and functional capacity, but when clinicians try to develop the best protocol based on the evidence, it can be difficult to decide when and how to do it (Oliva et al., 2015). Besides applying the best evidence, the rationale must be discussed based on the expertise from the health professionals involved, which has recently been shown to be challenging. Mollison et al. (2017), applied a web-based survey to 704 orthopaedic surgeons in the USA asking questions about rehabilitation

A B

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after rotator cuff repair. The results showed substantial variability and there was a low agreement rate of when to start physiotherapy. One of the major discrepancies shows that only 37% of the surgeons recommend physiotherapy in the first 2 weeks, 23% between 2-3 weeks, 21% between 4-5 weeks and 15% between 6-7. Further findings revealed that the majority of the therapists (69%) started with passive ROM within the first 2 weeks and progression onto unrestricted passive ROM happened only after 6 to 7 weeks. Active ROM was started only after 7 to 10 weeks, which may be considered a very conservative approach. In the UK, Littlewood, and Bateman (2015) conducted a similar study with 122 physiotherapists. They applied an online questionnaire using a clinical case to ask physiotherapists when they would start shoulder mobilisation and when passive, active and resisted exercises were commenced. They found that most clinicians had their patients in a sling from 4 to 6 weeks. Different from Mollison et al. (2017), 51% of the respondents stated starting passive ROM which started in the first week and active ROM mostly starting at 4 to 6 weeks (58%). These conflicting data are worrisome as delaying rehabilitation may impact patients health causing complications like stiffness and postponing their return to work (Seo et al., 2012). However, it is noteworthy that the study of Mollison et al (2017) collected responses mainly from orthopaedic surgeons and the population of Littlewood, and Bateman (2015) was composed of physiotherapists, which may be another factor for the divergent results.