Optimizing the Management ofFull-Thickness Rotator Cuff Tears

Abstract

The American Academy of Orthopaedic Surgeons has developedAppropriate Use Criteria (AUC) on Optimizing the Management ofFull-Thickness Rotator Cuff Tears (RC). Evidence-basedinformation, in conjunction with clinical expertise of physicians, wasused to develop the criteria to improve patient care and obtain bestoutcomes while considering the subtleties and distinctionsnecessary in making clinical decisions. The RC AUC Writing Panelbegan the development of the clinical scenarios by identifyingclinical indications typical of patients commonly presenting with full-thickness rotator cuff tears in clinical practice, as well as from thecurrent evidence-based clinical practice guidelines and itssupporting literature. The 432 patient scenarios and 5 treatmentswere developed by the Writing Panel, a group of clinicians who arespecialists in this AUC topic. Next, the Review Panel, a separategroup of volunteer physicians, independently reviewed thesematerials to ensure that they were representative of patientscenarios that clinicians are likely to encounter in daily practice.Finally, the multidisciplinary Voting Panel (made up of specialistsand nonspecialists) rated the appropriateness of treatment of eachpatient scenario using a 9-point scale to designate a treatment asappropriate (median rating, 7 to 9), may be appropriate (medianrating, 4 to 6), or rarely appropriate (median rating, 1 to 3).

Overview and Rationale

This Appropriate Use Criteria (AUC)was approved by the AmericanAcademy of Orthopaedic Surgeons(AAOS) Board of Directors on Sep-tember 20, 2013. The purpose of theAUC is to help determine the appro-priateness of treatments of the het-erogeneous patient population rou-tinely seen in practice. The bestavailable scientific evidence is syn-thesized with collective expert opin-ion on topics for which gold-standard randomized clinical trialsare not available or which are inade-quately detailed for identifying dis-

tinct patient types. AAOS staff con-vened three independent volunteerphysician panels that developed thisAUC.

Musculoskeletal care is provided inmany settings by different providers.The AAOS created this AUC as aneducational tool to guide qualifiedphysicians through a series of treat-ment decisions in an effort to im-prove the quality and efficiency ofcare. These criteria should not beconstrued as including all indicationsor as excluding indications reason-ably directed to obtaining the sameresults. The criteria intend to addressthe most common clinical scenarios fac-

Jayson Murray, MA

Leeaht Gross, MPH

From the American Academy ofOrthopaedic Surgeons, Rosemont,IL.

Neither of the following authors norany immediate family member hasreceived anything of value from orhas stock or stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article: Mr. Murrayand Ms. Gross.

These appropriate use criteria wereapproved by the American Academyof Orthopaedic Surgeons onSeptember 20, 2013.

The complete Appropriate UseCriteria for Optimizing theManagement of Full-ThicknessRotator Cuff Tears includes alltables, figures, and appendices, andis available at http://www.aaos.org/research/Appropriate_Use/rotatorcuffaucfull.pdf. The RC AUCcontent is also available in a web-based mobile app and can beaccessed at the following address:www.aaos.org/aucapp.

J Am Acad Orthop Surg 2013;21:767-771

http://dx.doi.org/10.5435/JAAOS-21-12-767

Copyright 2013 by the AmericanAcademy of Orthopaedic Surgeons.

AAOS Appropriate Use Criteria Summary

December 2013, Vol 21, No 12 767

ing all appropriately trained surgeonsand all qualified physicians managingpatients with full-thickness rotator cufftears. The ultimate judgment regardingany specific criteria should address allcircumstances presented by the patientand the needs and resources particularto the locality or institution. The Op-timizing the Management of Full-Thickness Rotator Cuff Tears workgroup developed appropriateness treat-ment ratings for 432 patient scenarios.

Potential Harms andContraindications

Most treatments are associated withsome known risks, especially inva-sive and surgical treatments. In addi-tion, contraindications vary widelybased on the treatment administered.

Therefore, discussion of availabletreatments and procedures applica-ble to the individual patient rely onmutual communication between thepatient and physician, weighing thepotential risks and benefits for thatpatient.

Methods

The AAOS uses the RAND/UCLAAppropriateness Method1 to developAUCs. The process includes the fol-lowing steps:

Constructing a writing panel con-sisting of 6 to 10 clinicians who are

experts in the topic under study tocreate a list of patient indications, as-sumptions, and treatments based onan evidence-based systematic reviewof the literature conducted by AAOSstaff research analysts.

Constructing a review panel con-sisting of 10 to 30 clinicians to re-view the writing panel’s materialsand provide any suggestions for im-provement.

Constructing a multidisciplinaryvoting panel that uses a review of themost current and relevant literature,along with the expert clinical judg-ment of the voting panel members,to rate the appropriateness of treat-ment of various patient scenarios.

General assumptions were devel-oped by the RC AUC panel membersto clarify the interpretation of thepatient scenarios and provide stan-dardization for the parameters usedto rate the appropriateness of treat-ment.

This AUC was approved by theAppropriate Use Criteria Section ofthe Committee on Evidence-BasedQuality and Value, the Council onResearch and Quality, and the AAOSBoard of Directors. All tables, fig-ures, and appendices, as well as thedetails of the methods used to pre-pare these appropriate use criteria,are detailed in the full AUC, which isavailable at http://www.aaos.org/research/Appropriate_Use/rotatorcuffaucfull.pdf.

Patient Indications andClassifications

Table 1 provides the list of patientindications and classifications devel-oped by the RC AUC Writing Panel.Definitions of the patient indicationsand classifications are indicated be-low.

Symptom SeverityThe symptom severity indicationtakes both pain and functional lossinto consideration. Examples of fac-tors that the clinician can use tograde the pain are interference withactivities of daily living (ADLs), rec-reation, work (eg, laborer, profes-sional athlete), livelihood (eg, hob-bies that are indispensable to thepatient for a high quality of life),sleep/night pain, or pain at rest.Functional loss can similarly be as-sessed by its effect on ADLs, recre-ation, work (eg, laborer, professionalathlete), sleep, livelihood (eg, hob-bies that are indispensable to thepatient for a high quality of life), theability to be independent, andself-care, or to be a caregiver in one’shousehold, community, or work-place.

The classification of patient symp-toms as mild, moderate, or severeshould be performed on a basis ofboth patient history/self-assessmentand physician assessment (Table 2).

Optimizing the Management of Full-Thickness Rotator Cuff Tears AUC Writing Panel: William Beach, MD, Mark A. Frankle, MD,James J. Irrgang, PhD, PT, ATC, FAPTA, Brian G. Leggin, PT, DPT, OCS, Phillip W. McClure, PhD, PT, FAPTA, Louis McIntyre, MD,Ronald A. Navarro, MD, Charles A. Thigpen, PhD, PT, ATC, Stephen C. Weber, MD, Brian Wolf, MD, and Joseph D. Zuckerman, MD.Review Panel: Jeffrey S. Abrams, MD, Richard L. Angelo, MD, Asheesh Bedi, MD, Stephen S. Burkhart, MD, Neal C. Chen, MD,Brian J. Cole, MD, MBA, Frank A. Cordasco, MD, Edward V. Craig, MD, Allen A. Deutsch, MD, David M. Dines, MD, Larry D. Field,MD, Bryce Gaunt, PT, SCS, Mark Getelman, MD, Andrew Green, MD, Robert E. Hunter, MD, June Kennedy, PT, MS, Dirk Kokmeyer,PT, SCS, COMT, Sumant G. Krishnan, MD, John E. Kuhn, MD, Patrick J. McMahon, MD, Matthew W. Menet, MD, Eric Jon Olson,MD, CDR Matthew T. Provencher, MD, MC, USN, Lee Rosenzweig, PT, DPT, CHT, Felix H. Savoie III, MD, Angela R. Tate, PT, PhD,Stephen J. Thomas, PhD, ATC, Gerald R. Williams, Jr, MD, and Ken Yamaguchi, MD, MBA. Voting Panel: Alan S. Curtis, MD,Christopher C. Schmidt, MD, Patrick David George Henry, MD, FRCS, Robert L. Waltrip, MD, Steve A. Petersen, MD, Amee L. Seitz,PT, PhD, DPT, OCS, Bernard F. Morrey, MD, Gerard P. Brennan, PT, PhD, Paula Ludewig, PT, PhD, Jaimo Ahn, MD, PHD, JosephH. Kostuch, PT, SCS, Kellie C. Huxel Bliven, PhD, ATC, Mark E. Baratz, MD, Nitin B. Jain, MD, MSPH, Paul A. Manner, MD, FRCSC,and William D. Murrell, Jr, MD, MSc. Moderators: James O. Sanders, MD, and Michael Warren Keith, MD. AAOS Staff: William R.Martin III, MD, Deborah S. Cummins, PhD, Jayson Murray, MA, Ryan Pezold, MA, Ann Woznica, MLS, Leeaht Gross, MPH, andYasseline Martinez.

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American Society ofAnesthesiologists (ASA)Status (comorbidities)The ASA 1 status refers to a normal,healthy patient, the ASA 2 status re-fers to a patient with mild systemicdisease, the ASA 3 status refers to apatient with severe systemic disease,and the ASA 4 status refers to a pa-tient with severe systemic diseasethat is a constant threat to life.

Identifiable Factors ThatNegatively Affect HealingThe following factors may negativelyaffect healing in some individuals. Itshould be noted that factors that neg-atively affect healing do not necessar-ily affect outcomes. Factors that nega-tively affect healing are physiologicfactors that may make it less likely forthe tendon to heal: diabetes mellitus(poorly controlled); obesity (body massindex >30); osteoporosis; history of in-fection; advanced age; smoking; mul-tiple corticosteroid injections; use of im-munosuppressive drugs, catabolites, orprednisone; parkinsonian disorder; orother medical comorbidities.

This is not an exhaustive list, and itshould not be treated as such. These arefactors to take into consideration,

backed by published evidence and/orthe Writing Panel’s expert opinion in theface of insufficient published evidence.

Identifiable Factors ThatNegatively Affect OutcomeThe following factors may negativelyaffect the outcome of rotator cuff sur-

gery. Factors that negatively affect out-come should be nonphysiologic (ie,psychosocial): workers’ compensationclaim, accident litigation, substanceabuse, and psychiatric disorder.

This is not an exhaustive list, andit should not be treated as such.These are factors to take into consid-

Table 1

Full-thickness Rotator Cuff Tear: Indications and Classifications

Indication Classification

Symptom severity MildModerateSevere

ASA status (ie, comorbidities) 1–4Identifiable factors that nega-

tively affect healingPresentAbsent

Identifiable factors that nega-tively affect outcome

PresentAbsent

Tear size and retraction (Snyderclassification)

C1: Small complete tear, ie, pinhole sizedC2: Moderate tear (ie, <2 cm) in any direction of

only one tendon without retractionC3: Large, complete tear with an entire tendon with

retraction, usually 3–4 cm in any directionC4: Massive rotator cuff tear involving two or more

rotator cuff tendons with associated retraction andscarring of the remaining tendon

Atrophy/fatty infiltration G 0–2 (possibly indicating more acute pathology)G 3–4 (possibly indicating more chronic pathology)

Previous treatment Response to previous treatmentNo response to previous treatment

ASA = American Society of Anesthesiologists

Table 2

Full-thickness Rotator Cuff Tear: Classification of Patient Symptoms

Classificationa

ADLs Mild Moderate Severe

Work/activities that requireoverhead motion or liftingaway from body

Can perform with some pain atprevious level

Painful, cannot perform at previouslevel, requires restrictions

Painful, cannot perform any la-bor with that arm, cannot liftarm/pseudoparalysis

Recreation/hobbies/sports Can perform with some pain atprevious level

Painful, cannot perform at previouslevel

Has to give up

Sleep/rest Only occasional disruption,largely good sleep, good rest

Affected substantially, needs medi-cations to sleep, wakes up often,does not get rest as before

Sleep and rest are poor, re-quires narcotics

Pain at rest Absent Absent or rare, not significantcomplaint

Present, can never get quitepain free or comfortable,needs narcotics

ADLs = activities of daily livinga Mild = can perform with some pain at previous level; Moderate = painful, notes restrictions with certain ADLs; Severe = painful with almostall ADLs

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eration, backed by published evi-dence and/or the Writing Panel’s ex-pert opinion in the face ofinsufficient published evidence.

Tear Size and RetractionTear size and retraction are deter-mined based on the Southern Cali-fornia Orthopaedic Institute (SCOI)Classification (ie, Snyder Classifica-tion): C1, small complete tear (ie,pinhole sized); C2, moderate tear <2cm in any direction of only one ten-don without retraction; C3, large,complete tear with an entire tendonwith retraction, usually 3 to 4 cm inany direction; and C4, massive rota-tor cuff tear involving two or morerotator cuff tendons, with associatedretraction and scarring of the re-maining tendon.

Response to PreviousTreatmentResponse to previous treatment isincluded in the primary patientvariables because it has direct impli-cations for further treatment; that is,for a patient with poor healingpotential with mild symptoms andexcellent previous response to treat-ment, repeating nonsurgical treat-

ment may be an excellent option.Another example would be a young,active patient with excellent healingpotential with severe symptoms forwhom first-line treatment is surgery(ie, repair or reconstruction, as indi-cated per tear characteristics) andthat may not be that relevant in thatsetting. In the same example of theyoung, active patient who presents aweek after an acute rotator cuff tear,if the pain has not diminished duringthis period, then it could be deemedas failure.

Identified Treatments

Identified treatments for full-thickness rotator cuff tear includethe following:

1. Nonsurgical management: Thisoption includes medications,patient education, manual ther-apy, or supervised exercise.

2. Partial repair and/or débride-ment: This includes subacromialdébridement, débridement ofacromioclavicular joint spurs,débridement of the cuff edges,glenohumeral joint débride-ment, and, finally, biceps tenot-omy or tenodesis. Suprascapu-lar nerve decompression is anoption for débridement and re-pair.

3. Repair: Open or arthroscopicrotator cuff repair—single- ordouble-row/transosseous/suturebridge/transosseous equivalent,anatomic, or medialized repair.The surgeon must choose therepair configuration that in hisor her hands is most reproduc-ible and will likely give the pa-tient the best outcome andtendon-to-bone healing. Ancil-lary procedures such as débride-ment (see above), bicepstenotomy/tenodesis, and supra-scapular nerve decompressionmay be performed.

4. Reconstruction: The tendoncannot be reattached to its in-sertion, even when medialized.Hence, an augmented repairwith a patch or tendon transferis required, but the glenohu-meral joint is preserved.

5. Arthroplasty: Hemiarthroplasty,reverse shoulder arthroplasty,or other arthroplasty optionsmay be appropriate, based onsurgeon preference and/or pre-senting indications.

Results ofAppropriateness Ratings

Out of 2,160 total voting items (ie,432 patient scenarios and 5 treat-ments), 1,148 voting items (53%)were rated as “Rarely Appropriate,”677 voting items (31%) were ratedas “May Be Appropriate,” and 335voting items (16%) were rated as“Appropriate” (Figure 1). Addition-ally, the voting panel members werein agreement on 1,238 voting items(57%) and disagreed on 2 votingitems (0.09%). The two items thatthe voting panel disagreed on wererepair treatment of scenarios 400and 424.

The final appropriateness ratingsassigned by the voting panel can beaccessed online via the AAOS RCAUC web-based mobile applicationat www.aaos.org/aucapp.

Mobile Application

As part of the dissemination effortsfor the RC AUC, a web-based mo-bile application (www.aaos.org/aucapp) has been developed to pro-vide physicians with immediateaccess to information to assist themwith providing evidence-based pa-tient care. The mobile application in-cludes the list of patient indicationsand treatment recommendations.

Once the clinician enters a patient

Summary of appropriatenessratings of the full-thickness rotatorcuff tear AUC mobile application.

Figure 1

Optimizing the Management of Full-Thickness Rotator Cuff Tears

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indication profile by clicking on theradio buttons provided for each indi-cation, a list of treatment recommen-dations is provided. For the selectedpatient profile, green circled check-marks reflect appropriate treatments,yellow Caution symbols reflect treat-

ments that may be appropriate, andred-circled X’s reflect treatments thatare rarely appropriate. The app alsoincludes a demonstration (“tour”),definitions, background information,assumptions, a literature review, anda list of contributors.

Reference

1. Fitch K, Bernstein SJ, Aguilar MD, et al:The RAND/UCLA AppropriatenessMethod User’s Manual. Santa Monica,CA, RAND Corporation, 2001.

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