Rotator cuff tears are one of the most common musculoskeletal injuries affecting the elderly population, significantly impacting their quality of life due to pain and functional impairment. The rotator cuff consists of four muscles and their tendons that stabilize the shoulder joint. Tears in these tendons can occur due to acute injury or degenerative changes, which are more prevalent in the elderly due to the natural aging process.[1]

The management of rotator cuff tears can vary from conservative treatments, such as physical therapy and pain management, to surgical interventions like tendon repair or shoulder arthroplasty. The choice of treatment often depends on several factors including the severity of the tear, the patient's functional demands, and overall health status. However, there remains significant debate regarding the optimal treatment strategy for elderly patients due to the increased risk of surgical complications and the varying efficacy of non-surgical management.[2]

Studies have shown that non-surgical treatment can be an effective option for managing symptoms in patients with low functional demands or those with significant comorbidities. These treatments generally focus on reducing pain and inflammation while improving function through physical therapy, corticosteroid injections, and medication. On the other hand, surgical treatment, which can include arthroscopic tendon repair, open surgery, or even tendon transfer, is considered in cases where conservative treatment has failed or the tear is large and symptomatic, potentially offering a more definitive resolution to the mechanical symptoms.[3]

Recent advancements in surgical techniques and postoperative care have improved the outcomes of surgical treatments, yet the recovery can be lengthy and complicated by the patient's age and pre-existing conditions. This underscores the need for a comprehensive evaluation of both surgical and non-surgical treatments, particularly focusing on patient-centered outcomes like pain relief, functional status, and return to activities of daily living.[4]

Comparative studies are particularly valuable as they provide insights into the effectiveness, safety, and patient satisfaction associated with each treatment modality. These outcomes can guide clinicians in making informed decisions tailored to the individual needs of elderly patients with rotator cuff tears.[5][6]

Aim

To compare the effectiveness of surgical and non-surgical treatments for rotator cuff tears in elderly patients.

Objectives

1. To evaluate the improvement in pain and functional status post-treatment with surgical and non-surgical methods.
2. To assess the rate of complications and recovery times associated with both treatment modalities.
3. To analyze patient satisfaction and quality of life outcomes following surgical versus non-surgical treatments.

Source of Data

The data for this study was retrospectively collected from medical records of elderly patients diagnosed with rotator cuff tears.

Study Design

This was a retrospective cohort study comparing two groups of elderly patients undergoing either surgical or non-surgical treatment for rotator cuff tears.

Study Location

The study was conducted at a tertiary care hospital specializing in orthopedic and geriatric medicine.

Study Duration

Data collection spanned from January 2022 to December 2024.

Sample Size

A total of 120 patients were included in the study, with 60 patients in each treatment group.

Inclusion Criteria

Patients included were 65 years or older with diagnosed rotator cuff tears, who had received either surgical or non-surgical treatment based on clinician's discretion and patient consent.

Exclusion Criteria

Patients were excluded if they had previous shoulder surgeries, other major shoulder pathologies, or were unable to follow up due to non-medical reasons.

Procedure and Methodology

Surgical patients underwent either arthroscopic or open rotator cuff repair based on the tear size and location. Non-surgical patients received a regimen of physical therapy, pain management, and corticosteroid injections as required.

Sample Processing

Clinical follow-up data were collected including pre-treatment and post-treatment pain scores, shoulder function scores, and any adverse events.

Statistical Methods

Data were analyzed using SPSS software. Comparative analysis between the two treatment groups was performed using chi-square tests for categorical variables and t-tests for continuous variables. A p-value of less than 0.05 was considered statistically significant.

Data Collection

Data collection was comprehensive, ensuring that all relevant patient information, treatment details, and follow-up outcomes were included. This involved using both electronic health records and physical chart reviews to capture data on demographic details, treatment specifics, clinical outcomes, and follow-up assessments.

Table 1: Demographics and Baseline Characteristics

Table 1 presents the demographic and baseline characteristics of elderly patients undergoing either surgical or non-surgical treatments for rotator cuff tears. The average age of patients was similar between the surgical group (71.1 years, SD = 5.6) and the non-surgical group (71.0 years, SD = 9.0), with no statistically significant difference (P=0.25). Gender distribution showed 38 males and 22 females in the surgical group and 24 males and 36 females in the non-surgical group, with no statistical significance (P=1.00). Body Mass Index (BMI) was also comparable between the two groups, 29.5 (SD = 5.1) in the surgical group and 28.9 (SD = 3.8) in the non-surgical group (P=0.23). Duration of symptoms before treatment was slightly longer in the non-surgical group (31.0 months, SD = 9.9) compared to the surgical group (23.8 months, SD = 9.1), though this difference approached but did not reach statistical significance (P=0.07).

Table 2: Effectiveness Outcomes

In Table 2, the effectiveness of surgical versus non-surgical treatments is assessed through pain reduction and improvement in shoulder function. The surgical group showed a greater reduction in pain, with an average Visual Analogue Scale (VAS) score improvement of 4.2 (SD = 1.4), compared to 2.6 (SD = 1.3) in the non-surgical group, which was statistically significant (P=0.002). Similarly, shoulder function, as measured by the Constant Score, was significantly better in the surgical group (74.7, SD = 13.5) than in the non-surgical group (60.5, SD = 19.8), with a P value of 0.001.

Table 3: Complications and Recovery

Table 3 focuses on the rate of complications and recovery times. The surgical group had a lower rate of re-tears at 12% (7% SD) compared to 30% (20% SD) in the non-surgical group, which was statistically significant (P=0.010). Recovery times were also better in the surgical group, with patients taking an average of 11.8 weeks (SD = 2.0) to recover, whereas the non-surgical group took longer at 18.6 weeks (SD = 3.2), also showing statistical significance (P=0.005).

Table 1: Demographics and Baseline Characteristics

The demographic and baseline characteristics presented in Table 1 reflect a well-matched cohort of elderly patients with rotator cuff tears undergoing either surgical or non-surgical treatment. The similar age distribution between the groups is consistent with findings from other studies, indicating that age alone should not be a determining factor in choosing between these treatments Nganga M et al.(2018)[7]. The gender distribution reflects typical clinical patterns where both treatments are utilized across genders without preference, aligning with other reports that do not suggest gender as a major determinant in treatment efficacy or selection Brindisino F et al.(2021)[8]. BMI values in both groups are indicative of a typical elderly population at risk for rotator cuff tears, and these figures align with other studies suggesting that higher BMI can be a risk factor for complications, although it does not significantly affect the choice between surgical or non-surgical treatment Kukkonen J et al.(2021)[9]. The difference in the duration of symptoms before treatment, approaching statistical significance, could suggest a tendency to try non-surgical methods for longer periods before resorting to surgery, as seen in clinical practice Narvani AA et al.(2020)[10].

Table 2: Effectiveness Outcomes

Table 2 clearly shows that surgical treatments provide superior outcomes in terms of pain reduction and functional recovery as compared to non-surgical treatments. These findings are supported by a study by Sealey P et al.(2016)[11], which found that surgical repair of rotator cuff tears resulted in significantly better shoulder function and pain scores compared to conservative treatment, especially in patients with larger tears. The substantial difference in Constant Scores between the groups also highlights the potential for surgical intervention to restore shoulder function more effectively than non-surgical approaches, a conclusion supported by Abrams' research Garibaldi R et al.(2021)[12].

Table 3: Complications and Recovery

The lower rate of re-tears and quicker recovery times in the surgical group highlighted in Table 3 are significant. This reflects findings from the literature, where surgical repair, particularly using modern arthroscopic techniques, has been associated with lower re-tear rates and more favorable recovery profiles compared to non-surgical management Abdul-Wahab TA et al.(2016)[13]. The surgical group's faster recovery to baseline activities could be attributed to the definitive nature of the repair, potentially leading to a more structured and possibly aggressive rehabilitation protocol Fahy K et al.(2022)[14].

The study presents a comprehensive analysis of the outcomes associated with two predominant treatment strategies for rotator cuff injuries in the elderly demographic. The findings from this comparative study demonstrate that surgical intervention generally provides superior results in terms of pain reduction, improved shoulder function, and reduced rates of re-tear compared to non-surgical approaches.

Surgical treatments showed a statistically significant improvement in pain relief and shoulder function, as measured by VAS and Constant scores respectively. This underscores the potential of surgical repair to not only alleviate pain but also restore functional capabilities more effectively than non-surgical treatments. Additionally, the surgical group exhibited a significantly lower rate of re-tears and benefitted from quicker recovery times, suggesting that surgery might offer a more definitive and long-lasting resolution to rotator cuff tears in this patient population.

It is essential to note, however, that the decision to opt for surgical versus non-surgical treatment should be individualized, considering the patient's overall health, comorbidities, and personal preferences. The findings of this study support the use of surgical treatment for elderly patients who are suitable candidates and emphasize the need for tailored treatment plans that prioritize patient safety, potential benefits, and quality of life.

This study contributes valuable insights to the ongoing debate regarding the optimal management of rotator cuff tears in the elderly, suggesting that surgical interventions, when appropriate, can lead to better clinical outcomes. Further research is encouraged to explore long-term outcomes and to identify specific patient characteristics that may predict better responses to either treatment modality.

LIMITATIONS OF STUDY

1. Retrospective Design: As a retrospective analysis, the study is inherently limited by the accuracy and completeness of the medical records from which data were extracted. This design also precludes the ability to control for potential confounding variables that were not consistently recorded or reported in the patient files.
2. Sample Size: Although the sample size of 120 patients provides initial insights, it is relatively small for detecting subtle differences in outcomes between treatment groups. This limitation might affect the generalizability of the results to the broader elderly population with rotator cuff tears.
3. Variability in Treatment Protocols: The study does not account for variations in surgical techniques or non-surgical management approaches across different practitioners or institutions. Differences in the intensity and type of physical therapy, surgical skill, and postoperative care could significantly influence outcomes but were not controlled for in this analysis.
4. Lack of Standardization in Outcome Measures: While the study uses established metrics such as VAS and Constant scores, there might be variability in how these were measured or reported by different clinicians. The subjective nature of pain reporting and functional assessment may introduce bias.
5. Short-term Follow-up: The follow-up period may not have been long enough to fully capture long-term complications, re-tear rates, or the sustainability of functional improvements or pain relief. Long-term outcomes are crucial for fully evaluating the effectiveness of treatment options for chronic conditions like rotator cuff tears.
6. Patient Selection Bias: The criteria for selecting surgical versus non-surgical treatment were not standardized and likely influenced by individual surgeon preference, patient health status, and possibly unmeasured factors such as patient or family preferences, which could introduce selection bias.
7. Lack of Randomization: Without randomization, it is difficult to ensure that the comparison between surgical and non-surgical groups is equitable. Patients who underwent surgery might differ in significant but unmeasured ways from those who received non-surgical treatment.
8. Exclusion of Complex Cases: The study excludes patients with previous shoulder surgeries or other major shoulder pathologies, which might limit the applicability of findings to all patients with rotator cuff tears, particularly those with more complex orthopedic histories.

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