Surgical Referral Criteria for Degenerative Rotator Cuff Tears: A Delphi Questionnaire Study

Abstract

Selecting the most appropriate patients to refer for surgery is crucial for high-quality and efficient clinical care. However, there are no specific referral criteria to guide the referral of appropriate patients for rotator cuff repair surgery. The aim of the present study was to design robust surgical referral criteria for patients with degenerative rotator cuff tears using consensus methodology. A two-round Delphi questionnaire was undertaken with a nationally representative sample of 41 specialist shoulder surgeons experienced in rotator cuff repair. Surgical referral criteria for degenerative rotator cuff tear were developed where consensus of at least 70% agreement was achieved. The initial questionnaire consisted of 24 items. Consensus was reached on 14 items, including: severity of pain, functional limitation, the identification of fat atrophy, agreement that a course of physiotherapy should be attempted before surgical referral, and exclusion for those with an active frozen shoulder. However, there was no consensus with regard to the dimensions of the tear. The surgical referral criteria developed were novel and promising for patients with degenerative rotator cuff tears, and further research is required to examine their efficacy.

Rotator cuff disease: opinion regarding surgical criteria and likely outcome

“…Within a close community of surgeons based in Western Australia ( n = 23) considerable heterogeneity exists in surgical decision‐making criteria, consistent with previous studies from the USA and UK . This study surveyed a younger surgeon sample (9 versus 18 years of consultancy practice in the USA study), with a similar estimated failure rate (12 versus 15%) .…”

“…Clinical agreement was achieved for only vignette 2 in this study, whereas the previous USA study failed to achieve agreement for any vignette. For vignette 1, less than half of surgeons surveyed (48%) recommended surgery with RCR, despite weak evidence that early surgical repair for tear after traumatic injury is indicated and failure of a conservative physiotherapy program is considered to be an indication for surgery . For vignette 2, clinical agreement (83%) was attained for surgery with RCR, in keeping with clinical guidelines recommending early surgical repair for full thickness tears after traumatic injury .…”

“…Surgical criteria for RCD are not clear, with clinical practice guidelines and surveys of surgeon opinion outlining a lack of consensus agreement between surgeons for the management of RCD . Evidence‐based clinical guidelines, surgeon education, surgeon personal experience and individual patient factors, may inform surgical decision‐making.…”

“…Clinical examination tests, such as weakness or pain on muscle testing or clinical orthopaedic tests may assist with decision‐making, however tests also lack robust evidence. A systematic review determined that most tests for RCD are inconclusive, with limited recommendation for their clinical use …”

Living with a symptomatic rotator cuff tear ‘bad days, bad nights’: a qualitative study

“…There is a lack of concensus regarding the optimal treatment of degenerate cuff tears and limited and inconclusive evidence regarding the relative effectiveness and harms of surgical and conservative treatment approaches [1,7,8]. Non-operative management such as physiotherapy is recommended prior to considering surgery but surgical referral criteria are not straightforward [9,10]. The need for further research was highlighted at a recent consensus meeting on the management of disorders of the rotator cuff which identified 30 unresolved issues/areas for future research to improve management [9].…”