Decision Making for Labral Tears and Rotator Cuff Tears [video]

…and we should NOT think like mechanics.

Orthopedists and Twitter

Thanks to an orthopedic colleague, Dr. Katherine Burns, the Orthopedic community and any other interested parties on twitter were given a chance to observe for the first a well done live tweeting of an orthopedic meeting — focusing predominantly on the shoulder. Now,  those of you have been around twitter for a long time,  and certainly those of you who attended many healthcare meetings, and certainly healthcare marketing meetings clearly know that live tweeting of events is nothing new, however,  from an orthopedic perspective — this was a big leap forward.

We are not mechanics… We treat patients, not MRI findings

The one upsetting issue is a theme that I see repeated over and over in the realm of orthopedic surgery,  both in resident education, in what many people are told in offices around the world,  as well as the focus of much of the literature that I read in the realm of shoulder surgery.   That is the issue of *Mechanical Thinking*. Something is broken or torn so I must fix it!

A not insignificant focus withing the orthopedic literature —  and certainly most of this meeting which was live tweeted focused on how to fix something, what techniques could be utilized to fix something, and what the overall results were from utilizing those techniques. The didactic sessions were followed by a laboratory session where the surgeon attendees were actually able to perform the surgery on cadavers in order to hone their skills.  That’s all well and good.  HOWEVER, this assumes that surgery was *necessary* or advisable in the first place. There was very little discussion centered about who needs surgery, when they need surgery, or why they need surgery.

A Patient Centric Approach

I received many questions through my website and certainly in my office in the form of second opinions where people put forth the issue that surgery was being recommended to repair a rotator cuff tear – – – yet they had relatively little if any discomfort.  Many people offered that their pain was having little if any effect on their quality of life … and important Shared Decision Making principle.  These were typically situations where they most likely had shoulder pain for a short period of time and were referred for an MRI (perhaps a little early), a rotator cuff tear was identified and purely mechanical thinking led to the recommendation for surgery.  Since the recommendation, most of the patients who presented had already realized significant improvement in their pain and they were wondering whether surgery was indicated.

Orthopedic surgeons have been taught in the past that most tears *need* to be fixed. Again, mechanical thinking – – – if something is broken, we must fix it. We now know that this  is probably not true. Why don’t I use the word probably? I use the word probably simply because we don’t have enough evidence to say with absolute certainty what tears need to be fixed and which tears do not need to be fixed. Very few surgeons would argue that acute or posttraumatic tears of the rotator cuff truly deserve to be fixed. However, many tears, or in fact most tears of the rotator cuff are attritional in nature — this is where the tissue simply wore out.  The analogy that I frequently use is — your favorite pair of blue jeans you’ve been wearing for years. You look down one day or you feel a breeze around your knee and you look down and there is a hole in the front of your bluejeans.  Did you rip it purposefully,  did you lean on it or kneel on it or inflict some form of trauma to your pants :-) ? No, the tissue,  or in this case the fabric simply wore out.    So if that tissue is wearing out and we choose to repair it what’s the likelihood that the tissue has the ability to heal?  If it is *successfully* repaired – – – because the tissue is degenerative, what’s to prevent it from simply tearing again?  Once again, we simply do not have good answers to those questions.

Do I *need* surgery?

The same issue came up with  labral tears. There was a lot of discussion about techniques to be utilized to fix labral tears, what techniques should be utilized in various age groups, etc.  The number one number question in my mind,  however,  was not well addressed.  That question of course is — “Do labral tears need to be fixed?”   In many situations the answer is clearly yes. If your shoulder is unstable or dislocating then you need to have your labor repaired to minimize the risk of re-dislocation. If you are an overhead athlete and you sustain a labral tear, do you need to have that repaired?  Occasionally the answer is yes. Unfortunately, some recent literature has shown that the vast majority of high-performance overhead athletes are not able to return to their prior level of function following a labral repair. Are surgeons informing these overhead athletes about these facts?  There are many surgical success stories where we are clearly able to return a high-performance athletes back to their usual function.  But it does not appear that labral surgery in this unique patient population is often successful … in weekend warriors and many high school or college players, a repair appears to be successful.  But the margin for success is not high.

So, by and large this was a good week for the world of Orthopedics and Social Media. There are many more orthopedic surgeons on Twitter and other social media properties. This will ultimately prove to be a *good thing* for people searching for quality orthopedic information.

Eminence  vs Evidence Based Medicine and Surgical Decision Making

On the flip side .. due to the persistence of Eminence Based Medicine in the community and the issue of purely mechanical thinking  — I simply suggest that you temper your decision to proceed with a recommended surgery until you obtain a very clear understanding and an adequate  discussion about the evidence that exists as to why the suggestion for shoulder surgery is  being made — prior to you considering   surgery.  Have a clear understanding of what shared decision-making principles are. Perhaps even utilize the multitude of shared decision-making tools which are available to you on the Internet. If your surgeon is either not willing or capable of discussing the evidence or going through a shared decision making process with you — consider a second opinion—  or moving on.