Is Surgery the Only Answer for Rotator Cuff Tears?
POSTED ON 1/4/2015 IN Shoulder BY Christopher Centeno
I had a little dust up with an orthopedic surgeon on Twitter this A.M. about shoulders and stem cells, so even though I wasn't going to release this shoulder arthritis and rotator cuff data set until next week, today seemed like a better time. The operative issue from that discussion is whether orthopedic surgery for rotator cuff tears is a good idea, or if an injection of stem cells is a better idea. The reality, like everything in life, is likely somewhere in between. First, the rotator cuff is a structure made up of muscles and tendons that surround the shoulder joint. It's responsible for shoulder and arm movement as well as playing a major active stability role. Tears in the shoulder rotator cuff are common as we get older and the most common solution for these injuries that fail a trial of physical therapy is surgery. Generally, before surgery a steroid shot is tried in the shoulder, but yesterday's blog showed pretty convincingly that this was a dumb idea. On the topic of rotator cuff surgery, the research literature hasn't been kind. First, we have absolutely no high level evidence that rotator cuff surgery works-i.e. there are no large randomized controlled trials where patients who get surgery do better than those who are randomly assigned to no surgery. In fact, one recent study of surgery versus physical therapy for a rotator cuff tear, the surgery group didn't do any better than those who just had physical therapy. Another recent study showed that when looking at 900 patients who underwent rotator cuff surgery, there were no outcome differences in those who had evidence of healing of the tear versus those who had no healing, suggesting that sewing the tear may not be important for improvement. Finally, another recent study of 500 patients showed that 6 in 10 surgical repairs of the rotator cuff failed (i.e. the tendon re-tore). So if surgery alone isn't the answer, how about surgery plus stem cells? We have pretty good circumstantial evidence that surgery plus stem cells may work. For example a study just last month showed that poking holes in the bone to release bone marrow stem cells enhanced surgical repair. Earlier last year, stem cell pioneer Phillpe Hernigou published a large case series of shoulder surgery patients who had the addition of stem cell injections after the rotator cuff repair and those patients had about half the re-tear rate of patients who didn't get the injections. So, surgery plus stem cells may be a winner. How about stem cells without surgery? That procedure, if it worked, would be far less invasive with much fewer complications and a much quicker recovery. We've seen several great cases of full thickness rotator cuff tears heal with stem cell injections using a very specific and unique protocol proprietary to Regenexx (see MRI case 1, MRI case 2, ultrasound case 1). We've also submitted for publication our registry experience on shoulders and continue to publish this data on-line. Above is the 2014 data that I'm releasing today on 199 patients (see above). This is a mix of rotator cuff tears with and without arthritis, none of which were treated with surgery, all of which instead got the Regenexx-SD procedure. This data shows robust relief and improvement in function out to two years. Whats the future of treating shoulder rotator cuff tears? I expect that surgery for about 70-80% of rotator cuff tears will become a thing of the past over the next 20 years, instead being replaced with precise ultrasound guided stem cell injections as the logical shoulder surgery alternatives. I also expect that new tools will allow bigger and bigger tears to be treated via injection without surgery. Having said that, for massive tears, it's likely that surgery plus stem cells will be the answer. It's even possible that bio-printing of a new rotator cuff with the patient's own stem cells and surgical installation could be possible in my lifetime. The upshot? Despite the twitter comments of an acerbic orthopedic surgeon without any publications in stem cells (we've published 29% of the world's literature on orthopedic injuries in stem cells based on patient n), I believe nonsurgical rotator cuff tear repair is in most cases, the future. Having said that, there will likely always be a place for surgery in some tears. We're putting our money where our mouth is on the subject, having just submitted a large registry paper for publication. We've also sponsored a randomized controlled trial that's recruiting now to see if our clinical experience is backed up by a rigorous research design. In the end, as the future allows for more non-surgical treatment for rotator cuff tears, this will be a great boon for patients by allowing less invasive care!
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