We’re all familiar with the phrase “lesser of two evils,” but I’m an optimist and prefer the phrase “better of two goods.” In the October 2, 2019 issue of JBJS, Ramme et al. compare surgical versus nonsurgical treatment of full-thickness rotator cuff tears. Both cohorts had improved outcomes relative to baseline, but surgical management was the better of two goods.
The authors retrospectively analyzed a prospective cohort of adult patients with full-thickness rotator cuff tears who had elected either surgical or nonsurgical treatment. Ramme et al. utilized propensity score matching to pair up patients in each group according to factors thought to influence outcome, such as age, sex, tear size, chronicity, muscle atrophy, and the Functional Comorbidity Index. This matched-pair analysis is a valiant attempt to eliminate bias that is inherent in retrospective analyses, and this study design also mimics the real-world scenario of shared decision making between physician and patient.
The 2-year follow-up analysis of 107 propensity score-matched patients revealed that both groups improved in 4 patient-reported functional outcomes and pain compared to their baseline measures before treatment. However, the final outcome measurements and magnitude of improvement were statistically greater in the surgical management group (p <0.001).
This study will help shoulder surgeons have more meaningful discussions with their patients about treatment options for full-thickness rotator cuff tears. We know that with proper treatment—either surgical or nonsurgical—patients can expect improvement in pain and function. However, patients who elect surgical management may have the potential for even greater outcomes, and that definitely sounds like the “better of two goods.”
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Spine surgeons have two basic approach options when performing surgery on patients with degenerative cervical myelopathy—anterior or posterior. Each approach has advantages and disadvantages, and numerous studies have attempted to elucidate which approach might be better for specific clinical situations.
In the June 21, 2017 edition of The Journal of Bone & Joint Surgery, Kato et al. add to the evidence base regarding this question. They report on results from an analysis comparing the two approaches in 80 pairs of “propensity-matched” patients who had multilevel compression myelopathy. Propensity matching allowed the authors to adjust for multiple baseline factors and MRI characteristics, thus minimizing the risk of selection bias.
After the propensity-matched analysis, there were no two-year between-group differences in mJOA score, Neck Disability Index, or SF-36 Physical Component score. The overall rates of perioperative complications were similar between the two groups, although dysphagia and dysphonia were reported only in the anterior group, while surgical site infection and C5 radiculopathy were reported only in the posterior group.
The authors claim that propensity matching helps to “reflect the ‘real-world’ clinical setting and likely has greater generalizability than a smaller, narrowly randomized controlled trial,” but they ultimately conclude that the surgical approach in such cases “should be carefully chosen by evaluating risk profiles in a shared decision-making process on a case-by-case basis.”