A title such as "Patients with Workers' Compensation Claims Have Worse Outcomes After Rotator Cuff Repair" provokes the question: "What am I to do with this information; should I not repair the cuff tears in these patients?" Let us see if Henn et al. answer this question.
Rotator cuff disorders comprise the most common indications for shoulder surgery. However, it is probably not appropriate to say (as the authors have said), "surgical treatment and repair of chronic tears is indicated when nonoperative treatment fails." Failure to respond to one treatment surely does not automatically justify another. For example, chronic tears may not be amenable to repair. Failure of nonoperative treatment may be related to noncompliance with the recommendations, and this same noncompliance may bode ill for a surgical treatment as well.
While the authors state that rotator cuff repair results in good-to-excellent outcomes in most patients, it is important to ask the following questions in the context of this paper:
Ultimately, the question we need the answer to is "How should we manage a cuff tear in a worker?" or, better still, "How should we manage a worker with a cuff tear?"
The authors made a concerted effort to assess the pretreatment and post-treatment status of individuals with cuff repairs—for those with Workers' Compensation claims and those without. Importantly, emphasis was placed on the patients' assessment of their own health status, comfort, and function. Key demographic information, including smoking and type of work, was documented.
The authors used the Disabilities of the Arm, Shoulder and Hand (DASH) instrument as the primary outcome variable and used multivariable regression with backwards elimination to remove noncontributory independent variables. One might wonder what the best primary outcome variable is for a study of this type. Is it the DASH or the Simple Shoulder Test (SST) at follow-up, or is it the difference between the postoperative score and the preoperative score? Is the "outcome" what we are looking for, or is it the benefit of the procedure as characterized by the difference between the postoperative status and the preoperative status? Or, in a population of workers, is the key indicator of success the ability of the individual to return to work? As the authors point out, the DASH unfortunately does not include an assessment of the ability to do the patient's usual work.
The authors are to be commended on a most thoughtfully constructed and carefully conducted study. They have robustly documented that Workers' Compensation status is an important variable affecting the preoperative and postoperative status of individuals with rotator cuff tears. As a result, subsequent clinical studies of the results of cuff repairs will need to manage this potentially confounding variable, perhaps by analyzing the results of Workers' Compensation cases separately.
We are still left with the following unanswered questions:
In closing, I invite you to contemplate how you might manage the following patients covered by Workers' Compensation and to consider what "success" would look like for these patients:
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.