Improving the lives of patients with rotator cuff tears

Mr Toby Colegate-Stone, is clinical lead for shoulder at King’s College Hospital NHS Foundation Trust, specialising in keyhole rotator cuff repair.

What is the incidence of rotator cuff tears and repairs?

Toby: In a GP setting the shoulder is the third most common joint doctors see. And three quarters of these are rotator cuff related. Patients suffer from direct and referred pain, dysfunction and poor movement, sleep disturbances, and an impact on day to day life and psychological wellbeing. When left - and this happens all too often in large numbers of patients - surgery has a higher risk of failure.

How do you achieve better results from rotator cuff surgery?

Toby: The time to treat is so often delayed. There’s a far greater chance of successful surgery - ie 80 to 90% success rates - with early treatment. Delaying surgery in significant tears in favour of protracted use of pain medication and physiotherapy can result in muscles atrophying and fatty tissue infiltration. And smaller tears gradually become larger, rendering successful treatment a slim possibility - with a greater chance of re-tear after late surgery.

The joint then becomes arthritic - sometimes requiring a much more complex shoulder replacement procedure, with a poorer prognosis.

How are you improving techniques in rotator cuff repair surgery?

Toby: There are many good surgeons performing rotator cuff repairs, and often using instrumentation that minimises a surgeon’s input. However, I prefer to use my own bespoke, hand-tied technique for finding the exact placement of anchors and sutures to reattach tendon to bone.

This restores the anatomy to its rightful place as opposed to the railroading applied in generic machine-led techniques.

How do you improve the chances of better outcomes from surgery?

Putting yourself in the hands of an experienced surgeon used to complex cases.

Toby: As with any orthopaedic surgery, you want to choose a surgeon specialising in one area of the body, and performing the procedure in very high volumes. Furthermore, select a surgeon who is fellowship trained in a major, high volume, internationally renowned centre.

High volume surgeons tend to be experienced at making quick decisions and being comfortable with the uncomfortable. So, when things don’t go as planned they make better decisions.

I’m also privileged to be clinical lead for shoulder at King’s College Hospital where I treat many patients with complex cases. This makes my routine work, wonderfully routine.

As with all aspects of healthcare, it’s about teamwork - and surrounding the patient with specialised and experienced allied healthcare professionals.

What’s next in shoulder surgery for you?

Toby: I have a particular interest in outcomes - they speak louder than words - but interestingly, this focus is not where it could be in healthcare. This is changing as research, published papers and peer to peer work is increasingly - and rightfully - being translated for patients.

I continually turn a critical eye on my own practice, grouping patients and pathologies, and finding new ways of improving techniques and protocols. Currently my success rates for rotator cuff repair stand at >95%. But ultimately, if we reach patients sooner, we can achieve better healing, faster recovery, and lower re-tear rates.

Mr Toby Colegate-Stone is passionate about research and data. As lead in such a high volume trauma unit as King's College Hospital in London, Toby is championing value-based healthcare. He speaks about the need for timely rotator cuff tear repair (versus reconstruction) to improve outcomes after surgery. His private practice is at Cleveland Clinic London.