Management of Massive Rotator Cuff Tears in the Wheelchair Bound, Spinal Cord Injury Population: Study Proposal toward the Establishment of Higher Level of Evidence Care
ABSTRACT OF THE THESIS
Management of Massive Rotator Cuff Tears in the Wheelchair
Bound, Spinal Cord Injury Population: Study Proposal toward the Establishment of Higher Level of Evidence Care
Hansel E. Ihn
Master of Science in Biomedical and Translational Science
University of California, Irvine
Professor Thay Q. Lee, Chair
Background: The wheelchair bound, paraplegic population are heavily reliant on their upper extremities for independence. As a result, there is a high prevalence of rotator cuff tears within this population. However, there is no established clinical practice guideline to help guide the care of this problem.
Aims: The original goal of this thesis was to conduct a systematic review and meta- analysis of the available literature in the hopes of take a step toward establishment of a clinical practice guideline. Once a preliminary evidence- mapping procedure was done, it was decided there was not enough evidence available to warrant a meta- analysis. Consequently, the aim of this thesis then shifted toward the proposal of a potential clinical trial that would provide a high level of evidence.
Methods: The evidence mapping procedure simulated the process ordinarily taken for systematic reviews as outlined in the Preferred Reporting Items for Systematic reviews and Meta- Analyses (PRISMA) guidelines. PubMed, Web of Science, and the Cochrane Library databases were searched using pre-determined search strategies with keywords. The clinical trial proposal process that then followed utilized the evidence gained from the evidence mapping procedure as well as that attained from a literature review of high level of evidence studies in orthopaedic surgery.
Results: The evidence mapping procedure netted a total of 191 studies of which only 6 studies were fully reviewed. Upon review, these six studies were found to be all of level IV evidence. These studies represented a heterogeneous use of surgical techniques and outcome measures. Consequently, they did not meet the inclusion criteria to perform a meta- analysis.
Discussion: The data extraction process made it apparent that the evidence available has multiple methodologic flaws precluding meaningful synthesis. Even by case series standards as outlined by Obremskey et al., these six studies did not meet many of the criteria necessary to provide evidence that would be deemed useful for clinical judgement. To that end, the thesis concludes with a proposal of a clinical trial that would provide a higher level of evidence for clinical management. Specifically, the proposal addresses massive rotator cuff tears in the wheelchair bound, paraplegic population. The interventions compared in the study will be rotator cuff repair with subacromial decompression or subacromial decompression alone. The potential pitfalls and ethical dilemmas that may present during the study are also discussed