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Revista Brasileira de Ortopedia

Print version ISSN 0102-3616On-line version ISSN 1982-4378

Rev. bras. ortop. vol.52 no.5 São Paulo  2017

https://doi.org/10.1016/j.rboe.2017.08.013 

REVIEW ARTICLE

Outcome assessment in the treatment of rotator cuff tear: what is utilized in Brazil?

Jorge Henrique Assunção1  *  

Eduardo Angeli Malavolta1 

Vitor Rodrigues Domingues1 

Mauro Emilio Conforto Gracitelli1 

Arnaldo Amado Ferreira Neto1 

1Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brasil


ABSTRACT

This review evaluated the outcomes used in clinical studies involving rotator cuff tear published in the last decade in the two leading Brazilian orthopedic journals. A literature review was performed using the journals Revista Brasileira de Ortopedia and Acta Ortopédica Brasileira. It included all original clinical articles describing at least one outcome measured before or after any clinical or surgical intervention related to rotator cuff tear, published between 2006 and 2015. The authors evaluated range of motion, muscle strength, patient satisfaction, and tendon integrity and functional outcomes scores. There were 25 clinical studies published about rotator cuff in the two principal Brazilian orthopedic journals in the last decade, 20 case series (80%), one case-control (4%), and four cohorts (16%). Objective measures such as muscle strength, patient satisfaction, and evaluation of tendon integrity were little used. Range of motion measurements were performed in 52% of the articles. Evaluations of muscle strength and patient satisfaction were reported by 28% and 16% of the studies, respectively. Only 28% of the articles evaluated tendon integrity after surgery. Of these, 16% did so by magnetic resonance imaging and 12% by , ultrasonography. The most used scale was the UCLA, present in 92% of the articles, while the Constant-Murley appeared in 20%. Scales deemed reliable, with high internal consistency and good responsiveness, were rarely used.

Keywords: Shoulder; Evaluation of results of therapeutic interventions; Rotator cuff

RESUMO

Avaliamos os desfechos usados nos estudos clínicos que envolvem rotura do manguito rotador publicados na última década nos dois principais periódicos ortopédicos brasileiros. Foi feita uma revisão da literatura nos periódicosRevista Brasileira de OrtopediaeActa Ortopédica Brasileira. Foram incluídos todos os artigos clínicos originais que descreviam ao menos uma medida de desfecho antes ou após alguma intervenção clínica ou cirúrgica referente ao manguito rotador publicados entre 2006 e 2015. Os desfechos avaliados foram arco de movimento, força muscular, satisfação, integridade tendínea e escalas clínicas. Foram publicados 25 estudos clínicos sobre manguito rotador nos dois principais periódicos ortopédicos brasileiros na última década, 20 séries de casos (80%), um estudo tipo caso-controle (4%) e quatro coortes (16%). Medidas objetivas como força muscular, satisfação do paciente e avaliação da integridade tendínea foram pouco empregadas. As medidas do arco de movimento foram descritas em 52% dos artigos. A avaliação da força muscular e a satisfação do paciente foram descritas em 28% e 16% dos estudos, respectivamente. Apenas 28% dos artigos avaliaram a integridade tendínea após a cirurgia. Desses, 16% o fizeram com a ressonância magnética e 12% com a ultrassonografia. A escala mais usada foi a da UCLA, presente em 92% dos artigos, enquanto a de Constant-Murley foi usada em 20%. Escalas consideradas confiáveis, com grande consistência interna e boa responsividade, raramente foram usadas.

Palavras-chave: Ombro; Avaliação de resultado de intervenções terapêuticas; Manguito rotador

Introduction

Shoulder pain has a high prevalence in the population, ranging from 7 to 26%.1 Rotator cuff conditions, the main cause of pain in the shoulder girdle, affect 20% of the general population and up to 50% of patients over 80 years.2

Standardized clinical assessment is essential to determine the efficacy of a treatment and also to compare the results of different studies; it is crucial in clinical research.3,4 Methods for evaluating the results of orthopedic treatment have been modified in recent years.5,6 Previously, measurements were based on physical examination, by examining joint mobility and muscle strength. However, questionnaires or clinical scales have been developed that have improved the evaluation of results.7,8 However, there is a wide variation in the measurement tools.9 More than 40 scales are described to assess shoulder pain and function.10 In addition, the measurement of the range of motion and strength, and the description of the imaging findings also do not have a consensus.9

Makhni et al.9 recently published a review involving the six leading international orthopedic journals, and described the tools used to assess outcome in rotator cuff disorders. We do not have a survey showing the main types of clinical evaluation in Brazil. Most instruments have been developed and evaluated in the English language.10 For these instruments to be used in Brazil, translation, cultural adaptation, as well as tests that evaluate measurement properties of these instruments, such as internal consistency, reproducibility, validity and responsiveness are recommended.5

The objective of this study was to evaluate the outcome used in clinical studies involving the rotator cuff published in the last decade in the two main Brazilian orthopedic journals.

Methods

Design

A literature review was performed in the two main Brazilian orthopedic journals, Revista Brasileira de Ortopedia (RBO) and Acta Ortopédica Brasileira. The period covered was one decade (January 2006 to December 2015). This study was approved by the local Ethics Committee with number 1197.

Search strategy

The search strategy initially included the reading of all titles of the articles by one of the authors (JHA), using the journals’ table of contents. In cases of doubt with the reading of the title, the abstract was evaluated. This way, all articles that did not involve the shoulder joint were excluded. Then the abstracts were read by three authors (JHA, EAM and VRD) and, if necessary, the full text, to determine if the article fit the selection criteria. In case of disagreement in the selection of a particular article among the three authors, whether including it or not was defined by consensus.

Selection criteria

All original clinical articles (randomized controlled trial, cohort, case-control and case series) that included at least one outcome measure before or after a certain clinical or surgical intervention for the rotator cuff were included. Case reports, description of surgical technique, articles on diagnostic methods accuracy, anatomical studies, articles involving animals or cadavers, basic science or reviews were excluded.

Outcomes

Data regarding the study title, year and volume of the publication, casuistry, minimum follow-up, regular follow-up and level of evidence were tabulated. In addition, the following outcomes were assessed:

Range of motion

The evaluation of the range of motion was investigated: frontal flexion, elevation, abduction, lateral rotation (with the arm at the side of the body or abduction) and medial rotation (with the hand toward the back or with the arm in abduction). The measure in any of the aforementioned positions was listed. Data were only considered if quantitatively described in the results section. The position of the patient (supine, sitting or in a orthostatic position) and the use of a goniometer were also evaluated.

Muscle strength

The position in which strength was evaluated was studied: frontal flexion, elevation, abduction, lateral rotation (with the arm at the side of the body or abduction) and medial rotation (with the hand toward the back or with the arm in abduction). The measure in any of the positions was listed. Data were only considered if quantitatively described in the results section. The position of the patient (supine, sitting or in a orthostatic position) and the use of dynamometer were also evaluated. Manual evaluation data (graduation from 0 to 5) were computed. Data on a subdomain of a clinical scale were also reported.

Tendon integrity

The imaging method used (magnetic resonance with or without contrast, computed tomography with or without contrast or ultrasonography) was evaluated. Radiographs were not analyzed. The periodicity and timing in which the test was performed were reported. The use of some integrity assessment scales, or categorical evaluation in ruptured and intact tendons has been described. We also describe the presence or absence of data related to the acquisition and analysis of imaging tests: device used, evaluators, images obtained.

Satisfaction

Any data regarding patient satisfaction was studied. This included questions regarding treatment satisfaction or whether the patient would recommend the procedure to a third party or if they would have surgery again. Data on a subdomain of a clinical scale were also reported.

Evaluation scales and questionnaires

The functional scales and the evaluation questionnaires used by the authors were evaluated. We also reported studies that used visual analogue scale (VAS) for pain or function.

Statistical analysis

Data were exposed in a descriptive way, by means of absolute numbers and percentage.

Results

In the period evaluated, 712 original articles were published in the Brazilian Journal of Orthopedics and 588 in Acta Ortopédica Brasileira, or 1300 publications. Among these, 84 (6.7% of the total) were clinical articles on shoulder diseases; 25 publications (1.9% of the total)11-35 evaluated the clinical results of treatment of rotator cuff tears (Table 1); twenty studies (80%) were case series (level of evidence IV), one (4%) case-control study (level of evidence III) and four (16%) cohorts (level of evidence II). No randomized study was published in the period. We studied 1651 shoulders, 66.1 ± 50.3 shoulders per study. Eight articles (32%) had follow-up time of patients greater than two years and only two (8%) followed up with standardized assessment time. The mean of the evaluated outcome was 2.2 ± 1.1 (Fig. 1).

Table 1 Publications on treatment of rotator cuff tears between 2006 and 2015. 

Author(s) Title Journal Year Volume (number) Pages
Pecora et al. Prognostic factors for the clinical outcome following rotator cuff repair Acta Ortopédica Brasileira 2015 23 (3) 146–149
Porto et al. Evaluation of patients undergoing rotator cuff suture with the modified Mason-Allen technique Acta Ortopédica Brasileira 2013 21 (3) 167–169
Ramos et al. Results of arthroscopic treatment of rotator cuff tears Acta Ortopédica Brasileira 2010 18 (1) 15–18
Checchia et al. Isolated tear of the subscapular tendon Acta Ortopédica Brasileira 2009 17 (1) 26–30
Veado et al. Rotator cuff tear in patients over 65 years: evaluation of function, integrity and strength Revista Brasileira de Ortopedia 2015 50 (3) 318–323
Miyazaki et al. Evaluation of results of arthroscopic surgical treatment of rotator cuff tears in patients ≥65 years Revista Brasileira de Ortopedia 2015 50 (3) 305–311
Godinho et al. Long-term functional evaluation of videoarthroscopic treatment of partial tears of the rotator cuff Revista Brasileira de Ortopedia 2015 50 (2) 200–205
Godinho et al. Result of arthroscopic surgical treatment of retears of the shoulder rotator cuff Revista Brasileira de Ortopedia 2015 50 (1) 89–93
Almeida et al. Comparative analysis of arthroscopic suture of large and extensive tears of the rotator cuff related to the level of osteopenia Revista Brasileira de Ortopedia 2015 50 (1) 83–88
Miyazaki et al. Functional evaluation of arthroscopic repair of the rotator cuff tears in pseudoparalysis patients Revista Brasileira de Ortopedia 2014 49 (2) 178–182
Ikemoto et al. Evaluation of the clinical-functional results of the repair of extensive rotator cuff tear with inclusion of the tendon of the long head of the biceps Revista Brasileira de Ortopedia 2013 48 (2) 165–169
Malavolta et al. Platelet-rich plasma in the arthroscopic repair of complete tears of the rotator cuff Revista Brasileira de Ortopedia 2012 47 (6) 741–747
Ikemoto et al. Arthroscopic repair of small and medium tears of the supraspinal muscle tendon: evaluation of clinical-functional results after two years of follow-up Revista Brasileira de Ortopedia 2012 47 (4) 436–440
Godinho et al. Results of the arthroscopic repair of isolated tears of the subscapular muscle tendon Revista Brasileira de Ortopedia 2012 47 (3) 330–336
Veado et al. Prospective and comparative study of the functional results after the open and arthroscopic repair of rotator cuff tears Revista Brasileira de Ortopedia 2011 46 (5) 546–552
Miyazaki et al. Evaluation of results of the arthroscopic repair of rotator cuff tears in patients up to 50 years of age Revista Brasileira de Ortopedia 2011 46 (3) 276–280
Almeida et al. Comparative analysis of the result of arthroscopic suture of the rotator cuff in smoking and non-smoking patients Revista Brasileira de Ortopedia 2011 46 (2) 172–175
Miyazaki et al. Evaluation of results of reoperations of patients with rotator cuff tears Revista Brasileira de Ortopedia 2011 46 (1) 45–50
Veado et al. Functional evaluation of patients undergoing arthroscopic debridement for the treatment of extensive and irreparable tears of the rotator cuff Revista Brasileira de Ortopedia 2010 45 (5) 426–431
Godinho et al. Evaluation of the anatomical integrity through ultrasound and functional integrity through Constant & Murley index of the rotator cuff after arthroscopic repair Revista Brasileira de Ortopedia 2010 45 (2) 174–180
Miyazaki et al. Extensive tears of the rotator cuff: evaluation of results of the arthroscopic repair Revista Brasileira de Ortopedia 2009 44 (2) 148–152
Veado et al. Functional evaluation of the arthroscopic repair of complete tears of the rotator cuff associated with acromyoplasty Revista Brasileira de Ortopedia 2008 43 (11/12) 505–512
Balsini et al. Arthroscopic repair of complete isolated tears of the subescapular Revista Brasileira de Ortopedia 2008 43 (11/12) 497–504
Veado et al. Functional and structural analysis of rotator cuff extensive tears repair Revista Brasileira de Ortopedia 2006 41 (8) 294–301
Veado et al. Efficacy of arthroscopic debridement in partial rotator cuff tears Revista Brasileira de Ortopedia 2006 41 (1/2) 22–28

Fig. 1 Percentage distribution of number of outcomes analyzed per study. 

Range of motion

Among the studies evaluated, 12 (48%) did not report the measurement of the range of motion in any position in the postoperative period. Nine articles (36%) presented medial rotation, 11 (44%) evaluated the lateral rotation, same number found of publications that evaluated the patients’ elevation. Three publications (12%) evaluated only one position of the range of motion, one (4%) evaluated two positions and nine (36%) presented the measurements of the range of motion in three positions (Fig. 2). The methodology applied in the measurement of the range of motion was reported in seven (28%) articles, the others did not report the use of goniometer, the measurement technique or the patient position.

Fig. 2 Percentage distribution of number of range of motion positions evaluated per study. 

Muscle strength

Muscle strength after rotator cuff repair was reported in seven studies (28%). In three studies (12%) it was presented as a subdomain of a functional scale, and in two articles (8%) it was reported categorically with the use of the contralateral side as a reference. Two studies (8%) used quantitative measurement of muscle strength using a dynamometer and reported the patient's position (orthostatic). Six studies (24%) evaluated only one position movement (elevation or abduction), one study15 evaluated the elevation and lateral rotation.

Tendon integrity

In 18 studies (72%), no postoperative imaging was performed to assess the integrity of the rotator cuff repair. Four publications (16%) used non-enhanced magnetic resonance imaging to check for tendon integrity, and in three (12%) an ultrasound exam was used. All studies used only a categorical evaluation, complete or ruptured repair. Only three studies (12%) mention the number of evaluators and in two (8%) the specifications of the device used are reported. No study mentions image acquisition protocols. The tests were done once in all studies, and only one study performed the exam on a regular basis (12 months).22

Satisfaction

Only four studies (16%) reported patient satisfaction in their results; two studies (8%) assessed whether the patient would agree to undergo treatment again, and two (8%) assessed satisfaction through a simple question with two categories (satisfied/dissatisfied).

Evaluation scales and questionnaires

Of the 25 studies included, 23 (92%) used the University of California, Los Angeles Shoulder Rating Scale (UCLA),36 five papers (20%) used the Constant-Murley evaluation questionnaire,37 two (8%) evaluated the results through the Simple Shoulder Test (SST)38 and one (4%) through the questionnaire American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)39 (Fig. 3); 20 publications (80%) used only one scale, four (16%) made the evaluation through two scales and one study (4%) through three questionnaires. In four articles (16%) VAS was used to quantify pain before and after treatment.

Fig. 3 Percentage of studies using clinical scales. 

Discussion

Rotator cuff tear is the main cause of shoulder pain2 and the repair of the rotator cuff is the most commonly performed surgery of this joint.40 However, in the period evaluated, only 25 publications were found that evaluated the clinical results of the treatment of rotator cuff tears in the two main Brazilian journals of orthopedics and traumatology. The national average was 2.5 articles per year. Between 2010 and 2014, an average of 4.8 and 8.8 articles per year were published in the two major comprehensive orthopedic journals, Journal of Bone & Joint Surgery and The American Journal of Sports Medicine, respectively.

The Brazilian studies evaluated the results with a mean of 2.2 outcomes per article, a number that was similar to that observed in international studies.9 However, only 32% of the studies had patients’ follow-up of more than two years, and 8% had a follow-up with standardized evaluation time. We also found that national publications on this topic have a low level of evidence, 80% were case series, and we did not find an article with level I evidence, unlike the main foreign journals, which report 13% of studies with level I, 17% with level II, 26% with level III, and only 43% with level IV.9 The predominance of case series is a characteristic of Brazilian orthopedic publications.41

The most used evaluation questionnaire for Brazilian studies was the UCLA scale, used in 92% of the publications. This number is far superior to that of Makhni et al.,9 who found that it had been used only in 35% of articles, the third in prevalence. This scale was initially developed for patients undergoing total shoulder arthroplasty.42 Ellman et al.43 were the first authors to apply this tool to evaluate the results of the treatment of rotator cuff tears; since then, it has been used in several publications. However, there are no studies to validate its development and the application of this instrument in these patients. It is considered a scale with low reliability and validity, and has several limitations in the collection of information.44 A recent systematic review comparing the assessment scales for shoulder diseases found that the best are the ASES, SST and Oxford Shoulder Score scales. They are considered reliable, with great internal consistency, good responsivity, and were previously validated.45 In our study, only one publication (4%)18 used the ASES scale, and two studies (8%)15,32 used SST for evaluation. On their turn, Makhni et al.9 observed that the publications of the six major international orthopedic journals between 2010 and 2014 used scales considered more reliable; ASES questionnaire was used in 59%, and the SST in 28%.

The Constant-Murley scale37 was the second most used, obsrved in five articles (20%). This scale is the most used in internationally published studies (61% of publications). This tool has as main limitation the difficulty and variability for the evaluation of the abduction strength, which represents 25% of its total score. Several authors report its inconsistency,46 depending on the dynamometer used,47 on the degree of shoulder abduction and rotation,48 and on strength relative to age and gender.49 Only recently has this scale been translated and culturally adapted to the Portuguese language.37 Indexes of normality are available for some countries but have not been validated in Brazil.49 We believe that the use of the Constant-Murley Individual Relative Scale, when compared to the contralateral shoulder when it is asymptomatic, the use of digital dynamometers, and scale training reduced bias in the use of this instrument.50-52

In the Brazilian journals, only 28% of studies evaluate tendinous integrity after surgery. Of these, 16% do so with MRI, and 12% with ultrasound. These values are lower than those reported in international journals, in which 65% of the studies use imaging in the postoperative period, MRI is cited in 38%, ultrasound in 31%, and arthrotomography in 8%.9 In addition, none of the articles evaluating integrity through MRI use a scale of evaluation, only the stratification into intact and ruptured. Except for the determination of the simple absence or presence of a tear, the classification proposed by Sugaya et al.53 is the most used and reliable, cited in 33 studies in a recent meta-analysis.54

Our results show that the description of measures of the range of motion is made in 52% of the articles, a figure slightly lower than the 63% reported in foreign journals.9 The same occurs regarding evaluation of strength, described in 28% of national studies, and 38% of international ones.9 Satisfaction, in its turn, is evaluated in only 16% of the studies, considerably less than the 54% found in international studies.9 However, few articles have reported the methodology used to evaluate these measures clearly and reproducibly. It should be noted that none of the national studies used tools to measure quality of life, unlike international journals, which cite these outcomes in more than 15% of cases.9

Our study has some limitations. It included all types of clinical studies, thus having level IV of evidence. However, the greater possibility of bias in articles of lower level of evidence did not influence our results, since we evaluated the tools used, not the outcomes themselves. In addition, we have reviewed the articles of only one decade and two national journals. The aim of this approach was to plot the national picture in a relatively recent period. Finally, our search strategy may have included articles by foreign authors published in national journals, and did not include articles by Brazilian authors published in international journals.

We believe that the members of the Brazilian Society of Shoulder and Elbow Surgery should initiate a discussion to standardize the evaluation tools. Attitudes such as these, already taken by US55 and Japan56 societies, facilitate data comparison among the studies, allow for more consistent exposure of results, and increase the possibilities of citing national articles. ASES and SST scale, already validated for the Portuguese language, and with good reliability,38,57 should be prioritized, along with the Constant-Murley scale adjusted for gender and age; normality indices should be obtained for the Brazilian population. In addition, quality of life assessment should be encouraged. Likewise, the assessment of strength and amplitude could be in line with that used in international studies. The assessment of tendinous integrity after surgery should be encouraged and when MRI is used, it should be made through the classification by Sugaya et al.53

Final considerations

Twenty-five clinical studies on rotator cuff were published in the two main Brazilian orthopedic journals in the last decade. The most used scale was UCLA, present in 92% of the articles. Scales considered reliable, with great internal consistency and good responsiveness, were rarely used. Objective measures such as muscle strength, patient satisfaction and evaluation of tendon integrity were poorly used.

References

1. Luime JJ, Koes BW, Hendriksen IJM, Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73-81. [ Links ]

2. Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elb Surg. 2010;19(1):116-20. [ Links ]

3. Gartsman GM, Brinker MR, Khan M. Early effectiveness of arthroscopic repair for full- thickness tears of the rotator cuff: an outcome analysis. J Bone Jt Surg Am. 1998;80(1):33-40. [ Links ]

4. Gartsman GM, Morris BJ, Unger RZ, Laughlin MS, Elkousy HA, Edwards TB. Characteristics of clinical shoulder research over the last decade: a review of shoulder articles in The Journal of Bone & Joint Surgery from 2004 to 2014. J Bone Jt Surg Am . 2015;97(5):e26. [ Links ]

5. Puga VO, Lopes AD, Costa LO. Avaliaç ão das adaptaç ões transculturais e propriedades de medida de questionários relacionados às disfunç ões do ombro em língua portuguesa: uma revisão sistemática. Rev Bras Fisioter. 2012;16(2):85-93. [ Links ]

6. Brinker MR, Cuomo JS, Popham GJ, O’Connor DP, Barrack RL. An examination of bias in shoulder scoring instruments among healthy collegiate and recreational athletes. J Shoulder Elb Surg . 2002;11(5):463-9. [ Links ]

7. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R. Quality of life measurement: bibliographic study of patient assessed health outcome measures. BMJ. 2002;324(7351):1417. [ Links ]

8. Higginson IJ, Carr AJ. Measuring quality of life: using quality of life measures in the clinical setting. BMJ . 2001;322(7297):1297-300. [ Links ]

9. Makhni EC, Steinhaus ME, Morrow ZS, Jobin CM, Verma NN, Cole BJ, et al. Outcomes assessment in rotator cuff pathology: what are we measuring? J Shoulder Elb Surg . 2015;24(12):2008-15. [ Links ]

10. Harvie P, Pollard TCB, Chennagiri RJ, Carr AJ. The use of outcome scores in surgery of the shoulder. J Bone Jt Surg Br. 2005;87(2):151-4. [ Links ]

11. Pecora JOR, Malavolta EA, Assunç ão JH, Gracitelli ME, Martins JP, Ferreira AA Jr. Fatores prognósticos para o resultado clínico após o reparo do manguito rotador. Acta Ortop Bras. 2015;23(3):146-9. [ Links ]

12. Porto FM, Alves MW, de Andrade AL. Avaliaç ão de pacientes submetidos à sutura do manguito rotador com a técnica de mason-allen modificada. Acta Ortop Bras . 2013;21(3): 167-9. [ Links ]

13. Ramos CH, Sallum JS, Sobania RL, Borges LG, Sola WC Jr, Ribeiro LY. Resultados do tratamento artroscópico das rupturas do manguito rotador. Acta Ortop Bras . 2010;18(1):15-8. [ Links ]

14. Checchia SL, Miyazaki AN, Fregoneze M, dos Santos PD, Silva LA, Ortiz RT, et al. Lesão isolada do tendão do subescapular. Acta Ortop Bras . 2009;17(1):26-30. [ Links ]

15. de Castro Veado MA, Prata EF, Gomes DC. Lesão do manguito rotador em pacientes maiores de 65 anos: avaliaç ão da funç ão, integridade e forç a. Rev Bras Ortop. 2015;50(3):318-23. [ Links ]

16. Miyazaki AN, Silva LA da, Santos PD, Checchia SL, Cohen C, Giora TS. Avaliaç ão dos resultados do tratamento cirúrgico artroscópico das lesões do manguito rotador em pacientes com 65 anos ou mais. Rev Bras Ortop . 2015;50(3):305-11. [ Links ]

17. Godinho GG, Franç a FO, Freitas JMA, Lago E, Santos FM, Resende DS, et al. Avaliaç ão funcional em longo prazo do tratamento videoartroscópico das lesões parciais do manguito rotador. Rev Bras Ortop . 2015;50(2):200-5. [ Links ]

18. Godinho GG, Franç a F, de O, Freitas JMA, Santos FM, Prandini A, et al. Resultado do tratamento cirúrgico artroscópico das rerrupturas do manguito rotador do ombro. Rev Bras Ortop . 2015;50(1):89-93. [ Links ]

19. Almeida A, Atti V, Agostini DC, Valin MR, de Almeida NC, Agostini AP. Análise comparativa da sutura artroscópica de lesões grandes e extensas do manguito rotador com relaç ão ao grau de osteopenia. Rev Bras Ortop . 2015;50(1):83-8. [ Links ]

20. Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, do Val Sella G, Neto DL, et al. Avaliaç ão funcional do reparo artroscópico da lesão do manguito rotador em pacientes com pseudoparalisia. Rev Bras Ortop . 2014;49(2):178-82. [ Links ]

21. Ikemoto RY, Murachovsky J, Nascimento LGP, Bueno RS, Almeida LH, Strose E, et al. Avaliaç ão dos resultados clínico-funcionais do reparo da lesão extensa do manguito rotador com inclusão do tendão da cabeç a longa do bíceps. Rev Bras Ortop . 2013;48(2):165-9. [ Links ]

22. Malavolta EA, Gracitelli MEC, Sunada EE, Benegas E, Prada FS, Bolliger Neto R, et al. Plasma rico em plaquetas no reparo artroscópico das roturas completas do manguito rotador. Rev Bras Ortop . 2012;47(6):741-7. [ Links ]

23. Ikemoto RY, Murachovsky J, Nascimento LGP, Bueno RS, Almeida LH, Strose E, et al. Reparaç ão artroscópica de lesões pequenas e médias do tendão do músculo supraespinal: avaliaç ão dos resultados clínico-funcionais após dois anos de seguimento. Rev Bras Ortop . 2012;47(4):436-40. [ Links ]

24. Godinho GG, Franç a F, de O, Freita JMA, Santos FM, dos Santos RB, et al. Resultados do reparo artroscópico das roturas isoladas do tendão do músculo subescapular. Rev Bras Ortop . 2012;47(3):330-6. [ Links ]

25. Veado MAC, Castilho RS, Maia PE, Rodrigues AU. Estudo prospectivo e comparativo dos resultados funcionais após reparo aberto e artroscópico das lesões do manguito rotador. Rev Bras Ortop . 2011;46(5):546-52. [ Links ]

26. Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, Val Sella G, Santos RM, et al. Avaliaç ão dos resultados do reparo artroscópico de lesões do manguito rotador em pacientes com até 50 anos de idade. Rev Bras Ortop . 2011;46(3): 276-80. [ Links ]

27. Almeida A, Valin MR, Zampieri R, de Almeida NC, Roveda G, Agostini AP. Análise comparativa do resultado da sutura artroscópica da lesão do manguito rotador em pacientes fumantes e não fumantes. Rev Bras Ortop . 2011;46(2): 172-5. [ Links ]

28. Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, do Val Sella G, Santos RM, et al. Avaliaç ão dos resultados das reoperaç ões de pacientes com lesões do manguito rotador. Rev Bras Ortop . 2011;46(1):45-50. [ Links ]

29. Veado MAC, Rodrigues AU. Avaliaç ão funcional dos pacientes submetidos ao desbridamento artroscópico para tratamento das rupturas extensas e irreparáveis do manguito rotador. Rev Bras Ortop . 2010;45(5):426-31. [ Links ]

30. Godinho GG, Franç a FO, Freitas JM, Watanabe FN, Nobre LO, Almeida Neto MA, et al. Avaliaç ão da integridade anatômica por exame de ultrassom e funcional pelo índice de Constant & Murley do manguito rotador após reparo artroscópico. Rev Bras Ortop . 2010;45(2):174-80. [ Links ]

31. Miyazaki AN, Fregoneze M, Santos PD, Silva LA, Pinto CM, Ortiz RT, et al. Lesões extensas do manguito rotador: avaliaç ão dos resultados do reparo artroscópico. Rev Bras Ortop . 2009;44(2):148-52. [ Links ]

32. Veado MA, Almeida Filho IA, Duarte RG, Leitão I. Avaliaç ão funcional do reparo artroscópico das lesões completas do manguito rotador associado a acromioplastia. Rev Bras Ortop . 2008;43(11/12):505-12. [ Links ]

33. Balsini NE, Balsini N, Kochen L, Palka LJ, Vilela A, dos Santos JS. Reparo artroscópico das lesões completas isoladas do subescapular. Rev Bras Ortop . 2008;43(11/12): 497-504. [ Links ]

34. Veado AM, Gomes TP, Pinto RZ. Análise funcional e estrutural do reparo das lesões extensas do manguito rotador. Rev Bras Ortop . 2006;41(8):294-301. [ Links ]

35. Veado AM, Bertolini FM, Maia PE, Rodrigues AU. Eficácia do desbridamento artroscópico nas lesões parciais do manguito rotador. Rev Bras Ortop . 2006;41(1/2):22-8. [ Links ]

36. Oku EC, Andrade AP, Stadiniky SP, Carrera EF, Tellini GG. Traduç ão e adaptaç ão cultural do Modified- University of California at Los Angeles Shoulder Rating Scale para a língua portuguesa. Rev Bras Reumatol. 2006;46(4):246-52. [ Links ]

37. Barreto RP, Barbosa ML, Balbinotti MA, Mothes FC, da Rosa LH, Silva MF. The Brazilian version of the Constant-Murley Score (CMS-BR): convergent and construct validity, internal consistency, and unidimensionality. Rev Bras Ortop . 2016;51(5):515-20. [ Links ]

38. Neto JOB, Gesser RL, Steglich V, Bonilauri Ferreira AP, Gandhi M, Vissoci JR, et al. Validation of the Simple Shoulder Test in a Portuguese-Brazilian population. Is the latent variable structure and validation of the Simple Shoulder Test Stable across cultures? PLOS ONE. 2013;8(5):e62890. [ Links ]

39. Knaut LA, Moser ADL, Melo SDA, Richards RR. Translation and cultural adaptation to the portuguese language of the American Shoulder and Elbow Surgeons Standardized Shoulder assessment form (ASES) for evaluation of shoulder function. Rev Bras Reumatol . 2010;50(2):176-89. [ Links ]

40. Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014;15:4. [ Links ]

41. Malavolta EA, Gobbi RG, Mancuso Filho JA, Demange MK. Análise crítica das publicaç ões científicas da Revista Brasileira de Ortopedia no período de 2006 a 2010. Rev Bras Ortop . 2013;48(3):211-5. [ Links ]

42. Amstutz HC, Sew Hoy AL, Clarke IC. UCLA anatomic total shoulder arthroplasty. Clin Orthop Relat Res. 1981;(155):7-20. [ Links ]

43. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End- result study of factors influencing reconstruction. J Bone Jt Surg Am . 1986;68(8):1136-44. [ Links ]

44. Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy. 2003;19(10):1109-20. [ Links ]

45. Schmidt S, Ferrer M, González M, González N, Valderas JM, Alonso J, et al. Evaluation of shoulder- specific patient-reported outcome measures: a systematic and standardized comparison of available evidence. J Shoulder Elb Surg . 2014;23(3):434-44. [ Links ]

46. Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. J Bone Jt Surg Br . 1996;78(2):229-32. [ Links ]

47. Walton MJ, Walton JC, Honorez LA, Harding VF, Wallace WA. A comparison of methods for shoulder strength assessment and analysis of Constant score change in patients aged over fifty years in the United Kingdom. J Shoulder Elb Surg . 2007;16(3):285-9. [ Links ]

48. Hirschmann MT, Wind B, Amsler F, Gross T. Reliability of shoulder abduction strength measure for the Constant-Murley score. Clin Orthop Relat Res . 2010;468(6):1565-71. [ Links ]

49. Tavakkolizadeh A, Ghassemi A, Colegate-Stone T, Latif A, Sinha J. Gender- specific Constant score correction for age. Knee Surg Sports Traumatol Arthrosc. 2009;17(5):529-33. [ Links ]

50. Fialka C, Oberleitner G, Stampfl P, Brannath W, Hexel M, Vécsei V. Modification of the Constant-Murley shoulder score - introduction of the individual relative Constant score. Injury. 2005;36(10):1159-65. [ Links ]

51. Constant CR, Gerber C, Emery RJ, Søjbjerg JO, Gohlke F, Boileau P. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elb Surg . 2008;17(2):355-61. [ Links ]

52. Blonna D, Scelsi M, Marini E, Bellato E, Tellini A, Rossi R, et al. Can we improve the reliability of the Constant-Murley score? J Shoulder Elb Surg . 2012;21(1):4-12. [ Links ]

53. Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome after arthroscopic full- thickness rotator cuff repair: single-row versus dual- row fixation. Arthroscopy . 2005;21(11):1307-16. [ Links ]

54. Saccomanno MF, Cazzato G, Fodale M, Sircana G, Milano G. Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review. Knee Surg Sports Traumatol Arthrosc . 2015;23(2):423-42. [ Links ]

55. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elb Surg . 1994;3(6):347-52. [ Links ]

56. Hirooka A, Yoneda M, Wakaitani S, Isaka Y, Hayashida K, Fukushima S, et al. Augmentation with a Gore- Tex patch for repair of large rotator cuff tears that cannot be sutured. J Orthop Sci. 2002;7(4):451-6. [ Links ]

57. Moser AD, de L, Knaut LAM, Zotz TG, Scharan KO. Validity and reliability of the Portuguese version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. Rev Bras Reumatol . 2012;52(3):348-56. [ Links ]

Paper developed at Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, Grupo de Ombro e Cotovelo, São Paulo, SP, Brazil.

Received: June 16, 2016; Accepted: July 26, 2016

* Corresponding author. E-mail: drjorgeassuncao@gmail.com (J.H. Assunç ão).

Conflicts of interest The authors declare no conflicts of interest.

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