Outcomes of arthroscopic treatment for rotator cuff tears

Abstracts

OBJETIVO: Analisar os resultados do reparo artroscópico das rupturas do manguito rotador. MÉTODOS: Realizado estudo retrospectivo com avaliação dos resultados da técnica em 42 pacientes operados entre 2002 e 2006. O seguimento médio foi de 31 meses e a média de idade foi de 57 anos, sendo o lado dominante operado em 73,8% dos casos. Para avaliação foram usadas escalas de UCLA e Escala Visual Analógica da dor no pós-operatório. RESULTADOS: Os resultados foram satisfatórios em 85,7% (59,5% excelentes e 26,2% bons respectivamente) e insatisfatórios em 14,3% dos pacientes. Nos casos com lesões associadas, a mais frequente foi no tendão da porção longa do bíceps (57,1%). Associação com outras lesões não comprometeu o resultado. O mesmo aconteceu com relação a idade e tempo de acompanhamento pós-cirurgia. Quanto ao tamanho da lesão, diferença significativa ocorreu nos casos de lesões grandes e maciças demonstrando resultados inferiores em relação às pequenas e médias. A função foi inferior principalmente nos casos de lesão maciça. CONCLUSÃO: A reparação artroscópica das lesões do manguito rotador (MR) proporciona baixa morbidade cirúrgica e possibilita diagnóstico de lesões articulares associadas. O benefício do procedimento foi confirmado principalmente pela melhora significativa da dor, mesmo nos casos de lesões maiores.

Bainha rotadora; Ombro; Artroscopia

ORIGINAL ARTICLE

Outcomes of arthroscopic treatment for rotator cuff tears

Carlos Henrique Ramos; João Said Sallum; Roberto Luis Sobania; Luis Gustavo Borges; Wilson Carlos Sola Junior; Leandro Yuji Pereira Ribeiro

Department of Orthopedics and Traumatology of Santa Casa de Misericórdia de Curitiba – Paraná – Brazil

Mailing Address

ABSTRACT

OBJECTIVE: To evaluate the results of arthroscopic treatment for rotator cuff tears.

METHODS: A retrospective study was carried out demonstrating the results of this technique in 42 patients operated between 2002 and 2006. The mean follow-up was 31 months and average age was 57 years. The dominant limb was operated in 73.8% of cases. Function and pain were evaluated using criteria of UCLA Score System and Visual Analogic Scale respectively.

RESULTS: The results were satisfactory in 85.7% (59.5% excellent and 26.2% good), with 14.3% unsatisfactory. The most frequent associated lesion was the long head of the biceps tendon (57.1%). Nevertheless, the presence of other lesions did not alter the end results. The same occurred in relation to age and follow-up period. When comparing large and massive tears with small and mid-sized ones, the first group had significantly inferior functional results. The function was worse in cases of massive tear.

CONCLUSION: Arthroscopic rotator cuff repair provides lower surgical morbidity and intrarticular diagnosis of associated lesions in comparison to open surgery. The benefit of the procedure was confirmed mainly by pain relief, even in cases of more extensive lesions.

Keywords: Rotator cuff. Shoulder. Arthroscopy.

INTRODUCTION

The rotator cuff (RC), formed posteriorly by the tendons of the supraspinatus (Ss), infraspinatus (Is) and teres minor (Tm) and, anteriorly by the tendon of the subscapularis (Sc), has an important contribution in the shoulder mobility and stability functions. Lesions of this structure represent one of the main causes of incapacity in the shoulder.^1,2 Satisfactory results of the conservative treatment vary in literature between 40 and 82%, whereas factors such as: age, comorbidities, activity levels and degree of shoulder dysfunction interfere therein. With the increase of functional demand such as practice of sports, work and/or daily activities, etc., in some patients the conservative treatment might not be successful. This situation has occurred more frequently due to the increase in life expectancy and quality.^2-4 In these cases, surgical repair has proven efficient, attaining a high level of satisfaction, with pain relief and function improvement, ranging between 70 and 95%.^5-9

The arthroscopic technique demonstrates similar results to open surgery, and is associated with advantages such as: preservation of the deltoid, possibility of articular diagnosis and lower surgical morbidity.^9-12

The aim of this work is to evaluate the outcome of the arthroscopic treatment of the rotator cuff performed in the service.

MATERIAL AND METHOD

A retrospective analysis of the outcome of the arthroscopic repair of the rotator cuff was conducted on patients operated in the service between 2002 and 2006. The diagnosis of the lesions was executed through clinical history, physical examination and radiological supplementation (simple x-ray, ultrasonography and/or magnetic resonance). The criterion for surgical indication in all cases was failure in the conservative treatment for at least 6 months. The postoperative follow-up period was at least 1 year.

SURGICAL TECHNIQUE

The patients were operated by the same surgeon, with general anesthesia associated with interscalenic block, lying on their side, with the assistance of longitudinal traction of the operated upper limb. Posterior portal was used for diagnosis and articular instrumentation, and supplementary portals for inspection and subacromial treatment. The extension of the lesions was measured with the use of a arthroscopic ruler with millimeter graduations, and classified as small (partial lesions completed or up to 1 cm), average (between 1 and 3 cm), large (between 3 and 5 cm) or massive (above 5 cm).¹³ The measurement considered was correspondent to the tendon retraction (Figure 1). The complete lesions (covering the entire breadth of the tendon) were repaired and the partial lesions with impairment above 50% of the tendon breadth, either by the bursal or articular surface (Figure 2), were completed and repaired, and interpreted as complete lesions of small extension in the study analysis. The repair was accomplished with the assistance of bone-anchored implants (metallic or absorbable) and non-absorbable threads nº2 (Ethibond® or Orthocord®), according to availability, with the use of tendon-tendon and/or tendon-bone type stitches depending on the lesion appearance.

In the postoperative period (PO), they were all immobilized with a thoraco-brachial splint for six weeks, with immediate passive and active mobilization of the elbow, wrist and hand, besides pendular exercises with the shoulder. Progressive passive and progressive active shoulder mobilization was initiated after the 6^th week for gain of articular amplitude, allowing muscular strengthening exercises after the third month. Radiological control was performed on a routine basis on the first PO day, for verification of the correct anchor positioning (Figure 3). Distal clavicle resection (Mumford procedure) was associated in the patients that presented radiological changes and mainly preoperative pain in the acromioclavicular joint (AC). In cases without pain in the AC, but with presence of osteophytes in the distal clavicle, observed during surgery, the surgeon associated their resection, a procedure defined as Mini-Munford.² Tenotomy with or without tenodesis was performed in the cases with lesion of the long head of the biceps brachii (compromising more than 50% of the breadth) (Figure 4). The criterion for tenodesis performance was the age and functional demand of the patient, and is therefore indicated in cases below 50 years of age or work requiring effort. When performed, the distal stump of the LHB was fixed with bony anchors. As all the cases were tears of the CR in its posterosuperior portion, changes in the subscapularis tendon were considered associated lesions (Figure 5).

A record was completed with particulars of each patient including: name, gender, address, age, dominant side, operated side, date of surgery and follow-up time, lesion size, associated lesions, associated procedures, type of repair, number of portals, number and type of anchors, postoperative mobility, complications and return to activities. Criteria from UCLA (University of California-Los Angeles)¹⁴ and the Visual Analogue Scale (0 to 10) for pain were used for evaluation of the outcome. The amplitude of joint mobility was evaluated according to the AAOS Convention.¹⁵

The results obtained were compared with: age, lesion size, associated lesions, associated procedures, pain level and postoperative follow-up time, analyzing them statistically by the Student's t-Test and Fischer's Exact Test.^16,17

RESULTS

Forty-two patients were evaluated, of whom 14 (33.3%) were male and 28 (66.7%) female, with ages ranging between 39 and 79 years (mean age 57.3 years). The dominant side was operated in 73.8% (31 cases). The average follow-up time was 31 months, with minimum of 12 and maximum of 66 months. The result was satisfactory in 36 patients (85.7%) (Table 1). The most common associated lesion was in the tendon of the long head of the biceps brachii (LHB), found in 22 cases. Of these, an additional procedure (tenotomy with or without tenodesis) was necessary in 68.1% (15 cases). Other lesions and associated procedures are demonstrated in Tables 2 and 3. Analyzed separately, between the patients above and below 50 years of age, there was no significant difference in the results. This also occurred in relation to the presence or not of associated lesions and when other procedures were performed. There was no difference considering groups with PO follow-up above and below 2 years either. Lesion size statistically influenced the outcome, with predominance of satisfactory results in the cases of small and medium lesions compared with large and massive lesions (Table 4).

This situation was reflected in the PO function, with cases of massive lesion impairing mainly elevation (Table 5). In evaluating pain, it was concluded that the average pain before surgery was significantly higher than in the PO period, even in the unsatisfactory cases. Therefore, even with decreased function, the majority obtained pain improvement. This is confirmed in the subjective data regarding satisfaction with surgery, in which all the patients referred to an improvement after surgery. The return to pre-surgical activities occurred in the fifth month on average, ranging from 45 days to 1 year PO. No patient had any complication with the procedure.

DISCUSSION

The results of the surgical treatment of CR lesions have been shown as satisfactory by the majority of authors.^8,9,11,14 With the improvement of quality and technology of materials, as well as an improvement in the learning curve for performance of the totally arthroscopic repair, this technique has been popularized as advantageous due to the reduction of surgical morbidity, besides allowing diagnosis and treatment of associated lesions in the joint. Accordingly, the results presented in recent literature have been better and better (70 to 95%).^1,5-9 We obtained similar results with 85.7% of satisfaction. These results are generally shown as inferior in older patients. Worland et al.¹⁸ demonstrated satisfactory results at 78.2% in patients over 70 years of age. Our results were perhaps superior as we were dealing with patients in a lower age bracket (mean age 57.3 years). Nonetheless, our results were not worse in older patients. The possibility of articular diagnosis proved an advantage, after we found associated lesions in 52.3% of the cases. The most frequent was observed in the LHB tendon in 57.1% of the cases. This corresponds to the report of Murthi et al.¹⁹ who found a greater association with biceps lesions. In spite of this, our results were not influenced when there were associated lesions. In fact, Gartsman et al.²⁰ found other articular lesions in 68% of the cases, considering them "lesser lesions" as they do not interfere in the results, requiring additional treatment in just 12.5% of them. The factor that statistically influenced our results was lesion size, which was higher in small and medium lesions compared to large and massive ones (97% and 55%, respectively). This relationship continued in relation to PO function with massive lesions demonstrating inferior mean elevation (103.3°) compared with smaller lesions (166.8°). Although they impair function, even larger lesions were related to pain improvement. The difference of this factor observed in the PO period was significant, confirming the benefit of the procedure when the goal is mainly pain treatment. Therefore, even in the cases of massive lesions, which are often irreparable, we recommend the procedure after failure in the conservative treatment.

CONCLUSION

The arthroscopic repair of the rotator cuff demonstrated satisfactory results in 85.7% of the cases;

Factors such as: gender, age, association with other lesions and PO time did not interfere in the final result;

Larger lesions evolve with worse results;

Pain improvement was the main benefit obtained with the procedure, and was observed even in the cases with worse functional results.

REFERENCES

• 1. Murray TF, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic Repair of medium to large full-thickness rotator cuff tears: Outcome at 2-6-year follow-up. J Shoulder Elbow Surg. 2002;11:19-24.
• 2. Iannotti JP. Rotator cuff disease and tendon ruptures. In: Iannotti JP, Williams RG. Disorders of the shoulder [CD-Room]. Philadelphia: Lippincott Williams & Wilkins; 1999.
• 3. Williams RG, Rockwood AC, Bigliani LU, Iannotti PJ, Stanwood W. Rotator cuff tears: why do we repair them? J Bone Joint Surg Am. 2007;89: 2764-76.
• 4. Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL. Results of non-operative management of full-thickeness tears of the rotator cuff. Clin Orthop Relat Res. 1993;(294):103-10.
• 5. Walch G, Edwards B, Boulahia A, Nové-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14:238-45.
• 6. Galatz LM, Griggs S, Cameron BD, Ianotti JP. Prospective longitudinal analysis of postoperative shoulder function: a ten-year follow-up study of full thickness rotator cuff tears. J Bone Joint Surg Am. 2001;83:1052-6.
• 7. Bigliani LU, Cordasco FA, Mcllven SJ, Musso ES. Operative repairs of massive rotator cuff tears: long-term results. J Shoulder Elbow Surg. 1992;1:120-30.
• 8. Watson EM, Sonnabend DH. Outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11:201-11.
• 9. Checchia SL, Doneaux PS, Miyazaki AN, Fregonese M, Silva LA, Ishi M, et al. Avaliação dos resultados obtidos na reparação artroscópica do manguito rotador. Rev Bras Ortop. 2005;40:229-38.
• 10. Wolf EM, Pennigton MD, Vivek A. Arthroscopic rotator cuff repair: 4 to 10-Year Result. Arthroscopy. 2004;20:5-12.
• 11. Godinho GG, Souza JMG, Bicalho LA. Reparo das rupturas do manguito rotador do ombro pela videoartroscopia cirúrgica: técnica. Rev Bras Ortop. 1996;31:284-8.
• 12. Lee E, Bishop MD, Braman JP, Langforf J, Flatow E. Outcomes after arthroscopic rotator cuff repairs. J Shoulder Elbow Surg. 2007;16:1-5.
• 13. Deorio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. 1984;66:563-7.
• 14. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of actors influencing reconstruction. J Bone Joint Surg Am. 1986;68:1136-44.
• 15. American Academy of Orthopaedics Surgeons: Joint Motion. Method of Measuring and Recording. Chicago: AAOS; 1965.
• 16. Campos H. Estatística experimental não paramétrica. 4Ş . ed. Piracicaba, SP: ESALQ; 1983.
• 17. Sidney S. Estatística não - paramétrica para as ciências do comportamento. Tradução de AA de Farias, E Nick. São Paulo: McGraw-Hill; 1956.
• 18. Worland RL, Arredondo J, Angles F, Lopez-Jimenez F. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9:382-5.
• 19. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9:382-5.
• 20. Gartsman GM, Taverna E. The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy. 1997;13:450-5.

Publication Dates

• Publication in this collection
  23 Apr 2010
• Date of issue
  2010

History

• Accepted
  12 Dec 2008
• Received
  01 Sept 2008