Address for Correspondence
Alexander Berth, M.D. Orthopädische Universitätsklinik
Universitätsklinikum A. ö. R.
Leipziger Str. 44
39120 Magdeburg
Germany
phone: 0049 – 391 – 6714031
fax: 0049 – 391 – 6714029
e-mail: alexander.berth@med.ovgu.de
Abstract
Background: The surgical treatment of massive rotator cuff tears (RCT) is still controversial and offers a variety of different surgical repair methods.
Material and Methods: In the present study, 72 patients with massive RCT treated either with complete repair, partial repair or arthroscopic debridement were selected to detect possible differences in the functional outcome. Patients were examined before and 49 ± 18 months after surgery.
Results: Regardless of the treatment group the postoperative results demonstrated highly significant improvements compared with the preoperative values in most parameters. Due to better results in active range of motion for abduction, anteversion and internal rotation the overall constant score in the complete repair group was superior to the outcome in the partial repair or debridement group. There was no difference in the clinical outcome between the partial repair and debridement group.
All treatment groups had a similar pain relief and satisfaction reflected in equal values of Dash Score.
Conclusions: All patients in our series had a good or satisfactory outcome after rotator cuff surgery. The results of complete rotator cuff repair demonstrated a better functional outcome than partial repair or debridement. Therefore, the attempt of a complete repair is recommended in all cases of RCT. During the follow-up period in our study, the results of a partial rotator cuff repair in irreparable lesions offers no advantage when compared to arthroscopic debridement.
J.Orthopaedics 2011;8(3)e10
Keywords:
shoulder, rotator cuff tear, repair.
Introduction:
Lesions of the rotator cuff are a common source of pain, impairment and disability of the shoulder, especially in people aged 60 years and older 1, 2. Otherwise, many patients with rotator cuff tears (RCT) have no discomfort due to the lesion 3. Today there exists no prediction factor with regard to a further progressions of pathoanatomical changes associated with a chronic RCT and the possibility of the development of a rotator cuff tear arthropathy 4. Considering these possible progression an adequate therapy of symptomatic lesions, especially in traumatic cases and younger patients, is required.
The current management of patients with RCT include a wide range of non-pharmacological 5, pharmacological 6 and surgical modalities 7 and depends on the location, size and genesis of the lesion 8-11.
The surgical repair of small and middle sized RCT yields consistently a good and satisfactory outcome in a high percentage of patients 12. With respect to chronic large and massive RCT the results of a rotator cuff repair are more inhomogenous and the clinical outcome is considered to be correlated with the size of tendon lesion and the stage of fatty muscle degeneration 13, 14. In particular, rerupture after rotator cuff repair is known to occur in 20 % to 65 % over time 15, 16. Nevertheless, there exists some evidence that patients with a rerupture still had significant improvement compared with the preoperative level 17, 18. Although inferior, arthroscopic debridement or partial repair leads also to significant improvements of shoulder function 19-21.
Therefore the question arises whether the attempt of a complete repair in large RCT is justified under the criterion of a high rate of structural failures after rotator cuff repairs, a long rehabilitation period and in mind of acceptable results of arthroscopic debridement or partial repair.
Therefore, this study was done to evaluate the effectiveness of three different surgical repair methods to treat chronic RCT with particular emphasis on the results of a partial repair or debridement in contrast to a complete repair.
Material and Methods :
Patients
The present study involved 72 patients with symptomatic unilateral full-thickness RCT that were surgically treated at our institution from May 2005 to May 2008. The patients in this study were divided into 3 groups: group 1 (open complete rotator cuff repair), group 2 (open partial rotator cuff repair) and group 3 (arthroscopic debridement, subacromial decompression). The descriptive data of the patient groups are summarized in Table 1.
None of these patients reported about discomfort in the shoulder of the uninvolved side. The non-affected shoulder was examined clinically and showed no signs of a RCT. Additionally, the investigation by ultrasound showed moderate signs of tendon degeneration but no full-thickness RCT. Antero-posterior, axial and scapular view radiographs on the affected side were performed to exclude that considerable osteoarthritis of the shoulder was present. All patients had symptoms longer than 6 month before surgery and underwent a course of conservative treatment including anti-inflammatory medication and home-based physical therapy. The indication for operative treatment was a persistent, severe or moderate pain at rest and loss of shoulder function despite conservative treatment. No other significant neuromuscular or skeletal pathologies were present.
The study was approved by the local ethic committee and was performed in accordance with the ethic standards of the 1964 Declaration of Helsinki; written informed consent was obtained from all patients.
Evaluation of Rotator Cuff Tears
Full RCT was diagnosed preoperatively with magnetic resonance imaging. On the basis of the preoperative radiological findings the tear configuration was analyzed. Additionally, during surgery the tear size was measured in both the antero-posterior and the medio-lateral dimension. A specially marked probe was utilized during arthroscopy (group 3) to measure the size of the cuff tear. The size of the RCT was then classified according to Bateman 22. Furthermore the grade of tendon retraction was measured according to Patte 23 and the vitality of the muscle (fatty infiltration) was recorded according to the classification of Goutallier 13. The characteristics of the rotator cuff tears are summarized in Table 2.
Clinical Assessment
Subjects were assessed using the Constant-Score 24 and the Dash-Score 25. In addition, the range of motion in all direction was assessed with a goniometer. Complications were noted. The patients were first examined immediately before surgery. At follow up, the symptoms were assessed by an interview, and all patients were clinically examined by the authors.
Operative Technique and Rehabilitation Program
All patients had arthroscopy of the shoulder to assess the pathology. The decision to perform a complete or partial repair or a debridement was based on the intraoperative findings. In particular, there was no true randomization which was not considered ethical. After the antecedent arthroscopy the patients in group 1 and 2 underwent an open surgery. The antero-lateral approach was used and Neer`s acromioplasty 26 was done routinely. After a subtotal removal of the subacromial bursa a debridement of the tear was done. Then, the cuff was mobilized with traction and blunt dissection as full as possible. The rotator cuff was repaired with transosseous sutures. Modified Mason-Allen sutures were used in all cases. The rotator cuff was sutured into a bony trough in the footprint region (group 1) which was made with a chisel. The sutures tied over a bone bridge distally.
In group 2 the closure was incomplete and the defect was left according to the anatomy of the tear. In no case was the subscapularis tendon transferred.
In group 3 an arthroscopic debridement combined with an anterior acromioplasty was performed.
Adjunctive procedures included 23 biceps tenotomies (group 1: 0, group 2: 10 , group 3: 13).
The postoperative rehabilitation was standardized on an outpatient basis. In group 1 and 2 an abduction pillow was worn during the first six weeks after surgery. Passive mobilization and assisted active exercises within the pain-free range of motion were also performed up to six weeks after surgery. Afterwards active exercises with and without resistance were initiated. In group 3 the patients were mobilised rapidly and a sling was worn only if required during the first ten days postoperatively. Passive and active range of motion exercises were started on the first day after surgery and continued until a maximum movement was achieved.
Additionally, the rehabilitation program was supplemented that all patients were treated with a continuous passive motion within the first three weeks.
Statistical Analysis
Analysis of variance for repeated measures was performed to detect possible differences between the 3 treatment groups . The innersubject factor was time (preoperative, postoperative) and the intersubject factor was status (complete repair, partial repair, debridement). As post hoc comparison test, the least significant difference (LSD) pairwise multiple comparison test was used between the groups. We used the parametric paired t test to compare the pre- and postoperative values within the treatment groups. A significance level less than 0.05 was assumed. We used SPSS statistical software, version 12.0, for Windows, for all calculations. Unless specified otherwise, results are given as mean ± standard deviation.
Results :
Clinical Assessment
There were no significant differences between the groups with regard to age (P = 0.169, F = 1.829) and follow up (P = 0.12, F = 1.808).
The mean operative time showed equal values between group 1 (82 ± 27 minutes) and group 2 (74 ± 28 minutes) (P = 0.314) and were statistically different from group 3 (47 ±
17 minutes) (P < 0.001).
The pre- and postoperative functional status (Constant-Score, Dash-Score and range of movement) of the patients are presented in table 3 and table 4. Regardless of the treatment group the postoperative results demonstrated highly significant improvements compared with the preoperative values in most parameters.
We found a significant interaction between status (group 1, 2, 3) and time (preoperative, postoperative) in active range of movement for abduction (P = 0.004, F = 5.945), anteversion (P = 0.048, F = 3.187) and internal rotation (P = 0.027, F = 3.798) which indicate that the increase in ROM after surgery in patients treated with a complete rotator cuff repair were superior than in group 2 and 3. No differences was found between the partial repair and the debridement group in postoperative abduction (P = 0.31), anteversion (P = 0.067) and internal rotation (P = 0.616). The degree of adduction (P = 0.705, F = 0.351), retroversion (P = 0.767, F = 0.266) and external rotation (P = 0.74, F = 0.302) did not reveal significant differences between the 3 groups.
Furthermore, a significant time by status interaction was found for both the Constant-Score (P = 0.040, F = 3.365) and the age- and gender-related Constant-Score ( P = 0.047, F = 3.211) indicating a higher level in the complete repair group than in the partial repair and debridement group. This was in particular due to better results in the scoring system of the part activity (P < 0.001, F = 12.265) and motion (P = 0.33, F = 3.557) in group 1. Regarding pain, we found a significant improvement after surgery in the entire series but there were no differences between the treatment groups (P = 0.736, F = 0.308). Likewise the strength shows a postoperative increase in the entire series, especially in the complete repair group, with resulting slightly higher values when compared with the two other groups. But nonetheless the postoperative values did not reach statistical significance between the 3 groups (P = 0.153, F = 1.932).
The Dash-Score demonstrated a significant improvement compared with the preoperative measurements, however we could not detect a significant difference between the three treatment groups during the follow up (P = 0.433, F = 3.211).
Complications and Reoperations
Two patients had as medical complications a myocardial infarction. Three patients had a superficial wound infection, which was successfully treated with antibiotics.
Postoperatively, a hematoma developed in two patients. Of these patients one hematoma resolved without operative treatment (an aspiration was performed) and in the other case a superficial wound revision was required.
One patient in group 3 with a massive tear developed three years after surgery a severe gleno-humeral arthritis and therefore a shoulder hemiarthroplasty was performed.
Two patients in group 1 with a clinically apparent failure of rotator cuff tendon healing and a persistent postoperative pain underwent a rerepair of the rotator cuff tear.
Two patients in group 2 had a reoperation due to persistent postoperative pain and there were treated with an arthroscopic excision of hypertrophic bursal scar tissue and revision acromioplasty.
Discussion :
This study compared the midterm results of a complete- versus a partial- repair versus a debridement in patients with large, chronic full-thickness RCT. In general, the results of the clinical outcome after the 3 different surgical procedures during the follow up are comparable with those of other investigations 18, 20, 21, 27-29.
In accord with several other studies 15, 27, 30-33 our results indicate that the complete repair of full-thickness RCT have yielded more favourable results when compared with partial repair or debridement. For instance Cofield et al. 30 showed, that a standard repair technique in combination with acromioplasty provide a reliable pain relief and improved shoulder function. He found that age was related to tear size, with older patients having larger tears. It has also been noted that tear size was a important determinant for the need of a reoperation. In this connection, the study of Harryman et al. 34 indicates that the potential for a durable rotator cuff repair deteriorates with age. Even if there is a high rate of reruptures according to
Jost et. al. 18 it could demonstrated, that the long term outcome after rotator cuff repairs remained improved over the preoperative level and did not deteriorate over time such as an arthroscopic debridement alone 28, 35, 36.
The main finding of our investigations was, that we could not detect a significant difference in the functional outcome between arthroscopic debridement and partial rotator cuff repair. Furthermore, although not significant, there was a trend toward better results in the debridement group. These findings were in contrast to the study of Duralde et. al. 29 who found that the results of a partial repair were superior to those of debridement. The concept of a partial repair in terms of a “margin convergence technique” to restore the shoulders essential force couples caused by Burkhart et al. 20in which the RCT was converted to a “ functional tear”. In his theory, the rebalanced force couple of the remaining anterior and posterior parts of the rotator cuff allows a better function and decreased pain. However, our results does not support this assumption. This discrepancy may be related to older patients, a longer follow up period and significant lower preoperative values in ROM in our partial repair group when compared with the patients in the study of Burkhart.
The advantages of arthroscopic subacromial decompression and rotator cuff debridement include an accelerated rehabilitation program and the reported lower complication rates in this less invasive procedure 37. Furthermore, most of the patients in the debridement group were operated on an outpatient basis whereas the complete or partial repair stayed in hospital for 3 days after surgery. Otherwise, there exists some evidence, that the satisfactory results with debridement deteriorate during long term follow-up 37. For instance, Zvijac et al. 36 found a significant decrease in pain assessment and shoulder function after a 3 to 6 year follow up in patients treated with arthroscopic subacromial decompression for irreparable RCT. However, despite uncertain long-term results we see an advantage of arthroscopic debridement in particular in elderly patients in relation to partial repair. A temporary immobilization of the shoulder after partial repair and the associated interruption of active physical therapy is avoided. Therefore, the potential risk for development of a secondary frozen shoulder is clearly smaller. Overall, the activities of daily living after arthroscopic debridement especially in the early-and mid-term period after surgery are superior in comparison with partial repair. A further aspect in favor of arthroscopic debridement is to keep in mind. Performing a partial repair, the approach related weakening of the deltoid muscle has to be considered. This can affect the functional outcome of further surgical procedures such as shoulder arthroplasty.
A limitation of the present study is the absence of a proper randomization with regard to the 3 treatment strategies. However, a true randomization was not considered ethical. The decision to perform a complete or partial repair or a debridement was based on the preoperative radiological analysis of the tear configuration by MRI and especially the intraoperative findings. If the RCT tear configuration was considered to yield the slightest chance of a successful reconstruction, a complete repair was attempted. Nevertheless, in some of these patients, a complete repair could not be accomplished due to a strong retraction or poor quality of the remaining rotator cuff. If so, a partial repair was performed. In cases where the preoperative radiological findings and the intraoperative evaluation of the RCT considered not to be appropriate for a successful reconstruction an arthroscopic debridement was done. Consequently, our partial repair group represented patients with less biomechanical destruction of the rotator cuff compared to the debridement group and thus, we would have expected a better clinical outcome. However, we did not find any clinical advantage in our partial repair group. Therefore, we would expect that our results are not simply due to the lack of randomization. Our investigation may serve as a baseline investigation and the conclusions need to be confirmed in subsequently following true randomized trials.
In conclusion, all patients in our series had a good or satisfactory outcome after rotator cuff surgery. The present study indicates, that a complete repair is the treatment of choice in patients with chronic, massive RCT and leads to significant better improvement of shoulder function than partial repair or debridement alone. In cases of irreparable RCT the mid-term results of partial repair and arthroscopic debridement are comparable, indicating a preference for the latter due to the less invasive procedure.
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