|Year : 2021 | Volume
| Issue : 2 | Page : 144-148
Outcome of arthroscopic rotator cuff repair after 4 years of evaluation
Subhendu Das1, Partha Sarathi Sarkar2, Sabyasachi Santra3, Sanjay Keshkar4
1 Department of Orthopaedics, Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Orthopaedics, Raiganj Government Medical College and Hospital, Raiganj, West Bengal, India
3 Department of Orthopaedics, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
4 Department of Orthopaedics, ESIC Medical College and Hospital, Kolkata, West Bengal, India
|Date of Submission||12-Jun-2021|
|Date of Acceptance||02-Sep-2021|
|Date of Web Publication||27-Dec-2021|
Dr. Sabyasachi Santra
Department of Orthopaedics, College of Medicine and Sagore Dutta Hospital, Kamarhati, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Shoulder pain is a common musculoskeletal complaint in the general population, mostly in the elderly. Among them, the rotator cuff problems are found to be most common causes. The treatment of rotator cuff pathology has progressed from open repair, first described by Codman in 1911 to arthroscopy assisted “mini open” techniques, to all arthroscopic repair techniques, first reported by Johnson who used metal staples while E.M. Wolf pioneered the first completely arthroscopic repair using suture anchors in 1990. The purpose of this study is to evaluate the functional outcome following all arthroscopic repairs of full-thickness rotator cuff tears with suture anchors. Materials and Methods: A prospective study was done for 24 shoulders in 24 patients treated for full-thickness rotator cuff tear by all-arthroscopic repair between February 2014 and September 2015 and followed until May 2018. The results were evaluated using the University of California at Los Angeles (UCLA) shoulder scoring system. Patients younger than 18 and over 80 and also those with bony lesion were excluded from the study as were those which might have confounded the outcome were excluded. Results: Among the 24 patients, the UCLA clinical scores were excellent in 12 patients, good in 9 patients, fair in 2 patients, and poor in 1 patient. The average UCLA score was 31.84. Conclusion: All-arthroscopic repair is an excellent treatment option for full-thickness rotator cuff tears, although with a steep learning curve.
Keywords: Arthroscopic rotator cuff repair, rotator cuff tear, rotator cuff, shoulder pathology
|How to cite this article:|
Das S, Sarkar PS, Santra S, Keshkar S. Outcome of arthroscopic rotator cuff repair after 4 years of evaluation. J Orthop Traumatol Rehabil 2021;13:144-8
|How to cite this URL:|
Das S, Sarkar PS, Santra S, Keshkar S. Outcome of arthroscopic rotator cuff repair after 4 years of evaluation. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jul 4];13:144-8. Available from: https://www.jotr.in/text.asp?2021/13/2/144/333567
| Introduction|| |
Shoulder pain is a common musculoskeletal complaint in the general population, mostly in the elderly. Among them, the rotator cuff problems are found to be the most common causes. Rotator cuff can be torn from a single traumatic injury or a tear may result from overuse of the muscles and tendons over a period of years. The prevalence of full-thickness tears in the general population is about 20% and markedly increased after the age of 50 years but large proportion of these patients with rotator cuff tears are asymptomatic. The symptomatic rotator cuff tears may cause significant pain, weakness, and limitation of motion. A shoulder disorder can increase functional dependency in the elderly due to difficulties in completing activities of daily living. In younger adults, this morbidity may also lead to significant disability, including absenteeism from work and loss of productivity. The treatment of rotator cuff pathology has progressed from open repair, first described by Codman in 1911 to arthroscopy assisted “mini open” techniques, to all arthroscopic repair techniques, first reported by Johnson who used metal staples while E.M. Wolf pioneered the first completely arthroscopic repair using suture anchors in 1990., Traditional treatment of full-thickness tears of the rotator cuff has consisted of open surgical repair., Reported satisfactory outcomes for open repair have ranged from 70% to 95%.,,,,,,,,, Subsequently, arthroscopic double-row fixation for rotator cuff was developed with the idea that it strengthens the tendon-bone interface, though its superiority over single-row fixation is still being debated., The purpose of this study is to evaluate the functional outcome of all-arthroscopic repairs of full-thickness rotator cuff tears with suture anchors.
| Materials and Methods|| |
A prospective study was done for 24 shoulders in 24 patients treated for full-thickness rotator cuff tear by all-arthroscopic repair between February 2014 and September 2015 and followed until May 2018. Patients included were those who had either an acute tear or a failure of conservative treatment, as also those with severe night pain with disabling restriction of activities of daily living. Patients younger than 18 and over 80 were excluded from the study as were those with comorbid conditions which precluded surgical intervention or would have compromised rehabilitation. Furthermore, those with bony lesion which might have confounded the outcome were excluded.
For calculation of sample size, the formula applied:
Where, n = sample size, P = estimate of prevalence from previous studies, q = 1–p, L = maximum allowable loss, which was taken as 17% (as the power of study was 83%).
According to one study, the prevalence of rotator cuff tear is approximately 20% which was taken this as yardstick for calculation of sample size.
Therefore, by putting the values of P = 0.20, q = 0.80, and L = 0.17, the minimum required sample size was calculated to be 21. We studied total of 24 patients.
The patients were assessed preoperatively by thorough history and clinical examinations (Jobe's “Empty Can” Test, Gerber's “Lift Off” test, Napoleon Belly Press test, etc.) followed by radiograph of shoulder. Magnetic resonance imaging (MRI) was done in all cases to confirm rotator cuff pathology and also to exclude any associated lesions which might confound the functional outcome postoperatively. MRI picture of one patient is shown in [Figure 1]a and [Figure 1]b. Hematological investigations were done as per hospital protocol. They were operated with all-arthroscopic repair technique using suture anchors. Evaluation was done during the hospital stay and the rehabilitation phase. The results were evaluated using the Modified UCLA (University of California at Los Angeles) Shoulder Scoring Scale [Table 1].
|Figure 1: Ultrasonography (a) Magnetic resonance imaging (b) of shoulder of a patient showing rotator cuff pathology without any other associated lesions|
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|Table 1: Modified University of California at Los Angeles Shoulder Scoring Scale|
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All the surgical procedures were performed under general anesthesia with the patients in lateral decubitus position. An arm holder was used with 10 pounds of weight to put traction and keep the shoulder in 30° of abduction and 10° of forward flexion and patient tilted 30° posteriorly thereby allowing ready access to the posterior, anterior, and superior aspects of the shoulder and facilitating approximation of the free tendon edge to the region of the greater tuberosity [Figure 2]a. A standard 30° arthroscope was used in all cases. First Glenohumeral Inspection done to rule out any associated lesion followed by acromioplasty not only allows enhanced visualization and increased room for instrumentation but also to lessen the likelihood of later impingement of the repaired cuff. The rotator cuff tear pattern is determined and a plan for the repair is established, including single versus double row (DR), locations of anchors, and need of release. Anchors were placed in a position that affords minimal tension on the tendon margin at repair. Before anchor insertion, the greater tuberosity and footprint of the tendon are prepared by removing all interposed soft tissue, which could compromise healing, and lightly decorticating the bony surface. In single-row repair, anchors are placed at or just medial to the lateral margin of the greater tuberosity. In larger tears, when a DR repair is desired, medial anchors are placed 5 mm lateral to the articular margin and lateral anchors at the greater tuberosity or just lateral to it. For our study, we used 2.8 mm suture anchors [Figure 2]b preloaded with fiber wires and Antegrade passers for cuff repairs and additional 5.5 mm footprint anchors for DR repair techniques. Margin convergence was used wherever required and was done with absorbable polyglactin sutures. Steps of arthroscopic repair in a patient are shown in [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d.
|Figure 2: Patient positioning; an arm holder was used with 10 pounds of weight to put traction and keep the shoulder in 30° of abduction and 10° of forward flexion and patient tilted 30° posteriorly (a) and 2.8 mm suture anchors (b)|
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|Figure 3: (a-d) Operative technique of arthroscopic rotator cuff repair; margin convergence was used wherever required and was done with absorbable polyglactin sutures|
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Postoperative rehabilitation protocol
The patients were kept in a simple sling with abduction pillow for 6 weeks. Postoperative rehabilitation included passive range of motion exercises, forward elevation and external rotation in a supine position, and pendulum exercises as soon as the pain subsided and continued for 6 weeks (Phase I). Thereafter, till 12 weeks (Phase II) active assisted range of motion exercises in supine position progressing to the seated or standing position were allowed. After 12 weeks (Phase III), isometric exercises were started. Active elevation, pushing, pulling, and other strenuous activities were not allowed for 6 weeks. The postoperative rehabilitation evaluation done at 2 weeks, 6 weeks, 12 weeks, 6 months, 9 months and 1 year, 1.5 year, 2 years with follow-up questionnaire included subjective rating of pain, medication use, and mechanical symptoms like any limitations of work.
| Results|| |
Out of the total 24 patients, 20 were male and 4 were female. Majority of the patients were in the age group of 45–55 years (range was 28-65 years). Among 24 patients, 13 patients had their right shoulder involved while the rest 11 patients had their left shoulder involved. Fifteen patients were involved in a significant occupation requiring overhead activity such as sporting activities and agriculturists. Rest nine patients were involved in low demand occupation. Thirteen patients were smokers or they use tobacco and the rest nine patients were nonsmokers or had not used any form of tobacco previously.
Of the 24 patients included in the study, 21 (87.5%) had good to excellent results according to the UCLA shoulder scoring system at the final follow-up at 4 years, with 12 excellent (50%), 9 good (37.5%), 2 fair (8.3%), and 1 poor (4.2%). The average UCLA score was 31.84 at the end of 4 years. The mean score for pain was 8.25 (range: 0–10), mean for subjective function score was 7.92 (range: 0–10), mean for range of forward flexion was 4.83 (range: 0–5), mean score for strength was 4.29 (range: 0–5). Overall, 95.83% patients were satisfied in our study. One of the patients in our series was not satisfied with the procedure as she had developed superficial infection of the surgical site followed by stiffness of shoulder joint and persistent mild pain on movement.
| Discussion|| |
The treatment of rotator cuff pathology has evolved with an improved understanding of rotator cuff anatomy, more sophisticated instrumentation, and advances in surgical technique. The most effective method of surgical repair is controversial given that both arthroscopic and mini-open rotator cuff repairs have been shown to produce satisfactory clinical results. There has been growing interest in arthroscopic rotator cuff repair, and it is believed to be at least as effective as mini-open rotator cuff repair with the added advantages of reduced surgical morbidity, reduced postoperative stiffness, and, potentially, a more rapid return to baseline shoulder function once rotator cuff healing has occurred. Arthroscopic repairs are thought to be better able to reproduce rotator cuff anatomy because the three-dimensional evaluation allows for the recognition of tear configuration, thereby allowing the surgeon to formulate a strategy that is most appropriate for that particular pattern. In our study, we have tried to assess the functional outcome in patients, controlling the homogeneity of independent variables such as lesion mechanism, lesion pattern, surgical technique, postoperative rehabilitation, and duration of follow-up evaluation. In our study, among 20 males and 4 females, no differences were noted in mean postoperative UCLA scores. Both groups have shown equal results. On comparing age groups, it was found that as age advances, our UCLA scores are getting lower. We have also found that traumatic tears are having better results than chronic tears. It was also found that as age advances, number of chronic tears increases. That also correlates that as age advances, results are getting low. We noted that as time of repair after the beginning of symptoms increases, UCLA scores show significant decrease.
Murray et al. followed up 48 patients with medium to large rotator cuff tears for an average of 39 months after arthroscopic rotator cuff tear and found an average UCLA score of 33.7 with 46 out of 48 patients reporting a good to excellent score.
Jones and Savoie in their study of 50 patients of arthroscopic repair of large to massive rotator cuff tears followed up for 1–5 years reported 88% good or excellent score with 98% being satisfied with the outcome.
Wolf et al. followed up 96 shoulders in 95 patients for 4–10 years and reported 94% good or excellent result (53% excellent and 41% good). 96% of the patients were satisfied with the surgical outcome.
Our study correlates well with the results of recent studies in establishing all-arthroscopic rotator cuff repair as an excellent surgical technique in experienced hands.
| Conclusion|| |
We conclude that arthroscopic repair of rotator cuff tears with the use of suture anchors is an excellent surgical treatment option with respect to the functional outcome of shoulder, recurrence rate, and range of motion with the advantage of lower operative side morbidity. All arthroscopic rotator cuff repair can achieve high percentage of excellent subjective and objective results.
During the study period, the sole author(s) of this article were attached to N.R.S. Medical College and Hospital, Kolkata and did the study then and there. Author(s) thank the, then administration and other staff of this Institute for providing infrastructure and helping to complete the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]