Keywords rotator cuff - arthroscopy - treatment
Introduction
Partial rotator cuff injury is recognized as an important cause of shoulder dysfunction and pain.[1 ] Its incidence is not yet consensus in literature, although there are several studies about it.[2 ]
[3 ]
[4 ] Sher et al.,[3 ] analyzing 96 asymptomatic shoulders by ultrasound, found 20% of partial lesions. By dissecting 249 shoulders of corpses, Lohr and Uhthoff[2 ] found 32% of partial injuries, while Fukuda[5 ] found 13%. These authors described that around 1/3 (27%) of these lesions affect the joint part.
Ellman[6 ] was the first to propose, based on arthroscopic findings, a partial lesion classification system in relation to its location (A, articular; B, bursal; C, intratendinous) and its extension (grade 1: ˂ 3 mm; grade 2: 3–6 mm; grade 3: ˃ 6 mm).
As for the pathophysiology of partial lesions of the articular part (PLAP) of the rotator cuff, it is believed that they can occur either with intrinsic mechanisms (area of hypovascularization and metabolic alterations related to age) and extrinsic (posterosuperior internal impact, acute traumatic events, and recurrent microtraumas), or even a combination between them.[7 ] Weinreb et al.,[8 ] in 2014, published an article showing that there is evidence that intrinsic factors related to the tendon lead to the degeneration of its fibers in the articular face with tapering and disorientation of these, resulting in the anatomical injury of this region. Corroborating this evidence, Ozaki et al.[9 ] did not find signs of subacromial impact in the articular lesions of the rotator cuff, so they exclude it as a possible cause for these lesions. Another mechanism that leads to PLAP of the rotator cuff is found in pitchers, who can have a posterosuperior internal impact.[4 ]
[10 ]
The initial treatment for PLAP of the rotator cuff is performed with conservative measures, such as physiotherapy and change of habits to prevent the progression of the lesion.[11 ] Surgical treatment is indicated in the failure of conservative treatment and in cases in which the lesion takes up more than 50% of the tendon thickness, due to a higher risk of progression of the lesion; 40% of the PLAP of the rotator cuff evolve to complete lesions, according to Mall et al.[12 ] and Stuart et al.[13 ]
Different arthroscopic surgical techniques have been described to approach this type of lesion, from a simple arthroscopic debridement of the tendon, believing in its healing capacity (since performed in low-grade lesions[14 ]), to a transtendon repair of the lesion, initially described by Stephen Snyder,[15 ] or even the disinsertion of the affected tendon area (“completing the lesion”) followed by its repair.[16 ]
The main objective of the present study is to evaluate the clinical results of patients submitted to arthroscopic treatment of PLAP of the rotator cuff by transtendon suture techniques and after the lesion is completed and to compare the postoperative recovery time of the two techniques.
Casuists and Methods
From October 1999 to December 2016, 39 patients with diagnosis of PLAP of the rotator cuff underwent arthroscopic surgical treatment performed by the Shoulder and Elbow Group of the Department of Orthopedics and Traumatology of our institution.
The patients, all with partial joint lesion of the supraspinal muscle tendon, were divided into two groups: group I, those who underwent transtendon repair, and group II, patients submitted to treatment with repair after turning the partial lesion into complete.
The inclusion criteria were patients diagnosed with PLAP of the rotator cuff, performed by means of magnetic resonance imaging (MRI) in the preoperative period, submitted to arthroscopic treatment, and who had minimal follow-up ≥ 2 years.
In group I, there were 19 patients with mean follow-up of 4.61 years. Thirteen of these patients were male (68%) and 6 were female. The mean age was 48 years, ranging from 34 to 70 years. The dominant side was affected in 73% of the cases; 16 patients (84%) practiced sports and 9 patients (47%) reported traumatic event as triggering the condition.
Group II had 20 patients with mean follow-up of 4.35 years. Eleven of these were male (55%) and 9 were female. The mean age was 52 years, ranging from 29 to 75 years. The dominant side was affected in 85% of the cases, 11 patients (55%) practiced sports and only 3 patients reported a traumatic event.
There were no statistically significant differences between the samples in relation to age, gender, and affected limb, and in 78% of the cases, the dominant side was affected. All patients were submitted to the surgical procedure in beach chair position, under general anesthesia associated with anesthetic block of the brachial plexus. Articular arthroscopic inspection was performed, followed by subacromial inspection and partial bursectomy. In group I, seven patients presented SLAP-type lesion, two with arthrosis of the acromioclavicular joint, one with major tubercle fracture, already consolidated and which was treated conservatively, one patient with long biceps head injury and one patient with Bankart injury. In group II, six patients presented SLAP-type lesions, four had rupture of the long head of the biceps, and three had arthrosis of the acromioclavicular joint. From this point, the techniques differ: in group I patients, the wires of the anchors were passed through the transtendon, through the joint space to the bursal surface, following with the repair. When we opted for this type of repair, we increased the pressure of the serum infusion pump to close to 80 mmHg, which causes the joint space to increase and the tendon to lift from its insertion bed and allows intra-articular visualization of the passage of the anchors from subacromial to intra-articular and its correct positioning in the so-called footprint. Once the anchor is fixed, a wire is caught with birdbick tweezers and passed through the tendon at a point of tissue considered healthy, that is, outside of the lesion area. We return the pump pressure to normal value, to avoid an exaggerated and rapid edema that prevents the rest of the surgery. Then, the optics are positioned again in the subacromial space, and the wires are tied with simple sliding points. The procedure is repeated as many times as deemed necessary ([Figure 1 ]). In group II patients, the disinsertion of the bursal fibers, which remained intact, was performed, transforming it into a complete lesion, followed by repair through the passage of the suture threads through the bursal face ([Figure 2 ]). All of them were repaired by simple points technique via arthroscopy.
Fig. 1 Transtendon repair of the partial joint lesion of the supraspinal muscle tendon. A - Representation of partial joint injury, B - Way of passage of suture threads according to this technique, C - Sutured lesion.
Fig. 2 Repair after transforming the partial lesion into complete in the partial joint lesion of the supraspinal muscle tendon. A - Representation of partial joint injury, B - Partial lesion being completed, C - Way of passage of suture threads in the lesion already completed, D - Sutured lesion.
In the postoperative period, the patients were immobilized with functional sling between 4 and 6 weeks, continuing rehabilitation.
The amplitude of the range of motion was evaluated by measuring elevation, lateral and medial rotations. Clinical evaluation was performed using the University of California at Los Angeles (UCLA) score.[17 ] To evaluate the recovery time, we used the comparison of the time that patients in both groups took to reach their “maximum” value of the UCLA score,[17 ] per specific statistical test listed below.
Initially, a descriptive analysis was performed with calculation of the percentage distribution for each variable. The qualitative variables (gender, dominance, sport, intra and postoperative capsulitis) were analyzed by the chi-Squared independence test, when the hypotheses of independence of the sample were respected, and by Fisher exact test when not respected. The quantitative and qualitative ordinal variables (elevation, medial and lateral rotations, pre- and postoperative, follow-up time, UCLA value and UCLA time) were analyzed by the Mann-Whitney nonparametric test, when the distribution did not adhere to the normal distribution, and by the F-test, when there was adherence to the normal distribution, followed by analysis of the equality of means by Student t-test.
The analyses were performed using the statistical software Minitab (Minitab, LLC, State College, PA, USA), v.17. All hypotheses with descriptive levels (p -value) lower than 0.05 were rejected, which was the level of significance adopted.
The study was submitted to the Research Ethics Committee and approved according to CAAE: 79428617.2.0000.5479.
Results
Using the UCLA score,[17 ] group I had 9 excellent results (42%), 8 good results (38%), and 2 unsatisfactory results ([Table 1 ]). The mean time for rehabilitation was 6 months, postoperative range of motion with an average elevation of 142° (110–160°), lateral rotation of 59° (45–70°), and medial rotation of T8 (T3–L5).
Table 1
Nr. of patients
Gender
Age
Dominant side
Δtt
UCLA
Δt
COMPLICATIONS
1
F
50
03 a.
TOTAL:35
4 m
2
M
70
02 a.
TOTAL: 35
5 m
3
F
49
+
03 a.
TOTAL: 35
5 m
4
F
39
+
02 a.
TOTAL: 35
5 m
5
M
51
+
03 a.
TOTAL: 35
4 m
6
M
43
+
07 a.
TOTAL: 22
9 m
7
M
49
+
02 a.
TOTAL: 35
4 m
8
M
40
+
09 a.
TOTAL: 32
6 m
9
M
34
+
2 a.
TOTAL: 35
5 m
10
M
44
+
09 a.
TOTAL: 32
4 m
11
F
56
09 a.
TOTAL: 31
5 m
12
M
41
+
12 a.
TOTAL: 34
4 m
13
F
54
+
02 a.
TOTAL: 32
9 m
14
M
52
+
09 a.
TOTAL: 31
8 m
15
M
58
04 a.
TOTAL: 23
10 m
16
M
59
+
09 a.
TOTAL: 34
5 m
17
F
53
05 a.
TOTAL: 33
6 m
18
M
44
+
05 a.
TOTAL: 33
4 m
19
M
35
+
07 a.
TOTAL: 33
12 m
REVIEW FOR RELEASE WITH 8 MONTHS DUE TO CAPSULITIS
In group II, we had 5 excellent results (25%), 14 good results (70%), and an unsatisfactory result ([Table 2 ]). The mean time for rehabilitation was 5.2 months, postoperative range of motion with an average elevation of 146° (130–160°), lateral rotation of 56° (45–70°), and medial rotation of T8 (T5-L2).
Table 2
Case
Sex
Age
Dominant side
Δtt
UCLA
Δt
COMPLICATIONS
1
M
58
+
02 a.
TOTAL: 32
6 m
2
F
63
+
02 a, 10 m
TOTAL: 31
5 m
3
F
65
+
02 a.
TOTAL: 32
4 m
4
F
67
+
02 a.
TOTAL: 33
5 m
5
M
75
03 a.
TOTAL: 34
4 m
6
F
57
05 a.
TOTAL: 34
6 m
7
M
39
+
08 a.
TOTAL: 32
6 m
8
F
73
+
05 a.
TOTAL: 35
5 m
9
F
59
+
02 a.
TOTAL: 32
5 m
10
M
43
+
04 a.
TOTAL: 32
7 m
11
M
38
+
02 a.
TOTAL: 33
7 m
12
F
29
+
11 a.
TOTAL: 34
4 m
13
M
44
13 a.
TOTAL: 23
6 m
14
M
42
+
02 a.
TOTAL: 32
5 m
15
F
51
08 a.
TOTAL: 33
4 m
16
M
39
+
06 a.
TOTAL: 32
4 m
17
M
49
+
02 a.
TOTAL: 33
4 m
18
M
51
+
03 a.
TOTAL: 32
5 m
19
M
56
+
03 a.
TOTAL: 33
7 m
CAPSULITIS AFTER 3 MONTHS, PERFORMING BLOCKS AND PHYSIOTHERAPY.
20
F
47
+
02 a.
TOTAL: 35
5 m
As a complication, we had two cases of adhesive capsulitis, one in each group. The patient in group I underwent arthroscopic release after 8 months of repair of the lesion reaching a UCLA[17 ] score of 33 after 1 year. The patient in group II showed improvement after performing suprascapular nerve blocks and physiotherapy, reaching a UCLA[17 ] score of 33 7 months postoperatively.[18 ]
After the statistical analysis, there was no difference between the average UCLA[16 ] score for both groups, with a result of 32, ranging in group I from 22 to 35, and in group II from 23 to 35. In the analysis of the time required to achieve the result of UCLA,[17 ] there was a difference of 3 weeks in the mean, but without statistical relevance, with a p- value = 0.336.
Discussion
Surgical treatment for PLAP of the rotator cuff is indicated in the failure of conservative treatment and, commonly, in cases in which the lesion affects more than 50% of the tendon fibers,[13 ]due to a 40% risk in progression to complete injury, as described by Mall et al.[12 ] Mazzoca et al.[19 ] also demonstrated in cases with more than 50% of injury to the tendon fibers, the remaining tendon presents an increase in its tension, which would lead to its eventual complete rupture.
In the operative act, PLAP of the rotator cuff can be approached in two ways in relation to the tendon: either by maintaining its integrity in the insertion—a technique known as transtendon fixation of the lesion—or by a second technique in which there is complete disinsertion of the remaining fibers, transforming it into a complete lesion.
Studies such as those by Sethi et al.[20 ] and Mihata et al.[21 ] show biomechanical advantages of transtendon repair. In this technique, the bursal (intact and uninjured) and articular (containing the lesion) fibers are sutured separately ([Figure 1 ]), which provides less tension at the end of the suture in the bursa fibers, in addition to a larger contact surface in the insertion area. But as observed by Shin,[22 ] these patients present a more painful postoperative period and a slower recovery of the range of motion, which could be related to lesions with great retraction of the affected joint part, with an unbalance between the fibers repaired and those that were kept intact. In our study, we observed that patients in group I took 1 month longer, on average, to recover and reach the final UCLA[17 ] than patients in group II, but this difference was not statistically significant.
Shin[22 ] also mentions that the disinsertion of the entire lateral margin of the rotator cuff, by turning the partial lesion into complete, can lead to the risk of non-anatomical repair, altering the biomechanics and thus resulting in an early degeneration of the tendon. However, in our opinion, as in Shin's,[22 ] such a maneuver allows a better view and facilitates repair due to greater familiarity with the technique.[11 ]
[20 ] Although good functional result is not a specific factor for knowing whether or not there was anatomical repair of the lesion, we did not suspect any important biomechanical alteration, since patients in group II presented good postoperative evolution, with return of the usual activities, as found in the study by Godinho et al.,[23 ] who obtained 100% satisfaction and good/excellent results with the technique.
There is no consensus in the literature on the best technique for repairing this type of lesion. The comparative works between the two techniques, such as those of Shin,[22 ] Ono et al.,[24 ] and Castagna et al.,[16 ] do not present statistically significant differences among them, presenting similar results in the postoperative period, with the same healing rate, re-ruptures, and results. Our study demonstrates that both techniques enable good results, without statistical differences when evaluating the UCLA score[17 ] between the two groups, with a p -value = 0.321, including similar postoperative rehabilitation time, with p -value = 0.336.
Despite the good result obtained with both techniques, we had in our study three cases with unsatisfactory results, two from group I and one from group II. In group I, the 1st patient was 43 years old, a non-professional tennis player with injury affecting the dominant side and with symptoms presenting for about 20 years. With good preoperative mobility (140°, 80°, T3), he evolved with a loss in the postoperative period of 110°, 45° and L5, which remained. It evolved with the patient presenting pain when doing low-intensity work, with the patient being able to perform all domestic activities, but with limitation in movements above the shoulder line (grade IV strength). The second case of group I was a 58-year-old patient, a non-professional swimmer, presenting symptoms in the non-dominant side for 3 years. Good pre and postoperative range of motion, without limitation. He also developed pain to light work, with grade IV loss of strength above the shoulder. After all, the two said they are satisfied with the result. The case of group II was a 44-year-old patient with no history of sports practice, presenting symptoms for 1 year. Preoperative range of motion 160°, 70°, T7. It evolved postoperatively with pain to low-intensity work, and slight decrease in elevation and lateral rotation, without loss of strength. However, he is dissatisfied with the result due to the persistence of pain. What caught our attention in all three cases is that we did not find an objective cause for the maintenance of pain. All patients' imaging showed normal healing of the lesion.
Conclusion
Both the transtendinous suture and suture after completing the lesion led to satisfactory results in 93% of the patients in our series. We did not find a statistically significant difference in rehabilitation time between the two groups.
