Rev. bras. ortop. vol.50 número1

w w w . r b o . o r g . b r

Original

article

Result

from

arthroscopic

surgical

treatment

of

renewed

tearing

of

the

rotator

cuff

of

the

shoulder

夽

Glaydson

Gomes

Godinho

,

Flávio

de

Oliveira

Franc¸a

,

José

Márcio

Alves

Freitas

,

Flávio

Márcio

Lago

Santos

_,

_Alexandre

_Prandini

,

André

Couto

Godinho

,

Rafael

Patrocínio

de

Paula

Costa

a_{OrthopedicHospital,BeloHorizonte,MG,Brazil}

b_{BeloHorizonteHospital,BeloHorizonte,MG,Brazil}

c_{LifecenterHospital,BeloHorizonte,MG,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received31December2013 Accepted13March2014

Availableonline23February2015

Keywords: Rotatorcuff Treatmentfailure Arthroscopy

a

b

s

t

r

a

c

t

Objectives: Toevaluatefunctionamongpatientswithpostoperativerecurrenceofrotator cuffinjuriesthatwastreatedarthroscopically(caseseries)andcomparethiswithfunction inpatientswithoutrecurrence(controlgroup);andtocomparefunctionamongpatients withrecurrenceofrotatorcuffinjuriesthatweregreaterthanandsmallerthan3cm. Methods:Thiswasaretrospectiveevaluationofpatientswhounderwentarthroscopic revi-sionofrotatorcuffinjuriesusingtheASES,Constant&MurleyandUCLAscoresandavisual analogpainscale,incomparisonwithpatientsinacontrolgroupwhounderwentprimary rotatorcuffrepair.

Results:Thesizeoftherotatorcuffinjuryrecurrencehadastatisticallysignificantinfluence ontheresultfromthearthroscopicsurgicaltreatment.Thefunctionalscoresshowedworse resultsthanthosefromthefirstprocedure.

Conclusion: Arthroscopic surgical treatment of renewed tearing of rotator cuff injuries showedworsefunctionalscoresthanthosefromprimaryrepairoftheinjury.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Resultado

do

tratamento

cirúrgico

artroscópico

das

rerrupturas

do

manguito

rotador

do

ombro

Palavras-chave: Bainharotadora Falhadetratamento Artroscopia

r

e

s

u

m

o

Objetivos:Avaliara func¸ãode pacientesoperados por via artroscópicade recidiva pós-cirúrgicadelesãodomanguitorotador(sériedecasos)ecompará-loscomaquelessem recidiva(grupocontrole).Compararafunc¸ãodepacientescomrecidivadelesõesdo man-guitorotador(MR)maioresemenoresdoque3cm.

夽

WorkdevelopedatLifecenterHospital,BeloHorizonteHospitalandOrthopedicHospital,BeloHorizonte,MG,Brazil. ∗ _{Correspondingauthor.}

E-mail:Rtrauma@gmail.com(R.P.d.P.Costa). http://dx.doi.org/10.1016/j.rboe.2015.02.007

Métodos: Avaliac¸ãoretrospectivadepacientessubmetidosarevisãoartroscópicadaslesões domanguitorotadorcomousodosescoresdeASES,ConstanteMurley,UCLAeescala analógicade dor e comparac¸ãocompacientes dogrupocontrole submetidos areparo primáriodoMR.

Resultados: Otamanhodalesão domanguitorotadornarecidivaapresentouinfluência noresultadodotratamentocirúrgicoartroscópicocomsignificânciaestatística.Osescores funcionaismostrarampioresresultadosquandocomparadosàquelesdoprimeiro procedi-mento.

Conclusão: Otratamentocirúrgicoartroscópicodasrerrupturasdelesõesdomanguito rota-dormostroupioresescoresfuncionaisquandocomparadoaoreparoprimáriodalesão.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Surgical treatment of recurrence ofrotator cuff injuries is achallengebecauseofthediagnosticdifficultiesand surgi-caltechnique, and becauseit evolves withresultsthat are inferior tothose ofprimary surgery.1 _{The approach needs}

to be carefuland surgical treatment may not bethe only

option. The evolution of the lesions is unpredictable2 _and

theremay bediscordancebetweenthe clinical assessment

andtheimagingexaminations.3_{Persistenceofpainandloss} of function after conservative treatment may indicate the needforsurgicaltreatment.Moststudieshaveevaluatedthe resultsfromsurgicalrepairsperformedasopenrevision

pro-cedures. Arthroscopic repair presents advantages, such as

loweraggressioninrelationtothedeltoidmuscle,the possi-bilityofdiagnosingassociatedlesionsandbetterviewingand classificationofthesizeoftheinjury.4

Recurrencesofrotatorcuffinjuriesare acommon com-plication.Theincidenceofrecurrenceshasbeenestimatedas 35%forsmallinjuries5,6_{andmayreachmorethan94%incases} ofextensiveinjuries.7,8 _{Theetiologyofrecurrencesvaries.}1 Despitetheadvancesintreatmentthathavebeenachieved, thereareno preciseparameters fordiagnosingrecurrences oftheseinjuries.9_{Inthis regard,physicalexaminationand} imagingmethodsareofgreatimportance,inthattheyprovide additionaldatathatmightguidethediagnosis.

Theinitial radiographic evaluationmakes it possible to estimatetheupwardmigrationofthehumeralhead,presence ofsubacromialspurs,glenohumeralosteoarthritisandanchor positions.Additionalinformationmay beobtainedthrough othermethods,suchasultrasonography(US),magnetic

res-onance imaging (MRI) and arthro-computed tomography

(arthro-CT).10 _{These examinations are indicated when the} postoperativerecoveryevolvesinanunsatisfactorymanner.11 MRIisconsideredtobethemostsuitablenoninvasiveimaging examination.

Thecharacteristicsofthesupraspinatustendonafterthe operationcanbeassessedusingMRIintofivetypes, accord-ingtotheclassificationsystemproposedbySugayaet al.12

Thisexaminationmakesit possibleto evaluatethe degree

offatty infiltrationofthe muscle bymeans ofthe classifi-cationsystemofGoutallieretal.13_{andthedegreeofmuscle} trophismbymeansofthetangentsignproposedbyZanetti etal.14_{Allofthesefactorshaveprognosticvalueanddirectly}

influencepatientmanagementandtheresultsfromthe sur-gicaltreatment.3

Theobjectivesofthepresentstudywereasfollows:

1. Toevaluatefunctionamongpatientswhounderwent oper-ationsduetorecurrenceofrotatorcuffinjuries(caseseries) andcomparethemwithpatientswithoutrecurrences (con-trolgroup).

2. To compare function among patients with rotator cuff

injurieslargerandsmallerthan3cm.

Materials

and

methods

Patientswhounderwentarthroscopicrevisionofrotatorcuff injuriesattheLifecenter,BeloHorizonteandOrthopedic hos-pitalsin BeloHorizonte, MG,performed bythe fourtitular

surgeonsofthegroupbetweenJanuary2003andNovember

2012,wereretrospectivelyevaluated.

Withtheaimofhavingabetterstatisticalevaluationofthe results,twocomparativegroupswereusedinthisstudy:the casegroup,whichconsistedofpatientswithrenewedtearing whowerereoperatedarthroscopically;andthecontrolgroup, formedbypatientswhohadbeenoperatedonlyoncefor rota-torcuffrepair.

Casegroup

This group comprised 57 patients and 58 shoulders (one

patient affected bilaterally) and underwent reoperation to treat recurrences ofrotator cuff injuries. Fifteenshoulders (26.3%)hadtraumaticetiologyand45,non-traumatic.

Duringthesurgicalprocedure,thelesionsweremeasured intheanteroposteriordirectionandwere groupedaslarger thanorsmallerthan3cm.Thirty-eightshoulders(66.6%) pre-sentedlesionslargerthan3cmand20(35.4%),smaller.Among thelesionsoftraumaticorigin,sevenwerelargerthan3cm andeightweresmaller.

Fifty-three shoulders (91.4%) required only onerevision procedureandfive(8.7%),morethanonerevision.

The patients’ mean age was 63.6 years (range: 42–92).

Thirty-one patients(53.4%) were male and26 (46.6%) were

female. Forty-seven shoulders(82.5%) wereaffected on the

right side and 11 (17.5%) on the left side. The dominant

Table1–Comparisonofdemographicdatabetweenthe casesseriesandthecontrols.

Cases Controls

Meanage(years) 63.6 62.2

Male 31 14

Female 26 25

Dominance 55 39

Sideaffected(RS/LS) 47/1130 /9

Smoking 1 6

SAH 22 15

DM 8 6

Hypothyroidism 1 4

Dyslipidemia 12 5

SAH,systemicarterial hypertension;DM,diabetesmellitus; RS, rightshoulder;LS,leftshoulder.

ambidextrousandonepresentedbilateralrecurrenceof rota-torcuffinjuries.

Amongthecommonestcomorbidities,22patients(38.6%)

presentedsystemicarterialhypertension(SAH),seven(12.3%) hypothyroidism,eight(14%)diabetesand12(21%) dyslipide-mia.

Thescalesusedforevaluatingthepatientswerethevisual analogscale(VAS)forpain,AmericanShoulderandElbow Sur-geons(ASES)scale,15_{UCLAshoulderratingscale(UCLA)}16_and ConstantandMurleyscale.17

Controlgroup

Thiswasagroupof39patients(42shoulders)whounderwent arthroscopicrepairofrotatorcuffinjuriesonasingleoccasion,

performedbythesamesurgeonsbetweenMay1996andJuly

2008.

Twelveshoulders(28%)presentedlesionslargerthan3cm and30(72%),smaller.

Alloftheseshoulderswereoperatedonlyonce.

Themeanageamongthesepatientswas62.2years(range: 45–76).Elevenpatients(28.2%)weremaleand28(71.8%)were female.Therightsidewas affectedin32 shoulders(76.2%) andtheleftsideinten(23.8%).Thedominantsidepresented lesionsin 11patients (28.2%).None ofthesepatients were ambidextrous.Fifteenpatients(38.5%)werehypertensive,six (15.4%)werediabetic,four(10.3%)presentedhypothyroidism andfive(12.8%)haddyslipidemia(Table1).

Thefunctionalevaluationonthepatientsinthisgroupwas performedusingtheConstantandMurleyscore.

Statistical

analysis

TheMann–Whitneytestwasusedtoevaluatethefunctional scoresintheseriesofcontrolsandcasesandthesizesofthe lesionsweretakenintoconsideration.

ThestatisticalanalysiswasperformedusingtheStatistical PackagefortheSocialSciences(SPSS)software,version17.0. Thesignificancelevelwastakentobep<0.05.

Results

Comparisonofthefunctionalresultsbetweenthetwosizes oflesionsstudiedshowedastatisticallysignificantdifference. Patientswithlesionslargerthan3cmpresentedworse func-tionthanthosewithsmallerlesions.FromtheVASscoresfor pain,thesetwogroupsdidnotpresentanystatistical differ-ence(Table2).

In comparatively evaluating the Constant and Murley

scoresbetweenthecontrolandcasegroups,itwasobserved thatthepatientswhounderwentonlyonerotatorcuffrepair procedurehadstatisticallybetterfunctionalresults(Table3).

Discussion

Persistence of symptoms such as pain, loss of strength

and limitation of movements after a rotator cuff injury

has been repairedis a sign indicating aprobable needfor surgical revision,1 _{whenassociatedwithimaging} examina-tions demonstratingthepresenceofanewlesion.Itneeds to be taken into consideration that there is a possibility

of discordance between clinical assessments and imaging

examinations.3_Jostetal.2_{evaluated20patientswithimaging} diagnosesofrecurrenceofrotatorcuffinjuriesandobserved thatfourofthemwerecompletelyasymptomatic.Makingthis diagnosisusingphysicalexaminationalonewasimpossible.

Certain factors need to be taken into consideration in

order to distinguish which patients might benefit from a

newsurgicalprocedure.AccordingtoMontgomeryetal.,3_the best candidates are relatively young, with high functional demands,and presentreparablelesionswithout significant muscleatrophy,withagoodrangeofmotion,anintactdeltoid

Table2–Functionalandpainevaluationinrelationtothetwogroupsoflesionsize.

Variables Lesions n Median 95%CIfordifferencebetweengroups p-value

VAS <3cm 38 2.0 [1.0]−0.0to3.0 0.2

>3cm 20 3.0

TotalASES <3cm 38 80.8 [1.0]−26.7to−0.0 0.05

>3cm 20 65.8

UCLA <3cm 38 28.50 [1.0]−8.0to−2.0 0.004

>3cm 20 23.50

Constant <3cm 38 79.95 [1.0]−18.2to−5.6 <0.001

>3cm 20 69.00

Table3–FunctionalevaluationofthecasesseriesversuscontrolgroupbymeansoftheConstantscore.

Variables Group N Median 95%CIfordifferencebetweengroup p-value

Constant Controls 41 81.8 [1.0]2.2–11.6 0.006

Cases 58 74.8

Thesignificanceprobabilities(p-values)refertotheMann–Whitneytest.

muscleand onlyone previousoperation. Ifthere isa con-traindicationagainstsurgery,conservativetreatmentmaybe indicated,andthishasbeencorrelatedwithgoodresults.1

Some studies have evaluated the results from surgical

treatmentofrecurrencesofrotatorcuffinjuriesasopen pro-cedures. In 1984, DeOrio and Cofield18 _{published the first} caseseries,evaluatingtheresultsfrom24patientswhowere reoperated.Amongthese,onlyfourpatientspresentedgood results.After46monthsoffollow-up,thepainlevelwas mod-erateorseverein63%.Biglianietal.19_{evaluated31patients} withrecurrencesofrotatorcuffinjuriesandobtainedgood orexcellentresultsin52%ofthecases.Therewere

improve-ments of pain in 81% of the patients by the end of the

follow-up.Poorresultswereattributedtodeinsertionofthe deltoidmuscle,lateralacromionectomyandpoortissue qual-ity.Ontheotherhand,Djurasovicetal.20_{evaluatedthelargest} seriesofreoperationsdescribedintheliterature(80patients)

and found that58% ofthe resultswere good or excellent.

Inthatstudy,86%ofthepatientsevolvedwithimprovement oftheirpain.Similarly,NeviaserandNeviaser21_evaluated50 patientswhounderwentsurgicalrevisionoftherotatorcuff andreportedthattherewereimprovementsinpainin92%of thecases.Inanalyzingtheresultsfromthepresentstudy,we

observedthatthemeanpainlevelamongpatientswhohad

undergonesurgicaltreatmentofrecurrencesofrotator cuff injurieswas2.9points,measuredusingtheVAS.

CordascoandBigliani19,22_{believedthatthemainobjective} inrevisionsurgeryoughttobepainrelief,ratherthan improve-mentoffunction.FromevaluatingfunctionusingtheConstant andMurleyscoreinthepresentstudy,itwasshownthat reop-eratedpatientshadworsefunctionalresultsthanthoseofthe controlgroup.

Few studies have evaluated the effects of arthroscopic repaironrecurrencesofrotatorcuffinjuries,despitethe bene-fitsofthetechnique.Inaretrospectiveanalysison30patients whowerereoperatedeitherasopenorasarthroscopic pro-cedures,Miyasaki et al.23 _{foundthat unsatisfactory results}

predominatedamongpatientswhounderwent openrepair,

incomparisonwiththearthroscopicroute(p=0.001). Fromarthroscopicrevision,Loetal.24_{foundthat93%ofthe} resultsweresatisfactory.Intheirevaluation,theUCLAscore increasedfrom 13.1±2.3before the operationto 28.6±7.1 aftertheoperation.Inaseriesof54patientswhowere reoper-atedarthroscopicallysoastoperformrevisionofrotatorcuff injuries,Piaseckietal.4_{foundthattheASESscoreincreased} from43.8±5.7beforetheoperationto68.1±7.2afterthe

oper-ation,whiletherewasnoimprovementinpainasassessed

usingtheVAS.Keeneretal.25_{usedmethodologysimilartothat} ofthepresentstudyandretrospectivelyevaluated21patients whounderwentarthroscopicrevisionsurgeryontherotator cuff,withameanfollow-upof33months.ThemeanConstant andMurleyscorewas60.7inthecasegroupand76.2inthe

controlgroup,withstatisticalsignificance.Thepresentstudy onlytookintoaccounttheresultsfromarthroscopicrepairof recurrencesofrotatorcuffinjuries,withasampleof58 reoper-atedshoulders.Thefunctionalresultsfromthecontrolgroup, asassessedusingtheConstantandMurleyscore(81.8)were superiortothosefromthecaseseries(74.8).

In aseriesofarthroscopic revisions, Ladermannetal.26

compared lesions that were larger than and smaller than

5cmanddidnotfindanyfunctionaldifferencesbetweenthe groups.Thepresentstudyshowedadifferenceinfunctional

results throughcomparing lesions larger than and smaller

than3cm.Thisdivergencefromthepreviousstudyisdueto the factthatinthe firststudy,the lesionsweregroupedas largeandextensive,whereasinthesecond,thegroupingwas assmallandlarge.

The retrospective nature of the present study can be

highlightedasalimitation.Thus,therewasnopreoperative functionalevaluation.

Conclusion

Patients with recurrence of rotator cuff injuries achieved worsefunctionalresultsfromarthroscopicsurgerythanthose ofpatientswithoutrecurrence.

Patients who presented recurrence of lesions of sizes

smaller than 3cm presented better function than that of

patientswithlargerlesions.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.KilincAS,GiarretiR,DiazL,SauzièresP,ValentiP.Recurrent rotatorcufftears:anevaluationofopenre-surgeryresults. EurJOrthopSurgTraumatol.2010;20(5):373–80.

2.JostB,PfirrmannCW,GerberC.Clinicaloutcomeafter structuralfailureofrotatorcuffrepairs.JBoneJointSurgAm. 2000;82(3):304–14.

3.MontgomerySR,PetriglianoFA,GamradtSC.Failedrotator cuffsurgery,evaluation,anddecisionmaking.ClinSports Med.2012;31(4):693–712.

4.PiaseckiDP,VermaNN,NhoSJ,BhatiaS,BoniquitN,ColeBJ, etal.Outcomesafterarthroscopicrevisionrotatorcuffrepair. Arthroscopicrevisionrotatorcuffrepairoutcomes.AmJ SportsMed.2010;38(1):40–6.

5.GaziellyDF,GleyzeP,MontagnonC.Functionaland

6. WulkerN,MelzerC,WirthCJ.Shouldersurgeryforrotator cufftears.Ultrasonographic3-yearfollow-upof97cases.Acta OrthopScand.1991;62(2):142–7.

7. CalvertPT,PackerNP,StokerDJ,BayleyJI,KesselL. Arthrographyoftheshoulderafteroperativerepairofthe tornrotatorcuff.JBoneJointSurgBr.1986;68(1):147–50. 8. GalatzLM,BallCM,TeefeySA,MiddletonWD,YamaguchiK.

Theoutcomeandrepairintegrityofcompletely

arthroscopicallyrepairedlargeandmassiverotatorcufftears. JBoneJointSurgAm.2004;86(2):219–24.

9. PotterHG,JawetzST,FooLF.Imagingoftherotatorcuff followingrepair:humanandanimalmodels.JShoulder ElbowSurg.2007;16(5Suppl):S134–9.

10.WilliamsG.Painfulshoulderaftersurgeryforrotatorcuff disease.JAmAcadOrthopSurg.1997;5(2):97–108. 11.GeorgeMS,KhazzamM.Revisionrotatorcuffrepair.J

ShoulderElbowSurg.2012;21(4):431–40.

12.SugayaH,MaedaK,MatsukiK,MoriishiJ.Functionaland structuraloutcomeafterarthroscopicfull-thicknessrotator cuffrepair:single-rowversusdual-rowfixation.Arthroscopy. 2005;21(11):1307–16.

13.GoutallierD,PostelJM,BernageauJ,LavauL,VoisinMC.Fatty muscledegenerationincuffruptures.Pre-andpostoperative evaluationbyCTscan.ClinOrthopRelatRes.1994;(304):78–83. 14.ZanettiM,GerberC,HodlerJ.Quantitativeassessmentofthe

musclesoftherotatorcuffwithmagneticresonanceimaging. InvestRadiol.1998;33(3):163–70.

15.MichenerLA,McClurePW,SennettBJ.AmericanShoulderand ElbowSurgeonsStandardizedShoulderAssessmentForm, patientself-reportsection:reliability,validity,and responsiveness.JShoulderElbowSurg.2002;11(6): 587–94.

16.EllmanH,HankerG,BayerM.Repairoftherotatorcuff. End-resultstudyoffactorsinfluencingreconstruction.JBone JointSurgAm.1986;68(8):1136–44.

17.ConstantCR,MurleyAH.Aclinicalmethodoffunctional assessmentoftheshoulder.ClinOrthopRelatRes. 1987;(214):160–4.

18.DeOrioJK,CofieldRH.Resultsofasecondattemptatsurgical repairofafailedinitialrotatorcuffrepair.JBoneJointSurg Am.1984;66(4):563–7.

19.BiglianiLU,CordascoFA,McIlveenSJ,MussoES.Operative treatmentoffailedrepairsoftherotatorcuff.JBoneJoint SurgAm.1992;74(10):1505–15.

20.DjurasovicM,MarraG,ArroyoJS,PollockRG,FlatowEL, BiglianiLU.Revisionrotatorcuffrepair:factorsinfluencing results.JBoneJointSurgAm.2001;83(12):1849–55. 21.NeviaserRJ,NeviaserTJ.Reoperationforfailedrotatorcuff

repair:analysisoffiftycases.JShoulderElbowSurg. 1992;1(6):283–6.

22.CordascoFA,BiglianiLU.Thetreatmentoffailedrotatorcuff repairs.InstrCourseLect.1998;47:77–86.

23.MiyazakiAN,FregonezeM,SantosPD,SilvaLA,SellaGV, SantosRMM,etal.Avaliac¸ãodosresultadosdasreoperac¸ões depacientescomlesõesdomanguitorotador.RevBrasOrtop. 2011;46(1):45–50.

24.LoIK,BurkhartSS.Arthroscopicrevisionoffailedrotatorcuff repairs:techniqueandresults.Arthroscopy.2004;20(3):250–67. 25.KeenerJD,WeiAS,KimHM,PaxtonES,TeefeySA,GalatzLM,

etal.Revisionarthroscopicrotatorcuffrepair:repairintegrity andclinicaloutcome.JBoneJointSurgAm.2010;92(3):590–8. 26.LadermannA,DenardPJ,BurkhartSS.Mid-termoutcomeof