w w w . r b o . o r g . b r
Original
Article
Rotator
cuff
injury
in
patients
over
the
age
of
65
years:
evaluation
of
function,
integrity
and
strength
夽
Marco
Antonio
de
Castro
Veado
a,b,
Eric
Fontes
Prata
a,c,∗,
David
Correia
Gomes
a,caHospitalMaterDei,BeloHorizonte,MG,Brazil
bFaculdadedeCiênciasMédicasdeMinasGerais(FCMMG),BeloHorizonte,MG,Brazil cHospitalFelícioRocho,BeloHorizonte,MG,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received8July2013
Accepted29May2014
Availableonline16June2015
Keywords:
Shoulderjoint/surgery
Rotatorcuff
Arthroscopy
a
b
s
t
r
a
c
t
Objective:Toretrospectivelyevaluatetheresultsfrompatientswhounderwentarthroscopic
treatmentforrotatorcuffinjuries,amongthoseagedover65years,observingintegrity,
functionandstrength.
Methods:Thirty-fiveshoulderswereoperatedbetweenJuly2005andJuly2010,and28
shoul-derswerere-evaluatedregardingelevationstrengthandexternalrotation,usingadigital
dynamometer.Integritywasevaluatedbymeansofultrasoundexaminations.Thepatients,
whosemeanagewas70.54years(rangingfrom65to82years),werefollowedupfora
min-imumof26monthsandmeanof51.18months(rangingfrom26to82months).Toevaluate
function,theUCLAscore,theSimpleShoulderTest(SST)andavisualanalogscale(VAS)for
painwereused.
Results:Inanalyzingtheultrasoundscans,itwasobservedthattheintegrityoftherotator
cuffwasmaintainedin75%ofthecasesattheendofthefollow-up,alongwiththe
improve-mentintheUCLAscore,whichevolvedfrom17.46to32.39,i.e.excellentandgoodresults
in89.28%.ThemeanSSTandVASindiceswere9.86and1.5respectively.
Conclusion:Arthroscopicsurgerytorepairrotatorcuffinjuriesinpatientsovertheageof65
yearsleadstoimprovedfunctionandpainrelief,withmaintenanceoftheintegrityofthe
repair.Thedataonmusclestrengthwereinconclusive.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
Lesão
do
manguito
rotador
em
pacientes
maiores
de
65
anos:
avaliac¸ão
da
func¸ão,
integridade
e
forc¸a
Palavras-chave:
Articulac¸ãodoombro/cirurgia
r
e
s
u
m
o
Objetivo:Avaliarretrospectivamenteosresultadosdospacientessubmetidosaotratamento
artroscópicodaslesõesdomanguitorotadorempacientesacimade65anoseobservara
integridade,afunc¸ãoeaforc¸a.
夽
WorkdevelopedatHospitalGovernadorIsraelPinheiroandatHospitalMaterDei,inBeloHorizonte,MG,Brazil.
∗ Correspondingauthor.
E-mail:ericprata@gmail.com(E.F.Prata).
http://dx.doi.org/10.1016/j.rboe.2015.06.004
Bainharotadora Artroscopia
Métodos:Foramoperados35ombrosentrejulhode2005ejulhode2010e28ombros
reavali-adosquantoà forc¸adeelevac¸ãoe derotac¸ãoexternacomumdinamômetro digital.A
integridadefoiavaliadaporexamedeultrassonografia.Ospacientes,commédiade70,54
anos(variac¸ãode65a82),foramseguidospornomínimo26meses(variac¸ãode26a82),
comseguimentomédiode51,18meses.Paraaavaliac¸ãodafunc¸ãofoiusadooescoreda
UCLA,oSimpleShoulderTesteaescalaanalógicavisualdador.
Resultados: Naanáliseda ultrassonografiaobservou-seamanutenc¸ãodaintegridadedo
manguito rotadorem 75%dos casosno fim doseguimento, bemcomo a melhoriada
pontuac¸ãonoescoreUCLA,quepassoude17,46para32,39;ouseja,89,28%deexcelentese
bonsresultados.AmédiadosíndicesSSTeEAVfoi9,86e1,5respectivamente.
Conclusão: Acirurgiaartroscópicaparareparodalesãodomanguitorotadorempacientes
maioresde65anoslevaaumamelhoriadafunc¸ãoeumalíviodador,commanutenc¸ãoda
integridadedoreparo.Asinformac¸õessobreforc¸amuscularforaminconclusivas.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Todososdireitosreservados.
Introduction
Theincidenceofrotatorcuffinjuriesinthegeneral
popula-tionisbetween5%and33%,whileamongindividualsoverthe
ageof65yearsitisapproximately25%.1Ittendstoincrease
withagingandreaches50%ofindividualsovertheageof80
years.1,2
Atthebeginning ofthe1990s,therewasatrendtoward
more conservative approaches toward rotator cuff lesions
among the elderly. However, great technological advances
havemadeitpossibleforsurgeonstoachievebetterfunctional
resultsinthisagegroup.2,3
Theadvantagesofarthroscopic repairare its low
surgi-calimpact,thepossibilityofmaintainingtheintegrityofthe
deltoidandalesspainfulpostoperativeperiod.4Thefactors
contraindicatingsurgicalrepairamongtheelderlyincludethe
generally larger injuriesin this age group, with worse
tis-suequalityandslowerhealingresponsethaninindividuals
aged50–70years.2Moreover,elderlypeoplehaveatendencyto
presentgreaternumbersofcomorbidities(diabetesmellitus,
rheumatoidarthritisandrenaldiseases),whichmayinterfere
withsurgicalrecovery.2,5
A large variety of studies have analyzed the short-,
medium-andlong-termfunctionalresultsfromrotatorcuff
surgery.6–8Here,weevaluatedthemoreadvancedagegroup
through questionnaires on functional capacity, ultrasound
examinationsandmusclestrengthmeasurements,withthe
aimofanalyzingtheresultsfollowingarthroscopicrepairof
therotatorcuffinpatientsovertheageof65years,inrelation
tofunction,strengthandintegrity.
Material
and
methods
BetweenJune2005andJuly2010,35consecutivelyselected
shoulders inindividuals ofthe specified age, with a
clini-caldiagnosisofrotatorcuffinjurythathadbeenconfirmed
by means of magnetic resonance imaging, were treated
surgically. The surgical procedures were performed under
arthroscopicviewingbythesamesurgeon.
Theinclusioncriteriawerethatthepatientsshouldbeover
theageof65yearsatthetimeofthesurgery;theprocedure
wasperformedunderarthroscopicviewingandtheminimum
postoperativefollow-up periodwas24months.The
follow-ingwereexclusioncriteriainthisstudy:lesionslargerthan
5cmwithretractionasfarastheglenoid,associatedlesions
(SLAP,Bankart,etc.),previoussurgeryonthesameshoulder,
presenceof glenohumeralarthrosis,follow-up of lessthan
24months,refusaltoparticipateinthestudyandfailureto
adheretotheprotocolthathadbeenestablishedorincorrect
followingofthisprotocol.
Amongthe28patientswhowereoperated,8hadinjuries
thatwereconsideredsmall,12hadmedium-sizedinjuriesand
8hadlargeinjuries.
Thepatientswere evaluatedbytwo independent
exam-iners who did not take part in the procedures, using the
UniversityofCaliforniaatLosAngeles(UCLA)scorebeforethe
operationandthen,aftertheoperation,reassessmentusing
theUCLAscorealongwiththeSimpleShoulderTest(SST)and
avisualanalogscale (VAS).9,10 Theintegrityofthetendons
wasinvestigatedbymeansofultrasoundexaminations
per-formedbythesameexaminer,usingaToshibadevicewith
a7.5MHzlineartransducer.3,11Elevationstrengthand
exter-nalrotationwerealsomeasuredbyasingleexaminerusinga
dynamometer(IDOIsometerShoulderMuscleStrengthGauge,
UnitedKingdom).Afterdiscardingthelowestofthethree
mea-surements,theaverageofthehighertwomeasurementswas
used(Figs. 1and 2).Theresultswereanalyzedstatistically
usingLevene’stestforequalityofvarianceandthet-testfor
equalityofmeans.
Thepatientswerepositionedinlateraldecubitusandwere
operatedundergeneralanesthesiaandbrachialplexusblock.
Anterior,lateralandposteriorportalswereusedanda
com-pleteinventoryoftheglenohumeraljointwasroutinelymade.
Followingthis,bursectomywasperformedtoidentifythe
sizeofthelesionandthetendonsinvolved.Inallthecases,
economicaldebridementoftheedgesofthelesionwas
per-formedandthezoneforreinsertionoftherotatorcuffina
juxta-articularpositionwasprepared.Thetendonswere
rein-serted using 5mm titanium anchors in a single row, with
Fig.1–Measurementofelevationstrength:patient standingup,withtheupperlimbabductedandinternally rotated.
betweenthem.Acromioplastywasperformedwhenthe
sub-acromialspacewasfoundtobegreatlyreducedbyacurved
or hooked acromion, or in situations of fibrillation of the
coracoacromialligament. Thelong head ofthe bicepswas
tenotomized inthree patients(10, 23 and 24), and no
ten-odesiswasperformed. Duringthepostoperativeperiod,the
repairwasprotectedthroughuseofaVelpeauslingforsix
weeks.Self-administeredpassive exercisesfortheshoulder
Fig.2–Measurementofexternalrotationstrength:patient standingup,withtheelbowagainstthebody.
were started fourweeksafterthesurgeryand,afteruseof
theslinghadbeenwithdrawn,thepatientswerereferredfor
physiotherapeuticrehabilitation.Exercisesagainstresistance
werestartedonlyafterthethirdmonth.Amongthe28patients
evaluated,6(21.42%)weremaleand22(78.58%)werefemale;
theiragesrangedfrom65to82years,withameanof70.54.
Thedominantsidewasaffectedin18patients(64.28%).
Results
ThepreoperativemeanUCLAscoreresultwas17.46andthe
postoperativemeanwas32.39,i.e.89.28%oftheresultswere
excellentorgood.ThemeanresultfromtheSimpleShoulder
Testwas9.86;theworstresult(scoreof4)wasfromtheoldest
patientinthestudy(82yearsofage),whopresentedrenewed
tearingofthesupraspinatus,measuring2cmonpostoperative
ultrasoundperformed27monthsafterthetreatment,andan
UCLAscoreof13(Table1).
Thispatientalsopresentedthelowestelevationstrength:
theweightliftedwas1.08kg.Themeanelevationstrengthwas
4.64,fromevaluatingtheleftoperatedside.
Theworstresultontheanalogpainscalewas8,relatingto
patient19.However,onevaluatingthispatient’sultrasound,
itwasobservedthattherotatorcuffwasintactand,fromthe
physicalexamination,itwasperceivedthatthiscaseinvolved
cervicalpainthathadirradiatedtotheshoulder.
Patient 14 also presented only a fair result (UCLA 26).
Althoughthispatient’sstrengthwaspreservedandtherewas
norecurrenceofthelesion,paincontinuedtobepresent,with
functionalimpairment(Table2).
From evaluating the postoperative ultrasound, renewed
tearingwasdetectedin7(25.9%)ofthepatientswhoreturned
forcontrolexaminations.Insixcases,thelesionwaslessthan
1cminlength.Onlyinthemostelderlypatientwasthelesion
2cm. Allofthe other patientshad goodor excellentUCLA
scores.
Thestatisticalanalysesapplieddidnotshowsignificance,
probablybecauseofthesmallsamplesize.
Discussion
Intreatingsymptomaticlesionsoftherotatorcuffthathave
notrespondedtoconservativetreatmentbasedonanalgesics,
gainsinrangeofmotionandmusclestrengthening,surgical
treatmentdeservestobetakenintoconsideration.2,7,11,12
A decision to implement surgery needs to be made by
evaluating thepatient’s functional incapacityinday-to-day
activities,togetherwithimportantinformationfrommagnetic
resonance imaging, which makesit possible toassess the
degreeofretractionofatendonandtheexistenceofanyfatty
degenerationinthemusclebelly.13–15
Many patientsovertheage of65years areknowntobe
stillperformingactivitieswithhighfunctionaldemandsand
would benefit from repair toallow them tocontinue their
activities,eventhoughthesedemandsarelowerthanthose
ofyoungpatients.
Manypeoplemayconsiderthatthechangesthatoccurin
Table1–Descriptionofpatients’sex,ageandlengthoffollow-upandcomparisonbetweenpre-andpostoperativeUCLA scores.
Patients Sex Ageatthetimeofsurgery Lengthoffollow-up(months) PreoperativeUCLAscore PostoperativeUCLAscore
1 F 72 35 34 35
2 F 65 47 22 35
3 F 82 27 13 13
4 F 71 48 18 32
5 F 72 63 17 35
6 F 68 64 12 26
7 F 65 66 19 30
8 F 76 30 14 34
9 F 66 50 22 35
10 M 77 31 23 35
11 F 71 68 11 35
12 M 71 53 12 35
13 F 69 57 26 35
14 F 71 55 17 26
15 F 67 62 11 28
16 M 71 60 18 35
17 F 65 64 10 30
18 F 73 46 19 35
19 F 67 82 16 29
20 F 65 44 16 35
21 F 65 44 16 35
22 M 67 26 23 34
23 M 78 34 15 35
24 M 73 63 11 34
25 F 74 68 17 32
26 F 72 38 19 35
27 F 74 38 19 35
28 F 68 50 25 34
Means 6M,22F 70.54 51.18 17.46 32.39
forhealingandthatwhenrepairsaremade,therehabilitation requiresgreatereffort.5,16
Inthelightofthesedifficultiesencounteredinthetendons
ofthe rotatorcuffofthisgroupofpatientsoverthe ageof
65years,someauthorshaveperformeddecompressionand
simpledebridementofcompletetearsoftherotatorcuffthat
didnotrespondtoconservativetreatment.16–20 Since
recon-structionoftherotatorcuffisincreasingshowingresultsthat
arebetterthanthosefromsimpledebridement,performing
debridementalonecannolongerbejustified.2,4,6,7,21,22Inthe
studiesbyGartsman19 andGrondelet al.,23 thesame
con-clusionwasreached:painreliefandfunctionalimprovement
wereonlytemporaryifsimpledebridementwasperformed.
Inourstudy,wefoundthatthepostoperativeUCLAscore
washigherin27outofthe28patientsre-evaluated.The
mea-surementsofelevationstrength and external rotationthat
weremadeusingthedynamometerproducedresultsthatdid
notallowustocometoaconclusion,withregardto
compar-ingtheoperatedandnon-operatedsides,becausetherewas
somedisparityinthevalues.
Patientswhopresentedrenewedtearingsometimeshad
greaterstrengththanonthenon-operatedside.Sincewedid
notevaluatetheintegrityofthetendononthenon-operated
side,theseresultsmightbeexplainedbythepossible
exist-enceoflesionsintheseunevaluatedshoulders.
Postoperativecomplicationsfromarthroscopicrepairson
rotatorcufflesions,suchasstiffness,infection,sympathetic
reflexdystrophy,deepveinthrombosisanddeath,donothave
highprevalenceintheliterature,24andourstudycorroborates
thisinformation.Therewasnoanchorfailure,but renewed
tearing of the rotator cuff with lesions of up to 3cm was
observedinsevenofthe27patientswhowerere-evaluated
bymeansofultrasoundexaminations.Inthesepatients,the
postoperativeUCLAandSSTgavegoodresults.
Theoptionsforperformingsurgeryonthetendonsofthe
rotatorcuffincludeopenrepair,mini-openrepairandpurely
arthroscopicrepair.Thedecisiononwhichtypeofrepairto
performwilldependonthesurgeon’sfamiliaritywiththese
typesandhispreferences.Theadventofthetotally
arthro-scopic repair technique has enabled surgery with smaller
incisions (access throughportals), lower aggression toward
softtissues,maintenanceoftheintegrityofthedeltoid
mus-cleanditsacromialinsertion,reductionofpostoperativepain
andmorbidityandthepossibilityofcorrectingintra-articular
pathologicalconditions.4,6,20,25,26
Onelimitationofourstudywasthelackofacontrolgroup.
Weconsideredthattheminimumlengthoffollow-upof24
monthswasadequate,giventhatpreviousstudiesfoundthat
the maximum time taken for healing to be achieved was
sixtonine monthsafterthesurgery27 andthat aftera
12-monthperiod, no furtherchangesrelating tohealingwere
observed.28,29
During the operation, the rotator cuff was completely
reconstructed and debridement was not performed in any
of the cases.The resultsfrom this study suggest that if a
lesioncanbecompletelyrepairedatthetimeofthesurgery,
functional improvementscan beexpected in the patients,
Table2–VAS,SSTandelevationandrotationstrengthresultsaccordingtothesideoperated.
Patients VAS SST Side
oper-ated/dominant side
Right-side elevation strength
Left-side elevation strength
Right-side rotation strength
Left-side rotation strength
1 0 12 R/R 4.6 5.7 5.23 5.44
2 0 11 L/R 2.35 6 3 5.1
3 6 4 L/R 3.52 1.08 4.16 2.95
4 1 11 R/R 2.51 1.65 3.11 1.99
5 0 11 R/R 4.02 4.03 5.37 5.21
6 5 4 R/R 1.01 1.66 2.93 3.8
7 5 8 L/R 1.92 2.31 3.45 3.79
8 2 9 L/R 3.48 2.23 3.69 3.03
9 0 12 L/R 6.97 6.24 5.66 7.24
10 0 12 R/R 3.12 3.14 3.68 4.02
11 0 12 R/R 2.71 3.01 3.02 3.95
12 0 12 R/R 5.02 5.31 5.67 5.45
13 0 7 R/R 3.5 3.54 4.3 4.18
14 5 6 L/L 3.52 4.02 5.64 4.87
15 6 8 R/R 5.54 5.47 4.48 4.67
16 0 12 R/R 4.29 3.87 4.81 4.05
17 2 9 L/R 3.95 3.02 4.69 4.21
18 0 11 L/R 4.02 4.03 5.37 5.21
19 8 6 R/R 2.67 2.82 3.59 5.05
20 0 12 L/R 5.82 4.46 4.39 4.68
21 0 12 R/R 5.82 4.46 4.39 4.68
22 0 10 L/R 6.08 3.07 6.32 1.97
23 0 11 R/R 4.37 3.8 6.2 5.6
24 1 12 R/R 4.11 3.83 6.02 5.71
25 1 10 R/L 5.02 5.31 6.87 6.89
26 0 12 R/R 4.64 4.78 5.24 5.06
27 0 11 R/R 3.56 4.01 4.98 5.2
28 0 9 R/R 4.57 4.12 6.25 5.89
Means 1.50 9.86 4.06 3.82 4.73 4.64
We performed ultrasound examinations on 27 out of the28 patientsand consideredthat thiswas animportant additional factor in this study, which made it possible to examine the integrityof the rotator cuff. It isknown that renewedtearingoftherotatorcuffaftertheoperationdoes not necessarily lead to a poor result,2,3,30,31 and we also
observedthis.Choosingsurgerygivespatientsthepossibility
ofimprovingtheirpainfulsymptomsandachievingfunctional
improvement, and the data obtained suggest that surgical
indicationsarevalid,despitefrequentoccurrencesofrenewed
tearing.
Conclusion
Therepairsonrotator cufflesionsamongpatientsoverthe
ageof65yearsperformedbymeansofarthroscopyproduced
majorclinical improvements,basedonpainrelief, function
andintegrityoftherepair.Theinformationregardingstrength
wasinconclusive.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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