Rev. bras. ortop. vol.50 número4

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

Original

Article

Evaluation

of

the

results

from

non-arthroplastic

treatment

(arthroscopy)

for

shoulder

arthrosis

夽

Alberto

Naoki

Miyazaki,

Marcelo

Fregoneze,

Luciana

Andrade

da

Silva

_,

Guilherme

do

Val

Sella,

José

Eduardo

Rosseto

Garotti,

Sergio

Luiz

Checchia

DepartmentofOrthopedicsandTraumatology,FaculdadedeCiênciasMédicas,SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received31March2014 Accepted19June2014 Availableonline6July2015

Keywords:

Shoulder Arthroscopy Osteoarthritis

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Objectives: Toevaluatethefunctionalresultsfrompatientswitharthrosiswhounderwentan arthroscopicprocedure,inanattempttocorrelatetheseresultswiththepatients’ epidemi-ologicalprofile,surgicaltechniqueused,possiblecomplicationsandpostoperativeprotocol.

Methods:Between1998and2011,31patients(32shoulders)withshoulderarthrosis under-wentarthroscopictreatmentperformedbytheShoulderandElbowGroupoftheDepartment ofOrthopedicsandTraumatologyofSantaCasadeSãoPaulo.Primaryorsecondarycases ofshoulderarthrosisundertheageof70years,inwhichtherotatorcuffwasintact,were included.Furthermore,casesinwhich,despiteanindicationforanarthroplasticprocedure, anattempttoperformanalternativeprocedurehadbeenchosen,werealsoincluded.The followingwereevaluated:sex,age,dominance,comorbidities,lengthoftimewith com-plaint,associatedlesions,etiology,previoustreatment,operationperformed,postoperative protocolandpreandpostoperativeactiverangesofmotion.Thefunctionalevaluationwas conductedusingtheUCLAcriteria,beforeandaftertheoperation.Thejointcartilage alter-ationswereclassifiedinaccordancewithOuterbridgeandthearthrosisbymeansofWalch.

Results:Therewerestatisticallysignificantmeandifferencesinthevaluesforelevation, lateralrotationandmedialrotationfrombeforetoaftertheoperation(p<0.001)andthere wasatendency(p=0.057)towardpoorresultswithgreaterlengthoftimewithcomplaints beforethesurgery.ThetotalgaininUCLAscoredidnothaveanystatisticallysignificant relationshipwithanyoftheothervariablesanalyzed.

Conclusion: Arthroscopictreatmentofglenohumeralarthrosisprovidedfunctional improve-mentoftheglenohumeraljoint,withsignificantgainsinelevationandlateralandmedial rotation,andimprovementsinfunctionandpain.Greaterlengthoftimewithcomplaints wasafactorstronglysuggestiveofworseresults.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

WorkdevelopedintheShoulderandElbowGroup,DepartmentofOrthopedicsandTraumatology,FaculdadedeCiênciasMédicasda SantaCasadeSãoPaulo,FernandinhoSimonsenWing(DOT–FCMSCSP),SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](L.A.daSilva).

http://dx.doi.org/10.1016/j.rboe.2015.06.008

390

Avaliac¸ão

dos

resultados

do

tratamento

não

artroplástico

(artroscópico)

da

artrose

do

ombro

Palavras-chave:

Ombro Artroscopia Osteoartrite

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Objetivos:Avaliarosresultadosfuncionaisobtidosdospacientescomartrosesubmetidosao procedimentoartroscópicoetentarcorrelacioná-loscomoperfilepidemiológicododoente, atécnicacirúrgicausada,aseventuaiscomplicac¸õeseoprotocolopós-operatório.

Métodos: Entre1998e2011,31pacientes(32ombros)comartrosedoombroforam sub-metidosaotratamentoartroscópicopeloGrupodeOmbroeCotovelodoDepartamentode OrtopediaeTraumatologiadaSantaCasadeSãoPaulo.Foramincluídososcasosdeartrose deombroprimáriaousecundária,abaixodos70anos,commanguitorotadoríntegro,e aindaaquelesque,apesardeindicadooprocedimentoartroplástico,decidiramtentaruma opc¸ão.Foramavaliados:sexo,idade,dominância,comorbidades,tempodequeixa,lesões associadas,etiologia,tratamentoprévio,operac¸ãofeita,protocolopós-operatórioearcode movimentoativo,préepós-operatório.Aavaliac¸ãofuncionalfoifeitapeloscritériosda UCLApréepós-operatoriamente.Asalterac¸õesdacartilagemarticularforamclassificadas porOuterbridgeeaartroseporWalch.

Resultados: Houvediferenc¸amédia estatisticamente significativaentre os valores para elevac¸ão,rotac¸ãolateralemedialpréepós-operatória(p<0,001)eumatendência(p=0,057) demausresultadoscomomaiortempodequeixapré-cirúrgica.OganhototaldaUCLAnão temrelac¸ãoestatisticamentesignificativacomtodasasoutrasvariáveisanalisadas.

Conclusão: Otratamentoartroscópicodaartroseglenoumeralpropiciamelhoriafuncional daarticulac¸ãoglenoumeral,comganhossignificativosdeelevac¸ão,rotac¸ãolateralemedial emelhoriadafunc¸ãoedador,eomaiortempodequeixaéfatorfortementesugestivopara pioresresultados.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Shoulderarthrosisaffectsaround20%ofthepopulation,with greatestfrequencyinthesixthandseventhdecadesoflife, anditmayoccasionallyaffectyoungerpatients.Thisdisease mayfollowacoursewithpainfulconditionsthatare gener-allyaccompaniedbydiminishedrangeofmotion,especially regardinglateralrotation.Lossofthisrotationisassociated withcontractureoftheanteriorjointcapsuleandofthe ten-donofthesubscapularis,whichcausesaforcedirectedfrom anteriortoposteriorandleadstoprogressiveeccentricjoint incongruence1_(Fig.1A–C_).

Inadvancedcasesofarthrosis,orinsituationsoffailureof conservativetreatment,surgeryisindicated.Thisconsistsof arthroplastytomakeapartialortotalreplacementandis con-sideredtobethetreatmentofchoiceforelderlypatients(over theageof65years)and/orindividualswithstatesofdisease thataremoreadvanced.2_{Amongpatientswhoareyounger} andmoreactive,withhighfunctionaldemandsonthe shoul-derjoint,this optionhasnotbeenfoundtobesatisfactory, becauseofthewearonthecomponentsoftheprosthesisand becauseofthe needforsurgicalrevision.2 _Amongyounger patients, the literature cites various complications of this procedure,suchasloosening ofthe implant,dislocationof theprosthesis,periprostheticfracturesandpersistentpain.3–5 Levyetal.6 _{observedearlyappearanceofradiolucentareas} onradiographicexaminationsperformedonyoungpatients

whohadbeentreatedusingtotalshoulderprostheses. Sper-lingetal.7_{reportedthat65%oftheprosthesesimplantedin} patientsundertheageof50yearsproducedpoorresultsafter 15 years offollow-up, andnoted highincidence oferosion oftheglenoid inhemiarthroplasty.Thus, atthesame time thatrecentstudieshaveaffirmedthatthelong-termresults fromtreatingshoulderarthrosisbymeansofarthroplastyare encouragingamongpatientsofmoreadvancedage,treatment ofyoungerpatientsisstillconsideredbymanyauthorstobe achallenge.5,8,9

Fig.1–Drawingoftheleftshoulderfromaxialslice,showing:(A)themuscleforcesthatactontheglenohumeraljoint (arrows)andtheanteriorcapsule(inred)andwhichlead(B)tosubsequentsubluxation.Axialslicefromcomputed tomography(C)ontheleftshoulder,showingformationofosteophytes(arrow)andsubsequentsubluxation.

concludedthattheindicationsforeachprocedurestillpresent gaps.Godinhoetal.8 _{statedthatfewscientificarticleshave} shownlong-termresults,eventhoughclinicalexperience cor-roboratingthehypothesisthatthisproceduremightprolong jointsurvivalalreadyexists.

Theaims ofthis study were to evaluate the functional resultsobtainedfrompatientswitharthrosiswhounderwent anarthroscopicprocedureandtoattempttocorrelatethese resultswiththe patients’epidemiological profile,degreeof jointinvolvement,proceduresperformedandpostoperative protocol.

Sample

and

methods

Between January1998 and December 2011, 31 patients (32 shoulders)withadiagnosisofshoulderosteoarthrosis under-wentarthroscopictreatmentperformedbytheShoulderand ElbowGroupoftheDepartmentofOrthopedicsand Trauma-tologyofSantaCasadeSãoPaulo.

Theinclusioncriteriaweretakentobethatthepatients shouldpresentshoulderarthrosisofprimaryorsecondary eti-ology,beundertheageof70years,haveanintactrotatorcuff andhavebeenfolloweduppostoperativelyforaminimumof 12months.Furthermore,casesinwhich,despitean indica-tionforanarthroplasticprocedure,anattempttoperforman alternativeprocedurehadbeenchosen,werealsoincluded. Patientswithsecondary diagnoses thatmade it difficultto evaluatethetherapeuticmethodinquestion,especiallycases inwhichcomplete tearingoftherotator cuffhad occurred, wereexcluded.

Thepatientsevaluatedcomprised17malesand14females, ofmeanage54years(range:24–67years),amongwhom11 wereovertheageof60years.Itwasobservedthatthe domi-nantshoulderwasaffectedin15cases.

Themeanlengthoftimewithaclinicalcomplaintrelating totheshoulderwasfiveyears(range:twomonthsto15years). Themostprevalentetiologywasidiopathicarthrosis,which wasfoundin25cases,followedbypost-traumaticarthrosisin sixcasesandrheumatoidarthritisinonecase.The preopera-tiveimagingfindingswerebasedonradiographsandmagnetic resonanceimaging(whendone),whichpointedtoward gleno-humeralarthrosis.Itwasonlypossibletoclassifythedegree ofarthrosisin14shouldersand,whenthiswasdone,weused theclassificationofWalchetal.16_{Wehadthreecasesoftype} A1, sixA2, threeB1, threeB2 and onlyone casethat was consideredtobetypeC.Thedegreeofjointimpairmentwas evaluatedduringthearthroscopicsurgicalprocedureandwas classifiedinaccordancewithOuterbridge.17_{Allthepatients} wereconsideredtopresentgradeIV_{,i.e.presentingalesion} extendingacrosstheentirethicknessofthecartilage,thereby presentingsubchondralboneexposure.

Therangeofmotion(ROM)wasmeasuredinaccordance withthe manualofthe AmericanAcademyofOrthopaedic Surgeons, asdescribed byHawkins andBokor.18 _Themean arcsofelevationandlateralandmedialrotationbeforeand aftertheoperationcanbeobservedinTable1.Thefunctional evaluationwasmadeusingtheUCLAcriteria(Universityof

Table1–Meanchangeintherangeofmotion(flexion andexternalrotation)frombeforetoaftertheoperation.

Movement Before

operation

After operation

p-Value

Elevation(degrees) 116 140 <0.001

Externalrotation(degrees) 23 50 <0.001

Internalrotation(vertebral level)

L4 T11 <0.001

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California,LosAngeles,ShoulderRatingScale),asproposed byEllmanet al.,19 _{bothbeforeandaftertheoperation.The} lengthoffollow-upamongthepatientsrangedfrom1to13 years,withameanoffiveyearsandninemonths.

The patients underwent arthroscopic surgery in lateral decubitusin ordertoenableadequate accesstothe poste-riorandposteroinferiorportionsofthecapsule.Thefollowing stageswereperformedinasequentialmanner:debridement, removaloffreebodies,openingoftherotatorinterval,release ofthecoracohumeralligament,anteriorcapsulotomy,change ofportal, posteriorcapsulotomy,inferior capsulotomyand, finally,anteroinferior capsulotomy withthe aid of surgical baskettweezers,inordertoavoidinjuringtheaxillarynerve. SomeofthesestepscanbeseeninFig.2A–D.Inthreepatients, these procedures were considered sufficient. In the other patients, other procedures were added, on a case-by-case basis,andthesearedescribedandquantifiedinTable2.

After the surgical procedure, the patients underwent a rehabilitationprotocol,whichconsistedofphysiotherapywith earlymobility.However,twogroupsweredelineated:thefirst group,composedof20patients,hadaninterscalenecatheter forcontinuous administrationofanalgesia in the hospital, whichwasusedforfourtofivedays;andthesecondgroup, composedof11patients,didnothaveacatheterbecauseit wasimpossibletousecathetersintheoldercases.

Asignificancelevelof0.05(5%)wasdefinedforthisstudy. WeusedthepairedStudent’sttestforstatisticalanalysison thequantitativeROMandUCLAvalues,19_{bothbeforeandafter} theoperation.TheANOVAtestwasusedtocomparethetotal gaininUCLAscore19_{inrelationtoagegroups,dominance,} bilateralityandpostoperativeprotocol.Thedatawere tabu-latedandevaluatedusingtheSPSSV17,Minitab16andExcel Office2010software.

Results

Inrelation torange ofmotion,there were statistically sig-nificantmean differences(p<0.001)betweenthe valuesfor elevation(increaseof24◦_{),lateralrotation(increaseof27}◦_)and

medialrotation(increaseoffivevertebrallevels),frombefore toaftertheoperation,ascanbeseeninTable1.

Regardingthetypeofarthrosis,thepatientswereclassified asdescribedbyWalchetal.16_{TypeA1achievedanexcellent} result(meanof34 points;range:32–35).TypeA2(Mean:28; range:12–35),typeB1(mean:33;range:31–35)andtypeC(31)

Table2–Descriptionofadditionalproceduresand numberoftimesthattheywereperformed.

Procedure Numberofcases

Tenotomyofthelongheadofthebiceps 10

Microfracturesintheglenoid 2

Resectionofosteophytes 4

Acromioplasty 8

Mumfordprocedure 10

Total 32

Source:Files(SAME)oftheDepartmentofOrthopedicsand Trauma-tologyofSantaCasadeSãoPaulo.

Table3–ChangeinUCLAparametersfrombeforeto aftertheoperation.

Parameter(UCLA) Before

operationa

After operationa

p-Value

Function 4.83 8.21 <0.001

Activeflexion 3.10 4.17 <0.001

Muscleflexionstrength 4.90 4.83 0.326

Satisfaction 0.00 3.59 <0.001

Pain 3.21 7.21 <0.001

Total 16.2 28.0 <0.001

Source:Hospitalfiles(SAME).

a _Meanscore.

wereallconsideredtohaveachievedgoodresults.However, thetypeB2patientscored12points,whichwasapoorresult accordingtotheUCLAcriteria.19

TakingintoconsiderationtheUCLAscore,19 _the parame-tersofactiveflexion,satisfaction,painandfunctionpresented statisticallysignificant increases(p<0.001). Onlyinrelation tomusclestrengthwastherenodifference(p=0.326).These findingsarepresentedinTable3.

Fromqualitativecomparisons,i.e.bymeansofthe percent-agerelativefrequencydistribution,itwasnotedthataccording to thetotal UCLAparameter19 _{(sum ofthe scoresfor each} item), therewas adecrease inthe number ofcases classi-fiedaspoor(0–20points)andanincreaseinthenumbersof goodcases(28–33points)andexcellentcases(34–35points) withstatisticalsignificance(p<0.001).Thesedataare demon-stratedinTable4.

The total gain in UCLA19 _{did not have any statistically} significant relationship (p<0.001) with age, length of time with the complaint, dominance, duration of postoperative follow-uporpostoperativeprotocol.Longertimewitha com-plaintwasafactorstronglysuggestiveofworseresults,with

p=0.057.

Discussion

Glenohumeral arthrosis is a chronic degenerative disease that resultsin significant functional deficits.8 _Replacement witheitheratotal orpartialprostheticprovides significant relieffrompainfulconditionsandfunctionalimprovement.7,8 However, when this therapy is applied to patients under theageof50years,theresultspresentedareunsatisfactory, whichsuggeststhatotherapproachesshouldbeused.7_The

Table4–ChangeinfrequencyofUCLAclassification scoresfrombeforetoaftertheoperation.

UCLAclassification Before

operation(%)

After operation(%)

p-Value

Poor 89.7% 17.2% <0.001

Fair 10.3% 20.7% 0.277

Good 0 37.9% <0.001

Excellent 0 24.2% <0.001

Total 100% 100%

Fig.2–Intraoperativeviewofleftshoulder,withcamerapositionedinthelateralportaloftheleftshoulder,showing:(A) arthrosiswithlossofallofthecartilagefromthehumeralhead;(B)anteriorcapsulotomyinprogressusingbaskettweezers; (C)viewofinferiorcapsulotomy;(D)viewofposteroinferiorcapsulotomy.

literature shows that there have been encouraging results from arthroscopic treatment of glenohumeral osteoarthrosis.8,10–15

InrelationtoROMandUCLAscores,19_{wefoundthatthere} wasasignificantdifferenceintherangeofmotionandUCLA score19_{frombeforetoaftertheoperation(p<0.001).Thiswas} alsofoundbyRichardsandBurkhart13_{andVanThieletal.,}20 whoshowedthattherewasasignificantincreasein mobil-ityintheirpatientsaftertheoperation.Thedetailed UCLA evaluation19 _{showed significant differences in the fields of} pain,function,activeflexionandsatisfaction(p<0.001). God-inhoetal.8_{alsoevaluatedtheUCLAparameters}19_separately andfoundsimilarresults.

Nostatistical differences were notedin relationto age, dominance,postoperativeprotocolused(withorwithoutuse ofacatheterforadministeringanalgesia)orlengthof postop-erativefollow-up.Attentionneedstobedrawntothefinding thatthestatisticalanalysisindicatedthesuggestion(p=0.057) thatthelongerthetimespentwiththecomplaintwas,the worsetheresultsregardinggainsinUCLAwouldbe19_(from beforetoaftertheoperation).Wewouldneedalargernumber ofpatientstobeabletoconfirmthistendency.

Among the procedures performed during arthroscopic treatment,RichardsandBurkhart13_{highlightedcapsulotomy} and removal of joint debris as factors that predisposed towardgainsinelevationandlateralandmedialrotationand reductionsinpainfulconditions,withintreatmentsfor gleno-humeralosteoarthrosis,whichwasalsofoundinthepresent study, with statistical significance (p<0.001) in relation to improvementofboththerangeofmotionandpatients’ satis-factionwiththeprocedure,althoughitwasnotnotedwhich procedurewouldbemoreinfluentialforthefinalresult.

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thosewithsevereconditions,i.e.independentlyofthedegree ofarthrosis.

Intheliterature,severalauthorshavebelievedthatcertain factorssuchaspresenceofjointspaceonpreoperative radio-graphs,smalllossofmovement(inwhichtherewouldstillbe atleast20◦_{oflateralrotation)andtheabsenceoflarge}

osteo-phytesand/orconcentricjoint oratmostmildsubluxation (whichcouldbecorrectedbymeansofjointreleasewithor withoutglenoplasty),wouldleadtobetterresults.20,22,23

Whatwecanstateisthatafterameanlengthof follow-upofapproximatelysixyears,onlyfivepatients(15.6%)had undergonearthroplasty. Thisfindingisconsonantwiththe data in the literature. From following up 71 patients who underwentarthroscopictreatmentforglenohumeral arthro-sis,VanThieletal.20_{foundthat22%oftheircaseswithamean} follow-upof10monthshadundergonearthroplasty.

Inrelationtotheother28patients,thesecontinuenotto haveany clinical needfornewsurgery, i.e.replacementof the prosthesis. Nine patients havebeen followed up since the operationformorethan eightyears,and this corrobo-ratesthepropositionthatarthroscopictreatmentincasesof glenohumeralarthrosisextendsthesurvivalofthejoint.8

Conclusion

Arthroscopic treatment ofglenohumeralarthrosis provides functionalimprovementoftheglenohumeraljoint,with sig-nificantgains(p<0.001)inelevationandinlateralandmedial rotation,andimprovementsinfunctionandpain.Longertime spentwithacomplaintwasa factorstronglysuggestive of worseresults(p=0.057).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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