Rev. bras. ortop. vol.50 número2

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

Original

article

Long-term

functional

evaluation

of

videoarthroscopic

treatment

of

partial

injuries

of

the

rotator

cuff

夽

Glaydson

Gomes

Godinho

,

Flávio

de

Oliveira

Franc¸a

,

José

Márcio

Alves

Freitas

,

Flávio

Márcio

Lago

e

Santos

,

Danilo

Santos

Resende

,

João

Pedro

Zambrano

Wageck

,

Sara

Fortes

Barbosa

Portela

a_{HospitalOrtopédico,BeloHorizonte,MG,Brazil}

b_{HospitalBeloHorizonte,BeloHorizonte,MG,Brazil}

c_{HospitalLifecenter,BeloHorizonte,MG,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received12July2013 Accepted7March2014 Availableonline11March2015

Keywords:

Shoulder Arthroscopy Rotatorcuff

a

b

s

t

r

a

c

t

Objective:Tocomparethefunctionalresultsfromhighandlow-gradeisolatedpartiallesions

ofthesupraspinatustendonofbursalandarticulartypes,afterarthroscopictreatment.

Methods:Sixty-fourpatientswithisolatedpartiallesionsofthesupraspinatustendonwere

evaluated.Themeanlengthoffollow-upwas76months(range:29–193).Themeanagewas 59years(range:36–82).Thedominantsidewasaffectedin44patients(68.8%).Therewere35 bursallesions(54.7%)and29articularlesions(45.3%).WeusedtheEllmanclassificationand characterizedthelesionsasloworhigh-gradeaccordingtowhethertheyaffectedlessthan ormorethan50%ofthetendonthickness,respectively.Debridementwasperformedin15 patients(23.5%),repairwithoutcompletingthelesionin11(17%)andrepairaftercompleting thelesionin38(59.5%).Thefunctionalassessmentsonthepatientsweredoneusingthe Constant&MurleyandUCLAscores.

Results:ThemeanConstant&Murleyscoreamongthepatientswithbursallesionswas

82.64±6.98(range:59.3–99)andamongthose witharticularlesions,83.57±7.58(range: 66–95),whilethemeanUCLAscoreinthebursallesionswas33.37±2.85(range:21–35) andinthearticularlesions,32.83±2.95(range:22–35).

Conclusion:Videoarthroscopictreatmentofpartiallesionsoftherotatorcuffpresentsgood

orexcellentresultswhenthelow-gradelesionsaredebridedandthehigh-gradelesions arecompletedandrepaired.Theseresultsaremaintainedoverthelongterm,withahigh satisfactionrateandfewcomplications.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

WorkdevelopedattheShoulderSurgeryServicesoftheHospitalOrtopédicoandHospitalBeloHorizonte,BeloHorizonte,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](G.G.Godinho). http://dx.doi.org/10.1016/j.rboe.2015.02.015

Avaliac¸ão

funcional

em

longo

prazo

do

tratamento

videoartroscópico

das

lesões

parciais

do

manguito

rotador

Palavras-chave:

Ombro Artroscopia Manguitorotador

r

e

s

u

m

o

Objetivo: Compararosresultadosfuncionais,apósotratamentoartroscópico,daslesões

parciaisisoladasdotendãosupra-espinaldostiposbursalearticularnosgrausaltoebaixo.

Métodos:Foramavaliados64pacientescomlesõesparciaisisoladasdotendãosupra-espinal.

Seguimentomédiode76meses(29a193).Amédiadeidadefoide59anos(36a82).Olado dominantefoiacometidoem44pacientes(68,8%).Observadas35lesõesbursais(54,7%)e29 articulares(45,3%).Usamosaclassificac¸ãodeEllmanecaracterizamosaslesõescomobaixo ealtograuquandoacometiammenosoumaisde50%desuaespessura,respectivamente. Foifeitodesbridamentoem15pacientes(23,5%),reparosemcompletaralesãoem11(17%) ereparoapóscompletaralesãoem38(59,5%).Aavaliac¸ãoclínicafuncionaldospacientes foifeitacomousodosescoresdeConstant&MurleyeUCLA.

Resultados: A média dos escores de Constant dos pacientes com lesão bursal foi de

82,64±6,98(59,3a99)ecomlesãoarticularfoide83,57±7,58(66a95),enquantoquea médiadoUCLAnaslesõesbursaisfoide33,37±2,85(21a35)enaslesõesarticularesfoide 32,83±2,95(22a35).

Conclusão: Otratamentovideoartroscópicodaslesõesparciaisdomanguitorotador

apre-sentaresultadosbons/excelentesquandoaslesõesdebaixograusãodesbridadaseaslesões dealtograusãocompletadasereparadas.Essesresultadossemantêmemlongoprazo,com altoíndicedesatisfac¸ãoepoucascomplicac¸ões.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Partial lesions of the rotator cuff are a frequent cause of

pain and functional limitation of the shoulder. They can

occur oneither thearticular or thebursalside, or may be intrasubstantial.1 _{Theincidenceofarticularlesionsisthree} timesthatofbursallesions.2 _{Ithasbeenobservedthatthe} footprintofthesupraspinatustendonhasameanthicknessof 12mm.3_{Interfingeringofthefibersoftherotatorcufftendons} occursatthislocation,suchthatthedeepestfiberspresent obliqueorientation,whilethesuperficialfibersareparallelto theaxisofthemuscle.4

Ellman1_{describedaclassificationsystemforpartiallesions}

based on their locations and depths, as measured during

arthroscopy. In this system, articular lesions (A) or bursal lesions(B)aredescribedasgradeI_{iftheirdepthislessthan} 3mm,gradeII_{ifitisbetween3and6mmandgrade}III_ifit ismorethan6mm.GradeI_andII_{lesionscompromiseupto} 50%ofthetendonsurface(lowgrade),whilegradeIIIlesions

compromise morethan 50% ofthe thickness (high grade).

Intrasubstantiallesionsaredescribedas(C).

Some partial lesions of the rotator cuff do not heal,

despiteconservativetreatmentwithphysiotherapyanduseof anti-inflammatorydrugs,andrequiresurgicaltreatment.5–11 Severalmethodsofsurgicaltreatmenthavebeendescribed, includingacromioplastyalone,12,13_{debridementofthelesion} withorwithoutacromioplasty,7,14,15_{transtendonrepair,}16–21 conversiontoacompletelesionfollowedbyrepair11,22,23_and transosseousrepair.24_{Thereisstillnoconsensusregardingthe} besttreatmentforeachtypeoflesion,butithasbeenshown intheliteraturethatdebridement,withorwithoutassociated

acromioplasty,providessatisfactoryresultsincasesof

low-grade lesions, while high-grade lesions respond better to

repair.25

Themainobjectivesofourstudyweretoevaluatethe func-tionalresultsfollowingvideoarthroscopictreatmentofpartial lesionsoftherotatorcuffandcomparethetypesandgrades

of lesions. We believed that when low-grade lesions were

debrided and high-gradelesions were repaired, the results wouldremainsatisfactoryoverthelongterm,withlowfailure andcomplicationrates.

Materials

and

methods

This wasa retrospective study withfunctional evaluations

onpatientswho underwentvideoarthroscopictreatmentof

partiallesionsoftherotatorcuff.BetweenJanuary1995and December2010,704patientswithpartiallesionsofthe rota-torcuffwereoperatedbymeansofvideoarthroscopyatthe Orthopedic,BeloHorizonte andLifecenterhospitals,bythe BHOrthopedicSurgeryGroup.

Thelesionswerediagnosedbymeansofmagnetic

reso-nanceimaging(MRI)orarthro-MRIand thediagnoseswere

confirmed through arthroscopy.The patientsincluded

pre-sented partial lesions (articular or bursal) solely of the

supraspinatus tendon,withaminimumof2yearsof

post-operative follow-up. The patients had failed to respondto

conservative treatment over a periodof atleast 4months

beforeundergoingsurgery.Theexclusioncriteriacomprised previous surgery on the shoulder; sequelaeof fractures in

the region of the shoulder or the scapular belt; presence

Table1–Topographyofthelesions.

N %

Supraspinatus,bursal 35 54.7

Supraspinatus,articular 29 45.3

rheumatoidarthritis; involvementinemploymentlawsuits;

andfailuretolocatethepatientorinsufficientdocumentation. Thefunctionalevaluationwasmadebymeansofthescores ofConstant and Murley26 _{and the University of California} atLosAngeles(UCLA).27 _{ThevalidationofBoehm}28 _forthe Constantscorewasused.Inthis,thequantitativevaluesare expressedqualitatively, asfollows:excellent (91–100), good (81–90),satisfactory(71–80),fair(61–70)orpoor(<60).Usingthe UCLAscore,theresultscouldbeassessedasexcellent(34–35), good(28–33),fair(21–27)orpoor(0–20).

Limbdominance,anyassociationwithprofessionaland/or leisureactivitiesandthe typeand gradeofthelesionwere noted.Thesurgicalparameterstakenintoconsiderationwere: (1)techniqueapplied(debridement,debridement in associ-ation with repairor repair aftercompletion ofthe lesion); (2)presenceofassociatedpathologicalalterationsandtheir

concomitanttreatment;and (3)whetheracromioplastywas

performed.

Sixty-fourpatientswereincluded(64shoulders):31males (48.4%)and33 females(51.6%).Themeanfollow-upwas76

months (range: 29–193). The mean age at the time of the

surgerywas53years(range:26–76)anditwas59yearsatthe timeoftheassessment(range:36–82).Thedominantsidewas affectedin44patients(68.8%)andthe non-dominantin20 (31.2%).

Partialbursallesionswerepresentedby35patients(54.7%) andpartialarticularlesionsby29(45.3%)(Table1).In19cases (29.7%),associatedlesionswerepresent.

The surgical procedures performed were as follows:

debridement in15patients(23.5%); repairwithout comple-tionofthelesionin11(17%);andrepairaftercompletionof thelesionin38(59.5%).Theassociatedprocedureswere as follows:acromioplastyin61cases(95%);totalMunfordinone case(1.5%);partialMunfordintwocases(3%);repairofSLAP lesioninsixcases(9.3%);andrepairofBankartlesioninone case(1.5%)(Table2).

Thedifferencesintheclinicalcharacteristics(profession andsportsactivity)andthefunctionalresults(Constantand UCLA)betweenthegroupsofpatients,accordingtothetype

and grade of the lesion, were analyzed either using the

Mann–Whitneytest orusing the chi-squaretest (according

towhetherthevariablewasquantitativeorqualitative).The

nonparametric Kruskal–Wallis and Pearson testswere also

used.Theresearchdatawereprocessedthroughthe Statisti-calPackagefortheSocialSciences(SPSS),version17.0.Forall

Table2–Associatedprocedures.

Acromioplasty 61(95%)

TotalMunford(resectionofthedistalclavicle) 1(1.5%)

PartialMunford 2(3%)

RepairofSLAPlesion 6(9.3%)

Bankartsurgery 1(1.5%)

thestatisticalmeasurementsmade,thestatisticalsignificance levelwassetat5%.

Surgicaltechnique

Allthepatientswereoperatedbyfoursurgeons(GGG,FOF,JMF andFMLS)belongingtotheShoulderGroupoftheBH Lifecen-terOrthopedicHospital.Thepatientwaspositionedinlateral decubitusafteradministrationofgeneralanesthesiain asso-ciationwithbrachialplexusblock.Arthroscopicviewingwas obtainedthroughastandardposteriorportaland,iftherewas aneedtorepairanyintra-articularlesion,thiswasaddressed withtheaidofananteriorportallocatedintherotatorcuff interval.Thelesionwasdebridedandthedepthwas evalu-atedusingthetipoftheshaver(4.5mmindiameter).When thisbecamefullyimmersedinthelesion,thelesionwas con-sideredtobeofhighgrade.Thearticularlesionsweremarked

usingamonofilamentthreadthatwasinsertedinaneedle

andpassedpercutaneouslythroughthelesion.

Low-grade partial lesions were treated by means of

debridement,whilehigh-gradelesionswere completedand

then repairedusinganchors.Acromioplastywasperformed

whentherewereintraoperativesignssuggestiveof subacro-mialimpact,i.e.lesionsduetosubacromialfriction,viewed beforeusingtheshaverblade.Duringthepostoperativeperiod, thepatientscontinuallyusedapaddedabductionslingfor3

weeksand all underwent the same rehabilitationprotocol,

which consistedofanalgesia,rehabilitationoftherangeof motion(ROM)and,finally,strengthening.Thestrengthening

exercises were implemented after reaching the 60th

post-operative day, providedthat the passive ROMhad become

normal.

Results

The mean Constant score among the patients withbursal

lesions was 82.64±6.98 (range: 59.3–99) and with articular lesions,83.57±7.58(range:66–95),whilethemeanUCLAscore forthebursallesionswas33.37±2.85(range:21–35)andforthe articularlesions,32.83±2.95(range:22–35).Therewasno sta-tisticallysignificantdifferenceintheresultsaccordingtothe typeoflesion(Table3).UsingthevalidationofBoehm,28_we foundthattheresultswereexcellentandgoodin47patients (73.5%),satisfactoryandfairin16(25%)andpoorinone(1.5%).

Using the UCLAcategories,wefoundthatthe resultswere

excellentandgoodin62patients(97%)andfairandpoorin two(3%).

Nosignificantdifferencesinthetypesandgradesoflesions wereobservedinrelationtothevariables ofprofessionand sport.Therewerealsonosignificantdifferencesinageatthe timeofthesurgery,inrelationtothefunctionalresults.The statisticalanalysisshowedthatitwasmorecommonforthe patientswithlow-gradelesionstoundergoadebridement pro-cedure(p<0.05),whileitwasmorecommonforthepatients withhigh-gradelesionstoundergorepairaftercompletionof thelesionindependentofthelocationatwhichthetendon wasaffected(Table4).

Table3–Resultsfromthefunctionalscorescomparedwiththetypeoflesion.

Parameter n Bursal n Articular p-Value

Mean SD Mean SD

Constant 35 82.64 6.98 29 83.57 7.58 0.318

UCLA 35 33.37 2.85 29 32.83 2.95 0.355

Theprobabilitiesofsignificance(pvalues)refertotheMann–Whitneytest.

Table4–Distributionoflesionsandtreatments.

Variable Typeoflesionandgrade p-Value

Low-gradebursal High-gradebursal

n % n %

Surgery 0.000

Debridement 10 83.4% 1 4.5%

Debridement+repair 1 8.3% 3 13.6%

Repairaftercompletionoflesion 1 8.3% 18 81.9%

Total 12 100% 22 100%

Variable Low-gradearticular High-gradearticular p-Value

n % n %

Surgery 0.010

Debridement 4 31% 0 0%

Debridement+repair 2 15.3% 4 23.5%

Repairaftercompletionoflesion 7 53.7% 13 76.5%

Total 13 100% 17 100%

Theprobabilitiesofsignificance(pvalues)refertothechi-squaretest.

again.Amongtheseunsatisfiedpatients,themeanConstant scorewas68.1±9.39(range:59.3–78)andtheUCLAscorewas 24±4.35(21–29).Nosignificantdifferencesinthefunctional resultswere observedinrelationtothe presenceof associ-atedlesionsthatweretreatedconcomitantlywiththetendon repair(Table5).

Amongthepostoperativecomplications,twopatients(3%) witharticularlesionspresentedrenewedtearing(oneofthem wasduetotrauma)andunderwentarthroscopicrepairagain, withsatisfactoryevolution.Anothertwopatients(3%) devel-opedadhesivecapsulitis,alsowithfavorableevolution.

Discussion

Partiallesionsoftherotatorcuffmaycausepainand

func-tional limitation of the shoulder. Most of the symptoms

occuratnightandduringactivitiesinvolvingeffortwithan upperlimbelevated.29_{Theyarepotentiallymorepainfulthan}

complete lesions,possiblybecauseofthenon-physiological tensionthatiscreatedinthefibersoftheremnanttendon.30

Biomedical studies have demonstrated that after a partial

lesion of the rotator cuff occurs, the tension patterns in the fiberssurrounding thelesion becomealteredsuchthat lesion propagation is favored, even to the point of reach-ingacompletelesion.4,31–33_{Yamanakaetal.}34_demonstrated the progressionofpartialarticular lesionsover time. Forty patientswithlesionsofthistypewereevaluatedbymeansof arthrographyoverameanfollow-upperiodof412daysafter theinitialdiagnosishadbeenmade.Thelesionincreasedin sizein53%anditprogressedtoacompletelesionin28%ofthe cases.Thisprogressionprobablyoccurredthroughchangesto thetensionpatternsofthefibersintheremnanttendon,as observedinbiomechanicalstudies.31–33,35

Theinitialconservativetreatmentconsistsofrest,changes toactivities, useofanti-inflammatorydrugs,intra-articular infiltrationofcorticoidsandphysiotherapy.Whenthis treat-mentmethodfails,surgicalinterventionisindicated.29_Inthe

Table5–Profileofthepatientsevaluatedandcategorizedaccordingtothepresenceofassociatedlesions.

Parameters n Withoutassociatedlesion n Withassociatedlesion p-Value

Mean SD Mean SD

Constant 46 83.42 7.29 18 82.13 7.15 0.289

UCLA 46 32.08 3.12 18 33.22 2.24 0.982

literature,manysurgical approaches forthistypeoflesion havebeendescribed,withvaryingfunctional results.12–24,29 Thetendencyhasbeentodebridethelow-gradelesionsand repairthehigh-gradelesions.However,thedatareportedso farhavebeenlimitedtomakingindicationsforaspecifictype oftreatmentforeachtypeandgradeoflesion.25

Ourstudywasbasedon64patientswhopresentedpartial lesions(bursalorarticular)ofthesupraspinatustendonalone andwhohadbeenoperatedbymeansofvideoarthroscopy.In ourseries,unlikewhatwefoundintheliterature,wehadmore patientswithpartialbursallesions(54.7%)thanwithpartial articularlesions(45.3%).2,29

Intheliterature,wefoundfour prospectivestudiesthat comparedthefunctionalresultsbetweentreatmentsof par-tialarticularandpartialbursallesions.12,15,23,36_Intwoofthese studies,12,15 _{therewas nostatisticallysignificant difference}

between the groups. Another study36 _{demonstrated better}

resultsfrombursallesions,whilethelastofthesestudies23 founda highfailure rate amongthe bursallesions.Kartus etal.15_{foundameanpostoperativeConstantscoreof61.5in} thegroupwithbursallesionsafterdebridementand acromio-plasty, whilethe score was 72 inthe group witharticular lesionsthatunderwentthesametreatment,butwithoutany statisticaldifference.Parketal.36_{observedthatafter} debride-mentandacromioplasty,therewasanotablereductioninpain 6monthsaftertheoperation,inpatientswithbursallesions incomparisonwiththegroupwitharticularlesions.However,

this difference between the typesoflesion was not found

innewevaluationsthatweremadeafteroneand2yearsof follow-up.Itwasobservedinourstudythattherewasno dif-ferenceinthefunctional resultsbetweenthe patientswith regardtothelocationofthelesion(articularorbursal).

Cordascoetal.12_{observedahigherfailurerateinthegroup}

withbursallesionstreatedwithdebridementand

acromio-plasty.Failure occurred in 29% ofthe patients with bursal lesions(4outof14shoulders)andin3%ofthepatientswith articular lesions (2 out of63 shoulders). IN another study, Kamathetal.23_{comparedtheresultsfrom42shouldersthat} underwentrepairaftercompletionofthelesion(33with artic-ularlesionsandnine withbursallesions).Renewedtearing occurredin22.2%ofthepatientswithbursallesions, com-paredwith9.1%ofthepatientswitharticularlesions.

Inourstudy,weobservedrenewedtearingintwopatients witharticularlesions(3%)butnotinanyofthepatientswith bursallesions.

In1991,Snyderetal.7 _{evaluated31patientswithpartial}

articularlesionswho underwentarthroscopic debridement,

withor without associatedacromioplasty. They found sat-isfactory results (mean UCLA score of 32 points), without anydifferencesintheresultsbetweenperforming subacro-mialdecompressionandnotdoingthis.Budoffetal.14_found that86%oftheresultsweregoodorexcellent,accordingto

theUCLAscore,among62shouldersthatweretreatedwith

debridement of partial lesions of the rotator cuff, with or withoutacromioplasty.Kartusetal.15_{obtainedamean} Con-stantscoreof65pointsfromevaluating26patientswhowere treatedbymeansofdebridementinassociationwith acromio-plasty.Theseauthorsattributedtheunsatisfactoryresultsto degenerationoftherotatorcuffovertheyearsandconcluded

thatacromioplasty hadnot protectedthe tendonfrom the

degenerativeprocess.Inourstudy,10outofthe11patients

whopresentedbursallesionsandunderwentdebridementin

association withacromioplastypresentedamean Constant

score of 84.06 (range: 78–89.4) and a mean UCLA score of

34.7(range:33–35),whichwereconsideredtobegoodresults. Theeffectontheresultsfromperformingornotperforming acromioplastycouldnotbecomparedstatistically,giventhat thisprocedurewasperformedinthecasesof95%ofallofthe patientsevaluated.

Weperformedrepairsaftercompletionofthelesionsin19 patientswithpartialbursallesions(29.6%)andin20patients withpartialarticularlesions(31.2%).Themeanscores

result-ing from these treatments were 81.78 (range: 59.3–99) and

32.97(range:21–35),respectively.In2007,Deutsch11_evaluated

41 patientswithhigh-gradepartiallesions who underwent

repair afterthe lesionshad been completed. Aftera mean

follow-up of 38 months, significant improvements in pain

andfunctionalresultswereobserved,asassessedusingthe

scoreoftheAmericanShoulderandElbowSurgeons(ASES).

In2008,Poratetal.22_{usedthistechniquetotreat36patients} withhigh-gradearticularlesionsandobtainedgoodand excel-lentresultsin83.3%ofthecases,asassessedusingtheUCLA score.In2009,Kamathetal.23_{demonstratedasatisfactionrate} of93%among41patientswithhigh-gradearticularlesions whounderwentrepairaftercompletionofthelesions.These dataaresimilartotheresultsfoundbyourgroup,with100% satisfactionandgood/excellentresultswhentherepairwas performedaftercompletionofthelesionsinthehigh-grade cases.

Themainlimitationofthe presentstudy wasthe small samplesizefollowedup(64patients),incomparisonwiththe totalpopulationofpatientsoperated(704patients).This sit-uation occurredbecause ourservice receivespatients from manyregionsofthecountryand,thus,manyofthesepatients were unabletocomeinperson forthe evaluation. Further-more,becausethiswasaretrospectivestudy,wewereunable toobjectivelyobservetheevolutionofthefunctionalresults. Weconsider thatthepositive pointsofourstudy were the longfollow-up(meanof76months)inapopulationthatwas homogenousintermsofageanddemand,withspecific surgi-caltreatmentforeachtypeoflesionandasinglerehabilitation protocol.

Conclusion

Thevideoarthroscopictreatmentofthesepartiallesionsofthe rotatorcuffpresentedgoodorexcellentresultswhenthe low-gradelesionsweredebridedandthehigh-gradelesionswere repairedaftercompletion.Theseresultsweremaintainedover thelongterm,withahighsatisfactionrateandfew compli-cations.Nostatisticallysignificantdifferenceswereobserved betweentheresultsfromthearticularandbursallesions,or betweenthegradesoflesion.Long-termrandomized prospec-tivestudiescomparingthetechniquesoftranstendonrepair andrepairaftercompletionofthelesionbecomenecessary.

Conflicts

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