w w w . r b o . o r g . b r
Original
article
Comparative
analysis
on
arthroscopic
sutures
of
large
and
extensive
rotator
cuff
injuries
in
relation
to
the
degree
of
osteopenia
夽
Alexandre
Almeida
a,∗,
Vinícius
Atti
b,
Daniel
Cecconi
Agostini
a,
Márcio
Rangel
Valin
a,
Nayvaldo
Couto
de
Almeida
a,
Ana
Paula
Agostini
caHospitalSaúde,CaxiasdoSul,RS,Brazil bHospitalPompeia,CaxiasdoSul,RS,Brazil
cPontificalCatholicUniversityofRioGrandedoSul,CaxiasdoSul,RS,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received28December2013
Accepted10February2014
Availableonline24January2015
Keywords:
Bonedensity
Osteoporosis
Rotatorcuff
Shoulder
a
b
s
t
r
a
c
t
Objective:Toanalyzetheresultsfromarthroscopicsuturingoflargeandextensiverotator
cuffinjuries,accordingtothepatient’sdegreeofosteopenia.
Method:138patientswhounderwentarthroscopicsuturingoflargeandextensiverotator
cuff injuriesbetween2003and2011wereanalyzed.Those operatedfromOctober2008
onwardsformedaprospectivecohort,whiletheremainderformedaretrospectivecohort.
AlsofromOctober2008onwards,bonedensitometryevaluationwasrequestedatthetime
ofthesurgicaltreatment.Forthepatientsoperatedbeforethisdate,densitometry
examina-tionsperformeduptotwoyearsbeforeorafterthesurgicaltreatmentwereinvestigated.The
patientsweredividedintothreegroups.Thosewithosteoporosisformedgroup1(n=16);
thosewithosteopenia,group2(n=33);andnormalindividuals,group3(n=55).
Results:InanalyzingtheUniversityofCaliforniaatLosAngeles(UCLA)scoresofgroup3
andcomparingthemwithgroup2,nostatisticallysignificantdifferencewasseen(p=0.070).
Analysisongroup3incomparisonwithgroup1showedastatisticallysignificantdifference
(p=0.027).
Conclusion: Theresultsfromarthroscopicsuturingoflargeandextensiverotatorcuffinjuries
seemtobeinfluencedbythepatient’sbonemineraldensity,asassessedusingbone
densit-ometry.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
夽
WorkdevelopedatHospitalSaúdeandintheOrthopedicsResidencyServiceofHospitalPompeia,CaxiasdoSul,RS,Brazil.
∗ Correspondingauthor.
E-mail:bone@visao.com.br(A.Almeida).
http://dx.doi.org/10.1016/j.rboe.2015.01.004
Análise
comparativa
da
sutura
artroscópica
de
lesões
grandes
e
extensas
do
manguito
rotador
com
relac¸ão
ao
grau
de
osteopenia
Palavras-chave:
Densidadeóssea
Osteoporose
Bainharotadora
Ombro
r
e
s
u
m
o
Objetivo: analisar oresultadodasutura artroscópicadaslesõesgrandese extensasdo
manguitorotador(MR)deacordocomograudeosteopeniadopaciente.
Método: coorteprospectivanospacientesoperadosapartirdeoutubrode2008e
retrospec-tivanosdemais.Foramanalisados138pacientessubmetidosàsuturaartroscópicadelesões
grandeseextensasdoMRentre2003e2011.Aospacientesoperadosapartirdeoutubrode
2008erasolicitadaumadensitometriaóssea(DO)porocasiãodotratamentocirúrgico.Nos
pacientesoperadosantesdeoutubrode2008,pesquisaram-sedensitometriasfeitasdois
anosantesouapósotratamentocirúrgico.Ospacientesforamdivididosemtrêsgrupos.Os
comosteoporoseformaramogrupo1(n=16),oscomosteopeniao2(n=33)eosnormaiso
3(n=55).
Resultados: aoanalisaroescoredaUniversidadedaCalifórniaemLosAngeles(UCLA)do
Grupo3ecompará-locomoGrupo2,nãofoiverificadaumadiferenc¸aestatisticamente
significativa(p=0,070).AoanalisaroGrupo3ecompará-locomoGrupo1,foiverificada
umadiferenc¸aestatisticamentesignificativa(p=0,027).
Conclusão: oresultadodasuturaartroscópicadaslesõesgrandeseextensasdoMRparece
sofrerinfluênciadadensidademineralósseadopacienteavaliadapormeiodeDO.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Todososdireitosreservados.
Introduction
Development and dissemination of arthroscopic
sutur-ing techniques for the rotator cuff have made shoulder
arthroscopyoneofthemostfrequentlyperformedprocedures
inorthopedic surgical centers.1,2 The great challenge is to
identifyriskfactorsthatmightinterferewiththe
postopera-tiveevolutionofeachpatient,especiallyintheviewoflarge
andextensivenatureofrotatorcuffinjuries.Identificationof
theseriskfactorshassofarbeensubjectiveanddependenton
professionalexperience.
Someriskfactorshavealreadybeendescribedinthe
liter-ature.Thepatient’sageatthetimeofthesurgicalprocedure
seemstohaveaninfluenceonhealingandongainsrelatingto
rangeofmotionandmusclestrength.3,4Othervariablessuch
assex,5smoking,6–10tendonqualityshownonmagnetic
reso-nanceimaging,11humerus-acromiondistance<7mmshown
onX-rays12 andimpairment ofthelong headofthebiceps
havebeenconsideredtobedeleteriousforthefinalresultfrom
thetreatment.13–17
Somedataregardingbonemasslosses fromthe greater
tubercle induced by rotator cuff injuries have been
pub-lished in the literature.18–20 These data, along with some
mechanicalstudies,suggestthatosteopeniamayhavea
dele-terious effect on the postoperative healing of the rotator
cuff.11,21,22 We were unable to find any data analyses on
the relationship between the bone loss inherent to aging
and the results from arthroscopic suturing of the rotator
cuff.
Theaimofthepresentstudywastocomparatively
ana-lyze the results from arthroscopic suturing of rotator cuff
injuries,accordingtothepatient’sdegreeofosteopenia
mea-suredthroughbonedensitometry.
Methods
Thiswasaprospectivecohortstudyonpatientsoperatedfrom
October2008onwardsandaretrospectivecohortstudyonthe
remainder.
Atotalof138patientswhounderwentarthroscopic
sutur-ing of large and extensive rotator cuff injuries23 between
January21,2003,andFebruary4,2011,wereassessed.
Aftergeneralanesthesiahadbeeninduced,thepatientwas
positionedinlateraldecubituswiththeupperlimbabducted
at30◦,flexedat20◦andundertractionof5kg.Thejoint
dis-tension techniquecompriseduseofphysiologicalserumin
suspensionforthepatientsoperateduptoJanuary2006and
use of a joint distension pumpfrom this dateonwards.24
Arthroscopic suturingofthe rotatorcuffinjury wasalways
performedbythesamesurgeon.
Allthepatientswereimmobilizedwhilestillanesthetized,
inthesurgicaltheater,usingaslingtogetherwithan
abduc-tionpad.
For the purposesof analyzing the degreeof osteopenia
amongthe patients who were operatedfrom October2008
onwards, bonedensitometrywas requested as a
preopera-tiveexamination.ThepatientsoperatedbeforeOctober2008
were askedabout anydensitometryexaminationsthat had
beenperformeduptotwoyearsbeforeorafterthesurgical
treatmentontheshoulder.
Allpatientswhounderwentcompletearthroscopicclosure
oftherotatorcuffinjuryandwhoseoperationswerenotmore
than12monthsbeforetheassessmentdatawereevaluated.
All ofthesepatientshadabonedensitometryexamination
that wasconsidered tobevalid, whichwas performednot
morethantwoyearsbeforeorafterthedateofthesurgical
Table1–Groupsaccordingtothedegreeofosteoporosis.
n Densitometry Diagnosis
Group1 16 −3.90to−2.50 Osteoporosis Group2 33 −2.49to−1.01 Osteopenia Group3 55 −1.00to4.00 Normal
All patientsunder the age of40 years,those who were smokers,thosewhoserotatorcuffinjuryclosurewaspartial andthosewhounderwentrevisionsurgerywereexcluded.
For the purposesof the statistical analysis, the lumbar and femoral T values from bone densitometry were used. Patientswereconsideredtopresentosteopeniaiftheywere intherangeof−2.49to−1.01inoneorbothmeasurements. Theywere considered to presentosteoporosis if theywere below−2.49andwereconsiderednormaliftheywereabove −1.01.25–28Thepatientsweredividedintothreegroups
accord-ing to their densitometryvalues and degree ofosteopenia
(Table 1). These with osteoporosisformed Group 1(n=16);
thosewithosteopenia,group2(n=33);andnormal
individ-uals,group3(n=55).
TheresultswereevaluatedbymeansoftheUCLAscale.29,30
Thevariablesstudiedweresex,age,degreeofosteopenia,
UCLAindexandmusclestrength.
ThedatawereanalyzedusingtheSPSSsoftware(Statistical
PackagefortheSocialSciences),version19.0(SPSSInc.,2011).
Forthestatisticalanalysis,calculationsofmedians,
interquar-tileintervals,frequenciesandpercentageswereused.Tomake
comparisons,theMann–WhitneyUtestandchi-squaretest
wereused.Differenceswithp<0.05fora95%confidence
inter-valwereconsideredsignificant.
Results
Thisstudy evaluated138 shoulders that were operated, of
which34wereexcluded.Thus,thestudysamplecomprised
104.
Themedianlengthofthepostoperativeevaluationwas30
months(minimumof12andmaximumof97).Themeanage
was60.7±8.3years.Inrelationtosex,35patients(33.6%)were
maleand69(66.4%)werefemale.
Thegroups were analyzedregarding the proportions of
maleandfemalepatients(Table2).Thethreegroupswere
con-sideredtobesimilar,althoughfemalepatientspredominated
ingroup2(p=0.009).
Table2–Sexinrelationtoosteoporosis.
Diagnosis n Gendern(%) pa
Male Female
Group1 Osteoporosis 16 4(25.0) 12(75.0) 0.233 Group2 Osteopenia 33 7(21.2) 26(78.8) 0.009
Group3 Normal 55 26(47.3) 29(52.7) 0.680
a Chi-squarewithYatescorrection.
Group
Normal Osteopenia
Osteoporosis
Age
90
80
70
60
50
40
30
31
Male
Fig.1–Agesofthemalepatients.
Thegroupswereanalyzedregardingagegroupaccording
tothepatients’sex(Table3).Thegroupswereconsideredto
besimilar(Figs.1and2).
InanalyzingtheUCLAscoreofgroup3(55patients;52.8%)
andcomparingthiswiththescoreofgroup2(33;31.7%),no
statisticallysignificantdifferenceintheresultswasobserved
(p=0.070)(Table4).
InanalyzingtheUCLAscoreofgroup3(55patients;52.8%)
and comparingthiswiththescoreofgroup1(16;15.5%),a
statisticallysignificantdifferenceintheresultswasobserved
(p=0.027)(Table5).
InanalyzingtheUCLAscoreofgroup3andcomparingthis
withthescoresofgroups2and1,nostatisticallysignificant
differenceintheresultswasobserved(p=0.746)(Table6).
Thecolumnofvaluesrelatingtothestrengthofanterior
flexionontheUCLAscaleingroups3and1wasanalyzed
sep-arately.Patientswithvaluesof4and5wereconsideredtohave
Table3–Agegroupinrelationtoosteoporosis.
Diagnosis n Medianage(years)(IIQa) pb
Male Female
Group1 Osteoporosis 16 57.0(53.5–60.5) 64.5(56–70) 0.129
Group2 Osteopenia 33 58.0(55.5–64.5) 59.5(55–68) 0.708
Group3 Normal 55 58.0(53–65) 53.0(53–65) 0.846
a IIQ,interquartilerange.
Group
Normal Osteopenia
Osteoporosis
Age
80
70
60
50
40
Female
Fig.2–Agesofthefemalepatients.
Table4–Comparisonbetweennormalandosteopenic
groups.
UCLA Normaln=55 Osteopenicn=33 pa
Median(IIQb) 30(27–32) 32(29–34) 0.070
Minimum 9 16
Maximum 35 35
a Mann–WhitneyUtest.
b IIQ,interquartilerangeoramplitude.
Table5–Comparisonbetweennormalandosteoporotic
groups.
UCLA Normaln=55 Osteoporoticn=16 pa
Median(IIQb) 30(27–32) 27(21.5–29) 0.027
Minimum 9 12
Maximum 35 35
a Mann–WhitneyUtest.
b IIQ,interquartilerangeoramplitude.
recoveredtheirstrength,whereasthosewithvaluesfrom0to
3were consideredtopresent alteredstrength(i.e.theyhad
notrecovered).Comparisonofthestrength valuesbetween
thegroupsusingtheUCLAscaledidnotshowanystatistically
significantdifferenceintheresults(p=0.165)(Table7).
Table6–Comparisonbetweennormalgroupand
osteopenicandosteoporoticgroupstogether.
UCLA Normaln=55 Group1+group2n=49 pa
Median(IIQb) 30(27–32) 30(27–32) 0.746
Minimum 9 12
Maximum 35 35
a Mann–WhitneyUtest.
b IIQ,interquartilerangeoramplitude.
Table7–Analysisonmusclestrength.
Densitometry Strengthn(%) pa
Altered Normal
Osteoporosis 11(68.8) 5(31.2) 0.165
Normal 27(49.1) 28(50.9)
a Chi-squarewithYatescorrection.
Discussion
Surgical treatment ofrotator cuffinjuriespresents varying
results that depend on the type and size of the injuries
sutured. Injuries classified as large and extensive
accord-ing toCofield23are theonesthatpresenttheworstresults,
with the greatest numbers of cases offailure to heal and
reopening.17,31–33Thesearethereforetheinjuriesthatmost
evidently demonstrate the influence of factors for worse
prognoses.17
Theagesofthepatientsoperatedhasalreadybeenstudied
byseveralauthors asanimportantprognosticfactor,
espe-ciallyforindividualsovertheageof65years.3,4,34 Thus,we
chosetoexcludepatientsundertheageof40years,among
whom nobasisforstudyingosteoporosiswould exist.25We
tookcaretoevaluatethepatients’agesinthethreegroupsso
thatthesamplewouldbeashomogenousaspossible.
Withregardtosexasapredictivefactorfortheresult,ithas
beenfoundthatwomen’sexpectationsandconcernsinterfere
moresignificantlywiththepostoperativerecovery.6We
evalu-atedthegroupsinrelationtothenumbersofmenandwomen.
Eventhoughwomenpredominatedingroup2,allthegroups
wereconsideredtobesimilarfromastatisticalpointofview.
There is controversy in the literature with regard to
whethersmokingisafactorgivingapoorprognosisforthe
resultsfromsurgicaltreatmentoftherotatorcuff.
Boisson-naultetal.35didnotdemonstrateanynegativeimpactfrom
smokingonthepostoperativeresultsfromrotatorcuff
sutur-ing. However,most authors haveshown that smoking has
adeleteriouseffectonthesepatients’microvascularization,
healingandfinalclinicalresults.7–10,36,37 Inaccordancewith
thetrendamongthemajorityofarticlesintheliterature,we
excludedsmokers.
Charousset etal.11 and Miyazaki etal.16 studiedtendon
quality at the time of tendon suturing and observed that
injuriesthatweresutured earlyon,i.e.beforemuscle
atro-phyandfattydegenerationhadbecomeestablished,evolved
withbetterclinicalresults.Inourstudy,wedidnotinclude
the parameter ofthe timeinterval between theinjury and
thesuturingbecauseofdifficultyinobtainingthisinformation
anditsimprecision.
Thebonelossinherenttoaginghasbeenrecognizedas
givingrisetohigherincidenceoffracturesinthethirdage.38
Ontheotherhand,osteoporosisdoesnotseemtodelay
frac-turehealing,providedthatthefractureshavebeenadequately
stabilized.39
Inshouldersthathavebeenaffectedbyrotatorcuffinjuries,
thereisadecreaseinbonemasscenteredontheregionofthe
greatertubercle,duetolossofthestimulusoftendontraction.
rotatorcufffunctionthroughconservativetreatmentpresent
lesslocalizedboneloss.19
Galatzetal.20demonstratedthattherewasadeterioration
intissuehealingpropertiesinthegroupofpatientsforwhom
tendoninjuryrepairwaslate,whichcoincidedwithbonemass
lossinthegreater tubercle.These results,whichwere also
seenbyCharoussetetal.,11indicatethatbonemasslossin
thegreatertuberclemaybeanimportantfactorleadingtopoor
healing.11,20
Mechanical studies on cadavers and studies on animal
models have demonstrated a relationship between loss of
bonemineraldensityandfailureoftendonsutures.21,22Brown
etal.21 demonstratedthat lowbonemineraldensityinthe
greatertuberclesofcadaversthatunderwentoperationswasa
significantfactorfavoringreopeningafterarthroscopic
sutur-ingoftherotatorcuff.Cadetetal.22demonstratedthatwhen
thebonedensityintheregionoftherotatorcuffinsertionof
ratsthatreceivedbisphosphonateswasimproved,thetime
takenforthetendonsuturetofailthrough stresswas
pro-longed.
Evaluationofbonemineraldensitydirectlyintheproximal
humerusrequiresspecialsoftwarethatisnotavailableinmost
bonedensitometryservices inour setting.Densitometry is
anexaminationperformedtoevaluatepatients’bonemineral
densityand,throughwell-definedcriteria, helpsin
manag-ingpreventionandtreatmentforosteoporosis.28Toenableour
study,weusedevaluationsonlumbarandfemoralT
measure-ments,whichindirectlyassesspatients’bonemineraldensity.
From these results, the patients were stratified into three
groups:normal,osteopenicandosteoporotic.Thestatistical
analysisshowedthatthepatientsinthegroupwith
densit-ometricvalueswithintherangeforosteoporosispresented
worseclinicalresultsontheUCLAscalethandidthosewith
densitometricvalueswiththerangeofnormality(p=0.027).
Thiswasthe mainoutcome from ourstudy,giventhat we
didnotfindanyotherstudiesintheliteraturethathad
cor-relatedthe resultsfrom arthroscopic suturing oflargeand
extensiverotatorcuffinjurieswiththepatients’bonemineral
density.
Boileau et al.3 found that healingoccurred in only43%
of the patients over the age of 65 years who were
oper-ated.Similarresultswere foundbyFavardetal.34 Godinho
etal.4observedthatthegainsinmusclestrengthweremore
inconsistentamongpatientsovertheageof60years,which
suggests that tissue healingatthe tendon suture was not
takingplace.Thereisadirectrelationshipbetweenrecovery
ofmuscle strengthand healingofthesutureafterthe
sur-gicalprocedure.20 However,wewere unabletodemonstrate
this relationshipina statisticallysignificantmannerwhen
wecomparedtheitemthatevaluatedmusclestrengthonthe
UCLAscaleofthegroupswithnormalandosteoporotic
den-sitometricvalues(p=0.165).
Wecanstatethatthesourcesofbiasinourstudyconsisted
ofthefactthathigh-resistancethreadonlystartedtobeused
inoursamplein2006andthatweusedanindirect
measure-menttoevaluatethepatients’bonemineraldensity,bymeans
oflumbarandfemoralbonedensitometry.Itispossiblethat
directassessmentofbonemassintheproximalhumerusor
useofquantitativetomography(osteoabsorptiometry)would
havereacheddifferentresults.
Conclusion
Theresultsfromarthroscopicsuturingoflargeandextensive
rotator cuffinjuriesseem tobeinfluencedbythe patients’
bonemineraldensity,asassessedbymeansofthebone
den-sitometry technique available inour setting. Patients with
osteoporosispresentworseclinicalresults,asassessedusing
theUCLAscale.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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