SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
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Original
Article
Analysis
of
postoperative
monitoring
of
patients
undergoing
shoulder
arthroscopy
for
anterior
instability
夽
Alexandre
Almeida
a,∗,
Samuel
Millán
Menegotto
a,
Nayvaldo
Couto
de
Almeida
a,
Ana
Paula
Agostini
b,
Letícia
Agostini
de
Almeida
caHospitalPompeia,DepartamentodeOrtopediaeTraumatologia,CaxiasdoSul,RS,Brazil
bUniversidadedeCaxiasdoSul,CaxiasdoSul,RS,Brazil
cColégioSãoJosédeCaxiasdoSul,CaxiasdoSul,RS,Brazil
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r
t
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Articlehistory: Received19May2016 Accepted31May2016 Availableonline22June2017
Keywords:
Shoulderdislocation/surgery, Shoulderjoint/surgery, Arthroscopy/methods Treatmentoutcome
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Objective:Analyzethepostoperativefollow-upofpatientsundergoingshoulderarthroscopy fortreatmentofanteriorinstabilityandcorrelatewiththeprevalenceofrecurrence. Methods:A six-questionsurveywasapplied byphoneandmailto 65 patients,seeking informationonthecurrentresultofthesurgicalprocedure.Allpatientsweretreated arthro-scopicallyforanteriorshoulderinstability,withatleast12monthsofpostoperativetime. Patientswithassociatedposteriorlabiallesionsandrevisionsurgerieswerenotincluded. Results:Atthetimeofthesurveythepatientshadamedianof56(IQR:34.5–110.5) post-operativemonths.Themeansampleagewas24.6years(maximum=47,minimum=12; SD=7.3).Complaintofpainintheshoulderwasobservedin20patients(30.7%).Dislocation recurrencewasobservedin10patients(15.3%).Forty-fourpatients(67.6%)consideredtheir shouldernormal,whichwasmorefrequentinnon-recurrencepatients(p<0.001). Forty-threepatients(66.1%)returnedtotheirpreviouslevelofsportandtherewasnodifference betweenrecurrenceandnon-recurrencepatients(p=0.456).Itwasfoundthatthe preva-lenceofrecurrencewas5.6(95%CI:1.30–24.46)timeshigherinindividualswhoabandoned monitoringbeforesixmonthspostoperatively(p=0.012).
Conclusion:Theabandonmentofpostoperativemonitoringintheearlystages,whenthe patientsreceiveorientationformusclestrengthening,proprioceptiveeducation,and dan-gerousmovementstoavoid,canincreasetheratesofrecurrentshoulderdislocationin patientstreatedforanteriorinstabilitybyarthroscopy.
©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedattheHospitalSaúde,CaxiasdoSul,RS;andinHospitalPompeia,Servic¸odeResidênciaemOrtopedia,Caxiasdo Sul,RS,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](A.Almeida).
http://dx.doi.org/10.1016/j.rboe.2017.06.006
Análise
do
monitoramento
pós-operatório
dos
pacientes
submetidos
à
artroscopia
do
ombro
para
tratamento
de
instabilidade
anterior
Palavras-chave:
Articulac¸ãodoombro/cirurgia Luxac¸ãodoombro/cirurgia Artroscopia/métodos Resultadodotratamento
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o
Objetivo: Analisaroacompanhamentopós-operatóriodospacientessubmetidosà artro-scopiadoombroparatratamentodeinstabilidadeanteriorecorrelacionarcomaprevalência derecidiva.
Métodos: Foiaplicadoem65pacientes,atravésdeligac¸ãotelefônica,umquestionárioque buscavainformac¸õessobreasituac¸ãoatualdoresultadodoprocedimentocirúrgico.Todos ospacientesforamoperadosparacorrigirumainstabilidadeanteriordoombropor artro-scopiaetinhampelomenos12mesesdepós-operatório.Nãoforamincluídospacientes comassociac¸ãodelesãolabralposteriorecirurgiasderevisão.
Resultados: Oquestionáriofoiaplicadocomumamedianade56(IIQ:34,5a110,5)meses. Amédiadeidadedaamostrafoide24,6anos(máximade47emínimade12–DP7,3).Foi verificadaqueixadedorem20pacientes(30,7%)erecidivadaluxac¸ãoemdez(15,3%).44 pacientes(67,6%)consideraramseuombronormale43(66,1%)retornaramaoesporteprévio. Foiverificadoqueosindivíduosqueabandonaramoacompanhamentopós-operatórioantes dosseismesestiveramumaprevalência5,6(IC95%:1,30-24,46)vezesmaiorderecidiva (p=0,012).
Conclusão: Oabandonodo acompanhamentopós-operatóriona fase inicial,naqual o pacienterecebeorientac¸õesparaoreforc¸omusculareaeducac¸ãoproprioceptiva,pode colaborarnoaumentodoíndicederecidivadaluxac¸ãonospacientestratadospor artro-scopia.
©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Traumatic shoulder instability is a pathology that affects mainlyyoungadultsandoftenleadstodifficultytoperform someactivities.Itisanimportantcauseofworkabsenceand limitationofqualityoflife.1Anteriorshoulderinstabilityisthe mostcommonpresentation,andisgenerallyassociatedwith a labral lesion or capsular laxity.2–5 Dislocation recurrence leadstoosteoarticularcapsuloligamentousdeteriorationand, inmostcases,surgeryisrequired.2
Surgicaltreatmentofanteriorinstabilityofthe shoulder canbeperformedusingeitheropenorarthroscopicaccess.In recentyears,atendencytoincreaseindicationsfor arthro-scopic treatment has been observed.1,4,6–10 In the United States,between2003and2005,71.2%ofallBankartlesions weretreatedwitharthroscopy,whilebetween2006and2008 this percentage increasedto 87.7%.2 The literatureis con-troversial regarding which method achieves better results, especiallywhentheprevalenceofrecurrenceofdislocation aftersurgeryisassessed.1,4,6,7
Open treatment advocates point to a more anatomical and secure repairasan advantage,withbetter orientation inthe placement ofanchors,and recurrence ratesranging from3.5%to23%in4–6yearsandfrom10%to22.6%in11–29 years postoperatively.1–3,11 Proponents of the arthroscopic treatmentindicatethelowerriskofinfectionandstiffness, lesssubscapularisinjury,lesspostoperativepain,andfaster recovery.1–3,10–12 Recurrenceratesare approximately10% at 3.6yearspostoperatively.1,4,6,7Astudyindicatedarecurrence
rateof23%at10.9yearsoffollow-up,suggestinga deterio-rationofsurgicalresultsinalongerfollow-up.11Morerecent studiesdemonstratedthatthestandardizationofthe arthro-scopictechniqueandcarefulselectionofpatientsdecreased theprevalenceofrecurrence,withratessimilartotheopen technique.2,3,8,9
Thisstudyaimedtoanalyzethepostoperativefollow-upof patientswhounderwentshoulderarthroscopyfortreatment ofanteriorinstabilityandtocorrelatewiththeprevalenceof recurrence.
Methods
Thiswasaretrospectiveandcross-sectionalstudy.
FromNovember2002toNovember2013,96patientswith traumaticanteriorshoulderdislocationweretreatedthrough thearthroscopictechnique.
Allcaseswereoperatedbythesamesurgeon,headofthe department.
Surgical technique consisted of general anesthesia pre-cededbyinterscaleneblockade.Patientswereplacedinlateral decubitus with a slight posterior drop of the trunk while the upperlimb(UL)was under5kgtraction, with20◦
flex-ion and 30◦ lateral abduction. Arthroscopy was performed
with a30◦ anglearthroscope. The labral suturewas made
Table1–Surveyquestionnaire.
1.Doyouhavepainintheoperatedshoulder?
2.Nowadays,doyoufeelyourshouldercomesoutofplace? 3.Didyouhaveanyepisodesofshoulderdislocationaftersurgery (completelyoutofplace)?
4.Haveyoubeenreoperatedbyanyothersurgeonorotherservice forthesameproblem?
5.Didyoureturnyouroriginalsportactivity(whichyouperformed beforeyoustartedhavingyourshoulderproblem)?
6.Doyouconsideryourshouldertobenormal?
Caption:questionsnumberedinorder.
ofthelengthoftheanteriorbandoftheglenohumeral liga-mentwasroutinelyperformedatthelowermostpointofthe labralsuture.
UntilDecember2010,allpatientswereimmobilizedwhile stillunderanesthesiaintheoperatingroom,usingaslingwith abductioncushion; from that dateonwards, patients were immobilizedwithaslingwithneutralULrotation.
Patientswhounderwentrevisionsurgerieswereexcluded fromthestudy,aswellasthosewithposteriorlabrallesion associated with anterior shoulder instability; therefore, 77 patientswereassessed.
Atotal of57 patients were contactedby telephoneand aquestionnairewasappliedtocollectupdatedinformation aboutthestateoftheoperatedshoulder.Eightotherpatients answered the questionnaire duringtheir clinics visit, after contactbyletter.Atotalof65questionnaireswereanswered, resultinginalossof15.5%.
Questionnaireswere answered atanaverageof56 (IQR: 34.5–110.5)months postoperatively.Atthe timeofcontact, allpatientswereinformed thatthedatacollectedwouldbe usedinastudy regardingsurgicaltechniqueandthattheir nameswouldnotbedisclosed.Thisstudywasapprovedby theethicscommitteesoftheinstitutionsinwhichthepatients wereoperated.
Meanageattimeofsurgicaltreatmentofthe65patients includedinthe study was24.6±7years.Regarding sex,56 were male (86.2%) and nine were female. Right side was affectedin36cases(55.4%).Dominantsidewasaffected in 37cases(56.9%).
Thequestionnaire,whichconsistedofsixobjective ques-tionswithyesornoanswers(Table1),wasappliedbyaperson who was not aware of the surgical treatment used or the patient’sevolution.
Variablesstudiedwere:age,sex,operatedside,dominance, postoperativetime,dateofthelastpostoperativevisit.
Regardingpostoperativefollow-upofpatients,presenceof pain,complaintofsubluxation,dislocationrecurrence,need foranewsurgical procedure, returnto thesport practiced beforetheinjury,andpatient’sperceptionofhavinganormal shoulderwereevaluated. Patientswereanalyzedintotality andseparated,accordingtotheprevalenceofrecurrence.
DatawereanalyzedusingIBMSPSS22.0statisticalpackage (IBMCorporation1989–2013)fortheanswers oftheapplied questionnaire. In cases of normal data distribution, they wereexpressedbymeanandstandarddeviation;incasesof asymmetricaldistribution,themedianandtheinterquartile range(IQR) wereused. TheChi-squaredtest(Fisher’sexact
test)andtheprevalenceratioandtheirrespective95% confi-denceintervalswereusedtocomparetheproportionsfound. Statisticaltestsweretwo-tailed,andap-value≤0.05was con-sideredstatisticallysignificant.
Results
Analysis of the applied questionnaire indicated that 20 patients (30.7%)hadcomplained ofpain. Subluxation com-plaints(symptomatictranslationofthehumeralheadintothe glenoidcavity)wereobservedinonlyfivepatients(7.6%).
Theprevalenceofrecurrenceofdislocationwas15.3%.All 10patientswhopresentedrecurrencehadundergoneasecond surgerybythetimeofapplicationofquestionnaire.
The answer to the question about pain in the oper-atedshouldershowedatendencytopaincomplaintsamong patients who presented recurrence. Shoulder pain was observedinfivepatientswhohadrecurrence(50%)and27.3% ofthosewhodidnot(p=0.262).Thedifferencewasnot con-sideredtobestatisticallysignificant.
Atotalof43patientsreturnedtothesportpracticedbefore injury(66.1%).Sixofthosewhohadrecurrence(60%)and67.3% ofthosewho didnotwereabletoreturntotheirsport.No statisticalsignificancewasobservedregardingahigherreturn tosportbetweenthetwogroups(p=0.456).
When asked whether they considered their shoulderto benormal,44patients(67.6%)respondedpositively,while21 (32.3%) respondednegatively. Two patients who had recur-rence(20%)and76.4%ofthosewhodidnotconsideredtheir shouldertobenormal.Patientswhodidnotpresent disloca-tionrecurrenceduringfollow-upweremorelikelytoconsider theirshoulderstobenormal,withastatisticallysignificant difference(p<0.001).
Thedate ofthe last postoperativefollow-up visit wasa minimum oftwo months and a maximum of 137 (IQR-12 [4–27months]).Itwasobservedthatindividualswholeftthe postoperative follow-up beforesixmonths hada 5.6times higher prevalence (95%CI: 1.30–24.46)of dislocation recur-rence(p=0.012).
Discussion
Surgical treatment of recurrent anterior shoulder disloca-tionshasimprovedinrecentdecades.Studieshavecompared the results and the prevalence of dislocation recurrence betweenopenandarthroscopicsurgery.1,3,4,6,7,12,13Increasein thesuccessratesofarthroscopic surgeryisassociatedwith improvementofsurgicaltechniqueandmaterialused,aswell astothecarefulselectionofpatientsbyidentifyingrecurrence riskfactors.8,14 Evengeneticstudies,intheearlystages,are beingconductedinordertoimprovetreatmentoutcomes.15
from1985to2006,showedthatevolutionofsurgicaltechnique withtheuseofmountedanchorshadattainedpostoperative arthroscopicresultssimilartoopentechnique.12Similar find-ingswereobservedbyHarrisetal.13
Themainobjectiveofarthroscopictreatmentistorestore capsulolabralinsertionandtensionwiththeaidofanchors fix-atedintheglenoidortoreincorporatetornbonefragments.16 Thetechniqueisperfectlyreproducible,witharelativelyeasy learningcurve.
Prevalence of dislocation recurrence after arthroscopic surgeryisapproximately10%,increasingwithtimeof post-operative follow-up; it can reach around 25% in longer follow-ups.11 Mohtadietal.1foundarecurrencerateof23% inafollow-up oftwoyears.vander Lindeetal.11 found a recurrencerateof35%inafollow-uprangingfromeightto tenyears;ofthese,15%wereobservedinthefirsttwoyears.11 Boileauetal.17indicatedadislocationrecurrencerateof15.3%, withameanfollow-upofthreeyears.Watermanetal.,18ina follow-upoftwotosevenyears,observedadislocation recur-rencerateof13.8%,butwithnodistinctionbetweenopenor arthroscopicprocedure,althoughthearthroscopicprocedure had beenperformed in84%ofcases. Inthe present study, a15.3%rateofdislocationrecurrencewasobserved,witha meanfollow-upofmorethanfouryears,similartothereports intheliterature.
Thepresenceofpainintheoperatedjointissubjectiveand variesgreatlyamongindividuals.Steinetal.19 conducteda studyinathleteswhousedtheshoulderintheiractivity.They dividedtheathletesintofourgroups,dependingontheirsport modality.All groups presentedresidual pain with progres-sivedecreasethatdidnotpreventsportspractice,evenafter 32months offollow-up.19 Thesamplerecurrence ratewas 10%,butmostathletespresentedpaincomplaintseven with-outrecurrence,especiallywhendoingactivitiesthatrequired excessiveeffortshoulder.19 Miyazakietal.9 observedarate of8%forpersistenceofpostoperativepainwithout a plau-sible explanation for patients with good result at the end oftreatment.Thoseauthors didnotincludeintheanalysis casesthatpresentedrecurrence.9Inthepresentstudy, pres-ence of shoulderpain complaints was observed in 30% of thesample.Presenceofpaindoes notappeartoberelated totreatmentsuccessorfailure.Halfofthepatientswhohad dislocationrecurrenceandwerereoperatedpresented shoul-derpain.Similarly,approximatelyone-thirdofpatientswho didnotexperiencedislocationrecurrencealsohadshoulder pain.
Return to sports activity also varied in the literature. Brophy5 observed a rate of 80% for return to sport after arthroscopictreatmentofanteriorshoulderinstability.They demonstratedthatthisindexwasdifferentdependingonthe typeofsport.Throwingathleteshadarateof68%forreturn tosport,whileotherathleteshadarateof90%.5Parketal.4 indicatedarateof67.7%forreturntothesportwiththe arthro-scopictreatment,and51.6%reachedthesamesportinglevel pre-injury.Priviteraetal.7assessednon-professionalathletes andfoundarateof40%forreturnwithoutlimitationstothe sportpracticed priortoinjury andof30%forreturntothe sportwithlimitations.Returntosportsdoesnotappeartobe associatedwithtreatmentsuccessorfailure.Inthepresent
study,therateofreturntosportsactivitywas67%inpatients whodidnotpresentarecurrenceofthedislocation.Similarly, 60%ofthepatientswhohaddislocationrecurrenceandwere reoperatedwerealsoabletoreturntotheirprevioussports. Thepresentsampledidnotevaluateprofessionalathletes.
The perceptionthat the operatedjoint returned to nor-malityisalsoverysubjective.Inthepresentstudy,patients wereaskedayesornoquestionregardingthenormalityof theirshoulder.Moststudiesintheliteratureusedqualityof lifescoresto tryto answerthis question.Themainscores used are: Disability ofthe Arm, Shoulder and Hand Score (DASH);ShoulderPainandDisabilityIndex(SPADI);Modified RoweScore;andWesternOntarioShoulderInstabilityIndex (WOSI).
Mohtadietal.1usedtheWOSIscore(scaleof0–100)as pri-maryendpoint,showingaprogressiveincreaseinthescoresof thepatientsinafollow-upoftwoyears.Theyfoundno statis-ticallysignificantdifferencebetweenopen(meanWOSIscore: 85.2)andarthroscopictreatment(meanWOSIscore:81.9).1
Priviteraetal.7alsoassessedtheirpatientswiththeWOSI score.Themeanscoreofalloperatedshoulderswas80%,on ascaleof0–100%.Theycomparedtheoperatedshoulderwith thenormalcontralateralshoulderandfoundastatistically sig-nificantdifferenceintheWOSIscore.Thisanalysisshowed thatalthoughsurgicaltreatmentwassuccessful,thepatient doesnotalwaysperceivethejointasnormal.
Inasubjectiveassessment,73%ofthepatientsinthestudy by Boileau etal.17 were very satisfiedor satisfied and 23% weredissatisfiedorverydissatisfied.However,only15%ofthe patientspresentedtreatmentfailureduetorecurrence,which againsuggeststhateveniftreatmentissuccessfulinrelation torecurrences,notallpatientsbecomefullysatisfiedwiththe surgicalresult.17
Inthe presentstudy,asignificantdifference inpatient’s perception of a normal shoulder was observed. One-third (32.3%) ofthepatients inthis samplewho presented good results and who were satisfied with the results did not consider their shoulder to be normal. The difference was considered significant when comparing patients with and withoutrecurrenceintheirpostoperativefollow-up.Only20% ofpatientswhohadrelapsesandunderwentrevisionsurgery consideredtheir shouldertobenormal.Thisfindingbrings lighttotheimportanceofthefirstsurgicaltreatmentforthe finalresult.
Postoperativemanagementvariedamongauthors. Immo-bilization time, initiation of mobilityrecovery, initiation of musclestrengthening,andproprioceptiveworkfocusingon the original sport activity should be individualizedamong patients.
Parketal.4suggestedthattherehabilitationschemeshould featureimmobilizationwithaslingforsixweeks.Afterthis period,gentlepassiveanteriorflexionmovementsshouldbe performedforthreeweeks,followedbythreemoreweeksof externalrotationexercises.Muscularstrengtheningshouldbe initiatedapproximately12weeksaftersurgery;sportactivities shouldbedelayedforsixtoninemonths,dependingonthe sportpracticedbythepatient.4
activeelbowandwristmovementswerestimulated.Afterthe fourthweek,passiveflexion,abductionupto90◦,and
exter-nalrotationto0◦wereinitiated;isometricmovementsofthe
deltoidandperiscapularmuscleswereauthorized.Afterthe sixthweek,thetotalrangeofactivemovementswaspracticed, andafter12weeks,musclestrengtheningexerciseswere initi-ated.Returntosportwasauthorizedafterfourorsixmonths, dependingonthetypeofactivity.7
Studiesindicatethatthereisalossofexternalrotationand adecreaseinabductionforceevenafterrehabilitation.2,7Even withaproperrehabilitationprogramandmedicalmonitoring, postoperativelimitationsmay occur;theyshould guidethe orientationforasafereturntosportsactivity.
Thepresentstudydemonstratedtheimportanceof post-operative follow-up when evaluating recurrences. A much higherrateofrecurrencewasobservedinpatientswho aban-donedfollow-upbeforereceivingappropriateguidelines for theirreturntodailylifeand sportsactivity.Theprevalence ofdislocationrecurrencewas5.6higherinthesepatients.It ispossible thatignorance ofriskymovements, insufficient recovery of muscle strength, and inadequate propriocep-tive recovery may make the patient vulnerable to future relapses.
Theauthorsconsiderthecontinuousandprogressive evo-lution of the author’s learning curve in the arthroscopic surgicalproceduresince2002tobeabiasofthepresentstudy, aswellastheuseofdifferenttypesofslingforimmobilization intheimmediatepostoperative.
Conclusion
Individuals who abandoned post-operative follow-up after arthroscopic stabilization ofrecurrent shoulder dislocation beforesixmonthspresenteda5.6-foldhigherprevalenceof dislocationrecurrence.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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