Rev. bras. ortop. vol.49 número2

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

Original

Article

Functional

evaluation

of

arthroscopic

repair

of

rotator

cuff

injuries

in

patients

with

pseudoparalysis

夽

,

夽夽

Alberto

Naoki

Miyazaki,

Marcelo

Fregoneze,

Pedro

Doneux

Santos,

Luciana

Andrade

da

Silva,

Guilherme

do

Val

Sella

∗

_,

_Douglas

_Lobato

_Lopes

_Neto,

Melvis

Muchiuti

Junior,

Sergio

Luiz

Checchia

OrthopedicsandTraumatologyService,FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received18March2013 Accepted16August2013 Availableonline13April2014

Keywords:

Paralysis

Rotatorcuff/injuries Shoulderjoint/surgery

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b

s

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Objective:toevaluatethefunctionalresultfromarthroscopicrepairofrotatorcuffinjuries inpatientswithpseudoparalysis,definedasincapacitytoactivelyraisethearmabove90◦_, whilecompletepassiveelevationwaspossible.

Methods:wereevaluated38patientswithameanfollow-upof51months(minimumof24). Weanalyzedthepseudoparalysisreversionrateandthefunctionalresultobtained.

Results:accordingtotheassessmentcriteriaoftheUniversityofCaliforniainLosAngeles (UCLA),31(82%)patientshadgoodandexcellentresults,two(5%)hadfairresultsandfive (13%)hadpoorresults.Themeanactiveelevationwentfrom39◦_before_the_operation_to₁₃₉◦ aftertheoperation(p<0.05);themeanactivelateralrotationwentfrom30◦_to₄₈◦₍_p_<_0.05) andthemeanactivemedialrotationwentfromlevelL3toT12(p<0.05).

Conclusion:arthroscopicrepairofrotatorcuffinjuriesproducedgoodandexcellentresults in82%ofthecasesandastatisticallysignificantimprovementofactiverangeofmotion, withreversionofthepseudoparalysisin97.4%ofthecases.Itisthereforeagoodtreatment option.

Avaliac¸ão

funcional

do

reparo

artroscópico

da

lesão

do

manguito

rotador

em

pacientes

com

pseudoparalisia

Palavras-chave:

Paralisia

Manguitorotador/lesões Articulac¸ãodoombro/cirurgia

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e

s

u

m

o

Objetivo:avaliaroresultadofuncionaldoreparoartroscópicodaslesõesdomanguitorotador empacientescompseudoparalisia,definidacomoincapacidadedeelevaçãoativadobraço acimade90◦_,_com_elevação_passiva_completa.

Métodos:reavaliamos38pacientescommédiadeseguimentode51meses(mínimode24). Analisamosataxadereversãodapseudoparalisiaeoresultadofuncionalobtido.

夽_Please_cite_this_article_as:_Miyazaki_AN,_Fregoneze_M,_Santos_PD,_da_Silva_LA,_do_Val_Sella_G,_Neto_DLL,_et_al._Avaliac¸ão_funcional_do

reparoartroscópicodalesãodomanguitorotadorempacientescompseudoparalisia.RevBrasOrtop.2014;49:178–182.

夽夽

WorkperformedintheShoulderandElbowGroup,DepartmentofOrthopedicsandTraumatology,SchoolofMedicalSciences,Santa CasadeSãoPaulo,FernandinhoSimonsenWing.

∗ _{Corresponding}_author_.

E-mail:guilton@ig.com.br(G.doValSella).

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Resultados: peloscritériosdeavaliaçãodaUniversidadedaCalifórniaemLosAngeles(Ucla), 31(82%)pacientestiverambonseexcelentesresultados;dois(5%)resultadosregularese cinco(13%)ruins.Amédiadaelevaçãoativapassoude39◦_no_{pré-operatório}_para₁₃₉◦_no pós-operatório(p<0,05),amédiadarotaçãolateralativapassoude30◦_para₄₈◦₍_p_<_0,05)_e amédiadarotaçãomedialativapassoudonívelL3paraoT12(p<0,05).

Conclusão: oreparoartroscópicodaslesõesdomanguitorotadorproporcionoubonse exce-lentes resultados em82% doscasos eumamelhoria, estatisticamentesignificativa,da amplitudedemovimento(ADM)ativa,comreversãodapseudoparalisiaem97,4%doscasos. É,portanto,umaboaopc¸ãodetratamento.

Introduction

Thefunctionsoftherotatorcuffaretostabilizethehumeral headinsidetheglenoidcavityandrotatethehumerusin rela-tiontothescapula.1_The_{supraspinatus}_muscle_is_responsible forthefirst10◦_to₁₅◦_of_shoulder_elevation_range_of_motion and,together withtheinfraspinatus,teres minorand sub-scapularismuscles,opposestheforceofthedeltoidmuscle, whichtendstomovethehumeralheadupwardsduring ele-vationmovements.2,3_Rotator_cuff_injuries_may_lead_to_loss_of thesefunctionsandconsequentlytochronicpain,weakness andfunctionalincapacity.4

Pseudoparalysisduetorotatorcuffinjury(PRCI)hasbeen definedbysomeauthors5–7 _as_incapacity_to_perform_active elevationofthearmabove90◦_,_with_normal_passive_mobility oftheshoulder.Thisdeficitofactiveelevationisassociated withrotatorcuffinjuriesthatareusuallylargeorextensive.8,9 The results from repairing large or extensive rotator cuff injuries have generally been reported in the literature as satisfactory.10–12_However,_the_functional_recovery_of_patients withPRCI who undergo arthroscopic surgical repairisstill knownonlyalittle.

Theobjective ofthe present study was to evaluatethe resultsfromarthroscopicrepairofrotatorcuffinjuriesinPRCI patients.

Sample

and

methods

Between January1996and October2011, the Shoulderand ElbowGroupoftheDepartmentofOrthopedicsand Trauma-tology,SchoolofMedicalSciences,SantaCasadeSãoPaulo, performedarthroscopicoperationson38patientswithPRCI.

Allcaseswiththesecharacteristicswereincludedinthis study.Patientswithrotatorcuffinjurieswithoutparalysisand caseswithfollow-upsshorterthan24monthswereexcluded. Therewere21malepatients(55%);theagerangewasfrom 49to81years(meanof68years);andthedominantlimbwas operatedin30cases.Allthepatientsexceptforonereported havinghadawell-defineepisodeoftraumatothejointor trau-maticmuscleeffortthatledtolossofactiveelevationofthe affectedlimb.Thetimethathadelapsedbetweentheinjury andthesurgicaltreatmentrangedfromtwoto740days,with ameanof83days.Noneofthepatientshadundergoneany previoussurgeryontheaffectedshoulder(Table1).

Therangeofactivemotionbeforetheoperation,as mea-suredusingthestandardizationoftheAmericanAcademyof

OrthopaedicSurgeons(AAOS),13_was_from₀◦_to₉₀◦_of_elevation (meanof39◦_);_the_range_of_lateral_rotation_was_from₀◦_to₈₀◦ (meanof30◦_);_and_the_range_of_medial_rotation_was_between thegreatertrochanterandT7(meanatL3)(Table2).

Thepresenceofarotatorcuffinjurywasconfirmedinall thepatientsbymeansofmagneticresonanceimaging(Fig.1). Allthepatientsunderwentthesurgicalprocedureinthe “deckchair” position, under general anesthesia combined withanesthetic blockofthebrachialplexus. Thejoint was arthroscopicallyinspectedbeforetherotatorcuffrepairwas performed. Next, the subacromial spacewas entered, with debridement ofthebursa,mobilizationofthe tendonsand openingofthebonebedofthefemoralhead,followedbyrepair oftherotatorcuffinjury(Fig.2).Tenlargelesionsand28 exten-sivelesionswerefound,inaccordancewiththeclassification proposedbyCofield8₍_Fig.₃_)._Regarding_the_tendons_affected, 26patientshadinjuriestothesupraspinatusand infraspina-tus and12 hadinjuriestothe supraspinatus,infraspinatus andsubscapularis.Noneofthepatientshadinjuriestojust onetendonalone(Table1).Inrelationtothetendonofthe long head ofthe biceps brachiimuscle, 12 patients under-went tenotomy, sevenunderwent tenotomyplus tenodesis andsevendidnotundergotheseprocedures.Acromioplasty wasperformedon32ofthe38patients.Resectionofthe lat-eralportionoftheclaviclewasperformedineightofthe38 patients.Arthrex®_material_was_used_on_all_our_patients.

Duringthepostoperativeperiod,thepatientswere immo-bilizedforsixweeks,inaslingwiththearmabductedand

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Table1–Dataonthepatients.

No. Sex Age (years)

Dominance T(days) Follow-up (months)

Pre-opactive ROM:EL,LR,MR

Tendon Size Post-opactive ROM:EL,LR,MR

UCLA

1 F 75 + 21 24 50,45,T7 SS+IS L 130,45,T7 16 2 F 61 − 7 24 80,40,T7 SS+IS L 140,45,T12 31 3 M 68 + 2 35 30,45,L2 SS+IS EXT 140,30,T12 32 4 F 71 + 4 74 0,30,L5 SS+IS EXT 140,30,T10 18 5 M 72 + 30 116 80,45,L3 SS+IS EXT 150,45,L1 32 6 F 78 − 7 65 0,0,L3 SS+IS EXT 150,60,L1 34 7 F 81 + 30 26 60,30,T7 SS+IS EXT 140,40,T7 34 8 F 73 + 20 49 0,30,TR SS+IS+SUB EXT 150,60,L3 34 9 F 76 + 3 48 0,10,L5 SS+IS+SUB EXT 130,60,L1 34 10 F 75 + 20 38 80,30,L1 SS+IS+SUB EXT 120,40,L1 10 11 M 72 + 4 72 30,60,GL SS+IS EXT 160,60,T8 34 12 M 60 + 14 94 45,30,L3 SS+IS EXT 150,45,T10 34 13 M 67 − 14 45 30,10,T7 SS+IS+SUB EXT 150,60,T8 34 14 M 64 + 7 87 0,30,L3 SS+IS+SUB EXT 150,45,L1 32 15 F 67 + 30 74 60,0,T8 SS+IS EXT 140,45,L1 34 16 F 81 + 3 26 45,20,T7 SS+IS+SUB EXT 45,30,T7 15 17 F 79 + 10 25 80,0,T10 SS+IS EXT 150,60,L1 29 18 F 79 − 4 24 30,30,L1 SS+IS EXT 150,45,L1 32 19 M 62 + 45 75 90,60,L1 SS+IS L 150,60,L1 34 20 M 66 + 60 73 30,60,L5 SS+IS L 140,60,L1 34 21 M 74 + 1 29 30,0,T7 SS+IS EXT 120,20,L1 33 22 M 49 + 740 26 80,50,GL SS+IS+SUB EXT 140,60,L3 33 23 M 74 − 14 56 0,0,T7 SS+IS L 150,50,T7 34 24 M 68 + 15 51 60,0,L1 SS+IS L 150,45,L5 34 25 M 56 + 15 25 70,20,L1 SS+IS+SUB EXT 150,50,T7 34 26 F 79 + 30 53 80,60,T7 SS+IS EXT 120,45,L2 29 27 F 69 + 4 50 30,80,T12 SS+IS EXT 120,80,T12 34 28 M 65 + 32 24 60,45,L3 SS+IS EXT 150,45,L1 34 29 M 71 + 30 33 20,70,L3 SS+IS+SUB EXT 150,60,T8 32 30 M 70 − 20 37 0,60,T10 SS+IS EXT 120,60,L1 34 31 M 81 + 15 24 0,0,T8 SS+IS+SUB EXT 150,45,L1 32 32 M 55 + 10 24 0,0,T7 SS+IS L 150,45,T7 32 33 M 74 + 60 25 30,0,T10 SS+IS EXT 150,0,T8 32 34 M 74 + 60 26 80,80,L5 SS+IS+SUB EXT 150,60,T10 34 35 M 53 − 2 24 0,80,T10 SS+IS L 160,60,T10 34 36 F 72 + 150 45 70,45,T7 SS+IS L 120,45,T7 27 37 F 57 − 600 26 90,35,T10 SS+IS+SUB EXT 120,45,T9 19 38 F 62 + 330 48 90,20,GL SS+IS L 140,50,T9 22

Source:hospitalmedicalfiles.

T,timeelapsedbetweendiagnosisandoperation;ROM,rangeofmotionmeasuredindegrees;Pre-op,beforeoperation;EL,elevation;LR,lateral rotation;MR,medialrotation;Tendon,tendonsaffected,asseenduringoperation;Post-op,afteroperation;SS,supraspinatus;IS,infraspinatus, SUB,subscapularis;EXT,extensive;L,large;T,measurementaccordingtoheightofthethoracicvertebra;L,measurementaccordingtoheight ofthelumbarvertebra;GL,measurementaccordingtoheightofthegluteus;UCLA,scoreonthescaleoftheUniversityofCaliforniainLos Angeles.

Table2–Patients’preoperativeandpostoperativemobility.

Pre-opactiveROM(mean) Post-opactiveROM(mean) mobility

EL 39 139 100

LR 30 48 18

MR L3 T12 3levels

Source:hospitalmedicalfiles.

ROM,rangeofmotion;Pre-op,beforeoperation;Post-op,afteroperation;mobility,differenceinactiveROMfrombeforeoperationtoafter operation.

in neutral rotation. After this period, the sling was with-drawn and elevation, lateral rotation and medial rotation wereallowed,bothpassivelyandactively.Fourmonthsafter theoperation,musclestrengtheningwasstarted(Fig.4).The resultswereevaluatedinaccordancewiththeUCLAmethod14

andtherangeofmotionwasmeasuredinaccordancewiththe standardizationoftheAAOS.13

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Fig.2–Arthroscopicsurgicalimage(subacromialview) showingcompleteclosureofanextensiverotatorcuff injury.

theoperationwereanalyzed,takingthesignificancelevelto be5%(p<0.05).

Thelengthoffollow-upforthesepatientsrangedfrom24 to116months(meanof51).

Results

Themeanactiveelevationaftertheoperationwas139◦_(range: 45◦_to₁₆₀◦₎₍_p_<_0.05),_the_mean_lateral_rotation_was₄₈◦_(range: 0◦ _to₈₀◦₎₍_p_<_0.05)_and_the_mean_medial_rotation_was_at_the levelofthe12ththoracicvertebra(range:fromthesacrumto T7)(p<0.05)(Table2).

ThemeanscoreusingtheUCLAmethodinthefinal evalu-ationwas27points(range:10to34).Nineteenpatients(50%) wereclassifiedashavingexcellentresults,12(32%)good,two (5%)fairandfive(13%)poor.Amongthefivecasesthatwere consideredtohavepoorresults,onlyoneneededtobe reop-erated.

Discussion

PRCIisassociatedwithinabilitytoperformsimplearm move-ments of day-to-day life, such as raising the hand to the

Fig.3–Arthroscopicsurgicalimage(subacromialview) showinganextensiverotatorcuffinjury.

Fig.4–Clinicalimageofapatientafterfunctional rehabilitation.

mouth,brushingteethandcombinghair,becauseofthelossof activeelevationofthearm.Thetreatmentoptionsfor pseu-doparalysisincludestrengtheningoftheanteriorportionof theanteriordeltoid,15_reverse_total_arthroplasty_with_or with-out associatedmuscle transfer,6,7 _repair_of_the _rotator _cuff injury10,16 _and_transfer_of_the_latissimus_dorsi_muscle_to_the greatertubercle.17

Levyetal.15_{prospectively}_evaluated₁₇_patients_with exten-siveirreparablerotatorcuffinjuriesthatweretreatedthrough arehabilitationprogramfortheanteriorportionofthedeltoid musclebecausetheywerenotinasuitableclinicalcondition toundergosurgicaltreatment.Theirmeanagewas80years. Theiractiveelevationincreasedfrom40◦_to₁₆₀◦_after_the reha-bilitationprogram,withaminimumfollow-upofninemonths. However,theirmusclestrengthdidnotimprove.

Gerber et al.17 _proposed _transfer_of_the _latissimus_dorsi muscle to the greater tubercle as a treatment option for patientswithextensiveirreparableinjuriestotherotatorcuff. Amongthesepatients,themeanelevationbeforethesurgery was62◦_and_it_became₁₅₀◦_after_the_muscle_transfer.

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arthroplasty together with transferof the latissimus dorsi teresmajormuscles.Theanterioractiveelevationincreased from 70◦ _to ₁₄₈◦_, _lateral _rotation _increased _from ₋₁₈◦ _to 18◦ _and _medial _rotation _decreased _from _L1 _to _S3. _On _the other hand,Mulieri etal.18 _reported_a_complication _rate_of around 20% after reverse arthroplasty, over the course of amean follow-up periodof 52 monthsamong60 patients withpseudoparalysiswithoutarthrosisoftheshoulderjoint. Amongthesepatients, 34had nothadprevioussurgeryon theshoulderand,inthisgroup,theanterioractiveelevation increasedfrom54◦_to₁₃₆◦₍_p_<_0.001).

Webelievethatarthroscopicrepairofrotatorcuffinjuries inpatients with PRCI presenteda lower complicationrate than that ofreversetotal arthroplasty ofthe shoulder. We alsoobservedthattherewasasignificantimprovementinall shouldermovementsofelevation,lateralrotationandmedial rotation after the rotator cuff injuries had been repaired (Table2).

Morerecently, Oh et al.10 _showed _that _there _was pseu-doparalysisreversionrateof76%among29patients.These authorsdidnotconsiderthatadiminishedintervalbetween the acromion and the humerus or fatty infiltration ofthe tendons ofthe rotator cuff were contraindications against repair. Theyrecommended thatthe first-linetreatment for patientswith PRCIwithout arthropathydue torotator cuff injuryshouldbeprimaryarthroscopicrepair.

Denardetal.16 _reported_a_{pseudoparalysis}_reversion_rate of90%amongagroupof39patientswhounderwentprimary arthroscopicrepairofrotatorcuffinjuries.Inanothergroup of14patientswhounderwentrevisionofrenewedtearingof therotatorcuff,the reversionratewas43%.Ourstudy cor-roboratesthedataintheliteratureonarthroscopicrepairof rotatorcuffinjuriesinpatientswithPRCI,withareversionrate of97.4%.

Weonly had one casethat required reoperation (2.6%). Thispatientcontinuedtopresentintensepain, diminished strengthandlittlemovementintheaffectedlimb,andforthis reasonhadtoundergoreversetotalarthroplasty.

Conclusion

Arthroscopic repair of rotator cuff injuries in cases with PRCIprovidedastatisticallysignificantimprovementinactive range of motion, with reversion ofthe pseudoparalysis in 97.4%ofthepatientsthustreated.Goodandexcellentresults wereobservedin82%ofthecasesandthisfunctional improve-mentwasobtainedwithlowcomplicationrates.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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