w w w . r b o . o r g . b r
Original
Article
Rotator
cuff
injuries:
current
perspectives
and
trends
for
treatment
and
rehabilitation
夽
Fabio
Antonio
Vieira
∗,
Paul
Juma
Olawa,
Paulo
Santoro
Belangero,
Gustavo
Gonc¸alves
Arliani,
Eduardo
Antônio
Figueiredo,
Benno
Ejnisman
EscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
a
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t
i
c
l
e
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n
f
o
Articlehistory:
Received16July2014 Accepted21August2014 Availableonline31October2015
Keywords:
Rotatorcuff Therapeutics Rehabilitation
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b
s
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t
Objective:TomapouttheapproachesusedbyBrazilianorthopedistsintreatingcomplete tearsoftherotatorcuff.
Methods:Amultiple-choicequestionnairewashandedoutto232orthopedistsatthe45th BrazilianCongressofOrthopedicsandTraumatology.Ofthese,207werereturnedbutfive wereincompleteandwereexcluded.Thus,202questionnaireswereused.
Results:Amongtheorthopedistswhoansweredthequestionnaires,around60%werefrom thesoutheasternregionand46%wereshoulderandelbowsurgeons.Therewasa signifi-cantassociation(p<0.05)betweenlengthofexperienceandnumberofrotatorcuffrepairs performedperyear.Therewasalsoasignificantassociation(p<0.05)betweenshoulder spe-cialtyandthefollowingvariables:arthroscopictechnique,useofanchorsinasingle-row configuration,meantimetakenforanindicationforsurgerytobemadeincasesof trau-maticanddegenerativelesions,useofaspecificprotocolforpostsurgicalrehabilitation, returntosportandindicationofirreparableinjuries.
Conclusions: Brazilianshouldersurgeonshavewell-establishedapproachestowardtreating rotatorcuffinjuries.Mostoftheseapproachesdiffersignificantlyfromthoseofother special-ties.Thisshowstheimportanceofplacingvalueontraininginpreparingshoulderspecialists inthiscountry.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkperformedintheSportsTraumatologyGroup,OrthopedicsandTraumatologyService,EscolaPaulistadeMedicina,Universidade FederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:fabioavepm74@gmail.com(F.A.Vieira).
http://dx.doi.org/10.1016/j.rboe.2015.10.012
Lesão
do
manguito
rotador:
tratamento
e
reabilitac¸ão.
Perspectivas
e
tendências
atuais
Palavras-chave:
Manguitorotador Terapêutica Reabilitac¸ão
r
e
s
u
m
o
Objetivo: Mapearascondutasdosortopedistasbrasileirosnotratamentodaslesões com-pletasdomanguitorotador.
Métodos: Umquestionáriodemúltiplasescolhasfoientreguea232ortopedistasno45◦ CongressoBrasileirodeOrtopediaeTraumatologia.Foramdevolvidos207questionários, mascincoestavamincompletoseforamexcluídos.Totalfinalde202questionários.
Resultados: Dosortopedistasqueresponderamosquestionários,cercade60%foramda RegiãoSudeste,46%eramcirurgiõesdeombroecotovelo.Houveassociac¸ãosignificativa (p<0,05)entretempodeexperiênciaenúmerodereparosdomanguitorotadorfeitos anual-mente.Tambémhouveassociac¸ãosignificativa(p<0,05)entreespecialidadedeombroeas seguintesvariáveis:técnicaartroscópica,usodeâncorasnaconfigurac¸ãodefileirasimples, tempomédioparaindicac¸ãodecirurgiaemlesõestraumáticasedegenerativas,usode pro-tocoloespecíficoparareabilitac¸ãopós-cirúrgica,retornoaoesporteeindicac¸ãodelesões irreparáveis.
Conclusões: OscirurgiõesdeombrodoBrasiltêmcondutasbemestabelecidasemrelac¸ão aotratamentodaslesõesdomanguitorotadorquediferem,emsuamaioria, significativa-mente,dascondutasdoscirurgiõesdeoutrasespecialidades.Issomostraaimportânciada valorizac¸ãodotreinamentonaformac¸ãodosespecialistasdeombroemnossopaís.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Rotatorcuffinjuriesareasignificantsourceofshoulderpain anddysfunction.1Theyoccurmainlyinpatientsbetween40 and60yearsofageandmaybeoftraumaticordegenerative origin.
Despitethevastquantityofpublishedpapersonthistopic, wewereunabletofindanyconsensusonthissubjectinthe Brazilianliterature.2
Thehighincidenceoftheseinjuriesandthegreat impor-tanceofthesocialandeconomicissuesrelatingtothem,along withthedivergencesthatexistonthissubjectintheliterature, makeitextremelyimportanttoevaluatetheapproachesand trendsthatexitinBrazilonthistopic.
The aim of the present study was to evaluate the approachesandproceduresusedbyorthopedicsurgeonsin Brazilintreatingandrehabilitatingrotatorcuffinjuriesofthe shoulder. From the resultsofthis study,wewould beable todelimitthenationaltrendsonthismatterandalsoguide futurestudiesofquality.
Materials
and
methods
This was a descriptive study with application of a ques-tionnairetoasampleofBrazilianorthopedicsurgeons.The questionnairewasdrawnupandapprovedbytheauthorsin suchawaythatitwouldbesimpleandveryeasyto under-stand. It consisted of 16 closed questions that addressed topics suchas the number ofyears ofexperience and the annual number of surgical procedures performed by the
surgeons, and a variety of factors relating to treatment and rehabilitation of rotator cuff injuries of the shoulder (Annex1).Thequestionnairewasappliedtoorthopedic sur-geons duringthe 3days ofthe 45thBrazilian Congress of Orthopedics and Traumatology, in 2013. Only orthopedists who performedsurgeryfilledout thequestionnaire.Inthis manner, 207 questionnaires were filled out, but five were incomplete and were excluded. Thus a total of 202 ques-tionnaires were evaluated. To resolve any possible doubts whiletheformswerebeingfilledout,tworesearcherswere presentthroughouttheperiodwhenthequestionnaireswere applied.
Descriptivestatisticalanalysiswasperformedonthe vari-ablesinvolvedinthedataretrievedfromthequestionnaire,in ordertocharacterizethesample.
The data were analyzed using the SPSS for Windows software, version 16.0, and the significance level used was5%.
Results
Table1–Descriptionofthenumberofrepairsaccordingtothespecialty.
Howmanyrotatorcuffrepairsdo youdoperyear(numberperyear)?
Specialty Total p
Shoulder Others
n % n % n %
<20 8 17.4 58 79.5 66 55.5 < 0.001
20–30 9 19.6 6 8.2 15 12.6
30–40 5 10.9 3 4.1 8 6.7
40–60 2 4.3 3 4.1 5 4.2
>60cases 22 47.8 3 4.1 25 21.0
Total 46 100 73 100 119 100
Table2–Descriptionofthetypeofrepairaccordingtospecialty.
Whattypeofrepairdoyouuse? Specialty Total p
Others Others
n % n % n %
Singlerow 33 71.7 27 37 60 50.4 0.002
Doublerow 8 17.4 23 31.5 31 26.1
Transosseousstitch 4 8.7 15 20.5 19 16.0
Transosseousequivalent 1 2.2 8 11.0 9 7.6
Total 46 100 73 100 119 100
Table3–Descriptionofthedurationofimmobilizationrecommended,accordingtospecialty.
Howmuchimmobilizationtimedo yourecommend?
Specialty Total p
Shoulder Others
n % n % n %
Earlyrehabilitation 2 4.3 12 16.4 14 11.8 0.020
<3weeks 4 8.7 16 21.9 20 16.8
3–6weeks 31 67.4 36 49.3 67 56.3
Dependsontheinjury 9 19.6 9 12.3 18 15.1
Total 46 100 73 100 119 100
Withregardtothe typeofrepairperformed, 50%ofthe surgeonsusedanchorsconfiguredasasinglerowand26%as adoublerow.Wefoundthattherepairconfiguration(single row)andthetypeoftechnique(arthroscopic)showeda statis-ticallysignificantrelationshipwiththespecialtyofshoulder andelbowsurgery(p<0.05)(Table2).
Theshouldersurgeonsagreedinrelationtothelengthof postoperativeimmobilization(3–6weeks)andthetimetaken
toreturntosports(>6months).Bothoftheseshoweda sig-nificantdifferenceinrelationtosurgeonsinotherspecialties
(Table3).
In defining irreparableinjuries, the shoulder specialists usedthedegreeoffattyinfiltrationmorefrequentlythandid surgeonsinotherspecialties(p<0.01)(Table4).
Lastly,theshouldersurgeonsindicatedsurgicaltreatment at an earlier stage, in relation to both traumatic injuries
Table4–Descriptionofthecriteriaforirreparableinjury,accordingtospecialty.
Whatcriteriadoyouuseforclassifying injuriesasirreparable?
Specialty Total p
Shoulder Others
n % n % n %
Acromion-humerusdistance 18 39.1 38 52.1 56 47.1 0.010
Fattyinfiltrations 23 50 16 21.9 39 32.8
Patient’sage 4 8.7 13 17.8 17 14.3
Numberoftendonsaffected 1 2.2 6 8.2 7 5.9
Table5–Descriptionofthedurationoftreatmentfortraumaticinjuriesbeforetheprocedure,accordingtospecialty.
Whatistheaveragedurationofphysiotherapythat youprescribebeforeindicatingsurgeryfor traumaticrotatorcuffinjuries?
Specialty Total p
Shoulder Others
n % n % n %
Immediatesurgery 27 58.7 14 19.2 41 34.5 < 0.001
2months 8 17.4 12 16.4 20 16.8
2–6months 11 23.9 37 50.7 48 40.3
>6months 0 0.0 7 9.6 7 5.9
Idon’toperate 0 0.0 3 4.1 3 2.5
Total 46 100 73 100 119 100
Table6–Descriptionofthedurationoftreatmentfordegenerativelesions,accordingtospecialty.
Whatistheaveragedurationofphysiotherapythat youprescribebeforeindicatingsurgeryfor degenerativerotatorcufflesions?
Specialty Total p
Shoulder Others
n % n % n %
Immediatesurgery 5 10.9 5 6.8 10 8.4 < 0.001
2months 8 17.4 8 11.0 16 13.4
2–6months 32 69.6 34 46.6 66 55.5
>6months 1 2.2 17 23.3 18 15.1
Idon’toperate 0 0.0 9 12.3 9 7.6
Total 46 100 73 100 119 100
Table7–Descriptionofthetypeofanchoraccordingtospecialty.
Whattypeofanchordoyouuse? Specialty Total p
Shoulder Others
n % n % n %
Metallic 23 50.0 42 57.5 65 54.6 0.494
Bioabsorbable 22 47.8 27 37.0 49 41.2
Peek 1 2.2 3 4.1 4 3.4
Others 0 0.0 1 1.4 1 0.8
Total 46 100 73 100 119 100
anddegenerativelesions,thandidspecialistsinotherareas (p<0.01)(Tables5and6).
Theresultsrelatingtotheanchormaterialused(Table7) andthemostfrequenttypesofcomplications(Table8)were notstatisticallysignificant.
Discussion
Theincidenceofcompletetearsoftherotatorcuffrangesfrom 5%to40%.Epidemiologicalstudieshavecorrelatedincreased
Table8–Descriptionofthemaincomplicationsobserved,accordingtospecialty.
Maincomplicationsobserved Specialty Total p
Shoulder Others
n % n % n %
Nocomplications 5 10.9 4 5.5 9 7.6 0.135
Infection 0 0.0 3 4.1 3 2.5
Repeatedrupture 15 32.6 33 45.2 48 40.3
Adhesivecapsulitis 26 56.5 32 43.8 58 48.7
Reactiontoanchor 0 0.0 1 1.4 1 0.8
frequencyoftheseinjurieswithadvancingage.Symptomatic lesionsoftherotatorcuffarecommonlyseenduringdaily clin-icalpractice.AccordingtoDiasetal.,1 rotatorcufftearsare themostfrequentcauseofpainduringday-to-dayactivities, andtheyhavegreaterprevalenceamongwomenandonthe dominantside.Accordingtoasystematicreviewpublishedby Ejnismanetal.,2nostudieswithahighlevelofevidencehave demonstratedwhatthebestapproachshouldbe,indealing withrotatorcuffinjuries.
Likewise,thereisnostandardapproachusedbyBrazilian orthopedists.Thenovelfeatureofthepresentstudywasthat itsaimwastoshowtheapproachesusedamongorthopedists whoweremembersoftheBrazilianSocietyofOrthopedicsand Traumatology(SBOT),inrelationtothisinjury.Thegreatest representationinoursamplecomprisedorthopedists work-inginthesoutheasternregionofBrazil,whichportraysthe situationinthiscountry,inwhichthereisnolackof profes-sionals,butthereispoordistributionofphysiciansbetween thedifferentregions.
Fromthedataobtained,itcanbeperceivedthatthegreater thedegreeofspecializationinthisarea(shoulderandelbow surgery)andthegreater thesurgeon’sexperiencewere,the largerthenumberofrepairsperformedwas.Thespecialists inthisareaindicatedsurgicaltreatmentatanearlierstage, independentoftheetiologyofthelesion(traumaticor degen-erative).Thiscan beexplainedbecause inour sample,the surgeonsdefinedinjuriesasirreparableonthe basisofthe degreeoffatty infiltration,andnotaccordingtothesizeof thelesion,whichdemonstratestheirconcernregardingthe evolutionarynatureoftheinjury.
Currently,there are nostudies witha high level of evi-dencethat provethat a doublerow issuperior toa single row,especiallythroughclinicalassessmentsdoneusing func-tionalscales(UCLA,DASH,ConstantorASES).3–9However,the latesttwoarticlesdescribeabiomechanicaladvantagefrom fixationandbetterreestablishmentofmusclestrengthamong patientswhounderwentrepairbymeansofadoublerow, com-paredwithasinglerow.Althoughthedouble-rowtechnique does not show functional superiority over the single-row technique,surgeonsrequire greater skilland experience to performthedoubletechnique.However,inoursample,there wasnostatisticalcorrelationbetweenthetypeofrepair per-formedand the surgeon’s degree of experience or level of specialization.Nonetheless, our datashowed that the cur-rent preference of shoulder surgery specialists is for the single-rowtechnique.Thestrongpointofourstudyisthat it provided a current portrayal of the approaches used by Brazilianorthopedists in relation totreatments for rotator cuffinjuries, and thatit provesdata forguiding the train-ing ofresidents inshoulder and elbowsurgery atservices
accredited by the Brazilian Society ofShoulder and Elbow Surgery.
Conclusion
ShouldersurgeryspecialistsinBrazilhaveagreatertendency toindicatesurgicaltreatmentforrotatorcuffinjuriesatan earlier stage than do non-specialists. There is currently a preferenceamongBrazilianshouldersurgeonsforperforming repairsusingasinglerowofanchors.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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