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18 Arthroscopic repair of full-thickness rotator cuff tears
I Shoulder Volume 7,
Elbow Number
Abstracts
Surg 3
Results: The average
measured displacement force for all specimens after scapular neck fracture was 191.8 ? 9.8 N (180-204). After sequential sectioning of the CA ligament and CC ligament the average displacement forces were 130 i 10.2 N (1 1 O-l 42) and 0 N, respectively. The addition of a clavicle fracture (prior to any ligament sectioning) decreased the average measured displacement force to 147.1 i- 11.8 N (130-157.1). Subsequent sequential sectioning of the CA and AC ligaments yielded average displacement forces of 13 1.5 2 16.2 N (120-l 43) and 0 N, respectively. Discussion: Combined scapular neck and clavicle fracture without CA and AC ligamentous disruption does not produce a floating shoulder. In fact, the resistance to displacement of a surgical neck fracture was decreased by an average of only 23.3% with the addition of a clavicular shaft fracture. Therefore, surgical stabilization is probably not indicated in cases of ipsilateral clavicular shaft and scapular neck fracture unless displacement of the scapular neck component is significant enough to have disrupted the CA and AC capsular ligaments.
17
Six patients had prior surgical treatment of their fractures and one of them underwent a second surgery for treatment of the nonunion. Method: Seven patients were treated with ORIF and bone grafting; 10 patients underwent hemiarthroplasties; 2 patients were submitted to a total shoulder, and one to Jones’ procedure (massive rotator cuff tear). Results: Based on the UCLA rating score, 6 patients had satisfactory results and 14 unsatisfactory. However based on the “limited oals” Neer score, 12 had satisfactory results an dg 8 unsatisfactory. Five patients were reoperated (one of them twice). No statistical difference was noted between groups: type of lesion, treatment regimen, time of lesion, etc. Discussion: 2-part fractures may develop nonunion in distinct manners. The HIGH 2-part type presents great cavitation and has a very small proximal fragment making ORIF hard to perform. The LOW 2-part fracture, has a greater proximal fragment, theoretically presenting better chances of ORIF. It was observed that cavitation was not related to the time of lesion. The results were very poor: mean UCLA 5.8. However, 75% of patients were satisfied with the improvement of pain: mean UCLA 7.6. The main objective of this classification is to differentiate cases with good prognosis from those with poor prognosis making the comparison of results possible.
PROPOSITION OF A CLASSIFICATION FOR NONUNIONS OF THE PROXIMAL HUMERUS AND RESULTS OF TREATMENT Sl Checchia, MD, PS Doneux, MD, AN Miyazaki, MD, /AZ Spir, MD, R Bringel, MD, CH Ramos, MD, Department of Orthopedics, Santa Casa Hospitals, School of Medicine, S~O Paulo, Brazil Very few papers have been published to date on nonunions of the proximal humerus, and most of these show unfavorable results. This study was based on a group of 21 patients (22 shoulders) with this lesion, presenting equally disappointing results. Comparisons are difficult to be made between the experience of different authors since there is no specific classification for this disease. Based on the authors’ experience, a classification is proposed.
Classification: A - HIGH 2-PART SURGICAL
NECK - The nonunion is located close to the great tuberosity with significant cavitation of the humerus head. The proximal fragment is very small. B - LOW 2-PART SURGICAL NECK -The nonunion is located close to the diaphysis and the proximal fragment is larger. C - 3 AND 4-PART - Resulting from fractures in 3 or 4 parts (with or without necrosis), with a deviation greater than 5 mm of the tuberosities (with or without tuberosities union). D - LOST FRAGMENTS - Usually secondary to open fractures and/or post traumatic osteomyelitis. Material: Twenty of the 22 cases had a 41-month follow-up. Nine patients were males and 10 were females (one case had bilateral lesion); mean age was 55.3 years; mean time between the fracture and treatment of the nonunion was 14.1 months.
309
18
ARTHROSCOPIC REPAIR OF FULL-THICKNESS ROTATOR CUFF TEARS GM Gartsman, Texas, Orthopedic
M
Khan, Hospital,
M Hammerman, SM Houston, TX Materials and Methods: The cohort consisted of seventy-three patients: thirty-nine men and thirtyfour women. The average age at the time of operation was 60.7 years (range, thirty-one to eighty-two years). Evaluation systems included the UCLA shoulder scale, the Constant scoring system and the American Shoulder and Elbow Surgeons Index. All patients completed an SF-36 Health Survey before treatment and at final evaluation. The average interval from operation to final evaluation was thirty months (range twenty-four to forty months). Results Active and passive range of motion improvements were statistically significant (p
3 10
Abstracts
J Shoulder Elbow May/June
as good to excellent. Preoperatively no patients were rated overall as good to excellent while at final follow-up 84 per cent (sixty-one of seventythree) were rated as good to excellent. Significant improvements (p <0.015) were noted in the SF-36 Health Survey Scales and Summary Measures. The arthroscopic operation is successful and has the advantages of glenohumeral joint inspection, treatment of intra-articular lesions, smaller incisions, no deltoid detachment and less soft-tissue dissection. However, these advantages must be balanced against the technical difficulty of the method which restricts its use to surgeons skilled in both open and arthroscopic shoulder operations.
19
several variables including functional results, length of operative time, duration of hospital stay, as well as the rate of complications. Methods: Thirty patients with full-thickness rotator cuff tears isolated to the supraspinatus tendon were identified. In each case, no other shoulder pathology was present. Fifteen of the patients underwent a traditional open acromioplasty and rotator cuff repair. The other fifteen patients underwent arthroscopic acromioplasty followed by rotator cuff repair through a “mini” incision. This incision consisted of a 2.5 to 3.0 cm distal extension of the anterolateral arthroscopy portal. Operative time as well as length of hospital stay were noted. At a minimum follow-up of one year, all patients filled out a subjective questionnaire on functional results, and were reexamined by one of the two senior authors. Results: The average operative time for the miniopen patients (123 minutes) was significantly longer than those undergoing the traditional open repair (98 minutes) with p ~0.049. The percentage of mini-open patients discharged to home on the same day of surgery (73%) was significantly greater than those undergoing open repair (8%) with p <0.0003. However, the ostop complication rate (including number of Prozen shoulders, failed cuff repairs, or deltoid detachments) was 27% in the mini-open patients compared to 0% in the open patients ( ~0.05). There was no difference in subjective Punctional outcome between the two groups, but there was a significantly higher percentage of restricted range of motion in the mini-open group (20% versus 0% in the open group; p ~0.05). Although the scar length was significantly longer in the open group (7.3 cm compared to 3.8 cm), there was no difference in subjective rating of the postoperative scar. Discussion/Conclusion: Based on significantly longer operative times and an increased incidence of complications with mini-open repair, as well as poorer objective functional results, the authors prefer the traditional open technique for repair of full thickness rotator cuff tears.
ALL ARTHROSCOPIC VERSUS MINI OPEN REPAIR IN THE MANAGEMENT OF TEAR OF THE ROTATOR CUFF: A PROSPECTIVE STUDY Weber, MD, 2801 K St., Sacramento, 95816 Mini open rotator cuff repair has been shown by several studies to provide predictable results in the management of small to moderate rotator cuff tears for those patients that require surgical repair. More recent1 , all arthroscopic repairs have been describe cr Presented here is the first prospective report to compare all arthroscopic repairs with miniopen rotator cuff repairs by a single surgeon with extensive experience with operative shoulder arthroscopy. Twenty nine chose an all arthroscopic repair versus 15 1 with an open repair. Follow-up averaged 36.3 months for the arthroscopic and 47.8 for open with a minimum of two years. Age, gender, associated findings at surgery, and duration of surgery were not significantly different between the two groups. Perioperative morbidity was significantly decreased with all arthroscopic repair, allowing 94% to be performed outpatient versus 28% (p ~0.01) and significantly less narcotic use. Recovery of motion was not significantly different at any time of follow-up. Final motion, pain, and UCLA scores were good to excellent for both groups (31.4 versus 30.2, p = N.S.). There were two manipulation and two reoperations for failed repair in the open group (2%). Four patients were noted to have loose anchors in the arthroscopic group with two failed repairs with a reoperation rate of 14% (p ~0.01). The short term improvement in operative morbidity with all arthroscopic repairs must be weighed carefully against the increase in complications seen given the predictable results of miniopen repair.
SC
20
MINI VS. OPEN REPAIR OF ISOLATED SUPRASPINATUS TENDON TEARS GR Williams, MD, JP lannotti, MD, W Luchetti, MD, A Ferron, MD, Dept. of Orthopaedic Surg., Univ. of Pennsylvania, Philadelphia, PA Introduction: We sought to examine the proposed advantages of mini-open rotator cuff repair over the more traditional open approach by analysis of
Surg 1998
21
LONG-TERM FUNCTIONAL OUTCOME FOLLOWING LARGE AND MASSIVE ROTATOR CUFF REPAIR AS Rokito, MD, F Cuomo, MD, MA Gallagher, PhD, JD Zuckerman, MD, Shoulder Service, Hospital for Joint Diseases, New York There have been conflicting reports relating the size of tear and the recovery of function following rotator cuff repair. The urpose of this study was to quantify long-term iso R inetic strength and functional outcome measures in patients who underwent repair of large (3-5 cm) and massive (>5 cm) rotator cuff tears. Methods: Thirty consecutive patients (2 1 males and 9 females, mean age 55.7 years) with large and
Elbow Number
Abstracts
Surg 3
Results: The average
measured displacement force for all specimens after scapular neck fracture was 191.8 ? 9.8 N (180-204). After sequential sectioning of the CA ligament and CC ligament the average displacement forces were 130 i 10.2 N (1 1 O-l 42) and 0 N, respectively. The addition of a clavicle fracture (prior to any ligament sectioning) decreased the average measured displacement force to 147.1 i- 11.8 N (130-157.1). Subsequent sequential sectioning of the CA and AC ligaments yielded average displacement forces of 13 1.5 2 16.2 N (120-l 43) and 0 N, respectively. Discussion: Combined scapular neck and clavicle fracture without CA and AC ligamentous disruption does not produce a floating shoulder. In fact, the resistance to displacement of a surgical neck fracture was decreased by an average of only 23.3% with the addition of a clavicular shaft fracture. Therefore, surgical stabilization is probably not indicated in cases of ipsilateral clavicular shaft and scapular neck fracture unless displacement of the scapular neck component is significant enough to have disrupted the CA and AC capsular ligaments.
17
Six patients had prior surgical treatment of their fractures and one of them underwent a second surgery for treatment of the nonunion. Method: Seven patients were treated with ORIF and bone grafting; 10 patients underwent hemiarthroplasties; 2 patients were submitted to a total shoulder, and one to Jones’ procedure (massive rotator cuff tear). Results: Based on the UCLA rating score, 6 patients had satisfactory results and 14 unsatisfactory. However based on the “limited oals” Neer score, 12 had satisfactory results an dg 8 unsatisfactory. Five patients were reoperated (one of them twice). No statistical difference was noted between groups: type of lesion, treatment regimen, time of lesion, etc. Discussion: 2-part fractures may develop nonunion in distinct manners. The HIGH 2-part type presents great cavitation and has a very small proximal fragment making ORIF hard to perform. The LOW 2-part fracture, has a greater proximal fragment, theoretically presenting better chances of ORIF. It was observed that cavitation was not related to the time of lesion. The results were very poor: mean UCLA 5.8. However, 75% of patients were satisfied with the improvement of pain: mean UCLA 7.6. The main objective of this classification is to differentiate cases with good prognosis from those with poor prognosis making the comparison of results possible.
PROPOSITION OF A CLASSIFICATION FOR NONUNIONS OF THE PROXIMAL HUMERUS AND RESULTS OF TREATMENT Sl Checchia, MD, PS Doneux, MD, AN Miyazaki, MD, /AZ Spir, MD, R Bringel, MD, CH Ramos, MD, Department of Orthopedics, Santa Casa Hospitals, School of Medicine, S~O Paulo, Brazil Very few papers have been published to date on nonunions of the proximal humerus, and most of these show unfavorable results. This study was based on a group of 21 patients (22 shoulders) with this lesion, presenting equally disappointing results. Comparisons are difficult to be made between the experience of different authors since there is no specific classification for this disease. Based on the authors’ experience, a classification is proposed.
Classification: A - HIGH 2-PART SURGICAL
NECK - The nonunion is located close to the great tuberosity with significant cavitation of the humerus head. The proximal fragment is very small. B - LOW 2-PART SURGICAL NECK -The nonunion is located close to the diaphysis and the proximal fragment is larger. C - 3 AND 4-PART - Resulting from fractures in 3 or 4 parts (with or without necrosis), with a deviation greater than 5 mm of the tuberosities (with or without tuberosities union). D - LOST FRAGMENTS - Usually secondary to open fractures and/or post traumatic osteomyelitis. Material: Twenty of the 22 cases had a 41-month follow-up. Nine patients were males and 10 were females (one case had bilateral lesion); mean age was 55.3 years; mean time between the fracture and treatment of the nonunion was 14.1 months.
309
18
ARTHROSCOPIC REPAIR OF FULL-THICKNESS ROTATOR CUFF TEARS GM Gartsman, Texas, Orthopedic
M
Khan, Hospital,
M Hammerman, SM Houston, TX Materials and Methods: The cohort consisted of seventy-three patients: thirty-nine men and thirtyfour women. The average age at the time of operation was 60.7 years (range, thirty-one to eighty-two years). Evaluation systems included the UCLA shoulder scale, the Constant scoring system and the American Shoulder and Elbow Surgeons Index. All patients completed an SF-36 Health Survey before treatment and at final evaluation. The average interval from operation to final evaluation was thirty months (range twenty-four to forty months). Results Active and passive range of motion improvements were statistically significant (p
3 10
Abstracts
J Shoulder Elbow May/June
as good to excellent. Preoperatively no patients were rated overall as good to excellent while at final follow-up 84 per cent (sixty-one of seventythree) were rated as good to excellent. Significant improvements (p <0.015) were noted in the SF-36 Health Survey Scales and Summary Measures. The arthroscopic operation is successful and has the advantages of glenohumeral joint inspection, treatment of intra-articular lesions, smaller incisions, no deltoid detachment and less soft-tissue dissection. However, these advantages must be balanced against the technical difficulty of the method which restricts its use to surgeons skilled in both open and arthroscopic shoulder operations.
19
several variables including functional results, length of operative time, duration of hospital stay, as well as the rate of complications. Methods: Thirty patients with full-thickness rotator cuff tears isolated to the supraspinatus tendon were identified. In each case, no other shoulder pathology was present. Fifteen of the patients underwent a traditional open acromioplasty and rotator cuff repair. The other fifteen patients underwent arthroscopic acromioplasty followed by rotator cuff repair through a “mini” incision. This incision consisted of a 2.5 to 3.0 cm distal extension of the anterolateral arthroscopy portal. Operative time as well as length of hospital stay were noted. At a minimum follow-up of one year, all patients filled out a subjective questionnaire on functional results, and were reexamined by one of the two senior authors. Results: The average operative time for the miniopen patients (123 minutes) was significantly longer than those undergoing the traditional open repair (98 minutes) with p ~0.049. The percentage of mini-open patients discharged to home on the same day of surgery (73%) was significantly greater than those undergoing open repair (8%) with p <0.0003. However, the ostop complication rate (including number of Prozen shoulders, failed cuff repairs, or deltoid detachments) was 27% in the mini-open patients compared to 0% in the open patients ( ~0.05). There was no difference in subjective Punctional outcome between the two groups, but there was a significantly higher percentage of restricted range of motion in the mini-open group (20% versus 0% in the open group; p ~0.05). Although the scar length was significantly longer in the open group (7.3 cm compared to 3.8 cm), there was no difference in subjective rating of the postoperative scar. Discussion/Conclusion: Based on significantly longer operative times and an increased incidence of complications with mini-open repair, as well as poorer objective functional results, the authors prefer the traditional open technique for repair of full thickness rotator cuff tears.
ALL ARTHROSCOPIC VERSUS MINI OPEN REPAIR IN THE MANAGEMENT OF TEAR OF THE ROTATOR CUFF: A PROSPECTIVE STUDY Weber, MD, 2801 K St., Sacramento, 95816 Mini open rotator cuff repair has been shown by several studies to provide predictable results in the management of small to moderate rotator cuff tears for those patients that require surgical repair. More recent1 , all arthroscopic repairs have been describe cr Presented here is the first prospective report to compare all arthroscopic repairs with miniopen rotator cuff repairs by a single surgeon with extensive experience with operative shoulder arthroscopy. Twenty nine chose an all arthroscopic repair versus 15 1 with an open repair. Follow-up averaged 36.3 months for the arthroscopic and 47.8 for open with a minimum of two years. Age, gender, associated findings at surgery, and duration of surgery were not significantly different between the two groups. Perioperative morbidity was significantly decreased with all arthroscopic repair, allowing 94% to be performed outpatient versus 28% (p ~0.01) and significantly less narcotic use. Recovery of motion was not significantly different at any time of follow-up. Final motion, pain, and UCLA scores were good to excellent for both groups (31.4 versus 30.2, p = N.S.). There were two manipulation and two reoperations for failed repair in the open group (2%). Four patients were noted to have loose anchors in the arthroscopic group with two failed repairs with a reoperation rate of 14% (p ~0.01). The short term improvement in operative morbidity with all arthroscopic repairs must be weighed carefully against the increase in complications seen given the predictable results of miniopen repair.
SC
20
MINI VS. OPEN REPAIR OF ISOLATED SUPRASPINATUS TENDON TEARS GR Williams, MD, JP lannotti, MD, W Luchetti, MD, A Ferron, MD, Dept. of Orthopaedic Surg., Univ. of Pennsylvania, Philadelphia, PA Introduction: We sought to examine the proposed advantages of mini-open rotator cuff repair over the more traditional open approach by analysis of
Surg 1998
21
LONG-TERM FUNCTIONAL OUTCOME FOLLOWING LARGE AND MASSIVE ROTATOR CUFF REPAIR AS Rokito, MD, F Cuomo, MD, MA Gallagher, PhD, JD Zuckerman, MD, Shoulder Service, Hospital for Joint Diseases, New York There have been conflicting reports relating the size of tear and the recovery of function following rotator cuff repair. The urpose of this study was to quantify long-term iso R inetic strength and functional outcome measures in patients who underwent repair of large (3-5 cm) and massive (>5 cm) rotator cuff tears. Methods: Thirty consecutive patients (2 1 males and 9 females, mean age 55.7 years) with large and