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Complications After Arthroscopic Rotator Cuff Repair
Complications After Arthroscopic Rotator Cuff Repair Kenneth J. Brislin, M.D., Larry D. Field, M.D., and Felix H. Savoie III, M.D.
Purpose: The purpose of this study was to determine the complication rate of a consecutive series of patients undergoing arthroscopic rotator cuff repair. Methods: From January 2003 to June 2003, all patients undergoing primary arthroscopic rotator cuff repair were identified. A total of 263 patients were identified. Medical records were reviewed to identify complications in the study patients. Results: A total of 28 patients (10.6%) sustained a complication. Complications included shoulder stiffness, failure of healing, infection, reflex sympathetic dystrophy, deep venous thrombosis, and death. Conclusions: The most common complication was recognized as persistent stiffness that usually responded to extensive physical therapy. Complications after arthroscopic rotator cuff repair are similar to results published for open rotator cuff repair. Level of Evidence: Level IV, therapeutic case series. Key Words: Arthroscopy—Shoulder—Rotator cuff—Complications.
S
houlder arthroscopy has gained increasing popularity for treating many shoulder pathologies. The reported advantages of arthroscopic rotator cuff repair include the enhanced ability to assess the glenohumeral joint, avoidance of deltoid detachment, less tissue dissection, improved cosmesis, decreased pain after surgery, and more rapid return of motion.1,2 The short-term and midterm outcomes after arthroscopic rotator cuff repair have been good to excellent even in older populations.1-8 However, there has been a paucity of literature regarding the complications associated with arthroscopic rotator cuff repair. Studies have reported overall complication rates after a wide variety of shoulder arthroscopic procedures, but none has specifically addressed arthroscopic rotator cuff repair.9-14 Studies have reported complication rates after open rotator cuff repairs. Mansat et al.,13 in their
From Orthopaedic Associates of Allentown (K.J.B.), Allentown, Pennsylvania, and Mississippi Sports Medicine and Orthopaedic Center (L.D.F., F.H.S.), Jackson, Mississippi, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Kenneth J. Brislin, M.D., Orthopaedic Associates of Allentown, 1243 S Cedar Crest Blvd, Allentown, PA 18103, U.S.A. E-mail: kjbrislin@ hotmail.com © 2007 by the Arthroscopy Association of North America 0749-8063/07/2302-0582$32.00/0 doi:10.1016/j.arthro.2006.09.001
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review of 40 articles evaluating open rotator cuff repairs, found a complication rate of 10.5%. Complication rates after arthroscopic shoulder procedures ranging from 4.8% to 10.6% have been reported.9-12,15,16 Reported complications included direct nerve injury, brachial plexus stretch neurapraxia, reflex sympathetic dystrophy (RSD), infection, stiffness, failure of repair, instrument breakage, hardware failure, fluid extravasation, deep venous thrombosis (DVT), and complications related to anesthesia. Other studies have compared complication rates between arthroscopic and “combined” arthroscopic and open procedures. Curtis et al.10 reported a rate of 4.8% for arthroscopic shoulder surgeries and a rate of 8.8% for the combined procedures. In contrast, Berjano et al.11 found that the complication rate was 10.6% after arthroscopic shoulder procedures and 5.3% after combined procedures. The purpose of this study was to determine the complication rate for a consecutive series of patients undergoing primary arthroscopic rotator cuff repair. We expected the complication rate after arthroscopic rotator cuff repair to be comparable to that after open rotator cuff repair.
METHODS All patients who underwent arthroscopic rotator cuff surgery by the 2 senior authors (L.D.F. and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 2 (February), 2007: pp 124-128
ARTHROSCOPIC ROTATOR CUFF REPAIR F.H.S.) between January and June 2003 were identified. There were no open or mini-open rotator cuff repairs performed by either author during the study period. We excluded patients with a primary diagnosis of adhesive capsulitis who underwent capsular release along with a rotator cuff repair, those with a primary diagnosis of instability who were found to have a rotator cuff tear at surgery, and those undergoing revision surgery. A retrospective chart review of all patients was carried out to identify those patients who sustained a complication within the first 90 days postoperatively. A complication was defined as any postoperative event or condition that required additional treatment, either nonoperative or operative. For all patients, the following information was collected: age, sex, hand dominance, operative shoulder, size of tear and tendons involved, type of repair, any complication, time to diagnosis of complication, treatment of complication, and time to resolution of complication. For all patients in this study undergoing arthroscopic rotator cuff repair, the procedure began with a diagnostic glenohumeral assessment. Pathologic glenohumeral conditions identified at surgery were addressed. Rotator cuff tear identification and debridement were then carried out. Next, subacromial bursectomy and decompression with acromioplasty were performed. Distal clavicle excision was performed when preoperative clinical examination showed a symptomatic acromioclavicular joint and radiographs were positive for acromioclavicular joint arthrosis. The distal 10 mm of the clavicle was resected through an anterior portal with a bur. Care was taken not to violate the superior and posterior capsule of the acromioclavicular joint. The senior authors also agreed with Fischer et al.,17 who recommended an “all-ornone” rule regarding distal clavicle excision. According to their approach, if violation of the acromioclavicular joint was required to adequately decompress the subacromial space, complete resection of the distal clavicle was the preferred approach. Patients underwent arthroscopic rotator cuff repair by use of absorbable anchor fixation with or without convergence sutures depending on rotator cuff tear orientation and size. Postoperative rehabilitation regimens were altered to some extent depending on the specifics of the patient’s rotator cuff tear. All patients in this consecutive series started passive range-of-motion exercises on postoperative day 1 and began an organized exercise program under the supervision of a physical therapist within 5 to 14 days after surgery.
125 RESULTS
A total of 263 patients underwent arthroscopic rotator cuff repair during the study period between January 1 and June 30, 2003. We identified the development of a complication in 28 patients (10.6%), and no patient had more than 1 complication. All complications were diagnosed within 90 days postoperatively. There were 10 men and 18 women affected, with a mean age of 61 years (range, 26 to 76 years). The dominant extremity was involved in 20 patients, and the right shoulder was operated on in 17. Concurrent procedures on the affected extremities in 6 of 28 patients included arthroscopic distal clavicle excision, labral repair, arthroscopic biceps tenodesis, carpal tunnel release, and lateral epicondylitis release (Table 1). All 28 patients underwent a diagnostic glenohumeral arthroscopy, followed by subacromial decompression with release of the acromioclavicular ligament, acromioplasty, and rotator cuff repair. A distal clavicle excision was performed in 24 of 28 patients (86%) sustaining complications. The percentage of patients undergoing distal clavicle excision among this group did not vary significantly from that in the larger consecutive group. All intra-articular pathology was treated at the time of rotator cuff repair. Three patients had concurrent anterior labral repair via anchor fixation. Two had arthroscopic biceps tenodesis for biceps tears involving greater than 50% of the tendon thickness. The biceps tendons underwent tenodesis via a soft-tissue technique incorporating the biceps tendon into the rotator interval and rotator cuff repair. In 4 patients extra-articular pathology was addressed. There were 3 patients who underwent ipsilateral carpal tunnel releases and 1 who had an ipsilateral open lateral epicondylitis release. No statistically significant correlation between treatment of intra-articular or extra-articular pathology and development of a complication was found. The complications identified included stiffness, failure of healing, RSD, DVT, infection, and death (Table 2). Stiffness was diagnosed in the operative
TABLE 1. Procedures Performed Concurrently in Ipsilateral Extremity in Patients With Complications Subacromial decompression Distal clavicle excision Labral reattachment Biceps tenodesis Endoscopic carpal tunnel release Lateral epicondyle release
28 24 3 2 3 1
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K. J. BRISLIN ET AL. TABLE 2.
Stiffness Failure of healing RSD DVT Infection Death
Complications 23 1 1 1 1 1
shoulder when one of the following was present: total passive external rotation with the arm at the side of less than 10°, total passive external rotation with the arm in 90° abduction of less than 30°, or total passive forward flexion of less than 100°. The diagnosis of stiffness was made only when these motion deficits persisted for 90 days postoperatively. Postoperative stiffness was diagnosed is 23 patients. Within this group of patients in whom stiffness developed, there were 5 partial tears, 11 small tears, 4 medium tears, and 3 large tears identified, where the tear size was categorized as small (ⱕ1 cm), medium (1-3 cm), large (3-5 cm), or massive (⬎5 cm).18 The tear size distribution was not found to vary significantly from the group of patients in whom stiffness did not develop (2 test, P ⬍ .081). Absorbable anchor fixation with or without nonabsorbable convergence sutures was used in all but 3 of the 28 patients. These 3 patients underwent repair without anchors, and all had partial rotator cuff tears. In addition, the choice of fixation and techniques to repair these tears was not found to vary from that in the larger consecutive group. Of the 23 patients in whom stiffness developed, 21 were treated successfully with aggressive physical therapy. Three patients also underwent a subacromial steroid injection at 3 months postoperatively. Stiffness resolved with minimal motion deficits (⬍10% passive loss in any plane) at a mean of 5 months after surgery in 14 patients. The other 9 still lacked significant passive motion in 1 or more planes at 5 months postoperatively. In these patients the mean forward flexion deficit was 22°. Three patients also had persistent external rotation deficits averaging 26°. One of these patients with persistent stiffness underwent arthroscopic surgical release. This patient had undergone a suture repair of a partial subscapularis tendon tear. The passive range of motion was recorded as normal at the time of the initial surgery but was noted to be severely limited early in the postoperative course. At 4 months, arthroscopic release was carried out. The rotator cuff was noted to be healed at the time of surgery, and the patient recovered full passive mo-
tion by 4.5 months after release. Another patient with persistent stiffness remained dissatisfied after extensive physical therapy but declined to have a recommended arthroscopic release performed. Failure of the rotator cuff tendon to heal, leading to persistent symptoms, was known to have occurred in 1 patient. This 71-year-old woman had a small supraspinatus tendon tear repaired with 1 anchor but continued to complain of pain and popping throughout her early postoperative course. At 5 months postoperatively, she continued to have weakness and pain despite additional physical therapy. Magnetic resonance imaging was performed, revealing a full-thickness supraspinatus tear. She underwent a second arthroscopy that revealed complete failure of the tendon to heal at the suture-tendon interface, along with significant biceps tendinopathy. A second rotator cuff repair was performed, and a soft-tissue biceps tenodesis was performed concurrently with the repair. This patient subsequently regained full motion recovery. One patient was diagnosed with RSD after surgery. This patient, a 37-year-old man, underwent multiple procedures on the operative extremity including an endoscopic carpal tunnel release, an anterior labral repair, and repairs of the subscapularis and supraspinatus tendons. The labrum and rotator cuff tendons were repaired to bone via absorbable anchors. He continued to have severe pain and stiffness. Skin discoloration and warmth were noted in the operative extremity. At 2 months postoperatively, he was referred to a pain management specialist for evaluation; a diagnosis of RSD was made, and medical treatment was initiated. A postoperative infection developed in 1 patient. Our protocol was to use prophylaxis in all patients with 1 g of cephalexin preoperatively. For penicillinallergic patients, 600 mg of clindamycin was used. Vancomycin was only used in patients who could not take either cephalexin or clindamycin. The patient underwent repair of a large cuff tear with margin convergence sutures and an absorbable anchor. Cellulitis developed around the anterior portal 2 weeks after surgery, and he began taking oral antibiotics. Subsequent drainage developed 1 week later, and a decision was made to proceed with an arthroscopic irrigation and debridement. All implants and sutures were removed, and rerepair only with margin convergence sutures was carried out. The patient was treated with 6 weeks of intravenous antibiotics in accordance with an infectious disease consultation. The infection was
ARTHROSCOPIC ROTATOR CUFF REPAIR eradicated based on the patient’s last follow-up visit with the infectious disease consultant. DVT developed in the ipsilateral upper extremity of a patient and was diagnosed after the development of symptoms 1 month after surgery. Appropriate medical consultation was sought and treatment instituted. There was 1 death, which occurred in a 61-year-old man. He was preoperatively evaluated, was cleared medically, underwent surgery without intraoperative complications, and was discharged on the same day. One week after surgery, the patient died. At the family’s request, no autopsy was performed, and no official cause of death has been established. We routinely seek preoperative medical clearance for any patient with a history of cardiac disease, diabetic disease, bleeding disorders, arrhythmias, or cancer or for a patient who appears to be in poor health. DISCUSSION Arthroscopic rotator cuff repair is a procedure that has been shown to have outcomes as successful as traditional open and mini-open repairs.1,6,8 This procedure offers several potential advantages but is technically challenging, and complications certainly do occur. Our study had a complication rate of 10.6%. This rate is comparable to rates reported for open rotator cuff repair.7,13,14,18 Mansat et al.13 examined 40 articles reporting results after open rotator cuff repair and determined that the overall mean complication rate was 10.5%. The identified risk factors for a complication developing in the study of Mansat et al. were rotator cuff tear size; advanced age; preoperative limited motion; weakness in abduction, internal rotation, and flexion; and a diminished acromiohumeral interval. In our study stiffness was the most common complication. Other studies have reported postoperative stiffness rates ranging from 2.7% to 15%, but criteria to define stiffness have varied widely.10,11,15,16 Mansat et al.13 found that smaller cuff tears were more likely to develop stiffness postoperatively, presumably because of a larger amount of tissue being available to participate in the inflammatory response. For our patients with stiffness, tear size was not found to be statistically significant. Our study used strict criteria for the diagnosis of stiffness in the operative shoulder. Stiffness after rotator cuff repair regardless of technique can lead to severe functional limitations.14 Bigliani et al.19 attributed stiffness to inadequate postoperative rehabilitation and recommended beginning
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pendulum exercises and gentle passive motion early. Mormino et al.20 reported on patients in whom subdeltoid adhesions developed after rotator cuff repair. Their patients required arthroscopic release to regain motion. We initiated early postoperative motion exercises in an attempt to decrease the prevalence of this condition. Of the 23 patients with stiffness, 22 responded to nonoperative measures. Nine patients did have some residual motion deficits. One patient did not respond to additional therapy and underwent arthroscopic release. We could not ascertain any predisposing causes of stiffness in our study group. Upper extremity DVT is an uncommon complication, occurring in only 1% to 4% of patients in whom DVT develops.21 The presentation can include shoulder, neck, or arm pain; edema; skin discoloration; tenderness; or venous distension. Venous thrombosis of the upper extremity can also be asymptomatic, and a high index of suspicion is required in patients at risk. Risk factors include acquired or inherited hypercoagulable states, anatomic abnormalities causing venous compression, strenuous upper extremity exercise, venous catheterization as with pacemakers, and cancer.20 The rate of infection after arthroscopic shoulder surgery is very low. Studies have reported infection rates ranging from 0.04% to 3.4%.16 Infection after shoulder arthroscopy often presents in a delayed fashion and without many symptoms.13,14 Laboratory and imaging studies may not be very helpful in early infections. A postoperative infection should be suspected as having developed in any patient with increasing redness, swelling, pain, fever, or drainage. Our patient initially presented with redness around the portal. The portal sites were not closed with any type of suture per the surgeon’s preference. When there was continued worsening of pain and redness despite treatment with oral antibiotics, a decision to proceed with formal arthroscopic debridement was made. There were multiple weaknesses in this study. It was a retrospective chart review, which can introduce bias. There are multiple variables that were not studied. We did not record operative time or compliance with physical therapy and did not identify whether workers’ compensation or litigation was involved. These variables may influence whether a patient was at risk for the development of a complication. In addition, there was no control group of open procedures performed during the study period.
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K. J. BRISLIN ET AL. CONCLUSIONS
This study revealed a 10.6% complication rate in our series of patients undergoing arthroscopic rotator cuff repair. Arthroscopic rotator cuff repair continues to gain acceptance as an alternative to traditional open rotator cuff repair, but the surgeon must be aware that, even in experienced hands, complications commonly occur. Most complications were a result of significant and persistent stiffness that resolved without additional operative treatment. REFERENCES 1. Severud EL, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Arthroscopy 2003;19: 234-238. 2. Gartsmam GM. Arthroscopic rotator cuff repair. Clin Orthop Relat Res 2001:95-106. 3. Tauro JC. Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 1998;14:45-51. 4. Gartsman GM, Brinker MR, Khan M. Early effectiveness of arthroscopic repair of full-thickness tears of the rotator cuff: An outcome analysis. J Bone Joint Surg Am 1998;80:33-40. 5. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique—Margin convergence direct tendon-to-bone. Arthroscopy 2001;17:905-912. 6. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): A prospective study with 2- to 4-year follow-up. Arthroscopy 2003;19:249-256. 7. Grondel RJ, Savioe FH, Field LD. Rotator cuff repairs in patients 62 years of age or older. J Shoulder Elbow Surg 2001;10:97-99.
8. Murray TF, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 2002;11:19-24. 9. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 10. Curtis AS, Snyder SJ, Del Pizzo W, Friedman MJ, Ferkel RD, Karzel RP. Complications of shoulder arthroscopy. Arthroscopy 1992;8:395 (abstract). 11. Berjano P, Gonzalez BG, Olmedo JF, Perez-Espana LA, Munilla MG. Complications in arthroscopic shoulder surgery. Arthroscopy 1998;14:785-788. 12. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy 2002;18: 88-95 (suppl). 13. Mansat P, Cofield RH, Kersten TE, Rowland CM. Complications of rotator cuff repair. Orthop Clin North Am 1997;28: 205-213. 14. Karas EH, Iannotti JP. Failed repair of the rotator cuff: Evaluation and treatment of complications. Instr Course Lect 1998; 47:87-95. 15. Rupp S, Seil R, Muller B, Kohn D. Complications after arthroscopic subacromial decompression. Arthroscopy 1998;14: 445 (abstract). 16. Muller D, Landsiedl F. Arthroscopy of the shoulder joint: A minimal invasive and harmless procedure? Arthroscopy 2000; 16:425 (abstract). 17. Fischer BW, Gross RM, McCarthy JA, Arroyo JS. Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241-248. 18. Post M, Silver R, Singh M. Rotator cuff tear: Diagnosis and treatment. Clin Orthop Relat Res 1983:78-91. 19. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515. 20. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: A complication of rotator cuff surgery. Arthroscopy 1996;12: 457-461. 21. Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2002;28: 89-99.
Purpose: The purpose of this study was to determine the complication rate of a consecutive series of patients undergoing arthroscopic rotator cuff repair. Methods: From January 2003 to June 2003, all patients undergoing primary arthroscopic rotator cuff repair were identified. A total of 263 patients were identified. Medical records were reviewed to identify complications in the study patients. Results: A total of 28 patients (10.6%) sustained a complication. Complications included shoulder stiffness, failure of healing, infection, reflex sympathetic dystrophy, deep venous thrombosis, and death. Conclusions: The most common complication was recognized as persistent stiffness that usually responded to extensive physical therapy. Complications after arthroscopic rotator cuff repair are similar to results published for open rotator cuff repair. Level of Evidence: Level IV, therapeutic case series. Key Words: Arthroscopy—Shoulder—Rotator cuff—Complications.
S
houlder arthroscopy has gained increasing popularity for treating many shoulder pathologies. The reported advantages of arthroscopic rotator cuff repair include the enhanced ability to assess the glenohumeral joint, avoidance of deltoid detachment, less tissue dissection, improved cosmesis, decreased pain after surgery, and more rapid return of motion.1,2 The short-term and midterm outcomes after arthroscopic rotator cuff repair have been good to excellent even in older populations.1-8 However, there has been a paucity of literature regarding the complications associated with arthroscopic rotator cuff repair. Studies have reported overall complication rates after a wide variety of shoulder arthroscopic procedures, but none has specifically addressed arthroscopic rotator cuff repair.9-14 Studies have reported complication rates after open rotator cuff repairs. Mansat et al.,13 in their
From Orthopaedic Associates of Allentown (K.J.B.), Allentown, Pennsylvania, and Mississippi Sports Medicine and Orthopaedic Center (L.D.F., F.H.S.), Jackson, Mississippi, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Kenneth J. Brislin, M.D., Orthopaedic Associates of Allentown, 1243 S Cedar Crest Blvd, Allentown, PA 18103, U.S.A. E-mail: kjbrislin@ hotmail.com © 2007 by the Arthroscopy Association of North America 0749-8063/07/2302-0582$32.00/0 doi:10.1016/j.arthro.2006.09.001
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review of 40 articles evaluating open rotator cuff repairs, found a complication rate of 10.5%. Complication rates after arthroscopic shoulder procedures ranging from 4.8% to 10.6% have been reported.9-12,15,16 Reported complications included direct nerve injury, brachial plexus stretch neurapraxia, reflex sympathetic dystrophy (RSD), infection, stiffness, failure of repair, instrument breakage, hardware failure, fluid extravasation, deep venous thrombosis (DVT), and complications related to anesthesia. Other studies have compared complication rates between arthroscopic and “combined” arthroscopic and open procedures. Curtis et al.10 reported a rate of 4.8% for arthroscopic shoulder surgeries and a rate of 8.8% for the combined procedures. In contrast, Berjano et al.11 found that the complication rate was 10.6% after arthroscopic shoulder procedures and 5.3% after combined procedures. The purpose of this study was to determine the complication rate for a consecutive series of patients undergoing primary arthroscopic rotator cuff repair. We expected the complication rate after arthroscopic rotator cuff repair to be comparable to that after open rotator cuff repair.
METHODS All patients who underwent arthroscopic rotator cuff surgery by the 2 senior authors (L.D.F. and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 2 (February), 2007: pp 124-128
ARTHROSCOPIC ROTATOR CUFF REPAIR F.H.S.) between January and June 2003 were identified. There were no open or mini-open rotator cuff repairs performed by either author during the study period. We excluded patients with a primary diagnosis of adhesive capsulitis who underwent capsular release along with a rotator cuff repair, those with a primary diagnosis of instability who were found to have a rotator cuff tear at surgery, and those undergoing revision surgery. A retrospective chart review of all patients was carried out to identify those patients who sustained a complication within the first 90 days postoperatively. A complication was defined as any postoperative event or condition that required additional treatment, either nonoperative or operative. For all patients, the following information was collected: age, sex, hand dominance, operative shoulder, size of tear and tendons involved, type of repair, any complication, time to diagnosis of complication, treatment of complication, and time to resolution of complication. For all patients in this study undergoing arthroscopic rotator cuff repair, the procedure began with a diagnostic glenohumeral assessment. Pathologic glenohumeral conditions identified at surgery were addressed. Rotator cuff tear identification and debridement were then carried out. Next, subacromial bursectomy and decompression with acromioplasty were performed. Distal clavicle excision was performed when preoperative clinical examination showed a symptomatic acromioclavicular joint and radiographs were positive for acromioclavicular joint arthrosis. The distal 10 mm of the clavicle was resected through an anterior portal with a bur. Care was taken not to violate the superior and posterior capsule of the acromioclavicular joint. The senior authors also agreed with Fischer et al.,17 who recommended an “all-ornone” rule regarding distal clavicle excision. According to their approach, if violation of the acromioclavicular joint was required to adequately decompress the subacromial space, complete resection of the distal clavicle was the preferred approach. Patients underwent arthroscopic rotator cuff repair by use of absorbable anchor fixation with or without convergence sutures depending on rotator cuff tear orientation and size. Postoperative rehabilitation regimens were altered to some extent depending on the specifics of the patient’s rotator cuff tear. All patients in this consecutive series started passive range-of-motion exercises on postoperative day 1 and began an organized exercise program under the supervision of a physical therapist within 5 to 14 days after surgery.
125 RESULTS
A total of 263 patients underwent arthroscopic rotator cuff repair during the study period between January 1 and June 30, 2003. We identified the development of a complication in 28 patients (10.6%), and no patient had more than 1 complication. All complications were diagnosed within 90 days postoperatively. There were 10 men and 18 women affected, with a mean age of 61 years (range, 26 to 76 years). The dominant extremity was involved in 20 patients, and the right shoulder was operated on in 17. Concurrent procedures on the affected extremities in 6 of 28 patients included arthroscopic distal clavicle excision, labral repair, arthroscopic biceps tenodesis, carpal tunnel release, and lateral epicondylitis release (Table 1). All 28 patients underwent a diagnostic glenohumeral arthroscopy, followed by subacromial decompression with release of the acromioclavicular ligament, acromioplasty, and rotator cuff repair. A distal clavicle excision was performed in 24 of 28 patients (86%) sustaining complications. The percentage of patients undergoing distal clavicle excision among this group did not vary significantly from that in the larger consecutive group. All intra-articular pathology was treated at the time of rotator cuff repair. Three patients had concurrent anterior labral repair via anchor fixation. Two had arthroscopic biceps tenodesis for biceps tears involving greater than 50% of the tendon thickness. The biceps tendons underwent tenodesis via a soft-tissue technique incorporating the biceps tendon into the rotator interval and rotator cuff repair. In 4 patients extra-articular pathology was addressed. There were 3 patients who underwent ipsilateral carpal tunnel releases and 1 who had an ipsilateral open lateral epicondylitis release. No statistically significant correlation between treatment of intra-articular or extra-articular pathology and development of a complication was found. The complications identified included stiffness, failure of healing, RSD, DVT, infection, and death (Table 2). Stiffness was diagnosed in the operative
TABLE 1. Procedures Performed Concurrently in Ipsilateral Extremity in Patients With Complications Subacromial decompression Distal clavicle excision Labral reattachment Biceps tenodesis Endoscopic carpal tunnel release Lateral epicondyle release
28 24 3 2 3 1
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K. J. BRISLIN ET AL. TABLE 2.
Stiffness Failure of healing RSD DVT Infection Death
Complications 23 1 1 1 1 1
shoulder when one of the following was present: total passive external rotation with the arm at the side of less than 10°, total passive external rotation with the arm in 90° abduction of less than 30°, or total passive forward flexion of less than 100°. The diagnosis of stiffness was made only when these motion deficits persisted for 90 days postoperatively. Postoperative stiffness was diagnosed is 23 patients. Within this group of patients in whom stiffness developed, there were 5 partial tears, 11 small tears, 4 medium tears, and 3 large tears identified, where the tear size was categorized as small (ⱕ1 cm), medium (1-3 cm), large (3-5 cm), or massive (⬎5 cm).18 The tear size distribution was not found to vary significantly from the group of patients in whom stiffness did not develop (2 test, P ⬍ .081). Absorbable anchor fixation with or without nonabsorbable convergence sutures was used in all but 3 of the 28 patients. These 3 patients underwent repair without anchors, and all had partial rotator cuff tears. In addition, the choice of fixation and techniques to repair these tears was not found to vary from that in the larger consecutive group. Of the 23 patients in whom stiffness developed, 21 were treated successfully with aggressive physical therapy. Three patients also underwent a subacromial steroid injection at 3 months postoperatively. Stiffness resolved with minimal motion deficits (⬍10% passive loss in any plane) at a mean of 5 months after surgery in 14 patients. The other 9 still lacked significant passive motion in 1 or more planes at 5 months postoperatively. In these patients the mean forward flexion deficit was 22°. Three patients also had persistent external rotation deficits averaging 26°. One of these patients with persistent stiffness underwent arthroscopic surgical release. This patient had undergone a suture repair of a partial subscapularis tendon tear. The passive range of motion was recorded as normal at the time of the initial surgery but was noted to be severely limited early in the postoperative course. At 4 months, arthroscopic release was carried out. The rotator cuff was noted to be healed at the time of surgery, and the patient recovered full passive mo-
tion by 4.5 months after release. Another patient with persistent stiffness remained dissatisfied after extensive physical therapy but declined to have a recommended arthroscopic release performed. Failure of the rotator cuff tendon to heal, leading to persistent symptoms, was known to have occurred in 1 patient. This 71-year-old woman had a small supraspinatus tendon tear repaired with 1 anchor but continued to complain of pain and popping throughout her early postoperative course. At 5 months postoperatively, she continued to have weakness and pain despite additional physical therapy. Magnetic resonance imaging was performed, revealing a full-thickness supraspinatus tear. She underwent a second arthroscopy that revealed complete failure of the tendon to heal at the suture-tendon interface, along with significant biceps tendinopathy. A second rotator cuff repair was performed, and a soft-tissue biceps tenodesis was performed concurrently with the repair. This patient subsequently regained full motion recovery. One patient was diagnosed with RSD after surgery. This patient, a 37-year-old man, underwent multiple procedures on the operative extremity including an endoscopic carpal tunnel release, an anterior labral repair, and repairs of the subscapularis and supraspinatus tendons. The labrum and rotator cuff tendons were repaired to bone via absorbable anchors. He continued to have severe pain and stiffness. Skin discoloration and warmth were noted in the operative extremity. At 2 months postoperatively, he was referred to a pain management specialist for evaluation; a diagnosis of RSD was made, and medical treatment was initiated. A postoperative infection developed in 1 patient. Our protocol was to use prophylaxis in all patients with 1 g of cephalexin preoperatively. For penicillinallergic patients, 600 mg of clindamycin was used. Vancomycin was only used in patients who could not take either cephalexin or clindamycin. The patient underwent repair of a large cuff tear with margin convergence sutures and an absorbable anchor. Cellulitis developed around the anterior portal 2 weeks after surgery, and he began taking oral antibiotics. Subsequent drainage developed 1 week later, and a decision was made to proceed with an arthroscopic irrigation and debridement. All implants and sutures were removed, and rerepair only with margin convergence sutures was carried out. The patient was treated with 6 weeks of intravenous antibiotics in accordance with an infectious disease consultation. The infection was
ARTHROSCOPIC ROTATOR CUFF REPAIR eradicated based on the patient’s last follow-up visit with the infectious disease consultant. DVT developed in the ipsilateral upper extremity of a patient and was diagnosed after the development of symptoms 1 month after surgery. Appropriate medical consultation was sought and treatment instituted. There was 1 death, which occurred in a 61-year-old man. He was preoperatively evaluated, was cleared medically, underwent surgery without intraoperative complications, and was discharged on the same day. One week after surgery, the patient died. At the family’s request, no autopsy was performed, and no official cause of death has been established. We routinely seek preoperative medical clearance for any patient with a history of cardiac disease, diabetic disease, bleeding disorders, arrhythmias, or cancer or for a patient who appears to be in poor health. DISCUSSION Arthroscopic rotator cuff repair is a procedure that has been shown to have outcomes as successful as traditional open and mini-open repairs.1,6,8 This procedure offers several potential advantages but is technically challenging, and complications certainly do occur. Our study had a complication rate of 10.6%. This rate is comparable to rates reported for open rotator cuff repair.7,13,14,18 Mansat et al.13 examined 40 articles reporting results after open rotator cuff repair and determined that the overall mean complication rate was 10.5%. The identified risk factors for a complication developing in the study of Mansat et al. were rotator cuff tear size; advanced age; preoperative limited motion; weakness in abduction, internal rotation, and flexion; and a diminished acromiohumeral interval. In our study stiffness was the most common complication. Other studies have reported postoperative stiffness rates ranging from 2.7% to 15%, but criteria to define stiffness have varied widely.10,11,15,16 Mansat et al.13 found that smaller cuff tears were more likely to develop stiffness postoperatively, presumably because of a larger amount of tissue being available to participate in the inflammatory response. For our patients with stiffness, tear size was not found to be statistically significant. Our study used strict criteria for the diagnosis of stiffness in the operative shoulder. Stiffness after rotator cuff repair regardless of technique can lead to severe functional limitations.14 Bigliani et al.19 attributed stiffness to inadequate postoperative rehabilitation and recommended beginning
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pendulum exercises and gentle passive motion early. Mormino et al.20 reported on patients in whom subdeltoid adhesions developed after rotator cuff repair. Their patients required arthroscopic release to regain motion. We initiated early postoperative motion exercises in an attempt to decrease the prevalence of this condition. Of the 23 patients with stiffness, 22 responded to nonoperative measures. Nine patients did have some residual motion deficits. One patient did not respond to additional therapy and underwent arthroscopic release. We could not ascertain any predisposing causes of stiffness in our study group. Upper extremity DVT is an uncommon complication, occurring in only 1% to 4% of patients in whom DVT develops.21 The presentation can include shoulder, neck, or arm pain; edema; skin discoloration; tenderness; or venous distension. Venous thrombosis of the upper extremity can also be asymptomatic, and a high index of suspicion is required in patients at risk. Risk factors include acquired or inherited hypercoagulable states, anatomic abnormalities causing venous compression, strenuous upper extremity exercise, venous catheterization as with pacemakers, and cancer.20 The rate of infection after arthroscopic shoulder surgery is very low. Studies have reported infection rates ranging from 0.04% to 3.4%.16 Infection after shoulder arthroscopy often presents in a delayed fashion and without many symptoms.13,14 Laboratory and imaging studies may not be very helpful in early infections. A postoperative infection should be suspected as having developed in any patient with increasing redness, swelling, pain, fever, or drainage. Our patient initially presented with redness around the portal. The portal sites were not closed with any type of suture per the surgeon’s preference. When there was continued worsening of pain and redness despite treatment with oral antibiotics, a decision to proceed with formal arthroscopic debridement was made. There were multiple weaknesses in this study. It was a retrospective chart review, which can introduce bias. There are multiple variables that were not studied. We did not record operative time or compliance with physical therapy and did not identify whether workers’ compensation or litigation was involved. These variables may influence whether a patient was at risk for the development of a complication. In addition, there was no control group of open procedures performed during the study period.
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K. J. BRISLIN ET AL. CONCLUSIONS
This study revealed a 10.6% complication rate in our series of patients undergoing arthroscopic rotator cuff repair. Arthroscopic rotator cuff repair continues to gain acceptance as an alternative to traditional open rotator cuff repair, but the surgeon must be aware that, even in experienced hands, complications commonly occur. Most complications were a result of significant and persistent stiffness that resolved without additional operative treatment. REFERENCES 1. Severud EL, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Arthroscopy 2003;19: 234-238. 2. Gartsmam GM. Arthroscopic rotator cuff repair. Clin Orthop Relat Res 2001:95-106. 3. Tauro JC. Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 1998;14:45-51. 4. Gartsman GM, Brinker MR, Khan M. Early effectiveness of arthroscopic repair of full-thickness tears of the rotator cuff: An outcome analysis. J Bone Joint Surg Am 1998;80:33-40. 5. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique—Margin convergence direct tendon-to-bone. Arthroscopy 2001;17:905-912. 6. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): A prospective study with 2- to 4-year follow-up. Arthroscopy 2003;19:249-256. 7. Grondel RJ, Savioe FH, Field LD. Rotator cuff repairs in patients 62 years of age or older. J Shoulder Elbow Surg 2001;10:97-99.
8. Murray TF, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 2002;11:19-24. 9. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 10. Curtis AS, Snyder SJ, Del Pizzo W, Friedman MJ, Ferkel RD, Karzel RP. Complications of shoulder arthroscopy. Arthroscopy 1992;8:395 (abstract). 11. Berjano P, Gonzalez BG, Olmedo JF, Perez-Espana LA, Munilla MG. Complications in arthroscopic shoulder surgery. Arthroscopy 1998;14:785-788. 12. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy 2002;18: 88-95 (suppl). 13. Mansat P, Cofield RH, Kersten TE, Rowland CM. Complications of rotator cuff repair. Orthop Clin North Am 1997;28: 205-213. 14. Karas EH, Iannotti JP. Failed repair of the rotator cuff: Evaluation and treatment of complications. Instr Course Lect 1998; 47:87-95. 15. Rupp S, Seil R, Muller B, Kohn D. Complications after arthroscopic subacromial decompression. Arthroscopy 1998;14: 445 (abstract). 16. Muller D, Landsiedl F. Arthroscopy of the shoulder joint: A minimal invasive and harmless procedure? Arthroscopy 2000; 16:425 (abstract). 17. Fischer BW, Gross RM, McCarthy JA, Arroyo JS. Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241-248. 18. Post M, Silver R, Singh M. Rotator cuff tear: Diagnosis and treatment. Clin Orthop Relat Res 1983:78-91. 19. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515. 20. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: A complication of rotator cuff surgery. Arthroscopy 1996;12: 457-461. 21. Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2002;28: 89-99.