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Does a reconstructed larg and massive rotator cuff tear survive a 10 years follow up study
J. Shoulder Elbow Surg. Volume 4, Number 1, Part 2
36
DOES A RECONSTRUCTED LARG AND MASSIVE ROTATOR CUFF TEAR SURVIVE A 10 YEARS FOLLOW UP STUDY.
Abstracts
38
We retrospectively reviewed 57 consecutive patients who underwent rotator cuff repairs (RCR) with a minimum follow-up of 1 year. Pre-operative variables studied were age, size of tear, history of smoking, and presence of a worker's compensation claim (WCC). Post-operatively we evaluated subjective improvement, pain level, range-of-motion (ROM), strength, and the ability to carry out 8 activities of daily living (ADL). Four groups were evaluated: I) Non-smoker, no WCC (9 patients); II) Non-smoker, WCC present (1 patient); ]II) Smoker, no WCC (31 patients); IV) Smoker, WCC present (16 patients). Overall, 47 of 57 (82%) patients currently smoked > 1 pack/day or had a 40+ pack/year history of smoking. Statistical analysis of results showed that tear size averaged 1.5 cm. in non-smokers and 2.9 cm. in smokers (P < 0.0l). Smokers did worse after RCR than non-smokers in terms of ROM (P< 0.01), pain relief (P <0.001), and improvement in ability to perform ADLs (P<0.01). Patients with worker's compensation claims (Groups II/IV) also did worse after RCR than non-WCC patients in terms of ROM (P< 0.05), pain relief (P<0.05), and improvement in ability to perform ADLs (P<0.05). The worst results overall were in patients who both smoked and had a WCC (Group IV). Compared to Groups I/II and Group III, these results were significantly worse (P < 0.01) in all measured parameters. The very high prevalence of smoking (82%) in this study group has not been reported before in patients undergoing rotator cuff repairs. It is significantly higher (P<0.00001) than the prevalence of smoking in North Carolina (35%) and United States (27%) populations. This suggests an association between smoking and development of large rotator cuff tears. The results in this study in patients who both smoked and had worker's compensation claims were poor and would suggest that cessation of smoking prior to rotator cuff repair should be recommended to these patients as a possible means of improving outcome.
INTRODUCTION:This series represents a retrospective examination of an inclusive and consecutive group of patients who underwent Neer'e anterior acromiplasty and reconstruction of larg and massive rotator cuff tears. To our knowiage this is the first long term study of this type of repair. Follow up consisted of clinical exam, questionnaire of pain and function and a scncgraphic evaluation of the rotator cuff. MATERIAL AND METHODS:Fifty-three pa~.,flts underwent 54 procedures of repair of massive rotator cuff tear and ant. acromioplasty between 1982 and 1987. AC joint ptasty was done in 14 c a m , modified AC joint plasty in 6 and reconstruction of an open acromlal epiphysla in three c a m . The average age was 58.5 years, the postoperative management included immobilisation and in abduction brace for one week followed by a three phases rehabilitation program. The average duration of follow up of 45 cases of this series was seven years, The patients were evaluated postoperatively utilizing the Neer'e classification scale of excellent, satisfactory and unsatisfactory. RESULTS: The sonographic evaluation of the rotator cuff showed two cases of rotator cuff tear, two cases of subscromial calcificaton, eight cases of thin fibrotic tendon and thirty-threa cases of good functioning tendon. The average active elevation was 170 degreaes, the external rotation 55. Thirty-three patients were very satisfied and 12 were satisfied. Using Neer's clasificatlen 29 cases were excellent, 14 cases were satisfactory and two Were unsatisfactory. CONCLUSION: Based on this study, we recommend the reconstruction of larg and massive rotator cuff tsars to have a long lasting good result. A ten years follow up showed that massive rotator cuff tear when reconstructed combind wP0n anterior acromioplasty will last without change of the earlY good results after surgery.
LOSS OF DELTOID FOLLOWING SHOULDER OPERATIONS: AN OPERATIVE DISASTER. G.I. Groh, M. Simoni, P. Rolla, C. A. Rockwood, Jr., Univ. of Texas at San Antonio Health Science Center. MATERIAL AND METHODS: A series of thirty-six patients, who had a post-operative loss of the anterior or anterior lateral deltoid muscle following shoulder operations, i.e. impingement syndrome, anterior shoulder reconstructions or arthroplasty procedures, have been referred to the senior author. All patients had loss of function of the deltoid muscle secondary to either detachment of the deltoid from the clavicle and acromion, or injury to the axillary nerve with resultant denervation of the deltoid. Four patients lost the function of their deltoid following an injury to the axillary nerve and thirty-two patients lost deltoid function following loss of the origin of the deltoid from the clavicle and acromion. RESULTS: All patients were significantly disabled. All patients were dissatisfied with the result of the previous operation, and eight patients developed painful anterior or anterior/superior dislocation of the glenohumeral joint. Treatment was non-specific and supportive. CONCLUSION: The authors conclude that loss of anterior deltoid function secondary to denervation or detachment, results in irrevocable pain and impairment of function. Careful attention to the surgical technique of deltoid reattachment to bone and protection of the axillary nerve is essential to the prevention of dire consequences to shoulder function.
Smoking and Worker's Compensation: Relation to Outcome After Rotator Cuff Repair. William J. Mallon, M.D., Triangle Orthopaedic Associates, Durham, NC.
B.A. Fleega, J.A. Kittani (GOC-Klinik/Godesberger Orthopedic Hospital, Bonn, Germany.)
37
$15
39
LATISSIMUS DORSI TRANSFER FOR IRREPARABLE TEARS OF THE ROTATOR CUFF: A PROSPECTIVE STUDY FROM CONCEPT TO END - RESULTS. Christian Gerber, MD, Jacques Rossier, MD. Kantonsspital, 1708 Fribourg, Switzerland. In analogy to obstetrical palsy with dysfunction of the supra- and infraspinatus, transfer of the latissimus dorsi was studied as a salvage operation for irreparable tears of the cuff with the goal to depress and thereby center the humeral head as well as to provide external rotation control by either an active transfer or at least an external rotation tenodesis. In a prospective trial 16 consecutive cases (ages 39 to 75 years) were treated and followed for a minimum of 5 years (59 to 75 months). To be admitted the patient needed to have a painful shoulder disability non - responsive to conservative treatment for at least 6 months, caused by an irreparabl e cuff tear of at least two complete tendons with a diameter of more than 5 cm. At final follow - up, 9 patients were asymptomatic, pain had been improved in all. Flexion, abduction and external rotation averaged 125, 111 and 23 °, representing a gain of 42, 39 and 13° respectively. The average Constant score was 59 points and corresponded to an age and sex matched shoulder function of 73% of normal, identical to the value obtained at two years postoperatively. The five patients with a non - functioning subscapularis (lift - off positive) regained 49% of normal shoulder function, those eleven with a functioning subscapularis 85% Latissimus dorsi transfer could not recenter the cranially migrated humeral head but functionally restored external rotation in all cases. The operation has provided very satisfactory long term results for cases with irreparable supra- and infraspinatus tears if the subscapularis was intact. It yielded poor results if the subscapularis was non functioning and the intervention should be considered contraindicated under these circumstances.
36
DOES A RECONSTRUCTED LARG AND MASSIVE ROTATOR CUFF TEAR SURVIVE A 10 YEARS FOLLOW UP STUDY.
Abstracts
38
We retrospectively reviewed 57 consecutive patients who underwent rotator cuff repairs (RCR) with a minimum follow-up of 1 year. Pre-operative variables studied were age, size of tear, history of smoking, and presence of a worker's compensation claim (WCC). Post-operatively we evaluated subjective improvement, pain level, range-of-motion (ROM), strength, and the ability to carry out 8 activities of daily living (ADL). Four groups were evaluated: I) Non-smoker, no WCC (9 patients); II) Non-smoker, WCC present (1 patient); ]II) Smoker, no WCC (31 patients); IV) Smoker, WCC present (16 patients). Overall, 47 of 57 (82%) patients currently smoked > 1 pack/day or had a 40+ pack/year history of smoking. Statistical analysis of results showed that tear size averaged 1.5 cm. in non-smokers and 2.9 cm. in smokers (P < 0.0l). Smokers did worse after RCR than non-smokers in terms of ROM (P< 0.01), pain relief (P <0.001), and improvement in ability to perform ADLs (P<0.01). Patients with worker's compensation claims (Groups II/IV) also did worse after RCR than non-WCC patients in terms of ROM (P< 0.05), pain relief (P<0.05), and improvement in ability to perform ADLs (P<0.05). The worst results overall were in patients who both smoked and had a WCC (Group IV). Compared to Groups I/II and Group III, these results were significantly worse (P < 0.01) in all measured parameters. The very high prevalence of smoking (82%) in this study group has not been reported before in patients undergoing rotator cuff repairs. It is significantly higher (P<0.00001) than the prevalence of smoking in North Carolina (35%) and United States (27%) populations. This suggests an association between smoking and development of large rotator cuff tears. The results in this study in patients who both smoked and had worker's compensation claims were poor and would suggest that cessation of smoking prior to rotator cuff repair should be recommended to these patients as a possible means of improving outcome.
INTRODUCTION:This series represents a retrospective examination of an inclusive and consecutive group of patients who underwent Neer'e anterior acromiplasty and reconstruction of larg and massive rotator cuff tears. To our knowiage this is the first long term study of this type of repair. Follow up consisted of clinical exam, questionnaire of pain and function and a scncgraphic evaluation of the rotator cuff. MATERIAL AND METHODS:Fifty-three pa~.,flts underwent 54 procedures of repair of massive rotator cuff tear and ant. acromioplasty between 1982 and 1987. AC joint ptasty was done in 14 c a m , modified AC joint plasty in 6 and reconstruction of an open acromlal epiphysla in three c a m . The average age was 58.5 years, the postoperative management included immobilisation and in abduction brace for one week followed by a three phases rehabilitation program. The average duration of follow up of 45 cases of this series was seven years, The patients were evaluated postoperatively utilizing the Neer'e classification scale of excellent, satisfactory and unsatisfactory. RESULTS: The sonographic evaluation of the rotator cuff showed two cases of rotator cuff tear, two cases of subscromial calcificaton, eight cases of thin fibrotic tendon and thirty-threa cases of good functioning tendon. The average active elevation was 170 degreaes, the external rotation 55. Thirty-three patients were very satisfied and 12 were satisfied. Using Neer's clasificatlen 29 cases were excellent, 14 cases were satisfactory and two Were unsatisfactory. CONCLUSION: Based on this study, we recommend the reconstruction of larg and massive rotator cuff tsars to have a long lasting good result. A ten years follow up showed that massive rotator cuff tear when reconstructed combind wP0n anterior acromioplasty will last without change of the earlY good results after surgery.
LOSS OF DELTOID FOLLOWING SHOULDER OPERATIONS: AN OPERATIVE DISASTER. G.I. Groh, M. Simoni, P. Rolla, C. A. Rockwood, Jr., Univ. of Texas at San Antonio Health Science Center. MATERIAL AND METHODS: A series of thirty-six patients, who had a post-operative loss of the anterior or anterior lateral deltoid muscle following shoulder operations, i.e. impingement syndrome, anterior shoulder reconstructions or arthroplasty procedures, have been referred to the senior author. All patients had loss of function of the deltoid muscle secondary to either detachment of the deltoid from the clavicle and acromion, or injury to the axillary nerve with resultant denervation of the deltoid. Four patients lost the function of their deltoid following an injury to the axillary nerve and thirty-two patients lost deltoid function following loss of the origin of the deltoid from the clavicle and acromion. RESULTS: All patients were significantly disabled. All patients were dissatisfied with the result of the previous operation, and eight patients developed painful anterior or anterior/superior dislocation of the glenohumeral joint. Treatment was non-specific and supportive. CONCLUSION: The authors conclude that loss of anterior deltoid function secondary to denervation or detachment, results in irrevocable pain and impairment of function. Careful attention to the surgical technique of deltoid reattachment to bone and protection of the axillary nerve is essential to the prevention of dire consequences to shoulder function.
Smoking and Worker's Compensation: Relation to Outcome After Rotator Cuff Repair. William J. Mallon, M.D., Triangle Orthopaedic Associates, Durham, NC.
B.A. Fleega, J.A. Kittani (GOC-Klinik/Godesberger Orthopedic Hospital, Bonn, Germany.)
37
$15
39
LATISSIMUS DORSI TRANSFER FOR IRREPARABLE TEARS OF THE ROTATOR CUFF: A PROSPECTIVE STUDY FROM CONCEPT TO END - RESULTS. Christian Gerber, MD, Jacques Rossier, MD. Kantonsspital, 1708 Fribourg, Switzerland. In analogy to obstetrical palsy with dysfunction of the supra- and infraspinatus, transfer of the latissimus dorsi was studied as a salvage operation for irreparable tears of the cuff with the goal to depress and thereby center the humeral head as well as to provide external rotation control by either an active transfer or at least an external rotation tenodesis. In a prospective trial 16 consecutive cases (ages 39 to 75 years) were treated and followed for a minimum of 5 years (59 to 75 months). To be admitted the patient needed to have a painful shoulder disability non - responsive to conservative treatment for at least 6 months, caused by an irreparabl e cuff tear of at least two complete tendons with a diameter of more than 5 cm. At final follow - up, 9 patients were asymptomatic, pain had been improved in all. Flexion, abduction and external rotation averaged 125, 111 and 23 °, representing a gain of 42, 39 and 13° respectively. The average Constant score was 59 points and corresponded to an age and sex matched shoulder function of 73% of normal, identical to the value obtained at two years postoperatively. The five patients with a non - functioning subscapularis (lift - off positive) regained 49% of normal shoulder function, those eleven with a functioning subscapularis 85% Latissimus dorsi transfer could not recenter the cranially migrated humeral head but functionally restored external rotation in all cases. The operation has provided very satisfactory long term results for cases with irreparable supra- and infraspinatus tears if the subscapularis was intact. It yielded poor results if the subscapularis was non functioning and the intervention should be considered contraindicated under these circumstances.