- Email: [email protected]
Return to Sports After in Situ Arthroscopic Repair of Partial Rotator Cuff Tears
Return to Sports After in Situ Arthroscopic Repair of Partial Rotator Cuff Tears Luciano A. Rossi, M.D., Nicolás Atala, M.D., Agustin Bertona, M.D., Ignacio Tanoira, M.D., Santiago Bongiovanni, M.D., Gastón Maignon, M.D., and Maximiliano Ranalletta, M.D.
Purpose: To evaluate return to sport, clinical outcomes, and complications in a series of athletes with painful partialthickness rotator cuff tears treated with the arthroscopic in situ repair with a minimum 2-year follow-up. Methods: Retrospective case series. Seventy-two patients who had undergone an arthroscopic in situ repair for partial-thickness rotator cuff tears were evaluated. We assessed return to sport and the level achieved after surgery. Clinical assessment consisted of glenohumeral range of motion measurement and the American Shoulder and Elbow Surgeons score. Pain was recorded using a visual analog scale. Postoperative complications were also assessed. Results: The mean age was 42.2 years (range, 21-66 years), and the mean follow-up was 54 months (range, 24-113 months). Sixty-one patients (87%) were able to return to sports. Fifty-six patients (80%) returned to the same level they had previous to the injury. The mean interval between surgery and return to competition was 5.6 months. The final functional outcomes were related neither to the type of sports nor to the level of competition before the injury. All active range of motion parameters improved significantly (P < .0001). The American Shoulder and Elbow Surgeons score improved from 43.3 to 88.1, and the visual analog scale scores improved from 6.1 to 1.2 (P < .0001). No significant difference regarding return to sports or functional outcomes was found between articular and bursal-sided tears. Only 5 patients developed a postoperative adhesive capsulitis that responded to physical therapy. Conclusions: In patients with partial-thickness rotator cuff tears, arthroscopic in situ repair resulted in excellent functional outcomes, with most of the patients returning to sport and at the same level they had before injury. The results were equally favorable in articular and bursal tears. Level of Evidence: Level IV, therapeutic case series.
P
artial-thickness rotator cuff tears (PTRCTs), are a common cause of pain and dysfunction in the adult shoulder.1,2 After failed conservative management, operative intervention is typically indicated for patients with persistent pain and disability symptoms.1,2 Generally, PTRCTs are considered for repair when they extend to >50% of the tendon thickness.1,2 The current evidence does not provide guidance as to the best management plan for symptomatic PTRCTs. Some surgeons prefer conversion from partial- into
From the Hospital Italiano de Buenos Aires, Buenos Aires City, Argentina. The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. This study was approved by the Ethical Committee of the Italian Hospital of Buenos Aires. Received March 9, 2018; accepted July 13, 2018. Address correspondence to Luciano A. Rossi, M.D., Peron 4190 (C1199ABB), Buenos Aires, Argentina. E-mail: [email protected] Ó 2018 by the Arthroscopy Association of North America 0749-8063/18319/$36.00 https://doi.org/10.1016/j.arthro.2018.07.037
full-thickness tear, and then repair in a traditional fashion,3-6 while others advocate in situ repair preserving the intact tendon.7-13 The few available studies comparing both procedures have not demonstrated the superiority of one technique over the other.14-17 Although both techniques have shown excellent functional results in the general population, there is a lack of studies in the literature reporting the outcomes of PTRCTs in athletes.18 The purpose of this study was to evaluate return to sport, clinical outcomes, and complications in a series of athletes with painful PTRCTs treated with the arthroscopic in situ repair with a minimum 2-year follow-up. We hypothesized that this technique would be effective in reducing pain and improving shoulder function in patients with PTRCTs, resulting in a reliable and timely return to play with a low rate of complications.
Methods Athletes who underwent arthroscopic repair of partial articular- or bursal-sided rotator cuff tears (PARCTs or
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PBRCTs) between December 2006 and December 2015 were retrospectively identified. The inclusion criteria were (1) patients between 20 and 60 years old, (2) with an unsuccessful minimum 3-month course of conservative treatment consisting of activity modification, anti-inflammatory medication, and a physical therapy, and (3) tears of >50% of the tendon thickness on the bursal or articular side (or 6 mm) diagnosed with preoperative magnetic resonance imaging (MRI) and confirmed during surgery. Exclusion criteria were (1) <2 years’ followup, (2) previous surgeries in the affected shoulder, and (3) associated procedures at the time of surgery. Preoperative and postoperative evaluation consisted of a patient-based questionnaire and physical examination performed by a physical therapist specialized in shoulder pathology who was blinded to the surgery type. Each patient was evaluated before surgery and at follow-up after 3, 6, and 12 months and annually thereafter. Only the final follow-up evaluation was used for data analysis in this study. Patients were asked if they had been able to play sports again and if they had been able to perform at the same level they had before the injury. We asked patients who did not return to sports the reasons for cessation. We stratified our cohort by age into 2 groups to evaluate return to sports (20-40 years and 41-60 years). Patient sport level was divided into competitive sport (regular sport with competition and practice >2 times per week) and recreational sport (regular sport without competition <2 times per week).18 The distinctive types of shoulderdependent sport were subdivided in an analog manner according to Allain et al.19: noncollision/nonoverhead shoulder sport (G1), high-impact/collision sport (G2), overhead sport (G3), and martial arts sport (G4) Clinical assessment consisted of the measurement of active glenohumeral range of motion (ROM) using a goniometer and the American Shoulder and Elbow Surgeons (ASES) score. Pain was recorded using the visual analog scale (VAS); a score of 0 indicated no pain, and 10 points indicated the worst possible pain. All patients underwent preoperative radiographs (anterior-posterior, axillary, and arch view) and MRI evaluation. The study protocol was approved by our Institutional Review Board (IRB 00010193). Surgical Technique Surgical procedures were performed by use of general anesthesia with adjuvant interscalene nerve blockade with the patient in the beach chair position. The repairs were performed by 3 surgeons using the same technique. We measured the medial aspect of the rotator cuff footprint using a calibrated probe and repaired PARCTs involving >6 mm of the footprint with an arthroscopic
in situ procedure. An anterior portal was placed in the rotator interval. An anterior subacromial portal was created. After bursectomy, the arthroscope was reintroduced into the glenohumeral joint through a posterior portal. To place transtendon anchors, we initially used a spinal needle as a guide. A small incision (<5 mm) was created on the lateral aspect of the shoulder at the point where the spinal needle was located. A 5.5 mm CrossFT anchor with 2 HiFi Sutures (Conmed Linvatec, Largo, FL) was then placed transtendon into the rotator cuff footprint after its decortication with the shaver in all cases. If the tear involved <1 cm of the footprint in an anterior-to-posterior direction, we used 1 anchor for the repair. However, if the tear involved >1 cm, 2 anchors were used: one was placed anteriorly, the other posteriorly on the footprint. One limb of suture was grasped and retrieved through the anterior portal. A spinal needle was passed through the supraspinatus. From the needle in this position, a shuttle relay was passed into the joint and was then retrieved through the portal. After the first suture was passed through the tendon, the same system was used for the second suture. After tying all the sutures, the arthroscope was reintroduced in the joint and an evaluation of the construct was performed. For PBRCTs, enough bursectomy was performed to allow good visualization of the cuff tear and manage arthroscopic tools. Once the rupture was discovered, the degenerative tissue was removed. The thickness of the tear was measured with a calibrated probe. Next, the greater tuberosity was prepared to promote healing of the reattached cuff using the crimson duvet procedure previously described by Snyder and Burns.20 Only the detached layer was reattached to the greater tuberosity using a 5.5 mm CrossFT anchor with 2 HiFi Sutures (Conmed Linvatec). All patients received a single-row repair. All sutures were passed with a simple repair. If the tear involved <1 cm of the footprint in an anterior-to-posterior direction, 1 anchor was used. If the tear involved >1 cm, 2 anchors were used, one placed anteriorly and the other posteriorly. Subacromial decompression or distal clavicle resection was not performed in any patient. Postoperative Management All patients followed a standard postoperative rehabilitation protocol. The arm was supported in a standard sling for 4 weeks with elbow and hand exercises when tolerated. After 4 weeks, supervised gentle physical therapy consisting of passive pendulum and gradual passive and active-assisted ROM exercises was begun. When the patient could perform active forward elevation above the shoulder level, shoulder-strengthening exercises were started. Patients started with bands and then with weights progressively once they recovered active ROM. Running was authorized at 8 weeks.
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RETURN TO SPORTS AFTER PARTIAL ROTATOR CUFF TEARS Table 1. Patients Demographics Variables No. of shoulders Sex, men/women Dominant involvement, n (%) Age at the time of surgery, yr (range) Mechanism of injury, n (%): Traumatic Atraumatic Preinjury sport level, n/N (%): Competitive Recreational Type of sport: G1: noncollision/nonoverhead G2: high-impact/collision sports G3: overhead sport G4: martial arts sports
Partial Bursal-Sided Rotator Cuff Tears 38 20/18 22 (58) 41 (21-60)
Partial Articular-Sided Rotator Cuff Tears 32 17/15 21 (62) 44 (22-59)
10 (26) 28 (74)
10 (31) 22 (69)
14/38 (37) 24/38 (63)
12/32 (38) 20/34 (62)
18 11 9 0
17 9 6 0
Return to competition was allowed when the patient was pain free, full-shoulder ROM had been achieved, and shoulder strength was near the same as before the injury.
participate in follow-up for 2 years, and 1 patient died of an unrelated disease. The final evaluation thus was carried out in 70 patients. The mean follow-up was 54 months (range, 24-113 months). The main demographic characteristics of the involved patients and their injuries are shown in Table 1. Sixty-one patients (87%) were able to return to sports. Fifty-six patients (80%) returned to the same level they had previous to the injury (Table 2). No significant difference regarding return to sports was found between PBRCTs and PARCTs (Table 3). There were 9 patients (13%) who did not return to sports after the procedure. Six patients referred to fear of another injury or loss of confidence in the shoulder, and 5 patients reported leaving for reasons independent of their shoulder (work, university, etc.) as the reasons for cessation. Four patients (6%) returned to sports but to a lower level than before the injury. Although they had good functional scores, the 4 patients referred to noticed a decrease in sports performance. The mean interval between surgery and return to competition was 5.6 months (range, 3-9 months). Regarding type of sports, patients belonging to group G1 (noncollision/ nonoverhead sports) returned significantly faster to sports than other patients (P < .001; Table 4). However, as shown in Table 4, the final functional outcomes were
Statistical Methodology Preoperative and postoperative scores were compared with the paired t-test for independent samples. Continuous variables were presented as means standard deviations, whereas categorical variables were presented as absolute and relative frequencies. Statistical analysis was performed using independent Student’s t-test with a 95% confidence interval to calculate the differences between the groups in ROM and functional scores. The statistical analysis was performed using the software STATA version 12 (Stata, College Station, TX). P < .05 was considered statistically significant.
Results From the 87 consecutive arthroscopic partial repairs performed in patients between 20 and 60 years old who practiced sports during the study period, 17 patients were excluded. Nine patients who underwent concomitant biceps procedures (7 tenodesis and 2 tenotomies) and 3 patients who underwent subscapularis repair were excluded. Four patients did not Table 2. Summary of Functional Outcomes and Return to Sport Variables American Shoulder and Elbow Surgeons, mean SD Visual analog scale, mean SD Forward flexion, mean SD External rotation in abduction, mean SD Internal rotation in adduction Return to sports, n/N (%) Still playing at 2 years follow-up, n/N (%) Same level, n/N (%) SD, standard deviation.
Preoperative 43.3 1 6.1 1 118 3 63.2 2 Sacrum
Final Follow-up 88.1 4 1.2 1 168 3 75.1 3 T5/T6 61/70 (87) 57/70 (81) 56/70 (80)
P Value <.001 <.001 <.001 <.001
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Table 3. Comparative Outcomes Between Partial Bursal-Sided Rotator Cuff Tears (PBRCTs) and Partial Articular-Sided Rotator Cuff Tears (PARCTs) Repairs PBRCTs Variables American Shoulder and Elbow Surgeons, mean SD Visual analog scale, mean SD Forward flexion, mean SD External rotation in abduction, mean SD Internal rotation in abduction Return to sport, n (%) Still playing at 2 years follow-up, n (%) Same level, n (%)
Pre 41.7 1 6.1 2 120.3 3 60.8 3 Sacrum
PARCTs
Post 89.1 5 1.1 1 168. 3 73.2 3 T5/T6 32/38 (84) 30/38 (79) 9/38 (76)
Pre 44.8 6.4 114.3 63.2 T5/T6
1 1 3 2
Post 86.1 5 1.4 1 172. 3 76.1 3 T5/T6 29/32 (90) 27/32 (84) 27/32 (84)
P Value .36 .09 .51 .12
SD, standard deviation.
related neither to the type of sports nor to the level of competition before the injury. A significant improvement in shoulder ROM was found between preoperative and postoperative results (Table 2). The ASES score and VAS showed statistical improvement after operation (P < .01). No significant difference in shoulder ROM and functional scores was found between articular- and bursal-sided repairs (Table 3). We compared average age and level of sports between patients who could return to sports and those who could not, and we did not find significant differences (Table 5). Complications Five patients developed an adhesive capsulitis. Two patients had articular partial tears, were recreational athletes, and were younger than 40 years old. The other 3 patients had bursal partial tears. One patient was younger than 40 and was a competitive athlete. The
other 2 patients were older than 40 and were recreational athletes. All resolved favorably with physical therapy within the first 3 months. No patient was reoperated.
Discussion The main findings of this study were that arthroscopic in situ repair of PTRCTs resulted in excellent functional outcomes, with most patients returning to sport and at the same level they had before injury. The results were equally favorable in articular- and bursal-sided tears. We prefer in situ repair. We preserve as much of the healthy tendon as possible and repair only the avulsed flap into the footprint. The advantages of this technique are that it restores anatomically the rotator cuff footprint and preserves the intact tendon fibers. Moreover, biomechanical studies have demonstrated superior fixation strength of an in situ repair when compared with completion of the tear with subsequent repair.21,22
Table 4. Comparative Results of Time to Return-to-Sport and Functional Scores
Type of sport: G1: noncollision/nonoverhead (n ¼ 35) G2: high-impact/collision sports (n ¼ 20) G3: overhead sport (n ¼ 15) G4: martial arts sports (n ¼ 0) P value Preinjury sport level: Competitive (n ¼ 26) Recreational (n ¼ 44) P value Age at time of surgery: 20-40 41-60 P value Mechanism of injury: Traumatic Atraumatic P value
Return to Sports (mo, mean SD)
American Shoulder and Elbow Surgeons (mean SD)
Visual Analog Scale (mean SD)
3.6 4 6.1 1 6.4 2 <.001
87.4 1 86.3 1 85.2 1 .49
1.3 2 1.1 7 1.6 2 .19
5.1 2 5.8 3 .09
85.3 1 84.2 1 .17
1.2 3 1.3 1 .63
5.2 2 5.7 4 .12
88.4 2 83.2 3 .14
1.1 2 1.3 2 .34
5.1 3 5.7 2 .26
88.3 1 86.2 1 .18
1.1 2 1.3 2 .19
NOTE. Values expressed in mean standard deviation (SD).
RETURN TO SPORTS AFTER PARTIAL ROTATOR CUFF TEARS Table 5. Comparative Results Between Patients Who Could and Could Not Return to Sports Total, n/N (%) Average age (range) Level of sports, n/N (%): Competitive Recreational
Return to Sports 61/70 (87) 39 (21-60) 24/26 (89) 37/44 (86)
No Return to Sports 9/70 (13) 42 (22-58) 3/26 (11) 6/44 (14)
In our study, most of the patients were able to return to sports (85%) and at the same level they had previous to the injury (78%). Interestingly, there were no significant differences regarding return to sports and the level achieved by the athletes between bursal- and articular-sided tears. Moreover we performed a stratified evaluation according to age between those who were younger or older than 40 years old and found no differences regarding rate of return to sports. Klouche et al.,23 in a recent systematic review regarding return to sport after rotator cuff tears, evaluated 25 studies including 683 athletes. They reported an overall rate of return to sport of 84.7%, with 66% returning to an equivalent level of play. An interesting finding of this review was that the rate of return at the same level was significantly lower in competitive athletes than in recreational athletes: 49.9% versus 81.4%, respectively. The higher rate of return to an equivalent level of play found in our study could be explained by 2 main factors. First, only 36% (26/72) of our patients were competitive athletes. Second, 56% of the included athletes in the Klouche et al. review practiced overhead sports (mainly baseball and tennis). Conversely, only 20% of our patients were overhead athletes. Previous investigators also reported high rates of decrease in sport performance after rotator cuff repairs in overhead athletes.24-27 The mean delay in return to competition was 5.6 months. As expected, patients belonging to group G1 (noncollision/nonoverhead sports) returned significantly faster to sports than other patients (P < .001). These types of sports imply a lower demand for the shoulder and could explain the faster return to sports in this subgroup of athletes. However, delay in return to competition and functional outcomes were related neither to the age at time of surgery nor to the mechanism of injury. The general assessment of our patients revealed excellent functional outcomes, with a final ASES score of 88 and a final VAS score of 1.2. These results are similar to those previously reported with the in situ repair in the general population.7-13 Moreover, no significant difference in shoulder ROM and functional scores was found between bursal and articular repairs. Similar findings were reported by Kim et al.,5 who evaluated clinical features and structural integrity after
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arthroscopic repair of bursal versus articular side PTRCTs in 83 patients. At 2-year follow-up, both groups showed significant improvement in pain and shoulder function, with no difference between groups in functional outcomes or retear rates. We also performed a stratified evaluation according to age and found no differences regarding functional outcomes. We had a low rate of complications and reoperations in our study. There were only 5 complications (7%), and all were adhesive capsulitis that resolved favorably with physical therapy. Moreover no patient needed to be reoperated. This is a relevant finding especially in young active patients since a new surgery would imply reinterrupting their sports practice and their work activity. Previous investigators also reported low rates of complications and reoperations with transtendon repair of partial tears.7-16 Limitations Some limitations to this study should be mentioned. First, it was a retrospective study. Second, we did not have a control group and therefore could not compare the in situ repair technique with other arthroscopic rotator cuff repair methods. Second, only 20% of our patients were overhead athletes and only 36% were competitive athletes. Possibly, the outcomes would not be as favorable with a larger number of overhead and high-level athletes. Third, we did not perform a sample size calculation, and the study could be underpowered to detect a difference in some of the outcomes analyzed. Finally, there was no MRI at follow-up, which would have been useful to evaluate the integrity of the repair and its relationship with clinical results.
Conclusions In patients with PTRCTs, arthroscopic in situ repair resulted in excellent functional outcomes, with most of the patients returning to sport and at the same level they had before injury. The results were equally favorable in articular and bursal tears.
References 1. Finnan RP, Crosby LA. Partial-thickness rotator cuff tears. J Shoulder Elbow Surg 2010;19:609-616. 2. Matthewson G, Beach CJ, Nelson AA, et al. Partial thickness rotator cuff tears: Current concepts. Adv Orthop 2015;2015:458786. 3. Deutsch A. Arthroscopic repair of partial-thickness tears of the rotator cuff. J Shoulder Elbow Surg 2007;16:193-201. 4. Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91: 1055-1062. 5. Kim KC, Shin HD, Cha SM, Park JY. Repair integrity and functional outcome after arthroscopic conversion to a
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partial-thickness rotator cuff tears: Comparison with the double-row suture-bridge technique. Am J Sports Med 2015;43:1976-1982. Sun L, Zhang Q, Ge H, Sun Y, Cheng B. Which is the best repair of articular-sided rotator cuff tears: A meta-analysis. J Orthop Surg Res 2015;10:84. Stein T, Linke RD, Buckup J, et al. Shoulder sport-specific impairments after arthroscopic Bankart repair: A prospective longitudinal assessment. Am J Sports Med 2011;39: 2404-2414. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852. Snyder SJ, Burns J. Rotator cuff healing and the bone marrow “crimson duvet” from clinical observations to science. Tech Shoulder Elbow Surg 2009;10:130-137. Peters KS, Lam PH, Murrell GA. Repair of partialthickness rotator cuff tears: A biomechanical analysis of footprint contact pressure and strength in an ovine model. Arthroscopy 2010 Jul;26:877-884. Gonzalez-Lomas G, Kippe MA, Brown GD, et al. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg 2008;17:722-728. Klouche S, Lefevre N, Herman S, Gerometta A, Bohu Y. Return to sport after rotator cuff tear repair: A systematic review and meta-analysis. Am J Sports Med 2016;44: 1877-1887. Azzam MG, Dugas JR, Andrews JR, Goldstein SR, Emblom BA, Cain EL Jr. Rotator cuff repair in adolescent athletes. Am J Sports Med 2018;46:1084-1090. Liu JN, Garcia GH, Gowd AK, et al. Treatment of partial thickness rotator cuff tears in overhead athletes. Curr Rev Musculoskelet Med 2018;11:55-62. Dines JS, Jones K, Maher P, Altchek D. Arthroscopic management of full-thickness rotator cuff tears in Major League Baseball pitchers: The lateralized footprint repair technique. Am J Orthop (Belle Mead, NJ) 2015;45:128-133. Mazoue CG, Andrews JR. Repair of full-thickness rotator cuff tears in professional baseball players. Am J Sports Med 2006;34:182-189.
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Purpose: To evaluate return to sport, clinical outcomes, and complications in a series of athletes with painful partialthickness rotator cuff tears treated with the arthroscopic in situ repair with a minimum 2-year follow-up. Methods: Retrospective case series. Seventy-two patients who had undergone an arthroscopic in situ repair for partial-thickness rotator cuff tears were evaluated. We assessed return to sport and the level achieved after surgery. Clinical assessment consisted of glenohumeral range of motion measurement and the American Shoulder and Elbow Surgeons score. Pain was recorded using a visual analog scale. Postoperative complications were also assessed. Results: The mean age was 42.2 years (range, 21-66 years), and the mean follow-up was 54 months (range, 24-113 months). Sixty-one patients (87%) were able to return to sports. Fifty-six patients (80%) returned to the same level they had previous to the injury. The mean interval between surgery and return to competition was 5.6 months. The final functional outcomes were related neither to the type of sports nor to the level of competition before the injury. All active range of motion parameters improved significantly (P < .0001). The American Shoulder and Elbow Surgeons score improved from 43.3 to 88.1, and the visual analog scale scores improved from 6.1 to 1.2 (P < .0001). No significant difference regarding return to sports or functional outcomes was found between articular and bursal-sided tears. Only 5 patients developed a postoperative adhesive capsulitis that responded to physical therapy. Conclusions: In patients with partial-thickness rotator cuff tears, arthroscopic in situ repair resulted in excellent functional outcomes, with most of the patients returning to sport and at the same level they had before injury. The results were equally favorable in articular and bursal tears. Level of Evidence: Level IV, therapeutic case series.
P
artial-thickness rotator cuff tears (PTRCTs), are a common cause of pain and dysfunction in the adult shoulder.1,2 After failed conservative management, operative intervention is typically indicated for patients with persistent pain and disability symptoms.1,2 Generally, PTRCTs are considered for repair when they extend to >50% of the tendon thickness.1,2 The current evidence does not provide guidance as to the best management plan for symptomatic PTRCTs. Some surgeons prefer conversion from partial- into
From the Hospital Italiano de Buenos Aires, Buenos Aires City, Argentina. The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. This study was approved by the Ethical Committee of the Italian Hospital of Buenos Aires. Received March 9, 2018; accepted July 13, 2018. Address correspondence to Luciano A. Rossi, M.D., Peron 4190 (C1199ABB), Buenos Aires, Argentina. E-mail: [email protected] Ó 2018 by the Arthroscopy Association of North America 0749-8063/18319/$36.00 https://doi.org/10.1016/j.arthro.2018.07.037
full-thickness tear, and then repair in a traditional fashion,3-6 while others advocate in situ repair preserving the intact tendon.7-13 The few available studies comparing both procedures have not demonstrated the superiority of one technique over the other.14-17 Although both techniques have shown excellent functional results in the general population, there is a lack of studies in the literature reporting the outcomes of PTRCTs in athletes.18 The purpose of this study was to evaluate return to sport, clinical outcomes, and complications in a series of athletes with painful PTRCTs treated with the arthroscopic in situ repair with a minimum 2-year follow-up. We hypothesized that this technique would be effective in reducing pain and improving shoulder function in patients with PTRCTs, resulting in a reliable and timely return to play with a low rate of complications.
Methods Athletes who underwent arthroscopic repair of partial articular- or bursal-sided rotator cuff tears (PARCTs or
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
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No
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(Month), 2018: pp 1-6
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PBRCTs) between December 2006 and December 2015 were retrospectively identified. The inclusion criteria were (1) patients between 20 and 60 years old, (2) with an unsuccessful minimum 3-month course of conservative treatment consisting of activity modification, anti-inflammatory medication, and a physical therapy, and (3) tears of >50% of the tendon thickness on the bursal or articular side (or 6 mm) diagnosed with preoperative magnetic resonance imaging (MRI) and confirmed during surgery. Exclusion criteria were (1) <2 years’ followup, (2) previous surgeries in the affected shoulder, and (3) associated procedures at the time of surgery. Preoperative and postoperative evaluation consisted of a patient-based questionnaire and physical examination performed by a physical therapist specialized in shoulder pathology who was blinded to the surgery type. Each patient was evaluated before surgery and at follow-up after 3, 6, and 12 months and annually thereafter. Only the final follow-up evaluation was used for data analysis in this study. Patients were asked if they had been able to play sports again and if they had been able to perform at the same level they had before the injury. We asked patients who did not return to sports the reasons for cessation. We stratified our cohort by age into 2 groups to evaluate return to sports (20-40 years and 41-60 years). Patient sport level was divided into competitive sport (regular sport with competition and practice >2 times per week) and recreational sport (regular sport without competition <2 times per week).18 The distinctive types of shoulderdependent sport were subdivided in an analog manner according to Allain et al.19: noncollision/nonoverhead shoulder sport (G1), high-impact/collision sport (G2), overhead sport (G3), and martial arts sport (G4) Clinical assessment consisted of the measurement of active glenohumeral range of motion (ROM) using a goniometer and the American Shoulder and Elbow Surgeons (ASES) score. Pain was recorded using the visual analog scale (VAS); a score of 0 indicated no pain, and 10 points indicated the worst possible pain. All patients underwent preoperative radiographs (anterior-posterior, axillary, and arch view) and MRI evaluation. The study protocol was approved by our Institutional Review Board (IRB 00010193). Surgical Technique Surgical procedures were performed by use of general anesthesia with adjuvant interscalene nerve blockade with the patient in the beach chair position. The repairs were performed by 3 surgeons using the same technique. We measured the medial aspect of the rotator cuff footprint using a calibrated probe and repaired PARCTs involving >6 mm of the footprint with an arthroscopic
in situ procedure. An anterior portal was placed in the rotator interval. An anterior subacromial portal was created. After bursectomy, the arthroscope was reintroduced into the glenohumeral joint through a posterior portal. To place transtendon anchors, we initially used a spinal needle as a guide. A small incision (<5 mm) was created on the lateral aspect of the shoulder at the point where the spinal needle was located. A 5.5 mm CrossFT anchor with 2 HiFi Sutures (Conmed Linvatec, Largo, FL) was then placed transtendon into the rotator cuff footprint after its decortication with the shaver in all cases. If the tear involved <1 cm of the footprint in an anterior-to-posterior direction, we used 1 anchor for the repair. However, if the tear involved >1 cm, 2 anchors were used: one was placed anteriorly, the other posteriorly on the footprint. One limb of suture was grasped and retrieved through the anterior portal. A spinal needle was passed through the supraspinatus. From the needle in this position, a shuttle relay was passed into the joint and was then retrieved through the portal. After the first suture was passed through the tendon, the same system was used for the second suture. After tying all the sutures, the arthroscope was reintroduced in the joint and an evaluation of the construct was performed. For PBRCTs, enough bursectomy was performed to allow good visualization of the cuff tear and manage arthroscopic tools. Once the rupture was discovered, the degenerative tissue was removed. The thickness of the tear was measured with a calibrated probe. Next, the greater tuberosity was prepared to promote healing of the reattached cuff using the crimson duvet procedure previously described by Snyder and Burns.20 Only the detached layer was reattached to the greater tuberosity using a 5.5 mm CrossFT anchor with 2 HiFi Sutures (Conmed Linvatec). All patients received a single-row repair. All sutures were passed with a simple repair. If the tear involved <1 cm of the footprint in an anterior-to-posterior direction, 1 anchor was used. If the tear involved >1 cm, 2 anchors were used, one placed anteriorly and the other posteriorly. Subacromial decompression or distal clavicle resection was not performed in any patient. Postoperative Management All patients followed a standard postoperative rehabilitation protocol. The arm was supported in a standard sling for 4 weeks with elbow and hand exercises when tolerated. After 4 weeks, supervised gentle physical therapy consisting of passive pendulum and gradual passive and active-assisted ROM exercises was begun. When the patient could perform active forward elevation above the shoulder level, shoulder-strengthening exercises were started. Patients started with bands and then with weights progressively once they recovered active ROM. Running was authorized at 8 weeks.
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RETURN TO SPORTS AFTER PARTIAL ROTATOR CUFF TEARS Table 1. Patients Demographics Variables No. of shoulders Sex, men/women Dominant involvement, n (%) Age at the time of surgery, yr (range) Mechanism of injury, n (%): Traumatic Atraumatic Preinjury sport level, n/N (%): Competitive Recreational Type of sport: G1: noncollision/nonoverhead G2: high-impact/collision sports G3: overhead sport G4: martial arts sports
Partial Bursal-Sided Rotator Cuff Tears 38 20/18 22 (58) 41 (21-60)
Partial Articular-Sided Rotator Cuff Tears 32 17/15 21 (62) 44 (22-59)
10 (26) 28 (74)
10 (31) 22 (69)
14/38 (37) 24/38 (63)
12/32 (38) 20/34 (62)
18 11 9 0
17 9 6 0
Return to competition was allowed when the patient was pain free, full-shoulder ROM had been achieved, and shoulder strength was near the same as before the injury.
participate in follow-up for 2 years, and 1 patient died of an unrelated disease. The final evaluation thus was carried out in 70 patients. The mean follow-up was 54 months (range, 24-113 months). The main demographic characteristics of the involved patients and their injuries are shown in Table 1. Sixty-one patients (87%) were able to return to sports. Fifty-six patients (80%) returned to the same level they had previous to the injury (Table 2). No significant difference regarding return to sports was found between PBRCTs and PARCTs (Table 3). There were 9 patients (13%) who did not return to sports after the procedure. Six patients referred to fear of another injury or loss of confidence in the shoulder, and 5 patients reported leaving for reasons independent of their shoulder (work, university, etc.) as the reasons for cessation. Four patients (6%) returned to sports but to a lower level than before the injury. Although they had good functional scores, the 4 patients referred to noticed a decrease in sports performance. The mean interval between surgery and return to competition was 5.6 months (range, 3-9 months). Regarding type of sports, patients belonging to group G1 (noncollision/ nonoverhead sports) returned significantly faster to sports than other patients (P < .001; Table 4). However, as shown in Table 4, the final functional outcomes were
Statistical Methodology Preoperative and postoperative scores were compared with the paired t-test for independent samples. Continuous variables were presented as means standard deviations, whereas categorical variables were presented as absolute and relative frequencies. Statistical analysis was performed using independent Student’s t-test with a 95% confidence interval to calculate the differences between the groups in ROM and functional scores. The statistical analysis was performed using the software STATA version 12 (Stata, College Station, TX). P < .05 was considered statistically significant.
Results From the 87 consecutive arthroscopic partial repairs performed in patients between 20 and 60 years old who practiced sports during the study period, 17 patients were excluded. Nine patients who underwent concomitant biceps procedures (7 tenodesis and 2 tenotomies) and 3 patients who underwent subscapularis repair were excluded. Four patients did not Table 2. Summary of Functional Outcomes and Return to Sport Variables American Shoulder and Elbow Surgeons, mean SD Visual analog scale, mean SD Forward flexion, mean SD External rotation in abduction, mean SD Internal rotation in adduction Return to sports, n/N (%) Still playing at 2 years follow-up, n/N (%) Same level, n/N (%) SD, standard deviation.
Preoperative 43.3 1 6.1 1 118 3 63.2 2 Sacrum
Final Follow-up 88.1 4 1.2 1 168 3 75.1 3 T5/T6 61/70 (87) 57/70 (81) 56/70 (80)
P Value <.001 <.001 <.001 <.001
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Table 3. Comparative Outcomes Between Partial Bursal-Sided Rotator Cuff Tears (PBRCTs) and Partial Articular-Sided Rotator Cuff Tears (PARCTs) Repairs PBRCTs Variables American Shoulder and Elbow Surgeons, mean SD Visual analog scale, mean SD Forward flexion, mean SD External rotation in abduction, mean SD Internal rotation in abduction Return to sport, n (%) Still playing at 2 years follow-up, n (%) Same level, n (%)
Pre 41.7 1 6.1 2 120.3 3 60.8 3 Sacrum
PARCTs
Post 89.1 5 1.1 1 168. 3 73.2 3 T5/T6 32/38 (84) 30/38 (79) 9/38 (76)
Pre 44.8 6.4 114.3 63.2 T5/T6
1 1 3 2
Post 86.1 5 1.4 1 172. 3 76.1 3 T5/T6 29/32 (90) 27/32 (84) 27/32 (84)
P Value .36 .09 .51 .12
SD, standard deviation.
related neither to the type of sports nor to the level of competition before the injury. A significant improvement in shoulder ROM was found between preoperative and postoperative results (Table 2). The ASES score and VAS showed statistical improvement after operation (P < .01). No significant difference in shoulder ROM and functional scores was found between articular- and bursal-sided repairs (Table 3). We compared average age and level of sports between patients who could return to sports and those who could not, and we did not find significant differences (Table 5). Complications Five patients developed an adhesive capsulitis. Two patients had articular partial tears, were recreational athletes, and were younger than 40 years old. The other 3 patients had bursal partial tears. One patient was younger than 40 and was a competitive athlete. The
other 2 patients were older than 40 and were recreational athletes. All resolved favorably with physical therapy within the first 3 months. No patient was reoperated.
Discussion The main findings of this study were that arthroscopic in situ repair of PTRCTs resulted in excellent functional outcomes, with most patients returning to sport and at the same level they had before injury. The results were equally favorable in articular- and bursal-sided tears. We prefer in situ repair. We preserve as much of the healthy tendon as possible and repair only the avulsed flap into the footprint. The advantages of this technique are that it restores anatomically the rotator cuff footprint and preserves the intact tendon fibers. Moreover, biomechanical studies have demonstrated superior fixation strength of an in situ repair when compared with completion of the tear with subsequent repair.21,22
Table 4. Comparative Results of Time to Return-to-Sport and Functional Scores
Type of sport: G1: noncollision/nonoverhead (n ¼ 35) G2: high-impact/collision sports (n ¼ 20) G3: overhead sport (n ¼ 15) G4: martial arts sports (n ¼ 0) P value Preinjury sport level: Competitive (n ¼ 26) Recreational (n ¼ 44) P value Age at time of surgery: 20-40 41-60 P value Mechanism of injury: Traumatic Atraumatic P value
Return to Sports (mo, mean SD)
American Shoulder and Elbow Surgeons (mean SD)
Visual Analog Scale (mean SD)
3.6 4 6.1 1 6.4 2 <.001
87.4 1 86.3 1 85.2 1 .49
1.3 2 1.1 7 1.6 2 .19
5.1 2 5.8 3 .09
85.3 1 84.2 1 .17
1.2 3 1.3 1 .63
5.2 2 5.7 4 .12
88.4 2 83.2 3 .14
1.1 2 1.3 2 .34
5.1 3 5.7 2 .26
88.3 1 86.2 1 .18
1.1 2 1.3 2 .19
NOTE. Values expressed in mean standard deviation (SD).
RETURN TO SPORTS AFTER PARTIAL ROTATOR CUFF TEARS Table 5. Comparative Results Between Patients Who Could and Could Not Return to Sports Total, n/N (%) Average age (range) Level of sports, n/N (%): Competitive Recreational
Return to Sports 61/70 (87) 39 (21-60) 24/26 (89) 37/44 (86)
No Return to Sports 9/70 (13) 42 (22-58) 3/26 (11) 6/44 (14)
In our study, most of the patients were able to return to sports (85%) and at the same level they had previous to the injury (78%). Interestingly, there were no significant differences regarding return to sports and the level achieved by the athletes between bursal- and articular-sided tears. Moreover we performed a stratified evaluation according to age between those who were younger or older than 40 years old and found no differences regarding rate of return to sports. Klouche et al.,23 in a recent systematic review regarding return to sport after rotator cuff tears, evaluated 25 studies including 683 athletes. They reported an overall rate of return to sport of 84.7%, with 66% returning to an equivalent level of play. An interesting finding of this review was that the rate of return at the same level was significantly lower in competitive athletes than in recreational athletes: 49.9% versus 81.4%, respectively. The higher rate of return to an equivalent level of play found in our study could be explained by 2 main factors. First, only 36% (26/72) of our patients were competitive athletes. Second, 56% of the included athletes in the Klouche et al. review practiced overhead sports (mainly baseball and tennis). Conversely, only 20% of our patients were overhead athletes. Previous investigators also reported high rates of decrease in sport performance after rotator cuff repairs in overhead athletes.24-27 The mean delay in return to competition was 5.6 months. As expected, patients belonging to group G1 (noncollision/nonoverhead sports) returned significantly faster to sports than other patients (P < .001). These types of sports imply a lower demand for the shoulder and could explain the faster return to sports in this subgroup of athletes. However, delay in return to competition and functional outcomes were related neither to the age at time of surgery nor to the mechanism of injury. The general assessment of our patients revealed excellent functional outcomes, with a final ASES score of 88 and a final VAS score of 1.2. These results are similar to those previously reported with the in situ repair in the general population.7-13 Moreover, no significant difference in shoulder ROM and functional scores was found between bursal and articular repairs. Similar findings were reported by Kim et al.,5 who evaluated clinical features and structural integrity after
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arthroscopic repair of bursal versus articular side PTRCTs in 83 patients. At 2-year follow-up, both groups showed significant improvement in pain and shoulder function, with no difference between groups in functional outcomes or retear rates. We also performed a stratified evaluation according to age and found no differences regarding functional outcomes. We had a low rate of complications and reoperations in our study. There were only 5 complications (7%), and all were adhesive capsulitis that resolved favorably with physical therapy. Moreover no patient needed to be reoperated. This is a relevant finding especially in young active patients since a new surgery would imply reinterrupting their sports practice and their work activity. Previous investigators also reported low rates of complications and reoperations with transtendon repair of partial tears.7-16 Limitations Some limitations to this study should be mentioned. First, it was a retrospective study. Second, we did not have a control group and therefore could not compare the in situ repair technique with other arthroscopic rotator cuff repair methods. Second, only 20% of our patients were overhead athletes and only 36% were competitive athletes. Possibly, the outcomes would not be as favorable with a larger number of overhead and high-level athletes. Third, we did not perform a sample size calculation, and the study could be underpowered to detect a difference in some of the outcomes analyzed. Finally, there was no MRI at follow-up, which would have been useful to evaluate the integrity of the repair and its relationship with clinical results.
Conclusions In patients with PTRCTs, arthroscopic in situ repair resulted in excellent functional outcomes, with most of the patients returning to sport and at the same level they had before injury. The results were equally favorable in articular and bursal tears.
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