Shoulder function after surgical repair of rotator cuff tears

Shoulder of rotator M. Kronberg, MD, Umec?, Sweden

function after cuff tears PhD, P. Wahlstr6m,

MD,

surgical

and 1-A. Brostrom,

MD,

repair PhD,

function was assessed in 37 patients with a mean age of 57 years after acromioplas?/ and repair of full-thickness rotator cuff tears were performed. The cuff tears were closed without transfer of other muscles or use of synthetic materials. At review 2 years after surgery 32 patients had significant pain relief and improved shoulder function. Range of motion, muscle strength, and endurance were increased. The mean Constant score was 77, and 80% of the patients were graded as having Shoulder

mild

or no disability.

Radiographic

measurements

disclosed

an increased

supraspinafus outlet area after surgery. It is concluded that in patients with impingement syndrome and a full-thickness rotator cuff tear, shoulder function will be improved after acromioplasty and cuff repair, but a slight decrease in range of motion and muscle strength will remain when (J SHOULDER ELBOW SURG 1997;6: 725-30.)

Th e natural history of rotator cuff tears is somewhat unknown, but it is clear that these tears are usually an effect of degeneration.2, 7, 22 The cuff degenerates with aging, and most patients with cuff tears are older than 40 years. Among patients with impingement syndrome full-thickness rotator cuff tears have an incidence of 30% in the age group 60 years and older compared with 5% in the age group younger than 60 years.37 However, there are some anatomic configurations that might predispose for development of the impingement syndrome and rotator cuff tearing. The impingement syndrome can be defined as a “space problemN in the shoulder region, and impingement occurs against the anterior edge and the undersurface of the anterior one third of the acromion and the coracoacromial ligament. The supraspinatus outlet area, identified as the total coracoacromial arch area subtracting the area of the humeral head within the coracoacromial arch, is reported to be smaller in patients with rotator cuff tears compared with those shoulders with intact ~uffs,~~ and this

From

the Department

Reprmts requests Orthopaedlcs,

of Orthopaedlcs,

Margareta Unlverslty

Supported

by grants

from

Copynght

0

by Journal

Board

1997

Unlverslty

the Swedish

Society

of Shoulder

of Trustees

10%2746/97/$500+0

Hospltol

Kronberg, MD, PhD, Department of Hospital, S-901 8.5 Ume6, Sweden

32/l/78514

of Medlclne and

Elbow

Surgery

compared

with the contralateral

side.

difference is possibly of prognostic significance. To increase the supraspinatus outlet area the acromioplasty as described by Neer18 in 1972 needs to be extended. To reduce the “overhang” of the acromion, the portion of acromion projecting beyond the anterior border of the clavicle should be resected to give the structures in the subacromial space additional room. 30, 31 Impingement occurs between the anterior edge of the acromion and the underlying rotator cuff rather than between the lateral aspect of the acromion and the cuff.18 Previous studies have demonstrated hypovascular regions in the supraspinatus tendon at its insertion at the greater tuberosity in the nonpathologic state.4, 2** 32 Repeated microtrauma in this area with impaired blood supply of the supraspinatus tendon may result in an inflammatory reaction with swelling of the tendinous structures. In 1934 Codman7 suggested that trauma causing an incomplete thickness cuff tear within the deep layer will progress to a complete full-thickness rupture of the tendon. The indication for surgical repair of cuff tears is still under debate, but surgical intervention is proposed to give pain relief and promote recovery of shoulder function. Some small and moderate tears can be closed by side-to-side sutures, and medium and large tears can in most cases be closed after advancement of the rotator cuff edges with sutures to the greater tuberosity. In massive tears other 125

126

Kronberg,

WahlstrZjm

and Brostrijm

techniques may be needed such as transposition of muscles such as the subscapularis* and the latissimus dorsi12 or use of allogenic tissue20 or synthetic materials.24 The aim of this retrospective study was to assess the functional outcome in patients operated with an extended anterior acromioplasty and rotator cuff repair 2 or more years after surgery. MATERIAL Forty consecutive patients (38 men, 2 women) with chronic impingement syndrome and a unilateral full-thickness rotator cuff tear were included in this study. The mean age was 57 years (range 41 to 67 years). All had symptoms of pain and restricted range of motion for at least 6 months. Before surgery all had proven resistance to conservative treatment such as antiinflammatory drugs and intrabursal steroid injections. All patients were operated with an open/extended anterior acromioplasty3’ with subacromial decompression and excision of the coracoacromial ligament. Excision of the lateral end of the clavicle was performed in 17 patients. The cuff tears were measured by their largest diameter. There were 7 small (cl.5 cm), 12 medium (1.5 to 3 cm), 14 large (3 to 4 cm), and 4 massive (>4 cm) tears. Rotator cuff repair was performed in all patients without use of muscle transfers or synthetic materials. Three patients were excluded: one because he was primarily operated on with acromioplasty and than underwent reop eration with repeat acromioplasty and cuff reconstruction and two because they could not return for review. All three reported excellent shoulder function. Thus 37 patients were examined. All patients have been followed clinically and radiographitally for at least 2 years (range 2 to 3 years). METHODS Surgical technique. The subacromial space was exposed with a curved skin incision extending from the anterior rim of the acromion distally between the anterior and the middle parts of the deltoid muscle. From the anterolateral corner of the acromion an approximately 3 cm split was developed between the anterior and middle parts of the deltoid muscle. This technique allows a relatively avascular approach with good exposure of the subacromial space. Only a minor detachment (less than 2 cm) of the deltoid muscle was performed subperiosteally. The portion of the acromion that projected anteriorly beyond the anterior border of

J. Shoulder Elbow Surg. March/April 1997

the clavicle was resected vertically. Bursectomy and subacromial decompression combined with resection of the major portion of the coracoacromial ligament was performed. In 17 cases excision of the lateral edge of the clavicle was performed. In all these shoulders degenerative changes were visible radiographically, and there was tenderness on palpation of the acromioclavicular joint with relief of symptoms by injection of local anesthetics into the joint. Inferior bony spurs were always resected. Rotator cuff tears were closed after softtissue mobilization was performed with bone sutures with resorbable material. No transfer of other muscles and tendons was performed. The deltoid muscle was carefully reattached to the acromion and deltotrapezius fascia. The shoulder was immobilized for 5 weeks in internal rotation and adduction with a sling. Passive exercises were started the first postoperative day. Active exercises were allowed 5 weeks after the operation. Clinical examination. All patients have been examined at 6 weeks, 3 months, and 1 and 2 years after surgery. At follow-up range of move ment (ROM) for flexion, abduction, and internal and external rotation was measured in both shoulders in a standing position with use of a goniometer. Preoperative values for the affected side were obtained from the files. Isometric muscle strength was measured for abduction and internal and external rotation with the lsobex 2.0 apparatus (Cursor AG, Swiss). Muscle endurance was assessed by the ability (time in seconds) to keep a weight of 2 kg in the hand with the arm in a straight and 90” abducted position. Pain was scored with a 0 to 10 graded visual analog scale (VAS). Shoulder function at follow-up was assessed with the Constant score, which takes into consideration age, sex, and activity level of the patient such as normal working activities, occupation, and leisure activities. Radiographic examination. Radiographs were taken in the anteroposterior view, in a 30” inferiorly angulated position, and in a scapular lateral view. On the radiograph taken in this last view the area of the coracoacromial arch was determined as the triangle formed by the anterior and posterior acromial reference points and the coracoid reference point (Figure 1). The supraspinatus outlet area was calculated by subtracting the area of the humeral head within the coracoacromial arch from the calculated coracoacromial arch area. As a pilot study for method evaluation one

1. Shoulder Elbow Surg. Volume 6, Number 2

Kronberg,

Wahlstrijm

and Brostriim

127

skeleton was radiographically investigated in different positions of angulation. Radiographs were taken with projections from 25” anterior to 25” posterior and from 25” cranial to 25” caudal. Measurements done on radiographs within 20” from the usual axial projection gave an error on area calculations of less than 5%. The error in the calculated area between repeated radiographic examinations was less than 5%. Statistical methods. Mean values, standard deviations (+ SD), and range were used to present data. Student’s paired t test was used to test differences between groups, and p < 0.05 was used as the level for significance. Pearson’s correlation coefficient was used to test relationships between variables.

RESULTS Clinical examination ROM. Flexion was increased from mean a value 90” to 160” and abduction from a mean value 80” to 150”. Internal rotation in 90” of abduction was increased from a mean value 10” to 39”, but external rotation in 90” of abduction was almost unchanged, having a mean value of 45” (Table I). ROM for the five patients graded as failures was significantly decreased (p < 0.05) compared with the patients with no, mild, or moderate disability, and ROM was also significantly decreased (p < 0.05) compared with the contralateral shoulder (Table II). The patients with no, mild, or moderate disability at follow-up had an almost normal range of motion, and their mean values were flexion 174” (+25.5), abduction 164” (-t33.9), internal rotation in 90” abduction 43” (t 14.7). Th ere were no significant differences compared with the contralateral unoperated shoulder. Muscle endurance. Mean muscle endurance for the operated side after the operation was 71 seconds and 90 seconds for the contralateral side. In the five patients graded as failures the mean muscle endurance was 1 second, and for the patients with no, mild, or moderate disability the mean muscle endurance was 83 seconds. Muscle strength. After surgery all the patients had increased muscle strength, but it was still decreased compared with that of the contralateral side (Table Ill). For the five patients graded as failures the muscle strength for abduction was 1.4 kg, for internal rotation in adducted position it was 9.1 kg, and for external rotation in adducted

Figure

1 Coracoacromlal by anterior and posterior coracold reference point

arch acromial

represents reference

area formed points and

position it was 3.5 kg (Table IV). Values were significantly decreased (p < 0.05) compared with the patients with no, mild, or moderate disability. The patients with no, mild, or moderate disability did not regain a normal muscle strength compared with the contralateral side: abduction, 1 1.4 compared with 15.7 (p < O.OOl), internal rotation in adducted position, 12.7 compared with 14.1 (p < O.Ol), and external rotation in adducted position, 7.0 compared with 8.5 (p < 0.001)). Pain. Pain was decreased in all patients from a mean value VAS 7 before surgery to VAS 2 at review. The five patients graded as having failures graded pain as VAS 5. Patients with no, mild, or moderate disability graded pain as VAS 1. A painful ROM was observed only in the five patients classified as having failures, and night pain persisted in only one patient. Limitation of activities of daily living was persistent in two patients. Constant score. After surgery, at follow-up the mean Constant score was 77. Twenty-seven patients were graded as having mild or no disability, and two patients were graded as having

128

Kronberg,

WahlstrCm

and Brostrijm

1. Shoulder

Elbow Surg.

March/April

Table I Ran e of motion, mean values, and SD in all 37 patients for unilateral s ull-thickness rotator-cuff tear Operated

side

90 ? 25.2 80 2 32.5 10 2 4.5 -

45 2 10.5

syndrome

operated

Contralateral

Preoperative Flexion (“) Abduction (“) internal rotation - adducfed position (g - 90” abduction (“I External rotation - odducted position rj - 90” abduction (g

with impingement

At review 158 151

2 37.8* + 42.8*

1997

on

side

At review 170 165

” 27.4 t 32.0

80 2 3.3 NS 39 2 16.7t

80 % 3.2 47 + 11.3

52 ? 13.1* 462 11.8NS

58 48

2 7.6 2 9.7

*p < 0.05. tp < 0.01.

Table

II

patients

Ran e of motion at review classi 9ied as failures Operated side

Flexion (“) Abduction (“1 Internal rotation - 90” abduction

89 5 30.0* 81 k 23.6* (g

19 + 16.7*

in the five Contmlateral side 153 142

? 40.0 2 43.8

39 2 16.7

*p < 0.05.

moderate disability. Five patients with severe disability (Constant scores 2 1, 32, 36, 46, and 47) were considered to be failures. In the group of failures three patients had a large, one a medium, and one a small tear. Four patients had massive tears, and at review two patients were classified as having no disability (Constant scores 86 and 91), one mild disability, and one moderate disability. The mean Constant score for the contralateral nonoperated side was a mean value of 92, indicating no disability at all. In the 17 patients with resection of the lateral clavicle the mean Constant score was 86, and only one was classified as a failure. The functional outcome did not differ significantly from those who had only an acromioplasty (mean Constant score 70). Radiographic examination. Cystic and sclerotic changes in both the acromion and the greater tuberosity were found in 23 patients. Calcifying tendinitis was observed in 23 shoulders before surgery and in 1 1 of the 37 shoulders at review. Three out of five failures had calcifying tendinitis at review. The mean preoperative supraspinatus outlet

area was 557 mm* (~242) (range 219 to 927 mm*). The four patients with a massive tear had a preoperative mean supraspinatus outlet area of 708 mm* (2310) (range 488 to 927 mm*). After surgery the supraspinatus outlet area for the whole series increased to a mean value of 794 mm* (2251) (range 251 to 1421 mm*). The mean preoperative coracoacromial arch area was 1229 mm* (5293) (range 680 to 1472 mm*), and at review it was 1572 mm* (+283) (range 1030 to 2625 mm*). No correlation (r < 0.15) was found between postoperative supraspinatus outlet area and pain, supraspinatus outlet area and Constant score, or between supraspinatus outlet area and strength. DISCUSSION It has been shown in previous studies that satisfactory results can be achieved after open surgical repair of full-thickness rotator cuff tears.15, 27 In studies with a short follow-up period 88% good or excellent results are reported after acromioplasty and repair of the cuff tear.31 On the other hand, good results are also reported after only acromioplasty and no repair of the cuff tear,3, 29, 33 but adequate restoration of shoulder . function has been questioned. There are also studies indicating stable long-term results of rotator cuff repair without deterioration over time 1, 15, 35, 36 In this retrospective study we have focused our interest on shoulder function. After closure of the cuff tear muscle strength and endurance were improved, and all patients indicated significant pain relief and improved shoulder function. The Constant score, taking into consideration age, sex,

Kronberg,

J. Shoulder Elbow Surg. Volume 6, Number 2

Table III Isometric muscle strength, mean values, and SD In 36 patients with impingement syndrome operated on for unilateral full-thickness rotator cuff tear Operated side Abduction Intern01

(“)

9.7

*p

patient

was

Table IV Isometric and SD at review failures

Operated side

&a*

15.4

i- 6.6

Abduction (“) Intern01 rotation - adducted position External rotation

14

1 1.8

2 4.9*

14.3

!I 5.5

(4

6.5

2 2.8*

8.3

? 3.0

- odducted

excluded

because

of ankylosis

and Brostrijm

lp

<

position

129

muscle strength, mean values, in the five patients classified as

Confralateral side

rotation

- adducfed position External rotation - adducted position One

f

Wahlstrijm

Contralateral side

1.4

2

1.7*

15.7

t

1”)

9.1

2 2.9*

15.9

5 5.9

(“j

3.5

If- 3.0*

6.6

t

9.3

4.5

0.05.

of the elbow.

< 0.001.

and activity level of the patient, graded disability as mild or absent in 80% of the patients at the 2-year review. Shoulder function did not deteriorate in any patient after the operation. The patients with no, mild, or moderate disability at follow-up had regained a normal range of motion, but the five patients with severe disability (failures) had a significantly decreased range of motion compared with the contralateral shoulder (Table II). The patients graded as failures also had significantly decreased muscle strength (Table IV) and muscle endurance, probably because of persistent pain. Although one patient reported a decrease in pain after the operation, all also subjectively felt improved muscle strength after the operation. However, in this retrospective study no muscle strength values were available in the preoperative records, and thus objective comparison cannot be done. lsobex measurements at review revealed that patients with no, mild, or moderate disability did not regain full muscle strength compared with the contralateral side. The size of the rotator cuff tear was not found to have a significant influence on the results. Half the number of cuff tears were of small and medium size, which could be one explanation why we did not find any significant relationship between cuff tear size and the functional outcome at the 2-year review. With regard to shoulder function we consider the surgical approach to be important. We believe that the deltoid-splitting technique used in our patients gives an adequate approach to the subacromial space, and it requires minimal postoperative immobilization. In our patients with cuff repairs passive shoulder exercises were started the first postoperative day, but active training was

delayed to after 5 weeks because of the cuff repair. Removal of the anterior prominence of the acromion, removal of the anterior-inferior portion of the acromion, and reattachment of the full thickness of the deltoid to the acromion makes the subacromial space even larger. In agreement with Rockwood and Burkhead,3’ we believe that resection of the lateral part of the clavicle should not be performed routinely. On radiographic evaluation the mean supraspinatus outlet area and coracoacromial arch area were increased after the operation, but there were great variations. No correlation was found between the size of cuff tear and the supraspinatus outlet area. Although different angulated projections were found to give only minor variations in area measurements, we know that magnification can influence our area measurements and that the degree of muscle activity will affect humeral head position and will also influence the supraspinatus outlet area. The major object of performing anterior acromioplasty is to increase the subacromial space, and for accurate measurements of the supraspinatus outlet area as an indicator of this space we believe that a more reliable method than standard plain radiography is needed with control of humeral head position. We conclude from this retrospective study that in patients with impingement syndrome and a fullthickness rotator-cuff tear, shoulder function will improve after extended acromioplasty and rotator cuff repair. Most patients will gain pain relief, increased ROM, and improved muscle strength and endurance, and many will return to the preiniury state. To answer the question of whether cuff tears should always be repaired in elderly patients, a prospective randomized study should be performed, and an accurate radiographic method is needed for evaluation of the subacromial space.

130

Kronberg,

Wahlstriim

and Brostrijm

J. Shoulder Elbow March/April

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