IJCRR - Vol 07 Issue 07, April, 2015
Date of Publication: 30-Nov--0001
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FUNCTIONAL OUTCOME OF SHOULDER FOLLOWING MINI OPEN REPAIR FOR ROTATOR CUFF INJURIES
Author: Jalaluddeen Mahin Vaidyar, Shabir Kassim, Sandeep Shibli, U. Hashir Safwan
Abstract:Background: Rotator cuff injuries are a common cause of shoulder pain in the adult population. The present study aims to assess the outcome following rotator cuff repair by mini open approach Materials and methods: This is a prospective study done on thirty patients with rotator cuff injuries. 13 full thickness and 17 partial thickness were followed up for 2 years following repair by mini open approach and functional scoring was done, preoperatively and postoperatively with the Constant and Murley scoring system.Statistical analysis of scores were done with ANOVA and pairwise comparisons between mean scores at different time intervals done with Bonferroni correction test. Results: The mean preoperative score was 59.5 while the mean score at 2 year follow up was 91.8 which is highly significant. There was no significant difference between mean scores of the full thickness tear mini open repair versus the partial thickness tear miniopen repair. Conclusion: Miniopen repair of rotator cuff injuries offers excellent functional outcome at 2 year followup.There is no difference in functional outcome between partial and full thickness tear treated by miniopen repair.
Keywords: Rotator cuff tear, Mini open approach, Functional outcome
Shoulder pain is the third most common musculoskeletal symptom encountered in medical practice after back and neck pain. The point prevalence of shoulder pain has been estimated to be 7–25% and the incidence as 10 per 1,000 per year, peaking at 25 per 1,000 per year among individuals with ages 42–46 years.1,2 Rotator cuff disease encompasses a wide range of pathology from minimal bursal articular side irritation and tendonitis to severe degenerative rotator cuff arthropathy. Rotator cuff pathology affects adults of all ages and other shoulder afflictions must be ruled out by careful history and physical examination 3. Epidemiological studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased 13% in youngest group ( aged 50-59yrs) to 20 % ( aged 60- 69yrs), 31% ( aged 70-79yrs) and 51% in oldest group ( 80-89yrs)4 Already in the beginning of the 20th century, the rotator cuff was recognized as an important contributor to normal shoulder function, and tears of the rotator cuff as a possible cause of shoulder pain and dysfunction Rotator cuff tears can lead to a variety of clinical manifestations, including debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. Optimal repair of the rotator cuff includes achievement of high fixation strength, minimal gap formation and maintenance of mechanical stability under cyclic loading, and proper healing of tendon to bone.5 Mini-open repairs were developed because they had the potential advantage of less deltoid morbidity, and they have demonstrated results that have been similar to those of open repairs. The use of the complete arthroscopic repair is technically demanding and requires a large volume practice in order for a surgeon to obtain proficiency. Because of the technical demands of this procedure, many orthopaedic surgeons still consider the mini-open repair to be the gold standard for rotator cuff repair.6 The standard treatment for full-thickness rotator cuff repair is with an open acromioplasty procedure. An alternative procedure for a full-thickness rotator cuff tear is with a combined procedure of arthroscopic subacromial decompression and mini-open repair, which has the potential advantages of a preserved deltoid origin, lower perioperative morbidity, shorter hospital stays and less soft tissue dissection. In addition to adequate activity level, chronicity of tear with rapidly advancing surgical techniques and modes of fixation, optimal rehabilitation following rotator cuff surgical repair has become increasingly important and challenging for the orthopedic surgeon and physical therapist. This study will address the role of miniopen repair in treatment of rotator cuff tear and assess the functional outcome in the form of range of motion using Constant and Murley Scale (Table 1 ) In constant and murley system following parameters were determined
? Activities of daily living
? Range of motion
This is a prospective study conducted on 30 patients at our institute who underwent miniopen rotator cuff repair between January 2010 and December 2012. 30 patients were included in the study who had clinical or radiological(MRI) evidence of rotator cuff tear and have underwent atleast 6 weeks of conservative management from onset of symptoms. Patients with associated fractures of the shoulder were excluded.The patients were evaluated clinically with a standard range of tests for individual rotator muscles. Shoulder function was recorded preoperatively using the constant and murley score. There were 20 males (66.7%) and 10 (33.3%) female patients in the study.The mean age was 53.6 (range 35- 70 years) (Table 2).There were 13 (43.2%) full thickness tears and 17 (56.6%) partial thickness tears. Of the tears, 8 (26.6%)were degenerative tears and 22 (73.2%) were traumatic tears. 24 (79.9%) patients presented with inability to lift the shoulder and only 6 (19.9%) patients presented with pain in the shoulder. Jobes empty can test was positive in all cases. External rotation stress test was positive in 25 cases and negative in 5 cases. The arm lift off test was positive in only 3 cases and negative in 27. The belly press test was positive in 11 and negative in 19. The speed test was negative in all cases. The mean preoperative constant and murley score was 59.50 ( range 45- 68). The mean score for a full thickness tear was 58.79 (range 48-65) and the mean score for a partial thickness tear was 60.13 (range 45 -68).
Surgical technique and Postoperative treatmen
t Under general anaesthesia, an initial arthroscopic subacromial decompression was done. Then a direct repair of the rotator cuff was done via an anterolateral portal extension approach (mini –open) with a deltoid split without detachment. By manouvering the arm, the entire extent of the tear can be seen. The edges of the tear are debrided, insertion site for suture anchors on greater tuberosity prepared , tear is mobilized, sutures placed through the edge of the tear and tied down to the anterolateral aspect of the greater tuberosity with suture anchors. For large tears , under some tension, special intratendinous sutures are placed through the cuff and these are repaired using the suture anchors placed in the superolateral greater tuberosity7 Following the procedure, the operated arm is placed at the side in a sling with a small pillow. The sling is worn continuously for 6 weeks, except during bathing and exercises. The standard postoperative rehabilitation program is summarized below (Table 2). However, if a subscapularis repair is performed, passive external rotation is limited to 90 degrees (i.e., straight ahead) for the first 6 weeks. In addition, terminal extension of the elbow is restricted if a biceps tenodesis was performed.
Patients treated post operatively was immobilized for 6 weeks in shoulder immobilizer with 30 degree abduction and pendulum exercises started from first post operative day and patients continues in shoulder immobilizer for rest of the day for 6 weeks were followed up at 3weeks,6weeks,12weeks, 6months, 1 year and 2 year . Patient functional assessment was done based on pain relief, ability to carry on activities of daily living, strength and patient satisfaction post operatively . A proforma was designed which would be filled by the patient himself and shoulder scoring system was calculated accordingly. Ultrasound examinations of the operated shoulder were done and cuff integrity was checked. Strength and range of motion were documented by operating surgeon. Results were finally evaluated using Constant and Murley shoulder scoring system.
Data was analysed using ANOVA and further post hoc analysis was performed by Bonferroni correction test.
The mean constant and murley score at the final follow up was 91.8 ± 1.5 (excellent as per score). The mean score for full thickness tear at final followup after repair was 91.3 ± 1.3 and that for partial thickness tear was 92.1 ±1.5 . The constant and murley scores at different time intervals are tabulated (Table 4) Pairwise comparison was made between the mean constant and murley score of each followup interval using the Bonferroni correction test to determine significant change of score. ( Table 5) The maximum change ( Mean difference 32.3 ± 0.9) in the score was noted between preoperative mean score and the mean score at final followup which was highly significant(pα o.ooo) Comparison of constant murley score according to type of tear was done (Table 6) by t-test. The t-value at 2 year followup between mean scores for full thickness and partial thickness tears was 1.53 which was not significant (p 0.137).
Rotator cuff pathology affects adults of all ages and other shoulder afflictions must be ruled out by careful history and physical examination3 . Epidemiologica*l studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased 13% in youngest group ( aged 50-59yrs) to 20 % ( aged 60-69yrs), 31% ( aged 70-79yrs) and 51% in oldest group ( 80-89yrs) 4 Rotator cuff tears can lead to a variety of clinical manifestations, including debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. Optimal repair of the rotator cuff includes achievement of high fixation strength, minimal gap formation and maintenance of mechanical stability under cyclic loading, and proper healing of tendon to bone.1 Mini-open repair has the potential advantage of less deltoid morbidity, and they have demonstrated results that have been similar to those of open repairs. Because of the technical demands of this procedure, many orthopaedic surgeons still consider the mini-open repair to be the gold standard for rotator cuff repair.6 The standard treatment for full-thickness rotator cuff repair is with an open acromioplasty procedure. An alternative procedure for a full-thickness rotator cuff tear is with a combined procedure of arthroscopic subacromial decompression and mini-open repair, which has the potential advantages of a preserved deltoid origin, lower perioperative morbidity, shorter hospital stays and less soft tissue dissection. The study was taken up to evaluate the functional outcome of patients treated with miniopen repair for rotator cuff tears. The functional outcome was assessed by using Constant and Murley scoring system. In 1990, Levy et al.8 reported a preliminary one-year follow-up study of twenty-five patients who had been treated with an arthroscopic subacromial decompression and then a lateral deltoid-splitting open repair. Twenty of the patients had a good or excellent result .In our study total number of 30 patients with a follow up of 2years, preop Constant Murley score had a mean of 59.80 and by the end of 2years it was 91.80 with a p value <0.001 , which shows it is statistically significant outcome In our study where we compared outcome we found we had statistically significant improvement in constant and Murley score values, preop and post op at 6 months and not much of difference between 1year and 2 years . Baysal et al. 9 prospectively reviewed 84 patients with tears of all sizes, including 17 with large or massive tears, who underwent mini-open repair, and reported a statistically significant improvement in shoulder scores and range of motion. They found no difference in outcome between different tear sizes. Subsequent reports demonstrated that the mini-open technique can be used effectively for even large and massive tears 10,11,12. In our study, we reviewed 30 patients who had undergone miniopen repair for all size of tear; we found functional outcome does not depend on the type of tear. We compared our study results with a study conducted by B.C. Hanusch, L. Goodchild and A. Rangan. in their study -24 patients were included which were assessed prospectively before and at a mean of 27 months after miniopen repair using constant and Murley score. The mean Constant and Murley score improved significantly from 36 before to 68 after surgery (p <0.0001). Four of twenty four their patients had a re-tear13. In our study we included 30 patients which were assessed preoperatively and postoperatively using Constant and Murley score17 and found that score improved from 45 preoperatively to 82 at 6months and 90 by the end of 2years (p <0.0001) which showed highly significant. Our study showed no re-tear in any of the patients. Structural integrity rotator cuff was maintained which was assessed by ultrasonography of the operated shoulder. Anterior-inferior acromioplasty was performed in all shoulders in this series and continues to be an important part of rotator cuff repair in our practice. We agree with other authors that acromioplasty, by creating space for the rotator cuff tendons, provides better surgical exposure and thus improves the quality of the surgical repair, and that, by relieving impingement; it offers protection to the tendons during healing, facilitates rehabilitation, and lessens postoperative pain 4,14,15,16
? Most of the patients were between the age 51- 60 years which formed 36.6 % of the total study group who had difficulty in carrying out their activities of daily living
? Majority of them were male patients forming 67 % where as rest of them were female patients forming 33%
? In most of patients the etiology was due to history of fall on affected shoulder which comprise 73.3% of the total number of patients studied
? Majority of patients complained of inability to lift the shoulder following trauma which comprise 80 % and pain in the affected shoulder was presented by 20% of the patients studied
? The incidence of partial thickness tear was 56.7% which formed the majority and full thickness tear comprised of 43.3%
? Acromioplasty and sub acromial decompression provided better pain relief in patients who had positive impingment sign preoperatively
In comparison to other studies our study shows the mean age of incidence of rotator cuff tears is between the age group 51-60 years with male predominance with majority presented with supraspinatus partial thickness tear. The mini open repair of rotator cuff tears at 2 year follow up shows excellent functional outcome. In comparison to other studies our study shows that there is no difference in functional outcome between partial and full thickness tear treated by miniopen repair.
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors, editors, publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
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