Rotator Cuff Tear AND Stiffness? Repair the Tear
New research from Australia, just published in the Journal of Shoulder and Elbow Surgery, has found that for patients who have both rotator cuff tears and shoulder stiffness, it’s likely just fine to proceed with repairing the tear. The study involved 25 people who underwent a concomitant rotator cuff repair and glenohumeral joint capsule release, and 170 people who only received cuff repairs. George Murrell, D.Phil., M.D. is director of the Orthopaedic Research Institute at St. George Hospital in Sydney, Australia. Dr. Murrell told OTW, “I had a sense that patients who had an arthroscopic capsular release for their stiff shoulder and a rotator cuff repair for their torn rotator cuff did well, and yet every now and then an insurance company would knock back a request to do those procedures, citing another orthopaedic surgeon, saying the stiff shoulder/capsulitis needed to resolve before doing a rotator cuff repair.”
“We found that these patients did very well—not only did their stiffness resolve, their rotator cuffs healed very well, with a 0% re-tear rate. I had never found this before. Improvement in clinical outcomes was statistically significant at the 2-year follow-up compared with preoperative values. In both groups at the two-year mark, we found similar range of motion for forward flexion, abduction, and external rotation; the non-stiffness group had a superior range of internal rotation. Patients in the group with stiffness had 0 of 25 re-tears at 2 years compared with 34 of 170 in the non-stiffness group.”
“If you have a patient with capsulitis and a rotator cuff tear—our data suggests you should go ahead and repair the cuff—those patients will do very well.”
Double Row Repair = Lower Re-tear Risk After Quick Rehabilitation
For those undergoing an accelerated rehab program following a rotator cuff (RC) repair, does a double or a single row repair make more sense? Researchers in the UK and Italy asked that question, and undertook a randomized controlled trial with 58 Italian patients. The researchers found a significantly lower full-thickness re-tear rate in those who underwent double RC repair than for those who had the single row repair (8% vs 24%, respectively). Nicola Maffulli, M.D., Ph.D., is with the Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry. He told OTW, “Some patients have a torn rotator cuff, need surgical repair, and are at risk of developing stiffness of the repaired shoulder following surgery. These patients therefore would benefit from a rehabilitation programme which allowed them to move their shoulder faster. Early mobilisation, however, has to rely on a repair that is strong enough to withstand the strains imposed on it by early mobilisation. Double row repair allows just this: the repair is secure, and able to sustain the early stresses imposed onto it by active rehabilitation.”
“In patients who have been identified as at risk to develop stiffness following a rotator cuff repair, the mechanically strong construct afforded by a double row repair allows[us] to mobilise these patients early and safely, preventing the loss of motion that would result if their pathology had been treated in the usual fashion.”
“In ‘normal patients, ’ double row rotator cuff repair does not confer any advantages over the simpler and cheaper single row rotator cuff repair. However, in these difficult at risk patients, a double row rotator cuff repair allows them to return to their previous level of activities without risks of re-tearing the cuff. It is a question of horses for courses!”
Latarjet: Reasonable for Subset of Patients
For those with recurrent anterior shoulder instability and an engaging Hill-Sachs lesion, bone loss is a real problem. Specifically, for patients with humeral head and mild glenoid bone loss (less than 25%), the issue of treatment remains unsettled. Justin S. Yang, M.D., is with the Department of Orthopedics at Kaiser Permanente Los Angeles Medical Center. He told OTW, “Over the past few years, the orthopedic community has become more aware of limitations of the popular arthroscopic Bankart procedure. In certain populations, it has an unacceptably high recurrence rate, the main one being bone loss (both on the glenoid and humeral head). The Latarjet procedure has been well described to treat recurrent shoulder instability with glenoid bone loss over 25%. Recent studies have shown patients may have suboptimal outcome with arthroscopic Bankart in the ‘subcritical’ bone loss group of less than 25%. Our study is the first to report on the outcome of the Latarjet in glenoid bone loss less than 25%; we expanded the indications for this procedure to include engaging Hill-Sachs lesions (or off-track lesion) with glenoid bone loss less than 25%.”
“Our team performed a modified Latarjet on 40 patients with recurrent anterior shoulder instability, engaging Hill-Sachs, and ≤25% anterior glenoid bone loss. In another group (12 patients), all individuals were identified as having greater than 25% glenoid bone loss with an engaging Hill-Sachs lesion. We found that in the treatment group, glenoid bone loss averaged 15%; in the second group it was 34%.”
“We think that the Latarjet is a reasonable procedure for patients with subcritical bone loss and off-track lesion (engaging Hill-Sachs); however, it is a technically demanding procedure with a 25% complication rate even in experienced hands. We believe that the physician should be wary of mild bone loss on both the glenoid and humeral head side, and consider the Latarjet in this subset of patients.”
“We discovered that more than anything, two factors influence outcome after a Latarjet: # of previous surgeries and degree of laxity (as measured by the Beighton score). The results may be limited in patients who had more than one previous surgery, and/or in patients with Beighton score over 6. The Single Assessment Numeric Evaluation (SANE) score was better in patients with less glenoid bone loss, although other outcome measures were relatively similar.”
