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Rotator Cuff Tears: Short- and long-term aspects on treatment outcome
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-3766-8410
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Rotator cuff tear is a common disorder and there is a lack of knowledge of appropriate treatment and consequences of different treatment modalities. The overall aim of this thesis was to examine short- and long-term results of rotator cuff tear treatment.

In Paper I we did a retrospective 21 to 25-year follow-up of a consecutive series of patients with partial and full-thickness rotator cuff tears, treated with acromioplasty without cuff repair. The cuff status had been documented in a specific perioperative protocol in all patients at the index operation. We did x-ray, ultrasonography and clinical scores with Constant score and Western Ontario Rotator Cuff index (WORC) at follow-up. We identified 111 patients with either a partial or a full-thickness tear, but at follow-up 21 were deceased and 11 were too ill from medical conditions unrelated to their shoulder. Out of the remaining 78 eligible patients, 69 were examined (follow-up rate 88 %) and they had a mean age at the index operation of 49 years (range 19-69 years). Forty-five had a partial tear and 24 a full-thickness tear at the index operation. At follow-up, 74% of patients with full-thickness tear had cuff tear arthropathy grade 2 or more according to the arthropathy classification of Hamada (grade 1 to 5) and 87% had developed tear progression (i.e. a larger tear). Corresponding numbers in those with a partial tear was 7 % arthropathy and 42 % tear progression, and the differences between the full-thickness group and the partial tear group was significant for both outcome measures (P<0.001 for both analyses). In those with arthropathy, the mean Constant score was 47 (standard deviation [SD], 23), the mean age and gender-adjusted Constant score 62 (SD, 27) and the mean WORC 58 % (SD, 26). Patients with a partial tear at follow-up had mean Constant score and WORC within the normal range. In multivariable analysis with logistic regression, having a full-thickness tear at the index operation was a risk factor for arthropathy (odds ratio [OR] 37.8; 95% confidence interval [CI], 8.2-175.0) and for tear progression (OR 6.09; 95% CI, 1.41-26.29).

In Paper II we examined the contralateral shoulder in the same patients as in paper I and with the same methodology. Sixty-one patients were examined and 38 had had a partial tear at the index operation 21-25 years ago and 23 a full-thickness tear. The overall rate of contralateral full-thickness tears was 50.8 %, which is higher than the 16-35 % rate found in previous studies of newly diagnosed cuff patients. The rate of contralateral full-thickness tear ranged from 13.6 % in patients with a partial tear in the index shoulder at follow-up, to 90 % in patients with a full-thickness tear and arthropathy in the index shoulder. There was a significant correlation regarding conditions between shoulders in the same patient, with a Spearman coefficient of 0.72 for the number of ten-dons with a full-thickness tear, 0.31 for Hamada grade of arthropathy and 0.65 for Constant score. The number of tendons with a full-thickness tear in the index shoulder at follow-up was a risk factor for a contralateral full-thickness tear (OR 3.28; 95% CI, 1.67-6.44) in a multi-variable logistic regression model. We also found that cuff tear arthropathy was significantly more common in patients who had undergone an acromioplasty (P<0.001), a finding which is not confirmatory but may generate a hypothesis.

Paper III addressed 17 to 20-year results after operation with a synthetic interposition graft for irreparable cuff tears. We used X-ray, ultrasonography and clinical scores at follow-up. We identified a consecutive series of 13 patients, one of whom was deceased at follow-up. Ten of the remaining 12 participated in a complete follow-up and 2 did only x-ray examination. Nine out of 12 (75 %; 95% CI, 43-95 %) had cuff tear arthropathy Hamada grade 2 or more in the index shoulder at follow-up. The mean Constant score was 46 (SD, 26) and the mean WORC 59 % (SD, 20). Seven out of 12 had contralateral cuff tear arthropathy, and the difference in frequency of arthropathy between shoulders was not statistically significant (P=0.667).

In Paper IV we tested whether early repair of small cuff tears, involving mainly supraspinatus, would give a superior clinical result com-pared to physiotherapy without repair in a prospective randomised trial with 12 months follow-up. We used Constant score as the primary out-come, and WORC, EQ-VAS and Numerical Rating Scale for pain (NRS) as secondary outcomes. We also aimed at assessing the rate of tear progression in unrepaired shoulders and the healing rate in repaired shoulders by Magnetic Resonance Imaging (MRI) performed at 12 months. With a high grade of follow-up (100 % for 12 months Constant score and 95 % for 12 months MRI), the repair group had a 12 months median Constant score of 83 (Quartile range [QR], 25) and the conservative group 78 (QR, 22). This between-group difference in medians of 4.5 (95% CI,-5 to 9; P=0.68) was not statistically significant and we did not detect any significant differences in the secondary outcomes at 12 months. The retear rate was 6.5 % in repaired patients and 29 % of unrepaired patients had a tear enlargement >5 mm.

The results in this thesis indicate that patients with small, traumatic, full-thickness tears of mainly supraspinatus have no clinical benefit of early surgical repair compared to physiotherapy alone, but in the long-term, patients with full-thickness tears have an increased risk of tear progression, cuff tear arthropathy and low clinical scores. These results are especially important in the treatment decision of repair or not in younger patients. Having a full-thickness tear is also a risk factor for having a contralateral cuff tear, a phenomenon that underlines the importance of endogenous factors in the development of rotator cuff tears. If a cuff tear is not repairable to bone, the addition of a synthetic inter-position graft does not seem to prevent cuff tear arthropathy.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2020. , p. 125
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1727
National Category
Surgery Cardiac and Cardiovascular Systems Gastroenterology and Hepatology Neurology
Identifiers
URN: urn:nbn:se:liu:diva-162408DOI: 10.3384/diss.diva-162408ISBN: 9789179299248 (print)OAI: oai:DiVA.org:liu-162408DiVA, id: diva2:1374503
Public defence
2020-01-17, Hjärnan, Länssjukhuset, Kalmar, 09:30 (English)
Opponent
Supervisors
Available from: 2019-12-03 Created: 2019-12-02 Last updated: 2019-12-12Bibliographically approved
List of papers
1. Clinical and structural outcome 22 years after acromioplasty without tendon repair in patients with subacromial pain and cuff tears
Open this publication in new window or tab >>Clinical and structural outcome 22 years after acromioplasty without tendon repair in patients with subacromial pain and cuff tears
2017 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 26, no 7, p. 1262-1270Article in journal (Refereed) Published
Abstract [en]

Background: Long-term results regarding tear progression, arthropathy, and clinical scores of unrepaired rotator cuff tears are largely unknown. This study investigated whether the condition of the glenohumeral joint and rotator cuff had deteriorated at a minimum of 20 years after an acromioplasty without cuff repair and assessed the clinical results. Methods: A retrospective analysis was conducted of a consecutive series of patients treated between 1989 and 1993 with acromioplasty without cuff repair due to subacromial pain and cuff tear. At follow-up results of x-ray, ultrasonography, and clinical scores were recorded. Results: At a mean of 22 years (range, 21-25 years), 69 patients were available for follow-up with Western Ontario Rotator Cuff Index, Constant-Murley (CM) score, x-ray, and ultrasonography. Mean age at operation was 49 years (range, 19-69 years). There were 45 partial-thickness tears (PTT) and 24 full-thickness tears (FTT). Of 23 patients with FTT, 17 (74% with x-ray) had developed cuff tear arthropathy (Hamada amp;gt;= 2) and 20 (87% with ultrasonography) had progressed in tear size. Mean relative CM in patients with FTT and cuff tear arthropathy was 62 (standard deviation [SD], 27), and the mean WORC was 58% (SD, 26%). In the 43 PTT patients, 3 (7% with x-ray) had developed cuff tear arthropathy and 16 (42% with ultrasonography) had tear progression. With PTT at follow-up, the mean relative CM was 101 (SD, 22), and the mean WORC was 81% (SD, 20%). Conclusions: After an acromioplasty, most unrepaired full-thickness tears will, in long-term, increase in size and be accompanied by cuff tear arthropathy changes. Most partial thickness tears remain unchanged; cuff tear arthropathy is rare, and clinical scores generally good. (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Place, publisher, year, edition, pages
MOSBY-ELSEVIER, 2017
Keywords
Shoulder; rotator cuff; long-term; tear progression; cuff tear arthropathy; acromioplasty; natural history
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-140975 (URN)10.1016/j.jse.2016.11.012 (DOI)000406341000026 ()28131687 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden [FORSS 383191]

Available from: 2017-09-19 Created: 2017-09-19 Last updated: 2019-12-03
2. Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago
Open this publication in new window or tab >>Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago
2018 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 27, no 3, p. E68-E74Article in journal (Refereed) Published
Abstract [en]

Background: The prevalence of contralateral full-thickness cuff tears (FTTs) and cuff tear arthropathy (CTA) is presumed to be higher in patients with long-standing cuff tears than in those with newly diagnosed tears, but data are currently lacking. Methods: Sixty-one patients with 38 partial and 23 full-thickness tears of 1 shoulder at arthroscopy were examined with bilateral radiographs, ultrasound, and the Constant-Murley score at a mean of 22 years (range, 21-25 years) after arthroscopy. Results: The overall rate of full-thickness tears in the contralateral shoulder was 50.8%. In patients with a full-thickness tear and CTA (Hamada grade amp;gt;= 2) in the index shoulder at follow-up, 18 of 20 (90%) had a contralateral full-thickness tear and 4 of 20 (20%) had CTA. In patients with a partial tear in the index shoulder at follow-up, 3 of 22 (13.6%) had a contralateral full-thickness tear and none had CTA. CTA changes were more common in patients with FTT and a previous acromioplasty (P amp;lt; .001). The correlation between shoulders was 0.72 for the number of tendons with FTT (P amp;lt; .001), 0.31 for the Hamada grade (P = .016), and 0.65 for the absolute Constant-Murley score (P amp;lt; .001). The number of tendons with a full-thickness tear at follow-up was a risk factor (odds ratio, 3.28; 95% confidence interval, 1.67-6.44; P amp;lt; .001) for a contralateral full-thickness tear. Patients with a partial or full-thickness tear in the contra-lateral shoulder had pain in 39.2% of cases. Conclusion: Patients with long-standing cuff tears have high rates of contralateral cuff tears. The severity of the condition is strongly correlated between the shoulders. Patients with full-thickness tears and a previous acromioplasty have a significantly higher frequency of CTA than patients with cuff tears who had not undergone a previous acromioplasty. (C) 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Place, publisher, year, edition, pages
MOSBY-ELSEVIER, 2018
Keywords
Shoulder; rotator cuff; contralateral tear; cuff tear arthropathy; long-term follow-up; ultrasonography
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-145733 (URN)10.1016/j.jse.2017.10.007 (DOI)000425934900002 ()29249548 (PubMedID)
Available from: 2018-03-22 Created: 2018-03-22 Last updated: 2019-12-03
3. Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up
Open this publication in new window or tab >>Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up
2018 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 27, no 9, p. 1622-1628Article in journal (Refereed) Published
Abstract [en]

Background

Treatment options for irreparable cuff tears include synthetic interposition grafts, but whether such grafts can maintain acceptable shoulder function and prevent cuff tear arthropathy in the long-term is unknown.

Method

This was a retrospective case series of 13 consecutive patients treated with a synthetic interposition graft made of Dacron (DuPont, Wilmington, DE, USA). Patients were examined with bilateral ultrasonography, bilateral x-ray imaging, Constant-Murley score, and Western Ontario Rotator Cuff score.

Results

After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplastyin the follow-up period. The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667).

Conclusion

These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective.

Place, publisher, year, edition, pages
Philadelphia, United States: Mosby, Inc., 2018
Keywords
Shoulder; rotator cuff; synthetic graft; cuff tear arthropathy; long-term follow-up; ultrasonography
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-150851 (URN)10.1016/j.jse.2018.03.011 (DOI)000441743600018 ()29731397 (PubMedID)2-s2.0-85046807436 (Scopus ID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden [FORSS 383191]

Available from: 2018-09-06 Created: 2018-09-06 Last updated: 2019-12-03Bibliographically approved

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