Arthroscopic Debridement of Irreparable Massive Rotator Cuff Tears A Comparison of Debridement Alone and Combined Procedure with Biceps Tenotomy
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1 Acta chir belg, 2005, 105, Arthroscopic Debridement of Irreparable Massive Rotator Cuff Tears A Comparison of Debridement Alone and Combined Procedure with Biceps Tenotomy H.-M. Klinger*, G. Spahn**, M. H. Baums*, H. Steckel* Department of Orthopaedic Surgery*, Georg-August-University, Göttingen, and Clinic of Arthroscopy and Joint Surgery**, Eisenach, Germany. Key words. Rotator cuff tear ; debridement ; biceps tendon ; tenotomy ; arthroscopy. Abstract. The goal of the study was to compare the results of arthroscopic debridement in massive, irreparable rotator cuff tears with and without tenotomy of the long head of the biceps (LHB). We evaluated 41 patients who were treated by a single surgeon for massive, irreparable rotator cuff tears either by arthroscopic debridement alone (24 patients) or with additional tenotomy of LHB (17 patients). The mean age was 67 years (range : 61 to 82 years) and the average follow-up was 31 months (range : 24 to 48 months). There was no significant difference between the two groups in age, gender, pain, function, and follow-up. All patients had significant disabling pain weakness preoperatively. Assessments were made using the Constant score. The average Constant score for the group without LHB tenotomy improved from a mean of 39 points (range : 19 to 54 points) preoperatively to a mean of 67 points (range : 41 to 87 points) and for the group with additional LHB tenotomy from a mean of 41 points (range : 16 to 54 points) preoperatively to a mean of 69 points (range : 49 to 87 points) at the time of follow-up. The radiological study showed no significant narrowing of the subacromial space. No statistical significance (P >.05) was found between the two groups. However, patients with additional LHB tenotomy had a longer duration of postoperative pain relief, but final pain score difference was not statistically significant. There was no complication related to the procedure. Arthroscopic débridement of massive, irreparable rotator cuff tears provides reliable expectation for improvement in function, decrease in pain, and improvement in shoulder scores for most patients. Additional LHB tenotomy did not significantly influence the postoperative results at the latest follow-up. In our series we noted no significant humeral head migration or developing rotator cuff arthropathy. Introduction Rotator cuff tears are a common cause of shoulder pain and dysfunction. CODMAN (1) is credited with the first surgical repair of a full-thickness tear of the rotator cuff tendon in Subsequent debate has centered on surgical repair versus nonsurgical management of these lesions. This controversy is especially intense over the optimal treatment of large and massive tears of the rotator cuff (2). Massive tears have been classified as tears greater than 5 cm (3) and usually occur in the elderly population. The tendons are retracted and the long head of the biceps tendon (LHB) is often ruptured (4). Although repair of these tears is recommended, the large size of defect and poor quality of the tissues make a successful repair difficult. Different authors have differing attitudes when faced with this problem. Several investigators (5-6) have recommended débridement and decompression for the treatment of irreparable lesions of the rotator cuff. An irreparable tear is one in which the quality of the tendon tissue is so poor that direct tendonto-bone repair is not possible. With a massive rotator cuff tear that is no longer reparable (acromiohumeral distance less than 7 mm) the remaining LHB is very often responsible for the pain, because it serves as the final restraint to proximal migration of the humeral head and becomes entrapped between the humeral head and acromion (7). Arthroscopic tenotomy of the LHB, as proposed by WALCH (8), can be combined with arthroscopic débridement in this low-demand population. However, the function of LHB remains controversial. Several studies involving electromyographic (EMG) analysis show that it functions as an elbow muscle and has little to no shoulder-related activity except when the elbow is being actively used (9-11). On the other hand, cadaveric biomechanical studies suggest a humeral head stabilizing effect and a weak, depressing effect (12-13). KIDO et al. (14) showed that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff. In the contrast to the controversy surrounding the LHB function, the biceps is often implicated as the source of anterior shoulder pain. Untreated or
2 298 H.-M. Klinger et al. undiagnosed biceps-related pathology may be a cause of persistent pain and dysfunction after shoulder surgery. The purpose of this study was to evaluate the outcome of patients who underwent arthroscopic débridement of massive, irreparable rotator cuff tears with and without tenotomy of the LHB. Our aim was especially to find out, if additional LHB tenotomy leads to humeral head migration or developing rotator cuff arthropathy. Material and Methods Between 1998 and 2000, arthroscopic débridement in massive, irreparable rotator cuff tears with and without tenotomy of the long head of the biceps has been performed in 41 cases by one single surgeon. Indications for surgery were persisting pain and functional disability without improvement after conservative treatment for minimum of 6 months. The criterion for inclusion in the study was a massive tear that could not be attached to the greater tuberosity after appropriate mobilization. No patient demonstrated acromioclavicular joint tenderness or acromioclavicular joint pain with cross-body adduction. Patients who had a tear that could be repaired or had a previous procedure involving the shoulder were excluded. The indications to perform a LHB tenotomy was based on a clinical examination in which the patient reported point tenderness over the biceps tendon and an arthroscopic examination that showed some type of LHB pathology : tendinosis (3 cases), subluxation (5 cases), prerupture (3 cases), and dislocation (6 cases). Demographic information showed that the patients without a biceps tenotomy (group I) had an average age of 66 years with an age range from 61 and 79 years. The dominant extremity was affected in 14 cases. There were 9 women and 15 men. Of the biceps tenotomy patients (group II) the average age was 68 years with an age range from 63 to 82 years. The dominant extremity was affected in 10 cases. There were 7 women and 10 men. At the time of surgery, the mean duration of pain before surgical intervention was 11 months (range : 6 to 23 months) in group I and 10 months (range : 6 to 18 months) in group II. All patients have been reviewed by an independent observer who was not involved in the surgical procedure to ensure an objective assessment. The preoperative and postoperative status of all 41 patients was analyzed using the CONSTANT and MURLEY scoring system (15). Radiographic documentation included subacromial frontal and lateral views standardized by radioscopic control according to the protocol defined by LIOTRAD et al. (16). All 41 shoulders were studied by MRI preoperatively. Additionally, a minimum of 24 months follow-up was chosen. Thus, follow-up times range from 24 to 48 months, with an average of 31 months. Patients were evaluated with the scoring system at 3, 6, 12, and 16 weeks and then at 6, 12, and 24 months. Patients with longer follow-up times were also evaluated at 36 and 48 months. Surgical Technique and Postoperative Care Standard shoulder arthroscopy was performed with the patient in the modified lateral decubitus position. To diminish postoperative pain, regional (interscalene block) anaesthesia was used before general anaesthesia was induced. The extend of the rotator cuff tear classified by size according to their greatest diameter, using the system of DEORIO and COFIELD (17), as small (< 1 cm), medium (< 1 to 3 cm), large (3 to 5 cm), massive (> 5 cm). Adhesions were removed from retraced tendons until full extension was possible. The tendon was grasped with a surgical instrument and reparability was determined (18). Intraarticular surgery consisted of synovectomy, trimming labrum tears, shaving chondromalacia, and débriding loose fragments of rotator cuff tears (19). The goal of débridement and decompression is to remove any prominent stumps of the rotator cuff tissue or bony prominences that may catch or impinge with shoulder abduction. If the LHB was pathological (Fig. 1), LHB tenotomy described by WALCH et al. (20) was performed. After surgery, all patients were included in our routine shoulder rehabilitation program including full active range of motion from the first day followed by strengthening exercises, specifically concentrating on the rotator cuff. Statistical analysis Statistical analysis of the results between the two groups was performed using a 2-sample t-test. Comparison between groups were made using analysis of variance (ANOVA). Statistical significance was determined at a P value less than.05. Results All of the 41 patients were available for review at mean 33 months (range : 24 to 48 months) postoperatively. The 41 shoulders in the study included 24 in the group without LHB tenotomy and 17 in the group with additional LHB tenotomy. The two groups showed no significant differences (P <.05) in age, preoperative pain, function, active forward flexion and strength of forward flexion. The average time interval from surgery to follow-up in group I was 29 months with a range from 24 to 43 months. In the group II the average follow-up time intervall was 33 months with a range from 26 to 47 months. The score of CONSTANT and MURLEY improved in group I without LHB tenotomy from a mean of 39 points (range : 19 to 54 points) preoperatively to a mean of 67 points (range : 41 to 83 points) at the time of
3 Rotator Cuff Tears 299 Fig. 1 A partial tear of LBH tendon in a patient with a massive tear of the rotator cuff. follow-up. In the group II with biceps tenotomy the CONSTANT and MURLEY score averaged 41 points (range : 16 to 60 points) preoperatively and it averaged 69 points (range : 49 to 87 points) at review. The data did not statistically show that one or the other of the surgical techniques resulted in a better outcome (P <.05). Also, the global CONSTANT and MURLEY score did not differ significantly (Fig. 2). The group without LHB tenotomy experienced significantly lower pain at 6 and 12 weeks than the group with additional LHB tenotomy (P <.05). However, the final follow-up pain scores were not significantly different between the groups. In the group with additional LHB tenotomy no deficit of flexion or extension of the elbow was observed compared with the contralateral side. The shape and contour of the biceps was conserved in all but two patients. Radiographic results The acromiohumeral distance (AHD) did not change significantly (P <.05) by the intervention in both groups. We found no progressive degenerative changes in the glenohumeral joint of any patient. Analysis of unsatisfactory outcomes Ten patients (24%) had unsatisfactory CONSTANT and MURLEY ratings (< 50 points). The result was considered unsatisfactory in the group without LHB tenotomy because of inadequate pain relief in four shoulders, because of limited active abduction in one and because of limited external rotation in another. If a very small muscular strand of the subscapularis was still attached to the most distal part of the crista of the lesser tuberosity, the subscapularis tear was considered complete. Two of four patients in the LHB tenotomy group with unsuc- Fig. 2 Graphs showing the CONSTANT and MURLEY scores of both groups. group I : arthroscopic débridement alone. group II : arthroscopic débridement with LHB tenotomy. cessful outcome had decreased passive range of motion (ROM), one of six had superior migration of the humeral head and one of six had glenohumeral osteoarthritis. The superior migration of the humeral head and the glenohumeral osteoarthritis was present before the operative procedure. Complications There were no relevant complications in this series of patients. Especially, we did not observe haematoma, infection, or neurovascular compromise. Three patients were diagnosed with temporary complex regional pain syndrome (CRPS) type I because of persistent pain and stiffness after the operation. Rehabilitation allowed to regain complete motion and all patients were pain free at review. Two patients complained of a cosmetic deformity of their biceps muscle but no pain. Discussion Chronic, retracted, irreparable rotator cuff tears are probably the most challenging to treat. Especially in an elderly, low-demand population, where pain relief is the most important goal to achieve, arthroscopic débridement seems a successful treatment option (5-6, 21-23). ROCKWOOD et al. (5) reported on 53 patients with
4 300 H.-M. Klinger et al. irreparable, massive rotator cuff tears (at least two tendons) who underwent open acromioplasty, coracoacromial ligament resection, and cuff débridement, with 83% satisfactory results at 6.5 years. The patients with the best results had a well-rehabilitated deltoid, an intact LHB, and significant improvement in pain level. GARTSMAN (6) found in a similar group of patients that 79 % were subjectively improved after surgery. It is important to note that these results, though clearly showing improvement from preoperative levels of pain and function, are inferior to results achieved with acromioplasty and repair of the rotator cuff. The long head of the biceps is a well-known cause of shoulder pain because of the multiple possibility of pathology of the tendon itself and its pulley system (20, 24-26), leading to tenosynovitis, prerupture, subluxation, or dislocation of the tendon. A high incidence of microscopic chronic inflammation and gross degeneration of the biceps tendon was evident in those shoulders with either partial-thickness or full-thickness rotator cuff tears (27). Surgical treatment for disorders of LHB is limited to removal of the intraarticular portion of the tendon, with either tenotomy or tenodesis (28-31). Arthroscopic biceps tenotomy has been proposed for patients with chronic and significant shoulder pain in the presence of a massive irreparable rotator cuff tear, leading to complete resolution of pain (8, 30). The decision to perform tenotomy or tenodesis of the LHB during rotator cuff surgery remains controversial. SETHI et al. (32) believe that persistent pain from the LHB is likely to have more negative functional consequences than loss of the tendon itself. At this time however, peer-reviewed scientific investigations either supporting or opposing concomitant biceps tenotomy/tenodesis with rotator cuff surgery are not available. In the current series of biceps surgery was performed only in patients with grossly apparent biceps tendon abnormalities. The question is wether initially acceptable results with this palliative techniques in combination or alone remain acceptable over the long-term. MONTGOMERY et al. (33) found that five of 27 large and massive tears treated by subacromial decompression alone, progressed to cuff arthropathy over a period of three to five years. APOIL and AUGEREAU (34) reported on the progression to arthropathy in more than 25% of their 43 patients 10 or more years after superior arthrolysis. WARNER and MCMAHON found (35) increased superior migration of the head of the humerus during elevation in patients with ruptures of the LHB. In our series, we observed no significant migration of the humeral head, although no developing rotator cuff arthropathy was observed. There was no significant difference between the two groups. But the long-term outcome of this procedure is unknown at this time and therefore we need a longer follow-up to be certain that arthroscopic débridement with and without LHB tenotomy in massive, irreparable cuff tears will not deteriorate with time and lead to progressive degenerative changes. KEMPF et al. (36) found in a multicenter study of 210 rotator cuff tears treated by arthroscopic, acromioplasty in 147 cases pathological LHB tendon. These LHB lesions prejudiced clinical manifestations. Pain was aggravated by the presence of LHB lesion or LHB instability. However in our series we noted no significant difference of the CONSTANT and MURLEY score between the group with and without LHB tenotomy. Perhaps the number of patients was too small to get a significant validity. KEMPF et al. (36) performed in 38 cases LHB tenotomy and observed some significant differences by comparing tenotomy versus abstention of surgical gestures on the LHB tendon. In cases of tenotomy, they noted that postoperative periods were more complicated : postoperative periods of pain were more frequent, passive range of motion was more limited and recovery was delayed. We made the same observations, but in contrast to their series, the level of physical activity, active mobility, and pain parameters improved after LHB tenotomy at the latest follow-up and the CONSTANT and MURLEY score did not differ significantly. Furthermore in this series LHB tenotomy did not alter subacromial space. Our own results supported these observations. But it should be emphasized that routine tenotomy is not recommended during operative treatment for the rotator cuff (7). In conclusion, we believe, that after nonoperative treatment had failed, older patients with fewer physical demands who had a massive, irreparable rotator cuff tear simple arthroscopic débridement with biceps tenotomy does appear to be a viable, palliative treatment option. Our study demonstrates that arthroscopic débridement of massive, irreparable rotator cuff tears provides reliable exspectation for improvement in function, decreases in pain, and improvement in shoulder scores for most patients. Additional LHB tenotomy did not significantly influence the postoperative results at the latest followup. Its long-term consequences, for example humeral head migration or developing rotator cuff arthropathy, remain to be evaluated by studies with long-term followup. References 1. CODMAN E. A. Rupture of the supraspinatus tendon and other lesions in or about the subaromial space. In : The shoulder. Boston : T Todd, JONES C. K., SAVOIE F. H. Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy, 2003, 19 : DEORIO J. K., COFIELD R. H. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg, 1984, 66 : ROCKWOOD C. A., MATSEN F. A. The Shoulder. Philadelphia, WB Saunders, eds, 1990.
5 Rotator Cuff Tears ROCKWOOD C. A., WILLIAMS G. R., BURKHEAD W. Z. Débridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg, 1995, 77 : GARTSMAN G. M. Massive, irreparable tears of the rotator cuff. J Bone Joint Surg, 1997, 79 : HABERMEYER P., WALCH G. The biceps tendon and rotator cuff disease. In : BURGHEAD W. Z. (ed.). Rotator cuff disorders. Philadelphia : Williams & Wilkins, eds., 1996, pp WALCH G. Arthroscopic tenotomy of the long head of biceps in rotator cuff ruptures. In : GAZIELLY D. F., GLEYZE P., THOMAS T. (eds.). The cuff. Paris : Elsevier, 1997, BRADLEY J. P., TIBONE J. E. Electromyographic analysis of muscle action about the shoulder. Clin Sports Med, 1991, 10 : GOWAN I. D., JOBE F. W., TIBONE J. E., PERRY J., MOYNES D. R. A comparative electromyographic analysis of the shoulder during pitching : Professional versus amateur pitchers. Am J Sports Med, 1987, 15 : YAMAGUCHI K., RIEW D. K., GALATZ L. M., SYME J. A., NEVIASER R. J. Biceps activity during shoulder motion : An electromyographic analysis. Clin Orthop, 1997, 336 : KUMAR V. P., SATKA K., BALASUBRAMANIAM P. The role of the long head of the biceps brachii in stabilization of the head of the humerus. Clin Orthop, 1989, 244 : RODOSKY M. W., HARNER C. D., FU F. H. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med, 1994, 22 : KIDO T., IDO T., ITOI E. et al. The depressor function of biceps on the head of the humerus in shoulders with tears of the rotator cuff. J Bone Joint Surg, 2000, 820 : CONSTANT C. R., MURLEY A. H. G. A clinical method of functional assessment of the shoulder. Clin Orthop, 1987, 214 : LIOTARD J. P., COCHARD P., WALCH G. Two roentgen projections for the subacromial space before and following acromioplasty (in German). Orthopäde, 1991, 20 : DEORIO J. K., COFIELD R. H. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg, 1984, 66 : GARTSMAN G. M. Arthroscopic assessment of the rotator cuff tear reparability. Arthroscopy, 1996, 12 : ESCH J. C., OZERKIS L. R., HALAGER J. A., KANE N., LILLIOTT N. Arthroscopic subacromial decompression : results according to the degree of rotator cuff tear. Arthroscopy, 1988, 4 : WALCH G., NOVE-JOSSERAND L., BOILEAU P., LEVIGNE C. Subluxations and dislocation of the tendon of the long head of the biceps. J Shoulder Elbow Surg, 1998, 7 : OGLIVIE-HARRIS D. J., DEMAZIERE A. Arthroscopic débridement versus open repair for rotator cuff tears. J Bone Joint Surg, 1999, 75 : BURKHART S. S. Arthroscopic débridement and decompression for selected rotator cuff tears. Orthop Clin North Am, 1993, 24 : BURKHART S. S. Reconciling the paradox of rotator cuff repair versus débridement : a unified biomechanical rationale for the treatment of rotator cuff tears. Arthroscopy, 1994, 10 : POST M., BENCA P. Primary tendinitis of the lon head of the biceps. Clin Orthop, 1989, 246 : PFAHLER M., BRANNER S., REFIOR H. J. The role of the bicipital groove in tendinopathy of the long biceps tendon. J Shoulder Elbow Surg, 1999, 8 : JS BOILEAU P., KRISHNAN S. G., COSTE, WALCH G. Arthroscopic biceps tenodesis : A new technique using bioabsorbable interference screw fixation. Arthroscopy, 2002, 18 : MURTHI A. M., VISBURGH C. L., NEVIASER T. J. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg, 2000, 9 : FROIMSON A. L. Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop, 1974, 112 : BERLEMAN U., BAYLEY I. Tenodesis of the long head of the biceps bracchii in the painful shoulder : Improving the results in the long term. J Shoulder Elbow Surg, 1995, 4 : WALCH G., PATTE D., BOILEAU P. Luxation de la longue portion du biceps et rupture de la coiffe des rotateurs (in French). Rev Chir Orthop, 1990, 76 : CURTIS A. S., SYNDER S. J. Evaluation and treatment of biceps tendon pathology. Arthroscopy, 1993, 24 : SETHI N., WRIGHT R., YAMAGUCHI K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg, 1999, 8 : MONTGOMERY T. J., YERGER B., SAVOIE F. H. Management of rotator cuff tears : A comparison of arthroscopic débridement and surgical repair. J Shoulder Elbow Surg, 1994, 3 : APOIL A., AUGEREAU B. Anterosuperior arthrolysis of the shoulder for rotator cuff degenerative lesions. In : POST M., MORREY B. F., HAWKINS R. J. (eds.). Surgery of the shoulder. St. Louis : Mosby Year Book, 1990, pp WARNER J. J. P., MCMAHON P. J. The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint Surg, 1995, 77 : KEMPF J.-F., GEYZE P., BONNOMET F. et al. A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthroscopy, 1999, 15 : H.-M. Klinger Department of Orthopaedic Surgery Georg-August-University of Göttingen Robert-Koch-Str. 40 D Göttingen, Germany Tel. : Fax : michael.klinger@med.uni-goettingen.de
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