Research Article
Comparison of One-Stage Versus Two-Stage Procedure for Management of Patients with Rotator Cuff Tear and Concomitant Shoulder Stiffness
Hongwu Zhuo*
Department of Sports Medicine, Fuzhou Second Hospital, Fuzhou, China
*Corresponding author: Hongwu Zhuo, Department of Sports Medicine, Fuzhou Second Hospital, Fuzhou, China
Published: 18 Sep, 2018
Cite this article as: Zhuo H. Comparison of One-Stage
Versus Two-Stage Procedure for
Management of Patients with Rotator
Cuff Tear and Concomitant Shoulder
Stiffness. Clin Surg. 2018; 3: 2115.
Abstract
Purpose: To compare the clinical outcomes of one-stage and two-stage procedure for management
of patients with rotator cuff tear and concomitant shoulder stiffness.
Methods: From December 2013 to June 2016, we recruited 42 consecutive patients with rotator
cuff tear and concomitant shoulder stiffness. Twenty-two patients underwent one-stage procedure
including arthroscopic capsule release and concomitant rotator cuff repair within 2 weeks of the
diagnosis. For the remaining twenty patients, conservative treatment for the recovery of ROM
was initially performed before arthroscopic rotator cuff repair. The range of motion (ROM), VAS,
American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score and satisfaction rate
were assessed preoperatively; 3, 6, 12, 24 months after surgery; and at final follow-up.
Results: The mean follow-up period was 26.3 months (range, 24-33 months). There were no significant
differences in preoperative demographic data between the groups (P>0.05). After treatment, there
was significant improvement in ROM and functional scores in both groups (P< 0.05). At 3 months
postoperatively, the two-stage group exhibited significantly improved forward flexion and internal
rotator compared with the one-stage group (P=0.001 and P=0.038, respectively). There was no
significant difference in ROM between the 2 groups at any other time point (P>0.05). In addition,
no significant difference was found in functional scores and satisfaction rate between the 2 groups
at final follow-up (P>0.05).
Conclusion: In the treatment of rotator cuff tear with concomitant stiffness, even though the
recovery of ROM took longer in patients who underwent one-stage procedure, satisfactory results
can be achieved either by one-stage procedure or two-stage procedure at final follow-up.
Study Design: Retrospective comparative study; Level of evidence, 3.
Keywords: Rotator cuff; Repair; Stiffness; Arthroscopic surgery; Capsular release; Conservative
treatment be no difference between these two groups in ROM, functional scores
and satisfaction rate at final follow-up.
Introduction
Rotator cuff tear is a common condition that causes shoulder pain and disfunction in daily life
[1-3]. For many patients with rotator cuff tear, they might also have concomitant shoulder stiffness,
with a reported incidence of up to more than 40% [4,5].
The optimal management of patients with rotator cuff tear and concomitant shoulder stiffness
still remains controversial [6-13]. Traditionally, when a patient had a rotator cuff tear with
concomitant shoulder stiffness, the stiffness should be addressed initially through conservative
treatment before rotator cuff repair because the repair is a “shoulder-tightening” procedure and
might increase stiffness postoperatively [9-11]. However, this two-stage procedure would prolong
the patient’s suffering owing to the delay of surgery and the rotator cuff tear may extend during the
treatment of the stiffness [6-8,12-14]. Recently, an one-stage procedure has been proposed for the
management of patients with rotator cuff tears and concomitant stiffness [7,12,13]. However, to
our knowledge, there is limited data comparing the clinical outcomes of one-stage and two-stage
procedure for treatment of patients with rotator cuff tear and concomitant stiffness.
The purpose of the present study was to compare the clinical outcomes of one-stage and twostage
procedure for rotator cuff tear and concomitant stiffness. We hypothesized that there would
Figure 1
Figure 2
Materials and Methods
Study population
This was a retrospective study. From December 2013 to June
2016, fifty-six consecutive patients with rotator cuff tear and
concomitant shoulder stiffness underwent either one-stage or twostage
procedure for treatment in our institution. The inclusion criteria
were the following: (1) patients with a small-sized (tear size < 1 cm) or
medium-sized (tear size 1~3 cm) full-thickness rotator cuff tear; (2)
patients with a concomitant limited passive ROM: forward flexion
was less than 100° passively, external rotation with the arm at the side
was less than 30° passively, internal rotation of a vertebral level where
the thumb reached was lower than the first lumbar spine junction
passively; (3) patients with a minimum follow-up period of 2 years.
Patients who had previous shoulder fractures or previous surgical
procedures on the ipsilateral joint were excluded. Patients with
concomitant shoulder lesions such as arthritis in the glenohumeral
joint or labral lesions were also excluded.
According to the criteria, forty-two patients were included in this
study. The one-stage group consisted 22 patients (6 men, 16 women)
and the two-stage group consisted 20 patients (4 men, 16 women).
Approval of the study was obtained through the institutional review
board at our institution. All patients had provided signed informed
consent to allow their clinical and radiologic data to be used for
research programs.
Assessment
Demographic data that could affect the outcomes of arthroscopic
rotator cuff repair, including patient’s age, sex, hand dominance,
history of diabetes mellitus, duration of symptoms, fatty infiltration
of the rotator cuff muscles, tear size, repair technique, and
concomitant procedures (such as biceps tenotomy or tenodesis,
acromioplasty, distal clavicle resection), were collected from
our database. Fatty infiltration of the rotator cuff muscles was
evaluated using preoperative MRI (3.0-T MR System, Signa Excite;
GE Medical Systems, Waukesha, Wisconsin, USA) and classified
according to the criteria established by Goutallier et al. [15] and
modified by Fuchs [16]. Scans were evaluated at the level where the
scapular spine and body form a Y-shape in the oblique sagittal view.
The tear size of rotator cuff was measured intraoperatively under
direct arthroscopic visualization with a calibrated probe and classified
according to the criteria established by DeOrio et al. [17]. The patients
were routinely followed at 1, 3, 6, 12 and 24 months after surgery.
ROM
For all patients, passive ROM including forward flexion, external
rotation with the arm at the side and internal rotator was evaluated
preoperatively; 3, 6, 12, 24 months after surgery; and at final followup.
Forward flexion and external rotation were evaluated with a
goniometer with patients in the supine position. Internal rotation,
which was measured in the seated position, was evaluated by the tip of
the thumb reaching the vertebral level. For statistical analysis, internal
rotation up to the level of the sacrum was designated as 0 point, and
1 point was added for each level above this. All the assessment data
were collected by a clinical researcher who was blinded to this study.
Functional and satisfaction assessments
At final follow-up, functional assessment was performed using
Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons
(ASES) score and Constant-Murley score. The VAS was scored on
a scale of 0 to 10, with 10 indicating the highest level of pain. The
ASES score consisted of a score summation using a 100-point system
(50 points for daily function and 50 points for pain). Patients were
additionally asked about their satisfaction regarding their clinical
outcomes (i.e., very satisfied, satisfied, neutral, or not satisfied). The
proportion of very satisfied and satisfied patients was defined as the
satisfaction rate.
Surgical procedure
All of the surgeries were performed by our senior author who had
performed nearly 300 shoulder arthroscopic surgeries per year for the
last 6 years.
One-stage group
In this group, all the patients underwent one-stage procedure
including arthroscopic capsule release and concomitant rotator cuff
repair within 2 weeks of the diagnosis. After induction of general
anesthesia, each patient was positioned in a lateral decubitus position
with the involved arm suspended to an arm-holding device using 10
to 15 pounds of suspension. A routine arthroscopic glenohumeral
examination was performed through the standard posterior and
anterior portals. After confirmation of synovial hypertrophy and capsular thickening, sequential release of the rotator interval and
anterior, inferior, and posterior capsules using a radiofrequency
device (Arthrocare, Sunnyvale, California, USA) was performed
(Figure 1). Capsular release was done just off the glenoid rim so as to
avoid damaging the axillary nerve. The arthroscope was then placed
in the subacromial space and lateral portals were established as the
working portal. After removal of residual bursa and debridement of
degenerated tendon edges, the rotator cuff tear was accessed using
a calibrated probe. For small-sized rotator cuff tears, the repair was
conducted by single-row technique (Figure 2). For medium-sized
rotator cuff tears, a suture bridge technique was applied (Figure 3).
Two-stage group
In this group, conservative treatment for the recovery of ROM
was initially performed before arthroscopic rotator cuff repair.
Conservative treatment included Nonsteroidal Anti-Inflammatory
Medications (NSAIDs), corticosteroid injections, and rehabilitative
therapy. Rehabilitative therapy consisted of pendulum circumduction,
passive shoulder stretching in forward flexion, external rotation,
horizontal adduction, and internal rotation. Patients were instructed
to stretch the shoulder to the point of tolerable discomfort and hold the
position for 3 seconds. Rehabilitative therapy was performed 3 times
every day and each session last at least 15 minutes. Nonsteroidal antiinflammatory
drugs were prescribed when necessary. Rehabilitative
therapy was continued for 3 months and subsequent surgery for
rotator cuff repair was performed.
Postoperative rehabilitation
The postoperative rehabilitation protocol was identical in both
groups. Immobilization was maintained with an abduction brace at
30° for 6 weeks. From the first day after surgery, all patients engaged
in pendulum, passive forward flexion and external rotation exercises.
Active exercises were not allowed until 6 weeks postoperatively.
Muscle strengthening exercises were usually initiated at 3 months
postoperatively. A return to recreational activity with heavy demands
on the shoulder or to manual labor was delayed for 6 months.
Statistical analyses
All statistical analyses were performed using SPSS software
(IBM-SPSS statistics 19.0; New York, USA). The data were presented
as means and standard deviations for description.Paired t test was
used to compare the preoperative and postoperative results including
ROM and functional scores. Unpaired t test was used to compare the
continuous variables between the 2 groups. A chi-square analysis was
used to determine the differences in patient’s sex, side and satisfaction
rate. The significance level was set to 0.05.
Figure 3
Figure 4
Figure 4
The mean changes in forward elevation. At 3 months
postoperatively, the two-stage group exhibited significantly improved
forward flexion compared with the one-stage group (P=0.001). No significant
differences between groups were seen at any other time point (P>0.05).
Figure 5
Figure 5
The mean changes in external rotator. No significant differences
between groups were seen at any time point (P>0.05).
Figure 6
Figure 6
The mean changes in internal rotator. At 3 months postoperatively,
the two-stage group exhibited significantly improved internal rotator
compared with the one-stage group (P=0.038). No significant differences
between groups were seen at any other time point (P>0.05).
Results
Demographic data
Forty-two patients met the inclusion criteria and were included
in this study. There were 10 male and 32 female with a mean age of
54.1 years (range, 47 - 69 years). The mean follow-up period was
26.3 months (range, 24 - 33 months). The demographic data of the
patients are summarized in table 1. The one-stage group consisted 22
patients and the two-stage group consisted 20 patients. Overall, there
were no statistically significant differences in the demographic data
between the 2 groups (P>0.05, Table 1).
ROM
Before treatment, no significant differences were found between
the 2 groups in ROM (P>0.05, Figures 4-6). In two-stage group, six
patients with drawed from rehabilitative therapy because of severe
pain and underwent surgery in advance. However, the remaining 14
patients exhibited significant improved forward flexion and internal
rotation after rehabilitative therapy (72.50° ± 10.35° to 104.50° ±
12.90°, P< 0.05; 2.07 ± 0.98 to 3.15 ± 0.86, P< 0.05). And two patients
didn’t have subsequent surgery because of significant improvement in pain relieve and ROM.
At 3 months postoperatively, the two-stage group exhibited
significantly improved forward flexion and internal rotation compared
with the one-stage group (P=0.001 and P=0.038, respectively, Figure
4, 6). However, no significant difference was found between the 2
groups in external rotation (P>0.05, Figure 5). However, there were
no significant differences in ROM between the 2 groups at 6, 12,
24 months and final follow-up (P>0.05). In addition, both groups
achieved significantly improved ROM at final follow-up compared
with ROM before treatment (Figures 4-6).
Functional outcomes
Both groups had significant improvements in the VAS score,
ASES score and Constant score at final follow-up (P=0.001). No
significant differences were found between the 2 groups regarding the
VAS score, ASES score and Constant score at any period after surgery
(P>0.05, Table 2). The satisfaction rate was 90.5% in one-stage group
and 68.2% in two-stage group. There was no significant difference in
satisfaction rate between the 2 groups (P=0.085, Table 2).
Table 1
Discussion
The principal findings of the present study were that overall
satisfactory clinical outcomes could be achieved in both patients
after one-stage procedure or two-stage procedure for rotator cuff
tear and concomitant shoulder stiffness. At 3 months, the two-stage
group exhibited significantly improved forward flexion and internal
rotator compared with the one-stage group. However, there was no
significant difference in ROM between the 2 groups at any other time
point (P>0.05). In addition, no significant difference was found in
functional scores and satisfaction rate between the 2 groups at final
follow-up (P>0.05).
Factors leading to shoulder stiffness in patients with
rotator cuff tear
Several studies have reported that patients with rotator cuff tear
could also have shoulder stiffness [4,5]. Tauro et al. [4] reported on a
cohort of 72 patients who underwent rotator cuff repair and found that
40% of the patients had concomitant shoulder stiffness. According to
the published literature [4-6,12,18], the factors leading to shoulder
stiffness in patients with rotator cuff tear include the following: (1) the
pain from rotator cuff tears results in joint disuse, contracture of the
joint capsule and secondary muscular weakness which would finally
facilitate the joint stiffness; (2) secondary adhesive capsulitis, which is
precipitated by inflammation from the rotator cuff tear, could also be
a contributor to joint stiffness.
Management of patients with rotator cuff tear and
concomitant stiffness
The optimal management of patients with rotator cuff tears and
concomitant shoulder stiffness still remains controversial [6-14].
The main concern about one-stage procedure is the high risk of
developing postoperative stiffness [9-11]. Huberty et al. [11] reported
on a cohort of 489 patients who underwent rotator cuff repair. They
found that 24 patients (4.9%) developed postoperative stiffness and
the patients with preoperative shoulder stiffness were associated with
a significantly increased incidence of 15.6% for postoperative stiffness.
In the current study, we also found the patients who underwent one- stage procedure exhibited significantly lower forward flexion and
internal rotator at 3 months postoperatively.
Nevertheless, the two-stage procedure also has its own inherent
disadvantages, including the following: (1) the two-stage procedure
would prolong the patient’s suffering owing to the delay of surgery.
In the current study, six patients refused to tolerate the remaining
rehabilitation period because of severe pain during stretching
exercises. In another study by Kim [12], the author also reported on
a series of 33 patients who underwent conservative treatment before
rotator cuff repair and six patients (18.2%) with drawed because
of severe pain during rehabilitation; (2) nonsurgical treatment for
shoulder stiffness may be insufficient, especially in the presence of
rotator cuff lesions [1,19,20]; (3) in addition, inappropriate exercise
could lead to fatigue accumulation in the damaged tendon which
might actually worsen the rotator cuff injury [12].
The clinical outcomes of surgical treatment for rotator
cuff tear and concomitant shoulder stiffness
Recently, several studies have reported overall satisfactory clinical
outcomes of surgical treatment for rotator cuff tears and concomitant
stiffness [6,7,9,10,12,13]. Ho et al. [9] reported on a cohort of 211
patients who underwent rotator cuff repair. Forty-three patients
had severe concomitant shoulder stiffness and underwent 1-stage
arthroscopic capsular release and rotator cuff repair. They found the
clinical outcomes of the stiffness group were statistically the same as
those in the non-stiffness group. Oh et al. [13] reported a retrospective
comparative study of 125 patients who underwent rotator cuff repair.
Thirty patients had concomitant moderate shoulder stiffness at the
time of the repair. They found that differences in ROM and functional
scores did not reach statistical significance after 6 months of
operation if arthroscopic capsular release with manipulation is added
to the cuff repair procedure. Cho and Rhee [6] reported on a cohort
of 45 patients and they also determined good clinical outcomes after
rotator cuff repair with concomitant manipulation for treatment of
rotator cuff tears with stiffness.
However, the weakness of these studies is that there is no data
about the clinical outcomes after two-stage procedure for treatment
of rotator cuff tears and concomitant stiffness, which makes it
impossible to determine either one-stage procedure or two-stage
procedure is associated with better clinical outcomes. Recently, Kim
et al. [13] reported on a cohort of 63 patients with rotator cuff tears
and stiffness to compare the clinical outcomes of immediate rotator
cuff repair with capsular release and those of rotator cuff repair after
the stiffness was treated with rehabilitative therapy. The author found
improved results in both groups after 6 months postoperatively and
the effect was maintained until 12 months postoperatively. In the
present study, we further confirmed that similar satisfactory clinical
outcomes could be maintained until 24 months postoperatively.
Table 2
Limitations
There are some limitations to our study. First, this was a retrospective study that included all of the inherent limitations of this study design. Second, our study involved a relatively small number of patients. Third, the length of the follow-up was relatively short, and longer-term evaluations are required to compare the clinical outcomes of one-stage and two-stage procedure for rotator cuff tear and concomitant stiffness.
Conclusion
In the treatment of rotator cuff tear with concomitant stiffness, even though the recovery of ROM took longer in patients who underwent one-stage procedure, satisfactory results can be achieved either by one-stage procedure or two-stage procedure at final followup. To avoid unnecessary rehabilitation, one-stage procedure may be a helpful option for patients with rotator cuff tear and concomitant stiffness.
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