Arthroscopic Debriderment Versus Repair Of Rotator Cuff?

MOJ

eISSN: 2374-6939

Orthopedics & Rheumatology

Case Report Volume five Outcome 6

Is Arthroscopic Debridement an Effective Handling Option for Rotator Gage Arthropathy?

Ashvin 1000 Dewan, Nicholas A Jarmon, Juan Garzon Muvdi, Steve A Petersen

Department of Orthopedic Surgery, The Johns Hopkins University, USA

Correspondence: Steve A Petersen, Section of Orthopedic Surgery, Medstar Good Samaritan Infirmary, 5601 Loch Raven Blvd, Suite G-ane, Baltimore, USA, 21239, Tel 4434444740, Fax 4104444752

Received: September 03, 2022 | Published: September 22, 2022

Citation: Dewan AK, Jarmon NA, Muvdi JG, Petersen SA (2016) Is Arthroscopic Debridement an Effective Treatment Option for Rotator Cuff Arthropathy? MOJ Orthop Rheumatol five(half-dozen): 00199. DOI: 10.15406/mojor.2016.05.00199

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Abstract

To determine the clinical effectiveness of arthroscopic debridement in patients with rotator cuff arthropathy that is refractory to non operative management, we retrospectively reviewed information for 29 consecutive patients (mean age, 70 years [range, 52-83 years]) with rotator cuff tear arthropathy who underwent arthroscopic debridement by 1 surgeon, had 24 months or more than of follow-up (range, 24-69 months), and had complete subjective and objective outcomes evaluations. Statistical analysis involved paired Student's t-test, postal service hoc analysis, assay of variance, and the Fisher verbal examination (significance, P<.05). At 2 years, 18 (62%) satisfied patients graded their shoulders as 66% of normal; the eleven dissatisfied patients graded their shoulders as 31% of normal (P=.006). Satisfied patients had lower visual analog scale scores for night and overall pain and higher hateful American Shoulder and Elbow Surgeons (61±21 VS xl± 32) and University of California Los Angeles Shoulder Rating Calibration (24±6 VS xi±4, P=.001) scores. Satisfaction was not correlated with biceps release or postoperative range of motion. Patients with Hamada nomenclature of Grade 4 or 5 are poor candidates for this procedure (with a two.5 times [95% confidence interval 93-6.61] greater probability of dissatisfaction).

Keywords: Arthroscopic debridement, Reverse shoulder replacement, Rotator cuff arthropathy, Rotator cuff tear, Shoulder arthritis, Shoulder arthroscopy.

Introduction

Rotator cuff arthropathy is often associated with disabling pain and shoulder dysfunction. When non operative treatment options have failed, reverse shoulder replacement is usually indicated. Culling treatment options may be prudent in younger patients, those with multiple co morbidities compromising surgical options, or those unable to comply with postoperative rehabilitation. At that place is little guidance in the literature regarding the role of arthroscopic glenohumeral joint debridement for the handling of rotator cuff tear arthropathy. In the absence of glenohumeral osteoarthritis, arthroscopic debridement of irreparable rotator cuff tears affords sustained hurting relief and improved range of motion.^{one-half-dozen} Conversely, when the rotator cuff is intact, investigators have noted that arthroscopic debridement of mild to moderate glenohumeral osteoarthritis tin produce pain relief and improved range of motion.^7-12 The purpose of our study was to determine the subjective and clinical outcomes of arthroscopic debridementin patients with rotator cuff arthropathy refractory to not operative management.

Patients and methods

Institutional review lath approval was obtained for this retrospective cohort written report. From 2007 through 2022, 43 patients with rotator gage arthropathy refractory to not operative treatment were considered candidates for arthroscopic debridement rather than contrary shoulder replacement considering of co morbidities (38), inability to undergo the necessary postoperative rehabilitation (4), or age less than 55 years (1). The diagnosis of rotator gage arthropathy was made by a consummate history, physical examination and radiological and magnetic resonance imaging studies. Of the 14 (33%) patients excluded from the study, 6 declined participation, 3 could not exist reached, ii had died, 2 had advanced dementia, and 1 was not-English language speaking and could not complete the questionnaires. Therefore, our accomplice consisted of 29 patients with minimum 24-month follow-up (range, 24-69 months).

Demographic information, including age, sexual practice, and paw dominance, was recorded. Ten men and xix women had a mean age at surgery of 70 years (range, 52-83 years) (Table 1). Surgery was performed on the dominant arm for 22 of 29 (76%) patients. No patient had awaiting litigation or worker's compensation claims. Subjective visual analog calibration (VAS) pain scores (0-100 points) and physical examination findings, including shoulder range of motility, were documented. Grashey, scapular Y, and axillary radiological views of all shoulders were obtained at the initial patient appointments. Magnetic resonance images showed irreparable rotator cuff tears with greater than Goutallier^thirteen,xiv phase 3 atrophy in all patients. Surgery was indicated for shoulder hurting that was unresponsive to a non operative treatment programme at a minimum of 12 weeks, including shoulder injections, medical management of shoulder symptoms, and shoulder-specific physical therapy focused on range of motion and cuff and scapular strengthening.

Parameter	All Patients (N=29)	Arthroscopic Debridement		P Value
		Alone (Due north=22)	Converted to Replacement (North=7)
Mean age ± SE(yr)	seventy±ii	70±2	lxx±iii	0.93
Sex (n%)				0.541
Men	10 (35)	viii (36)	2 (29)
Women	19 (65)	14 (64)	five (71)
Dominant arm (north%)				0.556
Dominant	22 (76)	17 (77)	five (71)
Nondominant	7 (24)	five (23)	2 (29)

Tabular array 1 Demographic Data
SE: Standard Fault

Operative technique

All procedures were performed on an outpatient basis. Each patient was positioned in a embankment-chair position with regional anesthesia and intravenous sedation. Posterior and midanterior portals were used for inspection of the glenohumeral joint and instrument placement for arthroscopic debridement. All chondral lesions and degenerative labral tears were debrided to a stable surface using a 4.0-mm shaver. The rotator interval was released using a shaver and bipolar thermal ablation (VAPR Wand, DePuy Mitek, Inc, Raynham, Massachusetts). An anterior capsular release was performed, preserving the subscapularis tendon. The posterior capsule was likewise released, avoiding the five-o'clock to 7-o'clock interval where the axillary nervus is most vulnerable. None of the rotator cuff tears could be finer mobilized for repair. When present, the biceps was released at the glenoid origin by electrical cautery. The subacromial space was inspected, and all adhesions were debrided. For 5 patients, an inductive acromioplasty was performed with a 5.5-mmbarrel burr (Stryker, Kalamazoo, Michigan). A gentle manipulation was performed, releasing the junior capsule. The portals were closed with number 3 Monocryl sutures (Ethicon, Somerville, New Bailiwick of jersey) and steri-strips. After surgery, a sling was usedf or comfort. After regional anesthesia had resolved, the sling was discontinued, and agile shoulder range of motility was permitted as tolerated. All patients were instructed past a physical therapist for a domicile-based strengthening program after postoperative follow-up, 2 to three weeks later surgery.

Outcomes assay

Preoperative evaluation: Before surgery, all patients completed questionnaires that assessed VAS hurting scores. The senior surgeon documented shoulder range of motion, including active forwards flexion and agile external rotation with the arm at the side. Preoperative radiographs were graded in a blinded fashion by the senior surgeon using the nomenclature arrangement of Hamada and colleagues¹⁵ for rotator cuff arthropathy.

Postoperative evaluation: At a minimum of 24months of follow-upwards, all 29 patients completed validated questionnaires¹⁶ by postal service (v patients) or telephone (five patients) or were seen for follow-up(19 patients) to appraise range of motility and level of satisfaction with the procedure. American Shoulder and Elbow Surgeons (ASES) score,¹⁷ Academy of California Los Angeles Activity Shoulder Rating Scale (UCLA) score,¹⁸ and Single Cess Numeric Evaluation (SANE) score^xix were calculated from the data obtained in the follow-up questionnaires.

Statistical analysis

Paired Student's t-tests was used to assess the degree of improvement in clinical parameters at the fourth dimension of latest follow-up. A mail hoc assay of patients stratified by satisfaction was used to identify risk factors for dissatisfaction. Parametric information were compared using analysis of variance. Nonparametric data were compared using the Fisher exact examination. Significance was set at a P value less than .05. SPSS statistical software (IBM Corp, Armonk, New York) was used for data analysis.

Results

Of the 29 patients, xviii (62%) were satisfied and 11 (38%) were dissatisfied with surgery; 7 of the dissatisfied patients were converted to reverse shoulder replacements.

Multiple benefits from surgery were observed (Table 2).Overall, VAS hurting scores decreased from the preoperative scores (P=.020). Hateful agile forrard flexion and active external rotation with the arm at the side increased by 16% and 38%, respectively. Satisfied patients showed a pregnant comeback in overall VAS pain scores (P=.009), but dissatisfied patients did not. Satisfied patients had lower hateful VAS pain scores for night, rest, and activeness-related pain compared with dissatisfied patients.

Parameter	Preoperative (N=29)	Postoperative (North=29)	PValueb
Agile forward flexion(°)	131±6	152±iii	0.002
Agile external rotation arm at side (°)	41±four	57±four	0.007
Overall pain VAS scores	seven.0±.5	5.0±.6	0.02

Tabular array 2 Subjective and Objective Outcomes^a
VAS: Visual Analog Scale ^aValues are given as standard error of the mean.
^bStatistically significant difference (P<.05) past paired Student's t-tests of preoperativeversus postoperative scores.

A post hoc analysis revealed multiple postoperative differences between satisfied and dissatisfied patients (Table 3). Dissatisfied patients had SANE scores less than half of those of their satisfied counterparts (P=.006) and had significantly worse UCLA scores (P=.0001).

Parameter	All Patients (N=29)	Not Satisfied with Surgery (N=11)	Satisfied with Surgery (N=18)	P Value
Age(year)	lxx.0±2.0	63.0±four.iv	seventy.9±2.1	0.126
Follow-upward (months)	45.vii±2.4	49.v±iv.6	45.5±2.4	0.398
Outcome scores
SANE (%)	60±5	31±6	66±v	.006b
ASES (points)	57.iii±5.0	twoscore.4±16.1	61.one±4.viii	0.114
UCLA (points)	21.3±1.7	10.viii±2.1	23.7±ane.5	.001b
Active forward flexion (°)
Preoperative	131±6	139±17	129±6	0.535
Postoperative	152±iii	158±2	151±four	0.432
Change	21±6	28±eighteen	20±7	0.639
Active external rotation arm at side (°)
Preoperative	41±4	38±xi	42±4	0.684
Postoperative	57±4	73±4	54±4	0.073
Alter	16±5	47±7	11±5	.010b
Overall pain VASscores
Preoperative	7.0±.5	7.5±ane.0	6.9±.5c	0.634
Postoperative	5.0±.6	seven.5±.6	four.five±.7c	0.071
Postoperativepain VAS score subcategories
Night pain	4.1±.8	vi.0±2.two	3.vii±.viii	0.272
Restingpain	2.7±.vi	iv.3±ane.ix	ii.3±.6	0.247
Activity pain	5.iv±.7	seven.5±ane.iii	four.9±8	0.178

Table 3 Comparison of Subjective and Objective Outcomes Stratified by Patient Satisfaction with Surgery
ASES: American Shoulder and Elbow Surgeons Score; SANE: Single Assessment Numeric Evaluation; UCLA: University of California Shoulder Rating Scale; VAS: Visual Analog Scale
^aValues are given every bit ± standard error of the mean.
^bStatistically significant difference (P<.05)by analysis of variance test of satisfied versus dissatisfied patients.
^cStatistically significant difference(P=.009)by paired Pupil's t-tests of preoperative versuspostoperative scores.

To decide the factors that influenced patient satisfaction, we compared the characteristics of satisfied and dissatisfied patients. For the purpose of this analysis, we considered patients who were converted to reverse shoulder replacement to be dissatisfied with the arthroscopic debridement process. We establish no significant differences, with a trend toward greater dissatisfaction with preoperative Hamada Course 4 or 5 rotator cuff arthropathy (Table 4). These patients had a two.5-times (95% confidence interval 93-half dozen.61) greater probability of dissatisfaction with surgery compared with patients with rotator gage arthropathy of less than Hamada Grade 4.

Parameter	N	Hamada Classification (northward, %)
		Grade <4	Class 4 or5
Non satisfied	11	4 (36)	7 (64)
Satisfied	eighteen	13 (72)	5 (28)
All patients	29	17 (59)	12 (41)

Tabular array four Comparison of Hamada Rotator Cuff Arthropathy Classification Stratified past Patient Satisfaction with Surgery^a
aFisher exact test; P=.065

Word

To our noesis, ours is the first report to characterize the benefit of arthroscopic debridement specifically for patients with rotator cuff arthropathy that is refractory to non operative treatment. At a minimum follow-up of 24 months, 7 patients ultimately underwent shoulder replacement and 4 others were not satisfied, but the remaining 62% were satisfied with arthroscopic surgery. The procedure described resulted in clinically significant improvement in hurting relief, range of motion, and functional outcomes.

Multiple investigators accept endorsed arthroscopic debridement in the presence of glenohumeral osteoarthritis alone without rotator cuff tears.^7-12 In a study of 71 patients, Van Thiel and colleagues²⁰ showed that 55 had significant improvement in range of motion, ASES scores, and VAS scores at a mean follow-up of 27 months. Weinstein and colleagues¹² reported well to excellent results at 34 months in 80% of patients with arthroscopic debridement of glenohumeral osteoarthritis and capsular release. More recently, Millet and colleagues^ix studied a accomplice of 29 relatively immature patients with avant-garde glenohumeral arthritis at a mean follow-up of 2.6 years, finding that comprehensive arthroscopic management, including humeral osteoplasty, axillary neurolysis, distal clavicle resection, subacromial decompression, and/or long head biceps tenodesis, improved shoulder function, diminished pain, and potentially delayed replacement.

Investigators have as well shown the effectiveness of debridement for isolated massive rotator cuff tears.^i-six,21,22 Klinger and colleagues⁴ reported an 82% satisfaction rate for arthroscopic debridement of massive rotator cuff tears in a cohort of 33 patients with a mean follow-upwardly of 31 months. Rockwood and colleagues²² reported an 83% success charge per unit for open tendon debridement and decompression of massive rotator cuff tears in 50 patients at a mean follow-up of half-dozen.v years. Burkart²¹ advocated the use of rotator gage debridement in massive rotator cuff tears, particularly when the balance of the anterior and posterior gage could be preserved. In 25 patients with supraspinatus tears, arthroscopic debridement plus acromioplasty resulted in pain relief and restored shoulder function.

To our noesis, no studies accept specifically examined the role of arthroscopic debridement for rotator cuff arthropathy. Our results are similar to those of the studies of patients with advanced glenohumeral osteoarthritis or massive rotator cuff tears described above. Despite the patient-described satisfaction in our serial, the ASES, SANE, and UCLA issue scores were depression, this is likely related to the cumulative burden of both glenohumeral osteoarthritis and irreparable rotator cuff tears. The mean postoperative ASES and VAS score improvements of 20.2 and 2.0 points, respectively, showed significant improvement and exceeded the clinically significant changes in ASES and VAS scores of 17 points²³ and 1.3 points,²⁴ respectively, as reported in the literature.

In our study, Hamada's radiographic classification of rotator cuff arthropathy of Form four or 5 was associated with patient dissatisfaction with the procedure. Other authors have made the same observation with advancing stages of glenohumeral osteoarthritis alone. Ogilvie-Harris and Wiley,^ten in one of the first descriptions of arthroscopic direction of osteoarthritis, examined 54 patients at a hateful follow-upwards of three years and constitute that patients with mild arthritis on arthroscopy fared better than those with severe degeneration after arthroscopic debridement. In patients with glenohumeral osteoarthritis, Kerr et al.²⁵ constitute that those with unipolar lesions had higher outcome scores than patients with bipolar lesions after arthroscopic debridement. Van Thiel and colleagues^xx advocated the judicious use of arthroscopic debridement for less severe glenohumeral osteoarthritis in patients with residuum joint space and an absence of big osteophytes.

There are several limitations to our written report. The analysis was retrospective, with express sample size and power and no control group, and it relied on the accuracy of information documented in medical records or patient questionnaires. A longer follow-upwardly is necessary to decide natural affliction progression and longevity of the treatment effect. Furthermore, there was choice bias by the senior author and surgeon, given that patients included in the study were non considered candidates for reverse replacement. Finally, preoperative ASES, UCLA, and SANE patient scores were not available. Nevertheless, given the lack of other guidance, the clinician can use this information to counsel patients with rotator gage arthropathy about treatment options.

In conclusion, arthroscopic debridement is an effective handling that can decrease pain and improve shoulder range of motion in advisedly selected patients with rotator cuff arthropathy. Patients with Hamada classification of Grade 4 or 5 are likely poor candidates for this procedure.

Acquittance

None.

Conflicts of interest

None.

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Arthroscopic Debriderment Versus Repair Of Rotator Cuff?,

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