Abstract
Introduction
It is common for patients with a rotator cuff tear to present with shoulder stiffness. There is no consensus on the acceptable level of stiffness at time of rotator cuff repair.
We aim to determine if patients with stiffness undergoing rotator cuff repair and concomitant capsular release have different outcome than those with no stiffness undergoing rotator cuff repair alone. We hypothesize that patients with stiffness will not have poorer outcome than patients with no stiffness.
Method
We conducted a retrospective study of prospectively collected data for 47 patients who underwent arthroscopic rotator cuff repair under a single surgeon from 2010 to 2015. 25 patients were considered stiff (Stiff group) and 22 patients were considered to have no pre-operative stiffness (Non-stiff group).
Range of motion and functional outcomes were collected preoperatively and post-operatively at two-years.
Results
There were no significant differences in gender distribution, age and cuff tear size between both groups. Pre-operatively, patients in the Stiff group had significantly poorer active range of motion (Forward flexion – Stiff 74.8° vs Non-stiff 100.2°, P = 0.001) and poorer function (Constant score – Stiff 23.5 vs Non-stiff 43.2, P < 0.001). Post-operatively, both groups of patients had increased range of motion, strength and reported lesser pain compared to pre-operation. There were no significant differences in post-operative outcomes between both groups.
Conclusion
Single-stage surgery combining capsular release and rotator cuff repair is effective for patients with stiffness as they are able to achieve similar results to those without shoulder stiffness.
Keywords: Arthroscopic, Rotator cuff repair, Capsular release, Stiffness
1. Introduction
A rotator cuff tear can lead to secondary stiffness of the shoulder due to contracture of the shoulder capsule over time. The optimal time to perform a rotator cuff repair on patients with rotator cuff tears and concomitant stiffness is controversial. Some believe that since rotator cuff repairs are a shoulder tightening procedure,1 range of motion should be regained with physical therapy prior to repair.2, 3, 4
However, delaying rotator cuff repair for preoperative physical therapy may result in tear propagation, tendon retraction and muscular atrophy. This may make cuff repair more challenging or even impossible.5,6 Furthermore, preoperative physical therapy may be suboptimal due to pain, or may introduce additional injury to the rotator cuff.7
The alternative is a two-stage surgery – performing an arthroscopic capsular release followed by rotator cuff repair at a later date. This aids in improving range of motion prior to rotator cuff repair but subjects patients to the risk and burden of multiple operations. Therefore some authors have described a single stage procedure for treatment of rotator cuff tears with shoulder stiffness and have reported satisfactory outcomes.8,9
This study compares clinical outcomes of arthroscopic rotator cuff repair in a patients with stiff shoulders undergoing a concomitant capsular release against patients with no stiffness. We hypothesize that both groups of patients will be able to attain similar outcomes after surgery.
2. Methods
We conducted a retrospective study of prospectively collected data for 47 patients who underwent arthroscopic rotator cuff repair under a single surgeon from 2010 to 2015. Inclusion criteria were (I) Preoperative radiological evidence of rotator cuff tear (II) Symptoms for more than 3 months (III) Post-operative follow up for 2 years. Patients were considered to have pre-operative stiffness if there was a global reduction in active and passive range of motion, with passive forward flexion <135° and external rotation <90° (in 90° abduction).
Of the 47 patients, 25 patients were considered stiff (Stiff group) and 22 patients were considered to have no pre-operative stiffness (Non-stiff group).
Capsular release, bursectomy, acromioplasty and rotator cuff repair were performed for patients in the Stiff group. Patients in the Non-stiff group only underwent bursectomy, acromioplasty and rotator cuff repair. In the beach chair position flexed to 70°, release of the inferior capsule, rotator interval, middle glenohumeral ligament and anterior capsule were performed with a radiofrequency wand for patients in the Stiff group. Bursectomy and acromioplasty were performed via the lateral portal with an arthroscopic shaver for all patients. Cuff integrity was determined intraoperatively under direct vision of the arthroscope. The configuration of repair was determined prior to placement of suture anchors. The bone bed on the greater tuberosity of the humerus was prepared with a radiofrequency wand and the tear edges were debrided before repair. The rotator cuff was repaired with minimal tension and marginal convergence was performed if required. All cuff repairs were achieved with absorbable suture anchors. No subacromial or intra-articular injections were given postoperatively.
All patients received standardized postoperative care, which included appropriate oral analgesia and arm sling postoperatively for pain relief. All patients were allowed gentle range of motion exercises in the elbow and wrist on postoperative day one. Both patient groups underwent a similar physical therapy protocol regardless of rotator cuff tear size. Physical therapy was divided into 3 phases. From week 2–4, exercises were aimed to improve passive shoulder range of motion. From week 4–12, therapy focused on improving active range of motion. After week 12, active resistance and strengthening exercises were include in the post-operative rehabilitation regime.
The operating surgeon reviewed all patients at 2 weeks and up to 2 years after operation to check for recovery and surgical complications.
Subjective and objective data were recorded by a specialized data collection center run by independent technicians. Age, sex, medical comorbidities were collected via standardized survey forms. Active range of motion (ROM) in flexion and abduction of both shoulders were determined consecutively by two, experienced assessors using an inclinometer. External rotation and internal rotation were charted according to the respective component in the Constant Shoulder Score. Pain scores were recorded using the Visual Analogue Pain scale and Constant shoulder score pain component. Constant Shoulder Score, University of California Los Angeles Shoulder Score (UCLA) and the Oxford shoulder scores were collected.
Chi-Square test was used to compare the difference in gender distribution within groups. Rotator cuff tear size and age was compared using independent t-test between case and control group. All outcome variables were tested independently. All statistical analyses were performed using Statistical Package for Social Science (SPSS) Version 23 (IBM, SPSS Statistics, Armonk NY, USA).
3. Results
There were no significant differences in gender distribution, age and cuff tear size between both groups. Rotator cuff tear size was classified according to the DeOrio and Cofield classification , 10which defined 0–1 cm tear as Small; 1–3 cm as Medium; 3–5 cm as Large and 5 cm and above as massive. 76.6% of our patients had small to medium rotator cuff tears (Table 1).
Table 1.
Comparison of demographics.
| Stiff | Non-Stiff | P | |
|---|---|---|---|
| Gender | |||
| Male | 13 | 12 | 0.861 |
| Female | 12 | 10 | |
| Age (year ± SD) | 56.9 ± 10.9 | 58.9 ± 6.5 | 0.446 |
| Cuff Tear Sizea | |||
| Partial | 3 | 4 | 0.662 |
| Small | 13 | 8 | |
| Medium | 7 | 8 | |
| Large | 1 | 0 | |
| Massive | 1 | 1 | |
DeOrio and Cofield rotator cuff tear classification.
Pre-operatively, patients in the Stiff group had significantly poorer active range of motion compared to patients in the Non-Stiff group (Table 2). The maximum isometric forward flexion strength was also better in the Non-stiff group (Non-stiff – 4.6 lbs vs Stiff – 1.88 lbs; P = 0.06) and this trended towards statistical significance. Patients in the Non-stiff group also had significantly better functional scores compared to patients in the Stiff group (Table 2).
Table 2.
Pre-operative function.
| Stiff | Non-stiff | P value | ||
| Active ROM | ||||
| Forward flexion (°) | 74.8 | 100.2 | 0.001 | |
| Abduction (°) | 57.0 | 84.2 | 0.003 | |
| Internal RotationA | 2.32 | 6.8 | < 0.001 | |
| External RotationA | 1.1 | 6.1 | < 0.001 | |
| Strength | ||||
| Isometric (lbs.) | 1.88 | 4.6 | 0.06 | |
| Pain Score | ||||
| VAS | 7.5 | 6.5 | 0.18 | |
| Constant Score (Pain)A | 3.7 | 5.2 | 0.18 | |
| Functional score | ||||
| Constant Score | 23.5 | 43.2 | < 0.001 | |
| UCLA Score | 12.1 | 14.8 | 0.02 | |
| Oxford Shoulder Score | 40.1 | 32.3 | 0.02 | |
Component Constant and Murley Shoulder Score.
Post-operatively, both groups of patients had increased range of motion, increased strength and reported lesser pain compared to pre-operation. There were no significant differences in post-operative outcomes between both groups. (Table 3).
Table 3.
Post-operative outcome.
| Stiff | Non-stiff | P value | |
|---|---|---|---|
| Active ROM | |||
| Forward flexion (°) | 121.1 | 126.5 | 0.42 |
| Abduction (°) | 113.5 | 112.7 | 0.95 |
| Internal RotationA | 7.4 | 6.6 | 0.12 |
| External RotationA | 8.8 | 9.0 | 0.75 |
| Strength | |||
| Isometric (lbs) | 8.88 | 9.2 | 0.87 |
| Pain Score | |||
| VAS | 1.1 | 1.7 | 0.31 |
| Constant Score (Pain | 13.4 | 12.4 | 0.31 |
| Functional Outcome | |||
| Constant Score | 70.4 | 69.2 | 0.77 |
| UCLA Score | 28.3 | 28.8 | 0.79 |
| Oxford Shoulder Score | 15.3 | 16.6 | 0.47 |
Component Constant and Murley Shoulder Score.
The minimal clinically important difference for the Constant score is reported to be 6.7.11 There were no significant differences between the proportion of patients who managed to attain the MCID of 6.7 (Stiff – 100% vs Non-stiff 95.4%; P = 1.00). However, patients in the Stiff group had a significantly higher mean delta in shoulder abduction, internal and external rotation as well as functional outcome (Table 4).
Table 4.
Mean delta in outcome (post-operative vs pre-operative outcome).
| Stiff | Non-stiff | P value | ||
| Active ROM | ||||
| Forward flexion (°) | 42.5 | 26.3 | 0.09 | |
| Abduction (°) | 52.7 | 28.5 | 0.03 | |
| Internal RotationA | 4.9 | 0.5 | < 0.001 | |
| External RotationA | 7.5 | 2.2 | < 0.001 | |
| Strength | ||||
| Isometric (lbs.) | 7.7 | 4.5 | 0.08 | |
| Pain Score | ||||
| VAS | −6.2 | −4.7 | 0.10 | |
| Functional score | ||||
| Constant Score | 44.9 | 26.0 | < 0.001 | |
| UCLA Score | 15.8 | 13.9 | 0.36 | |
| Oxford Shoulder Score | −22.7 | −15.7 | 0.04 | |
Component Constant and Murley Shoulder Score.
No patients in either group required repeat operation within the follow-up period.
4. Discussion
It is common for patients to present with a rotator cuff tear and concomitant shoulder stiffness. There is currently no consensus on the acceptable level of stiffness at the time of rotator cuff repair.3,12 Shoulder stiffness is a debilitating condition which greatly affects patient's function. Pre-operative shoulder stiffness is a known risk factor for the development of post-operative stiffness,13 which leads to poor patient satisfaction after surgery.14 Hence, it is important to determine the optimal treatment for this group of patients. Tauro reported that patients with mild and moderate pre-operative stiffness tend to resolve after rotator cuff repair with early passive range of motion rehabilitation. However, patients with severe pre-operative stiffness and adhesive capsulitis confirmed on arthroscopy did not improve their range of motion after repair.3
Shoulder surgeons are divided with regards to the treatment of these patients – some surgeons perform two-stage procedures, while others advocate for a one-stage procedure.4,8,9,15 Kim found no advantage in delaying rotator cuff repair for pre-operative rehabilitation to treat stiffness over simultaneous capsular release and cuff repair.16 In fact, McGrath reported 0% re-tear rate in patients who received a concomitant rotator cuff repair and capsule release compared to 20% re-tear rate in patients with no-stiffness who underwent repair alone.9 Cho proposed an alternative single stage procedure, where rotator cuff repair was combined with manipulation instead of capsular release.15 In their case-control study, patients with stiffness were able to attain similar outcomes to those without shoulder stiffness at two years, but the recovery in range of motion was slower in patients with stiffness. In our study, patients with pre-operative shoulder stiffness did not have poorer post-operative outcome compared to patients without stiffness. In fact, the mean improvement in function and ROM in the Stiff group was significantly better given that patients in the Stiff group started off with poorer baseline function. Our results add to this growing evidence that single stage surgery may be the preferred treatment for patients who present with shoulder stiffness and a rotator cuff tear.
A systematic review by Grant comparing manipulation and arthroscopic capsular release for adhesive capsulitis showed that capsular release had better improvement in abduction and external rotation.17 This could be due to the fact that manipulation is a blunt method to address stiffness. On the other hand, arthroscopic capsular release allows precise visual control to selectively release tight structures. However, this did not translate to a meaningful difference in the median change in Constant score between the two modalities in Grant's review. Each method carries its own set of risks, albeit rare – in manipulation, there is a 0.4% risk of complication18 (rotator cuff tears, humeral head fractures and gleno-humeral dislocation) and a reported 0.6% risk in arthroscopic capsular release19 (superficial wound infection, brachial plexopathy).
Several studies have established the cost-effectiveness of rotator cuff repair. Vitale estimated the cost-effectiveness of rotator cuff repairs at USD 3091/quality-adjusted life years (QALY) in the United States,20 while a more recent study in the United Kingdom estimated the cost-effectiveness at £5694/QALY.21 Performing a single-stage combined capsular release and rotator cuff repair in a single healthcare encounter will certainly drive more value towards the patient and the healthcare system, given that the additional cost for capsular release is just the cost of the radiofrequency wand.
There are several limitations to this study. Firstly, we have a relatively small number of patients in each group. Secondly, there is no consensus on what defines a stiff shoulder. Some authors have used the criteria of forward flexion <135°,8 while others used <120°15 or <90°.9 Our definition of stiffness is consistent with what other authors have used. All our patients were also evaluated once under general anaesthesia to ensure the range of motion limitation was structural and not just due to pain. Nonetheless, this single surgeon study helps to ensure consistency in preoperative assessment and surgical technique. Independent assessors of patient outcomes with standardized questionnaires, assessment protocols and predetermined temporal time points also ensured homogeneity of results.
5. Conclusion
Our results support the growing body of evidence that surgery for patients with symptomatic rotator cuff tears and shoulder stiffness need not be delayed. With a single-stage surgery combining capsular release and rotator cuff repair, patients are able to achieve similar results to those without shoulder stiffness.
Author contribution
MWK contributed to study conceptualization, data collection, data analysis and preparation of manuscript.
WSRL contributed to study conceptualization, data analysis and preparation of manuscript.
DLTT contributed to study conceptualization, data analysis and preparation of manuscript.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors do not have any conflict of interest to disclose.
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