Abstract
Background: Currently, there is no information on the long-term
results of rotator cuff repair in young patients. The purpose of the present
study was to determine the results, the risk factors for an unsatisfactory
outcome, and the rates of failure of this procedure in patients fifty years of
age and younger.
Methods: Thirty-two patients (thirty-six shoulders) who were fifty
years of age or younger underwent repair of a full-thickness rotator cuff tear
between 1976 and 1987. Seven patients (seven shoulders) died after less than
thirteen years of follow-up. The remaining twenty-nine shoulders, which had
been followed for a minimum of thirteen years or until revision surgery, were
included in the analysis. The most recent follow-up was performed in the
clinic for five shoulders and by means of a questionnaire for twenty-four
shoulders.
Results: There were three small, fifteen medium, six large, and five
massive tears. Rotator cuff repair was associated with significant long-term
pain relief (p = 0.0001). However, there was no significant long-term
improvement in active abduction or external rotation. Postoperative pain,
active abduction, and external rotation did not vary significantly according
to gender, tear size, repair type, or whether a distal clavicular excision had
been performed. There were eleven excellent, five satisfactory, and thirteen
unsatisfactory results. Seven shoulders had additional surgery for the
treatment of a recurrent tear (five), instability (one), or osteoarthritis
(one). Three of the five repairs that were done for the treatment of a
recurrent tear were performed ten years or more after the time of the index
procedure.
Conclusions: Rotator cuff repair in young patients is associated
with long-term pain relief. However, this procedure is not associated with
significant long-term improvement in motion, and a large proportion of
patients have an unsatisfactory long-term result. The results of rotator cuff
repair in young patients appear to be less favorable than those in a mixed-age
population.
Level of Evidence: Therapeutic study, Level IV (case
series [no, or historical, control group]). See Instructions to Authors for a
complete description of levels of evidence.
While there have been numerous reports concerning the results of treatment
of rotator cuff tears in older patients, there is little information to guide
clinical decision-making with regard to rotator cuff tears in young patients.
Hawkins et al.1
reported the results of surgical treatment of full-thickness rotator cuff
tears in nineteen patients who were forty years of age or younger. After an
average duration of follow-up of 5.7 years, fifteen of the nineteen patients
had diminished pain. Ma et
al.2 reported the
results of surgical treatment of full-thickness rotator cuff tears in twelve
patients who were younger than forty years of age. After a mean duration of
follow-up of 1.9 years, the results were satisfactory. Tibone et
al.3 reported on the
results of surgical treatment of fifteen athletes who had full-thickness tears
and thirty athletes who had partial-thickness tears. After a mean duration of
follow-up of 3.5 years, thirty-four of the forty-five patients reported a
substantial reduction in pain. To our knowledge, there have been no larger
series on the long-term results of rotator cuff repair in young patients. The
purpose of the present study was to determine the long-term results, the risk
factors for an unsatisfactory outcome, and the rates of failure of this
procedure in patients fifty years of age and younger.
Patients
Between January 1, 1976 and December 31, 1987, thirty-two patients
(thirty-six shoulders) who were fifty years of age or younger were managed
with a repair of a full-thickness rotator cuff tear by the senior author
(R.H.C.). Seven patients (seven shoulders) died after less than thirteen years
of follow-up. The remaining twenty-nine shoulders, which had been followed for
a minimum of thirteen years (mean, 16.2 years) or until revision, were
included in the study.
Patients were identified with the use of a computerized database containing
the files of all patients who have had surgery at our institution. Patients
who had had previous shoulder surgery were excluded from the study. Patients
were asked to return for an examination and interview at regular follow-up
intervals. Those who were unable to return for the evaluation were asked to
complete and return a questionnaire regarding shoulder motion and their
satisfaction with the result. The most recent follow-up was performed in the
clinic for five shoulders and by means of the questionnaire for twenty-four
shoulders.
The average age of the twenty-five patients (twenty-nine shoulders) who
were included in the study was 44.7 years (range, thirty to fifty years) at
the time of the rotator cuff repair. Seven shoulders were in women, and
twenty-two were in men. Eighteen shoulders were on the right side, and eleven
were on the left. Twenty-four shoulders had become painful following a
specific traumatic event. Ten shoulder injuries were work-related. The mean
duration of symptoms before surgery was eighteen months (range, one to 108
months). Twenty-four shoulders had been treated with physical therapy.
Fourteen shoulders had been treated with a cortisone injection.
Grading of Pain and Strength
Clinical assessment was recorded with use of a standard shoulder-analysis
sheet. Shoulder pain was graded as absent (1 point), slight (2 points),
present after unusual activity (3 points), moderate (4 points), or severe (5
points). At the time of the latest follow-up, patients were asked to assess
the strength of their shoulder as normal, good, fair, or poor.
Operative Technique
The surgical procedure was performed through an anterosuperior approach
(with detachment of the deltoid from the anterior part of the acromion) in
twenty-seven shoulders and through an anteromedial approach (with detachment
of the deltoid from the clavicle and anterior part of the acromion) in two.
There were three small tears, fifteen medium tears, six large tears, and five
massive tears4. The
tear involved the supraspinatus in seventeen shoulders; the supraspinatus and
infraspinatus in seven; the supraspinatus, infraspinatus, and subscapularis in
three; the supraspinatus and subscapularis in one; and the subscapularis in
one.
The shape of the tear was longitudinal in three shoulders, transverse in
eleven, longitudinal and transverse in thirteen, and triangular in two. A
combined tendon-to-tendon and tendon-to-bone repair was performed in twelve
shoulders, a tendon-to-bone repair was performed in ten, a tendon-to-tendon
repair was performed in four, and a subscapularis transposition repair was
performed in three. The repair was performed with number-2 Vicryl sutures in
the majority of cases.
An anteroinferior acromioplasty was performed in all shoulders. In ten
shoulders, the distal 1 cm of the distal part of the clavicle was resected in
order to treat severe acromioclavicular arthritis or to remove osteophytes
that resulted in outlet impingement. Three shoulders were treated with a
biceps tenodesis.
Postoperatively, a shoulder immobilizer was used for seventeen shoulders, a
humeral abduction splint was used for eleven shoulders, and a spica cast was
used for one shoulder for four weeks.
In the group of shoulders that were treated with an immobilizer or splint,
passive range-of-motion exercises in elevation and external rotation were
started on the second postoperative day and were continued for four to six
weeks. A program of gentle active-assisted isometric strengthening exercises
was started at four to six weeks. Stretching and strengthening exercises with
an elastic strap were started at three months.
Grading of Results
The result was rated according to the criteria described by
Neer5. The result
was considered to be excellent if the shoulder had at least 55° of
external rotation, at least 145° of active abduction, and no pain. The
result was considered to be satisfactory if the shoulder had no pain, slight
pain, or occasionally moderate pain; at least 30° of external rotation;
and 100° to 145° of active abduction. The result was considered to be
unsatisfactory if any of these criteria were not met. Patients who underwent
additional surgery were considered to have an unsatisfactory result.
Statistical Methods
The associations between nominal risk factors and the result rating as well
as the associations between risk factors and strength were assessed with the
chi-square test or, when necessary, Fisher's exact test. The associations
between risk factors and pain, abduction, external rotation, and internal
rotation were assessed with rank-sum tests. The level of significance was set
at p < 0.05. The rate of survival free of additional surgery was estimated
as a function of time since the index procedure with use of the Kaplan-Meier
method.
Complications and Revisions
Seven of the twenty-nine shoulders underwent an additional surgical
procedure. Five shoulders were revised because of a recurrent tear, one was
revised because of instability, and one was treated with total shoulder
arthroplasty because of osteoarthritis.
A forty-five-year-old man underwent revision surgery for the treatment of a
recurrent tear two months after the index procedure. A forty-eight-year-old
woman underwent revision rotator cuff repair following a fall that occurred
eight months after the index procedure. A forty-one-year-old man underwent
staple removal and repeat acromioplasty three years after the index procedure.
Ten years later, he underwent revision rotator cuff repair because of
increased pain and weakness resulting from a fall. A forty-eight-year-old
woman underwent revision rotator cuff repair ten years following the index
procedure. A fifty-year-old man underwent revision surgery because of a
recurrent tear seventeen years after the index procedure.
A forty-five-year-old man underwent a Magnuson-Stack procedure because of
shoulder instability four years after the index procedure, and a
forty-seven-year-old man underwent a total shoulder arthroplasty for the
treatment of osteoarthritis fourteen years after the index procedure.
According to Kaplan-Meier analysis, the estimated rate of survival free of
additional surgery was 86% (95% confidence interval, 75% to 99%) at five
years, 86% (95% confidence interval, 75% to 99%) at ten years, and 79% (95%
confidence interval, 65% to 96%) at fifteen years.
Pain
There was significant pain relief following rotator cuff repair, with the
average pain score decreasing from 4.8 to 2.6 points (p = 0.0001). At the time
of the most recent follow-up, eleven shoulders had no pain, four had slight
pain, five had pain after unusual activity, three had moderate pain, and six
had severe pain (see Appendix). Five of the six patients with severe pain
underwent revision surgery. Preoperative and postoperative pain scores did not
vary significantly with regard to gender, tear size, repair type, or whether a
distal clavicular excision had been performed.
Range of Motion
Active abduction improved from a mean of 141° to 153°; however,
this difference was not significant (p = 0.195). Preoperative active abduction
averaged 104° among shoulders with large or massive tears, compared with
163° among those with small or medium tears (p = 0.016). The amount of
preoperative active abduction did not vary significantly according to gender,
repair type, or whether a distal clavicular excision had been performed. The
amount of postoperative active abduction did not vary significantly according
to gender, tear size, repair type, or whether a distal clavicular excision had
been performed.
External rotation averaged 56° preoperatively and 55°
postoperatively (p = 1.00). Preoperative and postoperative external rotation
did not vary significantly according to gender, tear size, repair type, or
whether a distal clavicular excision had been performed.
The mean internal rotation (from the fifth lumbar vertebra) was unchanged
(p = 0.625). Preoperative and postoperative internal rotation did not vary
significantly according to gender, tear size, repair type, or whether a distal
clavicular excision had been performed.
Strength
At the time of the most recent follow-up, shoulder strength (as assessed by
the patient) was classified as normal for ten shoulders, good for nine, fair
for six, and poor for four.
Result Rating
Overall, there were eleven excellent results (38%), five satisfactory
results (17%), and thirteen unsatisfactory results (45%). Among the three
shoulders with a small tear, there were two excellent results and one
unsatisfactory result. Among the fifteen shoulders with a medium tear, there
were seven excellent results, one satisfactory result, and seven
unsatisfactory results. Four shoulders with a medium tear underwent revision
surgery for the treatment of a recurrent tear. Among the six shoulders with a
large tear, there was one excellent result, four satisfactory results, and one
unsatisfactory result. One shoulder with a large tear underwent revision
surgery for the treatment of a recurrent tear. Among the five shoulders with a
massive tear, there was one excellent result and four unsatisfactory
results.
An unsatisfactory result was not associated with gender, tear size, repair
type, whether the injury had been work-related, or whether a distal clavicular
excision had been performed. The most common reasons for an unsatisfactory
rating were pain (nine shoulders), additional surgery (seven), lack of active
abduction (four), and lack of external rotation (four).
To our knowledge, the present investigation represents the longest
follow-up study of rotator cuff repairs in young patients that has been
reported to date. We observed significant long-term pain relief following
rotator cuff repair. However, we did not observe a significant improvement in
motion. Additionally, the strength of ten of the twenty-nine shoulders was
rated by the patients as being only fair or poor. Therefore, the findings of
the present study are consistent with the concept that the primary benefit of
rotator cuff surgery is pain relief, not necessarily improvement in motion or
restoration of strength.
There were no significant differences in terms of postoperative pain,
motion, or the rating of the result when these variables were assessed
according to gender, tear size, repair type, or whether a distal clavicular
excision had been performed. However, four of the five shoulders with a
massive tear had an unsatisfactory result. Three of the five revisions that
were performed for the treatment of a recurrent tear and the one total
shoulder arthroplasty that was performed for the treatment of glenohumeral
osteoarthritis were performed ten years or more after the original repair.
Therefore, shorter-term studies may fail to identify these late failures.
The limitations of the present study include the subjective manner in which
strength was measured as well as the lack of data on functional outcome and
occupational status. In addition, long-term follow-up data were obtained
predominantly by means of a questionnaire, and radiographic review was not a
component of the study.
The long-term results of rotator cuff repair in the present study of
younger patients appear to be worse than those in a previous study by one of
us (R.H.C.) and colleagues, which included patients of all
ages6. In that
study, twenty-one (20%) of 105 patients had an unsatisfactory result after a
mean duration of follow-up of thirteen years. In comparison, thirteen (45%) of
the twenty-nine shoulders in the present study had an unsatisfactory result
according to identical criteria.
In conclusion, while this study suggests that there is marked long-term
pain relief following rotator cuff repair in young patients, there is not
significant long-term improvement in shoulder motion. The results of rotator
cuff repair in young patients do not appear to be as good as those seen in a
mixed-age population.
A table showing demographic and clinical data on all study patients is
available with the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM).
HawkinsRJ,
Morin WD, Bonutti PM. Surgical treatment of full-thickness rotator cuff
tears in patients 40 years of age or younger. J Shoulder Elbow
Surg.1999;8:
259-65.8259
1999
[CrossRef]
MaHL, Wu JJ,
Lin CF, Lo WH. Surgical treatment of full thickness rotator cuff tear in
patients younger than 40 years. Zhonghua Yi Xue Za Zhi
(Taipei).2000;63:
452-8.63452
2000
TiboneJE,
Elrod B, Jobe FW, Kerlan RK, Carter VS, Shields CL Jr, Lombardo SJ, Yocum
L. Surgical treatment of tears of the rotator cuff in athletes.
J Bone Joint Surg Am.1986;68:
887-91.68887
1986
[PubMed]
CofieldRH.
Rotator cuff disease of the shoulder. J Bone Joint Surg
Am.1985; 67:
974-9.67974
1985
NeerCS
2nd. Anterior acromioplasty for the chronic impingement syndrome in the
shoulder: a preliminary report. J Bone Joint Surg Am.1972;54:
41-50.5441
1972
[PubMed]
CofieldRH,
Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM. Surgical
repair of chronic rotator cuff tears. A prospective long-term study.
JBone Joint Surg Am.2001;83:
71-7.8371
2001