Patient Demographics
A computer-assisted search of the surgical database at our
institution was performed to identify patients with a preoperative diagnosis
of rheumatoid arthritis who had undergone repair of the rotator cuff from
January 1988 to December 2002. The minimum duration of follow-up was three
years. Patients who had undergone previous shoulder surgery or rotator cuff
repair in association with shoulder arthroplasty were excluded. A total of
thirty-one shoulders had had an isolated rotator cuff repair. Eight of those
shoulders had inadequate follow-up and were not included in the study.
Therefore, a total of twenty-three shoulders in twenty-one patients who met
the defined criteria were identified (see Appendix). The operations were
performed by nine surgeons, including the two senior authors (J.W.S. and
R.H.C.). The median duration of follow-up for the twenty shoulders that did
not require revision was 9.7 years (range, three to sixteen years). The most
recent follow-up evaluations had been performed three to five years
postoperatively for seven shoulders, five to ten years postoperatively for
five, and more than ten years postoperatively for eleven. The present study
was approved by the institutional review board.
All patients (with the exception of three patients who had had revision
shoulder surgery) were most recently evaluated with use of a questionnaire
designed to evaluate shoulder function and satisfaction. A review of the
medical records (including those related to associated surgical procedures)
and available imaging studies was performed. Data regarding preoperative and
postoperative pain, shoulder function, range of motion, strength, and overall
patient function were collected with use of the Simple Shoulder Test (SST) and
the patient section of the American Shoulder and Elbow Surgeons (ASES)
instrument18,19.
Shoulder pain was assigned a grade of 1 (no pain), 2 (slight pain), 3 (pain
after unusual activity), 4 (moderate pain), or 5 (severe pain). Three
shoulders had had revision surgery prior to the initiation of the present
study and could not be evaluated with regard to the outcome of the original
rotator cuff repair.
The study group included eleven women and ten men who had had a median of
sixty-five years of age (range, thirty-five to seventy-nine years) at the time
of the first repair. All patients had been diagnosed with adult-onset
rheumatoid arthritis prior to surgical intervention, and all patients met the
criteria for rheumatoid arthritis established by the American Rheumatism
Association20. All
twenty-one patients had used medications preoperatively to control the
manifestations of the rheumatoid process, with nineteen patients taking oral
nonsteroidal medications. Fifteen patients had used disease-modifying
medications, including methotrexate, sulfasalazine, minocycline,
hydroxychloroquine sulfate (Plaquenil), or azathioprine (Imuran). Sixteen
patients had used oral corticosteroids, and two patients had used newer
biologic agents such as etanercept. Eighteen patients had used a combination
of medications from at least two of the above-mentioned drug classes, and
thirteen patients had used a combination of medications from at least three of
the drug classes.
The functional capacity classification was used to assess overall patient
function with regard to activities of daily living prior to surgical
intervention21,22.
Twenty-two shoulders were in patients who had class-2 disease (as indicated by
adequate ability to perform activities but with pain and discomfort in more
than one joint), and one shoulder was in a patient who had class-3 disease (as
indicated by the ability to perform few or none of the duties of one's usual
occupation or the activities of self-care).
Indications and Operative Technique
Operative indications included unrelenting shoulder pain and dysfunction
that interfered with daily activities in the presence of a rotator cuff tear.
Conservative measures included physical therapy, anti-inflammatory medication,
rest, or subacromial injections of corticosteroids. All of the patients'
histories were rereviewed to evaluate the duration of shoulder symptoms and
the duration of nonoperative treatment. Twenty-one of the twenty-three
shoulders had had symptoms for a minimum of three months before surgery. The
histories of the remaining two patients did not specify the duration of
shoulder pain. Fifteen patients had been referred from other physicians, and
the exact duration of nonoperative treatment could not be determined.
The type of surgical procedure that had been performed had been chosen
solely on the basis of surgeon and patient preference after assessment of the
disease process and patient needs. The diagnosis of a rotator cuff tear was
established on the basis of clinical and radiographic findings. In the group
of nine shoulders with a partial-thickness tear, the diagnosis was confirmed
with use of magnetic resonance imaging (four), arthrography (three), or
arthroscopy (two). In the group of fourteen shoulders with a full-thickness
tear, the diagnosis was confirmed with use of arthrography (six), magnetic
resonance imaging only (five), radiographs only (two), or arthrography and
magnetic resonance imaging (one).
Tears were characterized as partial thickness or full thickness on the
basis of the intraoperative findings. Partial-thickness tears were
characterized as being greater or less than 50% of the thickness of the intact
cuff. Full-thickness tears were further subdivided on the basis of their size
as small (<1 cm), medium (1 to <3 cm), large (3 to 5 cm), or massive
(>5 cm)23. When
the tears were evaluated with regard to location, they were found to involve
the supraspinatus only (sixteen shoulders), the supraspinatus and
subscapularis (four), or the supraspinatus and infraspinatus (three). Of the
nine partial-thickness tears, six were on the articular side and three were on
the bursal side. In the six patients with articular-sided partial-thickness
tears, the initial diagnosis had been established preoperatively on the basis
of arthrography or magnetic resonance imaging.
Eighteen shoulders had open treatment only through an anterosuperior,
anteromedial, or deltopectoral approach, and five had combined arthroscopic
and open treatment. Arthroscopic techniques were used for diagnostic purposes
in five patients. Fourteen shoulders had a full-thickness tear (specifically,
nine had a medium tear, four had a large tear, and one had a massive tear),
and nine had a high-grade partial-thickness tear (involving >50% of the
tendon thickness). Partial-thickness tears that were deemed to involve =50%
of the tendon thickness were repaired after excision of the thinned portion of
the tendon.
With regard to the method of repair, eighteen shoulders had undergone
tendon-to-tendon and tendon-to-bone repairs through transosseous tunnels. One
of those shoulders also had had a subscapularis transposition. Of the
remaining five shoulders, three had had a tendon-to-bone repair through
transosseous tunnels only and two had had a tendon-to-tendon repair only.
Number-2 absorbable braided and polyester sutures were used in all cases.
Additional procedures had been performed on the basis of the intraoperative
findings. All patients had had an acromioplasty, eighteen had had a
bursectomy, seven had had a distal clavicular excision, three had had a
synovectomy, two had had biceps tendon débridement, and one had had a
biceps tendon tenodesis.
Rehabilitation
Patients were managed with a shoulder immobilizer, either with the arm at
the side (eighteen shoulders) or with the shoulder slightly abducted (five) on
the basis of surgeon preference. 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. An active-assisted program involving
gentle 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 patient self-report section of the American Shoulder and Elbow Surgeons
(ASES)
questionnaire18 and
the Simple Shoulder Test (SST)
questionnaire19
were used to assess patient function. The result of the procedure was rated
according to the criteria of
Neer24. The result
was considered to be excellent if the patient 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 patient had no pain, slight pain, or
occasionally moderate pain; external rotation of =30°; and 100° to
145° of active abduction. The result was considered to be unsatisfactory
if any of these criteria were not met. Patients who had had additional surgery
were considered to have an unsatisfactory result. Patients were asked to
assess satisfaction with the involved shoulder or shoulders on a scale of 1
(poor) to 10 (excellent) preoperatively, postoperatively, and at the time of
the latest follow-up.
Statistical Analysis
Descriptive statistics are reported as the median and the range (from
minimum to maximum). The estimated change in clinical outcomes was calculated
as the preoperative median value minus the postoperative median value. The
change in clinical outcomes was assessed with use of the Wilcoxon signed-rank
test, both for the overall group of twenty-three shoulders and for the
subgroups of shoulders with partial-thickness tears (nine shoulders) and
full-thickness tears (fourteen shoulders). The association between tear
thickness (partial or full) and the ordered Neer-rating results was assessed
with use of an exact test for ordered categorical data. The level of
significance was set at p < 0.05.
Clinical Results
Overall, the median pain score improved from 5 to 2 points
(Table I), with nineteen of the
twenty-three shoulders having a reduction in pain at the time of the last
follow-up (p < 0.001). Nineteen shoulders had pain at night preoperatively,
and nine had pain at night postoperatively (p < 0.01). Satisfaction with
the involved shoulder (as assessed on a scale of 1 to 10, with 10 being
excellent) improved from a median of 1 preoperatively to a median of 7
postoperatively (p < 0.001); however, five patients had no improvement
(three) or had decreased satisfaction (two). Three of the latter five patients
required revision surgery.
The median change in active elevation was 10° (from 155°
preoperatively to 165° postoperatively), and the median change in external
rotation was 10° (from 50° preoperatively to 60° postoperatively).
Neither change was significant, with the numbers available. Manual strength
was assessed preoperatively and postoperatively on a scale of 1 to
525. The median
forward flexion strength was unchanged. However, external rotation strength
improved somewhat (median change, 0.5; range, -1 to 2) (p = 0.05).
Evaluation of the overall results at the time of the last follow-up
revealed eleven excellent, four satisfactory, and eight unsatisfactory results
according to the system described by
Neer24. The reasons
for the unsatisfactory results included revision surgery (three shoulders),
decreased motion only (three), pain only (one), and decreased motion and pain
(one). The median ASES score was 69 points (range, 12 to 100 points; maximum
possible score, 100 points). The median number of "yes" responses
on the SST questionnaire was nine (range, two to twelve; maximum possible,
twelve).
Results According to Rotator Cuff Status
Patients with both full (p < 0.0001) and partial-thickness tears (p =
0.02) had significant improvement in the pain score
(Table II). Patients with
partial-thickness tears had significant improvement in active elevation
(median change, 18°; p = 0.03) but not in external rotation (median
change, 8°; p = 0.44). Patients with full-thickness tears did not have
significant improvement in either active elevation (p = 0.92) or external
rotation (p = 0.84). Satisfaction with the involved shoulder (or shoulders)
improved significantly in patients with both partial-thickness (p = 0.03) and
full-thickness tears (p = 0.004). Two (22%) of the nine shoulders with a
partial-thickness tear had an unsatisfactory result, compared with six (43%)
of the fourteen shoulders with a full-thickness tear.
Complications and Revisions
Of the twenty-three shoulders that underwent rotator cuff repair, two
required revision to a total shoulder arthroplasty. One of these two shoulders
underwent revision to a total shoulder arthroplasty nine years after the
repair of a partial-thickness tear, and the other shoulder underwent revision
to a total shoulder arthroplasty six years after the repair of a medium
full-thickness tear. One other patient underwent débridement and
drainage of an acromioclavicular cyst, humeral head bone contouring, and
synovectomy four years after the repair of a massive tear. Interestingly, the
rotator cuff was found to be functionally intact in all three patients during
inspection at the time of repeat surgery. No patient had an infection that
required reoperation.
We identified a total of only thirty-one shoulders in patients with
rheumatoid arthritis that underwent repair of the rotator cuff over a
fourteen-year period at our tertiary referral center, of which twenty-three
were followed for more than two years. While this group represents the largest
series reported in the literature, we speculate that the relatively small
number of patients who were identified indicates that most patients with
rheumatoid arthritis and shoulder problems have either associated glenohumeral
changes necessitating arthroplasty procedures or large cuff tears with such
poor tissue quality that repair is deemed not possible.
Patients who had had repair of partial-thickness rotator cuff tears had
improvements with regard to overall pain, active elevation, and satisfaction
with the shoulder at the time of the last follow-up. Patients with
full-thickness tears had improvement with regard to pain and satisfaction with
the shoulder but did not have significant improvement in active elevation.
These findings support those of other authors who have reported on patients
who did not have rheumatoid
arthritis23,26-32.
The Neer, ASES, and SST functional outcome scores were less predictable
when the results for shoulders with partial-thickness tears were compared with
those for shoulders with full-thickness tears. Two of the nine shoulders that
had had repair of a partial-thickness tear had an unsatisfactory result,
compared with six of the fourteen shoulders that had had repair of a
full-thickness tear. While these differences were not significant, a trend for
less shoulder function was evident following the repair of a full-thickness
tear.
While reports have shown that the status of the repaired rotator cuff does
not seem to affect the outcome for most patients, the integrity of the rotator
cuff repair may play a role in the functional
result28,30.
Indeed, three patients in the present study (including one who had had repair
of a partial-thickness tear and two who had had repair of a full-thickness
tear) eventually required revision, with all three patients noted to have
healing of the previously repaired rotator cuff tendons.
The limitations of the present study are related to the inherent problems
of a retrospective review. No comparison group was included for evaluation.
The number of patients in the present study is relatively small when compared
with those in other reports on patients without rheumatoid arthritis. The
selection of patients for the operative procedure was not randomized, which
likely introduced surgeon bias resulting in the preselection of patients with
less severe radiographic changes. This may indicate that the overall
inflammatory phase of rheumatoid arthritis was less severe, accounting for a
more robust rotator cuff and surrounding soft tissues and allowing for an
effective repair. Preoperative radiographs were not available for all
patients, which substantially limited our ability to make any conclusions
regarding outcome relative to the preoperative radiographic assessment.
Furthermore, postoperative radiographic data were not reported because the
variability of follow-up limited any conclusions that could have been made on
the basis of radiographic assessment. Finally, many of these patients had had
other procedures in addition to the rotator cuff repair, the most note-worthy
of which was acromioplasty, which was performed as a matter of routine during
the open rotator cuff repair. Previous authors have cautioned against
sacrificing the coracoacromial ligament, thus compromising the coracoacromial
arch, because of concerns about rheumatoid disease progression, loss of
humeral head containment, and rotator cuff
insufficiency8,33,
and we agree with that approach.
In conclusion, repair of rotator cuff tears in patients with rheumatoid
arthritis can be technically challenging when less-than-ideal tissues are
available for repair. The value of the present study lies in the documentation
of outcomes for an often difficult-to-treat group. While pain relief and
patient satisfaction are achievable, functional gains should not be expected
in patients with full-thickness rotator cuff tears. Patients should be aware
of these expected outcomes if operative repair of a torn rotator cuff is to be
undertaken.
A table describing all patients in detail 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
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