POSTSURGICAL STIFFNESS IN ROTATOR CUFF REPAIR P.Avanzi, M. Collarile, R. Giovarruscio, C. Zorzi P. Avanzi M.D. Sacro Cuore Don Calabria Hospital Negrar-Italy
STIFFNESS IN SHOULDER ARTHROSCOPY. restricted motion and persistent pain with activity after shoulder arthroscopy.
STIFFNESS IN SHOULDER ARTHROSCOPY. restricted motion and persistent pain with activity after shoulder arthroscopy. BUT when is it a true stiffness?
COMPLICATIONS AFTER ARTHROSCOPIC ROTATOR CUFF REPAIR (from 4.8% to 10.6%) Stiffness (from 2.7% to 15%) Upper extremity DVT (from1% to 4%) Infection (from 0.04% to 3.4%.) direct nerve injury brachial plexus stretch neurapraxia reflex sympathetic dystrophy (RSD) Failure of repair Instrument breakage Hardware failure Fluid extravasation Deep vein thrombosis (DVT) Complications related to anesthesia Complications After Arthroscopic Rotator Cuff Repair Kenneth J. Brislin, M.D., Larry D. Field, M.D., and Felix H. Savoie III, M.D. Arthroscopy, vol 23, No 2, 2007: pp 124-128
STIFFNESS IS THE MOST COMMON COMPLICATION Failure of surgical treatment of rotator cuff pathology is usually attributed to disruption of the repair itself BUT Patient dissatisfaction, may be related to postoperative adhesions and capsular contracture
PREDISPOSING FACTORS FOR THE DEVELOPMENT OF STIFF SHOULDER Diabetes (1.9%) Hypothyroidism (5.6%) Calcific tendonitis (16.7%) Adhesive capsulitis (15.0%) Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair David P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D. Arthroscopy vol 25, No 8, 2009: pp 880-890
PREDISPOSING FACTORS FOR THE DEVELOPMENT OF STIFF SHOULDER Smaller tears and fewer tendon lead to postoperative adhesions and clinical restriction of motion A significantly increased prevalence was noted in PASTA lesion Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair David P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D. Arthroscopy vol 25, No 8, 2009: pp 880-890
PREDISPOSING FACTORS FOR THE DEVELOPMENT OF STIFF SHOULDER Concomitant subacromial decompression, distal clavicle excision, biceps tenodesis, and interval slide technique of contracture release did not significantly impact the incidence of postoperative stiffness Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair David P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D. Arthroscopy vol 25, No 8, 2009: pp 880-890
PREDISPOSING FACTORS FOR THE DEVELOPMENT OF STIFF SHOULDER The combination of a labral repair with rotator cuff repair increased the prevalence of postoperative stiffness. Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair David P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D. Arthroscopy vol 25, No 8, 2009: pp 880-890
PREDISPOSING FACTORS RELATED TO THE OPERATIVE REPAIR ITSELF Biodegradable implants (sporadic cases of capsular synovitis, pain, and stiffness) No significant association was observed between the volume of biodegradable implant and incidence of stiffness 1. KellyJDII.Disintegration of an absorbable rotator cuff anchor six weeks after implantation. Arthroscopy 2005;21:495-497. 2. Barber FA. Biodegradable shoulder anchors have unique modes of failure. Arthroscopy 2007;23:316-320.
PREDISPOSING FACTORS RELATED TO THE OPERATIVE REPAIR ITSELF NO SIGNIFICANT ASSOCIATION BETWEEN DOUBLE ROW REPAIR AND STIFFNESS. THE INCIDENCE OF POSTOPERATIVE STIFFNESS IS 4.8% Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair David P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D. Arthroscopy vol 25, No 8, 2009: pp 880-890
PREDISPOSING FACTORS RELATED TO THE OPERATIVE REPAIR ITSELF Revision rotator cuff repairs (particularly open technique) have been associated with lower success and higher complication rates. Encouraging results following an arthroscopic revision rotator cuff repair. 1. Djurasovic M, Marra G, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am 2001;83:1849-1855. 2. Lo IK, Burkhart SS. Arthroscopic revision of failed rotator cuff repairs: Technique and results. Arthroscopy 2004;20:250-267.
POSTOPERATIVE REHABILITATION PROGRAM Is a critical aspect in the surgical treatment of rotator cuff injury at least 3 months are required for Sharpey fibers to develop at the tendon bone reattachment site. Healing of torn rotator cuff tendon Sonnabend D. et al. 10th International Congress of Shoulder and Elbow Sur- gery; Costa do Sauipe, Brazil; September 18, 2007
POSTOPERATIVE REHABILITATION PROGRAM Immobilization after rotator cuff repair promotes superior mechanical properties in the healing tissues 1. Thomopoulos S, Williams GR, Soslowsky LJ. Tendon to bone healing: Differences in biomechanical, structural, and compo- sitional properties due to a range of activity levels. J Biomech Eng 2003;125:106-113.19. 2. Gimbel JA, VanKleunen JP, Williams GR, Thomopoulos S, Soslowsky LJ. Long durations of immobilization in the rat result in enhanced mechanical properties of the healing supraspinatus insertion site. J Biomech Eng 2007;129:400-404.
POSTOPERATIVE REHABILITATION PROGRAM EARLY POSTOPERATIVE MOTION PROTOCOL (4.3%) rate of postoperative STIFFNESS CONSERVATIVE REHABILITATION PROTOCOL (4.9%) 1. Tauro J. Stiffness and rotator cuff tears: Incidence, arthro- scopic findings, and treatment results. Arthroscopy 2006;22:581-586. 2. Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff RepairDavid P. Huberty, M.D., John D. Schoolfield, M.S., Paul C. Brady, M.D., Antonio P. Vadala, M.D., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D.
OUR EXPERIENCE FROM JANUARY 2010 TO DECEMBER 2010 234 ARTHROSCOPIC ROTATOR CUFF REPAIR 3 STIFF SHOULDERS
OUR EXPERIENCE 1. Man 49 year old-family Doctor 1. Woman 54 year old-workers Compensation insurance 1. Woman 58 year old-saleswoman
OUR EXPERIENCE Medium lesions Medialized Single row repair Simple stitch technique Gentle postoperative passive of motion protocol
OUR EXPERIENCE Ultrasound or MRI at 4 months after surgery has shown: Complete tendon healing
OUR EXPERIENCE AND STIFFNESS resolved in 5 months in 2 pts BUT One pts (the doctor, of course) is still stiff and maybe he ll need an arthroscopic release the next month
OUR EXPERIENCE
CONCLUSIONS The rate of postoperative stiffness, after arthroscopic rotator cuff repairs goes from 2.7% to 15.1% Stiffness is the most common complication Arthroscopic release during the second look showed complete healing of the rotator cuff (95.8%) and is effective for recovering a full ROM
CONCLUSIONS RISK FACTORS: calcific tendinitis adhesive capsulitis Single tendon cuff repair PASTA repair Being <50 years of age Workers Compensation Insurance.
CONCLUSIONS RISK FACTORS: calcific tendinitis adhesive capsulitis Single tendon cuff repair PASTA repair Being <50 years of age Workers Compensation Insurance. and maybe
CONCLUSIONS IN OUR EXPERIENCE Postoperative stiffness after rotator cuff repair needs time to recover After 5 months, when the cuff is healed, we consider the opportunity of an arthroscopic release WE HAVE TO AVOID AGGRESSIVE PASSIVE MOBILIZATION OR EARLY ACTIVE REHABILITATION PROTOCOL IF PATIENT IS STILL PAINFULL TAKE CARE TO YOUR THERAPIST
THANK YOU FOR YOUR KIND ATTENTION P. Avanzi M.D. Sacro Cuore Don Calabria Hospital Negrar-Italy