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Don’t miss a step before TSA

By Jennie McKee

Consider less invasive procedures for concurrent arthritis, rotator cuff tears

“Managing patients with glenohumeral joint arthritis and symptoms consistent with rotator cuff pathology poses a clinical dilemma,” Raymond R. Drabicki, MD, told members of the American Orthopaedic Society for Sports Medicine. “Discerning the appropriate treatment for these patients is difficult because their pain may have multiple sources, including rotator cuff tears, shoulder impingement, and glenohumeral arthritis.”

When conservative treatments are not effective in these patients, orthopaedists often perform humeral head resurfacing, hemiarthroplasty, or total shoulder arthroplasty (TSA). But first, advised Dr. Drabicki, they should consider less invasive surgeries that may lead to decreased pain and improved range-of-motion and function.

Fig. 1 Arthroscopic microfracture and rotator cuff repair should be considered as surgical alternatives to more invasive procedures in patients with rotator cuff pathology and concurrent moderate glenohumeral arthritis. Courtesy of Raymond R. Drabicki, MD

“The results of our study suggest that arthroscopic débridement, chondroplasty microfracture, subacromial decompression, and rotator cuff repair, if warranted, consistently improve motion and function in patients with this specific group of pathologies,” he said.

The study
Researchers performed a retrospective review of patients treated by four fellowship-trained shoulder surgeons between 2003 and 2008. The 55 consecutive patients (28 females, 27 males; average age, 64.7 years) had clinical and radiographic findings strongly suggestive of rotator cuff pathology and glenohumeral joint arthritis.

Investigators evaluated pain, range of motion, and progression of osteoarthritis (OA) using radiographic imaging. In addition, magnetic resonance imaging scans were ordered if clinical findings suggested a rotator cuff tear.

“All patients exemplified positive lidocaine impingement tests and continued to have residual pain, limited motion, and crepitus with conservative treatment,” said Dr. Drabicki.

Patients whose symptoms did not improve subsequently underwent arthroscopic chondroplasty and microfracture of the humeral head or glenoid, subacromial decompression, and rotator cuff repair, if warranted (Fig. 1).

Other procedures identified during the review included capsular release, two loose body removals, seven biceps tenodeses, one biceps tenotomy, and two labral débridements. Arthroscopic distal clavicle excision was also performed on 53 patients who had pain at the acromioclavicular articulation in conjunction with arthritis on radiographic evaluation and arthroscopic examination.

“Most patients did have rotator cuff tears, which were repaired during surgery using standard arthroscopic techniques,” said Dr. Drabicki. “Most tears were less than 3 cm long.”

Patients who underwent rotator cuff repair participated in a rehabilitation program that began with immobilization and progressed to exercises to improve range of motion and strength. If cuff repair was not performed, patients had no restrictions and a sling was provided, as needed.

Effects on pain, range of motion, function
The patients filled out a questionnaire at an average follow-up time of 38.1 months (range: 7 to 111 months) to assess subjective measures and patient satisfaction. They also underwent a physical examination that focused mainly on range of motion, pain, and crepitus. Outcomes were evaluated using statistical analyses and post hoc tests.

At final follow-up, 6 patients had radiographic evidence of mild OA, and 49 had evidence of moderate OA. No patients had severe OA.

Researchers found a significant (p<0.038) improvement in forward flexion from 111.9 degrees to 144.0 degrees. Both external and internal rotation also improved.

A comparison of postoperative range of motion in patients who underwent rotator cuff repair and those who did not undergo that procedure did not reveal any significant differences.

“According to the questionnaire results, 80 percent of patients had reduced pain, and 70.9 percent had improved function,” said Dr. Drabicki. “We found that 67.2 percent of patients reported no or mild limitations regarding use of their shoulders, while 27.2 percent had moderate limitations, and 5.6 percent reported severe limitations.

“OA progression was mild to moderate in 13 percent of patients at the time of final follow-up and was moderate to severe in 60.3 percent of patients,” he continued. “Radiographic comparisons demonstrated a progression from moderate to severe arthritis in only 16.3 percent of patients.”

Researchers found that 61.8 percent of patients had rare or minimal issues with pain. Only 18.3 percent of patients reported severe pain.

“About three out of four patients said they would have arthroscopic surgery again because it was so beneficial,” noted Dr. Drabicki.

An ‘effective delay’
“To my knowledge,” said Dr. Drabicki, “this is the first study that examined the outcomes of a unique subset of patients treated with arthroscopic techniques for shoulder impingement, mild or moderate glenohumeral arthritis, and rotator cuff pathology.”

He noted that arthroscopic débridement, chondroplasty, microfracture, subacromial decompression, and rotator cuff repair, if warranted, were effective in providing pain relief as well as improving function and range of motion. He emphasized that these results apply to a particular patient population.

“Remember, this is a specific subset of patients—those with mild or moderate glenohumeral arthritis and rotator cuff pathology,” he said. “We think that arthroscopic surgery is a viable option for delaying more invasive procedures in these patients.”

Dr. Drabicki’s coauthors for “Outcomes following arthroscopic glenohumeral joint microfracture for glenohumeral joint arthritis in patients with concurrent rotator cuff pathology” are Larry D. Field, MD; Felix H. Savoie III, MD; J. Randall Ramsey, MD; and E. Rhett Hobgood, MD.

The authors report the following disclosures: Dr. Drabicki—none; Dr. Field—Smith & Nephew, Mitek, and Arthrex, Inc.; Dr. Savoie—Cayenne Medical, Medicine Lodge, Arthrocare, Mitek, and Smith & Nephew; Dr. Ramsey—Synthes, Arthrex, Inc., DePuy (A Johnson & Johnson Company), Mitek, Smith & Nephew, and Zimmer; Dr. Hobgood—Smith & Nephew, Arthrex, Inc., Mitek, and Smith & Nephew.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

AAOS Now
October 2009 Issue
http://www.aaos.org/news/aaosnow/oct09/clinical1.asp