Update rotator cuff vanuit Europese schouder en elleboog congres

Tijdens het Europese schouder en elleboog congres in Lyon werd volop gesproken over de rotator cuff ruptuur (gescheurde schouderpees). Hieronder worden de diverse interessante voordrachten besproken met verwijzing naar de abstracts van de presentaties.

Allereerst werd duidelijk (voor zover dit niet al zo was) dat de scheuren in de pezen rondom de schouder een uiting zijn van de normale veroudering van de mens. Eerder in deze weblog werden reeds de genetische veranderingen beschreven die men kan vinden in de pezen. Of deze een gevolg zijn van de scheur of dat de scheur een gevolg is van de genetische veranderingen, bleef ook deze keer in het midden (Carr et al).

Een Noorse studie (Moosmayer et al) beschreef dat scheuren welke nog niet hebben geleid tot symptomen (asymptomatisch) in een groot deel  later groter worden en wel tot symptomen leiden, terwijl dat dan al heeft geleid tot vervetten van de spier die deze pees moet bewegen, wat een slechtere prognose geeft als er dan toch geopereerd moet worden.

Wederom uit Oxford werd een studie gepresenteerd (Oag et al) die het gebrek aan correlatie aantoonde tussen de grootte van de scheur, de pijn die de patient ervaart en het verlies van schouderfunctie. De abnormale maar niet gescheurde pezen deden meer pijn dan de kleinere scheur, terwijl ze even veel pijn deden als de grote scheur. Desgevraagd werd dit verklaard door de auteurs dat mogelijk het slijten van de pees pijnlijk is en dat pas meer pijn ontstaat als er een verlies van balans ontstaat tussen de schouderpezen door een grotere scheur (de ongebalanceerde cuff ruptuur). Ook werd vermeld dat 50% van de mensen zonder symptomen bleef. 

Vervolgens waren er vele voordrachten over hoe nu het best de scheur te behandelen. Ondanks de grotere kosten die het hechten van de scheur op arthroscopische wijze (middels een kijkoperatie) over het algemeen met zich meebrengt (zie eerder op deze weblog), was er geen presentatie over de open wijze van opereren. Wel bleek dat de recidiefpercentages dermate hoog te liggen dat de vraag vanuit het publiek kwam of deze degeneratieve scheuren uberhaupt wel hechtbaar zijn en of de operatie dan wel gedaan moet worden. Ondanks het hoge re-ruptuur gehalte was er toch vaak een pijnvermindering bij de patient, welke zelfs langdurig aanhield (Galatz et al). Dit leidt logischerwijs tot de vraag of het nodig is om de pees weer waterdicht op het bot van de bovenarm te hechten of dat het genoeg is een evenwicht te creeren tussen de diverse pezen rondom de schouder door het voorste deel van de pees terug te hechten (zgn anterior band reconstruction).

Met betrekking tot de revalidatie na een hechting van de rotator cuff pezen werd gefocussed op het versneld dan wel vertraagd revalideren en de gevolgen die dit zou kunnen hebben op het uiteindelijke succes. Zo zou een vertraagd schema mogelijk leiden tot een betere hechting maar meer stijfheid en een versneld schema tot meer rerupturen. Van den Bogaert et al bewezen dat deze aannames niet waar zijn. Tevens lieten en Donaldson et al zien dat de verbeterde operatietechnieken met stevigere hechtingen niet hebben geleid tot een versnelling van de revalidatieschema's.

Overigens dient nog maar bewezen te worden dat de vernieuwde operatietechnieken inderdaad verbeterde technieken zijn: het percentage opnieuw ontstaan van een scheur in de pezen van de schouder (recidieven) is namelijk door de jaren niet gedaald! Het lijkt er dus inderdaad op dat de hechting van de schouderpees geen verjongingsoperatie is: de pees blijft oud en versleten.

Stimulering van de biologie zou mogelijk een rol kunnen spelen in het omhoog brengen van dit succespercentage. Het gebruik van PRP (bloedplaatjes met daarin groeifactoren) werd ook op dit congres gedetailleerd besproken, maar de conclusie van de diverse studies van hoge kwaliteit was eigenlijk dat er mogelijk een positief effect was in het begin van de revalidatieperiode (Randelli et al), maar op langere termijn kon geen effect worden aangetoond op pijn, functie en kwaliteit van de hechting (Randelli et al, Zumstein et al, Martinez et al). Nuancerend dient wel opgemerkt te worden dat het hier gaat om chronische rupturen en dat het stimuleren van de aangroei van pees op het bot afhangt van de resterende levensvatbaarheid van de peesstomp. Zoals de beroemde peesonderzoekers Carr en Galatz in hun discussie verwoordden: "a tendon is a dead rope, it has no will of its own, it is difficult to stimulate: actually it is boring material."

 

Genetic Profiles Of Changes Underlying Different Sized Human Rotator Cuff Tendon Tears
A. Carr (Oxford - UNITED KINGDOM)

 Purpose

 There is increasing evidence for a multi-stage model of rotator cuff (RC) tendon tears, wherein healing is affected by tear size. This study aimed to gain greater insight into size related tear pathogenesis by analyzing gene expression profiles from normal, small and massive RC tears.

Material and Methods

The genetic profiles of 28 human RC tendons were analyzed using microarrays representing the entire genome. 11 massive and 5 small torn RC tendon specimens were obtained from tear edges intraoperatively, and compared to 12 age matched normal controls. Semiquantitative real-time polymerase chain reaction (RT-PCR) and immunohistochemistry were performed for validation.

Results

Key gene changes included upregulation of aggrecan in massive tendon tears (p < 0.05 and > 2-fold change). Matrix metallopeptidases (MMP) -3,-10,-12,-13,-15, -21,-25 and a disintegrin and metallopeptidase (ADAMs) -12,-15,-22 were significantly upregulated in tears. Aggrecan was upregulated in massive tendon tears but not in small tears. Amyloid was downregulated in both tear groups. Small tears also involved upregulation of BMP-5. As part of the chemotaxis pathway, IL-3,-10,-13,-15,-18 were upregulated in tears, whereas downregulation of IL-1,-8,-11,-27, was seen.

Discussion

The gene profiles of normal, small and massive RC tear groups suggested they are biologically distinct groups. This study has identified a number of novel pathways which suggest that RC tear pathogenesis is contributed to by ECM remodeling genes, chemotaxis genes, aggrecan and amyloid. These genes may potentially have a role as biomarkers of failure. Modulating these ECM pathways may be a useful treatment strategy for improving clinical outcomes.

Natural history of asymptomatic rotator cuff tears - a longitudinal study of clinical, sonographic and MRI findings
S Moosmayer , R Tariq, M Stiris, HJ Smith (Bærum - NORWAY, Oslo - NORWAY)

Purpose

Fifty asymptomatic rotator cuff tears were followed over 3 years. We wanted to find out whether these tears remain asymptomatic, and whether development of symptoms would be related to a progression of tear size, muscle atrophy or fatty degeneration.

Material and Methods
Fifty individuals with a full-thickness rotator cuff tear on sonography and MRI in a shoulder with no present or earlier pain, an ASES score > 90 points and normal examination findings at baseline were included. After 3 years clinical, sonographic and MRI re-examination was performed.

Results
Eighteen (36 %) of 50 initially asymptomatic tears developed symptoms during follow-up. Decrease on the ASES scale for newly symptomatic tears was 30 points compared to 0 points for still asymptomatic tears (p < 0.0005). Increasing tear size and muscle atrophy were significantly associated to the development of symptoms but only in subjects in whom the study shoulder was combined with a pain free contralateral shoulder. In this subgroup (n = 28), tear size progression at follow-up was 0.6 mm in still asymptomatic subjects compared to 6.4 mm in newly symptomatic subjects (p = 0.001). Of 10 newly symptomatic subjects 5 had developed serious supraspinatus atrophy during follow-up compared to only 1 of 14 still asymptomatic subjects. (OR : 13.0 ; p = 0.04).

Discussion

Our results suggest that asymptomatic rotator cuff tears are at risk to become clinically relevant. Once detected, they should be followed clinically and by imaging to allow early therapeutic intervention. Progression of tear size and muscle atrophy was positively associated to the development of symptoms. This may indicate a causal relationship. The condition of the contralateral shoulder influenced the study results.

Relationship of rotator cuff tears, shoulder pain and functional loss in a normal population
H Oag , A Nichols, M Daines, A Kiran, N Arden, A Carr (Oxford - UNITED KINGDOM)

Purpose
This study describes the prevalence of pain, functional loss and rotator cuff tears (RCTs) in a general population cohort.

Material and Methods
The Chingford cohort is a 19-year old longitudinal population study comprising 1003 women aged between 44 and 67 at baseline. To date 183 consecutive subjects (366) shoulders have been interviewed about their shoulders. Myometric strength assessment and high-definition ultrasound examination (US) have been performed on all shoulders. Additionally pain thresholds and perceptions of pain have been tested using quantitative sensory testing (QST) and a number of validated questionnaires, including the illness attitudes scale and the pain detect score.

Results
The population prevalence of at least one full-thickness RCT was 24%, with 19% being unilateral and 5% bilateral.The pain and functional loss was significantly greater in the abnormal tendon-bone attachment group, and the full-thickness RCT (greater than 2 cm) group, compared to those with no abnormality on high-definition ultrasound examination.

Discussion

In a unique normal population-cohort study significant pain and/or loss of function was found in 48% of shoulders with high-definition US abnormalities of the tendon. High-definition US has allowed us to identify a group of tendons with an abnormality at the tendon bone interface. The pain and functional loss increases at this stage and then only further increases once a tear is greater than 2 cm. However over 50% remain asymptomatic.

Long Term Outcome After Failure of Healing after Rotator Cuff Repair- Minimum 10 year Follow Up
L Galatz , ES Paxton, S Teefey, N Dahiya, J Keener, K Yamaguchi (St. Lous, Mo - UNITED STATES, St. Louis, Mo - UNITED STATES)

Purpose

Little information exists regarding the long term outcome of shoulders after structural failure of rotator cuff repair. Early clinical improvement at a 2 year follow up was previously reported in 18 patients following arthroscopic repair of massive rotator cuff tears despite a 94% failure of healing. The purpose of this study is to report the 10 year follow up of these patients with known early structural failures of rotator cuff repairs.

Material and Methods

15 of 18 (83%) of patients were available for follow up at a minimum of 10 years. The patients were evaluated clinically using the American Shoulder and Elbow Score (ASES), Simple Shoulder Test (SST), Visual Analogue Scale (VAS) pain score, and Constant Score. Additionally, patients were assessed radiographically and ultrasonographically.

Results

The average age was 75 years, 10 men, 5 women. The ASES average score was 81.2 (range, 50-95) and the VAS average was 2.0 (range, 1-4), both unchanged from 2 years. The average SST was 9.4 (range, 6-12) and the average age-adjusted Constant Score was 75.3 (range, 58.7-97.5). Two patients underwent another surgical procedure- 1 arthroplasty, 1 revision repair. Of the remaining 13, 85% had radiographic progression of joint degeneration, 3 Hamada grade 2, 5 Hamada grade 3, and 3 Hamada grade 4 (2-4a and 1-4b). Ultrasound confirmed persistence of all tears seen at 2 years.

Conclusion

Early clinical improvements and pain relief after cuff repair of massive tears persist at long term follow up of 10 years despite early structural failure of repair. Shoulders had a high rate of progression of radiographic degeneration, yet only 2 underwent subsequent surgical procedures. These results demonstrate that healing is not critical for long term satisfactory results in older patients.

Standard or decelerated rehabilitation after arthroscopic rotator cuff repair: a randomized, prospective study
G van Den Bogaert , S Defoort, A Cools, E Witvrouw, O Verborgt (Herentals - BELGIUM, Brugge - BELGIUM, Gent - BELGIUM)

Purpose

To compare the effect on functional and structural outcome of standard and decelerated rehabilitation programs after arthroscopic rotator cuff repair.

Material and Methods

40 patients with full-thickness rotator cuff tears were randomly assigned to a standard or decelerated rehabilitation protocol after arthroscopic repair. Standard protocol included immediate physiotherapy with passive mobilisations, while the decelerated group did not get formal therapy the first 6 weeks. All patients were clinically assessed pre-operatively and post-operatively at 6 weeks, 3 months and 1 year using Constant score, VAS and SST. At 1 year postoperatively, the integrity of the repair was assessed with ultrasound examination.

Results

Clinically, there was no significant difference between standard and decelerated rehabilitation groups at 6 weeks, 3 months or 1 year post-operatively in terms of Constant score, SST and VAS score. Only pain (p = 0,10) and VAS score (p = 0,05) tended to be better at 6 weeks after decelerated rehabilitation compared to standard rehabilitation. On ultrasound examination there was no difference in structural integrity between the 2 groups.

Discussion

Concerns for recalcitrant stiffness and poorer functional outcomes have led to some to favor early postoperative therapy. We found that early restriction of motion did not lead to poorer functional outcome at 6 weeks, 3 months or 1 year postoperatively or difference in structural integrity on ultrasound after 1 year.

Systematic review of postoperative therapy protocols used in studies assessing arthroscopic rotator cuff repair: has there been a trend towards accelerated rehabilitation?
T Donaldson , L Funk, P Wright (Wigan - UNITED KINGDOM)

Purpose

Whilst there have been many developments in the arthroscopic techniques employed to treat tears of the rotator cuff, little has been done to determine whether postoperative rehabilitation has undergone a similar evolution.

Material and Methods

A literature search was performed using the Pubmed bibliographic database for studies of arthroscopic rotator cuff repair between 1996 and 2011. Studies were divided into two groups ; those published between 1996 and 2008 and between 2009 and 2011. Details of the rehabilitation protocol were recorded including duration and type of sling, initiation of passive range of movement, initiation of active range of movement and initiation of strengthening exercises.

Results

55 papers were included. The studies included varied widely in all aspects of the therapy programme used. Those studies published during the later time period there was a trend towards a longer period of immobilisation in a sling and the delay of strengthening exercises until the twelfth postoperative period or beyond. The initiation of passive and active range of movement exercises was similar in both groups.

Conclusion

Despite ongoing improvements in surgical technique to provide increasingly secure fixation of the rotator cuff there has not been a trend towards earlier mobilisation in the rehabilitation protocols published in the orthopaedic literature.

Platelet Rich Plasma (PRP) in Arthroscopic Rotator Cuff Repair. A Prospective RCT Study, 2 years Follow-up
P Randelli , P Arrigoni, A Aliprandi, V Ragone, P Cabitza (Milano - ITALY)

Purpose

Hypothesis : Local application of autologous PRP improves tendon healing in patients undergone arthroscopic rotator cuff repair. Study design : Prospective, randomized, controlled, double blind study ; Level of evidence, 1. Considering an alpha level of 5%, a power of 80%, 22 patients for group are needed.

Material and Methods

Fifty-three patients who undergone a shoulder arthroscopy for the repair of complete rotator cuff tear, were randomly divided into two groups (block randomization procedure) : a treatment group (N = 26) who received an intra-operative application of PRP in combination with an autologous thrombin component and a control group (N = 27). Patients were evaluated with Validated outcome score. An MRI was performed in all case at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol.

Results

The two groups were omogeneous. Pain score in treatment group was lower than control group at 3, 7, 14 and 30 days after surgery (p< 0,05). Strenght in External Rotation (dynamometer), SST, UCLA and Constant scores in treatment group were significantly higher than control group at 3 months after surgery (SER : 3 ±1,6kg versus 2,1±1,3kg ; SST : 8,9±2,2 versus 7,1±2,7 ; UCLA : 26,9±3 versus 24,2±4,9 ; Constant : 65±9 vs 57,8±11 ; p< 0,05). There was no difference between the two groups after 6, 12 and 24 months.The MRI follow-up showed no significant difference in the healing rate. In the subgroup of stage 1 and 2 tears, with less retraction and more prone to the effect of a biological therapy, SER in PRP group were significant higher at 3, 6, 12 and 24 months post-op. (p< 0,05).

Conclusion

The results of our study showed autologous PRP reduced pain in the first months post-op and promoted quicker healing. Long-term results of subgroups of stage 1 and 2 tears suggest PRP effectively affected cuff rotator healing.

Use of Platelet- and Leucocyte-Rich Fibrin (L-PRF) improves early vascularization but does not affect late rotator cuff tendon healing: A prospective randomized controlled study
MA Zumstein , AP Rumian, K O'shea, CE Thélu, V Lesbats, P Boileau (Nice - FRANCE)

Purpose

Leukocyte platelet-rich plasmas (L-PRP's) and pure platelet-rich fibrins (P-PRF's) didn't improve the anatomical healing rate up to now. There is a potential advantage of leukocyte platelet-rich fibrin (L-PRF) that has a solid matrix and can store and deliver growth factors up to 28 days. We hypothesized that arthroscopic rotator cuff repair with L-PRF results in better vascularization of the bone tendon unit and in a higher watertight healing rate and better tendon quality at 12 months follow up than without L-PRF.

Material and Methods

Thirty-five prospective randomized patients underwent arthroscopic rotator cuff repair for the treatment of chronic posterosuperior rotator cuff tears. In seventeen patients, leukocyte platelet-rich fibrin (L-PRF) was added in between the tendon and the bone. All patients were prospectively followed clinically and radiographically. Vascularization was measured with Power Doppler ultrasonography at 6 weeks and 3 months, anatomic watertight healing, tendon thickness and tendon quality was measured using MR arthrography.

Results

A double row technique was used in all patients. The mean SSV, SST and adjusted Constant increased significantly in both groups from pre- to postoperatively, but with no difference between the groups. Although early vascualrization of the operated tendon-bone insertions was significantly higher in the L-PRF group than in the control group (9.8 vs 5.8, p = 0.015 at 6 weeks ; 7.2 vs 4.6 at 3 months), there was no difference in anatomical healing rate (13/ 17 in the L-PRF ; 14/18 in the control group). Tendon thickness (5.3 mm vs. 6.0 mm) and tendon quality (Sugaya III) were not different in either group at 12 months.

Conclusion

Arthroscopic rotator cuff repair with application of leukocyte platelet-rich fibrin (L-PRF) yields higher early vascularization response without a beneficial effect in terms of anatomical healing rate, tendon thickness, tendon quality, and the functional results of the shoulder.

Local application of autologous platelet rich plasma with fibrin at the repair site of completely reconstructed massive rotator cuff tears: A prospective randomized clinical trial
JM Martinez , JM Sanchez-Marquez, R Barco, S Antuña (Madrid - SPAIN)

Purpose

The objective of this study was to evaluate the influence of Platelet Rich Plasma with Fibrin (PRP-F) on the functional outcome and integrity of the repair in patients with massive rotator cuff tears treated arthroscopically.

Material and Methods

A prospective, blinded, randomized clinical trial was performed on 28 patient (22 females, 6 males) with a mean age of 65 years (range, 53 to 77) undergoing complete arthroscopic repair of a massive rotator cuff tear. Patients with partial repairs were excluded. In 14 patients, 6 ccs of PRP-F (vivostat®) were locally applied to the repair site. In 14 patients no addition of PRP-F was performed. All patients were clinically and radiographically examined at a minimum of 1 year after the operation. Functional outcome was evaluated with the Constant score. The integrity of the repair was assessed with an arthro-MRI.

Results

There were no reported complications. Globally, the constant score improved from 45 pts (range, 25 to 65) to 64 pts (range, 20 to 79) (P<0.001). 26 patients were satisfied with their outcome. There was not any statistically significant difference in the preoperative (46 vs 43 pts ; P = 0.37) or postoperative constant score (61 vs 68 ; p = 0.125) between the control group and the PRP-F group. On the arthro-MRI, 19 of the 28 patients (68%) had a large full-thickness re-tear : 10 shoulders in the PRP-F group and 9 shoulders in the control group, with no differences between both groups.

Conclusion

Local application of PRP-F to the repair site of fully reconstructed massive rotator cuff tears does not improve either the clinical outcome or the healing rate of the tendons.