Early mobilisation following rotator cuff repair

Completed Research

Early mobilisation following rotator cuff repair

Background    

Patients diagnosed with a tear of the supraspinatus tendon were invited to participate in a study to evaluate the effectiveness of rehabilitation programs following rotator cuff repair.

Traditionally, patients have been advised by surgeons to follow a program which includes wearing a sling for 4 to 6 weeks which is known as “immobilization” or “immobilizing” the arm. This timeframe has been chosen based on experience rather than on scientific evidence.

Many patients report that spending 4 to 6 weeks in a sling is one of the most challenging parts of rehabilitation. There are also concerns that immobilizing the arm for that long increases the risk of stiffness, discomfort and time it takes patients to return to normal activities of daily living.

Research following surgeries to other joints such as the ankle suggests that decreasing immobilization time does not increase the risk of complications however there have been few such studies on the rotator cuff.

Objectives

The primary objective of the Study was to demonstrate that the clinical outcome of the healing rate of the tendons is the same between the 2 rehabilitation protocols i.e. the traditional protocol with 6 weeks immobilization and our early mobilization protocol with 2 weeks immobilization.

Integrity of repair on MRI at 6 months was the primary means of measuring outcome. Secondary measurement was via standardized assessments of the shoulder and general quality-of-life assessments at baseline and 6 months.

Design

This was a pilot prospective cohort study that enrolled 20 patients over a one year period.

Study Procedure

Patients had their shoulders immobilized in a standard abduction immobilization sling for 2 weeks. No mobilization and no physiotherapy of the shoulder was authorized during this time. Self-directed mobilization of the elbow, wrist, and hand was performed. The sling was removed at the beginning of the third week post-surgery and gentle activities of daily living (e.g. reading, eating, showering, typing etc.) permitted. The patients were specifically advised against lifting more than 1kg, attempted use of the arm at shoulder height or above, pushing, reaching or climbing. At week 6 post-surgery, a passive and active assisted range of motion protocol was introduced and supervised by a physiotherapist. A strengthening program was introduced at 3 months following surgery. Return to full unrestricted activities was anticipated at 6 months. Standard, functional parameters, patient outcome measures (Constant-Murley Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Veterans Rand 36 General Health Survey) and MRI scans were assessed pre-operatively, and post-operatively at 6 months. MRI scans were analysed by a single radiologist for the whole Study group.

Inclusion Criteria

Patient considerations:

  • Age ≤ 70 years old
  • Non smoker
  • No history of inflammatory disease
  • Patients who understand the conditions of the Study and are willing to participate for the length of the prescribed term of follow-up and rehabilitation
  • Patients who are capable of, and have given informed consent to their participation in the Study.

Anatomical considerations:

  • Biceps: Any
  • Isolated tear of the rotator cuff involving the supraspinatus tendon only
  • No marked tendinous retraction
  • Fatty infiltration no more than stage 2 (Goutallier) for any rotator cuff muscle
  • Normal infraspinatus and subscapularis
  • Degenerative or traumatic tear
  • Acromio-Clavicular joint: Any
  • No gleno humeral Osteoarthritis

Surgical procedures:

  • Repair using modern transosseous equivalent double row suture anchor technique
  • Standard immobilization sling
  • Systematic acromioplasty under arthroscopy
  • Full arthroscopic procedure or mini open procedure accepted

Imaging:

  • Post-operative imaging study using the same MRI machine
  • Review of imaging by trained musculoskeletal radiologist

Exclusion Criteria

Patient considerations:

  • Patient aged >70 yrs
  • Smoker or who have been heavy smokers within the last 6 months (i.e. more than 20 cigarettes per day)
  • Diabetic disease
  • Systemic inflammatory disease
  • Genetic collagen disease
  • Previous history of shoulder surgery for any reason
  • Recent treatment with oral steroids within the last 2 months or injectable within the last 4 weeks
  • Patients with an inability to complete post-surgery physical therapy or return for follow-up visits
  • Severely overweight patient, BMI > 35

Anatomical considerations:

  • Muscle fatty infiltration staged more than 2
  • Coronal retraction more than stage 2 (top of the humeral head)
  • Preoperative stiffness in forward elevation (<150°)
  • Shoulder instability or osteoarthritis

Surgical considerations:

  • Another surgical procedure than the ones described


Ethics and Governance

Approved by North Shore Private Hospital Human Research Ethics Committee to be undertaken at North Shore Private Hospital. HREC reference NSPHEC 2013-002.

Results

Baseline Characteristics

Of the 20 patients who were enrolled in the study all 20 completed follow-up including evaluation and MRI. Eight patients were female. The patients’ average age at the time of surgery was 50.9 ± 7.7 year (range 37-67 years). Pre-operative forward elevation was 129±39 degrees (range 60-180 degrees). All patients underwent a subacromial decompression at the time of surgery. Seventeen patients had a biceps tenodesis performed concurrently and two patients had a distal clavicle excision performed concurrently. The length of follow up averaged 6.2 ± 0.5 months (range 6-8 months).

Functional Outcomes

As expected following rotator cuff repair, patient-rated outcome measures improved (table I). ASES scores increased an average of 32.2 points (p<.001) and ranged from an 8 to 73 point increase. Normalized constant scores increased on average 31.5 points (p<.001) and ranged from 3 to 68 point increase. VR 36 physical scores improved on average 11.8 points (p<.001) and ranged from 1.3 to 25.7 point increase. There was no difference in VR 36 mental scores (p =.60).

Physical exam findings improved following rotator cuff repair. Forward elevation improved from 129±39 degrees to 167±23 degrees (p<.001). Abduction did not demonstrate significant change (p=0.24). Post-operative abduction strength measured by dynamometer was 5.4±2.7 kg.

Repair Integrity

Post-operative MRI results demonstrated clinical healing (Sugaya score of 1-3) in 19 patients and a failed repair in one patient with a Sugaya score of 5 (see table II). This represents a healing rate of 95%. No patients had development or progression fatty degeneration of any of the rotator cuff muscles on follow-up MRI. Figure 1 demonstrates an intact rotator cuff repair as seen on post-operative MRI.

With these results, we have concluded that early sling discontinuation following double row rotator cuff repair may be an acceptable option for small non-retracted rotator cuff tears in properly selected patients with a high likelihood of healing.

References

  • Biomechanical and magnetic resonance imaging evaluation of a single- and double-row rotator cuff repair in an in vivo sheep model. Baums MH, Spahn G, Buchhorn GH, Schultz W, Hofmann L, Klinger HM. 2012 Jun;28(6):769-77. 8.
  • Initial load-to-failure and failure analysis in single- and double-row repair techniques for rotator cuff repair. Baums MH, Buchhorn GH, Gilbert F, Spahn G, Schultz W, Klinger HM. Arch Orthop Trauma Surg. 2010 Sep;130(9):1193-9.
  • Comparative evaluation of the tendon-bone interface contact pressure in different single- versus double-row suture anchor repair techniques. Baums MH, Spahn G, Steckel H, Fischer A, Schultz W, Klinger HM. Knee Surg Sports Traumatol Arthrosc. 2009 Dec;17(12):1466-72
  • Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. Kim DH, Elattrache NS, Tibone JE, Jun BJ, DeLaMora SN, Kvitne RS, Lee TQ. Am J Sports Med. 2006 Mar;34(3):407-14.
  • Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared with single-row fixation. Ma CB, Comerford L, Wilson J, Puttlitz CM. J Bone Joint Surg Am. 2006 Feb;88(2):403-10.
  • The effect of double-row fixation on initial repair strength in rotator cuff repair: a biomechanical study. Meier SW, Meier JD. Arthroscopy. 2006 Nov;22(11):1168-73.
  • Comparison between single-row and double-row rotator cuff repair: a biomechanical study. Milano G, Grasso A, Zarelli D, Deriu L, Cillo M, Fabbriciani C. Knee Surg Sports Traumatol Arthrosc. 2008 Jan;16(1):75-80.
  • Biomechanical comparison of 4 double-row suture-bridging rotator cuff repair techniques using different medial-row configurations. Pauly S, Kieser B, Schill A, Gerhardt C, Scheibel M. Arthroscopy. 2010 Oct;26(10):1281-8. doi: 10.1016/j.arthro.2010.02.013.
  • A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. Smith CD, Alexander S, Hill AM, Huijsmans PE, Bull AM, Amis AA, De Beer JF, Wallace AL. J Bone Joint Surg Am. 2006 Nov;88(11):2425-31.
  • Early postoperative outcomes between arthroscopic and mini-open repair for rotator cuff tears. Cho CH, Song KS, Jung GH, Lee YK, Shin HK. Orthopedics. 2012 Sep;35(9):e1347-52. doi: 10.3928/01477447-20120822-20.
  • Clinical Outcome in All-Arthroscopic Versus Mini-Open Rotator Cuff Repair in Small to Medium Sized Tears: A Randomized Controlled Trial in 100 Patients With 1-Year Follow-up. van der Zwaal P, Thomassen BJ, Nieuwenhuijse MJ, Lindenburg R, Swen JW, van Arkel ER.
  • Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. Sauerbrey AM, Getz CL, Piancastelli M, Iannotti JP, Ramsey ML, Williams GR Jr. Arthroscopy. 2005 Dec;21(12):1415-20.
  • All-arthroscopic versus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Severud EL, Ruotolo C, Abbott DD, Nottage WM. Arthroscopy. 2003 Mar;19(3):234-8. Review.
  • Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcomes and patient satisfaction. Youm T, Murray DH, Kubiak EN, Rokito AS, Zuckerman JD. J Shoulder Elbow Surg. 2005 Sep-Oct;14(5):455-9.
  • All-arthroscopic versus mini-open rotator cuff repair: a retrospective review with minimum 2-year follow-up. Verma NN, Dunn W, Adler RS, Cordasco FA, Allen A, MacGillivray J, Craig E, Warren RF, Altchek DW. Arthroscopy. 2006 Jun;22(6):587-94.
  • Arthroscopic versus mini-open rotator cuff repair: a cohort comparison study. Warner JJ, Tétreault P, Lehtinen J, Zurakowski D. Arthroscopy. 2005 Mar;21(3):328-32.
  • Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I. Am J Sports Med. 2008 Sep;36(9):1824-8
  • Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. J Bone Joint Surg Am. 2007 Oct;89 Suppl 3:127-36
  • Early loading in physiotherapy treatment after full-thickness rotator cuff repair: a prospective randomized pilot-study with a two-year follow-up. Klintberg IH, Gunnarsson AC, Svantesson U, Styf J, Karlsson J. Clin Rehabil. 2009 Jul;23(7):622-38. doi: 10.1177/0269215509102952. Epub 2009 May 29.
  • Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: a prospective randomized study. Arndt J, Clavert P, Mielcarek P, Bouchaib J, Meyer N, Kempf JF; French Society for Shoulder & Elbow (SOFEC). Orthop Traumatol Surg Res. 2012 Oct;98(6 Suppl):S131-8. doi: 10.1016/j.otsr.2012.05.003. Epub 2012 Sep 1.
  • Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. Cuff DJ, Pupello DR. J Shoulder Elbow Surg. 2012 Nov;21(11):1450-5. doi: 10.1016/j.jse.2012.01.025. Epub 2012 May 2.
  • A clinical method of functional assessment of the shoulder. Constant CR, Murley AH. Clin Orthop Relat Res. 1987 Jan;(214):160-4.
  • A standardized method for the assessment of shoulder function. Richards, RR et al. J Shoulder Elbow Surgery (1994): 347-52.
  • Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fixation. Sugaya H, Maeda K, Matsuki K, Moriishi J. Arthroscopy. 2005 Nov;21(11):1307-16.

Lead Investigator:

Dr Allan Young

Commenced:

September 2013

Completed:

September 2015

Published:

Kruse LM, Falconer TM, Dimmick SJ, Balestro JC, Cunningham G, Cass B and Young AA (2016). Early Sling Discontinuation Following Rotator Cuff Repair. Techniques in Shoulder and Elbow Surgery (in press).

Presented:

Shoulder and Elbow Society of Australia bi-ennial closed conference Darwin, August 2016

Royal North Shore Hospital Shoulder Symposium, November 2016

Category:

Completed Research

{Updated November 2016}

In Research - Completed

Retrospective Review of the use of the Rota-Lok system for massive rotator cuff repairs

In Research - Completed

Early mobilisation following rotator cuff repair

Propionibacterium acnes
In Research - Completed

Propionibacterium acnes contamination in shoulder surgery

In Research - Completed

Modified Biceps Repair

In Research - Completed

Improving medial footprint coverage in double row cuff repair using FiberTape

In Research - Completed

Rate of P Acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique

In Research - Completed

Comparative study of physician applied and patient reported Constant Scores utilising bathroom scales to derive force measurements

In Research - Completed

Precision and Accuracy of Pumps used in Shoulder Arthroplasty