-
ORIGINAL ARTICLE
H.-G. Simank G. Dauer S. Schneider M. Loew
Incidence of rotator cuff tears in shoulder dislocations and
resultsof therapy in older patients
Received: 8 March 2004 / Published online: 8 September 2005
Springer-Verlag 2005
Abstract Introduction: In older patients we documentedthe
incidence of additional injuries in shoulder disloca-tions in a
non-randomised, prospective study and com-pared the results of
conservative and of operative therapyof rotator cu tears.Material
and methods: Between 1993and1999a total of 87patientswere
prospectively enrolled.In the case of documented tears of the
rotator cu incombination with symptoms persisting after
conservativetherapy patients were free to decide between surgical
andconservative treatment. Patients were monitored forfunction,
subjective stability, and satisfaction over aminimum follow-up
period of 1 year. Results: In 54% ofthe patients enrolled a cu tear
was documented; the fre-quency increased with advancing age to 100%
in patientsover the age of 70. Surgical treatment of the cu
tearsresulted in better function and satisfaction. There werethree
recurrences in the conservative treatment group,while no
recurrenceswere documented in surgically treatedpatients. The
signicant benet of cu repair was con-rmed by regression analysis.
Conclusion: In this selectedpatient group, we believe surgical
repair of the symptom-atic rotator cu tear should be discussed with
the patient.
Keywords Rotator cu Tear Older patient
Introduction
Traumatic or recurrent dislocation of the shoulder is acommon
injury in young individuals, but not as frequentin the older
patient. Since the 1950s it has been knownthat the recurrence rate
is higher in young than in olderpatients [7]. Therefore, in young
patients treatment is
focused on the prevention of recurrence as a
primarycomplication. In the older patient, the primary problemis
not recurrence, but is rather seen in the associated andoften
complex structural injuries [6, 12]. These can leadto major
problems, such as pain and functional decits.The prevalence of
rotator cu tears following traumaticdislocation increases with
advancing age [6], althoughthe incidence of pre-existing rotator cu
tears is notknown. The dierent injury patterns are thought to
besecondary to the changes in tissue properties that occurwith
aging [4].
Even now, the management of shoulder dislocationsin elderly
patients is a subject of controversy. Recom-mendations vary from
predominately conservativetreatment [5] to more aggressive surgical
protocols [13].As the optimum treatment has not been dened,
patientsin our institution were given information on both
con-servative and surgical methods and both treatment op-tions were
oered.
The purpose of this study was to determine injurypatterns and
medium-term results of the treatment ofshoulder dislocations in
patients of 40 years and over,with a focus on rotator cu pathology.
The managementconsisted in both conservative and surgical
treatment.The hypothesis was that elder patients suering
fromshoulder dislocation and rotator cu tears have benetsfrom
surgical treatment. The results are used as a basisfor discussion
on guidelines for treatment.
Materials and methods
From 1993 to 1999, all patients treated for shoulderdislocations
were prospectively enrolled in this study atadmission. The lower
age limit was dened as 40 years.On enrolment, each patients
personal data and historywere recorded. In all 87 patients a
physical examinationwas performed, including X-rays in two planes
andultrasonography [15]. In addition, CT scans were per-formed in
17 patients, and MR tomograms in 48. In20002001 all patients were
invited to attend an exami-
G. Dauer S. Schneider M. LoewDepartment of Orthopaedics,
University of Heidelberg,Schlierbacher Landstrasse 200, 69118
Heidelberg, Germany
H.-G. Simank (&)Orthopadische
Gemeinschaftspraxis,Orthopadisches Centrum Nordbayern,Eppenreuther
Strasse 28, 95032 Hof, GermanyE-mail:
[email protected]
Arch Orthop Trauma Surg (2006) 126: 235240DOI
10.1007/s00402-005-0034-0
-
nation or were interviewed by telephone if they were notable to
travel or refused a personal examination.
There were 48 male and 39 female patients; theiraverage age was
59 years (range 40.186.7) when theywere rst seen. In 53 of these
cases the patients weresuering from a primary traumatic
dislocation, while 34patients reported at least one additional
dislocation intheir history. Of the 87 patients originally
enrolled, 65(75%) were ultimately evaluated; 16 patients hadmoved,
three patients had refused to participate andthree had died (Fig.
1).
All patients with primary dislocation were treatedconservatively
by immobilisation by means of a slingand physiotherapy for 3 weeks.
In patients with primarydislocation and documented cu tear, if
there was noclinical improvement after that time they were
informedof the treatment options and were free to decide
betweenconservative and surgical treatment. Surgical treatmentwas
oered to patients suering from recurrent dislo-cation and
documented cu pathology. If patients gavetheir consent, surgical
repair was carried out. Additionalstabilising procedures were not
performed. In this seriesno major complications related to the
surgical therapywere documented. Non-surgical conservative
treatmentcomprising physiotherapy aimed at strengthening
thestabilising structures of the shoulder.
Surgical technique
Patients with proven rotator cu tears underwentarthroscopic
evaluation and arthroscopic subacromialdecompression. All patients
underwent an open repairthrough a deltoid-splitting mini-open
approach for therotator cu tear without detachment of the deltoid
fromthe clavicle or anterior part of the acromion. Partialthickness
defects were converted in full-thickness defectsand the medially
retracted deep bres were reinsertedinto the head wherever it was
reached with ease with thearm at the side. Thus, a repair was
achieved in all casesof this series of patients. Size and shape of
the defectwere not documented, as procedures were performed
inclinical routine. All patients underwent a
supervisedrehabilitation program postoperatively which
comprisedpassive mobilisation and careful stretching for the rst3
weeks followed by assisted active mobilisation for thenext 3 weeks.
After this period active exercises were al-lowed to restore the
strength of the internal and externalrotators and the deltoid
muscle.
Conservative treatment
In cases of non-operative management a supervisedrehabilitation
program was performed. The programconsisted of several steps.
First, pain was released bydetonisation exercises combined with
oral medication.Then, the exibility and range of motion was
restored bystretching exercises. The next step involved
restorationof strength of the internal and external rotators
againstresistance using a rubber tube or weights and improve-ment
of the deltoid strength. After approximately6 weeks the subsequent
steps were aerobic exercises andmodication of work and sport
activities.
At the end of the study, 39 patients were examinedand 26
patients were interviewed by telephone (75%).Both, examination and
interview, were standardised andincluded basic information, which
we were able to col-lect by clinical examination and by telephonic
interviewin the same way. Conducting researchers were blinded tothe
type of injury. As the scars were visible, we were notable to blind
the investigators to the type of therapy.Both data collections
included the same items; a scorewas used, including pain, mobility,
and activity (Fig. 2).The score was adapted to our special study
design andbased on the Constant score. In addition, numbers
ofrecurrences after treatment, satisfaction with treatment(scored
on a scale of 15, where 1=not satised and5=satised), and subjective
shoulder stability (scale of15, where 1=completely unstable and
5=absolutelystable) were documented.
There were no signicant dierences between patientsinterviewed by
telephone and those who underwentclinical examination in age (mean
59.04 years SD 12.44vs. 56.27 years SD 10.21; P=0.32), subjective
stabilityof the aected joint (median 3.5 points IR 1.0 vs.
4.0points IR 2.0; P= 0.08), score (mean 56.12 points SD16.25 vs.
61.38 points SD 11.78, P=0.16) or the itemsubjective satisfaction
with treatment (median 3.0 IR2.0 vs. 4.0 IR 2.0; P=0.122). Thus,
the data recorded inboth groups were pooled for further analysis in
order toallow statistical testing.
Statistical analysis
Mean and standard deviation (SD) were calculated forcontinuous,
median and interquartile ranges for ordinalvariables. The
paired-samples t test for continuous val-ues and the Mann-Whitney
U-test for ordinal values
Fig. 1 The graph represents thepatients included in the
study.75% of the patients enrolledwere included in the study
236
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were applied in order to determine whether the dier-ences in
outcome-parameters were signicantly dierent.Associations between
discrete variables were tested by
Cramers V-test. Ordinal and linear regression analyseswere
performed to determine which factors wereimportant for the outcomes
after adjustment of the po-
Fig. 2 Examination (clinical and telephoneinterview). The data
collection sheet includespain, mobility, and activity. The item
musclestrength was excluded, because 26 of 65 patientswere
interviewed by telephone
237
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tential confoundersage and sex. A two-tailed P-valueequal to or
less than 0.05 was considered signicant.Because of the exploratory
design of this study we per-formed all tests without alpha
adjustment. Data analysiswas performed with SPSS for Windows 10.0.7
(SPSSInc., USA).
Results
Injury pattern
Anterior dislocation was prevalent in all cases. Clinicallythere
were no major axillary nerve injuries. In 67 pa-tients (77%) a Hill
Sachs lesion was found, in 31 (36%) aBankart lesion, in 14 (16%) a
fracture of the greatertuberosity, and in 47 (54%) a full-thickness
tear of therotator cu. In all cases the tear was of medium to
largesize (15 cm).
Outcome in terms of rotator cu tears
Patients suering from rotator cu tears were older thanpatients
with intact cus (61.81 years SD 11.73 vs. 51.90,SD 7.91, P<
0.001***). The frequency of rotator cutears increased with
advancing age: in the 4055 agegroup the frequency was 41%, in the
5670 age group71%, and in those over 70 years of age the
frequencywas 100% (P=0.003** for Cramers V, Fig. 2). For thestudy
group as a whole, there was no statistical signi-cance of lower
score values in patients with rotator cutears than in patients with
intact rotator cus (57.67points, SD 14.27 vs. 61.55 points, SD
11.94, P=0.444).
Regardless of the type of therapy, both groups re-ported similar
levels of satisfaction with the therapy(3.00, IR 2.00 vs. 3.50, IR
1.25, P=0.153), and alsosimilar degrees of subjective stability of
the aectedshoulder (3.00, IR 1.00 vs. 4.00, IR 1.00, P=0.539). Inve
cases there was a recurrence after treatment: threeof the patients
concerned had non-operated rotatorcu tears (3/31 patients, approx.
10%) and two hadintact cus. In the group of patients suering froman
Hill Sachs lesion there were ve recurrences of 46cases with
documented follow-up. No recurrencewas found in shoulders with an
absent Hill Sachslesion.
Surgery
There were 33 patients out of 65 with rotator cu tearsamong
those who were available for the nal investiga-tion (51%). In 15 of
these patients the tear was operatedon, while in the other 18 the
tear was treated conserva-tively. Age did not dier signicantly
between the pa-tient groups (62.51 years SD 10.93 vs. 56.81 years
SD10.50, P=0.139), but surgically treated patients weresignicantly
more satised with their therapy (4.0, IR 2.0vs. 2.0, IR 2.3;
P=0.007**), as demonstrated by sig-nicantly higher scores (64.5
points, SD 9.1 vs. 51.9points, SD 15.5, P=0.009**). Again, there
was no sig-nicant dierence in the parameter subjective
stabilitybetween the groups (4.0, IR 2.0 vs. 3.0, SD 1.0;P=0.509).
There were no recurrences in any of thesurgically treated
patients.
Regression analysis
To describe prospective factors in outcomes, multiplelinear and
ordinal regression analyses with severalcombinations of the
independent parameters age,gender, rotator cu tear, and surgery
referred tosubjective stability, score, and subjective
satisfactionwere performed. Complete data sets were available for55
patients. After adjustment for age and sex the resultswere
validated. First, regarding the item subjectivestability there were
no signicant dierences betweenpatients with either intact rotator
cu, or operatedrotator cu tear, or non-operated rotator cu
tear.
Fig. 3 Incidence of rotator cu tears in the study population
Fig. 4 The graph demonstrates the items satisfaction (median
andIR), stability (median and IR), and score (mean and SD).
Dottedbars represent values of surgically treated patients, empty
barsconservatively treated patients
238
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Second, after controlling for age and sex the satisfactionof the
operated patients was 1.2 points higher comparedto all other
patients (P=0.031*) and 2.4 points highercompared only to the
non-operated patients with rotatorcu tear (P=0.003*). Third, after
controlling for ageand sex, repair of rotator cu tears resulted in
a signif-icantly better score than was obtained with
conservativetreatment of a rotator cu (+11.4 points,
P=0.023*).Thus, the better outcome of surgery cannot be explainedby
a confounding eect of age or sex, but is a genuinebenet of
treatment.
Discussion
With increasingly aged populations in the westernworld, the
absolute number of shoulder injuries in olderindividuals is
increasing. In parallel with the aging of ourpopulations, the
activity level of older individuals isincreasing. These factors
together have resulted in anincrease in the frequency of trauma and
in the necessityfor a good functional result when such trauma is
treated[3]. This makes it necessary to investigate injury
patternsin these patients and to verify our treatment
strategies.
In older patients the main problem after dislocation isnot the
stability but the inferior functional outcome,which is often caused
by rotator cu injuries. These tearsresult in pain and weakness of
the shoulder [9, 16, 17].McLaughlin [7] explained this nding by a
posteriormechanism of the injury. In older individuals the dy-namic
stabilizers are more likely to fail (rotator cu),whereas in young
individuals it is more often the staticrestraints that fail
(labrum). Additionally, with increas-ing age the incidence of
pre-existing, degenerative tearsof the rotator cu is increasing. In
this sense, we are notable to tell degenerative tears from
traumatic tears. Thisfact may partially explain the high incidence
of cu tearsin this series and in former studies [6].
At admission tears of the rotator cu were conrmedin 54% of all
the patients in our series. Similar rates werereported by Gumina
and Postacchini [3] (61%), Ribbanset al. [14] (61%), and Pevny et
al. [13] (35%), but higherrates (100%) were reported by Neviaser et
al. [11, 10].The frequency of rotator cu tears in
asymptomaticindividuals increases with age, but the data available
donot allow any denitive conclusion as to the exact inci-dence.
Hawkins et al. [4] reported a rate of 824% forcu pathology in
cadaver studies, but in ultrasoundstudies of asymptomatic shoulders
an incidence of up to80% was found in individuals in their eighties
andnineties [8]. In our series of symptomatic shoulders
thefrequency of rotator cu tears was 100% in patients over70 years
of age.
In general, injuries of the rotator cu had negativeeects on the
result of treatment, as demonstrated byregression analysis.
Although it has been shown repeat-edly in younger individuals that
early repair of cu tearsyields better results, there is no
agreement about the best
treatment of these injuries in the older patient [2, 5, 10,11,
13]. As we were not sure whether operative treatmentof rotator cu
tears would result in an improved outcomein this specic group,
symptomatic patients with con-rmed tears and no improvement after
initial conserva-tive treatment were given information about
operativeand conservative treatment and were free to decide
be-tween the options. This study design may result in acertain
bias, as it may be assumed, that more active andmore motivated
patients would have opted for the sur-gical treatment. However,
from the ethical point of viewwe felt there was no justication for
recommending oneof the potential treatments over the other.
No mass ruptures were documented in this patientgroup; all tears
treated were symptomatic and of med-ium to large size. In these
selected patients operativetreatment resulted in a signicantly
better outcome asreected in scores and in levels of subjective
satisfaction.The parameter subjective stability was not
aected.Again, this nding indicates that stability is not themajor
problem in this group. However, it is worthwhilenoticing that no
recurrences occurred in any of the pa-tients who had surgical
treatment for rotator cu tears,whereas among patients who had cu
tears that weretreated conservatively three recurrences were
docu-mented.
Only a few studies dealing with this subject areavailable in the
literature. Pevny et al. [13] reported 84%of good results after
early repair, as against only 50%after conservative treatment, and
concluded that earlysurgical repair and treatment yielded better
results thandid conservative treatment of cu tears. Bassett
andCoeld [1] also reported better results after surgical curepair
in terms of functional outcome and pain relieffollowing acute
dislocations. In all studies available,including this study, the cu
repair was combined withan acromioplasty. As this procedure itself
may improvethe clinical outcome, the documented clinical
improve-ment may be related in part to the acromioplasty. Fromthe
study design we are not able to exclude this possibleconfounder.
This fact in combination with the high rateof re- ruptures has to
be taken in account when inter-preting the results.
With these limitations our data indicate that, in theolder
patient at least, shoulder dislocation is not a be-nign injury.
This is because of the associated injury ofthe rotator cu. When a
rotator cu tear is known to bepresent and is symptomatic and when
short-term con-servative treatment does not result in improvement
interms of pain and function, surgical repair should beconsidered.
Further prospective and randomised studiesare required to validate
the promising results of surgicalcu repair in this patient
group.
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