Rotator cuff tears after 70years of age: A prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients

SummaryIntroductionArthroscopic repair of rotator cuff tears leads to better clinical outcomes than subacromial decompression alone; however the former is rarely proposed to patients above 70years of age. Our hypothesis was that arthroscopic repair would be superior to decompression in patient 70years or older. The primary goal was to compare the clinical results obtained with each technique. The secondary goal was to analyze the effects of age, tendon retraction and fatty infiltration on the outcome.MethodsThis was a prospective, comparative, randomized, multicenter study where 154 patients were included who were at least 70years of age. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 74.6years. Shoulders had a complete supraspinatus tear with extension limited to the upper-third of the infraspinatus and Patte stage 1 or 2 retraction. Clinical outcomes were evaluated with the Constant, ASES and SST scores.ResultsAll scores improved significantly with both techniques: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001). However, repair led to even better results than decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference between repair and decompression was not correlated with age; arthroscopic repair was also better in patients above 75years of age (Constant, ASES and SST scores P<0.01). There was no significant correlation between the final outcomes and initial retraction: Constant (P=0.14), ASES (P=0.92), SST (P=0.47). The difference between repair and decompression was greater in patients with stages 0 and 1 fatty infiltration (Constant P<0.02) than in patients with stages 2 and 3 fatty infiltration (Constant P<0.05).ConclusionThere was a significant improvement in all-clinical scores for both techniques 1year after surgery. Repair was significantly better than decompression for all clinical outcomes, even in patients above 75years of age. The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.Level of proofII (prospective, randomized study with low power)

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases

SummaryIntroductionStiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined.Patients and methodsThis prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3–28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements).ResultsConventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14–17% for the other techniques (P<0.05).DiscussionThe techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.Level of evidenceLevel III, case–control, prospective comparative