Rotator cuff repair improves pain in RA patients

Rheumatoid arthritis patients treated for full-thickness rotator cuff tears had no significant improvements in function.

Repairing rotator cuff tears in patients with rheumatoid arthritis can relieve pain. However, patients with full-thickness tears should not expect significant improvements in active elevation or external rotation, according to researchers at the Mayo Clinic in Rochester, Minn.

Adam M. Smith, MD, and colleagues reviewed the results of 23 rotator cuff repairs performed on 21 patients between 1988 and 2002. These included 11 women and 10 men with a mean age of 65 years at the time of surgery. All patients had preoperative diagnoses of rheumatoid arthritis and a minimum of three years follow-up.

Nine shoulders had partial-thickness tears and 14 shoulders had full-thickness tears. Nine surgeons performed the operations, with the type of procedure chosen based on surgeon and patient preference.

Of the 14 shoulders with full-thickness tears, nine had a medium tear of 1 cm to 3 cm, four had a large tear of 3 cm to 5 cm and one had a massive tear of at least 5 cm. The remaining nine shoulders had high-grade partial-thickness tears involving at least 50% of the tendon thickness, according to the study.

Surgeons performed open procedures in 18 shoulders and combined arthroscopic and open procedures in the remaining five. In all cases, surgeons used Number-2 absorbable braided and polyester sutures, they noted.

Additional procedures included acromioplasty in all cases, bursectomy in 18 shoulders, distal clavicular excision in seven, synovectomy in three, biceps tendon debridement in two and biceps tendon tendinosis in one, according to the study.

“Evaluation of the overall results at the time of the last follow-up revealed 11 excellent, four satisfactory and eight unsatisfactory results ...,” the study authors said. They attributed the unsatisfactory results to revision surgery in three shoulders, decreased motion in three, pain in one, and decreased motion and pain in one, according to the study.

Following surgery, shoulder pain, measured on a five point scale, improved from a mean of 5 points (severe pain) to 2 points postoperatively. At final follow-up, 19 of the 23 shoulders had reduced pain (P<.001).

The number of shoulders with pain at night also significantly decreased, from 19 preoperatively to nine at final follow-up (P<.01). Patient satisfaction, measured on a scale of 1 to 10, significantly improved from a mean of 1 point preoperatively to 7 points postoperatively (P<.001). However, three patients had no improvement and two patients had decreased satisfaction, according to the study.

Postoperatively, American Shoulder and Elbow Surgeons score averaged 69 points. Overall, active elevation and external rotation both increased nonsignificantly an average of 10º.

Patients with partial-thickness tears had significant improvements in active elevation, which averaged 18º (P=.03) but not in external rotation, which averaged an 8º improvement (P=.44). Patients who had full-thickness tears had no significant improvements in either active elevation or external rotation, according to the study.

Patients with partial-thickness tears and full-thickness tears both had significant improvements in shoulder satisfaction, although more patients with full-thickness tears were dissatisfied with their shoulder. Six of 14 full-thickness tear patients (43%) vs. two of the nine partial-thickness tear patients (22%) reported dissatisfaction, according to the study.

Only two shoulders required revision to total shoulder arthroplasty, and one patient required debridement and drainage of a acromioclavicular cyst, humeral head bone contouring and synovectomy. “Interestingly, the rotator cuff was found to be functionally intact in all three patients during inspection at the time of repeat surgery,” the study authors said.

For more information:
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg Am. 2005;87-A:1782-1787.