Hand lesion after arthroscopic rotator cuff repair: Association with complex regional pain syndrome

Bone marrow edema in the acromioclavicular joint after arthroscopic rotator cuff repair

BACKGROUND

Bone marrow edema (BME) in the acromioclavicular joint (ACj) may occur after arthroscopic rotator cuff repair (ARCR), resulting in persistent postoperative ACj pain. We investigated the incidence and clinical characteristics of BME in ACj after ARCR.

METHODS

Patients exhibiting ACj-related symptoms prior to ARCR surgery, no BME in the ACj on MRI, and an ability to undergo 2-year postoperative physical and MRI examinations of the ACj were included. Patients who underwent distal clavicle resection or osteophyte resection below the ACj and those unable to achieve primary repair of the rotator cuff were excluded. MRI evaluation was performed preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients who showed BME in ACj on fat-suppressed T2 MRI at 24 months postoperatively were classified into the BME + group, and those with no BME were classified into the BME- group. Patient background, operation time, Japanese Orthopedic Association (JOA) score, re-tear rate, ACj tenderness, and cross-body adduction test were compared between groups. In addition, we examined the time of occurrence of BME.

RESULTS

A total of 345 ARCRs were performed during the study period. After the exclusion of 114 shoulders, the remaining 231 shoulders were included in this study. There were 208 cases in the BME- group and 23 cases in the BME + group. The incidence of BME was 9.96 %. Although the JOA scores of both groups showed a significant improvement postoperatively compared to preoperatively, there was no significant difference between the two groups. In terms of re-tear, there was 1 case in the BME + group and 7 in the BME- group. Positive ACj tenderness and cross-body adduction test were significantly higher in the BME + group (P < 0.001). BME occurred in 6 cases at 3 months, 9 cases at 6 months, and 8 cases at 1 year postoperatively. None of the patients developed BME at more than 1 year postoperatively. BME was observed on MRI in all cases at 2 years postoperatively.

CONCLUSIONS

The rate of occurrence of BME in the ACj after ARCR was 9.96 %. Patients with BME were significantly more likely to have ACj tenderness and positive cross-body adduction test. BME in the ACj often occurs within 6 months to 1 year after ARCR of small-to-medium rotator cuff tears, suggesting a relationship with postoperative functional improvement of the shoulder joint. The ACj should be considered as a potential site of persistent pain after ARCR for small-to-medium rotator cuff tears.

Differences in incidence rate and onset timing of undiagnosed finger symptom among shoulder surgeries related to complex regional pain syndrome

The purpose of this study was to clarify the difference in onset timing and incidence of undiagnosed finger symptom (UDFS) between various shoulder surgical procedures. In this study, UDFS symptoms included the following four symptoms in the fingers;edema, limited range-of-motion, skin color changes, and abnormal sensations. UDFS cases were defined as those presenting with at least one UDFS. In result, the incidence rate of UDFS cases was 7.1% overall (58/816 shoulders), 7.4% (32/432) in arthroscopic rotator cuff repair (ARCR), 9.0% (11/122) in open rotator cuff repair (ORCR), 1.4% (2/145) in arthroscopic subacromial decompression (ASD), 13.2% (5/38) in open reduction and internal fixation (ORIF), 11.1% (3/27) in humeral head replacement, 4.8% (1/21) in anatomical total shoulder arthroplasty, and 12.9% (4/31) in reverse total shoulder arthroplasty cases. The Rate was significantly higher with ARCR compared to ASD (p<.01). About onset timing in weeks postoperatively, the ORIF group had a statistically earlier symptom onset than the Rotator cuff repair (ARCR + ORCR) group (2.4 weeks vs. 6.0 weeks, p<.01). When classifying the onset timing into before and after the removal of the abduction pillow, the ORIF group showed a statistically higher rate of onset before brace removal than the Rotator cuff repair groups (p<.01). Differences in UDFS among shoulder surgeries were demonstrated in this study. J. Med. Invest. 70 : 415-422, August, 2023.

Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair - carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome

Hypothesis/Background

Complications involving the fingers and hand after arthroscopic rotator cuff repair (ARCR) include complex regional pain syndrome, carpal tunnel syndrome (CTS), and flexor tenosynovitis (TS). The aims of this study were to diagnose the complications after ARCR and investigate the risk factors that could predispose individuals to these finger and hand complications.

Methods

Fifty patients (50 shoulders) who underwent ARCR participated in this study. The patients’ ages ranged from 36 to 84 years (mean, 63 years). Before ARCR, we determined the disease history of the fingers and hand (CTS or TS) and subjectively assessed their symptoms using a questionnaire that included a scale ranging from 1 (no symptoms or no disability) to 5 (the worst symptoms or severest disability). ARCR was performed in all patients using suture anchors. The mean observation period after surgery was 15.5 months (range, 12-48 months). We diagnosed complications involving the fingers and hand after ARCR and investigated the preoperative, intraoperative, and postoperative risk factors that could predispose patients to these complications using univariable and multivariable analyses.

Results

After ARCR, 20 patients (20 hands) (40%) had complications of the fingers and hand. Among them, the diagnosis was CTS in 2 hands, TS in 15 hands, and both CTS and TS in 3 hands. None of the hands exhibited complex regional pain syndrome. These complications occurred at an average of 1.8 months (range, 0.1-4 months) after ARCR. In the 47 patients who did not have symptoms just before the operation, both univariable and multivariable analyses between the complication group (n = 17) and the no-complications group (n = 30) showed a significant difference in the presence of a past history of CTS or TS (complication frequency: past history: 88%, no past history: 25%) (P < .05) and the preoperative subjective assessment for edema of the fingers and hand (complication frequency: edema ≥ 2 points: 89%, edema < 2 points: 24%) (P < .05). There were no relationships between the other candidate intraoperative and postoperative factors and complications.

Conclusion

In all 20 hands with complications of the fingers and hand after ARCR, the diagnosis was CTS or TS. Complications of the fingers and hand after ARCR easily occurred in patients with a past history of CTS or TS and in patients with edema as per a subjective assessment. We speculate that the ARCR triggered the occurrence of CTS and TS postoperatively in patients who had subclinical CTS or TS before surgery.

Complex Region Pain Syndrome Following Shoulder Surgery

Purpose

To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries.

Methods

Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported.

Results

The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients.

Conclusions

CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS.

Level of Evidence

IV, therapeutic case series.

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.

Clinical outcome in patients with hand lesions associated with complex regional pain syndrome after arthroscopic rotator cuff repair

Background

Complex regional pain syndrome (CRPS)-related hand lesions are one of the complications following arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the clinical outcomes of patients with CRPS-related hand lesions following ARCR.

Methods

Altogether, 103 patients with ARCR were included in this study (mean age, 63.6±8.2 years; 66 males and 37 females; follow-up period, preoperative to 12 months postoperative). Clinical assessment included the Japanese Orthopaedic Association (JOA) score, University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score from preoperative to 12 months postoperatively. The patients were either assigned to the CRPS group or non-CRPS group depending on CRPS diagnosis until the final follow-up, and clinical outcomes were then compared between the groups.

Results

Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively. Both groups showed significant improvement in JOA, UCLA, and Constant scores preoperatively to 12 months postoperatively (p<0.001). Comparisons between the two groups were not significantly different, except for SF-36 “general health perception” (p<0.05) at 12 months postoperatively. At final follow-up, three patients had residual CRPS-related hand lesions with limited range of motion and finger edema.

Conclusions

CRPS-related hand lesions developed in 19.4% of patients following ARCR. Shoulder or upper-limb function improved in most cases at 12 months, with satisfactory SF-36 patient-based evaluation results. Patients with residual CRPS-related hand lesions at the last follow-up require long-term follow-up.

Early detection and treatment of complications in the fingers and hand after arthroscopic rotator cuff repair

Background

Complications in the fingers and hand after arthroscopic rotator cuff repair (ARCR) have been reported to include carpal tunnel syndrome (CTS), flexor tenosynovitis (TS), and complex regional pain syndrome. These studies were conducted retrospectively; however, the reported complications have not been examined prospectively. The aim of this study was to evaluate the outcomes of early detection and treatment of the complications after ARCR.

Methods

Forty-six patients (48 shoulders) who underwent ARCR were prospectively examined to investigate complications in the fingers and hand after ARCR. We attempted to immediately detect and proactively treat these complications. We evaluated the outcomes of the early detection and treatment of the complications.

Results

Complications were observed in 17 hands (35%) and occurred an average of 1.5 months after ARCR. The symptoms in 3 hands resolved spontaneously, 2 hands were diagnosed with CTS, and 12 hands were diagnosed with TS. Of the 12 hands with TS, 11 exhibited no triggering of the fingers. Among the 14 hands diagnosed with CTS or TS, 13 hands (CTS: 2 hands, TS: 11 hands) were treated with corticosteroid injections; the mean interval between treatment initiation and symptom resolution was 1.0 months (0.5-3.0 months). None exhibited complex regional pain syndrome.

Conclusions

When symptoms occur in the fingers and hand after ARCR, CTS or TS should be primarily suspected. The diagnosis of TS must be made carefully because most patients with TS have no triggering. For patients with CTS or TS after ARCR, rapid corticosteroid injection administration can lead to improvement in these symptoms.