Avaliação funcional do reparo artroscópico da lesão do manguito rotador em pacientes com pseudoparalisia

Clinical Outcome of Partial Repair of Irreparable Rotator Cuff Tears

Objective  To evaluate the functional outcome of patients who underwent partial arthroscopic repair of massive rotator cuff tears. Methods  Retrospective case series evaluating patients with massive rotator cuff tears who underwent partial arthroscopic repair. The primary outcome was the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) at 24 months. The secondary outcomes were the Modified-University of California at Los Angeles Shoulder Rating Scale (UCLA), and the following subdomains: satisfaction, active forward flexion and strength of forward flexion subdomains. Results  We evaluated 33 patients. The ASES scale evolved from 39.7 ± 19.6 to 77.6 ± 17.4 ( p  < 0.001). The UCLA scale evolved from 13.3 ± 5.5 to 27.9 ± 5.6 ( p  < 0.001). The satisfaction rate was 97%. The number of patients with active forward flexion > 150° increased from 12 (36.4%) to 25 (75.8%) ( p  = 0.002). The number of patients with normal or good strength of forward flexion increased from 9 (27.3%) to 22 (66.7%) (p = 0.015). Conclusion  Partial repair of irreparable rotator cuff tears leads to significant improvement according to the ASES and UCLA scales.

Exploring expert variability in defining pseudoparalysis: an international survey

BACKGROUND

There is currently disagreement among experts in the field of shoulder surgery when attempting to define the term "pseudoparalysis." Multiple surgical techniques to address this condition have been investigated; however, many studies have recruited heterogeneous patient populations and have used varying definitions of pseudoparalysis. This makes it difficult to compare outcomes among various techniques. To our knowledge, no previous study has surveyed international experts regarding the definition of pseudoparalysis using a questionnaire and video-based patient assessment. The purpose of this study was to evaluate the level of agreement among shoulder surgeons in defining and applying the term "pseudoparalysis." We hypothesized that inter-rater agreement for classifying patients as having pseudoparalysis would be poor.

METHODS

Members of the American Shoulder and Elbow Surgeons, the European Society for Surgery of the Shoulder and the Elbow, and our national shoulder and elbow society were surveyed on 2 occasions using an electronic questionnaire. All surgeons were asked to identify their preferred definition of pseudoparalysis from 1 of 4 options. The surgeons then viewed video examinations of 10 patients and labeled them as having pseudoparalysis or not. Inter-rater reliability and intrarater reliability were calculated as κ coefficients. The Pearson χ² test was used to detect associations between the preferred definition and demographic information.

RESULTS

A total of 246 surgeons responded to at least 1 survey. Overall inter-rater agreement on classifying patients as having pseudoparalysis based on video consultation showed a κ value of 0.59 (95% confidence interval [CI], 0.58-0.60). The same verbal definition was selected by 56.1% of surgeons. The surgeons were not internally consistent in their choice of definition, with intrarater reliability showing a κ value of 0.64 (95% CI, 0.48-0.81). Intrarater reliability for classifying patients as having pseudoparalysis was better, with a κ value of 0.78 (95% CI, 0.72-0.83). An association was observed between how surgeons defined pseudoparalysis and their age (P = .03), as well as their shoulder caseload percentage (P = .04).

CONCLUSION

Shoulder surgeons do not agree on how best to define pseudoparalysis of the shoulder. Inter-rater agreement based on video consultation was weak overall and improved with the elimination of an outlier video. Intrarater agreement was less frequent when selecting a preferred definition compared with classifying patients as having pseudoparalysis based on video examinations. Surgeons may rely less on explicit criteria and more on a conceptual framework when assigning a "pseudoparalytic" label. Care should be taken with use of the term "pseudoparalysis" in clinical outcome studies when there is clearly a lack of consensus among experts in defining this term.

Treatment Strategy for Irreparable Rotator Cuff Tears

Recently, patients with shoulder pain have increased rapidly. Of all shoulder disorders, rotator cuff tears (RCTs) are most prevalent in the middle-aged and older adults, which is the primary reason for shoulder surgery in the population. Some authors have reported that up to 30% of total RCTs can be classified as irreparable due to the massive tear size and severe muscle atrophy. In this review article, we provide an overview of treatment methods for irreparable massive RCTs and discuss proper surgical strategies for RCTs that require operative management.

Outcome assessment in the treatment of rotator cuff tear: what is utilized in Brazil?

This review evaluated the outcomes used in clinical studies involving rotator cuff tear published in the last decade in the two leading Brazilian orthopedic journals. A literature review was performed using the journals Revista Brasileira de Ortopedia and Acta Ortopédica Brasileira. It included all original clinical articles describing at least one outcome measured before or after any clinical or surgical intervention related to rotator cuff tear, published between 2006 and 2015. The authors evaluated range of motion, muscle strength, patient satisfaction, and tendon integrity and functional outcomes scores. There were 25 clinical studies published about rotator cuff in the two principal Brazilian orthopedic journals in the last decade, 20 case series (80%), one case-control (4%), and four cohorts (16%). Objective measures such as muscle strength, patient satisfaction, and evaluation of tendon integrity were little used. Range of motion measurements were performed in 52% of the articles. Evaluations of muscle strength and patient satisfaction were reported by 28% and 16% of the studies, respectively. Only 28% of the articles evaluated tendon integrity after surgery. Of these, 16% did so by magnetic resonance imaging and 12% by ultrasonography. The most used scale was the UCLA, present in 92% of the articles, while the Constant-Murley appeared in 20%. Scales deemed reliable, with high internal consistency and good responsiveness, were rarely used.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders

PURPOSE

To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision.

METHODS

A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model.

RESULTS

For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result.

CONCLUSIONS

Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy.

LEVEL OF EVIDENCE

Level IV, economic and decision analysis.