Comparison of one-stage versus two-stage procedure for the management of patients with rotator cuff tear and concomitant shoulder stiffness

One-stage rotator cuff repair in stiff shoulders shows comparable range of motion, clinical outcome and retear rates to non-stiff shoulders: a systematic review

BACKGROUND

One-stage treatment involving rotator cuff repair and shoulder capsule release is mainly used to treat patients with rotator cuff tears (RCTs) and concomitant shoulder stiffness. Despite the increasing attention to the efficacy and safety of one-stage treatment, controversy still remains. Therefore, this systematic review aims to summarize the indications, operation procedure and rehabilitation protocol, and compare the range of motions (ROMs), functional outcomes and retear rates of one-stage treatment for RCTs in stiff shoulders and non-stiff shoulders.

METHODS

Multiple databases (PubMed, the Cochrane Library, Embase and MEDLINE) were searched for studies that investigated outcomes after one-stage treatment for RCTs concomitant with shoulder stiffness compared with rotator cuff repair for RCTs alone, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Descriptive statistics, including range of motion, patient-reported outcome and retear rate, are presented without meta-analysis due to the heterogeneity and low levels of evidence.

RESULTS

A total of 9 cohort studies were included, with 305 patients treated with one-stage treatment involving rotator cuff repair and simultaneous shoulder capsular release and 1059 patients treated with rotator cuff repair alone. Patients in both groups had significant symptom improvement and functional recovery after the one-stage treatment for the stiffness group and standard repair for the non-stiffness group, and most patients could return to normal life and work within 6 months after the operation. The retear rate in the one-stage treatment group was not higher than that in the rotator cuff repair group. No statistically significant differences between the two groups were observed in terms of range of motion and patient-reported outcomes in the vast majority of studies at the final follow-up, including the visual analog scale for pain, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California Los Angeles Shoulder Score, the Oxford shoulder score and the Simple Shoulder Test.

CONCLUSION

One-stage treatment for RCTs in stiff shoulders provides comparable ROM and patient-reported clinical outcomes as rotator cuff repair for non-stiff RCTs. In addition, the rate of postoperative retear in stiff shoulder treated with one-stage treatment was not higher than in non-stiff shoulders.

[Posttraumatic shoulder stiffness]

Posttraumatic stiffness of the shoulder joint is a frequent and socioeconomically relevant result of injury; however, prior to making the diagnosis as the only cause of a persisting impairment of motion, it is necessary to rule out other sequelae of trauma. Even intensive conservative treatment is mostly accompanied by the stagnation of the impairments of movement. In many cases the treatment of choice is early arthroscopic arthrolysis with a standardized approach and intensive follow-up treatment. In the surgical treatment of proximal humeral fractures with humeral head preservation, arthroscopic arthrolysis with simultaneous implant removal is a form of planned second intervention for improvement of shoulder function in cases of persisting motion deficits after bony consolidation. Despite sometimes substantial limitations of movement, a clinically relevant and lasting improvement of shoulder function can be achieved with arthroscopic arthrolysis in posttraumatic shoulder stiffness.

Functional outcome of single stage capsular release and rotator cuff repair for cuff tear in periarthritic shoulder

Rotator cuff tear and periarthritic shoulder is a concomitant condition. In this study, both were managed with single stage arthroscopic Capsular release and rotator cuff repair and its functional outcome was evaluated till one year postoperatively. 58 patients diagnosed clinically, radiologically by MRI and arthroscopically were included. Mean constant shoulder score preoperatively was 32.6 and at one year postoperatively 78.5. Mean SPADI preoperatively was 72.1% which decreased to 20.7% at one year postoperatively. These improvements were statistically significant (p < 0.001). Thus this single stage procedure is effective for patients having rotator cuff tear in periarthritic shoulder.

MicroRNA-29a Mitigates Subacromial Bursa Fibrosis in Rotator Cuff Lesion with Shoulder Stiffness

Rotator cuff lesion with shoulder stiffness is a major cause of shoulder pain and motionlessness. Subacromial bursa fibrosis is a prominent pathological feature of the shoulder disorder. MicroRNA-29a (miR-29a) regulates fibrosis in various tissues; however, the miR-29a action to subacromial bursa fibrosis remains elusive. Here, we reveal that subacromial synovium in patients with rotator cuff tear with shoulder stiffness showed severe fibrosis, hypertrophy, and hyperangiogenesis histopathology along with significant increases in fibrotic matrices collagen (COL) 1A1, 3A1, and 4A1 and inflammatory cytokines, whereas miR-29a expression was downregulated. Supraspinatus and infraspinatus tenotomy-injured shoulders in transgenic mice overexpressing miR-29a showed mild swelling, vascularization, fibrosis, and regular gait profiles as compared to severe rotator cuff damage in wild-type mice. Treatment with miR-29a precursor compromised COL3A1 production and hypervascularization in injured shoulders. In vitro, gain of miR-29a function attenuated COL3A1 expression through binding to the 3’-untranslated region (3′-UTR) of COL3A1 in inflamed tenocytes, whereas silencing miR-29a increased the matrix expression. Taken together, miR-29a loss is correlated with subacromial bursa inflammation and fibrosis in rotator cuff tear with shoulder stiffness. miR-29a repressed subacromial bursa fibrosis through directly targeting COL3A1 mRNA, improving rotator cuff integrity and shoulder function. Collective analysis offers a new insight into the molecular mechanism underlying rotator cuff tear with shoulder stiffness. This study also highlights the remedial potential of miR-29a precursor for alleviating the shoulder disorder.