International
International Orthopaedics (SICOT) (1992) 16:240-244
Orthopaedics © Springer-Verlag 1992
Rotator cuff tears in anterior dislocation of the shoulder E. Itoi and S. Tabata Department of Orthopaedic Surgery, Iwaki Kyoritsu General Hospital, Iwaki, Japan
Summary. We diagnosed 16 rotator cuff tears in 109 shoulders in 104 patients with a traumatic anterior dislocation. Twelve of these were followed up for an average of 32 months. A surgical repair of the cuff was carried out in eleven and the results were satisfactory in eight (73%) regardless of a Bankart lesion. The repair of a torn cuff seems to be sufficient to stabilise the shoulder in elderly patients, even when a Bankart lesion is present and is not repaired. R ~ s u m ~ . Parmi 104 malades ayant pr(sentd 109
luxations de lgpaule, nous avons observ6 16 cas de d6chirure de la coiffe des rotateurs . Douze patients ont dt( suivis pour ce travail et la durde moyenne de la surveillance a dt( de 32 mois. Onze de ces malades ont dt~ traitds par rdparation de la coiffe des rotatents. Les r6sultats d'ensemble du traitement opdratoire ont ( t ( satisfaisants dans 73% des cas, malgrd une 16sion de Bankart. A partir de ces observations nous pouvons conclure que la coiffe des rotateurs constitue un des 616ments stabilisateurs les plus importants de l gpaule, notamment chez les sujets gtgds.
Introduction R e c u r r e n c e is the m o s t c o m m o n c o m p l i c a t i o n o f a n t e r i o r d i s l o c a t i o n o f t h e s h o u l d e r in y o u n g p a t i e n t s [5, 6, 11] b u t is u n u s u a l in the e l d e r l y [6, 9, 11], in w h o m r o t a t o r c u f f tears are m o r e c o m m o n [ 12, 14, 16, 18]. T h e c u f f is n o r m a l l y d e s c r i b e d as a d y n a m i c s t a b i l i s e r o f the s h o u l d e r [1, 7, 17, 20], b u t t h e r e h a s
Reprint requests to: E. Itoi, Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendal 980, Japan
b e e n little d i s c u s s i o n a b o u t the r o l e it m i g h t p l a y in preventing anterior dislocation. T h e p u r p o s e o f this p a p e r is to i n v e s t i g a t e t h e possible stabilising function of the rotator cuff from the r e s u l t s o f s u r g i c a l r e p a i r o f tears o c c u r r i n g in association with anterior dislocation.
Materials and methods From January 1980 to December 1989, 109 shoulders in 104 patients with primary anterior dislocation of the shoulder were referred to our hospital. Rotator cuff tears were confirmed by arthrography in 16 patients; none had a fracture of the greater tuberosity. The incidence of tears in the whole series was 15%, and in patients aged over 40 years 30%. Twelve of these patients were followed for more than one year (Table 1). The average age was 63 years, range 46 to 82 years; 7 were men and 5 women. One patient (case 6) had a previous dislocation 10 years previously, but since she had no further dislocation in the intervening 10 years her recent injury was regarded as a primary event. None of the remaining patients had a previous dislocation or complaints referrable to the shoulder. The mechanism was a fall on the outstretched hand in 10 and a fall from a height in 2. Radiographs were taken of every shoulder. After a gentle manipulation, the arm was rested in a sting for 3 weeks, followed by physiotherapy. A transient axillary nerve palsy was diagnosed by electromyography in 4 patients. Eleven patients complained of loss of motion, 8 of marked or moderate weakness of abduction, 7 of pain on motion and 5 of pain at night, even after reduction. One patient had repeated dislocations. Arthrography was performed in every patient because their symptoms indicated a complete rotator cuff tear. The interval between injury and diagnosis of the tear was 3 months on average, with a range from several hours to 2 years. Surgical repair of the rotator cuff tear was carried out in 11 patients; one (case 12) was lreated conservatively because she refused operation. Seven had a tear of supraspinatns alone, 2 had combined tears of the supra- and infraspinatus tendons, 2 had tears of the supraspinatus and the rotator interval, and 1 had a massive tear.
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation
241
Table 1. Summary of cases Case #
Sex, side, age
Mechanism of injury
Associated injury
1
F,R 58
Fall
-
2
M,R 46
Fall (Skiing)
3
M,R 82
4
Injury to arthrography (days)
Site of tear
6
SSP
Axillary nerve palsy
46
SSP
Fall
Axillary nerve palsy
73
SSP,ISP,SSC
M,R 77
Fall
-
2
5
M,R 62
Fall from height
-
749
SSP,ISP
6
F,R 64
Fall from height
-
46
SSP,RI
7
M,L 57
Fall
Axillary nerve palsy
2
SSP,RI
8
F,R 62
Fall
-
0
SSP
9
M,R 61
Fall
Axillary nerve palsy
1
SSP
10
F,R 47
Fall
-
13
11
M,R 72
Fall
-
116
SSP
12
F,R 66
Fall
-
10
SSP a
SSP
SSP,ISP
a Judged from arthrographic findings. SSP = supraspinatus, ISP = infraspinatus, SSC = subscapularis, RI = rotator interval
Surgical technique: An anterolateral approach was used. After the edges of the tear were freshened, the humeral head was displaced backwards; a Bankart lesion was found in 4 shoulders. Repair was carried out by McLaughlin's method of tendon to bone suture [10] in 9 patients, a free fascial patch graft [19] in 1 and Debeyre's supraspinatus advancement [3] in 1. The fascial graft was used when the gap was too wide to close, and advancement in one case with a massive tear. Case 1 had the Bankart lesion repaired by stapling because the shoulder was found to be unstable after repair of the cuff. All the operations were done by S. T. After operation, the arm was supported on an abduction brace for 2 to 3 weeks to reduce tension on the repaired cuff and then an abduction pillow was used for 1 to 2 weeks. Isometric exercises for the deltoid were started on the day after operation active-assistive and pendulum exercises began when the brace was removed. Follow up: The average length of follow up was 32 months, range 12 to 64 months. The UCLA shoulder rating scale [4] was used for evaluation and is shown in Table 2. The maximum score is 35 points: 34 or 35 points is an excellent score; 29 to 33 good; 21 to 28 fair; and less than 20 poor. The scores before and after treatment were compared by the Wilcoxon signed rank test. Statistical significance was set at the 5 % level.
Results T h e o v e r a l l results w e r e e x c e l l e n t i n 4 patients, g o o d i n 4, fair i n 1 a n d p o o r i n 3. O f the 11 w h o w e r e o p e r a t e d on, 8 h a d e x c e l l e n t or g o o d results. T h e scores for p a i n a n d f u n c t i o n ( m a x i m u m 10) are s h o w n i n F i g u r e 1, a n d for m o t i o n a n d s t r e n g t h ( m a x i m u m 5) i n F i g u r e 2. A l l c a t e g o r i e s s h o w e d a n i m p r o v e m e n t at f o l l o w up. T h e d i f f e r e n c e s b e t w e e n the i n i t i a l a n d f o l l o w u p scores w e r e all statistically s i g n i f i c a n t , w h i c h was m o s t e v i d e n t i n f u n c t i o n a n d motion.
Case reports Case 6. A w o m a n , aged 64 years, h a d a p r e v i o u s d i s l o c a t i o n 10 years p r e v i o u s l y . H e r r e c e n t dislocat i o n w a s treated b y the r o u t i n e m e t h o d , b u t o n e m o n t h later she h a d a f u r t h e r d i s l o c a t i o n . T h i s w a s r e d u c e d i m m e d i a t e l y , b u t she c o m p l a i n e d o f p a i n a n d loss o f m o t i o n . A r t h r o g r a p h y s h o w e d a r o t a t o r c u f f tear. A t o p e r a t i o n , a s u p r a s p i n a t u s tear e x t e n d i n g to the rotator i n t e r v a l w a s r e p a i r e d b y t e n d o n to
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation
242 Table 1 (continued) Method of operation
F/U length (mos)
Pain scoreb Initial
Active motion (degrees) F/U
Abduction
ER
Initial
F/U
Initial
F/U
Tendon-to-bone + stapling
12
6
6
60
115
NR
0
Tendon-to-bone
31
8
6
80
80
NR
20
Advancement of SSP
48
6
6
0
65
10
0
Tendon-to-bone
12
6
8
80
120
0
45
Tendon-to-bone
55
4
8
85
150
NR
50
Tendon-to-bone
13
6
10
80
165
NR
45
Fascial pach
31
6
10
20
170
0
45
Tendon-to-bone
32
8
10
150
155
20
0
Tendon-to-bone
34
8
10
30
180
15
45
Tendon-to-bone
42
8
10
10
180
-20
35
Tendon-to-bone
64
6
10
60
170
30
40
Conservative
14
4
4
120
130
10
40
b Scored by UCLA shoulder rating scale FAJ = follow-up, NR = not recorded, ER = external rotation
b o n e suture, a n d t h e s h o u l d e r w a s t h e n stable. A B a n k a r t l e s i o n w a s also f o u n d , b u t w a s n o t r e p a i r e d . T h e r e w a s n o f u r t h e r r e c u r r e n c e a n d the r e s u l t w a s good. Case 11. A m a n , a g e d 72 y e a r s , h a d a p r i m a r y anter i o r d i s l o c a t i o n o f his r i g h t s h o u l d e r . A r t h r o g r a p h y w a s d o n e r o u t i n e l y o n b o t h sides a n d s h o w e d b i l a t e r al r o t a t o r c u f f tears. T h e t e a r o n the r i g h t w a s rep a i r e d b y t e n d o n to b o n e suture; t h a t on the left d i d n o t c a u s e s y m p t o m s a n d w a s n o t treated. F i v e y e a r s l a t e r h e fell a n d d i s l o c a t e d his left s h o u l d e r . A n ar-
10
n--n fI'IA
t h r o g r a m c o n f i r m e d t h e tear w h i c h h a d b e e n d e m o n strated, b u t n o t t r e a t e d , p r e v i o u s l y . A s h e h a d s y m p toms the supra- and infraspinatus tear was repaired b y a f a s c i a l g r a f t 2 m o n t h s after the d i s l o c a t i o n . T h e r i g h t s h o u l d e r h a d an e x c e l l e n t result. T h e left s h o u l d e r h a s n o t b e e n i n c l u d e d in this s e r i e s as the f o l l o w u p w a s t o o short_.
o=0.009
[ ] Initial
p=0.009 I - - I
....
[ ] Follow-up
[ ] Initial ~lIow-up
8
3
6 O o r/3
© ¢3
2
4
0
Pain
Function
Fig. 1. Pain and function before and after treatment. The scores of both had improved significantly at follow up and are presented as the mean _+ SEM
Motion
Strength
Fig. 2. Motion and strength before and after treatment. The scores of both had improved significantly at follow up and are presented as the mean + SEM. The increase in the motion is more evident.
E. Itoi and S. Tabata: Rotator cufftears in shoulder dislocation
243
Table 1 (continued) Abduction strength c
Function score c
Initial
FAJ
Initial
2
4
4
3
3
2
Results
Remarks
8
Fair
Anterior labrum repair by stapling
4
4
Poor
5
2
4
Poor
F/U
3
4
4
8
Good
4
4
2
8
Good
3
4
2
8
Good
2
4
4
10
4
4
6
8
2
5
6
10
Excellent
4
5
6
10
Excellent
4
5
6
10
Excellent
2
4
4
4
Recurrent dislocation, repair after the third dislocation
Excellent Good
Recurrence on the day of injury
Bilateral tears, left dislocation 6 years after the right one
Poor
c Scored by UCLA shoulder rating scale F/U = follow-up
Table 2 (continued)
Table 2. UCLA shoulder rating scale a Points Pain Present all of the time and unbearable; strong medication frequently
1
Present all of the time but bearable; strong medication occasionally
2
None or little at rest, present during light activities; salicylates frequently
4
Present during heavy or particular activities only; salicylates occasionally
6
Occasional and slight
8
None Function Unable to use limb
10 1
Points Active forward flexion 150 degrees or more 120 to 150 degrees 90 to 120 degrees 45 to 90 degrees 30 to 45 degrees Less than 30 degrees
5 4 3 2 1 0
Strength of forward flexion (manual muscle-testing) Grade 5 (normal) Grade 4 (good) Grade 3 (fair) Grade 2 (poor) Grade 1 (muscle contraction) Grade 0 (nothing)
5 4 3 2 1 0 5 0
Only light activities possible
2
Able to do light housework or most activities of daily living
Satisfaction of the patient Satisfied and better Not satisfied and worse
4
a Maximum score, 35 points
Most housework, shopping, and driving possible; able to do hair and dress and undress, including fastening brassiere
6
Slight restriction only; able to work above shoulder level
8
Normal activities
10
244
Discussion The association between primary anterior dislocation and rotator cuff tears is still poorly appreciated [12], but is a common complication in middle aged and elderly patients. Nonrecurrent anterior dislocations in the elderly are associated with posterior soft tissue damage as often as anterior damage is seen in recurrent dislocations in the young [11]. A case has been reported where recurrent anterior dislocation was associated with a supra- and infraspinatus tear, but the anterior capsule and ligaments were intact [2]. These observations have been supported by biomechanical studies in which the weakest part of the shoulder was shown to be the glenoid labrum attachment in the young and the rotator cuff in the elderly [15]. A cadaveric study has demonstrated that the infraspinatus and posterior capsule were important for anterior stability [13]. Two out of 4 of our patients with Bankart lesions developed recurrent dislocation, but neither recurred after repair of the cuff alone. This supports the view that the cuff is an important stabiliser of the shoulder. The presence of the Bankart lesion also suggests that damage to both the anterior and the posterior mechanism may not be unusual in older patients. Operation is suggested by many authors [2, 5, 8, 12], but there is discussion as to which structure should be repaired. Our results indicate that repair of a Bankart lesion is probably not necessary in older patients. It is uncertain whether the rotator cuff tear occurs as a result of the anterior dislocation or vice versa. Neviaser et al. assumed that tears occurred at the time of dislocation as none of their patients had symptoms previously [12]. But if the cuff is an important stabiliser, then patients with tears might have instability or a dislocation. The history of case 11 in our series suggests that the tear may precede the dislocation in some patients. In the elderly, cuff tears are commonly associated with anterior dislocation and repair of the cuff alone may be sufficient to achieve stability. References 1. Basmajian JV, Bazant FJ (1959) Factors preventing downward dislocation of the adducted shoulder joint. An electromyographic and morphological study. J Bone Joint Surg [Am] 41: 1182-1186
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation 2. Craig EV (1984) The posterior mechanism of acute anterior shoulder dislocations. Clin Orthop 190:212-216 3. Debeyre J, Patte D, Elmelik E (1965) Repair of ruptures of the rotator cuff of the shoulder. With a note on advancement of the supraspinatus muscle. J Bone Joint Surg [Br] 47: 36 - 4 2 4. Ellman H, Hanker G, Bayer M (1986) Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg [Am] 68:1136 - 1144 5. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ (1986) Anterior dislocation of the shoulder in the older patient. Clin Orthop 206: 192-195 6. Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius A, Lind B, Thorling J, Weckstr6m J (1983) Recurrences after initial dislocation of the shoulder. J Bone Joint Surg [Am] 65:343-349 7. Inman VT, Saunders JB deCM, Abbott LC (1944) Observations of the function of the shoulder joint. J Bone Joint Surg [Am] 2 6 : 1 - 3 0 8. Johnson JR, Bayley JIL (1982) Early complications of acute anterior dislocation of the shoulder in the middle-aged and elderly patient. Injury 13: 431 - 434 9. McLaughlin HL, Cavallaro WU (1950) Primary anterior dislocation of the shoulder. Am J Surg 80:615-621 10. McLaughlin HL (1962) Rupture of the rotator cuff. J Bone Joint Surg [Am] 44:979-983 11. McLaughlin HL, MacLellan DI (1967) Recurrent anterior dislocation of the shoulder. 1/. A comparative study. J Trauma 7:191-201 12. Neviaser RJ, Neviaser TJ, Neviaser JS (1988) Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg [Am] 70: 1308-1311 13. Ovesen J, Nielsen S (1986) Anterior and posterior shoulder instability. A cadaver study. Acta Orthop Scand 57: 324- 327 14. Pasila M, Jaroma H, Kiviluoto O, Sundholm A (1978) Early complications of primary shoulder dislocations. Acta Orthop Scand 49:260-263 15. Reeves B (1968) Experiments on the tensile strength of the anterior capsular structures of the shoulder in man. J Bone Joint Surg [Br] 50: 858- 865 16. Reeves B (1969) Acute anterior dislocation of the shoulder. Clinical and experimental studies. Ann Roy Coil Surg Engl 44:255-273 17. Saha AK (1971) Dynamic stability of the glenohumeral joint. Acta Orthop Scand 42:491 - 505 18. Stevens JH (1926) Dislocation of the shoulder. Ann Surg 83: 84-103 19. Tabata S (1989) Reconstruction of massive rotator cuff tears by fascia patch grafting. Rinsho Seikeigeka 24:47 -53 (Japanese) 20. Walker SW, Couch WH, Boester GA, Sprowl DW (1987) Isokinetic strength of the shoulder after repair of a torn rotator cuff. J Bone Joint Surg [Am] 69:1041 - 1044
International Orthopaedics (SICOT) (1992) 16:240-244
Orthopaedics © Springer-Verlag 1992
Rotator cuff tears in anterior dislocation of the shoulder E. Itoi and S. Tabata Department of Orthopaedic Surgery, Iwaki Kyoritsu General Hospital, Iwaki, Japan
Summary. We diagnosed 16 rotator cuff tears in 109 shoulders in 104 patients with a traumatic anterior dislocation. Twelve of these were followed up for an average of 32 months. A surgical repair of the cuff was carried out in eleven and the results were satisfactory in eight (73%) regardless of a Bankart lesion. The repair of a torn cuff seems to be sufficient to stabilise the shoulder in elderly patients, even when a Bankart lesion is present and is not repaired. R ~ s u m ~ . Parmi 104 malades ayant pr(sentd 109
luxations de lgpaule, nous avons observ6 16 cas de d6chirure de la coiffe des rotateurs . Douze patients ont dt( suivis pour ce travail et la durde moyenne de la surveillance a dt( de 32 mois. Onze de ces malades ont dt~ traitds par rdparation de la coiffe des rotatents. Les r6sultats d'ensemble du traitement opdratoire ont ( t ( satisfaisants dans 73% des cas, malgrd une 16sion de Bankart. A partir de ces observations nous pouvons conclure que la coiffe des rotateurs constitue un des 616ments stabilisateurs les plus importants de l gpaule, notamment chez les sujets gtgds.
Introduction R e c u r r e n c e is the m o s t c o m m o n c o m p l i c a t i o n o f a n t e r i o r d i s l o c a t i o n o f t h e s h o u l d e r in y o u n g p a t i e n t s [5, 6, 11] b u t is u n u s u a l in the e l d e r l y [6, 9, 11], in w h o m r o t a t o r c u f f tears are m o r e c o m m o n [ 12, 14, 16, 18]. T h e c u f f is n o r m a l l y d e s c r i b e d as a d y n a m i c s t a b i l i s e r o f the s h o u l d e r [1, 7, 17, 20], b u t t h e r e h a s
Reprint requests to: E. Itoi, Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendal 980, Japan
b e e n little d i s c u s s i o n a b o u t the r o l e it m i g h t p l a y in preventing anterior dislocation. T h e p u r p o s e o f this p a p e r is to i n v e s t i g a t e t h e possible stabilising function of the rotator cuff from the r e s u l t s o f s u r g i c a l r e p a i r o f tears o c c u r r i n g in association with anterior dislocation.
Materials and methods From January 1980 to December 1989, 109 shoulders in 104 patients with primary anterior dislocation of the shoulder were referred to our hospital. Rotator cuff tears were confirmed by arthrography in 16 patients; none had a fracture of the greater tuberosity. The incidence of tears in the whole series was 15%, and in patients aged over 40 years 30%. Twelve of these patients were followed for more than one year (Table 1). The average age was 63 years, range 46 to 82 years; 7 were men and 5 women. One patient (case 6) had a previous dislocation 10 years previously, but since she had no further dislocation in the intervening 10 years her recent injury was regarded as a primary event. None of the remaining patients had a previous dislocation or complaints referrable to the shoulder. The mechanism was a fall on the outstretched hand in 10 and a fall from a height in 2. Radiographs were taken of every shoulder. After a gentle manipulation, the arm was rested in a sting for 3 weeks, followed by physiotherapy. A transient axillary nerve palsy was diagnosed by electromyography in 4 patients. Eleven patients complained of loss of motion, 8 of marked or moderate weakness of abduction, 7 of pain on motion and 5 of pain at night, even after reduction. One patient had repeated dislocations. Arthrography was performed in every patient because their symptoms indicated a complete rotator cuff tear. The interval between injury and diagnosis of the tear was 3 months on average, with a range from several hours to 2 years. Surgical repair of the rotator cuff tear was carried out in 11 patients; one (case 12) was lreated conservatively because she refused operation. Seven had a tear of supraspinatns alone, 2 had combined tears of the supra- and infraspinatus tendons, 2 had tears of the supraspinatus and the rotator interval, and 1 had a massive tear.
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation
241
Table 1. Summary of cases Case #
Sex, side, age
Mechanism of injury
Associated injury
1
F,R 58
Fall
-
2
M,R 46
Fall (Skiing)
3
M,R 82
4
Injury to arthrography (days)
Site of tear
6
SSP
Axillary nerve palsy
46
SSP
Fall
Axillary nerve palsy
73
SSP,ISP,SSC
M,R 77
Fall
-
2
5
M,R 62
Fall from height
-
749
SSP,ISP
6
F,R 64
Fall from height
-
46
SSP,RI
7
M,L 57
Fall
Axillary nerve palsy
2
SSP,RI
8
F,R 62
Fall
-
0
SSP
9
M,R 61
Fall
Axillary nerve palsy
1
SSP
10
F,R 47
Fall
-
13
11
M,R 72
Fall
-
116
SSP
12
F,R 66
Fall
-
10
SSP a
SSP
SSP,ISP
a Judged from arthrographic findings. SSP = supraspinatus, ISP = infraspinatus, SSC = subscapularis, RI = rotator interval
Surgical technique: An anterolateral approach was used. After the edges of the tear were freshened, the humeral head was displaced backwards; a Bankart lesion was found in 4 shoulders. Repair was carried out by McLaughlin's method of tendon to bone suture [10] in 9 patients, a free fascial patch graft [19] in 1 and Debeyre's supraspinatus advancement [3] in 1. The fascial graft was used when the gap was too wide to close, and advancement in one case with a massive tear. Case 1 had the Bankart lesion repaired by stapling because the shoulder was found to be unstable after repair of the cuff. All the operations were done by S. T. After operation, the arm was supported on an abduction brace for 2 to 3 weeks to reduce tension on the repaired cuff and then an abduction pillow was used for 1 to 2 weeks. Isometric exercises for the deltoid were started on the day after operation active-assistive and pendulum exercises began when the brace was removed. Follow up: The average length of follow up was 32 months, range 12 to 64 months. The UCLA shoulder rating scale [4] was used for evaluation and is shown in Table 2. The maximum score is 35 points: 34 or 35 points is an excellent score; 29 to 33 good; 21 to 28 fair; and less than 20 poor. The scores before and after treatment were compared by the Wilcoxon signed rank test. Statistical significance was set at the 5 % level.
Results T h e o v e r a l l results w e r e e x c e l l e n t i n 4 patients, g o o d i n 4, fair i n 1 a n d p o o r i n 3. O f the 11 w h o w e r e o p e r a t e d on, 8 h a d e x c e l l e n t or g o o d results. T h e scores for p a i n a n d f u n c t i o n ( m a x i m u m 10) are s h o w n i n F i g u r e 1, a n d for m o t i o n a n d s t r e n g t h ( m a x i m u m 5) i n F i g u r e 2. A l l c a t e g o r i e s s h o w e d a n i m p r o v e m e n t at f o l l o w up. T h e d i f f e r e n c e s b e t w e e n the i n i t i a l a n d f o l l o w u p scores w e r e all statistically s i g n i f i c a n t , w h i c h was m o s t e v i d e n t i n f u n c t i o n a n d motion.
Case reports Case 6. A w o m a n , aged 64 years, h a d a p r e v i o u s d i s l o c a t i o n 10 years p r e v i o u s l y . H e r r e c e n t dislocat i o n w a s treated b y the r o u t i n e m e t h o d , b u t o n e m o n t h later she h a d a f u r t h e r d i s l o c a t i o n . T h i s w a s r e d u c e d i m m e d i a t e l y , b u t she c o m p l a i n e d o f p a i n a n d loss o f m o t i o n . A r t h r o g r a p h y s h o w e d a r o t a t o r c u f f tear. A t o p e r a t i o n , a s u p r a s p i n a t u s tear e x t e n d i n g to the rotator i n t e r v a l w a s r e p a i r e d b y t e n d o n to
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation
242 Table 1 (continued) Method of operation
F/U length (mos)
Pain scoreb Initial
Active motion (degrees) F/U
Abduction
ER
Initial
F/U
Initial
F/U
Tendon-to-bone + stapling
12
6
6
60
115
NR
0
Tendon-to-bone
31
8
6
80
80
NR
20
Advancement of SSP
48
6
6
0
65
10
0
Tendon-to-bone
12
6
8
80
120
0
45
Tendon-to-bone
55
4
8
85
150
NR
50
Tendon-to-bone
13
6
10
80
165
NR
45
Fascial pach
31
6
10
20
170
0
45
Tendon-to-bone
32
8
10
150
155
20
0
Tendon-to-bone
34
8
10
30
180
15
45
Tendon-to-bone
42
8
10
10
180
-20
35
Tendon-to-bone
64
6
10
60
170
30
40
Conservative
14
4
4
120
130
10
40
b Scored by UCLA shoulder rating scale FAJ = follow-up, NR = not recorded, ER = external rotation
b o n e suture, a n d t h e s h o u l d e r w a s t h e n stable. A B a n k a r t l e s i o n w a s also f o u n d , b u t w a s n o t r e p a i r e d . T h e r e w a s n o f u r t h e r r e c u r r e n c e a n d the r e s u l t w a s good. Case 11. A m a n , a g e d 72 y e a r s , h a d a p r i m a r y anter i o r d i s l o c a t i o n o f his r i g h t s h o u l d e r . A r t h r o g r a p h y w a s d o n e r o u t i n e l y o n b o t h sides a n d s h o w e d b i l a t e r al r o t a t o r c u f f tears. T h e t e a r o n the r i g h t w a s rep a i r e d b y t e n d o n to b o n e suture; t h a t on the left d i d n o t c a u s e s y m p t o m s a n d w a s n o t treated. F i v e y e a r s l a t e r h e fell a n d d i s l o c a t e d his left s h o u l d e r . A n ar-
10
n--n fI'IA
t h r o g r a m c o n f i r m e d t h e tear w h i c h h a d b e e n d e m o n strated, b u t n o t t r e a t e d , p r e v i o u s l y . A s h e h a d s y m p toms the supra- and infraspinatus tear was repaired b y a f a s c i a l g r a f t 2 m o n t h s after the d i s l o c a t i o n . T h e r i g h t s h o u l d e r h a d an e x c e l l e n t result. T h e left s h o u l d e r h a s n o t b e e n i n c l u d e d in this s e r i e s as the f o l l o w u p w a s t o o short_.
o=0.009
[ ] Initial
p=0.009 I - - I
....
[ ] Follow-up
[ ] Initial ~lIow-up
8
3
6 O o r/3
© ¢3
2
4
0
Pain
Function
Fig. 1. Pain and function before and after treatment. The scores of both had improved significantly at follow up and are presented as the mean _+ SEM
Motion
Strength
Fig. 2. Motion and strength before and after treatment. The scores of both had improved significantly at follow up and are presented as the mean + SEM. The increase in the motion is more evident.
E. Itoi and S. Tabata: Rotator cufftears in shoulder dislocation
243
Table 1 (continued) Abduction strength c
Function score c
Initial
FAJ
Initial
2
4
4
3
3
2
Results
Remarks
8
Fair
Anterior labrum repair by stapling
4
4
Poor
5
2
4
Poor
F/U
3
4
4
8
Good
4
4
2
8
Good
3
4
2
8
Good
2
4
4
10
4
4
6
8
2
5
6
10
Excellent
4
5
6
10
Excellent
4
5
6
10
Excellent
2
4
4
4
Recurrent dislocation, repair after the third dislocation
Excellent Good
Recurrence on the day of injury
Bilateral tears, left dislocation 6 years after the right one
Poor
c Scored by UCLA shoulder rating scale F/U = follow-up
Table 2 (continued)
Table 2. UCLA shoulder rating scale a Points Pain Present all of the time and unbearable; strong medication frequently
1
Present all of the time but bearable; strong medication occasionally
2
None or little at rest, present during light activities; salicylates frequently
4
Present during heavy or particular activities only; salicylates occasionally
6
Occasional and slight
8
None Function Unable to use limb
10 1
Points Active forward flexion 150 degrees or more 120 to 150 degrees 90 to 120 degrees 45 to 90 degrees 30 to 45 degrees Less than 30 degrees
5 4 3 2 1 0
Strength of forward flexion (manual muscle-testing) Grade 5 (normal) Grade 4 (good) Grade 3 (fair) Grade 2 (poor) Grade 1 (muscle contraction) Grade 0 (nothing)
5 4 3 2 1 0 5 0
Only light activities possible
2
Able to do light housework or most activities of daily living
Satisfaction of the patient Satisfied and better Not satisfied and worse
4
a Maximum score, 35 points
Most housework, shopping, and driving possible; able to do hair and dress and undress, including fastening brassiere
6
Slight restriction only; able to work above shoulder level
8
Normal activities
10
244
Discussion The association between primary anterior dislocation and rotator cuff tears is still poorly appreciated [12], but is a common complication in middle aged and elderly patients. Nonrecurrent anterior dislocations in the elderly are associated with posterior soft tissue damage as often as anterior damage is seen in recurrent dislocations in the young [11]. A case has been reported where recurrent anterior dislocation was associated with a supra- and infraspinatus tear, but the anterior capsule and ligaments were intact [2]. These observations have been supported by biomechanical studies in which the weakest part of the shoulder was shown to be the glenoid labrum attachment in the young and the rotator cuff in the elderly [15]. A cadaveric study has demonstrated that the infraspinatus and posterior capsule were important for anterior stability [13]. Two out of 4 of our patients with Bankart lesions developed recurrent dislocation, but neither recurred after repair of the cuff alone. This supports the view that the cuff is an important stabiliser of the shoulder. The presence of the Bankart lesion also suggests that damage to both the anterior and the posterior mechanism may not be unusual in older patients. Operation is suggested by many authors [2, 5, 8, 12], but there is discussion as to which structure should be repaired. Our results indicate that repair of a Bankart lesion is probably not necessary in older patients. It is uncertain whether the rotator cuff tear occurs as a result of the anterior dislocation or vice versa. Neviaser et al. assumed that tears occurred at the time of dislocation as none of their patients had symptoms previously [12]. But if the cuff is an important stabiliser, then patients with tears might have instability or a dislocation. The history of case 11 in our series suggests that the tear may precede the dislocation in some patients. In the elderly, cuff tears are commonly associated with anterior dislocation and repair of the cuff alone may be sufficient to achieve stability. References 1. Basmajian JV, Bazant FJ (1959) Factors preventing downward dislocation of the adducted shoulder joint. An electromyographic and morphological study. J Bone Joint Surg [Am] 41: 1182-1186
E. Itoi and S. Tabata: Rotator cuff tears in shoulder dislocation 2. Craig EV (1984) The posterior mechanism of acute anterior shoulder dislocations. Clin Orthop 190:212-216 3. Debeyre J, Patte D, Elmelik E (1965) Repair of ruptures of the rotator cuff of the shoulder. With a note on advancement of the supraspinatus muscle. J Bone Joint Surg [Br] 47: 36 - 4 2 4. Ellman H, Hanker G, Bayer M (1986) Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg [Am] 68:1136 - 1144 5. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ (1986) Anterior dislocation of the shoulder in the older patient. Clin Orthop 206: 192-195 6. Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius A, Lind B, Thorling J, Weckstr6m J (1983) Recurrences after initial dislocation of the shoulder. J Bone Joint Surg [Am] 65:343-349 7. Inman VT, Saunders JB deCM, Abbott LC (1944) Observations of the function of the shoulder joint. J Bone Joint Surg [Am] 2 6 : 1 - 3 0 8. Johnson JR, Bayley JIL (1982) Early complications of acute anterior dislocation of the shoulder in the middle-aged and elderly patient. Injury 13: 431 - 434 9. McLaughlin HL, Cavallaro WU (1950) Primary anterior dislocation of the shoulder. Am J Surg 80:615-621 10. McLaughlin HL (1962) Rupture of the rotator cuff. J Bone Joint Surg [Am] 44:979-983 11. McLaughlin HL, MacLellan DI (1967) Recurrent anterior dislocation of the shoulder. 1/. A comparative study. J Trauma 7:191-201 12. Neviaser RJ, Neviaser TJ, Neviaser JS (1988) Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg [Am] 70: 1308-1311 13. Ovesen J, Nielsen S (1986) Anterior and posterior shoulder instability. A cadaver study. Acta Orthop Scand 57: 324- 327 14. Pasila M, Jaroma H, Kiviluoto O, Sundholm A (1978) Early complications of primary shoulder dislocations. Acta Orthop Scand 49:260-263 15. Reeves B (1968) Experiments on the tensile strength of the anterior capsular structures of the shoulder in man. J Bone Joint Surg [Br] 50: 858- 865 16. Reeves B (1969) Acute anterior dislocation of the shoulder. Clinical and experimental studies. Ann Roy Coil Surg Engl 44:255-273 17. Saha AK (1971) Dynamic stability of the glenohumeral joint. Acta Orthop Scand 42:491 - 505 18. Stevens JH (1926) Dislocation of the shoulder. Ann Surg 83: 84-103 19. Tabata S (1989) Reconstruction of massive rotator cuff tears by fascia patch grafting. Rinsho Seikeigeka 24:47 -53 (Japanese) 20. Walker SW, Couch WH, Boester GA, Sprowl DW (1987) Isokinetic strength of the shoulder after repair of a torn rotator cuff. J Bone Joint Surg [Am] 69:1041 - 1044
