10_MCH sporthoArkel 2011 - Medisch Centrum Haaglanden

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10_MCH sporthoArkel 2011 - Medisch Centrum Haaglanden

1NRC-Study; Preliminary ResultsNederlandse vereniging voor artroscopie Rotator Cuff StudyPeer van der ZwaalRuud LindenbergBregje ThomassenJan Willem SwenEwoud van ArkelOrthopedie & TraumatologieMCH Fysiotherapiecongres 2011


2What is the Rotator Cuff?Dynamic stabilizers of glenohumeral joint.Primary function is control of humeral head in glenoid cavity during motion.


3Rotator Cuff Disease• Extrinsic factors• Bony impingement• Repetitive microtrauma• Glenohumeral instability• Capsule contracture• Intrinsic factors• Tissue degeneration• Diminished blood supply• Decreased healing capacity (e.g. smoking, DM)


4Clinical RelevanceRotator Cuff Tears• Very prevalent musculoskeletal disorder• High morbidity• ♀ = ♂• 50 – 70 years of age• Dominant shoulder


5LiteratureNo evidence of superiority of one over the other.1. Youm et al. J Shoulder Elbow Surg. 2005;14:455-4592. Severud et al. Arthroscopy. 2003;19:234-2383. Weber. Arthroscopy. 1999;15:126-1314. Sauerbrey et al. Arthroscopy. 2005;21:1415-14205. Verma et al. Arthroscopy. 2006;22:587-5946. Coghlan et al.. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005619NO randomized trials!


6ObjectiveRandomized Controlled TrialEvaluation and comparison of the outcome ofmini-open versus all arthroscopicrotator cuff repair procedures


7HypothesisAll-arthroscopic procedure will result in• Less pain• Faster recoveryAfter 1 year results will be similar


8Patient SelectionInclusion criteria– Symptomatic full thicknesscuff rupture on MRA– Informed consent– failed conservativetreatmentExclusion criteria– Age < 18 yr; > 75 yr– Glenohumeral instability– Traumatic shoulder– Frozen shoulder– RA– Previous shoulder infection– Previous cuff repair/Neer– Impaired woundhealing– Cuff arthropathy– High risk of non compliance– No Dutch language


9Study Design1. Randomized single center clinical trial• Medisch Centrum Haaglanden• 2 orthopaedic surgeons• 100 patients• 50 Mini-open• 50 All-arthoscopic• Evaluation– pre-op; 1.5, 3, 6, 12 months


10End Points• DASH• Constant• VAS-pain• Clinical function• Forward flexion• External rotation• Ultrasound at 1 year


12Results: DASHDASH (SD) Pre-op 6wks 3mth 6 mth 12mthOpen 93.7 (21.6) 96.1 (21.4) 70.1 (24.2) 58.5 (24.2) 51.0 (24.8)Scopic 87.9 (24.9) 85.4 (23.7) 66.6 (20.4) 55.8 (19.5) 51.8 (26.6)P-value .355 .020 .334 .217 .078


13Results: ConstantConstant(SD)Pre-op 6wks 3mth 6mth 12mthOpen 42.2 (12.2) 38.2 (13.2) 55.6 (14.8) 73.2 (16.4) 84.4 (15.7)Scopic 42.0 (12.3) 41.3 (11.7) 59.9 (13.3) 76.1 (13.8) 87.0 (13.4)P-value .778 .454 .283 .459 .547


14Results: VAS-painVAS-pain(SD)Pre-op 6wks 3mth 6mth 12mthOpen 6.9 (1.8) 5.1 (2.1) 4.0 (2.2) 3.1 (1.9) 2.6 (2.0)Scopic 6.8 (1.8) 4.2 (2.0) 3.8 (2.0) 2.6 (1.7) 2.7 (1.8)P-value .900 .027 .652 .266 .839


15Results: Forward flexionForwardflexion (SD)Pre-op 6wks 3mth 6mth 12mthOpen 107.5 (38.9) 59.3 (27.1) 112.7 (37.8) 142.6 (36.2) 165.0 (24.0)Scopic 111.2 (37.8) 75.4 (30.9) 123.4 (36.2) 153.1 (26.2) 169.3 (19.9)P-value .696 .028 .291 .343 .088


16Results: External rotationExternalrotation (SD)Pre-op 6wks 3mth 6mth 12mthOpen 46.5 (23.0) 30.3 (17.2) 46.4 (15.6) 53.2 (19.6) 73.2 (20.6)Scopic 47.6 (21.7) 35.7 (19.5) 44.4 (17.1) 51.9 (15.4) 82.1 (10.2)P-value .832 .246 .546 .758 .050


17Results: ComplicationsMini-OpenArthroscopicOR-time (SD) 53.8 (12.7) 73.5 (17.6)Retear 6 8Frozen shoulder 6 5Conversion 0 2Screw Back out 0 1Superficial infection 1 0Vascular 1 CVA 1 PE


18Discussion• Significant better results at 6 weeks– DASH– Forward flexion– VAS-pain• Trend in favor of arthroscopicprocedure• Results after 1 year the same


19HypothesisAll-arthroscopic procedure will result in• Less pain• Faster recoveryAt 6 weeksEarly phaseAfter 1 year results will be similarYes


20Conclusions• Arthroscopy = Mini-Open after 1 year• Arthroscopy = faster recovery in early postoperative period• Arthroscopy = complete evaluation of whole joint• Arthroscopy = preferred method of treatment


22orthofysio@mchaaglanden.nlsportafspraken@mchaaglanden.nl


23Thank you.

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