Introduction:
The rotator cuff tear is a well known and relatively frequent pathology in the general population, between 9.4% and 39.0% depending on the study, with increasing prevalence in the elderly [1-6] . Although rotator cuff tear is typically a degenerative disease, there are lesions of the rotator cuff in young patients under 50 years and most often related to trauma. A study by Yamamoto [7] reported an incidence of 5.1% for patients aged between 20 and 50 years. Many studies have reported satisfactory results in elderly patients, some technique is used: open pit techniques, mini-open and arthroscopic [8-12]. However few studies have evaluated the results of repair of partial or complete ruptures of the rotator cuff (arthroscopic or open) in a younger population [13-22]. The aim of this study was to conduct a review and analysis of the first literature on mechanisms of breaks and on clinical outcomes in the short and medium term repair of the rotator cuff in patients aged under 50 years.
Methods :
A literature search was performed in PubMed and Google scholar using the keywords “rotator cuff tears” “rotator cuff repairs” “younger patients”. The latest research was conducted on 15 April 2014. In addition, for each item, the references were checked and potentially includable items in the analysis were searched manually. Inclusion criteria were studies in English or French, for acute or chronic tears of the rotator cuff in patients under 50 years of level of evidence 1-4 and reporting of clinical results at least 10 patients. Exclusion criteria were literature reviews, expert opinions, older studies of over 15 years and non-clinical studies. Two authors separately analyzed the abstracts. When the abstract was relevant section was analyzed. The publications that have no accessible abstracts were eliminated from the analysis. Data extracted included: (1) the characteristics of the study (design, year and number of patients), (2) the characteristics of the study participants (age, sex, sports or not, active or not before the trauma ), (3) the characteristics of the lesion of the rotator cuff (mechanism of injury, severity and size of the lesion, time from injury and surgery), (4) the realized treatment, surgical technique: arthroscopic or open sky (5) the surgical procedures associated potential (acromioplasty biceps bulge), (6) the clinical results and track at last follow. The primary endpoint was the clinical outcome of repair of tears of the rotator cuff in subjects younger than 50 years. Secondary outcomes were the time and level of return to sport or work, subjective outcomes, patient satisfaction, complications or recurrences at follow.
results:
Study characteristics:
A total of 10 studies were included in the analysis according to predefined criteria. It was only injury of the rotator cuff in young patients under 50 years. There was a minimum of 11 patients [20] up to 72 cases [21]. All of these studies has analyzed a total of 306 patients published between 1999 [15] and 2013 [22].
Patient characteristics:
The average age of the 306 patients (324 shoulders operated) was 36.6 ± 7.05 years (17-49), with a total of 243 men and 67 women (79% men). The injury was secondary to physical work in 73 cases out of 237 (30%), it was associated with the practice of sport in 78 cases out of 221 ??(35%), and finally in 70 of 218 cases (32%) it n ‘there was no concept of trauma. The dominant limb was achieved in 62% of cases. (Table 1).
Surgical technique:
The earliest studies used an open repair technique between 1999 and 2004 [15,16,17], and from 2005 all teams except YP Lin [21] operated patients arthroscopically. The average time from injury (or onset of symptoms) and surgery was 15 months /- 13.7 (1-108). This period was shorter for sports patients. The type of failure and / or extent of the lesion were well informed in 7 studies with a majority of medium injuries. The classification of lesions of the rotator cuff was arthroscopic: depending on the size (Fig 1), thickness (total or partial), and tendons involved (supraspinatus, infraspinatus, and / or sub scapular). The breaks were defined by size: small (1 cm), medium (1-3 cm), wide (3-5 cm) or massive (> 5 cm) according to the classification of Cofield’s [23,24]. (Table 2) acromioplasty was performed in 229 cases (70%), treatment of a lesion of the biceps was realized 65 of 258 (25%) and treatment of instability repair the labrum in the same time procedure was carried out in 15 cases out of 207 (7%).
Disaster Recovery:
The patients were able to resume a professional or sports activity in 91% of cases with an average of 4.8 months /- 0.44. (Table 3)
complication:
Only two infections were reported and 12 reoperations for recurrent tears were necessary (9 open technical / 3 arthroscopy)
Objective results:
It was difficult to synthesize results as teams used different assessment scores: (SANE) score “Single Assessment Numeric Evaluation score” [25] (ASES) score “American Shoulder and Elbow Surgeons score” [ 26], (UCLA) score “University of California in Los Angeles score” [27] Constant score [28]. These results are summarized in Table 3.
Subjective results:
At mean 48 months /- 21.3 (18-71), the subjective results are good with more than 85 /- 3% 14.3 (55-97) patients satisfied or very satisfied, with a trend with poorer results after an open technique.
Discussion:
Traumatic mechanism: Most ruptures of the rotator cuff in that young people were traumatic in origin or sports. However, in almost 30% of cases there was no concept but chronic traumatic pathology of the rotator cuff. Also in radiological MRI study, Sher [29] showed that 4% of the tears of the rotator patients aged under 40 were asymptomatic and did not require surgery. Milgrom [30] highlighted in ultrasound partial tears of the rotator cuff in 8% of patients aged 30 and 50.
Type lesion rupture type varies according to studies but more often it is complete ruptures transfixing medium size. Analysis of the results of this literature review has shown, however, 14% of small breaks, 53% of medium breaks 26% of large ruptures and 7% of massive tears.
Surgical techniques and results: rotator cuff repair techniques are identical to those used in the elderly, with opencast techniques, arthroscopic or mini-open. Arthroscopic support (Fig 2 and 3) repair of the rotator cuff in over 50 elderly patients showed similar or even better results than open techniques, with reproducible results [8, 31-34]. These results were also found in a younger population. Indeed young patients have multiple biological and mechanical factors that promote the success of a rotator cuff repair. Meyer [35] showed that osteoporotic bone may be one of the weak links in the surgical repair of the rotator cuff, a factor rarely found in a young population. In addition, the quality and vascularity of tendons are improved in younger patients [36]. However, younger patients require higher stress on their shoulders, which could lead to subjective or worse functional outcomes after repair. Indeed, some teams (open procedure) showed significant pain relief in 76% to 79% of patients and even complete disappearance of pain in 34% to 62% [15,16]. But long-term functional results were not satisfactory and mobility were not significantly improved in forward elevation, external rotation, and internal rotation [15,16]. The young population of Hawkins with a mean follow-up of 5.7 years [15] showed a rate of 68% satisfaction, but 16% of patients required a new shoulder surgery. Only 63% of patients returned to work full time and 47% of patients regained a sport at the same level. Sperling [16], with a minimum follow-up of 13 years, found that 45% of patients had unsatisfactory results and 24% of patients required further surgery of the shoulder. In both studies, there was open repair. Few studies have evaluated the results of arthroscopic repair of complete ruptures of the rotator cuff of traumatic etiology in young patients [13,14,18,19,20,22] but they have shown good results. (Table 3) All studies showed a significant increase in postoperative strength with a recovery of 85 to 90% of their resistance to forward elevation and external rotation of the shoulder. Krishnan in the study [13], the arthroscopic treatment of ruptures of the rotator cuff in young patients gives very good results with a minimum of pain, an average forward elevation of 170 ° and a mean external rotation of 60 °. Using the mean Constant score showed better results than 80. There are significantly improved mobility in anterior elevation, abduction and external rotation. Analysis of subsets showed that the VAS score, ASES score, Constant score, mobility and strength were not significantly different by gender, injury of the dominant shoulder of etiology traumatic or non-traumatic, treatment of biceps tenodesis or tenotomy by.
Patient Satisfaction: The satisfaction of young patients was on average higher than 95%. Burns and Snyder [14] examined patients aged under 50 and have reported a patient satisfaction rate of 97%, with no significant loss of post-operative movement. Ma et al.2 reported the results of surgical treatment of ruptures of the rotator cuff in twelve patients under forty. After a mean of 1.9 years follow-up, results were satisfactory.
Resuming activity: The return to professional sport or postoperative activity is on average greater than 91%. Two studies have examined the traumatic ruptures of the rotator among rugby players with a mean Constant score of 93.5 and a sports recovery of over 88% in five months [19 20]. Krishnan [13] has had excellent results in pain with physical activities back to the same level and very good mobility of the shoulder with a mean postoperative ASES score of 92 and a 90% return to job.
Total: The literature review showed that the short- and medium-term outcomes of patients less than 50 years after surgical treatment of ruptures of the rotator cuff are good with minimal pain and good recovery of function shoulder. Most ruptures of the rotator cuff in this young population are sports or traumatic origin. These lesions are of medium size. Additional procedures can be associated as acromioplasty, a biceps tenodesis or tenotomy, an anterior posterior stabilization by repairing the labrum. Surgical treatment may be open or arthroscopic sky with a tendency today only to arthroscopic gesture. The patient satisfaction rate exceeds 95% and the return to professional sport or postoperative activity is greater than 91%.
Conclusion:
Among young people, the lesions of the rotator cuff are most often traumatic origin or sport, they primarily affect male patients.
The obtained functional results are good and should encourage the surgical treatment of ruptures of the rotator cuff. Possible techniques, arthroscopy has its advantages with a very low failure rates and complications while allowing to obtain clinical and anatomical results as good or better than open surgical techniques.
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Doctor Nicolas LEFEVRE, Doctor Yoann BOHU, Doctor Antoine GEROMETTA, Doctor Shahnaz KLOUCHE , Doctor Serge HERMAN. – 25 décembre 2014.
