Summary

The presence of gastroesophageal reflux disease and the treatment of partial lesions of the rotator cuff significantly influence the development of post-operative shoulder stiffness after single-row arthroscopic rotator cuff repair.

Abstract

Background

Post-operative shoulder stiffness (SS) after arthroscopic rotator cuff (RC) repair has been reported with variable incidence and numerous intra-operative risk factors have been described. This prospective study aims to document the incidence of post-operative SS and to evaluate the role of pre- and intra -operative risk factors in the development of this complication.

Methods

Pre- and intra-operative risk factors for SS were prospectively evaluated in 237 consecutive patients undergoing single-row arthroscopic RC repair for posterosuperior RC tears. The following intra operative factors were evaluated: tear size according to the Southern California Orthopedic Institute, type and configuration of the repair, involvement and repair of the subscapularis tendon, capsular and bicipital concomitant procedures, presence and treatment of degenerative changes of the glenohumeral and acromioclavicular joints, time and duration of surgery. The following pre-operative factors were evaluated: age, body mass index (BMI), sex, dominant side, smoking habits, diabetes mellitus, hypertension, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease, anxiety or depressive disorders, hyperthyroidism, hypothyroidism, dislipidemia, hypercholesterolemia. For female patients, specific attention was paid to menarche age, menopausal age, pregnancies, miscarriages and treatment with any hormonal therapy.

Results

The incidence of post-operative SS was 8.02%. The presence of GERD was significantly associated with development of post-operative SS (p=0.0026). The treatment of partial lesions was also significantly associated with development of post-operative SS (p=0.0083). Female sex, premenopausal condition, younger age, history of anxiety or depression appeared also associated with the development of this pathological condition.

Conclusions

The presence of GERD significantly influences the development of post-operative SS after single-row arthroscopic RC repair. An underlying aspecific pro-inflammatory condition, characterised by increased expression of TNF-a and TGF-ß, and disorders in retinoid metabolism are hypothesis which could explain this previously unknown association. The role of anxiety and depression has not been clearly defined yet and deserves further investigation. The documented incidence of post-operative SS falls among previously reported ranges, with females significantly more affected than men.
The treatment of partial lesions of the rotator cuff bears a higher risk of post-operative SS than the treatment of complete lesions. A possible explanation of this finding is the additional surgical trauma necessary to complete the lesion, related to local release of inflammatory cytokines. Another hypothesis is that the subgroup of patients who require treatment for partial tears have a tendency to localize shoulder pain in a more severe way, thus requiring surgery already with smaller tears and subsequently developing more frequently this painful complication.