CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2020; 55(04): 476-482
DOI: 10.1055/s-0039-3402475
Artigos Originais
Ombro e Cotovelo

Acetabularization as a Protective Factor in Rotator Cuff Arthropathy[*]

Article in several languages: português | English
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
,
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
,
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
,
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
,
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
,
1  Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
› Author Affiliations
 

Abstract

Objective To check if shoulders with acetabularization have better functional results in cases of rotator cuff arthropathy.

Methods A clinical and radiological cross-sectional evaluation of 65 shoulders with rotator cuff arthropathy by measuring the range of motion (RoM) of the shoulder, the Constant-Murley score, and the radiological classifications of Hamada and Seebauer. The clinical findings were compared with the radiographic findings.

Results According to the classification of Seebauer, we observed better results regarding the RoM in type-A shoulders. There was a statistically significant difference regarding anterior elevation and medial rotation between types A and B (p < 0.05). Lateral rotation did not show a statistically significant difference between types A and B. The Constant-Murley score presented better results in type A, and there was a statistically significant difference between groups A and B (p < 0.05). According to the classification of Hamada, we observed that the RoM had better results in types 3, 2 and 1, and there was a statistically significant difference regarding anterior elevation and medial rotation (p < 0.05) compared with groups 4A, 4B and 5. There was no statistically significant difference between the Hamada groups regarding lateral rotation. According to Hamada, the Constant-Murley score showed better results in types 3, 1 and 2, and there was a statistically significant difference between groups 3 and 5.

Conclusion The RoM and shoulder function were better in patients with acetabularization (Seebauer 1A and Hamada 3), and worse in those with glenohumeral arthrosis (Seebauer 1B, 2B and Hamada 4A, 4B and 5).


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Introduction

Rotator cuff arthropathy (RCA) is a possible evolution for rotator cuff chronic lesions.[1] [2] [3] It is usually associated with mobility deficit and an important shoulder pain scenario. However, we observed varying degrees of pain and range of motion (RoM),[4] [5] including asymptomatic patients.

Rotator cuff arthropathy can develop with shoulder arthrosis, bone erosion, osteopenia, decreased RoM and pain. Its pathophysiology is not fully understood, and there are mechanical theories (due to muscle imbalance), and theories involving nutrition and the deposition of calcium phosphate crystals. It mainly affects the female gender, the dominant limb and the elderly.[6] [7] [8] Its clinical picture involves pain mainly related to movement and nocturnal pain, joint effusion, muscular weakness and decreased RoM in varying degrees.[9] [10] [11]

In order to perform the present work, we assumed that, within the group of patients with RCA, there are those with intense pain and impaired shoulder mobility, and those who have controlled pain and satisfactory mobility to carry out their daily tasks. We also think that there is an adaptive phase in RCA, in which the shoulder should stabilize and consequently present satisfactory mobility and controlled pain.

In our clinical practice, we perceive that there could be a clinico-radiographic incompatibility, and that the radiographs do not always have a direct relationship with pain and shoulder function.

The objective of the present study was to functionally evaluate patients with RCA, correlating function and shoulder pain with the radiographic findings according to the Seebauer and the Hamada classifications, which are the two main radiographic classifications for this pathology ([Figures 1] and [2]). More specifically, we seek to verify whether acetabularization (concave deformity in the inferior surface of the acromion[9]) influences the functional results.

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Fig. 1 Anteroposterior radiographs of the shoulder and Seebauer classification.
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Fig. 2 Anteroposterior radiographs of the shoulder and Hamada classification.

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Materials and methods

The present is a cross-sectional descriptive study performed from December 2016 to January 2019 with patients with RCA. The inclusion criteria were: patients with rotator cuff arthropathy submitted to anteroposterior radiography of the shoulder, magnetic resonance imaging of the shoulder, and physical examination directed with evaluation of anterior elevation, lateral rotation, medial rotation and filling out the Constant-Murley score. The exclusion criteria were: previous neurological lesions with involvement of the studied shoulder, previous fracture of the shoulder, previous surgery, agenesis, and malformations of the shoulder. The present study was approved by the Ethics in Research Committee and by the Plataforma Brazil database under CAAE 79222017.0.0000.5505.

A total of 65 shoulders were studied. The mean age of the patients was 73 years old (range: 60 years to 88 years), and there were 11 men (16.9%) and 54 women (83.1%). There were 41 dominant (63.1%) and 23 non-dominant limbs (35.4%), in addition to 1 ambidextrous patient (1,5%) and 7 cases of bilateral impairment (10.8%). The duration of the pain ranged from 3 months to 30 years, with an average of 5 years.

The physical examination and the classification of the shoulders were performed by a single observer, an orthopedist and shoulder and elbow surgeon. Separating patients according to the Seebauer classification, there were 27 type-1A cases, 8 type-1B cases, 24 type-2A cases, and 6 type-2B cases. Taking into account the Hamada classification, there were 11 type-1 cases, 12 type-2 cases, 18 type-3 cases, 8 type-4A cases, 9 type-4B cases, and 7 type-5 cases.

In total, 6 patients reported having no pain (according to the Seebauer classification, 3 type-1A cases and 3 type-2A cases; according to the Hamada classification, 4 type-3 cases, 1 type-1 case, and 1 type-2 case), and 6 patients reported not having shoulder mobility deficit (according to the Seebauer classification, 5 type-1A cases, 1 type-2A case; according to the Hamada classification, 3 type-3 cases, 2 type-1 cases, and 1 type-4a case).

For the statistical analysis, a significance level of 0.05 and confidence intervals of 95% were established. Parametric tests were used for the quantitative and continuous variables. The distribution of the data was normal, and we used the following software: the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), version 20.0, Minitab (Minitab, LLC, State College, PA, US), version 16, and Excel 2010 (Microsoft Corp. Redmond, WA, US). We also used analysis of variance (ANOVA) and Tukey multiple comparison tests.


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Results

All of the patients presented complete lesion of the supraspinatus and infraspinatus tendons. The subscapular tendon had a distribution of 27.7% with complete lesion (the entire extension of the tendon), 47.7% with partial lesion (part of the tendon extension), 1.5% normal, and 23.1% with tendinopathy. In relation to the long head of the biceps, 47.7% were absent, and 52.3% were present.

According to the Seebauer classification, regarding RoM, we observed better results in cases of type A (the best results were found among group 1A, with averages of 147.41 degrees of anterior elevation, 37.59 degrees of lateral rotation, and 49.59 points in the Constant-Murley score). There was statistically significant difference in anterior elevation and medial rotation between types A and B (p < 0.05). Lateral rotation showed no statistically significant difference between types A and B (P > 0.05). The Constant-Murley score presented better results in cases of type A, and there was a statistically significant difference between groups A and B (p < 0.05) ([Figures 3] and [4]).

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Fig. 3 Charts of the existing relationships between the Seebauer classification types and the values of the averages of the anterior elevation, lateral rotation (with their averages in degrees) and Constant-Murley score (with the average in points).
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Fig. 4 Graph of the relationship between the Seebauer classification types and the distribution of the medial rotation.

According to the classification of Hamada, we observed that RoM had better results in cases of types 3, 2 and 1 (type 3 presented the best results for anterior elevation and Constant-Murley score averages, with 162.22 degrees and 59.50 points respectively. Regarding the lateral rotation, the best result was the mean of 40 degrees found in cases of type 1 followed by 36.11 degrees in cases of type 3). There was a statistically significant difference regarding anterior elevation and medial rotation (p < 0.05) when those groups were compared with groups 4a, 4b and 5. There was no statistically significant difference between the Hamada groups in relation to lateral rotation (p > 0.05). Still according to the Hamada classification, the Constant-Murley score presented better results in cases of types 3, 1 and 2, and there was a statistically significant difference (p < 0.05) between groups 3 and 5 ([Figures 5] and [6]).

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Fig. 5 Charts of the existing relationships between the Hamada classification types and the values of the averages of the anterior elevation, lateral rotation (with its averages in degrees) and Constant-Murley score (with the average in points).
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Fig. 6 Graph of the relationship between the Hamada classification types and the distribution of the medial rotation.

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Discussion

In our literature search, we perceived that RCA is regarded as a single group. There are studies comparing pre- and postoperative function and pain in the case of treatment of RCA with shoulder prostheses,[11] [12] [13] but no studies that report the great clinical variation that exists within the RCA group in relation to pain and RoM have been found.

We evidenced that RCA patients had varying degrees of mobility deficit and different intensities of pain, and some patients even report feeling no pain. In the literature, we did not find studies that attempted to divide the large group of patients with RCA into subgroups to try to understand the heterogeneity of these patients, nor the factors that could contribute to this clinical difference.

The use of the Seebauer and Hamada classifications enabled us to evidence the factors that may contribute for this clinical difference. In our study, we showed a correlation between worse function and worse RoM (medial rotation and elevation) in the type-B groups (1b and 2b) of Seebauer and in types 4a, 4b and 5 of Hamada. We can then consider that these potentially are the groups that benefited the most from the surgical treatment, either by hemiarthroplasty or by reverse shoulder arthroplasty.

On the other hand, patients who presented better mobility and better function were those of type A (1A and 2A) of Seebauer and Hamada types 1, 2 and 3. Within this group, we could still divide types 1A of Seebauer and 3 of Hamada as the ones that would have a better chance of achieving good results with the conservative treatment, because they presented the best functional outcomes among all groups studied.

Acetabularization probably acts as a stabilizing factor for the shoulder. Amaral et al[13] demonstrated, in their 2014 study, postoperative results with reverse arthroplasty of the shoulder for RCA treatment, with a mean elevation of 150 degrees and mean Constant-Murley score of 60 points, a similar score found in our study on the shoulders that presented acetabularization without glenohumeral arthrosis (Seebauer 1A, with an average anterior elevation of 147.41 degrees and a mean Constant-Murley score of 49.59 points. Hamada 3 with average anterior elevation of 162.22 degrees, and a mean Constant-Murley score of 59.50 points). This radiographic finding is, therefore, a potential indicator of conservative treatment for RCA.

In the present study, the highest incidence of patients without pain complaints and patients without complaints regarding RoM was observed in the groups who presented acetabularization.

The condition of the long head of the biceps and the subscapular tendon are factors that could interfere in the RoM of the shoulder. According to the Seebauer classification, the distribution of absence or presence of the long head of the biceps did not present a statistical significance, but was more present in cases of type A. The presence or absence of the subscapular tendon also did not present a statistical significance among the Seebauer groups ([Table 1]). Therefore, no positive or negative interference could be attributed to the results found in the present study regarding these parameters.

Table 1

Seebauer

Type 1A

Type 1B

Type 2A

Type 2B

Total

p-value

n

%

n

%

n

%

n

%

n

%

Long head of the biceps

Absent

9

33.3%

5

62.5%

12

50.0%

5

83.3%

31

47.7%

0.110

Present

18

66.7%

3

37.5%

12

50.0%

1

16.7%

34

52.3%

Subscapular

Complete injury

6

22.2%

3

37.5%

5

20.8%

4

66.7%

18

27.7%

0.489

Partial injury

15

55.6%

4

50.0%

11

45.8%

1

16.7%

31

47.7%

Normal

0

0.0%

0

0.0%

1

4.2%

0

0.0%

1

1.5%

Tendinopathy

6

22.2%

1

12.5%

7

29.2%

1

16.7%

15

23.1%

According to the Hamada classification, the statistical difference between groups 1, 2 and 3 was evident, with predominance of the presence of the long head of the biceps, and groups 4a, 4b and 5 with predominance of its absence. This result may have contributed to the best functional outcomes of groups 1, 2 and 3; therefore, considering the evolutionary aspect of the Hamada classification, the long head of the biceps could act as a humeral head depressor and prevent the progression of arthropathy, as evidenced by Garcia et al[14] in their 2018 study. Regarding the subscapular tendon, there was no statistically significant difference among the groups ([Table 2]), which leads to the belief that this parameter did not influence the functional results in the studied shoulders.

Table 2

HAMADA

Type 1

Type 2

Type 3

Type 4A

Type 4B

Type 5

Total

p-value

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Long head of the biceps

Absent

4

36.4%

2

16.7%

8

44.4%

6

75.0%

7

77.8%

4

57.1%

31

47.7%

0.048

Present

7

63.6%

10

83.3%

10

55.6%

2

25.0%

2

22.2%

3

42.9%

34

52.3%

Subscapular

Complete injury

0

0.0%

4

33.3%

3

16.7%

4

50.0%

4

44.4%

3

42.9%

18

27.7%

0.427

Partial injury

9

81.8%

4

33.3%

9

50.0%

3

37.5%

4

44.4%

2

28.6%

31

47.7%

Normal

0

0.0%

0

0.0%

1

5.6%

0

0.0%

0

0.0%

0

0.0%

1

1.5%

Tendinopathy

2

18.2%

4

33.3%

5

27.8%

1

12.5%

1

11.1%

2

28.6%

15

23.1%

Because the present is a cross-sectional study, there is doubt whether the Seebauer and Hamada classifications follow an evolutionary pattern or if there are groups that evolve differently. A group could evolve with stability, muscular balance of the shoulder, without arthrosis, with a favorable clinical scenario, and another group, with instability, muscular imbalance, glenohumeral arthrosis and unfavorable clinical scenario. A longitudinal study could help clarify this issue.


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Conclusion

Acetabularization, without glenohumeral arthrosis, has been shown to be associated with cases with better shoulder functional results in patients with RCA diagnosis, which can be considered a protective factor.


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Conflito de Interesses

Os autores declaram não haver conflitos de interesse.

* Work performed at the Center os Sports Traumatology (CETE), Departament of Orthopedics and Traumatology, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil.



Endereço para correspondência

Leonardo Roure Esteves
Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (Unifesp)
Rua Borges Lagoa 570, Vila Clementino, São Paulo, SP, 04038-000
Brazil   

Publication History

Received: 02 November 2018

Accepted: 26 March 2019

Publication Date:
08 June 2020 (online)

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revinter Publicações Ltda
Rio de Janeiro, Brazil


Zoom Image
Fig. 1 Radiografias anteroposteriores do ombro e tabela da Classificação de Seebauer.
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Fig. 2 Radiografias anteroposteriores do ombro e tabela da Classificação de Hamada.
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Fig. 1 Anteroposterior radiographs of the shoulder and Seebauer classification.
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Fig. 2 Anteroposterior radiographs of the shoulder and Hamada classification.
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Fig. 3 Gráficos das relações existentes entre os tipos da classificação de Seebauer e os valores das médias da elevação anterior, rotação lateral (com suas médias em graus), e escore de Constant-Murley (com a média em pontos).
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Fig. 4 Gráfico da relação entre os tipos da classificação de Seebauer e a distribuição da rotação medial.
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Fig. 5 Gráficos das relações existentes entre os tipos da classificação de Hamada e os valores das médias da elevação anterior, rotação lateral (com suas médias em graus), e escore de Constant-Murley (com a média em pontos).
Zoom Image
Fig. 6 Gráfico da relação entre os tipos da classificação de Hamada e a distribuição da rotação medial.
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Fig. 3 Charts of the existing relationships between the Seebauer classification types and the values of the averages of the anterior elevation, lateral rotation (with their averages in degrees) and Constant-Murley score (with the average in points).
Zoom Image
Fig. 4 Graph of the relationship between the Seebauer classification types and the distribution of the medial rotation.
Zoom Image
Fig. 5 Charts of the existing relationships between the Hamada classification types and the values of the averages of the anterior elevation, lateral rotation (with its averages in degrees) and Constant-Murley score (with the average in points).
Zoom Image
Fig. 6 Graph of the relationship between the Hamada classification types and the distribution of the medial rotation.