Complex regional pain syndrome (CRPS)-related hand lesions are one of the complications following arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the clinical outcomes of patients with CRPS-related hand lesions following ARCR.
Altogether, 103 patients with ARCR were included in this study (mean age, 63.6±8.2 years; 66 males and 37 females; follow-up period, preoperative to 12 months postoperative). Clinical assessment included the Japanese Orthopaedic Association (JOA) score, University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score from preoperative to 12 months postoperatively. The patients were either assigned to the CRPS group or non-CRPS group depending on CRPS diagnosis until the final follow-up, and clinical outcomes were then compared between the groups.
Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively. Both groups showed significant improvement in JOA, UCLA, and Constant scores preoperatively to 12 months postoperatively (p<0.001). Comparisons between the two groups were not significantly different, except for SF-36 “general health perception” (p<0.05) at 12 months postoperatively. At final follow-up, three patients had residual CRPS-related hand lesions with limited range of motion and finger edema.
CRPS-related hand lesions developed in 19.4% of patients following ARCR. Shoulder or upper-limb function improved in most cases at 12 months, with satisfactory SF-36 patient-based evaluation results. Patients with residual CRPS-related hand lesions at the last follow-up require long-term follow-up.
Rotator cuff tears commonly develop in middle-aged and elderly individuals [
Complex regional pain syndrome (CRPS) has various etiologic factors, including minor traumas, fractures, sprains, immobilization, and surgical interventions [
It has been reported in Japanese literature that CRPS-related hand lesions do not affect postoperative outcomes after ARCR [
The Institutional Review Board of Kurume University approved the study protocol (IRB No. 18129), and all subjects provided informed consent for participation.
Between January 2014 and September 2017, 276 patients underwent ARCR for a rotator cuff tear at our institution. Of these, 158 patients were transferred to our hospital in the early postoperative period (within 3 weeks) for postoperative rehabilitation. The inclusion criteria were (1) individuals who had ARCR, (2) individuals who underwent a postoperative rehabilitation program and were available for follow-up for at least 1 year postoperatively, and (3) individuals who had rigorous imaging evaluation with magnetic resonance imaging (MRI). The exclusion criteria were (1) individuals with periarticular fracture, (2) individuals with progressive arthritis, (3) individuals with osteoarthritis, (4) individuals with infection, (5) individuals with reoperation, and (6) individuals who had preoperative hand lesions such as ROM restriction or edema. Finally, 103 patients (66 males and 37 females; mean age, 63.6±8.2 years; mean period from onset to surgery, 10.4±11.6 months) were included in this study (
ARCR was considered for patients who did not respond to nonoperative treatment for ≥3 months, which included the administration of anti-inflammatory medication, subacromial/glenohumeral injections of corticosteroids or hyaluronic acid, and rehabilitation with a focus on physical therapy. ARCR was performed with the patient in the beach chair position under general anesthesia. The torn cuff was repaired using a single-row (one row of anchors placed on the lateral aspect of the footprint and the torn cuff fixed with interrupted sutures) or suture bridge (one row of anchors placed on the medial aspect of the footprint with or without tying and the torn cuff fixed with a transosseous knotless anchor on the lateral aspect of the footprint) method. Acromioplasty was performed in all patients, and capsular release and biceps tendon procedures (tenotomy/tenodesis) were performed as needed.
Postoperatively, patients were immobilized in a sling for 6 weeks using an abduction pillow and were instructed to maintain the shoulder at neutral rotation and 20° of abduction. Passive ROM exercises for the scapulothoracic, elbow, wrist, and finger joints were initiated immediately after surgery. Passive ROM of the glenohumeral joint was initiated 4 days postoperatively in small/medium tears and 4 weeks postoperatively in large/massive tears. Active ROM exercise was permitted at 6 weeks postoperatively. At 8 weeks, isometric muscle strengthening exercises were introduced and at 12 weeks, isotonic muscle strengthening exercises were allowed.
The present study used the criteria suggested by the MHLWJ [
Neurotropin (Nippon Zoki Pharmaceutical Co., Osaka, Japan) was administered orally to patients diagnosed with CRPS according to the CRPS criteria. If necessary, tramadol or pregabalin or both tramadol and pregabalin were added. Stellate ganglion block and vortex flow baths with laser beams were routinely applied. Patients with persistent symptoms were referred to an anesthesiologist who specializes in nerve blocks.
Patient information, including age, sex, and disease duration, was collected preoperatively. Japanese Orthopaedic Association (JOA) score (total score of 100 points, scored for items like pain, function, ROM, radiographic findings, and joint stability), University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were evaluated preoperatively and at 12 months postoperatively. Clinical outcomes of the study were assessed by three physiotherapists with more than 10 years of experience.
The integrity of the rotator cuff was determined using MRI at 12 months postoperatively. Fatty degeneration was assessed using the Goutallier classification (supraspinatus, infraspinatus, and subscapularis) on preoperative MRI “Y view” [
JMP 13 (SAS Institute Inc., Cary, NC, USA) was the software program used for statistical analysis. The Wilcoxon rank-sum test was used for continuous data such as age and clinical outcomes, and the chi-square test was used for categorical data such as sex and retear rate, to compare basic characteristics between the two groups. The Friedman test was used to compare the variance between CRPS scores from onset to 1 year postoperatively in the CRPS group. The Steel-Dwass test was used for multiple comparisons of CRPS scores. The significance level was set at <5%.
Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively (mean 19.6±19.6 days after surgery). Consequently, patients were divided into two groups: 83 patients in the non-CRPS group and 20 patients in the CRPS group. The CRPS score of the CRPS group was 2.4±0.5 points at the onset of CRPS (range, 1–8 weeks), 2.05±0.67 points at 8 weeks postoperatively, 2.05±0.76 points at 9 weeks postoperatively, 1.95±0.83 points at 10 weeks postoperatively, 1.9±0.85 points at 11 weeks postoperatively, 1.8±0.89 points at 12 weeks postoperatively, 0.95±1.0 points at 6 months postoperatively, 0.5±0.76 points at 9 months postoperatively, and 0.4±0.75 points at 12 months postoperatively. There was a significant improvement at 6 months postoperatively compared to the onset of CRPS (p<0.001) (
The JOA scores (CRPS and non-CRPS group) were 65.3±12.4 and 69.1±12.5 preoperatively and 87.3±7.1 and 88.0±9.4 at 12 months postoperatively, and both groups showed significant improvement at 12 months postoperatively compared with that observed preoperatively (p<0.001, respectively), but there was no significant difference between the two groups preoperatively and postoperatively (
In the SF-36 scores, there were no significant differences between the two groups, except for “general health perceptions” at 12 months postoperatively (p<0.05) (
At the final follow-up, three patients had residual CRPS-related hand lesions with limited ROM and edema of the fingers. These three patients showed a CRPS score of 2 points at the final follow-up, whereas the CRPS score was >3 points at the onset. The clinical scores of these three patients were relatively low compared with those of other groups (17 patients in the CRPS group and 83 patients in the non-CRPS groups) (
Complications associated with ARCR, including loose hardware, failure of repair, traction in the lateral position, direct injury, compression secondary to fluid extravasation, tourniquet-like problems associated with wrapping the operative extremity, and postoperative stiffness have been reported [
Previous Japanese studies have shown that CRPS-related hand lesions do not affect shoulder function after ARCR [
Generally, CRPS develops as a hand lesion on the operative side following ARCR [
In 1994, the IASP criteria were proposed as a diagnostic method for CRPS [
Harada et al. [
This study had several limitations. First, it has a retrospective design with a small sample size and short follow-up period. Second, the effects of drug treatments given only to the CRPS group cannot be ruled out. Third, all surgeries were performed in the beach chair position, and it is not clear whether differences in surgical posture affect hand symptoms. Fourth, the follow-up rate was relatively low because the subjects of the present study were patients transferred to our hospital for postoperative rehabilitation. However, the CRPS-related hand lesion incidence in this study was close to that observed in previous studies [
CRPS-related hand lesions developed in 19.4% of patients after ARCR. Shoulder or upper-limb function improved in most cases at 12 months, with satisfactory results of SF-36 patient-based evaluation. ROM of the involved fingers did not improve in three patients with high CRPS score at onset; therefore, long-term follow-up will be necessary in these patients.
None.
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Change in complex regional pain syndrome (CRPS) score from the onset of CRPS-related hand lesions to 12 months after surgery. *p<0.001.
Comparison of shoulder scores. (A) Japanese Orthopaedic Association score, (B) University of California at Los Angeles score, (C) Constant score. There were no statistically significant differences between the complex regional pain syndrome (CRPS) and non-CRPS groups in clinical shoulder scores before and at 12 months after surgery. NS: not significant.
Patient demographics
Variable | Total (n=103) | CRPS (n=20) | Non-CRPS (n=83) | P-value |
---|---|---|---|---|
Demographic variable | ||||
Age (yr) | 63.6±8.2 | 64.9±7.5 | 63.3±8.4 | 0.43 |
Sex (male:female) | 66:37 | 16:4 | 50:33 | 0.10 |
Diabetes | 12 (11.7) | 1 (5.0) | 11 (13.3) | 0.30 |
Dominant-side surgery | 64 (62.1) | 16 (80.0) | 48 (57.8) | 0.07 |
Traumatic onset | 48 (46.6) | 11 (55.0) | 37 (44.6) | 0.43 |
Symptom duration (mo) | 10.4±11.6 | 10.3±11.0 | 10.4±11.8 | 0.84 |
Workers' compensation | 14 (13.6) | 2 (10.0) | 12 (14.5) | 0.60 |
Structural variable | ||||
Tear size (cm) | 2.6±1.2 | 2.8±1.2 | 2.5±1.2 | 0.25 |
Tear size classification | 0.67 |
|||
Small | 17 | 2 | 15 | |
Medium | 40 | 7 | 33 | |
Large | 40 | 10 | 30 | |
Massive | 6 | 1 | 5 | |
Preoperative global fatty degeneration index | 1.2±0.6 | 1.1±0.7 | 1.2±0.6 | 0.48 |
Retear at 12 months | 14 (13.6) | 4 (20.0) | 10 (12.0) | 0.40 |
Intraoperative variable | ||||
Repair technique | 0.77 |
|||
Suture bridge | 99 | 19 | 80 | |
Single row | 4 | 1 | 3 | |
Capsular release | 24 (23.3) | 6 (30.0) | 18 (21.7) | 0.33 |
Manipulation | 17 (16.5) | 6 (30.0) | 11 (13.3) | 0.07 |
Contracture |
24 (23.3) | 7 (35.0) | 17 (20.5) | 0.18 |
Treatment of long head of biceps tendon | 0.48 |
|||
Untreated | 27 (26.2) | 4 (20.0) | 23 (27.7) | |
Treated | 25 (24.3) | 16 (80.0) | 60 (72.3) |
Values are presented as mean±standard deviation or number (%).
CRPS: complex regional pain syndrome.
Contracture was judged by Manipulation or Capsular release;
Continuous data; Wilcoxon rank sum test;
Categorical data; χ2 test.
Clinical results of SF-36 scores with or without CRPS
Variable | CRPS (n=20) | Non-CRPS (n=83) | p-value |
---|---|---|---|
Preoperative | |||
Physical functioning | 64.4±26.7 | 75.0±16.3 | 0.17 |
Role physical | 51.8±28.8 | 53.0±24.8 | 0.86 |
Bodily pain | 37.7±17.9 | 43.1±19.6 | 0.28 |
General health perception | 56.4±16.1 | 61.4±17.8 | 0.28 |
Vitality | 53.1±18.0 | 57.7±19.7 | 0.49 |
Social functioning | 53.1±15.2 | 65.3±24.5 | 0.11 |
Role emotional | 50.9±28.4 | 62.0±30.5 | 0.25 |
Mental health | 53.7±23.9 | 66.5±19.0 | 0.07 |
Postoperative 12 months | |||
Physical functioning | 77.0±24.6 | 83.4±17.8 | 0.29 |
Role physical | 72.8±21.9 | 77.3±23.7 | 0.32 |
Bodily pain | 68.1±17.8 | 69.7±19.3 | 0.85 |
General health perception | 59.0±20.3 | 67.3±16.7 | 0.04 |
Vitality | 66.3±21.6 | 67.7±17.5 | 0.96 |
Social functioning | 77.5±26.2 | 85.4±20.4 | 0.26 |
Role emotional | 82.9±21.9 | 82.3±22.7 | 0.89 |
Mental health | 73.5±20.7 | 74.3±17.5 | 0.76 |
Values are presented as mean±standard deviation.
SF-36: 36-item short form health survey, CRPS: complex regional pain syndrome.
Statistically significant among the two groups with the Wilcoxon rank-sum test.
Clinical results of QuickDASH scores with or without CRPS
Variable | CRPS (n=20) | Non-CRPS (n=83) | p-value |
---|---|---|---|
Preoperative | |||
Disability/symptom | 38.2 ±18.6 | 34.6±17.3 | 0.39 |
Work (14/51) |
42.0±26.0 | 43.0±30.6 | 0.81 |
Sports/music (7/25) |
74.1±29.2 | 53.3±38.8 | 0.18 |
Postoperative 12 months | |||
Disability/symptom | 14.8±10.7 | 12.7±13.9 | 0.15 |
Work (13/52) |
14.4±14.3 | 13.9±18.5 | 0.68 |
Sports/music (9/36) |
24.3±31.5 | 18.2±22.4 | 0.97 |
Values are presented as mean±standard deviation.
QuickDASH: Quick Disabilities of the Arm, Shoulder, and Hand, CRPS: complex regional pain syndrome.
Number of respondents (CRPS/non-CRPS).
Clinical scores for patients with CRPS-unimproved, CRPS-improved, and non-CRPS groups
Variable | CRPS (n=20) | Non-CRPS (n=83) | ||
---|---|---|---|---|
Unimproved (n=3) | Improved (n=17) | |||
JOA score | Preop | 56.8±10.8 | 66.7±12.3 | 69.1±12.5 |
Postop 12 mo | 83.5±8.2 | 87.9±5.8 | 88.0±9.4 | |
UCLA score | Preop | 16.0±4.6 | 15.5±5.3 | 15.8±4.9 |
Postop 12 mo | 25.7±14.4 | 27.7±5.6 | 29.2±5.8 | |
Constant score | Preop | 41.0±20.2 | 49.1±17.7 | 52.6±16.2 |
Postop 12 mo | 69.0±14.0 | 81.4±12.2 | 80.0±14.9 | |
QuickDASH | ||||
Disability/symptom | Preop | 55.7±20.9 | 35.7±17.7 | 34.6±17.3 |
Postop 12 mo | 25.0±6.0 | 13.0±10.4 | 12.7±13.9 | |
Work | Preop | - | 42.0±26.0 | 43.0±30.6 |
Postop 12 mo | 31.3±8.8 | 11.4±13.1 | 13.9±18.5 | |
Sports/music | Preop | 100 | 69.8±29.4 | 53.3±38.8 |
Postop 12 mo | 46.9±39.8 | 17.9±29.0 | 18.2±22.4 | |
SF-36 | ||||
Physical functioning | Preop | 35.0±14.1 | 70.3±23.5 | 75.0±16.3 |
Postop 12 mo | 36.7±24.7 | 84.1±16.8 | 83.4±17.8 | |
Role physical | Preop | 21.9±4.4 | 57.8±27.8 | 53.0±24.8 |
Postop 12 mo | 60.4±25.3 | 75.0±21.3 | 77.3±23.7 | |
Bodily pain | Preop | 26.5±6.4 | 39.9±18.9 | 43.1±19.6 |
Postop 12 mo | 62.0±21.5 | 69.2±17.6 | 69.7±19.3 | |
General health perception | Preop | 42.5±3.5 | 59.2±16.3 | 61.4±17.8 |
Postop 12 mo | 41.3±9.3 | 62.1±20.2 | 67.3±16.7 | |
Vitality | Preop | 34.4±13.3 | 56.9±16.8 | 57.7±19.7 |
Postop 12 mo | 62.5±25.0 | 66.9±21.7 | 67.7±17.5 | |
Social functioning | Preop | 37.5±0 | 56.3±14.7 | 65.3±24.5 |
Postop 12 mo | 58.3±14.4 | 80.9±26.6 | 85.4±20.4 | |
Role emotional | Preop | 16.7±11.8 | 57.8±25.6 | 62.0±30.5 |
Postop 12 mo | 80.6±17.3 | 83.3±23.0 | 82.3±22.7 | |
Mental health | Preop | 45.0±21.2 | 55.5±25.1 | 66.5±19.0 |
Postop 12 mo | 46.7±20.2 | 78.2±17.3 | 74.3±17.5 |
Values are presented as mean±standard deviation.
CRPS: complex regional pain syndrome, JOA: Japanese Orthopaedic Association, UCLA: University of California, Los Angeles, QuickDASH: Quick Disabilities of the Arm, Shoulder, and Hand, SF-36: 36-item short form health survey, Preop: preoperative, Postop: postoperative.