Flurin P-H, Landreau P, Gregory T, Boileau P, Brassart N, Courage O, Dagher E, Graveleau N, Guillo S, Kempf J-F, Lafosse L, Laprelle E, Toussaint B
Clinique de Bordeaux-Mérignac, 9, rue Jean-Moulin, 33700 Bordeaux-Mérignac.
Rev Chir Orthop Reparatrice Appar Mot. 2005 Dec;91(S8):31-42. doi: 10.1016/s0035-1040(05)84503-9.
Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy.
The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%.
On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome.
Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.
肩袖撕裂的全关节镜修复现已成为常规手术。法国关节镜学会通过一项回顾性多中心分析对所采用的技术进行了评估。
该系列研究仅限于对使用Constant评分以及关节造影磁共振成像（arthro - MRI）或关节扫描评估的冈上肌或冈下肌全层撕裂进行关节镜修复，且随访时间至少为一年。数据采用SPSS 10软件进行处理。该系列包括2001年1月至2003年6月间接受手术的576例患者。患者平均年龄为57.7岁；52%为男性，60%为体力劳动者。术前Constant评分平均为46.4±13.4/100。69%的肩部撕裂仅限于冈上肌，23.5%的肩部撕裂延伸至冈下肌上三分之一，7.5%的肩部撕裂累及整个冈下肌。41.7%的肩部冈上肌撕裂位于远端，44%位于中间段，14.3%为回缩型。60%的肩部冈上肌脂肪变性为0级，27%为1级，11%为2级，2%为3级。所有病例均进行了关节镜修复，60.9%采用局部麻醉。33%使用了生物可吸收植入物，62.1%使用了金属植入物。92.7%的患者进行了肩峰成形术，14.9%的患者进行了关节囊切开术。
平均主观评分为8.89/10。Constant评分从46.3±13.4提高到82.7±10.3，62%的患者肩部完全无痛。肌力从5.8±3.7提高到13.6±5.4。平均随访18.5个月时，94%的肩部结果优良。该系列的并发症发生率为6.2%，其中3.1%为持续性僵硬，2.7%为反射性交感神经营养不良，0.2%为感染，0.2%为锚钉移位。55.7%的肩部袖带被认为正常，19%的肩部出现肌腱内附加影像，即74.7%的未破裂袖带。9.5%的肩部完整性仅有轻微丧失，15.7%的肩部有明显丧失，即25.2%的复发性撕裂。
Constant评分与肩袖完整性密切相关（p<0.0001）。在力量（p<0.0001）、活动度（0.01）和活动能力（0.04）方面也发现了这种相关性，但在疼痛方面未发现。临床结果与术前病变的延伸、回缩、实质内撕裂和脂肪变性相关。对于年龄较大、范围广泛、回缩或伴有脂肪变性的撕裂，解剖学结果在统计学上不太理想。年龄与初始撕裂的范围相关，也与不太理想的解剖学和临床结果相关。职业事故与不太理想的临床结果相关。
愈合后的功能改善是进行修复的有力依据。关节镜检查具有并发症发生率低且临床和解剖学结果良好的优点。年龄与功能结果和愈合相关，但不是禁忌证。
