Department of Orthopaedic Surgery, Washington University School of Medicine, 14532 South Outer Forty Drive, Chesterfield, MO 63017, USA.
Clin Sports Med. 2012 Oct;31(4):665-74. doi: 10.1016/j.csm.2012.07.004.
Rotator cuff disease accounts for more than 4.5 million annual visits to a physician, and more than 75,000 surgical repairs are performed a year. Surgical techniques have evolved from all open repairs to all arthroscopic repairs being the most commonly used. The purpose of this article is to review the current evidence regarding the outcomes of surgical techniques in rotator cuff surgery. Reported outcomes have been favorable with open, mini-open, and arthroscopic repairs. Recently, a committee sponsored by the AAOS published a clinical practice guideline summary regarding the management of rotator cuff tears. The guidelines touched aspects of both nonoperative and operative repair. In regard to operative repair, the committee could not recommend a modality of surgical repair (eg, arthroscopic vs open) as a superior method, citing a lack of comparative studies. The theoretical advantage of arthroscopic surgery lies in smaller soft tissue dissection and the ability to evaluate and treat the glenohumeral joint. However, no study using patient-based outcomes has shown superiority compared with open or mini-open repairs. With the method of surgical repair not changing outcomes, investigation has recently focused on optimizing bone-tendon healing in rotator cuff repair. Double-row fixation allows for a more anatomic reapproximation of the rotator cuff footprint on the greater tuberosity versus single-row and has been shown to be biomechanically superior. Despite this, no clinical studies have shown superiority of one type of repair versus the other. The AAOS committee citing similar evidence gave a weak recommendation for the use of achieving tendon-to-bone healing with double-row fixation. Transosseous-equivalent repair, which provides a high compressive force on the tendon-to-bone interface of repair, is the newest fixation method under investigation to optimize healing. The use of collagen and biologic augmentation has gained interest as researchers are attempting to optimize rotator cuff healing. There is moderate evidence against the use of porcine small intestine submucosa xenograft patches. Other commercially available collagen augments have yet to be proven as either beneficial or detrimental. Other than PRP, which has not shown to have any benefit augmenting repair, no biologic augment has been investigated clinically. Overall, rotator cuff surgery portends a good outcome for appropriately selected patients. However, there is not much high-quality evidence-based research that can be used to conclude what surgical treatments are superior or appropriate for a given patient. Future research should be aimed at identifying whether and in whom rotator cuff healing is appropriate to better identify surgical candidates as well as to determine the best surgical repair strategy.
肩袖疾病每年导致超过 450 万人次就诊于医生，并且每年进行超过 75000 例手术修复。手术技术已经从所有开放性修复发展到最常用的所有关节镜修复。本文的目的是回顾肩袖手术中手术技术的现有证据。开放性、小切口和关节镜修复的报道结果是有利的。最近，AAOS 赞助的一个委员会发表了一份关于肩袖撕裂管理的临床实践指南摘要。该指南涉及非手术和手术修复的各个方面。关于手术修复，委员会不能推荐一种手术修复模式（例如关节镜与开放性）作为更好的方法，理由是缺乏比较研究。关节镜手术的理论优势在于较小的软组织解剖和评估和治疗盂肱关节的能力。然而，没有使用基于患者的结果的研究显示与开放性或小切口修复相比具有优越性。由于手术修复方法并未改变结果，因此最近的研究重点是优化肩袖修复中的骨腱愈合。双排固定允许更接近解剖学地重新接近大结节上的肩袖足迹，与单排相比具有生物力学优势。尽管如此，没有临床研究表明一种修复类型优于另一种。AAOS 委员会引用了类似的证据，对使用双排固定实现肌腱-骨愈合给予了弱推荐。经皮等长修复提供了修复的肌腱-骨界面的高压缩力，是正在研究的优化愈合的最新固定方法。胶原蛋白和生物增强剂的使用引起了人们的兴趣，因为研究人员试图优化肩袖愈合。有中等证据反对使用猪小肠粘膜下异种移植物补丁。其他市售的胶原蛋白增强剂尚未被证明是有益的或有害的。除了 PRP 外，没有任何证据表明 PRP 可以增强修复，没有任何生物增强剂在临床上进行过研究。总的来说，对于适当选择的患者，肩袖手术预示着良好的结果。然而，没有太多高质量的基于证据的研究可以用来确定哪种手术治疗对特定患者是优越的或合适的。未来的研究应该旨在确定肩袖愈合是否以及在谁中是合适的，以便更好地确定手术候选者，并确定最佳的手术修复策略。
