Jeon Yoon Sang, Kim Rag Gyu, Shin Sang-Jin
Department of Orthopaedic Surgery, College of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea.
Clin Orthop Relat Res. 2017 Jun;475(6):1596-1604. doi: 10.1007/s11999-017-5251-7. Epub 2017 Mar 13.
There have been numerous reports of clinical outcomes associated with tendon healing after repair that suggest a nonhealed tendon has a negative effect on postoperative clinical outcomes. However, to our knowledge, there has been no report on the relationship between tear size progression of nonhealed tendons and clinical outcomes.
QUESTIONS/PURPOSES: (1) Do patients with healed arthroscopic rotator cuff repairs have better outcomes, less pain, and more strength than patients whose repair did not heal? (2) In patients with nonhealed rotator cuff tendons, does tear size progression (increase or decrease) affect outcomes, pain, and strength? (3) Is there continued improvement beyond 6 months in outcomes, pain, and strength; and how do the improvements differ based on whether the tear size has increased or decreased?
Between May 2008 and December 2012, 647 patients underwent arthroscopic rotator cuff repair for full-thickness tears at our institution. Of those, 442 patients (68%) had all MRI and clinical information available to permit inclusion in this retrospective study at a minimum of 2 years followup (mean, 33 ± 4 months; range, 24-43 months). Healing of the repaired tendon and tear size progression were assessed using MRI at 6 months postoperatively. Eighty-two of 442 tears (19%) were not healed. Of the nonhealed tears, 45 (55%) had a decrease and 37 (45%) had an increase in tear size. Shoulder function outcomes using the American Shoulder and Elbow Surgeon (ASES) and Constant scores and pain severity using VAS scores were evaluated preoperatively, at 6 months postoperatively, and at the latest followup. Isometric muscle strength was measured at 6 months postoperatively and at the latest followup.
Compared with patients with nonhealed tendons after arthroscopic rotator cuff repair, patients with healed repairs had improved ASES scores (healed, 93 ± 5; nonhealed, 89 ± 8; mean difference, 4; 95% CI, 3-5; p < 0.001), better Constant scores (healed, 91 ± 5; nonhealed, 85 ± 8; mean difference, 6; 95% CI, 4-7; p < 0.001), and greater strength ([flexion: healed, 96% ± 7%; nonhealed, 85% ± 12%; mean difference, 11%; 95% CI, 9%-13%; p < 0.001]; [external rotation: healed, 92% ± 8%; nonhealed, 80% ± 12%; mean difference, 11%; 95% CI, 9%-14%; p < 0.001]; [internal rotation: healed, 97% ± 8%; nonhealed, 92% ± 8%; mean difference, 5%; 95% CI, 3%-7%; p < 0.001]); however there was no difference in pain level based on VAS scores (healed, 0.9 ± 0.8; nonhealed, 1.0 ± 0.8; mean difference, 0.2; 95% CI, 0.0-0.4; p = 0.226). Compared with patients with increased tear size, patients with decreased tear size had better ASES scores (decreased, 91 ± 6; increased, 8 6 ± 8; p = 0.001), improved Constant scores (decreased, 88 ± 6; increased, 82 ± 9; p = 0.003), greater flexion strength (decreased, 91% ± 9%; increased, 78% ± 11%; p < 0.001), and greater external rotation strength (decreased, 86% ± 10%; increased, 73% ± 11%; p < 0.001). However, the difference does not seem to meet a minimal clinically important difference. Patients with increased tear size differed from those with decreased tear size with respect to flexion and external rotation strength where the former had no improvement. There was no improvement in flexion (6 months, 78% ± 11%; latest followup, 78% ± 11%; p = 0.806) and external rotation strength (6 months, 74% ± 12%; latest followup, 73% ± 11%; p = 0.149).
Patients who had healed tendons after arthroscopic rotator cuff repair had better shoulder function than patients who had nonhealed tendons. Among patients with nonhealed rotator cuff tendons after surgery, those with decreased tear size, observed on their 6-month postoperative MRI, compared with their initial tear size, showed better shoulder function and muscle strength than those with increased tear size beyond 6 months. Although results are statistically different, they seem insufficient to achieve clinically important differences.
Level III, therapeutic study.
有大量关于肌腱修复后临床结果与肌腱愈合相关的报道，提示未愈合的肌腱对术后临床结果有负面影响。然而，据我们所知，尚未有关于未愈合肌腱撕裂大小进展与临床结果之间关系的报道。
问题/目的：（1）与修复未愈合的患者相比，关节镜下肩袖修复愈合的患者是否有更好的结果、更少的疼痛和更强的力量？（2）在肩袖肌腱未愈合的患者中，撕裂大小进展（增加或减少）是否会影响结果、疼痛和力量？（3）术后6个月后，结果、疼痛和力量是否会持续改善；基于撕裂大小增加或减少，改善情况有何不同？
2008年5月至2012年12月期间，我们机构有647例患者接受了关节镜下肩袖全层撕裂修复术。其中，442例患者（68%）具备所有MRI和临床信息，可纳入本回顾性研究，随访时间至少为2年（平均33±4个月；范围24 - 43个月）。术后6个月通过MRI评估修复肌腱的愈合情况和撕裂大小进展。442例撕裂中有82例（19%）未愈合。在未愈合的撕裂中，45例（55%）撕裂大小减小，37例（45%）撕裂大小增加。术前、术后6个月及最新随访时，使用美国肩肘外科医师（ASES）评分和Constant评分评估肩部功能结果，使用视觉模拟评分（VAS）评估疼痛严重程度。术后6个月及最新随访时测量等长肌力。
与关节镜下肩袖修复后肌腱未愈合的患者相比，修复愈合的患者ASES评分更高（愈合组，93±5；未愈合组，89±8；平均差异，4；95%可信区间，3 - 5；p<0.001），Constant评分更好（愈合组，91±5；未愈合组，85±8；平均差异，6；95%可信区间，4 - 7；p<0.001），力量更强（[屈曲：愈合组，96%±7%；未愈合组，85%±12%；平均差异，11%；95%可信区间，9% - 13%；p<0.001]；[外旋：愈合组，92%±8%；未愈合组，80%±12%；平均差异，11%；95%可信区间，9% - 14%；p<0.001]；[内旋：愈合组，97%±8%；未愈合组，92%±8%；平均差异，5%；95%可信区间，3% - 7%；p<0.001]）；然而，基于VAS评分的疼痛水平无差异（愈合组，0.9±0.8；未愈合组，1.0±0.8；平均差异，0.2；95%可信区间，0.0 - 0.4；p = 0.226）。与撕裂大小增加的患者相比，撕裂大小减小的患者ASES评分更好（减小组，91±6；增加组，86±8；p = 0.001），Constant评分改善（减小组，88±6；增加组，82±9；p = 0.003），屈曲力量更强（减小组，91%±9%；增加组，78%±11%；p<0.001），外旋力量更强（减小组，86%±10%；增加组，73%±11%；p<0.001）。然而，这种差异似乎未达到最小临床重要差异。撕裂大小增加的患者与撕裂大小减小的患者在屈曲和外旋力量方面存在差异，前者无改善。屈曲力量无改善（6个月时，78%±11%；最新随访时，78%±11%；p = 0.806），外旋力量也无改善（6个月时，74%±12%；最新随访时，73%±11%；p = 0.149）。
关节镜下肩袖修复后肌腱愈合的患者比肌腱未愈合的患者肩部功能更好。在术后肩袖肌腱未愈合的患者中，术后6个月MRI显示撕裂大小减小的患者，与初始撕裂大小相比，6个月后肩部功能和肌肉力量比撕裂大小增加的患者更好。尽管结果在统计学上有差异，但似乎不足以达到临床重要差异。
III级，治疗性研究。
