Walter Reed Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University, 8901 Rockville Pike, Bethesda, MD 20889.
Department of Orthopaedic Surgery United States Naval Academy, Naval Health Clinic Annapolis, 121 Blake Rd, Annapolis, MD 21402.
Mil Med. 2020 Sep 18;185(9-10):e1556-e1561. doi: 10.1093/milmed/usaa122.
There are no reports in the literature describing risk factors for failure of nonoperative treatment of patients with posterior labral tears on magnetic resonance imaging (MRI). The purpose of this study is to identify risk factors for failure of nonoperative treatment in patients with an isolated posterior glenoid labral tear identified on MRI only. Patients with posterior labral tears on MRI who fail to improve with nonoperative treatment likely share a constellation of clinical history, physical exam, and radiographic findings.
One hundred and fifty-nine active duty military service members under the age of 40 with a posterior labral tear seen on MRI and who were clinically evaluated by a musculoskeletal trained physician were identified. We retrospectively evaluated their records ensuring a minimum of 2 years follow-up after MRI to identify surgical intervention for the posterior labral tear during this time period. Patients were stratified into two groups, those treated with any combination of nonoperative modalities and those treated with posterior labral repair surgery during the 2 years after the MRI. The electronic medical records were reviewed for clinical presentation and physical exam results. We measured multiple radiographic parameters, including glenoid version, size of the tear, and bone loss on MRI. Qualitative and quantitative data were compared between groups using Fisher's exact test and Student's t-test, respectively. This study was conducted under institutional review board approval.
Of the 157 patients' shoulders in our study, 52% (n = 82) of patients with posterior labral tears underwent nonoperative treatment while 48% (n = 75) underwent surgery. The significant risk factors associated with surgery were a history of a specific injury, primary presenting complaint of instability, patient reported history of subluxation, inability to trust their shoulder with overhead activity, decreased strength with weight lifting, positive posterior load/shift exam, positive anterior apprehension, increased osseous glenoid retroversion, increased humeral head subluxation ratio, and anterior labral height (P < 0.05). Patients with a chief complaint of pain were much more likely to succeed with nonoperative treatment while those with instability underwent surgery more often. Ten (12.5%) of the surgical procedures included an anterior and posterior labral repair/stabilization procedure.
Patients with an MRI confirmed posterior labral tear, which present with subjective complaints and physical exam maneuvers consistent with instability, appear less likely to be treated nonoperatively. Increased glenoid retroversion and posterior humeral head subluxation may also predispose patients toward surgical treatment. Additionally, posterior labral tears may extend into the anterior labrum more frequently than is recognized on MRI.
目前尚无文献报道描述磁共振成像（MRI）显示的后盂唇撕裂患者非手术治疗失败的相关风险因素。本研究旨在确定仅在 MRI 上发现孤立性后肩胛盂唇撕裂患者非手术治疗失败的相关风险因素。MRI 显示后肩胛盂唇撕裂且经非手术治疗后无改善的患者，可能存在一系列临床病史、体格检查和影像学发现。
我们共纳入了 159 名年龄在 40 岁以下的现役军人，这些患者在 MRI 上显示存在后肩胛盂唇撕裂，且经肌肉骨骼训练有素的医生进行了临床评估。我们对这些患者的病历进行了回顾性评估，以确保在 MRI 后至少随访 2 年，以确定在此期间是否对后肩胛盂唇撕裂进行了手术干预。我们将患者分为两组，一组接受了非手术治疗的任意联合治疗，另一组在 MRI 后 2 年内接受了后肩胛盂唇修复手术。我们通过回顾电子病历，评估了患者的临床表现和体格检查结果。我们还测量了多种影像学参数，包括肩胛盂倾斜度、撕裂大小和 MRI 上的骨丢失。使用 Fisher 精确检验和 Student t 检验分别比较了两组间的定性和定量数据。本研究经机构审查委员会批准。
在我们的研究中，157 名患者中有 52%（n=82）接受了非手术治疗，48%（n=75）接受了手术治疗。与手术相关的显著风险因素包括特定损伤史、初次表现为不稳定、患者自述有半脱位史、无法对肩部进行过头活动、举重时力量下降、后负荷/移位试验阳性、前向恐惧试验阳性、肩胛盂骨倾斜度增加、肱骨头前向半脱位比值增加、前盂唇高度降低（P<0.05）。以疼痛为主诉的患者更有可能接受非手术治疗，而以不稳定为主诉的患者更有可能接受手术治疗。10 例（12.5%）手术包括前侧和后侧盂唇修复/稳定术。
MRI 证实存在后肩胛盂唇撕裂的患者，如果出现与不稳定相一致的主观症状和体格检查结果，则不太可能接受非手术治疗。肩胛盂骨倾斜度增加和肱骨头后向半脱位可能也会使患者倾向于接受手术治疗。此外，后肩胛盂唇撕裂可能比 MRI 上显示的更频繁地延伸到前盂唇。
