H. Inui, J. Yamada, K. Nobuhara, Nobuhara Hospital & Institute of Biomechanics, Hyogo, Japan.
Clin Orthop Relat Res. 2021 Jun 1;479(6):1275-1281. doi: 10.1097/CORR.0000000000001617.
Margin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear.
QUESTIONS/PURPOSES: (1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence?
Between 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author.
Pseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27).
Margin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group.
Level IV, therapeutic study.
在肩袖撕裂的尸体模型中，边缘收敛已被证明可以恢复肌肉张力。然而，对于因不可修复的肩袖撕裂而导致假性瘫痪的患者，该技术的临床实用性尚不确定。
问题/目的：(1)对于患有巨大不可修复肩袖撕裂的患者，边缘收敛术在多大比例的患者中可以逆转假性瘫痪？(2)对于患有巨大不可修复肩袖撕裂的患者，边缘收敛术是否可以改善美国肩肘外科医师协会（ASES）评分？(3)在边缘收敛术后，无 MRI 证据表明再撕裂的存活率是多少？
在 2000 年至 2015 年期间，我们用肩袖撕裂治疗了 203 例假性瘫痪患者。假性瘫痪的定义是主动抬高小于 90°，无僵硬，物理治疗师在肩峰下注射 10 cc 利多卡因消除疼痛后，在坐姿下使用量角器评估主动抬高。在这些患者中，我们考虑了在我院至少接受 3 周非手术治疗而未痊愈或失访的患者。在非手术治疗 3 周内，43 例（203 例的 21%）患者病情改善或失访，被排除在外。另外 12%（203 例的 25%）因颈椎麻痹、脱位或半脱位后的腋神经麻痹以及严重肩僵硬（被动肩抬高 < 90°）而被排除在外。修复是一线治疗方法，但如果术中通过移动肩袖使撕裂的肌腱无法到达原始附着点，认为撕裂不可修复，则使用边缘收敛术。如果边缘收敛术失败，则改用小肱骨头半关节成形术完成修复。因此，21%（203 例的 42 例）接受常规修复（18%[203 例的 36 例]）或半关节成形术（3%[203 例的 6 例]）的患者被排除在外。剩下的 93 名患者符合考虑条件。其中，13 名患者在最低 2 年研究随访前失访或数据不完整，86%（93 例的 80 例）进行了分析（49 名男性和 31 名女性；平均年龄 68 ± 9 岁；平均随访 26 ± 4 个月）。76%（80 例的 61 例）患者在最后 5 年未进行评估。我们将假性瘫痪的逆转作为我们主要的研究结果，定义为主动前抬高大于 90°；在护理中的物理治疗师通过使用量角器在坐姿下进行测量。临床结果根据 ASES 评分（图表回顾）、肩的主动 ROM（物理治疗师测量）以及作者第一作者的 8 个月 Kaplan-Meier 无 MRI 证据表明再撕裂的存活率进行评估。
假性瘫痪在 93%（80 例中的 74 例）患者中得到逆转，最终随访时 ASES 评分得到改善（术前 22 ± 10 至术后 62 ± 21，平均差异 40 [95%CI 35 至 45]；p < 0.01）。术后 8 个月的 Kaplan-Meier 无 MRI 证据表明再撕裂的存活率为 72%（95%CI 63%至 81%）。有无再撕裂的患者临床评分无差异（完整 ASES 64 ± 24，再撕裂 ASES 59 ± 10，平均差异 6 [95%CI -5 至 16]；p = 0.27）。
尽管再撕裂率较高，但边缘收敛术仍可为假性瘫痪和不可修复肩袖撕裂的患者提供良好的治疗选择。三肌腱受累患者的假性瘫痪逆转比例较低。需要进一步的研究来确定该组患者的适当治疗方法。
IV 级，治疗性研究。
