Hill J Ryan, Olson Jeffrey J, Sefko Julianne A, Steger-May Karen, Teefey Sharlene A, Middleton William D, Keener Jay D
Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Shoulder and Elbow Surgery, Orthopedic Associates of Hartford, Hartford Hospital Bone and Joint Institute, Hartford, CT, USA.
J Shoulder Elbow Surg. 2025 Feb;34(2):430-440. doi: 10.1016/j.jse.2024.05.056. Epub 2024 Jul 31.
The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short- to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively.
This comparative study consists of 2 separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included visual analog scale pain, American Shoulder and Elbow Surgeons, active range of motion, strength, and ultrasonography.
There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9 ± 5.3 yr vs. 61.2 ± 7.8 yr, P = .04). The median follow-up for control subjects after pain development was 5.1 years (interquartile range [IQR] 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; P = .45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; P = .06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (P = .43 and P = .58, respectively). At final follow-up, the surgical group demonstrated significantly lower visual analog scale pain (0 [IQR 2] vs. 3.5 [IQR 4], P = .0002), higher composite American Shoulder and Elbow Surgeons (95 [IQR 13] vs. 65.8 [IQR 32], P = .0002), and activities of daily living scores (29 [IQR 4] vs. 22 [IQR 8], P = .0002), greater abduction strength (69.6 N [standard deviation {SD} 29] vs. 35.9 N [SD 29], P = .0002), greater active forward elevation (155° [SD 8] vs. 142° [SD 28], P = .002), greater active external rotation in abduction (mean 98.5°, SD 12 vs. mean 78.2°, SD 20; P = .0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, P = .05; 17% vs. 34%, P = .03; respectively).
This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment.
肩袖撕裂的自然病程通常包括逐渐发展的疼痛、撕裂扩大以及肌肉脂肪变性进展。手术和保守治疗均已被证明是有效的治疗方法。我们的研究目的是比较肩袖修复术与无症状撕裂后出现疼痛并接受非手术治疗的对照组相比，在短期至中期对肩部功能、撕裂大小进展和肌肉变性的影响。
这项比较研究由2个独立的纵向研究组组成。对照组包括无症状的退行性肩袖撕裂，随访至出现疼痛，然后进行非手术治疗并持续监测。手术组由非手术治疗失败并接受手术干预且至少随访2年的退行性撕裂患者组成。观察指标包括视觉模拟评分法疼痛评分、美国肩肘外科医师学会（ASES）评分、主动活动范围、力量以及超声检查。
有83名对照者和65个接受手术的肩部。手术组入组时年龄较轻（58.9±5.3岁 vs. 61.2±7.8岁，P = 0.04）。疼痛出现后对照者的中位随访时间为5.1年（四分位间距[IQR]为3.6），手术组的术后中位随访时间为3.0年（IQR为0.2）。手术组和对照组的基线撕裂宽度（中位值14 mm，IQR为9 vs. 13 mm，IQR为8；P = 0.45）和撕裂长度（中位值14 mm，IQR为1 vs. 中位值11 mm，IQR为8；P = 0.06）相似。两组之间冈上肌或冈下肌脂肪变性的基线患病率无差异（分别为P = 0.43和P = 0.58）。在末次随访时，与对照组相比，手术组的视觉模拟评分法疼痛评分显著更低（0[IQR为2] vs. 3.5[IQR为4]，P = 0.0002），ASES综合评分更高（95[IQR为13] vs. 65.8[IQR为32]，P = 0.0002），日常生活活动评分更高（29[IQR为4] vs. 22[IQR为8]，P = 0.0002），外展力量更大（69.6 N[标准差{SD}为29] vs. 35.9 N[SD为29]，P = 0.0002），主动前屈角度更大（155°[SD为8] vs. 142°[SD为28]，P = 0.002），外展时主动外旋角度更大（平均98.5°，SD为12 vs. 平均78.2°，SD为20；P = 0.0002）。此外，手术组冈上肌和冈下肌的脂肪性肌肉变性患病率更低（分别为25% vs. 41%，P = 0.05；17% vs. 34%，P = 0.03）。
这项前瞻性纵向研究将接受肩袖修复术的手术队列与非手术治疗的对照组进行比较，支持了手术干预有可能改变退行性肩袖疾病早期自然病程的观点。手术组患者在疼痛和功能结局方面表现出临床相关差异。与非手术治疗相比，手术干预可预防肌肉变性进展。
