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2013年3月18日江苏徐州骨科运动创伤、关节镜Journal club预告
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Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, Scotland. Julie.McBirnie@luht.scot.nhs.uk.
The aim of this review was to present an over view of degenerative rotator cuff tears and a suggested management protocol based upon current evidence. Degenerative rotator cuff tears are common and are a major cause of pain and shoulder dysfunction. The management of these tears is controversial, as to whether they should be managed non-operatively or operatively. In addition when operative intervention is undertaken, there is question as to what technique of repair should be used. This review describes the epidemiology and natural history of degenerative rotator cuff tears. The management options, and the evidence to support these, are reviewed. We also present our preferred management protocol and method, if applicable, for surgical fixation of degenerative rotator cuff tears.
Shoulder and Elbow Surgery, Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA. Robert.Tashjian@hsc.utah.edu
The etiology of rotator cuff disease is likely multifactorial, including age-related degeneration and microtrauma and macrotrauma. The incidence ofrotator cuff tears increases with aging with more than half of individuals in their 80s having a rotator cuff tear. Smoking, hypercholesterolemia, and genetics have all been shown to influence the development of rotator cuff tearing. Substantial full-thickness rotator cuff tears, in general, progress and enlarge with time. Pain, or worsening pain, usually signals tear progression in both asymptomatic and symptomatic tears and should warrant further investigation if the tear is treated conservatively. Larger (>1-1.5 cm) symptomatic full-thickness cuff tears have a high rate of tear progression and, therefore, should be considered for earlier surgical repair in younger patients if the tear is reparable and there is limited muscle degeneration to avoid irreversible changes to the cuff, including tear enlargement and degenerative muscle changes. Smaller symptomatic full-thickness tears have been shown to have a slower rate of progression, similar to partial-thickness tears, and can be considered for initial nonoperative treatment due to the limited risk for rapid tear progression. In both small full-thickness tears and partial-thickness tears, increasing pain should alert physicians to obtain further imaging as it can signal tear progression. Natural history data, along with information on factors affecting healing after rotator cuff repair, can help guide surgeons in making appropriate decisions regarding the treatment of rotator cuff tears. The management of rotator cuff tears should be considered in the context of the risks and benefits of operative versus nonoperative treatment. Tear size and acuity, the presence of irreparable changes to the rotator cuff or glenohumeral joint, and patient age should all be considered in making this decision. Initial nonoperative care can be safely undertaken in older patients (>70 years old) with chronic tears; in patients with irreparable rotator cuff tears with irreversible changes, including significant atrophy and fatty infiltration, humeral head migration, and arthritis; in patients of any age with small (<1 cm) full-thickness tears; or in patients without a full-thickness tear. Early surgical treatment can be considered in significant (>1 cm-1.5 cm) acute tears or young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes.
Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40536, USA.
Degenerative, retracted, massive rotator cuff tears present surgeons with distinct challenges. Patient selection is key to a successful outcome. Treatment strategies range from non-operative to progressively more complex surgical options, including debridement, partial repair, complete repair utilizing margin convergence and interval slides, tendon transfers, arthrodesis, and arthroplasty. The rationale behind each of these options and more are discussed along with guidance for selecting the appropriate treatment strategy for individual patients. Outcomes of various treatment approaches are discussed as well to facilitate surgeons to successfully manage patients with retracted and degenerative tears of the rotator cuff.
Physician's Clinic of Iowa, Cedar Rapids, Iowa.
Recent reports on concurrent arthroscopic rotator cuff and type II superior labral anterior posterior (SLAP) repair have raised concerns over postoperative stiffness and patient satisfaction. However, it is unclear if the observed stiffness relates to the repair of degenerativeSLAP tears in older adults, the surgical technique, the postoperative rehabilitation, or to a combination of these factors.
PURPOSE:The purpose of this study was to evaluate the outcome and repair integrity of concurrent arthroscopic rotator cuff and type II SLAP repair.
STUDY DESIGN:Case series.
METHODS:Of 11 patients identified, 7 had a full-thickness rotator cuff tear and 4 had a high-grade partial thickness tear that was completed. A cannula placed through the rotator cuff tear improved the trajectory for posterior suture anchor placement during SLAP repair. Postoperative rehabilitation employed continuous passive motion to prevent stiffness.
RESULTS:At minimum of 1-year follow-up, mean yes responses on the Simple Shoulder Test improved from 5.4 to 10.7 (out of 12; P < .01), and mean American Shoulder and Elbow Surgeons scores improved from 40 to 87 (out of 100; P < .01). Mean forward elevation improved from 148° to 161° (P < .01) and external rotation from 58° to 67° (P < .01). Magnetic resonance imaging, obtained at most recent follow-up in 10 patients, demonstrated a healed SLAP tear in all patients and a persistent rotator cuff defect in 1 patient.
CONCLUSIONS:Arthroscopic rotator cuff repair can be successfully combined with type II SLAP repair in relatively young patients who have sustained traumatic injury to their shoulders. Allowing early passive motion may help prevent postoperative stiffness without compromising rotator cuffhealing.
Service de rhumatologie, hôpital Lariboisière, AP-HP, université Paris 7, 2, rue Ambroise-Paré, 75010 Paris, France.
Rotator cuff tears are very common. In 2005, about 45 000 patients in France underwent surgery. Surgical techniques and indications have evolved over recent years with the development of arthroscopic procedures. The lack of visibility on current practice and a request by the French Ministry of Health to assess the fixation devices used in arthroscopic surgery prompted the drafting of these guidelines.
OBJECTIVES:To produce guidelines on the indications and limitations of open surgery and arthroscopic surgery.
METHODS:A systematic review of the literature (2000-2007) was performed. It was submitted to a multidisciplinary working group of experts in the field (n = 12) who drafted an evidence report and clinical practice guidelines, which were amended in the light of comments from 36 peer reviewers.
MAIN RECOMMENDATIONS:(i) Medical treatment (oral medication, injections, physiotherapy) is always the first option in the management ofdegenerative tears of rotator cuff tendons. Surgery is a later option that depends on clinical and morphological factors, and patient characteristics.(ii) Surgery can be considered for the purpose of functional recovery in cases of a painful, weak or disabling shoulder refractory to medical treatment. (iii) Arthroscopy is indicated for nonreconstructive surgery or debridement, and for partial tear debridement or repair. (iv) Open surgery, mini-open surgery or arthroscopy can be used for a full-thickness tear accessible to direct repair by suture. (v) A humeral prosthesis or total reversed prosthesis is indicated for cuff tear arthropathy. (vi) The fixation devices used for bone reinsertion (anchors, screws, staples,and buttons) are indispensable for fully arthroscopic repair. No studies have determined the number of fixation devices to be used according to tear size.
Department of Anesthesiology and Pain Medicine, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea.
Although the incidence of partial-thickness rotator cuff tears (PTRCTs) was reported to be from 13% to 32% in cadaveric studies, the actual incidence is not yet known. The causes of PTRCTs can be explained by either extrinsic or intrinsic theories. Studies suggest that intrinsic degeneration within the rotator cuff is the principal factor in the pathogenesis of rotator cuff tears. Extrinsic causes include subacromial impingement, acute traumatic events, and repetitive microtrauma. However, acromially initiated rotator cuff pathology does not occur and extrinsic impingement does not cause pathology on the articular side of the tendon. An arthroscopic classification system has been developed based on the location and depth of the tear. These include the articular, bursal, and intratendinous areas. Both ultrasound and magnetic resonance image are reported with a high accuracy of 87%. Conservative treatment, such as subacromial or intra-articular injections and suprascapular nerve block with or without block of the articular branches of the circumflex nerve, should be considered prior to operative treatment for PTRCTs.
https://wap.sciencenet.cn/blog-394169-669401.html
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