肩袖修补术后再撕裂的相关研究进展

Clinical problems of structural failure after rotator cuff repairs

肩袖撕裂受到越来越多的关注，关节镜下肩袖修补术的开展也日益广泛。由于肩袖组织的血液供应及愈合特点，部分患者修补手术后会出现再撕裂。非外伤所致的再撕裂大多出现于术后早期（6个月内）。老年、糖尿病、骨质疏松患者发生率相对较高；原发撕裂大、病程长、肌肉脂肪浸润明显、缝合组织张力大、肌腱质量差及肩峰形态变异是其危险因素。目前再撕裂的诊断主要依靠MR及软组织超声检查，关节造影也有一定的作用。不同检查方法各有优缺点，但由于缺乏诊断金标准，对各项检查方法进行比较和全面评价较为困难。肩袖修补后发生再撕裂可表现为肩痛、无力等症状。但也有相当数量的研究证实发生再撕裂的患者仍有良好的肩关节功能，仅在某些检查中存在功能欠缺，如特定活动时的肌力欠佳。这种结论上的差异可能与研究采用的诊断方法、功能评价方法及随访时间点有关。就术后肩关节功能状况而言，患者主观感受与医生的客观检查结果常不能完全平行，长期随访研究结果也提示再撕裂对关节功能的影响随时间而变化。由于对再撕裂导致的症状及最终功能转归存在不同看法，目前治疗手段仍主要是观察及对症处理，二次手术相对少见。对特定患者特别是有症状者，二次手术能对症状起到一定的改善作用。

Arthroscopic rotator cuff repairs are preformed due to growing knowledge of rotator cuff tears among surgeons as well as patients. However, it is unavoidable and may sometimes very common that some patients develop structural failures or retears after surgical repairs because of unique blood supply and healing procedure of the rotator cuff, on which there is still much debate focusing on problems that one needs to deal with in clinical practice. Retears often occur, if without new trauma, during early postoperative period, or more specifically within the first 6 months after repair and are more frequently observed in those with old ages, diabetes or osteoporosis. In addition, risk factors of retears consist of longer preoperative duration of symptoms, larger primitive tear sizes, higher grades of fatty infiltration of muscles on preoperative imaging examinations, excessive tension within re- constructed structures, deteriorated quality of rotator cuff tissues and special shapes of the acromion, etc. Diagnosis is recently based on results of postoperative magnetic resonance imaging or eehogram examination. MR/CT arthrography is also used. Each instrument has its advantages and limitations. However, the lack of a golden standard when establishing a diagnosis of rotator cuff retears makes integrating evaluations and comparisons of different methods a difficult question. It has been reported by many that the onset of retear leads to obvious shoulder pain or weakness, whereas more than a few studies demonstrated that very limited influences of retears in spite of generally unaffected shoulder functions, like decreased muscle strength on certain motions. The dis- agreement is possibly caused by specific methods of diagnosis, function instruments and time point of assessments used by different researchers as studies have displayed that feelings of patients after surgery and results attained by objective examinations are not always parallel. Moreover, some long-time follow-ups studies indicated that the impact posted by retears on shoulder functions evolves over a period of time. Owing to the varied opinions on actual symptoms and final functional outcomes caused by structural failure, the mainstay of treatment for rotator cuff tears are still conservative protocols, including observation and symptoms relief in- stead of second surgery. Second surgery could be an effective choice for certain patients, especially for those who have apparent symptoms.