关节镜下双排缝合桥固定技术治疗全层肩袖撕裂的中期疗效

The mid-term outcomes after arthroscopic rotator cuff repair using a suture bridge technique for patients with full-thickness rotator cuff tears

目的评估关节镜下双排缝合桥固定技术治疗肩袖全层撕裂的中期疗效。方法回顾性分析2010年3月至2011年2月应用关节镜下双排缝合桥固定技术治疗的45例全层肩袖撕裂患者的术后效果。分别测定患者术前、术后休息和运动时的疼痛视觉模拟评分(visual analog scale,VAS),肩关节前屈、外展和体侧外旋角度,美国加州大学肩关节评分(University of California at Los Angeles,UCLA)和美国肩与肘协会评分系统(American shoulder and elbow surgeon′s form,ASES),并在术后对患者进行核磁共振(magnetic resonance imaging,MRI)检查。结果术后平均随访时间61.5个月(56~67个月),41例患者获得随访,随访率91.1%。与术前相比:休息时(Z=5.182,P<0.01)和活动时(Z=5.544,P<0.01)的VAS评分明显改善;前屈角度(Z=5.042,P<0.01)、外展角度(Z=5.060,P<0.01)和体侧外旋角度(Z=4.636,P<0.01)增加差异有统计学意义;UCLA评分(Z=5.584,P<0.01)和ASES评分(Z=5.580,P<0.01)明显改善,差异有统计学意义。患者对手术的满意率是100%,无术中和术后并发症。术后MRI检查有6例(19.4%)表现为再撕裂,其中1例(16.7%)位于腱骨交界处,5例(83.3%)位于腱腹交界处。结论关节镜下双排缝合桥固定技术治疗全层肩袖撕裂的中期疗效满意。

Background Recently,arthroscopic rotator cuff repair using a suture bridge technique has been a popular,well-described surgical procedure.Arthroscopic techniques using 2rows of fixation with crossed and interconnected sutures have been the subject of growing interest because they provide improved tendon-to-bone contact and compression over the anatomic footprint,therefore achieving high initial fixation strength and potentially improving healing.This was confirmed not only in biomechanical studies but also in animal experiments.In the aspect of clinical research,several studies on the suture bridge repair technique have been reported,which have obtained satisfactory functional results in 9.7to 27.4postoperative months.However,the mid-to long-term follow-up has not been conducted yet.In addition,structural failures still occur with suture-bridge repairs,and the reported retear rates range from 4.7% to 48.4%,as evaluated using magnetic resonance imaging(MRI),magnetic resonance angiography,or B ultrasonography.Although the clinical impact of rotator cuff retears remains controversial,several studies have shown that retears affect functional recovery.Regarding the location of failure,whether retears mostly occur at the tendon-bone interface or near the musculotendinous junction remains unknown.The present study was conducted to evaluate the mid-term outcomes of arthroscopic rotator cuff repair using a suture bridge technique in patients with full-thickness rotator cuff tears through clinical assessment and MRI.Methods Between March2010 and February 2011,45 patients with full-thickness rotator cuff tear were treated with the arthroscopic suture bridge repair technique and followed-up with MRI.The cuff tear size was defined as the length of the longest diameter measured with probes during surgery.The tear sizes were categorized into small(<1cm),medium(1to 3cm),large(3to 5cm),and massive(>5cm),according to the DeOrio and Cofield classification.Clinical and functional outcomes were assessed on the basis of the visual analog pain scale(VAS)score,range of motion(ROM),the University of California at Los Angeles(UCLA)rating scale score,and the American Shoulder and Elbow Surgeons(ASES)shoulder index.Radiological outcome was evaluated with follow-up MRI,which was performed using a 1.5-Tesla scanner(Sonata,Siemens, Germany). According to Sugaya′s classification,postoperative cuff integrity was classified into 5 categories using oblique coronal,oblique sagittal,and transverse views of T2-weighted images as follows:type Ⅰ,the repaired cuff appeared to have a sufficient thickness compared with that of the normal cuff,with homogeneously low intensity on each image;typeⅡ,the repaired cuff had a sufficient thickness compared with that of the normal cuff and was associated with a partially high-intensity area;typeⅢ,the repaired cuff had an insufficient thickness,which was less than half the thickness of the normal cuff,but without discontinuity,suggesting a partial-thickness delaminated tear;type Ⅳ,presence of a minor discontinuity in only 1or 2slices on both oblique coronal and sagittal images,suggesting a small fullthickness tear;and typeⅤ,presence of a major discontinuity in more than 2slices on both oblique coronal and sagittal images,suggesting a medium or large full-thickness tear.Types Ⅳ and Ⅴ were considered retears.Retear patterns were classified according to the classification of Cho et al.as follows:type 1,no remnant of the cuff tissue repaired at the insertion site of the rotator cuff,on the greater tuberosity;or type 2,with remnant cuff tissue at the insertion site despite retear.All operations were performed by a single senior surgeon,with the patient under general anesthesia in the beach-chair position.Four routine arthroscopic portals(anterior,posterior,anteriolateral,and lateral)were used to perform rotator cuff repair.A posterior portal was established as the primary viewing portal.After bursectomy,acromioplasty was performed on the basis of preoperative plain radiographs and arthroscopic findings that revealed the appearance of severe impingement at the undersurface of the acromion.The bursal side of the rotator cuff was then inspected,and the margin of the tear,especially the delaminated surfaces,was debrided to obtain fresh tendon tissues.The coracohumeral ligament,superior capsule,and/or rotator interval were released as needed to maximize the mobility of the rotator cuff before the repair,so that the tissue edges could be easily reduced over the greater tuberosity with the use of a grasper.For cases combined with a subscapularis tendon tear,a suture for the subscapularis was performed first.The footprint on the greater tuberosity was debrided thoroughly of soft tissue and burred until bleeding occurred.To insert a suture anchor,the suture anchor portal was made just lateral to the acromion.A Bio-Corkscrew suture anchor(4.5or5.5mm,Arthrex,Naples,FL)was inserted at the junction of the articular cartilage and the medial aspect of the footprint on the greater tuberosity.The number of anchors used was 1or 2,depending on the tear size.After that,the torn rotator cuff was pulled with a grasper,and a proper suture site was determined.Sutures were passed through the whole tendon in a horizontal mattress manner with SMC knots,one of the sliding knots.Suture bridge repair was then performed by placing 2knotless lateral row PushLock anchors(3.5or 4.5 mm Bio-PushLock,Arthrex)that held at least 1suture strand from each of the medial row mattress knots.While constant tension was maintained,the PushLock anchors were inserted in the lateral aspect of the greater tuberosity,with the sutures providing proper pressure across the rotator cuff footprint.Then,the sutures were cut.An identical rehabilitation protocol was applied in all the patients.Pendulum and active elbow range-of-motion exercises were started immediately after surgery.Passive forward flexion was started 3days after surgery.Early ROM was permitted in a tolerable range.Immobilization was maintained with anabduction brace for 6weeks.Active joint and muscle strengthening exercises were performed from the sixth postoperative week.Particularly for a massive rotator cuff tear,immobilization was maintained for 3months.After that,the active joint strengthening exercise was started.Return to recreational activity or manual labor was permitted 6months after the operation.Nonparametric tests were used to assess the differences between preoperative and postoperative results for clinical and functional evaluations.The SPSS software was used for all statistical analyses,with the significance level set at0.01.Results Forty-one patients returned for a functional evaluation with a follow-up rate of 91.1%.The mean time from surgery to the final follow-up functional evaluation was 61.5months(range,56-67months).The mean age was 52.1years(range,21-78years).Of the patients,20 were men and21 were women.The right shoulder was involved in 26cases;and the left shoulder,in 15 cases.The mean duration of the rotator cuff tears was 13.6 months(range,0.3-60 months).Twenty-three patients had involvement of the dominant arm.The cases comprised 12(29.3%)small,20(48.8%)medium,5(12.2%)large,and 4(9.8%)massive rotator cuff tears according to the arthroscopic examination.At the last follow-up,the postoperative VAS score at rest(Z =5.182,P <0.01)and during motion(Z =5.544,P <0.01)decreased significantly.The postoperative range of motion for forward flexion(Z =5.042,P <0.01),abduction(Z =5.060,P <0.01),and external rotation at the side(Z =4.636,P <0.01)increased significantly.Although 13patients(13.7%)had mild limitation of internal back rotation,their daily lives were not affected.The overall satisfaction rate was100%.The UCLA score(Z =5.584,P <0.01)and ASES shoulder index(Z =5.580,P <0.01)improved significantly at postoperative follow-up.No nerve injury,deep infection,or anchor-related complication occurred.The postoperative repair integrity was analyzed by using MRI in 31(68.9%)of the 45 shoulders. According to Sugaya′s classification,8 patients(25.8%)had type Ⅰpostoperative cuff integrity;15(48.4%),typeⅡ;2(6.5%),typeⅢ;6(19.4%),typeⅣ;and none had typeⅤ.Thus,MRI revealed retear in 6patients(19.4%).Three of 4patients with massive rotator cuff tears completed postoperative MRI examination,and their tears were all classified as typeⅡ.Four of 5patients with large rotator cuff tears completed postoperative MRI examination,of whom 1had a typeⅠtear,2had typeⅡtears,and 1had a typeⅢtear.In the patients considered as having a retear,the retear occurred at the greater tuberosity in 1patient and at the musculotendinous junction in 5patients.Conclusions Arthroscopic suture bridge repair of full-thickness rotator cuff tears was followed by a retear rate of 19.4%,as assessed on MRI,and resulted in a significant improvement in mid-term clinical results from the preoperative findings.Retears occurred mainly at the musculotendinous junction.