De arthroscopische rotator cuff hechting: wanneer wel een succes?

In de september editie van de Journal of Shoulder and Elbow Surgery verscheen het tweeluik over de arthroscopische rotator cuff hechting (de reparatie van de gescheurde schouderpees met een kijkoperatie).

In het eerste deel bleken de resultaten op functioneel gebied consistent over een periode van 5 jaar aanwezig en goed. De resultaten met betrekking tot het dichten van het gat in de pees bleken zelfs door de jaren heen te stijgen, zoals echografisch onderzoek na de operatie aantoonde.

In het tweede deel werden de factoren bestudeerd die een negatief resultaat voorspelden: de grootte van de scheur en het aantal pezen dat is gescheurd, hogere leeftijd en andere procedures die tegelijkertijd met de peeshechting moesten worden uitgevoerd. Opvallend is ook dat er geen relatie kon worden gevonden tussen een waterdichte genezing op de echobeelden en een uiteindelijk goed resultaat. Blijkbaar zijn er andere factoren die het functionele resultaat en de patienttevredenheid mede bepalen en is niet alleen de hechting van de pees van belang.

Genoemde resultaten zullen naar alle waarschijnlijkheid eveneens gelden voor de niet-arthroscopische hechtingen van de schouderpezen. Dit tweeluik geeft geen uitsluitsel of er beter open of arthroscopisch geopereerd kan worden. Een sneller herstel is in enkele onderzoeken aangetoond voor de arthroscopische wijze, maar de operatie is langer en technisch lastiger dan de open procedure, maar het uiteindelijke resultaat laat geen verschil zien.

Journal of Shoulder and Elbow Surgery, 20(6), 934-940, September 2011

Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part I - Functional outcomes and radiographic healing rates

Lawrence V. Gulotta, Shane J. Nho, Christopher C. Dodson, Ronald S. Adler, David W. Altchek, John D. MacGillivray, 

Background

A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. This study reports those results at 5 years.

 Materials and methods

 The study enrolled 193 patients who underwent all-arthroscopic rotator cuff repairs. Patients were evaluated preoperatively and at 1, 2, and 5 years postoperatively. Outcome measurements included the American Shoulder and Elbow Surgeons (ASES) score, range of motion, manual muscle testing, and ultrasonography.

 Results

 At 5-years, 106 patients completed follow-up, representing 55% of the patients originally enrolled but 77% of those who returned for evaluation at 1 year. ASES scores improved from 52.6 ± 23.2 preoperatively to 92.6 ± 14.8 at 5 years (P < .001). Paired analyses showed no differences between the ASES scores at 2 and 5 years, but the scores improved from 1 to 5 years (P = .002). Between years 2 and 5, passive forward elevation decreased from 173° ± 10.3° to 168.6° ± 16.8° (P = .02) and external rotation decreased from 73.6° ± 21.3° to 67.8° ± 19.6° (P = .04). Patients improved a full motor grade in forward elevation and external rotation and this remained stable over time. The healing rates for all patients were 64.3% at 1 year, 75.4% at 2 years, and 81.2% at 5 years. Paired analyses showed increased healing rates from 1 to 5 years (P = .001) and from 2 to 5 years (P = .05).

 Discussion

 The midrange results of all-arthroscopic rotator cuff repairs are good, and functional results remain constant over 5 years. The ultrasound healing rates continued to increase with time; however, the mechanism and the clinical significance of this are uncertain at this time.

 

Journal of Shoulder and Elbow Surgery, 20(6), 941-946, September 2011

Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part II–prognostic factors for clinical and radiographic outcomes

 Lawrence V. Gulotta, Shane J. Nho, Christopher C. Dodson, Ronald S. Adler, David W. Altchek, John D. MacGillivray

Background

 A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. The purpose of this study is to report prognostic factors for successful clinical and radiographic outcomes at 5 years.

Methods

One-hundred ninety-three patients underwent all-arthroscopic rotator cuff repairs. Pre- and intraoperative data were compared to the American Shoulder and Elbow Surgeon (ASES) score, range of motion, muscle strength, and ultrasound results at 5 years using univariate, and multivariate analyses.

Results

At 5 years, 106 patients completed follow-up. There were no pre- or intraoperative variables that were predictive of an ASES score >90. Factors predictive of a radiographic defect were larger size of the lesion (OR 1.72, 95% CI 1.04-2.85, P = .03), multiple tendon involvement (OR 5.56, 95% CI 1.23-25.22, P = .02), older age (OR 1.15, 95% CI 1.04-1.28, P = .01), concomitant biceps (OR 16.16, 95% CI 3.01-86.65, P = .001), and acromioclavicular joint procedures (OR 6.70, 95% CI 1.46-30.73, P = .01). Radiographic healing did not correspond to clinical outcomes. Resolution of a radiographic defect was seen in 14 patients. Younger age (OR 0.84, 95% CI 0.74-0.95, P = .004) and single-tendon tears (OR 7.59, 95% CI 1.71-84.45, P = .04) were predictive.

Discussion

Larger tears in older patients who undergo concomitant procedures are predictive of radiographic defects at 5 years; however, radiographic healing did not correspond to clinical results. Younger patients with single tendon tears are more likely to undergo spontaneous resolution of a radiographic defect. This information can be useful in counseling patients regarding the mid-term results of this procedure.