Surgery for rotator cuff disease

  • Review
  • Intervention

Authors

  • Jennifer A Coghlan,

    1. Monash University, Melbourne, Australia, Department of Epidemiology and Preventive Medicine, 183 Wattletree Road, Malvern, Victoria, Australia
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  • Rachelle Buchbinder,

    Corresponding author
    1. Department of Epidemiology and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology at Cabrini Hospital, Malvern, Victoria, Australia
    • Rachelle Buchbinder, Monash Department of Clinical Epidemiology at Cabrini Hospital, Department of Epidemiology and Preventive Medicine, Monash University, Suite 41, Cabrini Medical Centre, 183 Wattletree Road, Malvern, Victoria, 3144, Australia. rachelle.buchbinder@med.monash.edu.au.

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  • Sally Green,

    1. Monash University, Monash Institute of Health Services Research, Clayton, Victoria, Australia
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  • Renea V Johnston,

    1. Department of Epidemiology and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology at Cabrini Hospital, Malvern, Victoria, Australia
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  • Simon N Bell

    1. Monash University, Department of Surgery, Monash Medical Centre, Brighton, Victoria, Australia
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Abstract

Background

This review is one in a series of Cochrane reviews of interventions for shoulder disorders.

Objectives

To determine the effectiveness and safety of surgery for rotator cuff disease.

Search methods

We searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006 unrestricted by date or language.

Selection criteria

Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included.

Data collection and analysis

Two independent review authors assessed methodological quality of each included trial and extracted data.

Main results

We included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months.

Six trials that compared arthroscopic with open subacromial decompression reported no significant differences in outcome between groups at any time point although four trials reported a quicker recovery and/or return to work with arthroscopic decompression. Adverse events, which occurred in three trials and included infection, capsulitis, pain, deltoid atrophy, and reoperation, did not differ between surgical groups.

Authors' conclusions

Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease. There is "Silver" (www.cochranemsk.org) level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement. There is also "Silver" level evidence from six trials that there are no significant differences in outcome between arthroscopic and open subacromial decompression although four trials reported earlier recovery with arthroscopic decompression.

摘要

背景

旋轉肌疾病之手術

本文為肩部疾病處置一系列回顧之一

目標

研究旋轉肌疾病之手術的效果及安全性。

搜尋策略

搜尋包括Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006。

選擇標準

隨機臨床試驗或擬隨機臨床試驗研究旋轉肌疾病之手術,比上安慰劑、不治療或一種其它治療的研究

資料收集與分析

兩位作者進行資料摘錄,並對每篇試驗研究的品質進行評估。

主要結論

14個研究包含829例病患於分析中,包括11篇旋轉肌夾擊,2篇旋轉肌撕裂傷,1篇鈣化性肌腱炎。無一研究完全符合品質指標,進行少量合併分析。3篇比較開刀或關節鏡肩峰下減壓術比較積極非開刀治療﹝運動、物理治療及教案,或階段性肌力強化訓練,報告組間結果無顯著差異。1篇報告顯示6個月後Neer score在治療組比安慰組改善。6篇比較開刀與關節鏡減壓術,結果顯示任何時間點兩組無差異,雖然4篇報告關節鏡組恢復及回工作崗位較快。3篇報告副作用事件包括感染、關節囊炎、三角肌萎縮、再開刀,兩組並無差異。

作者結論

根據我們回顧了 4個異質性治療試驗研究及所有可能的誤差,我們不能得出手術治療旋轉肌疾病有效性和安全有關的肯定結論。有“銀”(www.cochranemsk.org)級 3項試驗的證據認為傳統手術或關節鏡治療肩峰下減壓和積極非手術治療,不存在顯著差異的結果。也有“銀”級的證明從 6個試驗中發現關節鏡和傳統肩峰下減壓無顯著差異,雖然有4個報告認為關節鏡減壓可較早恢復活動。

翻譯人

本摘要由林口長庚醫院余光輝翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

旋轉肌疾病的手術治療此Cochrane review摘要了我們所知道的有關手術治療旋轉肌疾病的效果。回顧表明,該手術: ‧與不同的運動計劃相比,對於疼痛,可能不會導致任何的差異與不同。 此回顧研究證明關節鏡手術: ‧與開放式手術相比,長遠來說可能不會導致任何結果的差異,但人們可能恢復更快。在納入的研究中沒有足夠的信息,以判斷手術對於正常使用你的肩膀能力,你的生活品質,你的肩膀的運動範圍,你的力量,你的症狀可能會回復的機會,恢復工作或運動花費的時間、以及人們是否會滿意手術等等方面是否會有差別。副作用發生的研究包括疼痛,感染,肩部手術後活動不便,肩膀肌肉的萎縮與需要有另外的手術。關節鏡手術與傳統手術沒有副作用的差異。什麼是旋轉肌疾病,手術是什麼?旋轉肌腱是一群讓肩關節到位的肌腱群。旋轉肌讓人們抬起他們手臂超過頭。在很多人,旋轉肌腱磨損和撕裂是正常老化的一部分,他們可能沒有症狀。但是很多人在某些時間,肌腱會退化進一步旋轉肌撕裂會引起肩膀疼痛。也可能是肩部肌腱或滑囊(肩膀另一部分,可幫助移動)發炎。通常,睡向患側,或肩牓移向某方向時會疼痛得更加嚴重。通常,在手臂上舉時因上方骨頭造成肌腱會有壓力。這就是所謂的夾擊。它可能讓肩膀在日常活動,運動或工作時困難運動。要診斷旋轉肌疾病,醫生會檢查你的肩膀,問你移動肩膀能力,與移動會導致疼痛的情況等問題。如果疼痛不能自行消失或各種治療如類固醇注射或物理治療或兩者兼而有之都沒效,可以進行手術。旋轉肌手術可能包括取下部分的骨頭(肩峰成型術)以減輕旋轉肌腱壓力,去除任何腫脹或發炎滑囊(關節周圍含液體的小囊),並去除任何已經受損的組織,以幫助癒合其餘的組織。這就是所謂的‘減壓’。如果旋轉肌腱其中一個的肌腱撕裂,醫生可能會使用特殊的針來修復它。這就是所謂的‘修復’。有些程序可以以關節鏡進行(手術器械通過小切口或鑰匙孔大小的洞,然後內視鏡可以看進去,引導醫生通過另一切口放去器械),這可能意味著更短的恢復時間。

Plain language summary

Surgery for rotator cuff disease

This summary of a Cochrane review presents what we know from research about the effect of surgery for rotator cuff disease. The review shows that surgery:

may not lead to any difference in pain compared with different exercise programs.

The review shows that arthroscopic surgery:

may not lead to any difference in outcome in the long run compared with open surgery but people might recover sooner.

There was not enough information in the included studies to tell whether surgery would make a difference in the ability to use your shoulder normally, your quality of life, your shoulder's range of motion, your strength, the chance that your symptoms might come back, the time it takes to return to work or sports and whether people are satisfied with surgery.

Side effects that occurred in the studies included pain, infection, difficulty moving the shoulder after the operation, wasting of the shoulder muscle, and the need to have another surgical procedure. There were no differences in side effects in the people who had arthroscopic surgery compared with those who had open surgery.

What is rotator cuff disease and what is surgery?
The rotator cuff is a group of tendons that hold the shoulder joint in place. The rotator cuff lets people lift their arm and reach overhead. In a lot of people, wear and tear of the rotator cuff tendons is a normal part of ageing and they may not have symptoms. However many people will develop pain in their shoulder at some time as the tendons degenerate further and tears in the rotator cuff tendons develop. There may also be inflammation of the shoulder tendons or bursa (another part of the shoulder that helps it move). Often the pain is made worse by sleeping on the affected shoulder and moving the shoulder in certain directions. Often there will be pressure on the tendons by the overlying bone when lifting the arm up. This is called impingement. It may become difficult to use the shoulder in every day activities, sports or work.

To diagnose rotator cuff disease, a doctor will examine your shoulder and ask you questions about your ability to move it, and the situations that cause pain.

If the pain does not go away by itself or with various treatments like steroid injections or physiotherapy or both, surgery can be performed. Surgery on your rotator cuff may include removing part of your bone to take the pressure off the rotator cuff tendons (acromioplasty), removing any swollen or inflamed bursa (the small sack of fluid around the joint), and removing any damaged tissue to help heal the remaining tissue. This is called a 'decompression'. If one of the tendons of the rotator cuff is torn, the doctor might use special stitches to repair it. This is called a 'repair'.

Some procedures can be performed arthroscopically (surgical instruments are inserted through a small incision or key hole and an endoscope to visualise the area and to guide the doctor is inserted through another incision), which can mean a shorter recovery time.

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