Clinical Results of Arthroscopically Assisted Rotator Cuff Repair by S. Fukushima, K. Okamura, T. Takahashi, M. Aoki, S. Ishii and M. Usui Department

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1 Clinical Results of Arthroscopically Assisted Rotator Cuff Repair by S. Fukushima, K. Okamura, T. Takahashi, M. Aoki, S. Ishii and M. Usui Department of Orthopaedic Surgery, Sapporo Medical University Purpose : The purpose of this study was to investigate the results of arthroscopically assisted rotator cuff repair. Materials and Methods : Fifty-one patients (52 joints) were studied at more than 6 months postoperatively. The mean age at operation was 57.3 years (range:32-79) and the mean duration of follow up was 15.7 months (range :6-20). The procedure was as follows. First, arthroscopic examination of the glenohumeral joint and subacromial bursa was performed and the size, location, and repairability of the tear were determined. Then the edges of the tear and any coexisting glenohumeral lesions were debrided. Next, arthroscopic subacromial decompression was performed, followed by repair of the cuff by splitting the deltoid muscle fibers bluntly about 4cm in line with the anterolateral arthroscopy portal. The torn cuff was repaired according to McLaughlin's method or using side-to-side suture and the deltoid muscle fascia was never detached from the acromion. Postoperative rehabilitation : Passive elevation exercises were usually started the day after surgery and assisted active elevation in the 2nd week. Cuff strengthening exercises were strated in the 8th week. Results : All patients had supraspinatus tears, including 45 complete tears and 7 partial tears (Snyder's A4 and B4). There were small tears (<1 cm) in 7 cases, medium tears (1-3 cm) in 25 cases, and large tears (3-5 cm) in 20 cases. Suture method : McLaughlin's repair was used in 43 cases and side-to-side suture in 9 cases. Concomitant lesions : There was a labral tears in 14 joints and synovitis in 20 joints. Using the JOA system, the total score improved from an average of 59.4 points (range : 40-78) preoperatively to of 87.7 points postoperatively (range : ). The average pain score improved significantly from 7.2 to 25.3 points. Discussion : Arthroscopically assisted rotator cuff pepair offers the following advantages. 1) The extent of pathology in the glenohumeral joint can be correctly determined (size, location, and repairability of the tear). 2) Treatment of coexisting glenohumeral pathology is possible. 3) Arthroscopic subacromial decompression can be done to avoid detaching the deltoid from the acromion. This makes early rehabilitation possible and reduces postoperative pain because there is less soft tissue damage.

2 The Shoulder Joint, Vol. 19, No. 2, , 1995.

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4 The Shoulder 図6 Joint, Vol. 19, No. 2, , 図7 腱板修復 McLaughlin法 閉創後 関節内に ドレー ンを留置 して手術 終了 に よ る修 復術 に認 めた.こ れ らの病 変 に対 して は鏡 視 下 デ ブ リー ド 例(76%)が 成 績 良 好 で,12例 マ ン(関 節唇 部 分 切 除,滑 膜 切 除)を 行 っ た. 例(92%)が 受 傷 前 の ス ポ ー ツ レベ ル へ の復 帰 を果 た 3)術 後 成績 は表1に ま と め て 示 した. OAス のathletesの して い る.ま たLiu3}は 平 均4.6年 のfollow コ ア は疹痛 点 が術 前 平 均7.2点 か ら術 後 平 均25.3点 に改 44例 の う ち84%がexcellentま 善 した,機 能点 は12点 か ら16.9点,可 動 域 が20.6点 足 が 得 られ た と報 告 して い る. か ら25.5点 へ とそれ ぞれ 改 善 し た.総 合 点の 改善 は Mini-open法 う ち11 upで, た はgood,88%に 満 で は全 例 に まず 肩 甲上 腕 関 節 の 鏡 視 を 術 前 の59.4点 か ら術 後 は87.7点 で あ り,良 好 な 成 績 行 う.し た が って 関 節 内 に病 変 が 合 併 して い れ ば,そ を示 した. れ を確 認 して 鏡 視 下 に処 置 をす る こ とが 可能 で あ る. Liu3)は44例 考 察 中15例 に関 節 唇 損 傷 や 上 腕 二 頭 筋 長 頭 腱 断 裂 な どの 関 節 内 病 変 が 存在 して い た と報 告 して い る.我 々 の 症 例 で も14関 節 に 関 節唇 損 傷 を,ま た20 従 来 よ り行 わ れ て いた 腱 板 修 復 法 で は,皮 切 の の ち 三 角 筋線 維 を肩 峰 よ り切 離 し大 き く展 開 す る.そ の た 関 節 に滑 膜 炎 が認 め られ た.鏡 視 下 に処 置(鏡 視 下 デ め に術後 に三 角筋 部 の 痛 みや 筋 力 低 下 な どが生 じ る こ ブ リー ドマ ン)を 行 う こ とが で きた た め,除 痛 の 点 に とが あ り,ま た後 療 法 が 円滑 に行 えな い とい う問題 点 おい て 有 利 で あ る と考 え られ た.ま た 鏡 視下 に腱 板 の が あ った.ま た腱 板 の 損 傷 が 関 節 面 の 不 全 断裂 で あ っ 断 裂 の 部 位 と大 き さ を確 認 して,創 た り,あ るい はpin hole tearの 場 合 に は,断 裂 部 位 の修 復 が 可 能 か 否 か(repairabnity)を を確 認 しず らい こ とも従 来 の 臆 板 修復 法 の欠 点 で あ っ が で きた.し か も鏡 視 下 肩 峰下 除圧 術8}を 行 うこ とで, た.近 年,肩 三 角 筋 の 肩 峰 か らの 剥 離 を最小 限 に して 腱板 修 復 を行 関節 にお け る鏡 視 下 手術 の 技術 的進 歩 に を開 ける 前 に腱 板 判断す るこ と よ り,腱 板 断裂 に対 し て も鏡 視 下 手術 を最大 限 に利 用 う こ とが 可 能 で あ っ た.三 角筋 の剥 離 が 最小 限 で済 む し よ う とす る考 えが 普 及 しつ つ あ る. た め,従 来 の 方 法 と比較 して術 後 早 期 か らの後 療 法 が Mini-open法 ch1)に よ る術 式 で あ る. assisted rotator cuff Weberら7)はmini open goodで,96%に Warnerら6)に approa repairと,ま upで80%の 後 の 病 院 滞 在 期 間 が48時 たEllman1)や repairと 称 し て い る.そ の 経 過 観 察 で17例 術 間以 内 で充 分 で あ る の で, 今 回,わ れ わ れ は,52関 機 会 が あ っ た.JOAス た は 節 にmini-open法 を行 う コ ア は疹 痛 点 が 術 前 平 均7.2 点 か ら術 後 平 均25.3点 に,総 合 点 で は術 前59.4点 か ら術 後87.7点 に 改善 した.こ の よ う にmini-open法 満 足 が 得 ら れ た と し て い る. よる と,2年 動域 の 改 米 国 の 医療 事 情 に適 して い る と述 べ て い る. の につ い て 最 低 症 例 がexcellentま 疹 痛 と機 能,可 善 が 早 期 に 得 られ た と報 告 して い る.ま たLiu3}は Levyら2 はarthroscopic 手術 成績 に つ い て は,Levyら2)は25例 1年 のfolow 可 能 と な り,Weberら7)は は腱板 修 復 術 の 際 に 鏡 視 下 手 術 と観 血 的 手術 の両 方 を行 う,い わ ゆ るcombined 中13 - はJOAス コ アの 改 善 の 点 で も満 足 の い く もの で あ っ

5 Cours, New Orleans, FEB 27, ) Warner JP, Altchek DW, Warren RF : Arthroscopic management of rotator cuff tears with emphasis on the throwing athlete. Oper Tech Orthop 1: , ) Weber SC : "Mini open" vs. traditional open repair in the management of small and moderate size tears of the rotator cuff. Presented at AANA Instructional 1) Ellman H and Gartsman GM : Rotator cuff disorders. In : Arthroscopic shoulder surgery and related procedures. Lea & Febiger. Pennsylvania : , ) Levy HJ, Urive JW, Delany LG : Arthroscopic assisted rotator cuff repair : preliminary results. Arthroscopy 6 : 55-60, ) Liu SH : Arthroscopicaly - assisted rotator - cuff repair. J Bone Joint Surg 76-B : , ) McLaughlin HL : Lesions of the musculotendinous cuff of the shoulder : The exposure and treatment of tears with retraction. J Bone Joint Surg 26 : 31, ) Snyder SJ, Pachelli AF, Delpizzo W et al. : Partial thickness rotator cuff tears : Results of arthroscopic treatment. Arthroscopy 7 : 1-7, 1991.

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