随着我国人民整体生活水平的不断提高，更多的人积极投身各种锻炼，随之而来的就是肩关节，特别是肩袖损伤的发生率不断提高。当然也有我们对这一疾病的认识和诊断水平不断提高带来的效应。但更多的人对于手术还是存在着恐惧，虽然口口声声要治标治本，但总是不断的反复问大夫能否保守治疗。这种现象不仅仅存在中国患者，全世界都有着同样的问题。于是，来自美国多个州的运动医学专家，联合进行了一项高质量随机对照研究，来对比手术与非手术治疗肩袖损伤的效果。对于手术治疗的效果评价来说，我们无法做到双盲，所以该项研究的证据级别已经达到了最高水平。而且，该研究持续了长达近十年，分别在接受治疗（手术或非手术）后的三个月，15个月和25个月多个时间点对治疗效果进行评价，从而得出了更加可靠的结论。

根据该研究的结果，在治疗后三个月左右的时间点，接受非手术治疗的患者的效果更好；然而在后面15个月和25个月左右进行的疗效评价时，手术治疗组的患者所获得的症状改善不断增加，远远超过了接受保守治疗的患者。

这一结果提示我们：

1、在手术过程中，我们的外科操作，对肩关节造成了进一步的损伤，虽然对撕裂的肩袖进行了修补，但其愈合还需要时间。因而，在三个月左右时进行的疗效评估，发现手术患者不如非手术患者。

2、手术后组织修复愈合需要时间，往往在一年以上，甚至到两年的时候还会继续获得改善。这提示我们的患者要给予机体恢复足够的时间。

3、对于存在器质损伤的疾病，保守治疗虽然能够改善症状，但由于大部分损伤是不能自行修复的，因而最终可能还是需要手术治疗。

Comparative Time to Improvement in Nonoperative and Operative Treatment of Rotator Cuff Tears

Song, Amos MD1; DeClercq, Joshua MS1; Ayers, Gregory D. MS1; Higgins, Laurence D. MD, MBA2; Kuhn, John E. MD, MS1; Baumgarten, Keith M. MD3; Matzkin, Elizabeth MD4; Jain, Nitin B. MD, MSPH1,a

Author Information

The Journal of Bone and Joint Surgery: July 1, 2020 - Volume 102 - Issue 13 - p 1142-1150

doi: 10.2106/JBJS.19.01112

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Abstract

Background:

Comparative time to recovery after operative and nonoperative treatment for rotator cuff tears is an important consideration for patients. Hence, we compared the time to achieve clinically meaningful reduction in shoulder pain and function after treatment.

Methods:

From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative or nonoperative treatment was recruited. After propensity score weighting, the Kaplan-Meier method was used to estimate the time to achieve a minimal clinically important difference (MCID), >30% reduction, and >50% reduction in the Shoulder Pain and Disability Index (SPADI) and the American Shoulder and Elbow Surgeons (ASES) scores. (In our analysis, both ASES and SPADI were coded such that a lower number corresponded to a better outcome; thus, the word “reduction” was used to indicate improvement in both ASES and SPADI scores.) A 2-stage test was conducted to detect a difference between the 2 groups.

Results:

In this cohort, 96 patients underwent nonoperative treatment and 73 patients underwent a surgical procedure. The surgical treatment group and the nonoperative treatment group were significantly different with respect to SPADI and ASES scores (p < 0.05). The maximum difference between groups in achievement of the MCID for the SPADI scores was at 3.25 months, favoring the nonoperative treatment group. The probability to achieve the MCID was 0.06 (95% confidence interval [CI], 0.00 to 0.12) for the surgical treatment group compared with 0.40 (95% CI, 0.29 to 0.50) for the nonoperative treatment group. The surgical treatment group had a greater probability of achieving >50% reduction in SPADI scores at 15.49 months (0.20 [95% CI, 0.12 to 0.29] for the surgical treatment group compared with 0.04 [95% CI, 0.00 to 0.09] for the nonoperative treatment group). The surgical treatment group had a greater probability of achieving >50% reduction in ASES scores at 24.74 months (0.96 [95% CI, 0.84 to 0.99] for the surgical treatment group compared with 0.66 [95% CI, 0.53 to 0.75] for the nonoperative treatment group). The differences for >30% reduction in SPADI and ASES scores and the MCID for ASES scores were not significant.

Conclusions:

Patients undergoing nonoperative treatment had significantly better outcomes in the initial follow-up period compared with patients undergoing a surgical procedure, but this trend reversed in the longer term. These data can be used to inform expectations for nonoperative and operative treatments for rotator cuff tears.

Level of Evidence:

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated