Mahir MAHİROĞULLARI, Hüseyin ÖZKAN, Mustafa AKYÜZ, ALİ AKIN UĞRAŞ, AHMET GÜNEY, Mesih KUŞKUCU

İzole travmatik anterior omuz instabilitesinde artroskopik ve açık cerrahi tedavi sonuçlarının karşılaştırılması

Amaç: Travmatik anterior omuz instabilitesinin cerrahi tedavi yöntemlerinden olan açık Bankart tamiri ile artroskopik Bankart tamirinin erken dönem sonuçları karşılaştırıldı. Çalışma planı: Tekrarlayan anterior omuz instabilitesi nedeniyle cerrahi tedavi uygulanan 64 erkek hasta çalışmaya alındı. Hastaların 30’una (ort. yaş 25.1) açık Bankart tamiri, 34’üne (ort. yaş 25.8) artroskopik Bankart tamiri uygulandı. Tüm hastalarda ameliyat öncesi manyetik rezonans görüntülemede labrum yırtığı saptandı ve hepsinde günlük aktivitelerini dahi yaparken instabilite yakınması vardı. Çıkık sayısı en az altı olan hastalar çalışmaya alındı; çok yönlü instabilitesi olan hastalar çalışma dışı bırakıldı. İlk travmadan cerrahiye kadar geçen süre açık cerrahi grubunda ortalama 4.4 yıl (dağılım 1-24 yıl), artroskopi grubunda 3.8 yıl (dağılım 1-17 yıl) idi. Ameliyat kararı verilirken, hastaların çıkık korkusu ile günlük aktivitelerinin kısıtlanması ve klinik muayenede instabilite testlerinin pozitif bulunması dikkate alındı. Her iki grupta da tamir metal ankor dikişlerle yapıldı. Klinik sonuçlar Rowe skalası kullanılarak değerlendirildi. Ameliyat sonrası ilk günde ağrı değerlendirmesi görsel analog skala (GAS) kullanılarak yapıldı. Ameliyat sonrası ortalama takip süresi, açık grupta 26.1 ay (dağılım 12-52 ay), artroskopi grubunda 26.6 (dağılım 12-51 ay) idi. Sonuçlar: Ameliyat süresi açık grupta ortalama 2 saat, artroskopi grubunda 2.5 saat bulundu. Kesi uzunluğu açık grupta yaklaşık 8 cm, artroskopi grubunda 3 cm idi. Ortalama Rowe skoru açık cerrahi grubunda 90.2, artroskopik tamir grubunda 91.6 bulundu. Klinik sonuçlar açık cerrahi grubunda 21 hastada (%70) mükemmel, sekiz hastada (%26.7) iyi, bir hastada (%3.3) kötü; artroskopik tamir grubunda 27 hastada (%79.4) mükemmel, beş hastada (%14.7) iyi, iki hastada (%5.9) kötü bulundu. Kötü sonuç alınan hastalarda ameliyat sonrası 5-18 aylarda travmatik düşme nedeniyle yeniden çıkık oluşmuştu. Ağrı değerlendirmesinde, ortalama GAS skoru açık cerrahi grubunda 5.0±1.3, artroskopik tamir grubunda 4.4±1.3 bulundu. Dış rotasyonda, açık cerrahi grubunda 15 hastada (8 hastada 20°, 4 hastada 10°, 3 hastada 5°), artroskopik tamir grubunda ise dokuz hastada (3 hastada 20°, 6 hastada 10°) kayıp saptandı. İki grup arasında Rowe skoru, ağrı skoru, hareket açıklığı, endişe testi ve tekrarlayan instabilite sıklığı açısından anlamlı fark bulunmadı (p>0.05). Çıkarımlar: Geçmişte artroskopik tamir sonuçları açık cerrahi tedaviye göre daha az tatminkar bulunurken, günümüzde bu durum değişmektedir. Çalışmamızda artroskopik tamir sonuçları açık tamir sonuçları ile eşdeğer bulundu. Artroskopik cerrahi tecrübe ve tamir yöntemlerinin gelişmesiyle, artroskopik tamirin açık cerrahi tedavinin önüne geçeceğine inanıyoruz.

Comparison between the results of open and arthroscopic repair of isolated traumatic anterior instability of the shoulder

Objectives: The aim of this study was to compare the early postoperative results of open and arthroscopic Bankart repair for isolated traumatic anterior instability of the shoulder. Methods: The study included 64 male patients who underwent surgery for traumatic recurrent anterior shoulder instability. Of these, 30 patients (mean age 25.1 years) underwent open Bankart repair and 34 patients (mean age 25.8 years) underwent arthroscopic Bankart repair. All the patients had labral tears on preoperative magnetic resonance scans and had complaints of instability even during daily activities. Patients with at least six dislocations were included in the study; patients with multidirectional instability were excluded. The mean time from the first trauma to surgical intervention was 4.4 years (range 1 to 24 years) in the open surgery group, and 3.8 years (range 1 to 17 years) in the arthroscopy group. Decision for surgical treatment was made based on limitation of activities because of fear of having a dislocation and on positive results of instability tests. Repair was performed using metal anchors in both groups. The clinical results were evaluated using the Rowe scale. The severity of pain on the first postoperative day was assessed using a visual analog scale (VAS). The mean follow-up period was 26.1 months (range 12 to 52 months) in the open surgery group, and 26.6 months (range 12 to 51 months) in the arthroscopic repair group. Results: The mean duration of operation was 2 hours for open surgery, and 2.5 hours for arthroscopic repair. The size of the incision was approximately 8 cm in the open surgery group, and 3 cm in the arthroscopic repair group. The mean Rowe scores were 90.2 and 91.6, being higher in the arthroscopic repair group. Clinical results of open surgery were excellent in 21 patients (70%), good in eight patients (26.7%), and poor in one patient (3.3%). In the arthroscopic repair group, the results were excellent in 27 patients (79.4%), good in five patients (14.7%), and poor in two patients (5.9%). All the patients with a poor result experienced redislocations due to traumatic falls 5 to 18 months after surgery. The mean VAS score was 5.0±1.3 in the open surgery group, and 4.4±1.3 in the arthroscopic repair group. Loss of external rotation was observed in 15 patients (20° in 8 patients, 10° in 4 patients, 5° in 3 patients) in the open surgery group, and in nine patients (20° in 3 patients, 10° in 6 patients) in the arthroscopic repair group. There were no significant differences between the two groups with respect to Rowe scores, VAS scores, range of motion, apprehension test results, and the incidence of recurrent instability. Conclusion: Although, in the past, the results of arthroscopic repair were less satisfactory compared to open surgery, this condition has changed remarkably. The results of arthroscopic repair in our study were similar to those of open repair. We believe that, with enhanced experience and advances in arthroscopic repair techniques, arthroscopic treatment may outweigh open surgery.

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