PDF(Sci-hub)
Abstract：
BACKGROUND: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs.
METHODS: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response.
RESULTS: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation.
CONCLUSIONS: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.
METHODS: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response.
RESULTS: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation.
CONCLUSIONS: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.
摘要：
背景：由于患者特征和结果的可变性，导致治疗建议缺乏一致性，因此对大量不可修复的肩袖撕裂（MIRCT）的管理仍存在争议。这项研究的目的是使用来自美国肩肘外科医生NeerCircle的专家实施Delphi程序，以确定有关各种MIRCT治疗方案的共识领域。
方法：向120名肩关节外科医师小组发送了一项关于MIRCT治疗的调查，包括关节镜清理和部分袖带修复，移植物增强，反向肩关节置换术(RSA),上囊重建（SCR），和肌腱转移。然后使用由13个患者因素组成的第一轮问卷进行迭代Delphi过程，并选择开放式响应，以确定影响MIRCT治疗的重要特征。第二轮调查试图确定与所包括的6种治疗方案相关的患者因素的重要性。第三轮调查要求参与者将60例MIRCT患者的治疗方案分类为首选治疗方案。可接受的治疗,不可接受/禁忌，或不确定/没有意见。当至少80％的调查受访者同意回应时，宣布患者方案对首选和不可接受/禁忌类别达成共识。可接受的治疗类别需要90%的阈值，由可接受的治疗或首选的治疗反应定义。
结果：72名成员同意参与，并根据他们对临床实践和患者数量的调查回答，被认为具有必要的专业知识。有20种临床方案达成了90%的共识，作为可接受的治疗，在18种情况下选择RSA，在2种情况下选择关节镜清理和/或部分修复。在8种情况下，RSA被选择为单一首选治疗方案。不可接受/禁忌的治疗方案在8种情况下达成共识，其中，4与SCR有关，3与RSA有关，1与移植物增强部分修复有关。
结论：本Delphi方法对RSA作为老年假性轻瘫患者的首选治疗策略表现出显著的共识，无法修复的肩胛骨下,动态不稳定性。此外,该过程确定了某些不可接受的MIRCT治疗方法,如老年假性轻瘫患者的SCR和不可修复的肩胛骨下肌萎缩症患者的SCR或年轻患者的RSA无假性轻瘫或动态不稳定的肩胛骨下肌萎缩症患者.这些方案和共识领域的发布可以为MIRCT管理从业人员提供有用的指导。
方法：向120名肩关节外科医师小组发送了一项关于MIRCT治疗的调查，包括关节镜清理和部分袖带修复，移植物增强，反向肩关节置换术(RSA),上囊重建（SCR），和肌腱转移。然后使用由13个患者因素组成的第一轮问卷进行迭代Delphi过程，并选择开放式响应，以确定影响MIRCT治疗的重要特征。第二轮调查试图确定与所包括的6种治疗方案相关的患者因素的重要性。第三轮调查要求参与者将60例MIRCT患者的治疗方案分类为首选治疗方案。可接受的治疗,不可接受/禁忌，或不确定/没有意见。当至少80％的调查受访者同意回应时，宣布患者方案对首选和不可接受/禁忌类别达成共识。可接受的治疗类别需要90%的阈值，由可接受的治疗或首选的治疗反应定义。
结果：72名成员同意参与，并根据他们对临床实践和患者数量的调查回答，被认为具有必要的专业知识。有20种临床方案达成了90%的共识，作为可接受的治疗，在18种情况下选择RSA，在2种情况下选择关节镜清理和/或部分修复。在8种情况下，RSA被选择为单一首选治疗方案。不可接受/禁忌的治疗方案在8种情况下达成共识，其中，4与SCR有关，3与RSA有关，1与移植物增强部分修复有关。
结论：本Delphi方法对RSA作为老年假性轻瘫患者的首选治疗策略表现出显著的共识，无法修复的肩胛骨下,动态不稳定性。此外,该过程确定了某些不可接受的MIRCT治疗方法,如老年假性轻瘫患者的SCR和不可修复的肩胛骨下肌萎缩症患者的SCR或年轻患者的RSA无假性轻瘫或动态不稳定的肩胛骨下肌萎缩症患者.这些方案和共识领域的发布可以为MIRCT管理从业人员提供有用的指导。
