肩袖损伤的治疗进展

肩关节是全身活动度最大的关节,也是参与日常活动中最重要的关节之一。肩袖是组成肩关节软组织中最重要的结构,包括冈上肌、冈下肌、肩胛下肌和小圆肌。肩袖损伤则是引起肩部疼痛中最重要的原因之一,使肩关节活动明显受限,严重影响患者的生活质量。肩袖损伤治疗目的在于减轻疼痛以及恢复肩关节功能。其方法包括保守治疗及手术治疗,由于保守治疗并发症较多,手术治疗逐渐成为主要方法。手术治疗主要包括肩袖修复术、肩峰成形术、肩关节置换术和肌腱转移术等。     

肩袖损伤的诊断和治疗进展

肩袖损伤在肩关节病变中约占17％～41％。其病因Meyer(1924)认为肩袖损伤是慢性磨损的结果。随后国内外科学工作者对其病因、病理、诊断和治疗进行了深入探讨。本文对其研究进展综述如下。1 肩袖的功能解剖 盂肱关节的稳定性依赖于静力性和动力性两个因素。静力性稳定是依靠肩盂和肱骨头的关节面对合,以及关节囊和韧带结构提供的;动力性稳定则是依靠肩袖的肌肉肌腱联合,通过肱骨头向肩盂施加压力提供。肩袖是由起源于肩胛骨,附着于肱骨头周围的冈上肌、冈下肌、肩胛下肌和小圆肌的肌纤维与肩关节囊混合构成。Clark等认为肩袖肌的作用中以冈上肌最为重要,也最易损伤。已证实冈上肌、冈下肌腱在止点近侧的终末端1～1.5cm范围内是无血管区,此处是肌腱近侧滋养血管的终末端与肌腱大结节止点部位,来自骨膜滋养血管的交界区域,也就是肌腱退变和断裂的好发部位。另外,肩部还有一种特殊结构,即肩峰下关节。喙肩穹和大结节之间有类似关节滑囊的肩峰下滑液囊,其下方有冈上肌腱及肱二头肌腱长头通过。当反复过度活动时易发生慢性磨损     

肩袖损伤的研究概况

肩袖是由冈上肌、冈下肌、肩胛下肌和小圆肌的肌腱构成的包裹肱骨头的袖套样结构。调查表明，肩袖损伤占肩关节疾患发病率的相当大的比重。本文通过查找研究相关资料，对肩袖的生理解剖，损伤的病因病理等方面进行概括总结，从而为肩袖疾病的诊断和治疗提供依据，具有重要意义。     

肩关节镜下肩袖缝合的手术配合

肩袖是由冈上肌、冈下肌、肩胛下肌、小圆肌的肌腱包绕肱骨头前后方形成的袖套样结构,其主要功能是控制肩关节的运动及维持肩关节的稳定性［1］。肩袖损伤是中老年常见的肩关节疾病,其发病率占肩关节疾病的17％～41％［2］。2011年6月～2013年3月我院行肩关节镜下肩袖缝合手术17例,护理体会报告如下。     

肩袖肌腱病与高脂血症的相关性研究

目的 探讨不同类型肩袖肌腱病与高脂血症的相关性.方法 回顾性分析2017年11月至2019年12月期间在西安市红会医院肩肘科就诊的1843例患者的临床资料.根据患者肩关节MRI表现将肩袖肌腱病分为肩袖肌腱炎组990例、部分撕裂组696例和完全撕裂组157例,根据肌肉和脂肪的比例将冈上肌脂肪浸润程度分为1～4级,根据血脂...     

振动治疗联合康复训练对肩袖损伤康复的疗效研究

目的探讨振动治疗联合康复训练对于肩袖损伤治疗疗效。方法选取2018年10月—2021年6月同济大学附属东方医院40例肩袖损伤患者,随机分为试验组(n=20例)和对照组(n=20例),两组均接受常规肩袖损伤康复治疗,试验组同时进行肩关节振动治疗。治疗前后进行等速肌力测试、表面肌电测试、美国加州大学洛杉矶分校肩关节评分系统评分、疼痛评分评定。结果共27例患者完成试验。治疗4周后,两组VAS评分较治疗前均有所改善(P<0.05),其中进行组间比较时,试验组优于对照组(P<0.05);治疗4周后,试验组及对照组冈上肌、三角肌前束及中束均方根值均较治疗前有所改善(P<0.05),且试验组优于对照组(P<0.05);两组中上斜方肌均方根值均较测试前下降(P<0.05),但组间比较差异无统计学意义(P>0.05);而上斜方肌、中斜方肌、下斜方肌、冈下肌、小圆肌、前锯肌的均方根值较治疗前无明显改善(P>0.05),治疗4周后,试验组及对照组前屈、外展的峰力矩体重比值较治疗前均有所改善(P<0.05),且试验组优于对照组,(P<0.05);而内外旋时峰力矩体重比值较治疗前无明显改善(P>0.05)。结论存在疼痛、肌力下降的肩袖损伤患者,在进行康复训练时,辅助使用上肢振动治疗,有利于恢复肩袖肌力,减轻疼痛,恢复功能。     

肩袖损伤诊断中体格检查和 MRI 检查的可靠性评价

目的：评价肩关节体格检查和MRI对诊断冈上肌断裂的可靠性。方法回顾性分析76例肩关节疾病患者,以肩关节镜诊断结果为金标准,统计学分析Neer征、Hawkins征、疼痛弧、坠臂试验、冈上肌试验、夜间痛、肩峰下或肱骨大结节处压痛和MRI用于诊断冈上肌断裂的结果。结果疼痛弧灵敏度最高为82.3％,冈上肌试验特异度最高为81.8％,Neer征约登指数最高为0.352,冈上肌实验、Neer征及Hawkins征三者联合试验特异度为95.5％。核磁的灵敏度和特异度分别是87.5％和90.9％。结论采用联合试验可以提高正确诊断率,冈上肌实验、Neer征及Hawkins征联合试验诊断正确率高且容易实施。 MRI可作为诊断肩袖损伤的首选方法。     

浅析用肩关节MR双斜冠状位扫描诊断肩袖损伤的临床价值

目的:探讨用肩关节MR双斜冠状位扫描诊断肩袖损伤的临床价值。方法:对2011年1月~2013年12月期间我院收治的120例疑似患有肩关节肩袖损伤患者的临床资料进行回顾性研究。将这120例患者分为参照组和实验组,每组各有60例患者。我院为参照组患者进行肩关节MR斜冠状位扫描,为实验组患者进行肩关节MR双斜冠状位扫描。然后比较两组患者图像显示的结果。结果:进行肩关节MR斜冠状位扫描和肩关节MR双斜冠状位扫描均可将两组患者的冈上肌腱长轴显示在图像中。但实验组患者进行的肩关节MR双斜冠状位扫描可以完全将冈上肌、冈上肌腱和肱骨长轴同时显示在一张图像上(显示率为100%)。而参照组患者进行的肩关节斜冠状位MR扫描不能将冈上肌、冈上肌腱和肱骨长轴同时显示在一张图像上(显示率为0%)。实验组患者采用肩关节MR双斜冠状位扫描诊断肩袖损伤的敏感性(指在诊断过程中未漏诊的几率)为93.33%(28/30)。参照组患者采用肩关节MR斜冠状位扫描诊断肩袖损伤的敏感性为66.67%(20/30)。实验组患者采用肩关节双斜冠状位MR扫描诊断肩袖损伤的敏感性明显高于对照组患者采用肩关节MR斜冠状位扫描诊断肩袖损伤的敏感性,二者相比差异具有显著性(P<0.05)。实验组患者采用肩关节MR双斜冠状位扫描诊断肩袖损伤的特异性(指在诊断过程中不误诊的几率)与参照组患者采用肩关节MR斜冠状位扫描诊断肩袖损伤的的特异性相同,均为83.33%(25/30),二者相比差异不明显(P>0.05),不具有统计学意义。结论:进行肩关节MR双斜冠状位扫描可以清楚地显示标准的肩关节冠状位图像,其对冈上肌腱病变的显示效果要优于肩关节MR斜冠状位扫描。因此,此检查方法可作为临床上诊断肩袖损伤的首选方法。     

MRI不同序列对肩袖损伤诊断价值

目的 探析MRI不同序列诊断肩袖损伤的临床价值.方法 随机选取该院2015年2月-2017年1月期间收治的60例肩袖损伤患者,均采取MRI不同序列扫描,分析其对肩袖损伤的检出率.结果 60例患者中39例单纯一个肌腱损伤,14例患者2个肌腱损伤,7例患者3个肌腱损伤.双斜冠状位对冈上肌肌腱的检出率为98.21%与斜冠状位89.29%﹑横断位71.43%﹑斜矢状位44.64%比较差异有统计学意义(P<0.05);横断位对冈下肌肌腱检出率94.73%与其他方位比较差异有统计学意义(P<0.05);PDFS对冈上肌肌腱检出率100%,对冈下肌肌腱检出率93.33%,对肩胛下肌肌腱80.0%与T1WI和T2WI对其检出率比较差异有统计学意义(P<0.05).结论 双斜冠状位PDFS序列可将患者肩袖损伤的情况充分显示,清晰显示其细微变化,大大提高其诊断准确率,应用前景好.     

肩袖损伤诊疗的研究进展

肩袖是附着于肱骨大结节的冈上肌、冈下肌、小圆肌和附着在肱骨小结节上的肩胛下肌构成的袖口状组织,包裹于肱骨上。其上方为肩峰、肩锁关节、喙肩韧带构成的喙肩弓,两者之间为肩峰下滑囊。肩袖在肩关节运动中起支持、稳定肩肱关节的作用,维持肱骨头与关节盂的正常支点关系。肩袖损伤是肩部最常见的功能紊乱[1]。尽管关于肩袖损伤已有大量文献报道,但是其手术指征仍存在争议,且并未形成统一的标准[2]。导致这一问题的潜在原因是由于其临床表现过于多变,缺乏相关损伤症状自然史及流行病学趋势的了解[3]。而自然史的缺乏可能是由于许多损伤在出现症状后才开始接受治疗。通过对肩袖损伤的自然史及流行病学趋势的了解,既可以观察到疾病的病因,也可以掌握手术和保守治疗的时机,以避免病情的加重。     

Morphological and Signal Characteristics of Rotator Cuff Tears on Conventional MRI and MR Arthrography： Comparing with Gross Anatomy and Histopathology

~~Morphological and Signal Characteristics of Rotator Cuff Tears on Conventional MRI and MR Arthrography: Comparing with Gross Anatomy and Histopathology     

MORPHOLOGICAL AND SIGNAL CHARACTERISTICS OF ROTATOR CUFF TEARS ON CONVENTIONAL MRI AND MR ARTHROGRAPHY： COMPARING WITH GROSS ANATOMY AND HISTOPATHOLOGY

Objective To study the MR characterizations of supraspinatus and infraspinatus tendon lesions by comparing with gross anatomy and histopathology. Methods The study group consisted of 20 cadaver shoulders which were underwent the same imaging protocols of conventional MRI and MR arthrography. Results SET2WI images or MR arthrography respectively possessed of high specificity （95. 6% , 100% ）, but low sensitivity （70. 6% , 58. 8% ） for diagnosing rotator cuff tears. By uniting two images techniques, could remedy its limitations and would markedly increase the sensitivity （88.2% ）. There were many factors influencing the visualizations of partial thickness tears of rotator cuff on MR images, from which uppermost factors are tear extent, ruptured synovial capsule, scar and synovial proliferation. Conclusion MR1 diagnoses of rotator cuff lesions （ especially partial thickness tears） must carefully be estimated by combining T2WI images and MR arthrography.     

肩袖全层撕裂中分层与非分层撕裂的MRI征象对比研究

目的：对比分析肩袖全层撕裂中分层与非分层撕裂的MRI表现。方法：回顾性分析243 例肩袖全层撕裂患者,根据撕裂类型及肌腱回缩距离分为病例1组、病例2组及对照组,记录撕裂口大小、肌腱回缩距离及冈上、冈下肌腹萎缩程度,根据数据分布类型,采用单因素方差分析或Kruscal-Wallis检验比较3组撕裂口大小、肌腱回缩距离及冈上、冈下肌腹萎缩程度。结果：243例肩袖全层撕裂患者中,分层撕裂145例（占59.7%）。病例2组滑囊侧肌腱回缩距离[（22.2±9.8）mm]与对照组[（29.7±12.0）mm]和病例1组 [（29.0±12.5）mm]比较差异有统计学意义（P ＜0.01）;病例2组关节侧肌腱回缩距离[（35.1±11.7）mm]与对照组[（29.7±12.0）mm]和病例1组[（29.0±12.5）mm]比较差异有统计学意义（P ＜0.01）,3组间撕裂口大小、肌腹萎缩程度比较差异无统计学意义。结论：肩袖全层撕裂中分层撕裂较非层撕裂常见,不同分型中关节侧及滑囊侧肌腱回缩距离存在差异,肩袖修补术前,应充分认识分层撕裂的存在及类型,以确保损伤肩袖得以完整修复。     

肩袖损伤程度和肱骨头上移距离间的相关性分析

目的: 评估肩袖组织损伤程度与肱骨头上移距离之间的关系。方法: 选取2015年9月至2016年5月北京大学人民医院创伤骨科收治的肩袖损伤患者30例,均已行患侧肩关节磁共振及X线检查。将患者根据X线正位片测量所得的肱骨头上移系数(upward migration index,UMI),即肱骨头中心至肩峰距离与肱骨头半径的比值分为3个小组,每组10人,组1:1.2≥UMI >1,组2:1.4≥UMI >1.2,组3:UMI >1.4,进行Spearman等级相关分析,判定不同的UMI值与肩袖组织脂肪变程度、肩袖撕裂范围、撕裂处冈上肌厚度之间的关系。结果: 在X线正位片上,平均UMI值为1.33(范围1.02~1.51,标准差为±0.22),UMI值与肩袖组织撕裂的大小呈负相关(R=-0.584,P<0.01),与冈上肌脂肪变程度呈负相关(R=-0.312,P=0.033),而与磁共振上撕裂处冈上肌厚度并无相关性(R=0.127,P=0.071)。结论: UMI与肩袖撕裂及肩袖脂肪变程度存在相关性,UMI值与肩袖组织撕裂大小和冈上肌脂肪化程度呈负相关,其数值减小是肩袖撕裂及脂肪化退变的可靠标志。当患者因急性肩痛就诊时,门诊医师可结合临床表现、体格检查及X线影像学检查结果作出初步判断,对初步筛查肩袖损伤及指导进一步治疗具有重要意义。     

肩峰成形在关节镜下冈上肌腱缝合术中的作用

目的 观察关节镜下肩峰成形对冈上肌腱修复临床效果的影响。 方法 收集我单位2010 年3 月- 2011 年12 月收治的肩袖损伤患者34 例,关节镜下证实冈上肌腱全层撕裂。将患者随机分为2 组,即肩峰成形组和非肩峰成形组,每组17 例。术后采用Constant-Murley 肩关节评分系统（Constant-Murley Score,CMS） 和加州大学（University of California at Los Angeles,UCLA） 肩关节评分系统评价关节功能。 结果 两组患者术后CMS 评分和UCLA 肩关节评分差异均无统计学意义（P ＞ 0.05）。 结论 肩峰成形术对冈上肌腱全层撕裂的患者肩袖修复术术后效果没有明显影响。     

Factors related to successful outcome of conservative treatment for rotator cuff tears

Background

Much controversy exists as to the management of full-thickness tears of the rotator cuff. Not all patients with rotator cuff tears require surgical treatment. We have little information whether there are factors that are related to successful outcome of conservative treatment.

Aim

The purpose of this study was to determine the factors related to the successful outcome following conservative treatment.

Methods

This study included 123 shoulders in 118 patients with full-thickness tears of the rotator cuff diagnosed by high-resolution magnetic resonance imaging with a microscopy coil. All patients were treated conservatively for at least 3 months. Clinical symptoms improved in 65 shoulders in 62 patients by conservative treatment (conservative group), but remained unchanged or aggravated in 58 shoulders in 56 patients, who eventually underwent surgical repair (surgical group).

Results

The following parameters showed significant differences: 1) integrity of the intramuscular tendon of the supraspinatus (24.1% in the surgical group and 58.4% in the conservative group showed an intact intramuscular tendon); 2) supraspinatus muscle atrophy (occupancy ratio was 69.8% in the surgical group and 78.0% in the conservative group); 3) impingement sign (positive in 79.3% in the surgical group and 30.7% in the conservative group); and 4) external rotation angle (35.0 degrees in the surgical group and 52.2 degrees in the conservative group). The success rate of conservative treatment was 87% in the cases with at least three of these four factors.

Conclusion

These four factors are useful in selecting patients who will respond well to conservative treatment before initiating the treatment.     

Biomechanical comparison of double-row versus transtendon single-row suture anchor technique for repair of the grade Ⅲ partial articular-sided rotator cuff tears

Background For partial-thickness tears of the rotator cuff, double-row fixation and transtendon single-row fixation restore insertion site anatomy, with excellent results. We compared the biomechanical properties of double-row and transtendon single-row suture anchor techniques for repair of grade Ⅲ partial articular-sided rotator cuff tears.Methods In 10 matched pairs of fresh-frozen sheep shoulders, the infraspinatus tendon from 1 shoulder was repaired with a double-row suture anchor technique. This comprised placement of 2 medial anchors with horizontal mattress sutures at an angle of .≤45° into the medial margin of the infraspinatus footprint, just lateral to the articular surface, and 2 lateral anchors with horizontal mattress sutures. Standardized, 50% partial, articular-sided infraspinatus lesions were created in the contralateral shoulder. The infraspinatus tendon from the contralateral shoulder was repaired using two anchors with transtendon single-row mattress sutures. Each specimen underwent cyclic loading from 10 to 100 N for 50 cycles, followed by tensile testing to failure. Gap formation and strain over the footprint area were measured using a motion capture system; stiffness and failure load were determined from testing data.Results Gap formation for the transtendon single-row repair was significantly smaller (P ＜0.05) when compared with the double-row repair for the first cycle ((1.74±0.38) mm vs. (2.86±0.46) mm, respectively) and the last cycle ((3.77±0.45) mm vs. (5.89±0.61) mm, respectively). The strain over the footprint area for the transtendon single-row repair was significantly smaller (P ＜0.05) when compared with the double-row repair. Also, it had a higher mean ultimate tensile load and stiffness.Conclusions For grade Ⅲ partial articular-sided rotator cuff tears, transtendon single-row fixation exhibited superior biomechanical properties when compared with double-row fixation.     

肩袖损伤的HRI诊断研究

目的研究肩袖损伤的MR1诊断特征。方法回顾性分析2010年1月至2012年8月48例肩袖损伤患者的MRI影像资料。结果MRI显示46例冈上肌腱损伤,其中10例完全撕裂,36例部分撕裂。19例显示冈下肌腱损伤,其中4例完全撕裂,15例部分撕裂。3例发现肩胛下肌腱部分撕裂。2例显示小圆肌腱部分撕裂。结论MRI能够清楚显示肩袖的解剖结构,能够帮助准确判断肩袖损伤的部位、范围、程度,为临床制定治疗方案提供重要参考。     

Shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears

Background

Complex regional pain syndrome (CRPS) is one of the serious complications after surgical treatment of a rotator cuff tear. Both a measurement of body surface temperature and bone scintigraphy have been used as diagnostic tools for the early phase of CRPS.Unfortunately, few studies have been carried out that applied these methods to the patients after rotator cuff repair.

Purposes

To clarify both shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears.

Subjects and methods

Subjects comprised patients with unilateral rotator cuff tears (five men and five women, mean age 61 years). For measurements of shoulder surface temperature, a Thermochron was attached to both shoulders. As for bone scintigraphy, intravenous injection of technetium-labelled hydroxymethylenebisphosphonic acid (99mTc-HMDP)was performed, and then images were taken with a gamma camera.

Results

During the measurements, the changes in body surface temperature for the affected and healthy shoulders remained within the standard deviation of the reference group. The intensity of radioisotope (RI) uptake for the affected shoulder joint was significantly increased compared to that for the healthy shoulder joint (P < 0.05).

Conclusion

RI uptake is increased in shoulders with rotator cuff tears, whereas shoulder surface temperature shows no differences on the affected and unaffected sides.