全厚层肩袖撕裂的治疗

肩袖损伤常见于40～70岁者,尸检证明60岁以上者有1/3以上的人有明显的肩袖疾病,其中包括全厚层肩袖撕裂。由于肌腱回缩、较差的血液供应、关节滑液的干扰及组织愈合所需要的微细胞环境不良等生物因素,致使全厚层肩袖撕裂不能在解剖位置愈合。 手术治疗包括肩峰成形术及将损伤的肩袖肌腱在肱骨上做精确的修复。手术经肩关节前上方入路,将喙肩韧带自肩峰上完全放松。本组共有72名患者,男性44名,女性28     

细胞工程技术在肩袖损伤修复中的应用

 肩袖损伤是最常见的需要外科干预的损伤之一。自从Codman于1911第一次介绍了肩袖修补术后,肩袖损伤的治疗方式已经从开放手术逐渐过渡到小切口手术,再到全关节镜手术。虽然手术技巧日趋成熟及完善,但术后再撕裂的发生率仍然很高。文献报道中单纯冈上肌损伤术后的再撕裂率约为25%,巨大肩袖损伤的再撕裂率甚至高达75%。再撕裂率与患者年龄、肌腱的变性情况、肌腱质量、手术操作及术后康复有关。因为肩袖组织血供相对缺乏,损伤后发生一系列退行性变化,如脂肪变性、肌肉萎缩等,手术修复后腱-骨连接处主要以瘢痕组织为主,机械强度远比正常的纤维软骨性腱-骨愈合的结构差,肩袖修补后的机械强度无法恢复到自然状态。因此探讨肩袖的自身修复机制,在此基础上通过调节其生物过程来促进肩袖损伤修复,达到肩袖止点的生物学重建较单纯提高手术技术更为重要。近年来,有学者认为组织自身的微环境所诱导出的愈合能力是肩袖修补转归的重要因素之一。研究方向更多地转向了肌腱修复的生物原理,使肌腱可以有二次生长的机会,最终达到治疗目的。     

犬肩袖损伤愈合模型的研究

目的比较研究不同肩袖损伤类型以及采用不同方法修复后的肩袖愈合差异,探讨能准确模拟临床肩袖损伤修复术后恢复进程的动物模型。方法取12只成年雄性比格犬,体质量10~15 kg,根据处理方法不同随机分为3组(n=4),分别制备急性肩袖损伤+Mason-Allen缝合修复(A组)、巨大肩袖损伤+Mason-Allen缝合修复(B组)及巨大肩袖损伤+Mason-Allen缝合并自体半腱肌扩张部修复(C组)动物模型;3组修复后均外固定架制动。术后观察各组动物一般情况;于术后6周取材大体观察冈下肌肌腱末端愈合情况,生物力学测试极限负荷,组织学观察肌腱细胞及纤维改变,比较肩袖修复程度。结果术后各组动物均存活至实验完成,切口均愈合良好,无感染发生。大体观察示,A组冈下肌肌腱末端瘢痕组织明显多于正常肌腱组织;B组冈下肌肌腱末端未见明显肌腱组织;C组冈下肌肌腱虽然部分覆盖瘢痕组织,但仍可观察到肌腱及其大致走向。A、B、C组极限负荷分别为(223.75±24.28)、(159.25±34.87)、(233.25±14.24)N,B组显著低于A、C组(P0.05),A、C组间比较差异无统计学意义(P0.05)。组织学观察示,A组肌腱纤维排列大致正常;B组肌腱纤维排列较紊乱,并且肌腱细胞明显少于A组;C组肌腱纤维排列整齐,且肌腱细胞多于B组。结论 Mason-Allen缝合联合自体半腱肌扩张部修复犬巨大肩袖损伤能获良好修复效果;制动模型可较好模拟临床肩袖损伤愈合过程,可作为相关研究的理想动物模型。     

肩袖钙化性肌腱炎中发生肩袖撕裂的MRI研究

目的探讨肩袖钙化性肌腱炎与肩袖撕裂的关系。方法回顾性分析自2016-12—2019-11诊治的86例肩袖钙化性肌腱炎(观察组)与86例非钙化性肌腱炎(对照组),2组均完善MRI检查,比较2组肩袖撕裂数、肩袖全层撕裂数、肩袖撕裂位置。结果 172例均顺利完成检查,2组肩袖撕裂数、肩袖撕裂位置比较差异无统计学意义(P>0.05)。观察组肩袖全层撕裂数较对照组少,差异有统计学意义(P<0.05)。观察组钙化和肩袖撕裂的位置一致性较差,24例钙化性肌腱炎合并肩袖撕裂,16例发生肩袖撕裂的肌腱不同于钙化的肌腱。8例同一肌腱内发生钙化和肩袖撕裂中只有3例肩袖撕裂发生在肌腱钙化的同一部位。结论肩袖钙化性肌腱炎患者肩袖撕裂的风险没有增加,钙化性肌腱炎和肩袖撕裂可能是由不同的病理过程引起的。     

糖尿病对肩袖损伤发病及预后影响的研究进展

糖尿病与不同部位肌腱改变之间存在联系,然而持续高血糖状态对肩袖部位肌腱的影响尚未得到很好的阐述。本文就糖尿病并发肩袖损伤的特点、发病机制及糖尿病对肩袖修补术后疼痛、活动度、组织愈合和感染发生的影响进行综述,以便进一步了解糖尿病患者肩袖损伤进展及术后的预后情况,为提供个性化的预防措施及康复指导提供依据。     

糖尿病对肩袖损伤发病及预后影响的研究进展

糖尿病与不同部位肌腱改变之间存在联系,然而持续高血糖状态对肩袖部位肌腱的影响尚未得到很好的阐述。本文就糖尿病并发肩袖损伤的特点、发病机制及糖尿病对肩袖修补术后疼痛、活动度、组织愈合和感染发生的影响进行综述,以便进一步了解糖尿病患者肩袖损伤进展及术后的预后情况,为提供个性化的预防措施及康复指导提供依据。     

促进肩袖止点腱骨愈合的研究进展

肩袖修补术是肩袖撕裂常用的治疗方式,能有效缓解肩关节疼痛,改善肩关节的活动,但肩袖修补术后肩袖再撕裂的发生率依然很高,主要原因在于肩袖修补术后肩袖止点处腱—骨愈合差,不能恢复原有的组织学结构和生物力学性能。因此,如何有效提高肩袖止点处腱骨愈合是解决此类问题的关键。目前随着人们对于肩袖止点研究的不断深入,各类治疗方法在改善肩袖止点腱骨愈合方面取得了较大的进展。本文将从影响肩袖止点处腱骨愈合的因素、肩袖止点处腱骨界面的恢复以利于肩袖腱骨愈合以及组织工程学在腱骨愈合中的应用3个方面阐述近几年关于肩袖腱骨愈合的研究进展,以期为肩袖撕裂的临床治疗提供一定的指导。     

肱二头肌腱在撞击综合征中的作用

肱二头肌腱长头在撞击综合征病损中起重要作用。肌腱的滑膜衬里来自肩关节滑膜延伸。肩关节滑膜的任何炎症均能沿肌腱扩散。由于狭窄的肱二头肌腱沟和紧张的横韧带,阻碍了腱鞘炎的扩散,并使病损迅速转为慢性。撞击综合征主要由肩峰弓长期压迫肩袖,引起肩袖肌腱炎所致。肩峰弓由肩峰、肩锁关节和喙肩韧带组成。肩袖出现肌腱炎时,可伴有滑膜炎,继而肱二头肌腱鞘炎,并向下向外扩展。鉴别肩袖性疼痛和肱二头肌疼痛较困难。大多数肩袖患者主诉外侧三角肌或     

糖尿病对肩袖损伤、修复及并发症影响的文献综述

糖尿病是肩袖损伤的危险因素之一,且影响肩袖修复及术后并发症的发生。区别于一般肩袖损伤,糖尿病病人肩袖损伤具有复杂性,影响骨科医师对于此类病人的评估与治疗。随着糖尿病病人数量的逐年上升,糖尿病对肩袖损伤的影响研究变得更为重要。本文回顾了有关糖尿病与肩袖损伤的现有相关文献,通过从糖尿病与肩袖损伤的关系,糖尿病病人肩袖肌腱的病理变化及其致病机制,以及糖尿病对肩袖损伤手术、愈合和修复术后并发症的影响等六个方面进行综述,为临床工作中肩袖损伤合并糖尿病病人的治疗提供参考。     

肌腱干细胞的研究进展

由运动损伤导致的跟腱断裂、肩袖撕裂、肌腱止点撕脱等常需通过手术修复,然而肌腱组织再生能力较差,患者术后将面临肌腱的瘢痕愈合或骨-腱接点愈合困难的问题.最近新发现的肌腱干细胞已被证实具有干细胞的特性,其在肌腱组织中的修复潜能逐渐获得人们的重视,有望成为组织工程中新的种子细胞.本文对肌腱干细胞的一般特性与年龄、微环境、力学的关系及其在骨-腱接点愈合中的作用作一综述.     

Biologic augmentation of rotator cuff repair

Rotator cuff repair is commonly performed to provide pain relief and improve shoulder function in patients with pain and disability related to cuff tears. However, re-tear rates following repair remain remarkably high in certain patient populations. Biologic strategies to reinforce repairs or augment tendon healing, such as extracellular matrices and platelet-rich plasma therapy, are an area of increased interest among orthopedic surgeons to improve these suboptimal healing rates. As more products have become commercially available, much attention has been turned to determining the optimal augmentation technique. However, data supporting the role and efficacy of these products is limited. Thus careful patient selection remains the most essential strategy for optimizing tendon healing potential following rotator cuff repair.     

骨质疏松对肩袖损伤修复的影响研究进展

老年人群因合并有不同程度的骨质疏松,肩袖损伤修复再撕裂率高。为解决这一难题,手术医师尝试通过增加锚钉初始固定强度、改变局部骨质情况等方法来降低这类患者肩袖损伤的再撕裂率。组织工程学的快速发展也使生长因子的辅助应用成为可能。但在目前的临床工作中,合并有骨质疏松的肩袖损伤修复仍然是临床工作者面临的一个巨大挑战。如何更好地增加锚钉固定强度,改善腱骨愈合微环境,降低肩袖再撕裂率成为了近年来的研究热点。本文从骨质疏松与肩袖损伤的关系、骨质疏松对肩袖腱骨愈合的影响及目前采用的减少骨质疏松对腱骨愈合的不同方法3个方面进行综述,以便更好地指导临床治疗,提高患者的手术效果及术后满意率。     

Editorial Commentary: Dermal Allografts Are Indicated for Repair of Irreparable Rotator Cuff Tears and for Revision Surgery,and May Be Cost-Effective for Primary Repair

Improving rotator cuff repair results is the goal of all shoulder surgeons. The addition of a biologic graft may speed healing, allow accelerated rehabilitation, and increase healing rates. Recent research suggests that augmentation of rotator cuff repair using dermal allograft may be cost-effective. Indications for dermal allografts are revision rotator cuff repairs and primary cuff repairs in which a tensionless repair cannot be accomplished. Allografts act as a load-sharing device to allow tendons to heal without tension. They also serve to fill the gap in irreparable cuff tears. It is important to understand that augmentation will not compensate for advanced muscle fatty atrophy or neurapraxia. Precautions to prevent Cutibacterium acne nosocomial infection are essential. The healing time or dermal grafts is considerably longer than the repaired native cuff tendon, requiring supervised rehabilitation. Dermal allografts are a crucial tool for repair of irreparable rotator cuff tears and for revision surgery. From an economic standpoint, they now also may be considered for use in primary rotator cuff repair surgery.     

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient’s prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient’s surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen.Level of EvidenceLevel V, expert opinion.     

Editorial Commentary: Shoulder Superior Capsule Reconstruction Leads to Good Outcomes Despite Ambiguous Graft Healing Suggesting a Spacer Effect

Massive, retracted rotator cuff tears with poor tissue quality continue to pose a problem for the shoulder surgeon. Augmentation of such repairs with grafts, patches, spacers, or biologics is being closely investigated to help improve clinical outcomes and healing rates. Specifically, superior capsule reconstruction augmentation of such rotator cuff tears may lead to good outcomes. However, we do not truly understand how much native cuff tissue or graft healing is actually taking place. Clinically, superior capsule reconstruction augmentation of rotator cuff repair may simply be serving as a spacer.     

肩袖撕裂的组织学及电子显微镜观察

目的观察肩袖的损伤过程及超微结构。方法３６例肩袖撕裂的标本分别制成组织切片和电镜超薄切片,比较手术所见与肩袖的病理变化。结果肩袖退变分别由滑膜和肌腱本身发生。肌腱的修复分为两种类型：Ⅰ型通过滑膜组织修复;Ⅱ型通过肌腱本身修复。结论肌腱虽然有自身修复能力,但肌腱全层和深层的断裂难以完全修复,应手术治疗     

关于骨髓刺激技术在肩袖撕裂治疗作用的系统评价及Meta分析

目的评估骨髓刺激技术在改善肩袖愈合及功能恢复中的作用。 方法计算机检索Cochrane Library、PubMed、Medline、Embase、中国知网（CNKI）、维普（VIP）、万方及中国生物医学文献数据库（CBM）等数据库中关于应用骨髓刺激技术和单纯肩袖修复的比较研究，包括临床随机对照和回顾性队列研究。手工检索纳入研究的参考文献。提取各研究中指标数据，包括总体再撕裂率，大到巨大肩袖撕裂的再撕裂率，术后肩关节活动度（range of motion，ROM），视觉模拟评分（visual analogue scale,VAS），Constant-Murley肩关节功能评分（Constant-Murley score，CMS）,加州福尼亚大学洛杉矶分校评分（University of California, Los Angeles shoulder rating scale，UCLA）,美国肩肘外科协会评分（American shoulder and elbow surgeons score，ASES）,手臂、肩膀和手的残疾问卷（disabilities of the arm, shoulder, and hand questionnaire ，DASH）各项功能评分。运用Revman 5.3软件对其进行分析和处理。 结果共纳入2篇随机对照研究、6篇回顾性队列研究、2篇非对照回顾性研究共10篇文献进行系统回顾，Meta分析只纳入前8篇文献，患者共641例。Meta分析结果显示，与单纯肩袖修复相比，结合骨髓刺激技术能明显改善肩袖总体愈合效果[OR = 0.42，95% CI（0.28，0.63），P< 0.0001]，大到巨大撕裂的肩袖修复术后再撕裂率也明显减少[OR = 0.28, 95% CI（0.13, 0.58）, P = 0.0007]。而在肩关节疼痛VAS评分[SMD = -0.63, 95% CI（-1.40, 0.14）, P = 0.11], ROM外旋[SMD = 0.05, 95% CI（-0.22, 0.32）, P = 0.70]、前屈[SMD = 0.10, 95% CI（-0.17, 0.37）, P = 0.47]，CMS评分[SMD = 0.12, 95% CI（-0.09, 0.32）, P = 0.26]，UCLA评分[SMD = -0.04, 95% CI（-0.29, 0.21）, P = 0.76]，ASES评分[SMD= -0.06，95% CI（-0.33, 0.21）, P = 0.67]及DASH评分[SMD = -0.15, 95% CI（-0.43, 0.13）, P = 0.29]等方面的差异均无统计学意义。 结论与单纯肩袖修复相比，结合骨髓刺激技术能明显改善肩袖修复能力，尤其值得关注的是该技术能够促进大到巨大撕裂肩袖的愈合，而在术后肩关节疼痛、ROM及功能方面未见明显差异。     

The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears

This study investigated whether a relationship exists between greater tuberosity osteopenia and chronicity of rotator cuff tears. In a retrospective study, anteroposterior radiographs of 28 shoulders in 27 patients who had undergone surgical repair for rotator cuff tears were reviewed. Greater tuberosity osteopenia scores were created using National Institutes of Health digital image software. There was no significant difference in the mean age between patients with minimal to mild rotator cuff tear retraction (63.1 +/- 6.14 years) and patients with moderate to severe rotator cuff tear retraction (63.4 +/- 9.76 years; P = .77). Of the 13 patients with minimal to mild rotator cuff tear retraction, 10 (77%) were women and 3 (23%) were men. Of 14 patients (50%) with moderate to severe rotator cuff tear retraction, 7 were men and 7 were women. The mean greater tuberosity osteopenia score in the 15 patients with moderate to severe retraction (0.48 +/- 0.095) was significantly less than the greater tuberosity osteopenia score in the 13 patients with minimal to mild retraction (0.58 +/- 0.135; P < .05). Furthermore, the mean greater tuberosity osteopenia score in 6 patients with chronic retracted rotator cuff tears (0.48 +/- 0.125) was significantly less than in the 6 patients with acute minimally retracted tears (0.64 +/- 0.119, P < .05). There were significantly greater osteopenic changes in the greater tuberosity in patients with chronic retracted rotator cuff tears. The greater tuberosity osteopenia may affect anchor pullout strength and the healing biology that influences overall rotator cuff repair healing rates.     

Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff

Recently, there has been an increased interest in the normal anatomy of the rotator cuff footprint and the re-establishment of the footprint during rotator cuff repair. Single-row suture anchor techniques have been criticized because of their inability to restore the normal medial-to-lateral width of the rotator cuff footprint. In this report, the authors describe a double-row technique for rotator cuff repair that re-establishes the normal rotator cuff footprint, increases the contact area for healing, and may potentially improve clinical results.