关节镜下修复类风湿关节炎病人肩袖损伤的疗效分析

目的 探讨关节镜下修复类风湿关节炎病人肩袖损伤的疗效。方法 回顾性分析2015年3月至2018年7月的17例（20肩）类风湿关节炎病人的病例资料,均行关节镜下肩袖修复术,其中肩袖部分撕裂6例（7肩）,完全撕裂11例（13肩）。收集并比较病人术前及术后1年的疼痛视觉模拟量表（visual analogue scale, VAS）评分。分析病人术前、术后6个月及1年的Constant-Murley肩关节功能评分和美国加利福尼亚大学洛杉矶分校（University of California at Los Angeles, UCLA）肩关节评分。分析病人术前、术后1年的外展、外旋、内旋等肩关节活动度。结果 17例病人术后均随访1年以上。本组术后6个月和1年的UCLA评分分别为（27.15±2.85）分、（30.55±2.11）分,Constant-Murley评分分别为（73.20±4.07）分、（83.35±3.84）分,与术前相比逐步提升,各个时间点的评分比较,差异均有统计学意义（P均＜0.05）。静息和活动状态下的VAS评分由术前的（5.95±2.37）分、（7.35±2.13）分改善至术后的（2.20±1.23）分和（2.40±1.43）分,术前肩关节外展、外旋及内旋活动度由术前的77.30°±18.20°、37.25°±10.03°、35.25°±12.74°改善至术后的131.80°±20.22°、47.85°±7.66°和59.40°±12.12°,差异均有统计学意义（P均＜0.05）。无论是肩袖完全撕裂还是部分撕裂的类风湿关节炎病人,通过关节镜下肩袖修复术后,病人动、静态疼痛及内旋活动度恢复良好;但在肩袖完全撕裂的病人中,术后外展活动度及病人满意度均未见明显改善（P均＞0.05）。结论 关节镜下修复类风湿关节炎病人肩袖损伤能较好地缓解病人疼痛,对于肩袖部分撕裂的病人也能较好地改善肩关节的活动度和术后满意度。     

Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft

Purpose:

This study presents a retrospective case series of the clinical and structural outcomes (1.5 T MRI) of arthroscopic rotator cuff repair with acellular human dermal graft reinforcement performed by a single surgeon in patients with large, massive, and previously repaired rotator cuff tears.

Materials and Methods:

Fourteen patients with mean anterior to posterior tear size 3.87 ± 0.99 cm (median 4 cm, range 2.5–6 cm) were enrolled in the study and were evaluated for structural integrity using a high-field (1.5 T) MRI at an average of 16.8 months after surgery. The Constant-Murley scores, the Flexilevel Scale of Shoulder Function (Flex SF), scapular plane abduction, and strength were analyzed.

Results:

MRI results showed that the rotator cuff repair was intact in 85.7% (12/14) of the patients studied. Two patients had a Sugaya Type IV recurrent tear (2 of 14; 14.3%), which were both less than 1 cm. The Constant score increased from a preoperative mean of 49.72 (range 13–74) to a postoperative mean of 81.07 (range 45–92) (P value = 0.009). Flexilevel Scale of Shoulder Function (Flex SF) Score normalized to a 100-point scale improved from a preoperative mean of 53.69 to a postoperative mean of 79.71 (P value = 0.003). The Pain Score improved from a preoperative mean of 7.73 to a postoperative mean of 13.57 (P value = 0.008). Scapular plane abduction improved from a preoperative mean of 113.64° to a postoperative mean of 166.43° (P value = 0.010). The strength subset score improved from a preoperative mean of 1.73 kg to a postoperative mean of 7.52 kg (P value = 0.006).

Conclusions:

This study presents a safe and effective technique that may help improve the healing rates of large, massive, and revision rotator cuff tears with the use of an acellular human dermal allograft. This technique demonstrated favorable structural healing rates and statistically improved functional outcomes in the near term.

Level of Evidence:

4. Retrospective case series.     

Failed prior rotator cuff repair is associated with worse clinical outcomes after reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared with RTSA for CTA with prior RCR.MethodsFrom 2006 to 2014, all patients who underwent RTSA by two surgeons after failed RCR with minimum 2-year follow-up were identified. Patients who underwent RTSA with failed prior RCR were matched in a 1:1 ratio to patients undergoing primary RTSA, while controlling for demographic factors, prosthesis design, and surgeon. Postoperative active forward elevation and active external rotation were recorded. Outcome measures included American Shoulder and Elbow Surgeons score, Visual Analog Scale (VAS), and Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were noted, and comparative multivariate analysis was performed.ResultsOf 262 patients, 192 (73.3%) were available at minimum 2-year follow-up. The prior RCR group had a significantly higher complication rate (17.4%, n = 15) than the primary RTSA group (3.8%, n = 4) (P = .001), although no significant difference in periprosthetic infection (P = .469) or secondary revision rate (P = .136) was observed. At mean 36.3 ± 26.1-month follow-up, the prior RCR group had statistically worse American Shoulder and Elbow Surgeons score (P < .001), VAS (P = .001), Simple Shoulder Test (P < .001), and active forward elevation (P = .006). Patients with multiple failed RCR attempts (n = 38) before RTSA demonstrated no significant differences versus isolated failed RCR (n = 48; P > .05).ConclusionThis study demonstrated that patients with RTSA after prior failed RCR have significantly worse patient-reported outcomes and greater rate of perioperative complications than patients undergoing primary RTSA for CTA.     

肩峰撞击征合并肩袖损伤的治疗

目的探讨对于肩峰撞击征合并肩袖损伤的治疗方法。方法2003年6月～2005年6月收治的肩峰撞击征患者25例,术前或术中诊断合并肩袖损伤者18例。对其中12例合并肩袖完全或不完全断裂的病例在进行肩峰成形的同时将断裂的冈上肌腱做紧缩缝合或做修复缝合锚钉止点重建术。术后指导患者系统功能康复,定期复查。按照ASES评分评价功能恢复情况。结果全部患者获得平均11个月随访。术前本组患者ASES评分平均为32.5分。术后:单纯肩峰成形患者ASES评分平均为92.5分,冈上肌腱做清创缝合的患者平均评分87.1分,冈上肌腱做止点重建患者平均评分85.9分。三种术式患者评分均较术前有显著性改善(P<0.01),而三种术式患者之间评分差异无显著性意义(P>0.05)。结论在对肩峰撞击征的治疗中要注意探查有无肩袖损伤,积极的肩袖修复治疗可获得满意的疗效。     

开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤

目的 探讨开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤的疗效.方法 2004年3月至2007年8月,对收治的20例术前明确诊断为肩峰撞击征合并肩袖损伤的患者采用开放性肩峰成形术治疗,同时修复肩袖,对肩袖全层撕裂患者以锚钉固定的方法行止点重建.术后进行系统功能康复.按照ASES评分评价功能恢复情况.结果 18例患者术后获6～13个月(平均11个月)随访.患者ASES评分术前平均为36.5分,术后为90.5分,差异有统计学意义(t=13.865,P<0.01).4例行因上肌腱直接修复患者术前ASES评分平均为53.4分,术后平均为93.2分,差异有统计学意义(t=1.387,P<0.05).14例行止点重建锚钉固定术患者术前ASES评分平均为33.4分,术后为86.2分,差异有统计学意义(t=2.962,P<0.05).结论 开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤可获得满意的疗效,易于在基层医院开展.     

肩袖撕裂患者肩部力量和肩部功能的相关性研究

目的探讨肩袖撕裂患者手术前肩部力量和肩部功能状况及两者之间的关系。 方法选择2016年3月至2019年7月在本院进行手术治疗的全层肩袖撕裂患者243例。在患者手术前应用等速肌力测试检测患者肩部力量,应用临床评分系统测量患者肩部功能。根据患者撕裂程度大小将患者分为4组：小型撕裂组、中型撕裂组、大型撕裂组、巨大型撕裂组。分析每组患者肩部力量和肩部功能的相关性。 结果在肩袖小型撕裂患者中,外展力量和视觉模拟评分（visual analogue scale,VAS）存在负相关（r=-0.307,P=0.018）;在肩袖中型撕裂患者中,外展力量和美国加州大学肩关节评分系统（ University of California at Los Angeles ,UCLA）（r=0.262,P=0.015）、SF-36躯体健康总评（physical component summary,PCS）（r=0.226,P=0.038）存在正相关;外旋力量和UCLA评分存在正相关（r=0.289,P=0.007）;在肩袖大型撕裂患者中,外展力量和Constant评分（r=0.282,P=0.043）、加州大学肩关节评分系统（American shoulder and elbow surgeon' form , ASES）（r=0.309,P=0.026）、SF-36PCS评分（r=0.317,P=0.022）存在正相关;外旋力量和UCLA评分（r=0.288,P=0.038）、Constant评分（r=0.293,P=0.035）、ASES评分（r=0.329,P=0.017）存在正相关;内旋力量和UCLA评分（r =0.383,P=0.005）、Constant评分（r=0.401,P=0.003）、ASES评分（r=0.314,P=0.023）、SF-36PCS评分（r=0.285,P=0.041）、SF-36精神健康总评（mental component summary , MCS）（r=0.304,P=0.028）存在正相关;在肩袖巨大型撕裂患者中,外展力量和VAS评分（r=-0.308,P=0.035）存在负相关,和UCLA评分（r=0.413,P=0.004）、Constant评分（r=0.489,P=0.000）、ASES评分（r=0.473,P=0.001）、SF-36PCS评分（r=0.772,P=0.000）、SF-36 MCS评分（r=0.293,P=0.046）存在正相关;外旋力量和VAS评分（r=-0.292,P=0.046）存在负相关,和UCLA评分（r=0.629,P=0.000）、Constant评分（r=0.413,P=0.004）、ASES评分（r=0.695,P=0.000）、SF-36 PCS评分（r=0.583,P=0.000）存在正相关;内旋力量和VAS评分（r=-0.309,P=0.035）存在负相关,和UCLA评分（r=0.512,P=0.000）、Constant评分（r=0.709,P=0.000）、ASES评分（r=0.802,P=0.000）、SF-36PCS评分（r=0.501,P=0.000）存在正相关。 结论撕裂程度可能是决定患者肩部力量和肩部功能相关程度的关键因素,部分修复不可修复的巨大撕裂非常重要。     

肩关节脱位合并肩袖与Bankart损伤的诊治

目的 探讨关节镜下修复肩关节前脱位合并肩袖与Bankart损伤的疗效.方法 1999年9月至2007年7月收治16例肩关节脱位合并肩袖与Bankart损伤患者,男14例,女2例;左肩6例,右肩10例.交通伤8例,运动伤4例,牵拉伤4例.受伤至手术时间平均4.5个月(1.5～11.0个月).肩关节x线片显示肩盂撕脱骨折3例.16例患者肩关节核磁共振造影显示肩袖与Bankart损伤.关节镜探查发现肩袖于肱骨大结节处撕脱伴肩袖挛缩12例.采用关节镜下松解、缝合锚钉和骨锚钉同定缝合9例;因肩袖挛缩明显,进行关节镜与小切口辅助下肩袖缝合固定术3例;肩衲组织因牵拉松弛抬肩无力,采用等离子刀皱缩和肩袖缝合紧缩术4例.Bankart损伤采用关节镜下可吸收Bankart钉固定3例,钛合金缝合锚钉固定3例,关节镜下直接缝合修补盂唇3例,骨锚钉加会属锚钉固定7例.结果 16例患者术后获平均16.5个月(7～34个月)随访.肩关节稳定,肩外展和上举功能恢复正常12例,术后肩关节外展、抬举活动轻度受限2例,前伸活动疼痛2例.金属锚钉拔出再手术2例.采用美国加州洛杉矶大学UCLA肩关节功能评分:术前平均(21.5±5.5)分;术后平均(32.4±5.6)分,优12例,良4例.结论 肩关节脱位合并肩袖与Bankart损伤核磁共振造影有助于诊断;肩袖挛缩者应进行充分松解,无张力缝合固定有利于肩袖愈合;异体骨锚钉修复肩袖与Bankart损伤,生物固定、费用低廉,具有重要的价值.     

Morphological changes of roof of subacromial bursa in patients with rotator cuff tear

Objective: To investigate the morphological changes of the roof of the subacromial bursa (SAB) and its involvement extent after rotator cuff tear. Methods: In the experimental group, the roof of SAB was obtained from 30 cases of rotator cuff tear both at the tear site and a site 2.5-3.0 cm distal to the tear site during rotator cuff repair. In the control group, the roof of SAB was obtained from the exposed site of recurrently dislocated shoulder or fractured humeral shaft of 8 cases. The specimens were stained with hematoxylin and eosin and observed under a transmission electron microscope. The cell number was quantitated through counting the bluestained nucleus in SAB with a computer image analysis system.Results:The mumber of calls increased significantly in the roof of SAB in the experimental group compared with that of the control group. However, no difference of the bursal reaction was found among the type of rotator cuff tear, the bursa thickness and the presence of fluid in the bursa. The great majority of cells were type B cells observed under the transmission electron microscope. Conclusions: The increase in cell number in the roof of SAB in the experimental group is a reactive increase rather than an inflammatory process and the involvement of SAB is not limited in extent. The change of the roof of SAB is a secondary reaction to the rotator cuff tear.