肩袖损伤修复研究进展

肩袖损伤是肩部最常见的肌肉软组织损伤,但其愈合率相对较低。一方面肩袖损伤外科修复失败率较高,另一方面肩袖本身退行性变及局部较差的血供也影响了其愈合。为了改善肩袖损伤修复效果,学者们对新修复技术进行了持续的探索,细胞外基质补片、细胞种植支架、干细胞技术、生长因子和富血小板血浆的应用等已表现出一定程度的辅助治疗效果。该文对当前肩袖损伤的临床治疗方案、动物实验研究以及处于临床前期研究的新技术进行综述。     

肩袖的生物学特性与肩袖损伤修复

肩袖疾病是肩周疼痛的最常见病因,深入了解肩袖的生物学特性及其损伤修复机制对指导临床治疗有重要意义。 1 肩袖的结构和组成 肩关节是人体活动范围最大的关节,同时也是最不稳定的关节,肩袖在维持盂肱关节稳定性和参与其运动方面起重要作用。因此,它既具有一般肌腱的特点,又具有独特的性质。     

补片技术修复肩袖损伤的应用研究

肩袖巨大撕裂单纯手术缝合后复发率高达50%~70%,学者们提出肩袖补片修补可增加肩袖生物力学性能。采用哪种材料的补片更有效地恢复其生理功能成为当今研究热点。肩袖补片分为人工合成(不可降解型,可降解型)和生物材料(自体或同种异体组织,异种异体材料)两种类型。人工合成材料具备载体力学强度,但术后免疫反应重;生物材料排异反应轻,生物活性转归好,降解率调控灵敏,但最大抗拉强度较低。本文综述目前肩袖补片应用过程中的常见问题和进展。     

肩袖损伤修复材料研究进展

[目的]探讨肩袖损伤修复材料的研究现状和进展。[方法]在Pub Med、Sino Med上查阅国内外有关肩袖损伤修复材料使用的文献,进行汇总分类。[结果]目前应用在肩袖损伤的修复材料主要有细胞外基质材料、不可降解的合成材料以及可以降解的合成材料,此外在材料修复的同时还可以添加不同的生长因子和种子细胞从而促进修复过程。[结论]肩袖损伤后在多种因素的影响下,传统修复方法失败率较高。未来随着组织工程学和材料学的发展,新材料的运用可能会取得更加确切的效果。     

肩袖损伤后修复的实验研究

目的观察肩峰下撞击征所致肩袖损伤后的修复反应及碱性成纤维细胞生长因子(basicfibroblastgrowthfactor,bFGF)的表达。方法雄性SD大鼠50只,剪取同侧肩胛冈骨块移位于肩峰底面,建立肩峰下撞击模型,对侧行假手术作为对照。分别于术后第3、7、14、28、56d处死动物,切取整个肩关节,观察冈下肌肌腱的修复反应及bFGF的表达,并使用计算机图像分析系统检测bFGF的表达变化,图像分析结果中光密度值(OD)和阳性面积值分别表示bFGF的表达强度和阳性细胞数。结果所有动物实验侧的冈下肌肌腱均出现滑囊面撕裂,肌腱断端细胞增生,来自肩峰下滑囊的结缔组织覆盖其表面。对照侧冈下肌肌腱完好,仅有少量的腱细胞和滑囊细胞表达bFGF;而实验侧沿腱外膜排列的腱细胞、从肩峰下滑囊迁移的炎细胞和成纤维细胞表达信号增强。结论肌腱损伤后bFGF的表达增强;肩峰下滑囊是肩袖修复的基础和bFGF分泌的主要来源,修补肩袖时应尽量给予保留。     

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。     

带线锚钉固定技术修复肩袖损伤生物力学研究

在肩袖肌肉中,冈上肌起着外展肩关节的作用。Inoue等[1]进行有限元分析,证实了冈上肌在肩关节运动起着重要的作用。但冈上肌也是肩袖中容易损伤撕裂的肌肉之一,双排带线锚钉固定修复法因其能增加冈上肌与肱骨头的接触面积,能降低肌肉再次损伤的风险而受到临床的亲睐,但有关该方法的生物力学分析还比较少。本研究分别建立可用于有限元分析的单/双排带线锚钉固定修复肩袖损伤的肩关节模型,比较两种方法修复后肩关节外展状态下冈上肌的应力变化,从生物力学的角度探讨双排带线锚钉固定法的优越性。     

肩袖损伤

肩袖损伤孙常太，黄公怡肩袖是由起于肩肿骨，附着于肱骨头周围的岗上肌、岗下肌、肩胛下肌和小圆肌组成的一组具有相似功能的肌群。四块肌肉的肌腱部分在肪骨头解剖颈处形成袖套状结构，肩袖在肩关节运动中起支持和稳定肩肱关节的作用。当肩关节外展上举时，肩袖肌肉的收...     

肩袖损伤

肩袖损伤（Rotator Cuff Tear）的发病率占肩关节疾患的17％～41％,最早是Smith在1834年发现并命名的,但在当时并未引起重视,直到1931年Codman和Akerson指出本病是引起肩疼的一个重要原因。据Depalma等人通过尸体解剖发现,50～60岁死亡人群中30％的人有肩袖损伤,70岁以上死亡者中有90％～100％有肩袖损伤。说明肩袖损伤广泛存在于社会人群中。     

肩袖损伤

肩袖又名旋转袖,是由岗上肌、岗下肌、小园肌和肩胛下肌四个短肌组成,跨越肩关节上方,其腱性部分相互融合,并与关节囊紧密连接,沿解剖颈上2/3附着于肱骨大结节与小结节。于止点部位腱性部分与关节软骨连接。肩袖深面为关节囊,浅面为肩峰下滑囊,实际上关节囊之滑膜形成肩袖“衬里”(图1)。肩袖的止点呈扁平状,又可分为三个区域,即岗上肌区域、岗下肌与肩胛下肌区域。在20～30岁以后肩     

肩袖损伤的关节镜下治疗

目的探讨肩关节镜手术治疗肩袖损伤的适应证选择、手术技巧和疗效。方法2002年3月至2005年5月对68例患者行关节镜下肩袖重建,其中40例获得随访,以其为研究对象。年龄30~81岁,平均年龄56岁,其中29例发生于主力侧。根据Gerber分型,其中部分肩袖损伤8例,中小型肩袖损伤27例,巨大肩袖损伤5例。手术均采用金属缝合锚(Super-Revo)进行肩袖重建。分别在术前及最终随访时采用美国肩肘医师协会评分(ASES)、Constant-Murley评分以及简易肩关节评分(SST)问卷进行功能评估。结果40例患者获得随访,随访时间12~40个月,平均20.6个月。40例患者手术前及终末随访时ASES平均分为72.6对92.3(P<0.001),其中VAS疼痛评分平均为6.2对1.8(P<0.001),肩关节平均前屈上举为74.5°对146.0°(P<0.001),平均外旋为27.8°对38.3°(P<0.01),ASES评分为优和良所占的比例为92.5%(37/40),平均Constant-Murley评分为69.6对90.4(P<0.001),Constant-Murley评分为优和良所占的比例为90.0%(36/40)。结论肩关节镜下肩袖重建手术具有损伤小、肩关节功能恢复快等特点,尤其在保护三角肌方面具有独到的优势,是治疗肩袖损伤的有效方法之一。正确的适应证选择、熟练的关节镜下操作技术以及术后严格的功能康复锻炼是手术成功的关键。     

Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is being performed by an increasing number of orthopaedic surgeons. The principles, techniques, and instrumentation have evolved to the extent that all patterns and sizes of rotator cuff tear, including massive tears, can now be repaired arthroscopically. Achieving a biomechanically stable construct is critical to biologic healing. The ideal repair construct must optimize suture-to-bone fixation, suture-to-tendon fixation, abrasion resistance of suture, suture strength, knot security, loop security, and restoration of the anatomic rotator cuff footprint (the surface area of bone to which the cuff tendons attach). By achieving optimized repair constructs, experienced arthroscopic surgeons are reporting results equal to those of open rotator cuff repair. As surgeons' arthroscopic skill levels increase through attendance at surgical skills courses and greater experience gained in the operating room, there will be an increasing trend toward arthroscopic repair of most rotator cuff pathology.     

Mini-open rotator cuff repair

Open shoulder procedures require a deltoid release for proper exposure. Arthroscopic techniques have progressed so that minimally invasive techniques give similar outcomes as more formal open procedures with less risk of morbidity. Arthroscopically assisted open rotator cuff repair offers advantages over open procedures with some diagnostic and decompression performed with the arthroscope. The mini-open technique has more aspects of a cuff repair performed through the arthroscope leaving a few steps to be done open. The modern use of arthroscopic techniques for minimally invasive rotator cuff surgery coupled with advances in rehabilitation is discussed.     

Technique for arthroscopic rotator cuff repair

Modern arthroscopic tools and techniques have allowed surgeons to operate on a wide variety of injuries using procedures less invasive than traditional open methods. For shoulder surgery in general, and rotator cuff repairs specifically, methods now yield a similar footprint as open procedures with several advantages, including reduced tissue trauma, postoperative pain, swelling, and concern about the deltoid attachment, which should lead to good outcomes.     

Arthroscopic rotator cuff repair

The arthroscopic operation for repair of full-thickness rotator cuff tears is successful and has the advantages of glenohumeral joint inspection, treatment of intraarticular lesions, smaller incisions, no deltoid detachment, less soft tissue dissection, less pain, and more rapid rehabilitation. However, these advantages must be balanced against the technical difficulty of the method, which limits its application to surgeons skilled in open and arthroscopic shoulder operations.     

Massive rotator cuff tears: the result of partial rotator cuff repair

Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P<.001). Active elevation improved from 114 degrees to 154 degrees , and no patient lost strength after surgery. The ability to raise the arm to at least 135 degrees improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears.     

LactoSorb plates for rotator cuff repair

Purpose: We present our preliminary studies using LactoSorb plates (Lorenz/Biomet, Warsaw, IN) for rotator cuff repair in humans. The use and application of this plate are described as an adjunct to prevent hole migration in trough-tunnel repairs of rotator cuff tears. Methods: Fifty patients with rotator cuff tears documented by magnetic resonance imaging underwent arthroscopic subacromial decompression followed by a mini-open repair of the rotator cuff. Tears were repaired using a trough and tunnel technique, horizontal mattress sutures, and a standard LactoSorb plate. Follow-up was obtained on 45 patients, 26 male and 19 female, with an average age of 61.6 years. The patients were followed-up and evaluated at 5 days, 1 month, 3 months, 6 months, and a minimum of 1 year postoperatively. All surgeries were performed by the same surgeon and followed a similar rehabilitation protocol. Results: There were 89% excellent results, 9% good results, and 2% fair results. There were no poor results. No significant swelling, tenderness, or erythema was noted at the operative site, and there were no infections. Postoperative radiographs at 3, 6, and 12 months did not show any bone erosion. No repeat surgical procedures were necessary. Conclusion: The results of our study support the use of LactoSorb bioabsorbable plates in the repair of rotator cuff tears to prevent hole migration and potentially poor results or failures of repairs. The LactoSorb plate appears to maintain its strength during the healing period of the repair and does not elicit any clinically noticeable inflammatory process.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 279–283