不可修复性巨大肩袖撕裂治疗进展

临床诊疗中将巨大肩袖撕裂分为可修复性和不可修复性撕裂。不可修复性巨大肩袖撕裂患者的症状更严重,对功能的影响更大。目前不可修复性巨大肩袖撕裂的治疗主要包括非手术治疗和手术治疗。非手术治疗包括物理治疗、康复锻炼、非甾体类抗炎药治疗等。手术治疗方式较多,关节镜下清理术及肱二头肌长头肌腱切断术可有效缓解患者的疼痛症状,肩袖部分修复术较单纯清理术对恢复肩关节功能更具优势,上关节囊重建术和肌腱转位术疗效显著,肩峰下假体植入术也是一种可行方案,但仍需研究证实其远期效果。该文对不可修复性巨大肩袖撕裂治疗进展作一综述。     

巨大肩袖损伤的治疗进展——探索及挑战

随着人口老龄化的进程,越来越多的肩袖撕裂病人进入临床医师的视野。近年来肩关节镜下肩袖修复技术发展迅速,因其独特优势,镜下修复已成为肩袖损伤最主要的治疗方式。因肩袖损伤病因的复杂性及术后运动要求的多样性,肩袖撕裂特别是巨大肩袖损伤的治疗仍然面临着诸多问题及挑战。本文综述了巨大型肩袖损伤的最新治疗及研究进展,以便临床医生能够制定并采取更为合适的治疗策略,为病人带来更加满意的治疗效果。     

肩袖撕裂后脂肪浸润对肩袖再撕裂的影响

<正>目前在国内,对于肩袖撕裂,特别是巨大肩袖撕裂,临床医师的主要精力及关注点大多集中在"如何完美地修复撕裂的肩袖"。但是肩袖撕裂,特别是巨大肩袖撕裂绝不是"一缝了之",以下两方面的问题值得关注:一是再撕裂,二是脂肪浸润。这两个问题相辅相成,互为因果。肩袖撕裂修复术后再撕     

不可修复肩袖撕裂的治疗研究进展

正随着人口老龄化的问题日趋严重,肩袖损伤患者数量也在逐年增多,其中不可修复肩袖撕裂在临床中越来越常见。不可修复肩袖撕裂的治疗方法仍存在争议,其治疗方法主要包括非手术治疗、关节镜下清理术联合肩峰下减压术、肌腱移位术、上关节囊重建术、部分修复术、移植物修复术、反式全肩关节置换术等。以上治疗方法的适应证不同,术后效果也存在很大差异。笔者通过查阅和总结关于不可修复肩袖撕裂的文献资料,明确此类损伤的特征和可供选择的治疗方法,以期寻找不可修复肩袖撕裂的最佳治疗方案,报道如下。     

关于《美国骨科医师协会肩袖损伤临床指南(2019)》中不可修复肩袖撕裂的认识

肩袖撕裂是肩关节中常见的疾病,巨大肩袖撕裂约占全部肩袖撕裂的40％[1 ].巨大肩袖撕裂如果治疗不及时,会逐渐出现肩袖肌肉脂肪浸润、肌腱回缩、肱骨头移位、关节退变等一系列变化,最终发展为不可修复肩袖撕裂,是运动医学专科医生面临的巨大挑战之一.对于急性外伤所致的巨大肩袖撕裂首选手术修复,但对于不可修复肩袖撕裂因其治疗方案...     

关节镜下肱二头肌长头肌腱转位治疗不可修复巨大肩袖撕裂的研究进展

目的综述关节镜下肱二头肌长头肌腱(long head of biceps tendon,LHBT)转位治疗不可修复巨大肩袖撕裂的研究进展。方法查阅近年来国内外关节镜下不同方式LHBT转位治疗不可修复巨大肩袖撕裂的相关文献,并进行总结分析。结果关节镜下LHBT转位是一种治疗不可修复巨大肩袖撕裂的有效方法,目前主要采用"断近端"、"两头断"、"断远端"及"不切断"4种方式。临床研究表明上述方式均能取得良好疗效,但远期疗效有待进一步随访明确。结论关节镜下LHBT转位治疗不可修复巨大肩袖撕裂手术简便、有效,患者损伤小、术后恢复快,但对术者技术要求较高,需严格把握手术适应证。     

肩袖撕裂治疗进展

肩袖撕裂的治疗方法有多种,目前临床上尚未形成统一标准.非手术治疗可缓解症状.关节清理术、肱二头肌长头腱切断术及部分修复术适用于年龄较大且对功能要求较低的患者,较年轻且有症状患者应接受完全修复术;完全修复术中单双排锚钉固定技术之间短期疗效无明显差异;线桥缝合技术具有生物力学优势,可减少再撕裂发生率;应用组织替代物可进行完全修复,但缺乏长期结论性数据.肌腱转位术适用于有高功能需求的巨大不可修复性肩袖撕裂患者.半肩关节置换术与反置式全肩关节置换术适用于巨大肩袖撕裂导致关节炎改变患者,但后者存在较多并发症发生风险.肩关节融合术很少采用.     

巨大肩袖撕裂治疗现状

巨大肩袖撕裂是目前骨科疾病难点之一,对于其最佳治疗方式目前仍缺乏统一认识。治疗方式主要有药物治疗、物理治疗、康复治疗以及手术治疗等。对于可修复性巨大肩袖撕裂可尝试通过开放手术、关节镜辅助小切口治疗或全关节镜治疗,对于不可修复性撕裂可通过部分修复、肌腱移位、重建上方关节囊、补片增强、关节置换甚至关节融合等方式进行治疗。随着对肩袖撕裂的病因、损伤机制以及肩关节解剖力学等理解的逐步深入,同时得益于肩关节镜手术技术和关节镜器械的飞速发展,开发利用成体干细胞、富血小板血浆、新型修复补片材料等以降低手术失败率、术后再撕裂率以及关节僵硬等并发症,逐渐成为了目前研究的热点和重点。本文旨在对巨大肩袖撕裂治疗现状和最新研究进展进行综述,并探讨未来治疗研究趋势。     

肩袖补片在巨大肩袖损伤治疗中的研究进展

巨大肩袖撕裂可引起关节疼痛、僵硬和活动范围限制.目前巨大肩袖撕裂以手术治疗为主,但术后再撕裂率很高,其原因与撕裂大小、血液供应、脂肪浸润、年龄、肌肉萎缩等因素相关.同时,张力是导致肩袖修补手术失败的一项重要原因,肩袖补片则被认为是进行无张力或微张力修复的极佳治疗选择.为降低再撕裂率、改善手术效果,各种类型肩袖补片应运而...     

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。     

巨大肩袖损伤关节镜手术治疗进展

巨大肩袖损伤的手术治疗是骨科医师面临的一个挑战,且肩袖撕裂后肌腱回缩、粘连及脂肪浸润会进一步加大手术修复难度,所以如何更好地修复巨大肩袖损伤成为了目前研究的热点与难点。近年来,随着关节镜技术不断发展,肩关节镜手术已成为治疗巨大肩袖损伤的金标准,但其不同术式的适应证、效果及联合应用仍存在争议。笔者认为对于功能要求较低的老年患者,可行肩关节清理联合肩峰成形术或肱骨大结节成形术,可短期缓解患者肩关节疼痛;对于伴有肱二头肌长头腱损伤的患者,肱二头肌长头腱切断或固定术效果显著;完全修补术依旧是巨大肩袖撕裂的一线治疗方法,而对于无法完全修补的巨大肩袖撕裂可行部分修补术;对于功能需求较高的年轻患者,补片增强技术可带来良好的效果;对于肩关节内外旋能力受限且功能要求较高的患者,建议选用肌腱转位术;对于无明显盂肱关节炎、三角肌力量较好、功能要求较高的患者,上关节囊重建术更具优势。此外,肩峰下假体植入术因其创伤小、费用低、相对安全等优点成为目前研究热点,其长期效果仍需进一步证实。     

Chronic massive rotator cuff tears: evaluation and management

Most studies of rotator cuff repairs report high success rates. However, the majority of these studies combine the results of surgical management of rotator cuff tears of various sizes; few published reports specifically evaluate the management of chronic massive tears. Chronic massive rotator cuff tears may be acute traumatic, chronic atraumatic, or acute-on-chronic. A detailed history and thorough physical examination often are sufficient to establish the diagnosis. Radiographic evaluation can reveal osseous changes suggestive of pathology. Magnetic resonance imaging can determine the size of rotator cuff tears and status of the muscles but generally is not necessary for patients who are not candidates for surgery. Chronic massive rotator cuff tears without glenohumeral arthritis can be managed nonsurgically or with sub-acromial debridement, rotator cuff repair, or rotator cuff reconstruction. However, treatment of these patients is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears.     

Editorial Commentary: What's Hamada With Partial Rotator Cuff Repair?

Early repair of acute traumatic rotator cuff tears has been shown to restore functional range of motion, whether or not there is complete healing. The ability to predict those cuff tears that can achieve only a partial repair can help with preoperative patient counseling. The Hamada classification can be predictive in determining outcomes in the treatment of massive rotator cuff tears.     

Editorial Commentary: What's in a Name: Is There a Difference Between Incomplete and Partial Rotator Cuff Repairs?

For the treatment of large to massive rotator cuff repairs, not all partial repairs are equivalent. The technique of rotator cuff repair in large to massive rotator cuff tears matters. By using mobilization techniques to mobilize the rotator cuff to obtain anatomic or near anatomic coverage, double-row techniques to increase footprint coverage, and medial mobilization to decrease tension on the repair, exposure of the humeral head can be minimized, which can improve outcomes.     

Arthroscopic treatment of massive rotator cuff tears

In the past 10 years, arthroscopic surgeons have gone from being unable to repair any rotator cuff tears arthroscopically to being able to repair virtually all rotator cuff tears, even complex massive tears, arthroscopically. The factors responsible for this rapid evolution have been: (1) recognition of the mechanical principles responsible for a secure repair (margin convergence, knot security, loop security); (2) recognition of major tear patterns that require different techniques of repair; and (3) development of instrumentation and arthroscopic portals that predictably accomplish secure repair of the rotator cuff and direct access to the pathologic areas. In the current study, the author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair. In the author's series of arthroscopic repair of rotator cuff tears, the results have been gratifying, with massive tears achieving final results equivalent to those of smaller tears.     

反式全肩关节假体置换治疗巨大不可修复肩袖撕裂

目的探讨反式全肩关节置换术（reverse total shoulder arthroplasty,RTSA）治疗巨大不可修复肩袖撕裂的临床治疗效果。 方法对南京中医药大学附属医院2018年5月至2020年1月收治的采取RTSA治疗的13例巨大不可修复肩袖撕裂患者的临床资料进行回顾性分析。记录术前及最后一次随访时患者的肩关节前屈、外展、外旋活动,美国肩肘外科协会评分（American shoulder and elbow surgeons score,ASES）及美国加州大学洛杉矶分校（University of California at Los Angeles,UCLA）评分评估患者肩关节功能。并记录患者发生并发症的情况及影像学检查结果。术前行MR确定肩袖脂肪浸润程度,CT评价肩胛盂骨质情况及有无缺损,术后使用X线评估假体情况。 结果13例患者均随访至少12个月以上。统计术前与术后12个月数据之间的关系,术后12个月肩关节前屈、外展、外旋活动,ASES评分和UCLA评分较术前明显提高,差异具有统计学意义（P<0.01）。随访期内13例患者中有1例患者因局部血肿在术后1周行切开血肿清除引流术,所有患者功能恢复良好。 结论RTSA治疗巨大不可修复肩袖撕裂临床效果良好。     

Reconstruction of chronic massive rotator cuff tears with synthetic materials

Synthetic materials for repairing experimental massive rotator cuff tears were investigated in 60 rats. The same materials were investigated for massive rotator cuff ruptures in 25 patients. The materials were well tolerated when used for repair of torn segments of the musculotendinous cuff. Of 25 patients with massive rotator cuff tears, 23 had satisfactory functional results. The muscle strength tests on tendons repaired with Teflon felt (which was thicker than the other materials) were superior to results of repairs with other materials; 3-5 mm proved to be the optimum thickness of Teflon felt used for repair of the musculotendinous cuff.     

Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model.

Twelve shoulders with known massive rotator cuff tears were imaged fluoroscopically. The observed kinematic patterns were correlated with the known locations of the rotator cuff tears. Three kinematic patterns emerged: Type I, stable fulcrum kinematics associated with tears of the superior rotator cuff (supraspinatus and a portion of the infraspinatus); Type II, unstable fulcrum kinematics associated with tears that involved virtually all of the superior and posterior rotator cuff; and Type III, captured fulcrum kinematics associated with massive tears that involved the supraspinatus, a major portion of the posterior rotator cuff, and a major portion of the subscapularis. In Type III, an "awning effect" of the acromion was observed to influence active motion. Based on the recorded kinematic patterns, a biomechanical model was developed comparing the rotator cuff tear to a suspension bridge (loaded cable). A biomechanical analysis of forces acting on the rotator cuff according to this model yielded data that supported the contention that certain rotator cuff tears in older individuals may be adequately treated with debridement and decompression, without repair.     

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.     

Partial cuff debridement for irreparable defects of the rotator cuff

The treatment of massive rotator cuff tears can pose a difficult problem for the unprepared orthopaedic surgeon.There are many ways to treat massive rotator cuff tears, and one viable option is debridement with acromioplasty. For this form of treatment to be successful, the surgeon must choose his patient carefully. This report will focus on patient selection, biomechanics, and postoperative rehabilitation. A thorough understanding of rotator cuff tear biomechanics is needed when treating a massive tear; thorough physical and radiological examinations will help the orthopedist understand the biomechanic characteristic of the patient's tear. A tear that is balanced in both the transverse and coronal planes is stable and functional and will do well with debridement. Conversely, a tear that is unbalanced in either the transverse or coronal planes is unstable and nonfunctional and will not do well with simple debridement. Nonfunctional tears demand an attempt at rotator cuff tendon repair to restore balance to the cuff, making the tear functional. Debridement of a functional tear can be successfully performed with arthroscopic or open technique. Preservation or reconstruction of the coracoacromial (CA) arch is important because it adds anterosuperior stability to the shoulder with a massive rotator cuff tear. Postoperative rehabilitation is as important as the surgery itself and will also be emphasized. Many surgeons have had success with debridement of massive rotator cuff tears; however, as with any procedure, proper understanding of the pathology and proper patient selection is paramount to obtaining a successful result.