有限元分析在肩袖撕裂中的应用进展

肩袖撕裂是临床3大骨骼肌肉系统疾患之一,而冈上肌腱是最常见的病变部位。肩袖撕裂可引起慢性肩痛、力弱及关节活动受限,并导致肩关节的继发性退行性变。由于传统的生物力学实验受到测量技术和伦理问题的限制,肩袖的生理及病理状态下的应力分布几乎无法获取。近年来,随着计算机技术、软件开发和图像处理的不断发展,构建肩袖有限元模型的技术...     

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。     

肩袖组织中力学感受器形态及分布的实验研究

目的：观察人体肩袖组织中机械性力学感受器的形态及分布，阐明力学感受器在诱导肩关节稳定性保护机制中所起的重要作用。方法：取6具成年男尸的6套完整肩袖，按肩胛下肌，冈上肌，冈下肌，小圆肌分成6组，用HE和改良银染色方法分别对肩袖组织连续切片进行染色，通过光学显微镜观察感受器的形态，并用特定的计算机成像系统分析，从而获取不同肩袖组织中力学感受器的分布数量。结果：在肩袖组织中，发现存在4种类型的力学感受器。Pacini小体，Ruffini小体，Golgi腱器官及游离神经末梢。其中肩胛下肌内上述四种感受器的分布数量分别为6－9个，3－4个，1－3个，7－11个，冈上肌内分别为5－7个，2－3个，1－3个，7－9个，冈下肌内分别为2－3个，0个，1－3个，6－8个，小圆肌内分别为1－3个，0个，1－3个，4－5个。结论：肩袖组织中存在着4种类型的机械性力学感受器，根据力学感受器在不同肩袖组织中分布数量的多少与该组织随的生物学应务大小成正相关，说明它们在肩关节稳定性保护机制中起重要作用。     

肩袖损伤的诊治进展

肩袖损伤是引起肩周疼痛、肩关节功能障碍最常见的疾病之一,随着人民生活水平提高及人口老龄化,人们对肩关节的功能要求也越来越高.     

肩袖部分撕裂的关节镜治疗

目的评估应用肩关节镜下冈上肌肌腱肱骨大结节止点重建术治疗EllmanⅢ级肩袖部分撕裂的临床疗效。方法本组15例(15侧),术前MRI提示肩袖损伤,术中关节镜均证实肩袖部分撕裂超过6 mm,其中关节侧9例(右肩6例,左肩3例),滑囊侧6例(右肩4例,左肩2例),全部滑囊侧及6例关节侧肩袖撕裂合并肩峰撞击征。全部病例均行关节镜下肩袖清创、带线锚钉冈上肌肌腱肱骨大结节止点重建,撞击征阳性病例同时行肩峰成形术。结果平均随访30个月(20～44个月),应用JOA评分标准进行肩关节功能评价,术前平均61.3分,术后94.5分(P0.01)。JOA评价体系中疼痛、功能、活动范围及肩关节提升部分明显优于术前,而外展力量、外旋及内旋部分评分则改善不明显。随访期末按JOA评价标准:优12例,良2例,可1例,术前存在肩峰撞击征的12例,末次随访评价撞击试验阴性。结论关节镜下冈上肌肌腱肱骨大结节止点重建术是治疗EllmanⅢ级肩袖部分撕裂的有效方法。     

肩袖修补术后肩关节的康复

肩袖修补术后的肩关节康复方案是个体化的,不仅与手术方式和修补质量有关,而且与撕裂尺寸和回缩程度相关。康复的最初阶段着眼于控制疼痛、恢复活动度以保留修补的完整性。肌腱修复完成时可以开始主动活动。在第3阶段增加肌力练习。恢复到日常活动前需要做功能性肌力练习。手术医师应当密切参与康复方案的制定与实施。     

肩袖损伤46例观察报告

[目的]探讨肩袖损伤的临床特点、诊断及治疗.[方法]对25例肩袖损伤的临床特点进行分析.[结果]经保守治疗、手术或关节镜治疗后,随访1～6年,平均3.1年.疼痛消失29例,过劳后疼痛 16例,疼痛明显1例;肌力正常24例,患肢稍感力弱21例,肌力明显减弱1例.[结论]肩袖损伤早期诊断、早期治疗,效果比较理想.     

关节镜下不同穿骨技术修复肩袖损伤的有限元分析

目的:应用有限元方法比较并分析关节镜下不同穿骨技术修复肩袖损伤的生物力学差异。方法:根据1名健康成年人的肩关节CT数据分别建立传统关节镜下穿骨(arthroscopic transosseous,ATO)技术,巨针技术(giant needle technique)及ArthroTunneler(AT)技术的有限元模型。对3种技术模型上的缝合线均分别施加10 N及20 N载荷,比较并分析3种模型骨隧道及缝合线的应力变化。结果:在相同载荷下,传统ATO技术模型外侧骨隧道及缝合线所受应力均最大,其次为巨针技术模型;AT技术模型中段骨隧道及缝合线所受应力均最大,其次为巨针技术模型。在不同载荷下,3种模型的高应力区均主要集中于缝合线与骨隧道的接触部位。与传统ATO技术模型相比,巨针技术及AT技术模型外侧骨隧道及缝合线的应力分布均较分散,但AT技术模型的中段骨隧道及缝合线均存在明显的应力集中现象。结论:相对于传统ATO技术,巨针技术及AT技术均可降低缝合线切割骨隧道的风险,可能是较佳的修复方式。但AT技术相对于巨针技术,其在骨质疏松患者中的应用可能有限。     

肩袖损伤修补金属锚钉置入角度——有限元分析

目的通过有限元分析方法比较肩袖修补术中冈上肌肌腱足印区处以90°、45°置入金属锚钉时钉体及周围骨组织的受力情况。 方法利用CT数据建立肱骨近端和锚钉的三维模型，在冈上肌肌腱止点足印区、肱骨大结节和关节软骨交接区模拟90°、45°置入锚钉，且加载15°、30°、45°、60°、75°、90°的100 N拉力，采用有限元分析软件ABAQUS模拟分析锚钉和肱骨近端骨组织应力分布情况。 结果在所有的模型中，锚钉的最大等效应力集中在锚钉下方小孔和近端螺纹之间。45°置入的锚钉周围骨组织的最大等效应力集中在近端锚钉螺纹和牵引侧的骨组织表面之间；而90°置入的锚钉周围骨组织等效应力比较均衡的分布在近端螺纹周围。以100 N的拉力从15°~75°对锚钉进行牵拉时，45°置入的锚钉所受的最大等效应力大于90°置入锚钉所受应力；随着角度的增大，两个角度置入锚钉之间应力差异逐渐减小。90°牵拉载荷时，90°置入的锚钉所受的应力稍大于45°置入锚钉所受应力。金属锚钉受从15°~90°牵拉载荷时，45°置入锚钉周围骨组织所受的最大等效应力均大于以90°置入锚钉周围骨组织的所受的最大等效应力。 结论有限元分析结果显示，以90°置入锚钉时锚钉及其周围骨组织所受的应力较45°置入锚钉更小，建议肩袖修补手术中采用90°置入锚钉。     

Biomechanical comparison of suture anchor versus margin convergence plus suture anchor for rotator cuff repair

Objective: To evaluate results of margin convergence versus suture anchors in rotator cuff repair, and to determine which method is mechanically superior. Methods: Eighteen kangaroo shoulders were randomly divided into three groups (n = 6). A full thickness tendon defect 1.0 cm × 1.5 cm in size was created in the supraspinatus tendon at humeral insertion, simulating a massive rotator cuff tear. Three different techniques were employed for rotator cuff repair: (i) Mitek GII suture anchor alone (Group 1); (ii) margin convergence alone (Group 2); and (iii) margin convergence plus Mitek GII suture anchor (Group 3). Combined loads were applied to each specimen. After completion of cyclic loading, the construct was loaded to failure. ANOVA and LSD (Least Significant Difference) multiple comparisons of the means were applied to results. Results: Cyclic load testing showed progressive gap formation in each repaired specimen with increasing cycles. Group 1 reached 50% failure at an average of 34 cycles, Group 2 at 75 cycles and Group 3 at 73 cycles. There were significant difference between Groups 1 and 2, and Groups 1 and 3 (P ≤ 0.001). After 100 loading cycles, the average gap size was 6.8 mm, 6.1 mm and 4.7 mm in Groups 1, 2 and 3, respectively. There was a significant difference between Groups 1 and 3 (P ≤ 0.015). All specimens eventually reached failure. Conclusion: Rotator cuff repairs with margin convergence +/? suture anchor were far stronger than suture anchor alone, both in gap formation and ultimate failure load. However, progressive gap formation with cyclic loading seems inevitable after cuff repair, which may facilitate clinical understanding of the phenomena of re‐tear or residual defect.     

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。     

The transacromial approach to the shoulder for ruptures of the rotator cuff

Summary A transacromial approach to the shoulder has been developed. The aim is to allow access to the rotator cuff whilst maintaining the integrity of the trapezius and deltoid muscles.The trapezius and deltoid are split in the line of their fibres up and down from the acromion. The incisions are joined by extension across the acromion. The acromion is divided in this line and retraction of the fragments reveals the rotator cuff below the subacromial bursa. Rotation of the humerus brings all portions of the cuff into the wound.The divided acromial fragments fall together on release of the retraction. Suture of the split muscles and of the periosteum of the acromion provides adequate closure.

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Résumé L'auteur présente une voie d'abord transacromiale de l'épaule, qui permet d'accéder à la coiffe des rotateurs tout en respectant le trapèze et le deltoïde. Le trapèze et le deltoïde sont fendus dans le sens de leur fibre, tant en avant qu'en arrière de l'acromion. Les incisions se rejoignent au niveau de l'acromion qui est sectionné dans le même sens. La totalité de la coiffe des rotateurs, située sous la bourse sous-acromiale, apparaît dans le champ opératoire, lors de l'écartement des fragments osseux et de la mobilisation en rotation de la tête humérale. L'opération terminée, les fragments acromiaux se rejoignent avec exactitude et la fermeture est aisée et correcte en suturant la brèche musculaire et le périoste acromial.

     

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis

BackgroundAn all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques.Material and methodsThe main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants.ResultsA total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0–56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5).ConclusionArthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.     

Measuring outcomes in rotator cuff disorders

Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.     

超声检查对肩袖损伤的诊断价值

目的 探讨超声检查对肩袖损伤的诊断价值。方法 具有肩撞击综合征和（或）肩袖损伤体征患者53例56肩，男32例34肩，女21例22肩；年龄38-75岁，平均52岁。行超声检查和开放手术或关节镜治疗。通过超声检查对肩袖损伤进行分型，并与开放手术或关节镜所见进行比较。结果 超声检查诊断肩袖损伤32肩，诊断正常肩袖24肩；手术诊断肩袖损伤33肩，诊断正常肩袖23肩。超声检查诊断的灵敏度为90．91％，特异度为91_30％，阳性预测值为93．75％，阴性预测值为87．50％。广泛和大面积肩袖损伤，超声检查诊断6肩，手术诊断6肩；中、小面积全层损伤，超声检查诊断10肩，手术诊断11肩；肩峰面部分损伤，超声检查诊断5肩，手术诊断5肩；关节面部分损伤，超声检查诊断11肩，手术诊断11肩。手术切开修补12肩，关节镜辅助探查有限切开修补16肩，关节镜下断端射频紧缩6肩，关节镜下肩峰成形术22肩。结论 超声检查在诊断肩袖损伤方面具有较高的精确度，尤其适用于诊断肩袖全层损伤。     

关节镜下肩袖肱骨止点内移技术与传统技术治疗巨大肩袖撕裂的疗效比较

目的 :探讨关节镜下肩袖肱骨止点内移技术的可行性,为治疗巨大肩袖撕裂提供一种方案。方法 :自2014年2月至2018年4月行手术治疗巨大肩袖撕裂患者40例,分成2组,研究组20例,男8例,女12例,年龄42～82(57.55±8.90)岁,病程1 h～2年;采用肩袖在肱骨头处止点内移,重建完整肩袖技术治疗巨大肩袖撕裂;对照组20例,男10例,女10例,年龄45～75(57.75±9.10)岁,病程1 h～5年,采用传统清理后部分缝合肩袖或原位高张力下缝合技术治疗巨大肩袖撕裂。采用VAS评分、Constant评分、UCLA评分评价两组临床疗效。结果:40例患者均获随访,时间12～14个月。两组术后VAS评分、Constant评分、UCLA评分与术前比较均明显改善(P<0.05);研究组在VAS评分、Constant评分和UCLA评分及疗效明显优于对照组(P<0.05)。结论:关节镜下肩袖肱骨止点内移治疗巨大肩袖撕裂在肩关节疼痛缓解,功能改善满意,治疗巨大肩袖撕裂是一种可行的方案。     

Trends in rotator cuff surgery: Research through the decades

IntroductionThe aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigationMethodsJournal Citation Index was searched to find articles using the search terms pertaining to “rotator cuff repair”. All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade.ResultsAll the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade’s most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade.ConclusionThere are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.