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...     

肩袖损伤关节镜下缝合修复术后再撕裂的风险因素分析

目的研究肩袖损伤肩关节镜下缝合术后发生再撕裂的风险因素，为术前评估术后再撕裂风险的大小及手术方式提供临床参考。 方法回顾性分析2015年1月至2019年1月624例在本科因"肩袖全层撕裂"住院并接受肩关节镜下肩袖缝合修复术患者的临床资料。使用二元Logistic回归分析方法研究术后肩袖再撕裂的风险因素。 结果病程>3个月、术前撕裂范围>3 cm、单排固定方式、脂肪浸润程度较高（Goutallier3级及以上）、糖尿病史及术后外伤均为术后肩袖再撕裂的高风险因素（P<0.05）。患者年龄、性别、是否优势肩、吸烟史、是否从事竞技运动等与肩袖术后再撕裂无明显相关（P>0.05）。 结论病程长、术前撕裂范围大、单排固定方式、肌肉脂肪浸润程度较高、糖尿病史及术后外伤均可能造成术后肩袖发生再撕裂。     

成体干细胞技术促肩袖损伤修复实验研究进展

由于肩袖损伤修复术后再撕裂率较高,有学者采用不同种类成体干细胞来修复肩袖损伤以降低再撕裂率。目前多数实验研究证实,成体干细胞具有提高肩袖损伤修复术后腱-骨界面最大失效负荷、增加肩袖胶原蛋白生成、促进界面纤维软骨形成、减少再撕裂率的作用;多种因素在成体干细胞促进损伤肩袖腱-骨界面愈合过程中起了诱导分化的作用。该文就成体干细胞技术促肩袖损伤修复实验研究进展作一综述。     

影响肩袖术后再撕裂相关因素及研究进展

肩袖再撕裂是肩袖术后的严重并发症，降低了患者的生活质量。肩袖再撕裂相关的因素多，如年龄、高血脂、骨质疏松等，是目前临床关注的热点与难点。为寻找肩袖再撕裂发生相关因素，本研究通过复习文献，以期待找出最佳单一或多个肩袖再撕裂因素，并做出评估，提高肩袖修复术疗效。     

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。     

早期康复训练与术后制动对关节镜下肩袖修复患者肩关节功能恢复的影响

目的 观察肩袖中度撕裂和肩袖较小撕裂患者关节镜下肩袖修复术后早期康复训练与肩关节制动对其肩关节功能及肌腱愈合的影响。方法 纳入自2021-01—2021-12完成的62例关节镜下肩袖修复术,其中31例术后未制动并早期进行康复训练（早期康复组）,31例术后制动6周并进行合适的康复训练（术后制动组）。比较两组术后疼痛VAS评分、肩关节活动度、肩关节ASES评分与肩袖再撕裂发生率。结果 62例均获得随访,随访时间12～15个月,平均12.97个月。早期康复组与术后制动组术后3个月、6个月疼痛VAS评分比较差异无统计学意义（P>0.05）。早期康复组术后3个月、6个月肩关节活动度及肩关节ASES评分优于术后制动组（P<0.05）。随访至术后12个月,早期康复组肩袖再撕裂发生率为9.68%(3/28),术后制动组肩袖再撕裂发生率为6.45%(2/29),组间差异无统计学意义（P>0.05）。结论 对于肩袖中度撕裂和肩袖较小撕裂患者,关节镜下肩袖修复术后早期康复训练在肩关节活动度及肩关节功能改善方面具有明显效果,而且并没有增加术后肩袖再撕裂发生风险,可以不考虑术后早期肩关节制动。     

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     

巨大肩袖撕裂的治疗及研究进展

目的总结巨大肩袖撕裂的治疗及研究进展。方法查阅巨大肩袖撕裂临床治疗及实验研究的相关文献,并进行综合分析。结果巨大肩袖撕裂的治疗方法主要有非手术治疗、清创减压术、直接修复术、肌腱转移术以及各种材料修复,其疗效各异。近年来,出现了许多有关巨大肩袖撕裂治疗的实验研究,如基因治疗、细胞治疗和组织工程技术,有望为临床医生提供新的治疗策略。结论巨大肩袖撕裂的治疗对临床医生是一个挑战,治疗方案的选择需要从多方面考虑;传统手术方法修复断裂肩袖效果有限,巨大肩袖撕裂的研究和治疗技术尚需进行深入研究。     

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。     

锚钉在肩袖撕裂修复术中的临床应用

肩袖撕裂好发于中老年人及上肢运动为主的运动员。肩袖撕裂修复术已在临床广泛开展，并取得了优良的疗效。1989年带线缝合锚钉首次应用于肩袖撕裂修复手术并取得了满意的临床效果，本文就近年来锚钉在肩袖撕裂修复术中的应用加以概述。     

Re-tears after rotator cuff repair: Current concepts review

Re-tear following rotator cuff repair is common and has been reported to range from between 13 and 94% despite satisfactory clinical outcomes following rotator cuff surgery. Various risk factors have been associated with an increased tear rate, including patient factors, tear and shoulder morphology, repair technique, and rehabilitation regimes. Different modes of rotator cuff failure have been described. The management of re-tear in patients following rotator cuff repair is challenging and depends on the age, functional status and requirements of the patient, and re-tear size and residual tendon length. This article aims to review the factors associated with rotator cuff re-tear. It describes which of these are associated with poor clinical outcomes, and discusses the long-term outcomes of re-tear and treatment options.     

Rates of medial and lateral row failure and risk factors for Re-tear in arthroscopic double row rotator cuff repair

A common postoperative complication after rotator cuff repair is re-tear requiring a secondary procedure. Double row and trans-osseous equivalent repair techniques have become increasingly popular in recent years, however repair failure remains a relatively common complication after primary rotator cuff repair. A retrospective observational study of 389 consecutive patients undergoing arthroscopic double-row rotator cuff repair from February 1, 2014 to March 31, 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities, and tear characteristics between patients who experienced re-tear and those who did not. Repair failures were confirmed by plain MRI or intraoperatively during repeat surgical treatment. A subgroup analysis of patients who experienced re-tear due to medial row failure was conducted. The overall re-tear rate was 8.2% (32 patients). Six patients (1.5%) experienced medial row failure, while 26 patients (6.7%) experienced lateral row failure. The average time to re-tear was 279.3 ± 291.2 days. On multivariate analysis, patients with Goutallier Classification ≥3 (OR: 4.274, p = 0.046) and 3 anchor repair (OR: 5.387, p = 0.027) were at significantly increased risk for any re-tear after controlling for other tear characteristics. No statistically significant independent risk factors for medial row failure were identified after controlling for confounding variables. Goutallier classification greater than 3 and a primary repair with 3 anchors are significant risk factors for re-tear after double row rotator cuff repair, however they are not associated with increased occurrence of medial row failure. Further evaluation of risk factors for medial row failure is required to avoid this rare but serious re-tear pattern.     

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。     

Supraspinatus Muscle and Tendon Stiffness Changes After Arthroscopic Rotator Cuff Repair: A Shear Wave Elastography Assessment

Re-tearing after arthroscopic rotator cuff repair (ARCR) frequently occurs, and high stiffness of the rotator cuff may be one of the factors. We investigated changes in stiffness of the supraspinatus muscle and tendon after ARCR as measured by shear wave elastography (SWE) with B-mode ultrasound, and compared the supraspinatus muscle stiffness of patients with recurrent tears and patients with healed rotator cuffs. Sixty patients with supraspinatus tears requiring ARCR underwent serial SWE of their supraspinatus muscles and repaired tendons. SWE was performed before surgery (Pre-Op) and at 1 week, 1 month, 2 months, 3 months, 4 months, 5 months, and 6 months after surgery. Additionally, the repaired rotator cuffs were evaluated using magnetic resonance imaging at 6 months after surgery to classify patients into a healed rotator cuff group and a recurrent tear group. Differences in SWE values between the groups were assessed at each time point. The SWE value of the repaired tendon at 1 week after ARCR was significantly greater than at 3 and 6 months. The SWE value for the supraspinatus muscle at 1 month after ARCR surgery in the healed group was lower than at Pre-Op and 4, 5, and 6 months after surgery, and it was also lower than that at 1 month after surgery in the re-tear group. There were no significant differences between time points in the SWE values of the supraspinatus muscle in the re-tear group. The SWE value of the muscle in the re-tear group was greater than in the healed group at 1 month after surgery (p < 0.05). Increased SWE values at 1 month after ARCR may predict recurrent rotator cuff tears after surgery rather than evaluating the tendon. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:219–227, 2020     

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。     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

关节镜下单排与双排缝合桥修复技术治疗老年肩袖损伤的对照研究

目的关节镜下采取双排与单排缝合桥修复术治疗老年肩袖损伤的效果对比分析。 方法前瞻性收集简阳市人民医院2016年1月至2018年2月期间收治的118例老年肩袖损伤病患者,按随机数字表法分为对照组（关节镜下行单排锚钉固定）与观察组（关节镜下行双排缝合桥修复术）,两组各59例,比较两组不同程度损伤患者手术前后ASES评分、Constant-Murley评分、UCLA评分;并对比两组术后再撕裂发生率。 结果治疗前两组四种撕裂程度Constant-Murley、UCLA、ASES评分差异均无统计学意义（P>0.05）;治疗后两组比较,只有轻度撕裂三种评分差异均无统计学意义（P>0.05）,而巨大、重度、中度撕裂的三种评分两组间差异均具有统计学意义（P<0.05）,观察组显著优于对照组。对照组再撕裂发生率17/59（28.81%）显著高于观察组6/59（10.17%）（χ²=6.535,P=0.011）。 结论老年肩袖损伤采取双排与单排缝合桥术均可行,但双排缝合桥术应用范围较为广泛,且对于患者巨大、重度、中度撕裂改善效果更佳。     

Current concepts on management of cuff tear

Among pathologies of the shoulder, rotator cuff tear is the most common. Diagnosis of cuff tear around mid twenties is unusual, but the prevalence increases significantly after the age of forty. The prevalence after the age of 60 is around 20–30%. A well recognised feature of cuff tear is being asymptomatic but, tear progression in asymptomatic is a known consequence. The spectrum of cuff tear ranges from partial, full thickness cuff tear with or without retraction. The mainstay of treatment for partial thickness cuff tear is systematic rehabilitation and for the full thickness cuff tear an initial rehabilitation is an accepted management. Failed rehabilitation for 3 months, acute traumatic tear, younger age, intractable pain, good quality muscle would be the indications for repair of a full thickness cuff tear. Though there are defined indications for surgical intervention in the full thickness rotator cuff tear, differentiating an asymptomatic tear that would not progress or identifying a tear that would become better with rehabilitation is an undeniable challenge for even the most experienced surgeon.Rehabilitation in cuff tear consists of strengthening the core stabilizers along with rotator cuff and deltoid muscles. In a symptomatic cuff tear that merits surgical intervention the objective is to do an anatomical foot print repair. In scenarios where the cuff is retracted, one has to settle for a medialised repair. As, a repair done in tension is more likely to fail than a tensionless medialised repair. The success rate of all these non anatomical procedures varies from series to series but it approximates around 60–80%.Augmenting cuff repair to enhance biological healing is a recent advance in rotator cuff repair surgery. The augmentation factors can be growth factors like PRP, scaffolds both auto and allografts. The outcome of these procedures from literature has been variable. As there are no major harmful effects, it can be viewed as another future step in bringing better outcomes to patients having rotator cuff tear surgery.Despite being the commonest shoulder pathology, the rotator cuff tear still remains as a condition with varied presenting features and a wide variety of management options. The goal of the treatment is to achieve pain free shoulders with good function. Correcting altered scapular kinematics by systematic rehabilitation of the shoulder would be the first choice in all partial thickness cuff tear and also as an initial management of full thickness cuff tears. Failure of rehabilitation would be the step forward for a surgical intervention. While embarking on a surgical procedure, correct patient selection, sound surgical technique, appropriate counselling about expected outcome are the most essential in patient satisfaction.     

Influence of a nerve injury proximal to the suprascapular nerve on healing of repaired rotator cuff tear

BackgroundMassive rotator cuff tears have a high rate of re-injury because of severe fatty infiltration. Our data showed that injuries proximal to the suprascapular nerve may be one cause of massive rotator cuff tears. The purpose of this study was to evaluate, using a rat model, how brachial plexus injury associated with a massive rotator cuff tear influences healing of the rotator cuff repair.MethodsSeventy Sprague–Dawley rats were divided into three groups: rotator cuff tear with BP injury (DT group) (n = 28), rotator cuff tear without brachial plexus injury (T group) (n = 28), and a sham-operated group (n = 14). In the DT group, the rotator cuff tear was made and repaired 4 weeks after brachial plexus ligation. The gross assessment (evaluated the wet weight), biomechanical testing (evaluated the yield stress and the Young's modulus) and histological analyses (using the Bonar scale) were performed at baseline in the sham group, and at 4 and 12 weeks postoperatively in the DT and T groups (n = 7/group/time).ResultsMean wet weight and yield stress were significantly lower in the DT group than in the T group. Additionally, the mean Young's modulus was significantly higher in the DT group than in the T group. Histologically, greater tendon degeneration was observed around the musculotendinous junction in the DT group than in the T group.ConclusionThe gross, biomechanical and histological data show that the repaired rotator cuff tendon with brachial plexus injury in rats does not heal as well as a repaired tendon without an accompanying brachial plexus injury. This suggests that more proximal neuropathy is one risk factor for re-tear of a repaired rotator cuff tendon.