关节镜辅助小切口肩袖修复术治疗肩袖撕裂

目的 探讨关节镜辅助小切口修复术治疗肩袖撕裂的临床效果. 方法 1999年3月～2004年3月应用关节镜辅助小切口修复术治疗肩袖撕裂22例.13例行关节镜检查,小切口肩峰下间隙减压及肩袖修复术;9例行关节镜下肩峰下间隙减压及小切口肩袖修复术.采用UCLA肩评分标准进行评价. 结果 22例随访12～72个月,平均47个月,UCLA评分由术前（14.8±3.8）分升至术后（32.0±4.7）分（t=15.086,P=0.000）.优7例,良13例,可1例,差1例;20例满意. 结论 关节镜辅助小切口修复术是治疗肩袖撕裂的有效方法,操作简单,创伤小.     

关节镜下治疗肩袖撕裂的现代理念

最近5年来,关节镜下修复肩袖撕裂已引起越来越多医生的兴趣。从解剖学角度讲,肩袖在肩关节的三维活动中起一定的作用。在冠状面,三角肌和肩袖下半部分(冈下肌、小圆肌、肩胛下肌)是一对力偶;在水平面,肩袖前部(肩胛下肌)和后部(冈下肌、小圆肌)之间是另一对力偶。肩袖撕裂修复的目的是使这两对力偶重新获得平衡,恢复肩关节稳定性,而不仅仅是修补撕裂口。不同的撕裂部位有不同的关节镜修复技术,其中肩袖的后上部撕裂又分为四种类型:新月形、U形、L形和巨大的挛缩的撕裂。对前3种撕裂在镜下先沿肩袖长轴缝合撕裂口的两边,再把缝合后的肩袖     

关节镜下肩袖修补术

关节镜下肩袖修补术是20世纪90年代初发展起来的微创治疗肩袖撕裂的手术方法。随着新技术、新设备、新理论的提出和应用,肩袖撕裂的修补正逐渐由开放手术转向关节镜下微创手术,关节镜下肩袖修补术的适应证逐渐扩大,手术技术日益成熟。该文综述了关节镜下肩袖修补术的进展。     

关节镜下手术治疗老年退行性肩袖撕裂的疗效分析

目的探讨关节镜下手术治疗老年退行性肩袖撕裂的疗效。方法2002年9月-2005年6月，对16例50岁以上肩袖撕裂的患者，采用关节镜下手术治疗。根据肩袖撕裂的大小和形状分成新月形和“U”形，新月形撕裂直接采用Mitek（GⅡ）铆钉腱骨缝合的方法，“U”形撕裂采用对边缝合后加用Mitek（GⅡ）铆钉固定的方法。结果16例患者均获得随访，随访时间为12～2，4个月，平均15个月。术前、术后的功能情况采用UCLA肩关节评分系统进行疗效评价：优8例，良7例，可1例，优良率为93．5％。术后无明显的并发症，两种修补方法疗效相同。结论关节镜下手术创伤小、出血少、术后恢复快，且能最大程度地恢复肩关节的功能，是治疗老年人肩峰撞击肩袖撕裂的首选术式。     

关节镜下巨大肩袖撕裂修补的几个关键问题

肩袖撕裂是一种由上肢反复过顶运动或肩关节慢性退行性病变引起的、以疼痛和功能障碍为主的疾病,临床上将其分为有症状肩袖撕裂和无症状肩袖撕裂。年龄增长是肩袖撕裂的重要危险因素之一,50～60岁死亡人群中有30%存在肩袖撕裂;70岁以上死亡人群中则高达90%～100%。无症状肩袖撕裂也存在于相当一部分人群之中。在病理学上,肩袖撕裂分为部分撕裂和全厚撕裂。有学者对部分肩袖撕裂进行系统分类,采取镜下肩袖修补联合肩峰下减压,     

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。     

关节镜下两种技术治疗肩袖关节侧部分撕裂的疗效比较

目的 探讨关节镜下经肌腱修补术和转全层撕裂修补术治疗肩袖关节侧部分撕裂的临床疗效。方法将46例肩袖关节侧部分撕裂患者采用随机数字表法分为经肌腱修补组(采用经肌腱修补术,23例)和转全层修补组(采用转全层撕裂修补术,23例)。比较两组末次随访时疼痛VAS评分、UCLA评分、ASES评分、肩关节活动度以及术后恢复活动时间。结果 患者均获得随访,时间12～22个月。术中及术后均无神经血管损伤、锚钉脱出及深部感染、肩关节功能明显受限等并发症发生。术后MRI和彩超复查肩袖肌腱再撕裂情况:转全层修补组发现2例,经肌腱修补组未发现。疼痛VAS评分、UCLA评分、ASES评分:末次随访时两组均较术前明显改善(P <0.05),两组间比较差异均无统计学意义(P> 0.05)。末次随访时肩关节活动度两组比较差异均无统计学意义(P>0.05)。术后恢复日常活动时间转全层修补组早于经肌腱修补组(P <0.05)。结论关节镜下经肌腱修补术和转全层撕裂修补术治疗肩袖关节侧部分撕裂,均可显著改善患者肩关节功能,但经肌腱修补术的患者术后肩关节功能恢复较慢。     

肩袖部分撕裂的诊断和治疗

目的探讨肩袖部分撕裂的诊断和手术方法。方法1999年4月~2004年1月,我所对14例肩袖部分撕裂进行手术治疗。术前均拍摄肩关节正位和冈上肌出口位X线片,11例B超检查,14例MR I或MRA检查。5例行肩峰下间隙减压及肩袖清理术;9例行肩峰下间隙减压及肩袖修复术。采用UCLA肩关节评分标准进行评价。结果滑囊侧部分撕裂7例,关节侧部分撕裂7例。14例随访1~6年,平均38个月,UCLA评分由术前(15.9±3.9)分升至术后(30.9±5.2)分(t=15.000,P=0.000)。良13例,差1例;13例满意。结论关节镜检查是诊断肩袖部分撕裂的可靠方法。肩袖修复术是治疗肩袖部分撕裂的有效方法。关节镜下手术创伤小、恢复快。     

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair

Purpose:Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique.Results:Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted.Conclusions:Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.

Level of Evidence:

Level IV     

Results of the repair of acute rotator cuff tears is not influenced by tear retraction

Purpose:

This study evaluated retraction in the setting of acute rotator cuff tears and determined its effects on patient outcomes and tendon repair integrity.

Materials and Methods:

A total of 22 patients had surgery within 6 weeks or less from the time of injury. Fifteen of these patients were prospectively followed at a minimum of 2 years; average 40.5 months (range 24-69). Pre-operative objective and subjective outcomes were compared. Tendon repair integrity was assessed with ultrasound at a minimum of 1 year from surgery. The population was stratified into Group 1 (8 patients) with minimal intra-operative medial tendon retraction to the mid-line level of the humeral head and Group 2 (7 patients) with a large medial tendon retraction to the glenohumeral joint or greater.

Results:

The average time to surgery from the onset of symptoms was 27 days (range, 6-42). Post-operative motion increased significantly for external rotation and forward elevation, 77% of patients were pain free, 80% were completely satisfied, and 100% would have the surgery again. Group 1 (small retraction) versus Group 2 (large retraction) showed that post-operative pain levels, satisfaction, range of motion, strength, subjective shoulder value (95.4% vs. 92.3%), Constant Score (80.8 vs. 78.1), and American Society of Shoulder and Elbow Surgeons (96.2 vs. 93.5) scores were not statistically different. Ultrasound showed a tendon repair integrity rate of 87%. 2 patients who did have a re-tear were in Group 2, yet had comparative outcomes.

Conclusion:

In acute rotator cuff tears, equal patient satisfaction, pain scores, range of motion, strength, and outcome measures should be expected with surgical repair despite the level of retraction.

Level of Evidence:

Therapeutic level IV     

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。     

Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: an electromyographic study

Adaptive muscle activation strategies following a massive rotator cuff tear (MRCT) are inadequately understood, and the relationship among muscles during everyday activities has not been considered. Thirteen healthy subjects comprised the control group, and 11 subjects with a MRCT the patient group. Upper limb function was assessed using the Functional Impairment test‐hand, neck, shoulder, and arm (FIT‐HaNSA). Electromyography (EMG) was recorded from 13 shoulder muscles, comprising five muscle groups, during a shelf‐lifting task. Mean FIT‐HaNSA scores were significantly lower in MRCT patients (p ≤ 0.001), reflecting a severe functional deficit. In MRCT patients, EMG signal amplitude was significantly higher for the biceps brachii‐brachioradialis (p < 0.001), upper trapezius‐serratus anterior (p = 0.025), muscle groups and for the latissimus dorsi (p = 0.010), and teres major (p = 0.007) muscles. No significant differences in the correlation among muscle groups were identified, pointing to an unchanged neuromuscular strategy following a tear. In MRCT patients, a reorganization of muscle activation strategy along the upper limb kinetic chain is aimed at reducing demand on the glenohumeral joint. Increased activation of the latissimus dorsi and teres major muscles is an attempt to compensate for the deficient rotator cuff. Re‐education towards an alternate neuromuscular control strategy appears necessary to restore function. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1140–1146, 2012     

关节镜下肩袖缝合术治疗肩袖撕裂

目的探讨关节镜下肩袖缝合术治疗肩袖撕裂的手术方法和临床效果。方法2002年12月至2005年10月，对27例肩袖撕裂患者行关节镜下肩袖缝合术，25例获得1年以上随访，其中男12例，女13例；年龄35～67岁，平均54．3岁；左肩6例，右肩19例，涉及优势侧19例。10例滑囊侧部分撕裂，1例滑囊侧及关节侧均有部分撕裂，14例全层撕裂。术前均拍摄肩关节正位和冈上肌出口位X线片，21例行B超检查，23例行MR或MRA检查。全部病例行肩峰下滑囊切除及前肩峰成形术。肩袖修复方式：1例直接行断端缝合，15例应用缝合锚钉行肩袖止点重建，9例联合应用断端缝合及缝合锚钉技术。分别在术前和最终随访时采用UCLA肩关节评分标准进行评价。结果随访时间1～3年，平均23个月。术后平均UCLA评分为（32．3±t2．3）分。手术前后疼痛评分平均为（2．6±t0．9）分和（8．6±1．4）分（P=0．000），功能评分平均为（5．0±1．8）分和（9．1±1．0）分（P=0．000），肩关节主动前屈评分平均为（3．6±1.5）分和（4．9±10.3）分（P=0．000），前屈肌力评分平均为（4．0±0．6）分和（4．7±0．5）分（P=0．000），差异均有统计学意义。优8例、良17例，所有患者均对手术效果表示满意。结论关节镜下肩袖缝合术是治疗肩袖撕裂的有效方法。术中应有效地控制出血，适度进行肩峰成形，正确识别撕裂的形状，充分松解粘连并采用恰当的缝合方式。手术创伤小、恢复快，其疗效可达到切开手术水平。