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。     

肩峰下撞击征的治疗进展

肩峰下结构与典型滑膜关节的结构非常相似,其中喙突、喙肩韧带、肩峰构成的穹隆状结构类似臼窝;肱骨大结节类似关节突;位于肩峰和喙肩韧带、冈上肌之间的肩峰下滑囊类似关节滑囊;冈上肌肌腱在肩峰与肱骨大结节间穿过,肱二头肌长头腱在其深面穿越肱骨头上方。因此,肩峰下结构又被称为“第二肩关节”。肩峰前外侧形态异常、骨赘形成,肱骨大结节骨赘形成,肩锁关节增生以及其它可能导致肩峰－肱骨头间距减小的原因均可造成肩峰下结构的挤压与撞击,即由于与肩峰底面的前 1/3、喙肩韧带和肩锁关节下面的反复异常碰撞,滑囊、肩袖及肱二头…     

肩袖损伤修复的生物治疗现状及进展

肩袖是冈上肌、冈下肌、小圆肌和肩胛下肌四块肌肉及其肌腱组成的复合体.它们环绕肱骨头上端,共同协调肩关节运动.在年龄、创伤、劳损等外在因素以及肌腱退变、血运不足、肩峰下撞击等内在因素作用下,肩袖易发生损伤,尤其是肌腱撕裂,进而引发肩部疼痛、力量减弱、活动范围减少.肩袖撕裂通常需手术修复,术后大部分疼痛减轻,肩关节功能改善...     

肩峰肱骨头相对位置与肩峰下撞击综合征关系的研究

[目的]探讨肩峰肱骨头相对位置对肩峰下间隙的影响,为肩峰下撞击综合征的诊断、预防和治疗提供理论依据.[方法]对本科2006年10月～2007年3月就诊的肩峰下撞击综合征患者3l肩(平均年龄54.3岁,男13肩,女18肩)的Graghey位片,计算肩峰指数即肩峰最外侧缘至肩关节盂平面的距离与肱骨近端最外侧缘至肩关节盂平面的距离的比值,通过肩峰指数对肩峰肱骨头相对位置进行定量评估,与正常人群40肩(平均年龄52.8岁;男18肩,女22肩)进行比较、分析.[结果]病例组平均肩峰指数及标准差为(0.72±0.05),正常组平均肩峰指数及标准差为(0.61±0.04),2组之间有明显差异(P＜0.0001).[结论]肩峰指数可准确的反映肩峰与肱骨头在冠状位上的位置关系,肩峰下撞击综合征与较大的肩峰指数有关.在较大的肩峰指数所反映的肩峰肱骨头位置关系中,外展时三角肌对肱骨头向上的分力大,肩峰下间隙内压力高,易引发肩峰下撞击综合征.     

肩袖撕裂的病因探讨

Ｃｏｄｍａｎ提出冈上肌离大结节止点１ｃｍ处为乏血管区，此区是造成肩袖撕裂的主要原因。ＮｅｅｒⅡ则提出９５％的肩袖撕裂是由肩峰下撞击引起。作者对３５例肩袖撕裂的病人进行了临床与手术的观察，发现肩袖撕裂的部位主要分布于冈上肌，占９７．１％。３５例中撞击征病人１０例。Ｃｏｄｍａｎ的乏血管区不仅存在于冈上肌，亦存在于肩袖其它肌腱，故乏血管区不是引起肩袖撕裂的主要原因。撞击征亦不是，只占全部撕裂总数的２８．６％。作者认为引起肩袖撕裂的内在因素包括肩袖肌腱的乏血管区和冈上肌的特殊位置和功能，外在因素包括肩关节反复应用，肩峰下撞击和不同程度的肩部外伤。     

肩峰形态影像学分型在肩袖损伤诊治中的应用价值研究

目的 ：提出一种肩峰撞击理论以及肩关节Rockwood位片的肩峰形态分型法,探讨该分型法在肩袖损伤诊治中的应用价值。方法：回顾性分析2017年1月至2017年12月因肩峰撞击症或肩袖撕裂行肩关节镜手术的101例患者,其中男34例,女67例;年龄34～76(56.31±9.63)岁;病程2～12个月,平均6个月。术前常规拍摄肩关节“三位片”,包括肩关节前后位、Rockwood位以及冈上肌Outlet位。基于肩峰撞击理论以及Rockwood位片将肩峰形态分为3型：Ⅰ型（平坦型）、Ⅱ型（隆起型）、Ⅲ型（撞击型）。两位观察者分别对101例患者的肩关节Rockwood位片按照新分型法、对冈上肌Outlet位片按照传统肩峰形态分型法进行分类统计;冈上肌腱损伤依据关节镜下所见分为无撕裂、部分撕裂、全层撕裂。分别对新分型法、传统分型法进行一致性检验（Kappa值）,采用秩和检验比较新肩峰分型法3种肩峰形态的平均肩肱距（acromiohumeral distance,AHD）,采用Spearman秩相关性检验以及Gamma法分析比较新肩峰分型法与冈上肌腱撕裂程度之间的相关性。结果：观察者间一致性检验新肩...     

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。     

肱二头肌腱在撞击综合征中的作用

肱二头肌腱长头在撞击综合征病损中起重要作用。肌腱的滑膜衬里来自肩关节滑膜延伸。肩关节滑膜的任何炎症均能沿肌腱扩散。由于狭窄的肱二头肌腱沟和紧张的横韧带,阻碍了腱鞘炎的扩散,并使病损迅速转为慢性。撞击综合征主要由肩峰弓长期压迫肩袖,引起肩袖肌腱炎所致。肩峰弓由肩峰、肩锁关节和喙肩韧带组成。肩袖出现肌腱炎时,可伴有滑膜炎,继而肱二头肌腱鞘炎,并向下向外扩展。鉴别肩袖性疼痛和肱二头肌疼痛较困难。大多数肩袖患者主诉外侧三角肌或     

肩关节检查

肩关节检查包括病史采集、一般检查、特殊检查及放射学检查。病史采集对于疾病的诊断有重要意义。一般检查按照望、触、动、量顺序进行。望是看肩关节有无畸形,肌肉有无萎缩,肩胛骨运动是否正常。触主要看肩锁关节、结节间沟、肩峰外缘及三角肌区有无压痛。肩关节的主、被动活动范围对于疾病的诊断有重要意义。肩峰下撞击综合征特殊检查由Neer征、Hawkins试验、疼痛弧试验,二者敏感性高特异性低。而Neer撞击试验特异性较高。肩袖损伤的检查包括肩袖肌力检查。Jobe试验阳性多提示冈上肌腱损伤,冈下肌腱损伤时将出现外旋肌力减弱,外旋松弛试验多为阳性。肩胛下肌是维持肩关节稳定及内旋肩关节的主要肌肉,常用的检查包括Lift-off试验、内旋松弛试验、压腹试验。肩关节过度外旋超过90°,肌内旋力量减弱也提示肩胛下肌损伤。琴键征、体前内收试验阳性、O′brien试验及肩锁关节局部压痛则提示肩锁关节病变。肱二头肌长头肌腱病变的检查包括结节间沟压痛、肱二头肌痛、Speed试验。SLAP损伤是年轻人常见的运动损伤,患者出现肩关节异响或绞锁,O′brien试验可出现阳性,主要确诊靠MRI及关节镜。恐惧试验主要用于检查肩关节不稳。     

肩峰下假体植入治疗巨大肩袖损伤或不可修复肩袖损伤研究进展

肩袖损伤(RCT)在老年人群中高发,且发病率可随年龄增长而增加。其中,巨大肩袖损伤(MRCT)或不可修复肩袖损伤(IRCT)损伤巨大,组织质量不佳且肌腱回缩,因此对其进行保守治疗或传统手术治疗均可能存在较大的失败风险。将肩峰下假体植入肩峰下间隙可直接避免肩关节活动过程中肱骨头与肩峰直接撞击和肩袖持续磨损,并可恢复正常肱骨头旋转中心位置,从而维持肩关节外展力臂。此外,肩峰下假体降解后形成的结缔组织可能形成间隔结构,可持续维持其治疗效果。该文将对肩峰下假体植入治疗MRCT或IRCT研究进展作一综述。     

MRI在常见肩关节疾病诊断中的应用

目的 探讨ＭＲＩ对慢性肩关节疼痛的诊断和鉴别诊断的重要性。方法 本组通过７０例８６肩的ＭＲＩ肩关节造影与手术发现结果的比较。评价肩关节造和ＭＲＩ在诊断肩袖疾忠和肩不稳定的应用价值。结果 在诊断肩袖完全撕裂中,关节造影的敏感性９１％,特异性为１００％,ＭＲＩ的敏感性为９５％,特异性为８８％。ＭＲＩ不但能够准确显示肩袖撕裂的部位。尚能显示出其它相关组织的病理改变。关节造影难以显示肩袖不全撕裂,ＭＲＩ虽     

Radiologic case study. Rupture of the long head of the biceps tendon

Rupture of the long head of the biceps tendon frequently is encountered in the setting of coexisting rotator cuff pathology and chronic impingement, but traumatic rupture is occasionally seen, as in this case. Signs and symptoms are not always diagnostic, and MRI or MR arthrography can be a useful tool for evaluation of the tendon in difficult cases. Ideally, an empty bicipital groove is seen, indicating absence of the tendon and rupture. Scar tissue within the groove can be problematic, and correlation with oblique coronal and sagittal images is always recommended. The superior labrum at the attachment of the bicipital anchor should always be inspected carefully, as this is the most common site of rupture, and there may be an associated tear of the superior labrum. Magnetic resonance arthrography is not necessary for diagnosis in most cases, but will provide better visualization of the tendon and bicipital-labral complex.     

Anterior internal impingement

Purpose: The source of pain in patients with a stable shoulder and clinical signs of impingement is traditionally thought to be subacromial or outlet impingement, as popularized by Neer. This report introduces the concept of anterior internal impingement in patients with signs and symptoms of classic impingement syndrome and arthroscopic evidence of articular-side partial rotator cuff tear. Contact that occurs between the fragmented undersurface of the rotator cuff and the anterosuperior labrum is the apparent source of pain in these patients. Type of Study: Case series. Methods: Ten patients with a primary symptom of pain and an arthroscopic finding of a partial rotator cuff tear were reviewed. Arthroscopic visualization of the subacromial space revealed no evidence of subacromial impingement or bursitis in any patient. All patients had clinical signs and symptoms of classic impingement. The initial part of the surgical procedure consisted of a complete diagnostic arthroscopy in a low-volume gas medium using a single posterior portal. While performing the Hawkins test, the locations of any areas of abnormal soft-tissue contact and impingement were observed directly. Results: There was anterior internal impingement in all 10 patients with partial-thickness rotator cuff tears. The abnormal and fragmented rotator cuff tissue made contact with the anterior superior labrum when the shoulder was visualized from the posterior portal while performing the Hawkins test. Preoperative magnetic resonance imaging correctly showed a partial-thickness rotator cuff tear in 20% of the cases. Conclusions: Recognition of anterior internal impingement as a clinical entity is important because magnetic resonance imaging results are often misleading. This is of particular importance in young patients with isolated lesions in whom arthroscopic acromioplasty and capsular reefing procedures would be unnecessary. When anterior internal impingement is recognized as the source of unresolved shoulder pain, patient selection for surgery and procedure selection can be improved.     

A comparative study of ultrasonography and arthrography in evaluation of the rotator cuff

Fifty patients with signs and symptoms of chronic impingement syndrome and/or rotator cuff tear were evaluated with shoulder arthrograms and ultrasonography. Ninety asymptomatic shoulders of a comparable age had ultrasonography to serve as a control group. All controls had normal ultrasonograms with no hypoechoic or sonolucent areas. The 50 symptomatic shoulder patients had the following: 28 had a normal arthrogram with either normal ultrasonograms or buckling of the supraspinatus tendon; eight had normal arthrograms, but ultrasonography indicated a thin (less than 4 mm) irregular supraspinatus tendon; 11 had complete rotator cuff tears visualized on both arthrography and ultrasonography (nine of these 11 patients had surgery confirming complete tears in all); two had a false-positive sonogram, and one had a false-negative sonogram. Thus, the ultrasonography's overall positive predictive value to detect a full-thickness rotator cuff tear was 85%, its negative predictive value was 97%, its sensitivity was 92%, and its specificity was 95%. Real-time ultrasonography is a diagnostically sensitive and specific noninvasive method to evaluate patients with shoulder impingement syndrome, leading to the recommendation that it be used as a primary imaging technique to obviate or supplement arthrography in evaluating rotator cuff disease. However, static ultrasonographic pictures, without real-time ultrasonography as a supplement, were not helpful.     

Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value

The sensitivity, specificity, and predictive value of magnetic resonance imaging in the diagnosis of lesions of the rotator cuff, glenohumeral capsule, and glenoid labrum were evaluated in ninety-one patients and fifteen asymptomatic volunteers. Magnetic resonance imaging demonstrated 100 per cent sensitivity and 95 per cent specificity in the diagnosis of complete tears, and it consistently predicted the size of the tear of the rotator cuff. There was a definite correlation between atrophy of the supraspinatus muscle and the size of a complete, chronic tear of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the differentiation of tendinitis from degeneration of the cuff were 82 and 85 per cent, and in the differentiation of a normal tendon from one affected by tendinitis with signs of impingement the sensitivity and specificity were 93 and 87 per cent. The formation of spurs around the acromion and acromiocalvicular joint correlated highly with increased age of the patient and with chronic disease of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the diagnosis of labral tears associated with glenohumeral instability were 88 and 93 per cent. The study showed that high-resolution magnetic-resonance imaging is an excellent non-invasive tool in the diagnosis of lesions of the rotator cuff and glenohumeral instability.     

肩关节前方盂唇损伤的MRI和MR关节造影诊断

目的:探讨MRI和MR关节造影在肩关节前方盂唇损伤中的诊断价值,评估MR关节造影在鉴别肩关节前方盂唇不同类型损伤中的作用。方法:自2007年1月至2010年12月,对经肩关节MRI、MR关节造影诊断后进行关节镜手术治疗的153例肩部损伤患者的临床资料进行了回顾性分析。由1位骨骼肌肉系统影像学医生和1位运动医学医生共同阅片,得出一致的MRI和MR关节造影诊断,并与关节镜下结果进行比较。计算MRI和MR关节造影诊断肩关节前方盂唇损伤的敏感性、特异性和准确性。在MR关节造影下存在前方盂唇损伤的患者中,对其不同类型损伤进行分型,与关节镜下分型进行对比研究。结果:153例中,肩关节前方盂唇损伤78例,肩袖损伤67例,上盂唇从前到后(superior labrum anterior to posterior,SLAP)损伤8例,MRI和MR关节造影诊断肩关节前方盂唇损伤的灵敏度分别为80.8%和92.3%,特异度分别为89.3%和97.3%,准确度分别为85.0%和94.8%。78例关节镜下存在肩关节前方盂唇损伤的患者中,Bankart损伤39例,前方盂唇骨膜袖套样撕脱(ALPSA)损伤32例,Perthes损伤7例,MR关节造影正确诊断Bankart、ALPSA和Perthes损伤的灵敏度分别为84.6%、84.4%和57.1%。结论:MR关节造影较MRI诊断肩关节前方盂唇损伤的灵敏度、特异度和准确度更高,MR关节造影能在术前进一步明确盂唇损伤的类型,为确定术前计划提供依据。     

Evaluation of the painful shoulder. A prospective comparison of magnetic resonance imaging, computerized tomographic arthrography, ultrasonography, and operative findings

Twenty-one patients who had had pain in the shoulder for more than three months were evaluated with ultrasonography and magnetic resonance imaging followed by computerized tomographic arthrography. The results of the imaging studies were then compared with the operative findings. Magnetic resonance imaging was found to be the most useful modality for establishment of the etiology of pain in the shoulder due to disease of the rotator cuff, instability associated with abnormality of the glenoid labrum, subacromial impingement, stenosis of the coracoacromial arch, and osteoarthrosis of either the glenohumeral or the acromioclavicular joint. The accuracy of magnetic resonance imaging was found to depend on both the operator and the technique and was decreased in extremely obese patients, due to difficulties in positioning, and in patients who had had a previous operation. Magnetic resonance imaging was more accurate than either computerized tomographic arthrography or ultrasonography in identifying partial-thickness tears (intrasubstance changes in the rotator cuff). Magnetic resonance imaging provided the same level of accuracy as computerized tomographic arthrography in the detection of abnormalities of the glenoid labrum.     

Ultrasonographic evaluation of the rotator cuff and biceps tendon

Ultrasonography of the rotator cuff and biceps tendon was investigated in 106 patients who had been referred for arthrography of the shoulder. Both the sensitivity and the specificity of ultrasound in detecting a tear of the rotator cuff were 91 per cent. The predictive value of a negative sonogram was 95 per cent and the predictive value of a positive sonogram was 84 per cent. Ultrasonography proved to be superior to arthrography in the examination of the normal and abnormal biceps tendon. Sonographically detectable effusions from the tendon sheath of the biceps were present in 19 per cent of this population of patients. This finding was statistically highly associated (90 per cent) with rotator cuff tears and other soft-tissue abnormalities of the shoulder. Based on these results, it appears that ultrasonography can be used as the initial imaging test for many patients with suspected abnormalities of the rotator cuff or biceps tendon.     

磁共振肩关节造影技术诊断肩关节损伤的临床应用

目的探讨磁共振(MR)肩关节造影诊断肩关节损伤的临床价值。方法回顾性分析20例肩关节损伤患者常规MRI和MR肩关节造影的影像表现,并与肩关节镜手术结果对照。结果关节镜诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MRI诊断结果:肩袖部分撕裂16例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤1例。MR肩关节造影诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MR肩关节造影诊断结果与关节镜结果一致。结论MR肩关节造影较常规MRI检查能够提高肩关节损伤的诊断准确性。     

Schultergelenkverletzung

Adequate imaging is mandatory for managing shoulder injuries. Radiographs in two or three different planes are an indispensable part of initial assessment, and may allow a first classification of a fracture, and the extent of degenerative changes. Helical CT with multiplanar reconstruction is helpful in deciding the appropriate surgical fixation of proximal humeral fractures. Most patients will require further diagnostic work-up for evaluating tears of the rotator cuff, labral tears, and other soft-tissue damage. MRI is established as the noninvasive diagnostic gold standard in this setting. Knowledge of anatomic details is important for interpretation of diagnostic imaging. From a legal point of view, MRI findings contribute substantial information to distinguish chronic from acute types of tendon lesions. MR arthrography allows the detection of affected soft-tissue, especially of the glenoid labrum and the glenohumeral ligaments which are associated with glenohumeral joint instability. Future studies must clarify whether dynamic imaging is helpful in providing a detailed evaluation of laxity and functional impairment of the shoulder joint.