早期康复与延迟康复对关节镜肩袖修补术后肩关节功能及肩袖愈合影响的Meta分析

目的 比较关节镜肩袖修补术后早期康复与延迟康复对术后肩关节功能和肩袖愈合的影响。方法 计算机检索PubMed、Web of Science、Cochrane Library、中国知网（CNKI）、万方数据库、维普数据库,查找比较关节镜肩袖修补术后早期康复与延迟康复肩关节功能和肩袖愈合的随机对照试验（RCTs）。按照文献纳入和排除标准筛选文献,并提取两种康复方案病人术后的美国肩肘外科学会（American Shoulder and Elbow Surgeons, ASES）评分、Constant-Murley评分、简明肩关节功能测试（simple shoulder test, SST）评分、疼痛视觉模拟量表（visual analogue scale, VAS）评分、肩关节活动度、肩袖愈合情况等信息,采用Review Manager 5.3软件对数据进行分析,使用GRADE（Grades of Recommendation, Assessment, Development and Evaluation）证据质量评级方法评价证据质量。结果 共纳入10篇文献,均为RCTs,共929例研究对象,其中早期康复组473例,延迟康复组456例。Meta分析结果显示：早期康复组与延迟康复组术后6个月和12个月的ASES、Constant-Murley评分、SST评分、VAS评分差异均无统计学意义（P均＞0.05）。早期康复组术后6个月的肩关节前屈活动度大于延迟康复组［MD=3.30,95% CI（0.15,6.45）,P=0.04］,外旋活动度大于延迟康复组［MD=2.44,95% CI（0.33,4.54）,P=0.02］;早期康复组术后12个月肩关节前屈活动度大于延迟康复组［MD=1.26,95% CI（0.31,2.22）,P=0.009］。在肩袖愈合方面,两组差异无统计学意义（P＞0.05）。结论 关节镜下肩袖修补术后,对比延迟康复,早期康复在术后恢复肩关节功能方面没有差别,但尽早开始康复训练可更好地改善术后早期（6个月）肩关节前屈及外旋活动度,以及术后长期（12个月）肩关节前屈活动度。早期康复与延迟康复对肩袖愈合情况没有明显影响。     

磁共振成像在肩袖损伤诊断中的应用——附100例临床结论分析

目的 通过对100例肩关节检查结果分析,讨论磁共振成像(MRI)对肩袖损伤诊断的作用.方法 回顾性研究2006年12月至2007年4月100例疑似肩袖损伤病人理学检查结果和MRI检查结论,并结合20例小切口开放肩袖修补术所见,比较两者对肩袖损伤诊断的作用.结果 对100例疑似肩袖损伤、Constant评分＜70分的病人行常规MRI检查,77例提示肩袖损伤(肌腱炎或肌腱断裂),7例肱二头肌长头腱损伤,8例肩锁关节炎,8例无明显影像学异常,临床诊断为"凝肩" .对20例肩袖损伤进行手术治疗,以术中所见分析术前不同理学检查和MRI检查对诊断肩袖损伤的作用.所有体检方式诊断肩袖断裂与否的特异性差,P＞0.05;MRI诊断肩袖断裂的特异性好,P＜0.05.结论 常规MRI检查对肩袖损伤的诊断具有重要作用,理学检查诊断肩袖损伤的灵敏度高,特异性差.理学检查结合MRI检查可提高肩袖损伤诊断的准确性,为临床制定治疗方案提供参考.     

肩袖损伤的处理临床实践指南(2019年)解读

2019年3月美国骨科医师协会(American academy of orthopaedic surgeons,AAOS) 颁布了《肩袖损伤的处理临床实践指南(2019年)》(简称2019年指南),公布在其官网上[1].该指南结合最新的循证医学证据,主要就肩袖损伤治疗领域备受关注的问题如肩袖损伤的诊断、部分与全层肩袖...     

基于Web of Science数据库近5年小儿肝移植研究热点知识图谱分析

目的 探究2016—2020年Web of Science核心数据库小儿肝移植研究热点内容.方法 下载Web of Science核心数据库数据作为本研究数据来源,通过Vosviewer和Citespace软件可视化分析近5年来小儿肝移植学科的发文情况、研究单位、核心研究作者、期刊分布、研究关键词及相关的聚类分析.结果...     

老年肩袖损伤的特点及治疗进展

肩袖损伤是老年人常见的肩关节疾病。肩袖的退行病变是老年肩袖损伤主要特点。肩袖作为肩关节软组织中最重要的结构,其损伤会出现肩关节疼痛和功能障碍,严重时影响肩关节活动。文章描述了肩袖损伤的X线、MRI和B超特点及其评估方法,进一步阐述了肩袖损伤的保守治疗及手术治疗方法,分析其优劣性,本文最后对肩袖损伤的功能康复锻炼方法进行了探讨,以期为临床提供诊疗依据。     

糖尿病对肩袖损伤、修复及并发症影响的文献综述

糖尿病是肩袖损伤的危险因素之一,且影响肩袖修复及术后并发症的发生.区别于一般肩袖损伤,糖尿病病人肩袖损伤具有复杂性,影响骨科医师对于此类病人的评估与治疗.随着糖尿病病人数量的逐年上升,糖尿病对肩袖损伤的影响研究变得更为重要.本文回顾了有关糖尿病与肩袖损伤的现有相关文献,通过从糖尿病与肩袖损伤的关系,糖尿病病人肩袖肌腱的...     

肩袖修补术后再撕裂危险因素的研究进展

肩袖再撕裂是肩袖修复术后主要的并发症,其严重影响了手术疗效。肩袖再发撕裂的影响因素包括术前年龄、糖尿病、高脂血症、症状持续时间、撕裂大小、肩袖脂肪浸润及回缩、手术方式的选择、生物制剂的应用、术后康复锻炼方案等。本文对关于肩袖修复术后再发撕裂危险因素进行了综述和分析,加深对再撕裂的认识,以期减少肩袖修补术后再次撕裂的发生,促进患者术后功能恢复和满意度。     

糖尿病对肩袖损伤发病及预后影响的研究进展

糖尿病与不同部位肌腱改变之间存在联系,然而持续高血糖状态对肩袖部位肌腱的影响尚未得到很好的阐述。本文就糖尿病并发肩袖损伤的特点、发病机制及糖尿病对肩袖修补术后疼痛、活动度、组织愈合和感染发生的影响进行综述,以便进一步了解糖尿病患者肩袖损伤进展及术后的预后情况,为提供个性化的预防措施及康复指导提供依据。     

糖尿病对肩袖损伤发病及预后影响的研究进展

糖尿病与不同部位肌腱改变之间存在联系,然而持续高血糖状态对肩袖部位肌腱的影响尚未得到很好的阐述。本文就糖尿病并发肩袖损伤的特点、发病机制及糖尿病对肩袖修补术后疼痛、活动度、组织愈合和感染发生的影响进行综述,以便进一步了解糖尿病患者肩袖损伤进展及术后的预后情况,为提供个性化的预防措施及康复指导提供依据。     

基于CiteSpace的鳞状非小细胞肺癌维持治疗相关文献可视化分析

目的 通过对关于鳞状非小细胞肺癌(squamous non-small cell lung cancer,Sq-NSCLC)维持治疗的文献进行可视化分析,探索近5年来该领域的研究现状及热点方向.方法 检索Web of Science(WOS)中的Science Citation Index Expanded(SCI-E...     

A scientometrics analysis and visualization of low back pain

BackgroundAlthough low back pain (LBP) contributes to the global disease burden, literature on the scientometric analysis of low back pain is limited.ObjectiveThis study aimed to demonstrate the research state and capture developmental dynamics of low back pain utilizing scientometric analysis and visualization methods.MethodsLiterature on low back pain from 2011 to 2020 was retrieved from the Web of Science core collection. CiteSpace software was used to generate the relevant knowledge map and carry out scientometric analysis on the volume of literature, cooperation between countries/regions and research institutions, disciplines, journals, highly cited references, and keywords. Research hotspots and trends of the included literature were then stated.ResultsA total of 27,968 publications were obtained and the number of annual publications maintained growth continually. Australia and the University of Washington had the maximum centrality. The USA and the University of Sydney were the most prolific country and institution respectively, thus indicating that they are important in this field. Publications were devoted to the disciplines of neurology, orthopedics and rehabilitation. The highest cited journal is Spine (18478), followed by European Spine Journal (11344) and Pain (11097). The systematic review, disease burden, epidemiology, clinical practice recommendations, and primary care management are the key subjects covered by highly cited papers. The keywords were primarily concerned with pain etiology, disease type, clinical treatment, and trials. Burst keywords in LBP were controlled trial, practice guideline, stability, adolescent, individual, activation and expression, which can be regarded as research hotspots and frontiers.ConclusionIn conclusion, the data clearly shows a consistent increase in LBP studies. The historical review provides insight into LBP as well as valuable information for researchers to identify new perspectives on potential cooperative institutions, hot topics, and a strong foundation for future research.     

Four‐week exercise program does not change rotator cuff muscle activation and scapular kinematics in healthy subjects

Rotator cuff and scapular muscle strengthening exercises are an essential part of shoulder rehabilitation and sports training. Although the effect of exercise training on pain and function have been widely investigated, few studies have focused on the changes in shoulder kinematics and muscle activity after exercise training. Therefore, the purpose of the present study was to investigate the effect of rotator cuff and scapular strengthening exercises on shoulder kinematics and the activation of rotator cuff and scapular muscles in healthy subjects. Thirty‐six healthy subjects were recruited and randomly assigned into either a training or control group. Subjects in the training group were trained with rotator cuff and scapular strengthening exercises for 4 weeks. Scapular kinematics and shoulder muscle activity during arm elevation were measured before and after exercise training. After the 4‐week training protocol, there was an increase in strength and a decrease in upper trapezius activation in the training group, which is consistent with previous studies. However, no difference was found in scapular kinematics and activation of rotator cuff muscles between the control and training groups after the training protocol. Although the exercise protocol resulted in strength gains for the rotator cuff, these gains did not transfer to an increase in muscle activation during motion. These results demonstrate the difficulty in changing activation patterns of the rotator cuff muscles. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2079–2088, 2016.     

Painful Shoulder After Surgery for Rotator Cuff Disease

Persistent shoulder pain after surgery for rotator cuff disease may be caused by conditions that are either extrinsic or intrinsic to the shoulder. Extrinsic causes of persistent shoulder pain include cervical radiculopathy, suprascapular neuropathy, abnormalities of scapular rotation (due to long-thoracic or spinal-accessory neuropathy), and adjacent or metastatic neoplasms. Causes of persistent pain that are intrinsic to the shoulder include both intra-articular conditions (e.g., glenohumeral osteoarthritis, adhesive capsulitis, recurrent anterior subluxation, and labral and bicipital tendon abnormalities) and extra-articular conditions (e.g., persistent subacromial impingement, persistent or recurrent rotator cuff defects, acromioclavicular arthropathy, and deltoid muscle deficiency). Successful management requires an accurate diagnosis, maximal rehabilitation, judicious use of surgical intervention, and a well-motivated patient. The results of revision surgery in patients with persistent subacromial impingement, with or without an intact cuff, are inferior to reported results after primary acromioplasty or rotator cuff repair.     

Rehabilitation following anterior acromioplasty

The shoulder region is one of the most challenging part of the human body to rehabilitate. Postoperative days following anterior acromioplasty are painful, with a high potential course of developing soft tissue fibrosis and joint contracture. In the past, following anterior acromioplasty and/or rotator cuff repair, the rehabilitation process was usually delayed for up to four to six weeks to allow healing of the repaired site. This conservative rehabilitation approach resulted in significant restrictions in glenohumeral and scapular joint mobility, weakness of the shoulder girdle musculature, prolonged pain, and functional limitations. Currently the trend of rehabilitation following anterior acromioplasty shifted toward a more earlier and aggressive approach thanks to improved surgical and soft tissue fixation techniques and advances in arthroscopic procedures. This has allowed active-assisted shoulder motion immediately after subacromial decompression and rotator cuff surgery. The rehabilitation team following anterior acromioplasty of the shoulder should consist of the physiatrist, orthopedic surgeon, physical therapist, and the patient.     

Scapular dyskinesis and its relation to shoulder injury

The scapula plays a key role in nearly every aspect of normal shoulder function. Scapular dyskinesis-altered scapular positioning and motion-is found in association with most shoulder injuries. Basic science and clinical research findings have led to the identification of normal three-dimensional scapular kinematics in scapulohumeral rhythm and to abnormal kinematics in shoulder injury, the development of clinical methods of evaluating the scapula (eg, scapular assistance test, scapular retraction test), and the formulation of rehabilitation guidelines. Primary scapular presentations such as scapular winging and snapping should be managed with a protocol that is focused on the scapula. Persons with associated conditions such as shoulder impingement, rotator cuff disease, labral injury, clavicle fracture, acromioclavicular joint injury, and multidirectional instability should be evaluated for scapular dyskinesis and treated accordingly.     

Shoulder impingement

Understanding the pathophysiology and treatment of rotator cuff disorders is the key to understanding all other aspects of shoulder rehabilitation. Impingement rehabilitation focuses on strengthening the humeral head depressors, while ignoring the deltoid and supraspinatus muscles. Later treatment includes specific retraining of scapular balancing muscles. The final phase of treatment includes strengthening the prime humeral movers in positions that avoid further stress to the injured rotator cuff tendons and, last of all, specifically strengthening the supraspinatus muscle.     

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.     

Shoulder Injuries in the Throwing Athlete

The throwing athlete with shoulder pain presents a diagnostic and treatment challenge to the orthopaedic surgeon. Because pitching a baseball requires the arm to accelerate at 7,000 degrees per second, tremendous forces are experienced at the shoulder joint. Electromyographic studies have shown that the larger scapular and trunk muscles are primarily responsible for arm acceleration. The smaller and more fragile rotator cuff muscles play a significant role in decelerating the arm. During the entire throwing mechanism, the rotator cuff and the capsulolabral complex act to stabilize the humeral head on the glenoid fossa. As a result, the labrum, the capsule, and the rotator cuff are frequently the site of shoulder injury in throwers. The diagnosis of injury to these structures is based on the findings from the history, physical examination, and imaging studies. The majority of throwing injuries respond well to a carefully designed rehabilitation program. Athletes who do not improve within 6 months are candidates for surgical repair. The procedure is planned so as to minimize the amount of surgical trauma and thereby to facilitate an early return to sport. Arthroscopy is a valuable first step to confirm the pathologic diagnosis. The arthroscope alone is used to perform subacromial debridement, labral repair, or debridement of undersurface partial-thickness rotator cuff tears. If the athlete has clinical evidence of shoulder instability and arthroscopic evidence of capsular stretch, an open stabilization procedure is performed.     

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BackgroundPatient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.Question/purposeAfter controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?MethodsFifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.ResultsThis model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r² = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.65; p < 0.001).ConclusionOur results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.Level of EvidenceLevel II, prognostic study.     

Muscle transfers involving the shoulder

Muscle transfer provides a viable treatment option for several difficult problems involving the shoulder. Muscle transfer is often the only alternative to a salvage procedure such as shoulder fusion, and whereas salvage procedures provide pain relief at the cost of function, muscle transfer can provide pain relief while retaining acceptable function. The five most commonly encountered shoulder problems for which muscle transfer can be utilized are subscapularis rupture, irreparable rotator cuff tear, deltoid injury and dysfunction, trapezial paralysis, and serratus anterior scapular winging. Although numerous muscle transfer procedures have been described, the following procedures have proven the most reliable and are the focus of this article: 1) transfer of the pectoralis major for subscapularis rupture, 2) transfer of the latissimus dorsi for irreparable rotator cuff tears, 3) latissimus dorsi transfer for deltoid injury or dysfunction, 4) modified Eden-Lange procedure for trapezial paralysis, and 5) modified Marmor-Bechtol pectoralis major transfer for serratus anterior scapular winging.