关节镜下双针头定位入路肌腱固定术治疗肱二头肌腱近端病损

 目的 探讨关节镜下双针头定位入路肌腱固定术治疗肱二头肌腱近端病损的手术效果。方法 2010年1月至2013年1月采用关节镜下双针头定位入路肌腱固定术治疗肱二头肌腱近端病损患者55例,男25例,女30例;年龄37~65岁,平均52.4岁。主要症状为肩关节前部疼痛,外展时加重,患肩功能障碍,经MRI诊断为肱二头肌腱近端病损。接受约6个月的系统保守治疗后症状无缓解。在全关节镜下行肌腱固定术,肌腱固定时采用两枚带线缝合锚钉经骨固定,肌腱固定后行残端清理术。手术入路除标准的后侧、肩峰外侧和前侧入路外,肌腱固定的操作和观察均采用双针头定位入路。应用美国肩肘外科医师评分（American Shoulder and Elbow Surgeons,ASES）、Constant-Murley肩关节功能评分、美国加利福尼亚大学洛杉矶分校（University of California,Los Angeles,UCLA）评分记录术前及术后3、6、12、18个月的疼痛程度、肩关节活动范围、前屈上举肌力、外展强度的状况。结果 术后随访18~24个月,平均20个月。术后3个月MRI示肌腱愈合,无肌腱再断裂发生,术后12个月肩关节功能基本恢复。术前ASES、Constant-Murley、UCLA评分分别为（10.22±3.02）分、（35.89±7.25）分、（8.53±2.07）分,术后18个月分别为（32.07±1.26）分、（89.75±4.07）分、（31.87±2.07）分,与术前比较差异有统计学意义。结论 关节镜下双针头定位入路肌腱固定术治疗肱二头肌腱近端病损近期疗效满意,双针头定位选择入路准确、操作简便。     

Tendinopathy Treatment: Where is the Evidence?

Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available. The variability in both quantity and quality of research into tendinopathy treatments makes it difficult to make definitive treatment recommendations. In general, however, a reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy. Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy. Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers; data are lacking to support sclerosing agents and proteinase inhibitors. Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options. Although the inability to make definitive therapeutic recommendations in some instances is discouraging, it is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective. Given the growing prevalence of tendinopathy and the impact it has on the general public, it is more important now than ever to continue the search for the most effective and accessible treatment modalities.     

Rehabilitation of running injuries

Rehabilitating the injured runner involves a thorough evaluation of the runner. The running history is at least as critical as the physical examination to determine the risk factors for injury and goals for rehabilitation. The medical assessment should include an office situation in which the runner can be seen walking and running to ensure that the rehabilitation program is complete and successful.     

Patients with rotator cuff tendinopathy can successfully self-manage,but with certain caveats: a qualitative study

Objectives

Evidence has emerged supporting the value of loaded exercises for rotator cuff tendinopathy but there are barriers that might prevent implementation of this intervention in the real-world. The purpose of this study was to explore these potential barriers with participants involved in a pilot randomised controlled trial (RCT) investigating a self-managed loaded exercise intervention.

Design

A qualitative study within the framework of a mixed methods design. Data were collected using individual interviews and analysed using the framework method.

Setting

One private physiotherapy clinic in northern England.

Participants

Six patients and two physiotherapists were purposively sampled from those allocated to the self-managed exercise group within the RCT.

Results

Three themes were generated: (1) Expectations and preferences, (2) characteristics of an unsuccessful outcome, (3) characteristics of a successful outcome. Most patients expressed expectations contrary to the philosophy of a self-managed approach. But this did not serve as a barrier when the intervention was offered within a positive and supporting environment where patients understood the reasons for undertaking the exercise, effectively self-monitored and engaged with pro-active follow-up. An early and appreciable response to therapy was also a key factor influencing continuing engagement with the exercise programme.

Conclusion

With certain caveats including the need to recognise and respond to individual characteristics, implement effective knowledge translation strategies and the need to engage with appropriately timed pro-active follow-up, the potential to implement programmes of self-managed loaded exercise for patients with rotator cuff tendinopathy in the real-world and in further research studies appears feasible but challenging.     

Endoscopic Achilles tenodesis: a surgical alternative for chronic insertional tendinopathy

This report describes an endoscopic approach for visualization and repair of heel structures potentially involved in patients presenting chronic calcaneal tendon insertion pain. Tendon–bone junction separation allows enthesis debridement. Tenodesis with a knotless absorbable anchor completes this minimally invasive surgical procedure for chronic insertional Achilles tendinopathy.     

关节镜下肌腱切断固定于滑车远端治疗肱二头肌长头肌腱病损合并肩袖损伤

目的:探讨通过肩关节镜将肌腱切断固定于滑车远端治疗长头腱病损合并肩袖损伤的手术方法及临床疗效。方法:自2015年6月至2016年11月,对23例患有肱二头肌长头肌腱病损合并有肩袖损伤的患者,行关节镜下肌腱切断固定于滑车远端及肩袖修补术,其中男9例,女14例;年龄44～71(56.38±5.74)岁;左肩3例,右肩20例。分别于术前及术后3、6和12个月随访时采用Constant-Murley肩关节评分、VAS评分对肩关节功能进行评价,并比较肩关节活动度改善情况。结果:23例患者获得随访,时间12～18(15.37±4.82)个月。患侧肩关节无明显疼痛,肱二头肌肉外形轮廓和肌力与术前比较无明显的变化,肩关节活动度及肌力基本恢复到健侧水平。Constant-Murley评分术后3、6、12个月分别为67.47±12.19、74.82±13.26、93.47±10.19,与术前39.62±12.39比较均显著提高。根据Constant-Murley评分,优18例,良4例,差1例。术前VAS评分(6.85±2.14)与术后12个月(0.36±0.54)比较差异有统计学意义。术后12个月肩关节前屈(163.55±15.24)°、外展(164.37±14.46)°较术前肩关节前屈(75.52±6.31)°、外展(84.36±13.36)°显著提高(P0.001)。结论:肩关节镜下将肌腱切断固定于滑车远端治疗长头腱病损合并肩袖损伤的临床治疗效果满意,能缓解肩关节疼痛,恢复肩关节功能,不损伤肱二头肌的外形及肌力。     

超声引导下富血小板血浆注射治疗肌腱训练伤的应用研究

目的探讨超声引导下自体血提取富血小板血浆（PRP）注射治疗军事训练肌腱伤的效果。 方法选取2018年3月至2019年6月于解放军总医院海南医院就诊的军事训练所致肌腱损伤患者共41例。常规超声检查并评估病变肌腱后，在超声引导下经皮穿刺对肌腱损伤灶多点注射自体PRP。观察并比较治疗前与治疗后2周、1个月的常规超声表现、肢体活动度和疼痛评分。 结果41例患者注射PRP剂量为（2.85±0.49）ml。治疗后超声表现为肌腱厚度变小、形态结构改善、周围血管增生减少。患者自觉疼痛症状减轻，治疗后2周、1个月的疼痛评分（4.66±2.43、2.71±1.39）与治疗前（6.53±2.78）相比明显降低，差异有统计学意义（治疗后2周vs治疗前：P=0.008，治疗后1个月vs治疗前：P=0.006）。治疗后患肢的活动幅度增大，治疗后2周、1个月的关节功能评分（72.33±3.34、79.70±5.09）与治疗前（61.84±9.98）相比明显增加，差异有统计学意义（治疗后2周vs治疗前：P=0.006，治疗后1个月vs治疗前：P=0.004）。 结论超声引导自体PRP治疗军事训练所致的肌腱伤安全、有效，值得临床推广应用。     

神经阻滞疗法应用于慢性疼痛性肌腱炎48例临床观察

【目的】探讨神经阻滞疗法应用于慢性疼痛性肌腱炎的临床效果。【方法】选取本院2010年12月至2012年12月收治的慢性疼痛性肌腱炎患者96例作为研究对象,将患者按照数字随机的方法分为观察组和对照组,每组各48例。其中对照组采用常规的处理方法,包括休息、冷敷和使用布洛芬进行对症处理,观察组在对照组的基础上采用神经阻滞疗法进行相关治疗。观察两组患者治疗效果及不良反应情况,以及采用疼痛评分量表（VAS）对患者治疗后疼痛情况进行评分,并对患者治疗期间生活质量进行对比分析。【结果】观察组显效24例,有效20例,无效4例,总有效率为91．67％,对照组显效14例,有效18例,无效16例,总有效率为66．67％,两组总有效率比较差异具有统计学意义（ P ＜0．05）。但对照组患者治疗过程中出现12例胃肠道反应,4例皮肤瘙痒,其他不良反应7例,不良反应发生率为47．92％,观察组在未出现不良情况（ P ＜0．05）。治疗后观察组VAS评分显著低于对照组,两组相比（2．13±0．79vs4．03±0．68）,差异具有统计学意义（ P ＜0．05）。且采用神经阻滞疗法,患者的生活质量明显改善,其心理指数、情感指数和健康指数与对照组比较,差异且有统计学意义（ P ＜0．05）。【结论】神经阻滞疗法对慢性疼痛性肌腱炎治疗效果显著,患者疼痛程度减轻,且提高了患者的生活质量。     

Evaluation of sonoelastography in Achilles tendon of healthy volunteers and patients with symptomatic Achilles tendon

Aim and objectives: To assess the role of SEL in evaluation of Achilles tendon. Methodology: This study included 40 healthy volunteers and 40 patients with symptomatic Achilles tendon. All patients were examined by conventional B-mode ultrasound, sonoelastography and MRI. Results: Achilles tendons of the volunteers were characterized by hard texture with higher strain ratios than those of the patients with Achilles tendinopathy. No significant differences could be detected between SR of male and female volunteers yet significant differences could be detected in the volunteer group above and below forty being lower with softer tendon properties in the group above forty with a cut-off value of ≤1.84 between healthy and diseased group. Sonoelastography had the sensitivity of 89.1% and specificity of 96.1% for diagnosis of tendinopathy with results superior to those of conventional B-mode ultrasonography. Conclusion: SEL is a reliable tool in the evaluation of Achilles tendinopathy with sensitivity and specificity superior to B-mode US. Strain ratio provides excellent non-invasive diagnostic data adds strongly in more objective evaluation of Achilles tendon properties.     

外源性前列腺素E2对兔跟腱胶原含量的影响

目的肌腱损伤后周围前列腺素E2(prostaglandin E2,PGE2)及体外牵伸载荷条件下肌腱细胞产生的PGE2均升高,通过观察外源性PGE2对兔跟腱胶原含量的影响,探讨其与肌腱病发生的关系。方法取健康3～4月龄日本短耳兔24只,体重2.0～2.5 kg,雌雄不限;根据PGE2注射剂量不同随机分为两组(n=12):低剂量组(50 ng)和高剂量组(500 ng)。随机选择一侧后肢跟腱中部经皮注射0.2 mL对应剂量PGE2,对侧对应部位注射0.2 mL生理盐水作为对照,每周注射1次至处死。注射4、8周后两组各处死6只实验动物,大体观察跟腱情况后,取双侧跟腱HE染色观察细胞结构、基质形态,苦味酸-天狼星红染色偏振光显微镜下观察肌腱组织的胶原变化并定量分析Ⅰ、Ⅲ型胶原含量,透射电镜观测胶原纤维密度及直径。结果 HE染色示两组实验侧均出现胶原纤维结构破坏。苦味酸-天狼星红染色示4、8周时两组实验侧Ⅲ型胶原纤维均较对照侧增加,Ⅰ型胶原减少(P<0.05);与低剂量组比较,高剂量组实验侧Ⅲ型胶原纤维增加,Ⅰ型胶原减少,Ⅲ/Ⅰ型胶原比值增高(P<0.05)。透射电镜示两组4、8周时实验侧单位面积内总胶原纤维横截面积所占百分比均较对照侧降低,直径>100 nm的纤维比例均较对照侧降低,直径<100 nm的纤维比例均增加(P<0.05);与低剂量组比较,高剂量组实验侧单位面积内总胶原纤维横截面积所占百分比更低,直径>100 nm的纤维比例均明显降低,直径<100 nm的比例明显增加(P<0.05)。结论重复注射PGE2能导致兔跟腱Ⅰ型胶原减少,Ⅲ型胶原增多,Ⅰ/Ⅲ型胶原比例倒置,单位面积总胶原纤维密度降低,直径变细,可能与肌腱病发生相关。