肩锁关节及关节盘的相关解剖学特征

背景:目前临床上多数认为,肩部疾病如肩锁关节脱位、肩峰下撞击综合征等与肩锁关节的解剖形态有很大的关系,但国内外文献很少有关于肩锁关节的形态学数据支持,特别对于肩锁关节关节盘的解剖学研究。同时肩锁关节属于微动关节,参与肩关节的联合运动,现临床上有关肩锁关节脱位的手术方式繁多,较流行的手术方式多为刚性固定,并未保留其微动特点以及锁骨和肩胛骨的运动特点,其中关节盘的取舍目前国内外并无大样本多中心对照研究。目的:对肩锁关节及关节盘行相关解剖学研究,用于更好地指导肩部疾病的诊治。方法:对58具肩锁关节尸体标本(同济大学解剖教研室提供)进行形态学及组织结构研究,共获得58个肩峰、58个锁骨和36个关节盘(包括完全型和不完全型)。采用BIGLIANI肩峰形态分型、DEPALMA锁骨形态分型、EMURA肩锁关节盘分型,获得各肩峰与锁骨组合下关节盘出现的频率并行苏木精-伊红染色(上海市普陀区人民医院提供)。结果与结论:①在58个肩锁关节尸体中,肩锁关节盘type1型共15例,所占比例最高,为25.9%;type3a型共4例,所占比例最少,为6.9%。②Ⅰ型肩峰32个,所占比例最高,为55.2%;Ⅲ型肩峰3个,所占比例最低,为5.2%。③Ⅰ型锁骨27个,所占比例最高,为46.6%;Ⅲ型锁骨9个,所占比例最低,为15.5%。④以Ⅰ型及Ⅱ型肩峰与Ⅰ型锁骨组合所占比例较大,分别为24.1%和22.4%,以Ⅲ型肩峰对Ⅰ型锁骨所占比例最小,为0%。⑤而在Ⅰ型肩峰与Ⅰ型锁骨组合下type1型和type2b型关节盘所占比例最大,分别为35.7%和28.6%;Ⅱ型肩峰与Ⅰ型锁骨组合下type2a型和type1型关节盘所占比例最大,分别为38.5%和23.1%。⑥苏木精-伊红染色在组织切片中可以发现,关节盘中的细胞外基质清晰可辨,细胞形态饱满,含有丰富的细胞质,提示为软骨细胞,即形成纤维软骨的主要成分。此外,从关节囊顶端和底端两侧可见部分骨膜纤维层移行至关节盘内侧,考虑共同组成关节盘结构,即关节盘由近骨面的软骨细胞及远离骨面的纤维层共同构成。     

超声介入治疗肩峰下撞击综合征疗效对比分析

目的 研究超声介入治疗肩峰下撞击综合征(SIS)患者的疗效及复发危险因素。 方法 回顾性分析92例SIS患者的临床资料,根据其超声表现进行分型,并分别采用超声引导肩峰下滑囊注射(单纯注射组)以及超声引导肩袖肌腱松解术联合肩峰下滑囊注射(联合治疗组),比较两组术后1周及1,3,6月的疗效差别。 结果两组患者术后1周及1,3,6月的VAS,CMS和OSS评分较术前均有不同程度改善,但术后6月均有复发病例,单纯注射组及联合治疗组的晚期复发率分别为34.9%及10.2%,两组差别有统计学意义(P<0.05)。 结论 对于SIS的患者,采用超声引导下介入治疗有确切的临床疗效; 但对于超声诊断为SIS 2型的患者,应采用超声引导肩袖肌腱松解术联合肩峰下滑囊注射,以降低晚期复发风险。     

Preoperative tendon retraction,not smoking,is a risk factor for failure with continuity after rotator cuff repair

BackgroundSmoking is a poor prognostic factor for healing after rotator cuff repair and is associated with inferior results. We hypothesized that smokers would have higher recurrent tear rates and more postoperative myotendinous junction (MTJ) retraction in healed repairs than nonsmokers three months postoperatively.MethodsRotator cuff repairs (RCRs) were retrospectively reviewed over a 2-year period. Patients underwent magnetic resonance imaging (MRI) within 6 months prior to surgery and again at 3 months postoperatively. Seventy-nine patients were included and stratified by smokers versus nonsmokers. Baseline patient demographics, tear characteristics, and surgical factors were collected. Preoperative and postoperative MRIs were assessed to quantify the MTJ position and to establish the recurrent tear rate.ResultsFor the total cohort (nonsmokers, n = 56; smokers, n = 23), significant differences in age, race, and traumatic onset of injury existed between groups. There were no significant differences in recurrent tear between smokers (26%) and nonsmokers (27%), but nonsmokers were more satisfied. For patients with healed RCRs (nonsmokers, n = 41; smokers, n = 17), there were significant differences in race. On univariate analysis, nonsmokers had a significantly more lateral MTJ postoperatively (P = 0.05). On multivariable regression analysis, medialized postoperative MTJ position in healed cuffs was driven only by greater preoperative rotator cuff retraction preoperatively. There were no significant differences in MTJ position based on smoking status for patients with healed RCRs.ConclusionSmoking does not appear to be an independent risk factor for postoperative MTJ retraction in healed RCRs, also known as failure in continuity. Preoperative tear size and retraction play the biggest roles in predicting postoperative MTJ position, regardless of smoking status. There are no significant differences in patient-reported outcomes for patients with healed RCRs, but nonsmokers had more satisfaction following RCR in the total cohort.Level of EvidenceLevel III; Retrospective cohort study; Diagnostic study     

新型锁骨瓣移位术对肱骨头缺血性坏死及近端骨不连的实验研究

AIM:To provide a new way of operation for repairing fracture necrosis of proximal humerrus. METHODS:Observing the course,branches and distributions of thoracoacromia artery on 40 sides of adult cadaveric.RESULTS:(1)Sending off 3 to 5 periosteal branches with diameter of 0.3 to 0.5 mm along the acromial branch of thoracoacromial,which distributed at the middle outboard and formed the part of acromial artery net.The acromial length was (5.1± 0.5) cm with diameter of (1.2± 0.2) mm.(2)Sending off 1 to 3 periosteal branches with diameter of (0.2 to 0.5) mm from the clavicular branches of thoracoactomial artery,which distributes at the inside part one second.The length was (2.0± 0.1) cm with diameter of (1.2± 0.2) mm. CONCLUSION: A new operation can be designed for repairing fracture necrosis of proximal humerus by transposing clavicle periosteal(bone) flap with the acromial branch of toracoacromial artery.     

锁骨钩钢板治疗肩锁关节脱位和锁骨肩峰端骨折

目的：探讨应用AO锁骨钩钢板治疗TossyⅢ型的肩锁关节脱位和NeerⅡ型的锁骨肩峰端骨折的疗效。方法：从2001年2月-2003年9月，应用A0锁骨钩钢板及韧带修复技术，治疗22例肩锁关节脱位或锁骨肩峰端骨折患。损伤时间除2例为陈旧性损伤，其它均为新鲜损伤：损伤原因，车祸19例，牵拉伤3例。其中肩锁关节脱位12例，按Tossy分型，Ⅱ型7例，Ⅲ型5例；锁骨肩峰端骨折10例，按Neer分型，Ⅱ型6例，Ⅲ型4例。取锁骨远端向肩峰端弧形偏后切口，行切开复位AO锁骨钩钢板内固定。术后早期行肩关节CPM功能锻炼。结果：随访3～16个月，平均9个月。术后10周均完全恢复术前日常工作，参照Kadsson肩锁关节修复术后疗效三级评定：A级19例，B级1例，C级0(有2例合并神经损伤未计入)；优良率100％。术后均无感染。复查X线无内固定松动、断裂。无再脱位，骨折端愈合良好结论：AO锁骨钩钢板治疗TossyⅢ肩锁关节脱位和NeerⅡ型锁骨肩峰端骨折，具有创伤小，疗效好，安全性高的特点。     

Pseudarthrosis of the acromion - a differential diagnosis in anterolateral shoulder pain

A case of longstanding posttraumatic anterolateral shoulder pain in a 25-year-old woman is presented. It was primarily unsuccessfully handled as impingement syndrome but turned out to be caused by pseudarthrosis of the acromion. The abnormality was not apparent on plain X-ray film. The suspicion was raised after scintigraphy, which showed increased density in the acromion. The diagnosis was made by computerized tomography and confirmed and treated successfully surgically.