两种不同术式治疗合并肩胛上神经损伤的巨大肩袖撕裂后神经恢复的临床对比研究

目的对比传统双排修复术与阔筋膜移植术两种术式治疗合并肩胛上神经损伤的巨大肩袖撕裂患者的功能恢复情况。 方法回顾性分析2013年1月至2018年1月因巨大肩袖撕裂损伤于本院行关节镜肩袖损伤修复术患者20例,其中传统双排缝合组（A组）10例，阔筋膜移植组（B组）10例。所有患者术前均经肩关节MRI及肌电图诊断为巨大肩袖损伤合并神经损伤。术后1个月、6个月定期随访患者。比较手术前后两组患者的疼痛视觉模拟评分（visual analogue scale，VAS）、美国加州大学洛杉矶分校（University of California at Los Angeles，UCLA）评分、Constant-Murely肩关节功能评分的变化情况。术后6个月复查肌电图及MRI评估肩袖愈合及神经恢复情况。 结果20例患者均获得随访，随访时间6~18个月。术后6个月A组VAS评分从术前（7.4±0.8）分下降到（2.3±1.7）分，差异有统计学意义（P<0.01），UCLA评分从术前（11.5±1.4）分上升到（28.3±5.8）分，差异有统计学意义（P<0.01），Constant-Murely评分从术前（45.6±6.2）分上升到（79.0±11.7）分，差异有统计学意义（P<0.01）。B组VAS评分从术前（7.9±0.6）分下降到（2.7±1.8）分，差异有统计学意义（P<0.01），UCLA评分从术前（10.1±1.4）分上升到（26.9±6.9）分，差异有统计学意义（P<0.01），Constant-Murely评分从术前（39.0±3.4）分上升到（72.9±9.4）分，差异有统计学意义（P<0.01）。术后6个月时两组患者VAS评分比较差异无统计学意义（P>0.05），两组患者UCLA评分比较差异无统计学意义（P>0.05），两组患者Constant-Murely评分比较差异无统计学意义（P>0.05）。术后6个月复查肌电图，A组患者无肩胛上神经损伤，B组患者中有5例患者仍有肩胛上神经损伤（P<0.01）。 结论关节镜下巨大肩袖损伤传统双排修复术及阔筋膜移植术均能改善患者肩关节功能，双排缝合对于肩胛上神经功能恢复的短期效果要比阔筋膜移植组好，但再撕裂可能性大。

Clinical contrast study of nerve recovery after two different surgical methods for treatment of massiverotator cuff tear with suprascapular nerve injury

BackgroundIn recent years, the incidence of rotator cuff injury has been increasing in population. Rotator cuff injury is not only the damage of tendon, but also often associated with different levels of nerve damage.Among them, the suprascapular nerve injury is the most commonone . The suprascapular nerve runs on the fascia between supraspinatus and infraspinatus.The severe retraction and fat infiltration of supraspinatus and infraspinatuscaused by massive rotator cuff tear will pull the suprascapular nerve and result in its dysfunction.The symptomsaremanifested as the posterolateral pain of shoulder joint which radiates toward the back of neck andarm and the disability of shoulder abduction and external rotation. Clinically, the disease can be easily missed.The incidence of massive rotator cuff injury accounts for approximately 10% to 40% of all rotator cuff injuries. According to the size of tear, Cofield divided rotator cuff injury intofour types:small tear (<1 cm) , medium tear (1-3 cm) , large tear (3-5 cm) and massivetear (>5 cm) . However, 30% of rotator cuff injuries are considered to be irreparable due to massive tear, atrophy of rotator cuff and fat infiltration, and the retear of 80% of patientis massive rotator cuff tear.The cause of suprascapular nerve damage after massive rotator cuff injury is unclear, which may be related to the retraction of rotator cuff and in turn the traction of suprascapular nerve around spinoglenoid notch.Some studies pointed out that the suprascapular nerve function can be restored with simple rotator cuff repair. For massive rotator cuff injury, there are traditional double-row repair and suture bridge technology.Transposition of latissimus dorsi muscle, transposition of deltoid muscle, patch repair, reverse shoulder arthroplasty,etc.have good efficacy in the treatment of massive rotator cuff injury with severe retraction and fat infiltration. However, there is a lack of study on the recovery of nerve damage.Objective To investigate the effects of traditional double-row repair and fascia lata transposition on the functional recovery of the patient with massive rotator cuff tear with suprascapular nerve injury. MethodsFrom January 2013 to January 2018, a total of 20 patients with massive rotator cuff tear received arthroscopic rotator cuff repair surgery in our hospital, and the data were retrospectively analyzed. There were 10 cases in traditional double-row repair group (group A) and 10 cases in fascia lata transposition group (group B) . All patients were diagnosed as massive rotator cuff injury with suprascapular nerve injury under MRI and electromyogram.The postoperative follow ups were conducted in the 1st and 6th months. Visual analogue scale (VAS) , University of California at Los Angeles (UCLA) scoring system and Constant-Murley scoring system were applied for comparison between the two groups before and 6 months after operation.The conditions of rotator cuff healing and nerve recovery were assessed by MRI and electromyogram 6 months after operation. ResultsTwenty patients were followed up for 6 months after surgery, and the average follow up time ranged from 6 to 18 months. Six months after operation: the VAS score of group A decreased from preoperative (7.4±0.8) points to postoperative (2.3±1.7) points with statistical difference (P<0.01) ; the UCLA score of group A increased from preoperative (11.5±1.4) points to postoperative (28.3±5.8) points with statistical difference (P<0.01) ; the Constant-Murley score of group A increased from preoperative (45.6±6.2) points to postoperative (79.0±11.7) points with statistical difference (P<0.01) ; the VAS score of group B decreased from preoperative (7.9±0.6) points to postoperative (2.7±1.8) points with statistical difference (P<0.01) ; the UCLA score of group B increased from preoperative (10.1±1.4) points to postoperative (26.9±6.9) points with statistical difference (P<0.01) ; the Constant-Murley score of group B increased from preoperative (39.0±3.4) points to postoperative (72.9±9.4) points with statistical difference (P<0.01) .Electromyogram was reviewed 6 months after operation.While there was no suprascapular nerve injury in the group A,there were 5 cases of suprascapular nerveinjury in the group B (P<0.01) . ConclusionBoth the arthroscopic traditional double-row repair and the fascia lata transposition can improve shoulder function. For the patient with suprascapular nerve injury, it is believed that the traditional double-row repair can better restore suprascapular nerve function than the fascia lata transposition does.However, the risk of retearmay be high.