肩峰撞击征合并肩袖损伤的关节镜下治疗

目的分析关节镜下肩峰减压成形术及肩袖修复的临床效果。方法自2005年初始，我院对11例肩峰撞击征并肩袖损伤行关节镜下肩峰减压成形术，部分行肩袖修复术，其中男5例，女6例，年龄21～57岁，平均40岁，8例无外伤史，3例有外伤史。患者均有肩关节疼痛、肌肉萎缩、活动受限、上举困难、疼痛反射弧阳性、撞击注射试验阳性，Neer征阳性；5例有患侧卧位痛。X线提示肱骨大结节骨赘9例和肩峰骨刺2例，A—H间隙距离变小，小于1．0cm8例、小于0．5cm3例。MRI扫描均示肩袖结构T1为强信号，如关节积液T2相强信号。关节镜检查可见肩袖大撕裂（30～50mm）4例，中撕裂（10～30mm）5例，小撕裂（小于10mm）2例。行关节镜下肩峰下减压成形术，其中8例行缝合锚钉肩袖修复术。分别在术前及最终随访时采用美国肩肘外科医师（American Shoulder and Elbow Surgeons，ASES）和Constant—Murley评分进行功能评估。结果术后随访22．5个月（13～34个月）。患者手术前平均ASES评分为62．4分（47～76分），VAS评分平均为5．8分（3～8分），Constant—Murley评分为66．7分（42～79分），平均外展35．5°（30°～50°），平均外旋为28．4°（0°～45°）；终末随访时平均ASES评分为94．6分（79～100分），其中VAS评分为0．6分（0～2分），Constant—Murley评分为93．6分（77～100分），肩关节外展160°（80°～180°），平均外旋30．2°（20°～55°）。8例患者冈上、下肌萎缩恢复，ASES评分优良率为81．8％，Constant—Murley评分优良率为90．9％。术后各项评分均存在显著性差异（ASES：P〈0．001，t一12．324；VAS：P〈0．001，t=14．765；外展：P〈0．001，t=15．236；外旋：P〈0．01，t=7．967；Constant—Murley：P〈0.001，t=16．647）。结论a）肩峰撞击征、肩袖损伤是关节镜手术的适应证；b）对肩袖单纯修复是不够的，必须同时解决撞击因素；c）不宜将肩峰切除过多，以免发生骨折；d）尽管镜下手术技术难度较大，但镜下视野广、创伤小、术后及早进行功能锻炼，功能可以得到很好恢复，故镜下进行肩袖损伤、肩峰成形等手术应值得提倡。

Arthroscopic Acromioplasy and Rotator Cuff Repair for the Treatment of Subacromial Impingement and Rotator Cuff Injury

Objective To evaluate the results of arthroscopic acromiaoplasty and rotator cuff repair. Methods Since 2005, 11 patients of rotator cuff injury and subacromial impingement underwent acromiaoplasty, partly with arthroscopic rotator cuff repair,in which 5 men, 6 women,aged 21- 57 years old,an average of 40,8 eases of nontraumatic history,and 3 eases of traumatic history. Patients had the symptoms of shoulder pain,muscle atrophy,and restricted activities,pain arc positive ,impact injection test positive and Neer sign positive. 5 cases have affected lateral position pain. X-ray showed 9 cases of osteophyte on the Greater tuberosity of humerus, 2 cases of acromial spur and smaller AH gap distance, 〈 1.0 cm in 8 cases, 〈0. 5 cm in 3 cases. MRI scans showed high signal in the rotator cuff in T1 ,joint fluid with high signals in T2.4 cases of massive large rotator cuff tear（30-50 ram）, 5 cases of middle tear （10- 30 mm）, 2 cases of a small tear （〈10 ram）can be seen under the scope： They are treated with arthroscopic acromiaoplasty. 8 eases of rotator cuff tears were repaired with suture anchor. In preoperative and final follow-up ,shoulder and elbow score Medical Association （ASES）,Constant-Mureley score were use for functional evaluation. Results The follow-up of 22.5 months（13 to 34）months. Pre-operative average ASES score 62.4（47-76） ,VAS score was average 5.8（3-8）,Constant-Murley score was 66.7（42--79）,the average abduction 35.5 degrees（30 degrees-50 degrees） ,external rotation an average of 28, 4 degrees（0 degrees to 45 degrees）;The ASES score in final follow-up was an average 94.6（79 100）,VAS score 0.6（0-2）,Constant-Murley score was 93.6（77-100）,the shoulder abduction was average 160 degrees （80 - 180）, the external rotation was average 30. 2 degrees （20 - 55）. The atrophied supraspinatus muscle and infraspinatus muscle resumed in 8 patients. The excellent and good rate of ASES score was 82.8% ,the excellent and good rate of Constant-Murley score was 91.2%. Post-operative scores were significantly different （ASES ：P〈0. 001 ,t = 12. 324 ; VAS ： P〈0. 001, t = 14. 765 ; outreach ： P〈0. 001, t = 15. 236 ;external rotation ： P 〈0.01 ,t = 7. 967 ;Constant-Murtey ：P〈0. 001 ,t = 16. 647）compared with the pre-operative ones. Conclusion 1. Subacromial impingement,rotator cuff injury is the indications of arthroscopic surgery. 2. Isolated Rotator cuff repair is not enough;the impingement factor is required to be addressed. 3. Acromion will not be resected too much in order to avoid fractures. 4. Although the endoscopic surgical technique is difficult,but they have advantages of wide arthroscopic vision,less trauma,and exercise as soon as possible and restore function well. Hence,arthroscopic rotator cuff repair and acromioplasy shouid be worth mentioning.