关节镜下缝线桥技术治疗巨大肩袖撕裂的临床研究

doi:10.3877/cma.j.issn.1674-134X.2018.05.002

目的

探讨关节镜下缝线桥技术缝合巨大肩袖撕裂的临床疗效。

方法

回顾分析2014年6月至2016年6月在广州市正骨医院收治并取得完整随访的38例采用关节镜下缝线桥技术修复的巨大肩袖撕裂患者的临床资料，排除无法取得随访、依从性差的患者，分析术前X线片、MRI检查，了解肩袖撕裂口大小、肩袖回缩程度、肌肉萎缩及脂肪浸润情况，应用SPSS 17.0统计学软件配对t检验对术前与术后半年随访时视觉模拟评分系统(VAS)评分和美国加州大学肩关节评分系统(UCLA)评分进行比较。

结果

本组患者38例，男23例，女15例，平均年龄(66±6)岁，所有患者均获半年以上的随访，随访时间(12±5)月。所有患者在关节镜下均发现有2条或以上的肌腱撕裂，关节镜下见15例患者冈上肌腱和冈下肌腱撕裂，8例冈上肌、冈下肌和小圆肌腱撕裂，10例冈上肌腱、冈下肌腱撕裂和肩胛下肌腱撕裂，5例冈上肌腱和肩胛下肌腱撕裂。术前VAS评分为(6.7±1.6)分，术后6月随访时为(2.4±1.7)分，术前与术后6月随访的VAS评分差异均有统计学意义(t ＝10.123，P<0.01)；术前UCLA评分为(7.9±1.2)分，术后6月随访时为(23.4±5.1)分，术前与术后6月随访的UCLA评分差异均有统计学意义(t ＝－18.979，P<0.01)；术后的UCLA、VAS评分均明显升高。术后半年MR检查结果，5例患者出现小型再撕裂，裂口均<3 cm，术后再撕裂患者与无再撕裂患者的VAS评分和UCLA肩关节评分无明显统计学差异(P>0.05)。

结论

关节镜下缝线桥技术修复巨大肩袖撕裂取得较好的短期疗效，是1种合理、有效的治疗方法。

关键词: 肩关节, 关节镜, 回旋套, 缝合锚

Objective

To investigate the clinical curative effect of the arthroscopic suture bridge technique in treating massive rotator cuff tear.

Methods

Between June 2014 and June 2016, except for those who were not able to follow up or poor compliance, 38 patients with massive rotator cuff tear were treated in Guangzhou Orthopedic Hospital. The size of the tear and the quality of the tendon were evaluated by the X-ray and MRI that were taken before surgery. Shoulder function was evaluated according to the University of California Los Angeles scoring (UCLA) and visual analogue scale (VAS). The VAS and UCLA before and after the operation were compared by paired t test with SPSS 17.0 statistical software.

Results

There were 38 cases collected, including 23 males and 15 females with a mean age of (66±6) years. All the 38 patients were followed up for at least six months with a mean time of (12±5) months. All the patients had two tendons involved in the massive rotator cuff tear. Fifteen patients were the supraspinatus and infraspinatus tendons. Eight patients were the supraspinatus, infraspinatus and teres minor tendons. Ten patients were the supraspinatus, infraspinatus and subscapular tendons. Five patients were the supraspinatus and subscapular tendons. The preoperative VAS score was (6.7±1.6) and significantly decreased to (2.4±1.7) six months after the operation (t=10.123, P<0.01). The preoperative UCLA score was (7.9±1.2) and significantly increased to (23.4±5.1) six months after the operation (t=-18.979, P<0.01). There were five pantients with rotator cuff retear when reviewed the MRI six months postoperation. The retear size was less than 3 cm. The VAS score and UCLA score of the reccurence patients showed no obvious difference with non-reccurence ones.

Conclusion

The arthroscopic suture bridge technique in treating massive rotator cuff tear can achieve a favorable short-term clinical curative effect, which seems to be a reasonable and effective therapy method.

Key words: Shoulder joint, Arthroscope, Rotator cuff, Suture anchors

图1 肩袖撕裂累及肌腱的情况

表1 术前与术后6月随访时VAS和UCLA评分比较[n＝38，(±s)]

类别	VAS评分	UCLA评分
术前	6.7±1.6	7.9±1.2
术后6月	2.4±1.7	23.4±5.1
t值	10.123	－18.979
P值	<0.01	<0.01

表1 术前与术后6月随访时VAS和UCLA评分比较[n＝38，(±s)]

类别	VAS评分	UCLA评分
术前	6.7±1.6	7.9±1.2
术后6月	2.4±1.7	23.4±5.1
t值	10.123	－18.979
P值	<0.01	<0.01

表2 术前与术后6月随访时患侧肩关节活动度的比较[n＝38, °，(±s)]

?	被动前屈	主动前屈	被动外展	主动外展	中立位外被动旋	中立位主动外旋
术前	87±34.9	47±16	67±24	37±12	12±7	7±4
术后6月	142±24.7	116±22	126±35	101±30	25±10	14±9
t值	－7.894	－13.748	－7.526	－11.335	－6.517	－4.286
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01

表2 术前与术后6月随访时患侧肩关节活动度的比较[n＝38, °，(±s)]

?	被动前屈	主动前屈	被动外展	主动外展	中立位外被动旋	中立位主动外旋
术前	87±34.9	47±16	67±24	37±12	12±7	7±4
术后6月	142±24.7	116±22	126±35	101±30	25±10	14±9
t值	－7.894	－13.748	－7.526	－11.335	－6.517	－4.286
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01

表3 术后6月随访时再撕裂与无再撕裂患者VAS和UCLA评分比较(±s，分)

?	例数	VAS评分	UCLA评分
术后再撕裂	5	2.2±0.8	24.2±2.0
术后无再撕裂	33	2.3±1.7	23.2±5.4
t值	?	－0.172	0.401
P值	?	>0.05	>0.05

表3 术后6月随访时再撕裂与无再撕裂患者VAS和UCLA评分比较(±s，分)

?	例数	VAS评分	UCLA评分
术后再撕裂	5	2.2±0.8	24.2±2.0
术后无再撕裂	33	2.3±1.7	23.2±5.4
t值	?	－0.172	0.401
P值	?	>0.05	>0.05

图3 右肩关节术前斜矢状位MRI，示肩袖肌肉脂肪浸润

图4 术中关节镜下图像。图A为关节镜下见巨大肩袖撕裂，肩峰下间隙与盂肱关节相通；图B为关节镜下内排带线锚钉分别过线、打结；图C为关节镜下置入外排钉；图D为关节镜下双排锚钉固定后

图5 右肩关节术后斜冠状位MRI，示肩袖组织缝合于足印区，肌腱连续性、张力恢复

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Clinical research of massive rotator cuff tear treated by arthroscopic suture bridge technique

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Clinical research of massive rotator cuff tear treated by arthroscopic suture bridge technique