反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

doi:10.3877/cma.j.issn.1674-134X.2020.03.002

中华关节外科杂志(电子版) ›› 2020, Vol. 14 ›› Issue (03) : 266 -273. doi: 10.3877/cma.j.issn.1674-134X.2020.03.002

所属专题：文献；

临床论著

反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

王庆¹, 黄华扬¹^,^†(

), 张涛¹, 贾震宇¹, 沈洪园¹, 区永亮¹, 孔令闯¹

^1. 510010　广州，中国人民解放军南部战区总医院骨科医院，全军创伤骨科研究所，广东省骨科矫形技术及植入材料重点实验室，全军热区创伤救治与组织修复重点实验室

收稿日期:2020-03-24 出版日期:2020-06-01
通信作者: 黄华扬
基金资助:
中国博士后科学基金(2018M643893); 广东省科技计划项目(2017B030314139); 广州市科技计划项目(201904010315)

Short-term efficacy of reverse total shoulder arthroplasty for glenohumeral osteoarthritis with massive rotator cuff tears

Qing Wang¹, Huayang Huang¹^,^†(), Tao Zhang¹, Zhenyu Jia¹, Hongyuan Shen¹, Yongliang Ou¹, Lingchuang Kong¹

^1. Department of Orthopaedic Surgery, Institute of Traumatic Orthopaedics of PLA, Guangdong Key Lab of Orthopedic Technology and Implant, Key Laboratory of Trauma & Tissue Repair of Tropical Area of PLA, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, China

Received:2020-03-24 Published:2020-06-01
Corresponding author: Huayang Huang
About author:
Corresponding author: Huang Huayang, Email: johnhzy@sina.com

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引用本文：

王庆, 黄华扬, 张涛, 贾震宇, 沈洪园, 区永亮, 孔令闯. 反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂[J/OL]. 中华关节外科杂志(电子版), 2020, 14(03): 266-273.

Qing Wang, Huayang Huang, Tao Zhang, Zhenyu Jia, Hongyuan Shen, Yongliang Ou, Lingchuang Kong. Short-term efficacy of reverse total shoulder arthroplasty for glenohumeral osteoarthritis with massive rotator cuff tears[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2020, 14(03): 266-273.

目的

探讨反式全肩关节置换术治疗盂肱关节骨关节炎合并巨大肩袖撕裂的近期临床疗效。

方法

回顾性分析2016年1月至2018年12月在南部战区总医院接受初次反式全肩关节置换术治疗的15例盂肱关节骨关节炎合并巨大肩袖撕裂患者，均有肩关节持续性疼痛、功能障碍，且三角肌无损伤具有功能；排除有臂丛或腋神经损伤以及有肩关节手术史的患者。评估其术前、术后1年的肩关节主动活动度，使用美国肩肘外科协会(ASES)肩关节评分、加州大学洛杉矶分校(UCLA)最终结果评分评价肩关节功能，分析X线及CT并发症出现情况。采用配对t检验对术前及术后的活动度和评分差异进行性分析。

结果

15例患者均顺利完成手术并获得随访，随访时间17个月(范围12～36个月)。反式全肩关节置换术后1年肩关节主动前屈(124±11)°较术前(58±18)°提高(t＝14.316，P<0.01)，外展(120±12)°较术前(58±20)°提高(t＝9.959，P<0.01)，内旋较术前改善，外旋(26±8)°较术前(25±9)°无明显变化(t＝1.598，P>0.05)，术后1年ASES评分(78±7)显著高于术前(33±8)(t＝16.487，P<0.01)；术后1年UCLA评分(31±4)显著高于术前(15±3)(t＝12.826，P<0.01)。

结论

RTSA能够有效治疗盂肱关节骨关节炎合并巨大肩袖撕裂，取得了良好的早期临床效果，但术后肩关节外旋无明显改善，术前需评价小圆肌情况以确定相关治疗方案。

关键词: 肩关节, 骨关节炎, 回旋套, 关节成形术

Objective

To investigate the short-term clinical efficacy of reverse total shoulder arthroplasty (RTSA) in the treatment of glenohumeral osteoarthritis(GHOA)with massive rotator cuff tears (MRCT).

Methods

A retrospective analysis was performed on 15 glenohumeral osteoarthritis patients complicated with massive rotator cuff tears underwent primary reverse total shoulder arthroplasty from January 2016 to December 2018 at General Hospital of Southern Theater Command. All the patients had persistent shoulder pain, dysfunction, and no damage to the deltoid muscle. The active range of motion (ROM) of shoulder was evaluated preoperatively and postoperatively (six months and one year). American Association of Shoulder and Elbow Surgery(ASES) shoulder score and University Of California at Los Angeles(UCLA) score were used to evaluate shoulder function. The X-ray and CT scan were used to assess the prevalence of surgery-related complications. ROM and evaluation scores were analyzed by t test.

Results

All 15 patients completed the operation successfully and were followed up for 17 months (range 12~36 months). one year after reverse total shoulder arthroplasty, active shoulder elevation(124±11)°was higher than preoperative (58±18)°(t=14.316, P<0.01), abduction(120±12)° was higher than preoperative(58±20)°(t=9.959, P<0.01), and internal rotation was better than preoperative. But there was no significant change in the active level of external rotation postoperative(26±8)° compared with preoperative(25±9)° (t=1.598, P>0.05). The ASES score(78±7)postoperative was significantly higher than that preoperative (33±8)(t=16.487, P<0.01), and the UCLA score postoperative (31±4) was significantly higher than that preoperative(15±3)(t=12.826, P<0.01).

Conclusions

GHOA with MRCT can be effectively treated with RTSA, which has achieved good early clinical results. However, there is no significant improvement in shoulder external rotation after surgery. It is necessary to evaluate the condition ofteres minor preoperatively.

Key words: Shoulder joint, Osteoarthritis, Rotator cuff, Arthroplasty

图1 RTSA(反式全肩关节置换术)手术示意图。图A肩关节前方入路示意图；图B肱骨后倾截骨；图C肱骨扩髓，安装肱骨假体；图D定位肩胛盂中心钻入导针；图E套管钻钻孔；图F基座扩髓器磨挫关节盂至下方出血；图G安装基座和球头；图H安装好反式全肩关节假体；图I反式全肩关节置换术后肩关节正常上举

图2 RTSA(反式全肩关节置换术)手术流程。图A为肱骨近端截骨；图B为磨挫关节盂；图C为安装肩胛盂基座；图D为安装盂球和肱骨假体；图E为使用试模确定聚乙烯衬垫型号；图F为安装好反式全肩关节假体(此图为另一患者)

表1 RTSA手术前后肩关节活动度和评分(±s)

时间	例数	活动度(°)			ASES评分			UCLA评分
时间	例数	前屈	外展	外旋	疼痛	日常生活	总分	UCLA评分
术前	15	58±18	58±20	25±9	17±5	17±5	33±8	15±3
术后1年	15	124±11	120±12	26±8	43±4	35±5	78±7	31±4
t值	?	14.316	9.959	1.598	15.565	11.026	16.487	12.826
P值	?	<0.01	<0.01	>0.05	<0.01	<0.01	<0.01	<0.01

表1 RTSA手术前后肩关节活动度和评分(±s)

时间	例数	活动度(°)			ASES评分			UCLA评分
时间	例数	前屈	外展	外旋	疼痛	日常生活	总分	UCLA评分
术前	15	58±18	58±20	25±9	17±5	17±5	33±8	15±3
术后1年	15	124±11	120±12	26±8	43±4	35±5	78±7	31±4
t值	?	14.316	9.959	1.598	15.565	11.026	16.487	12.826
P值	?	<0.01	<0.01	>0.05	<0.01	<0.01	<0.01	<0.01

图3 典型病例1术前术后的右肩关节影像学图像。图A为术前右肩关节正位X线片，示盂肱关节骨关节炎合并肱骨头啮合性半脱位；图B为术前右肩关节MR冠状位T2压脂像，示肱关节骨关节炎，冈上肌腱撕裂、断端回缩；图C为术后右肩关节正位、侧位X线片示RTSA(反式全肩关节置换术)假体位置满意；图D为术后右肩关节轴位CT，示肱骨假体后倾30°(红线标识角度)；图E为术后1年右肩关节正侧位X线片，示RTSA假体位置满意，无假体松动及切迹，大结节周围钙化影消失

图4 典型病例2术前术后的右肩关节X线片。图A为术前右肩关节正位X线片，示盂肱关节骨关节炎合并滑膜软骨瘤，肱骨头向上移位(提示巨大肩袖撕裂)；图B为术后右肩关节正侧位X线片，示RTSA(反式全肩关节置换术)假体位置满意;图C术后1年右肩关节正侧位X线片，示RTSA假体位置满意，无假体松动和肩胛盂切迹

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