中老年人肩关节脱位合并肩袖损伤诊治

doi:10.3877/cma.j.issn.1674-134X.2022.04.015

目的

探讨中老年人肩关节前脱位合并肩袖损伤等多种损伤的诊治方法及疗效。

方法

回顾性分析2016年6月至2020年8月长海医院收治的中老年(年龄>40岁)肩关节脱位合并肩袖损伤等多种损伤患者15例。经肩关节镜下手术治疗，术后指导关节功能锻炼，应用美国肩肘医师协会评分(ASES评分)、视觉模拟评分(VAS评分)及Constant评分对患者进行功能评估，结果分析采用配对t检验。

结果

14例患者获随访，1例患者因其他原因导致的瘫痪而被排除，平均随访时间(15±4)个月。ASES评分、VAS评分、Constant评分术前为(33.0±11.8)、(5.1±1.4)、(37.4±8.8)，末次随访时为(88.7±6.4)、(0.9±0.7)、(82.3±8.2)，差异有统计学意义(t＝17.341、12.902、13.270，均为P<0.001)。

结论

中老年人肩关节脱位常合并肩袖损伤、Bankart损伤或骨性Bankart损伤、Hill-sachs损伤等多种损伤，诊断明确后建议及时手术全面修复，重建肩关节稳定性，缓解疼痛及恢复肩关节功能。

关键词: 中年人, 肩脱位, 回旋套损伤

Objective

To investigate the diagnosis, treatments and related functional outcomes of different surgical choices in middle aged and elderly patients with anterior dislocation of shoulder joint associated with rotator cuff tears and other injuries.

Methods

Fifteen patients older than 40 with shoulder dislocation complicated with rotator cuff injury and other injuries from June 2016 to August 2020 in ChangHai Hospital were analyzed retrospectively. All the patients were treated by shoulder arthroscopy, and the exercise of joint function was guided after operation. The American Shoulder and Elbow Surgeons scale (ASES), visual analogue scale (VAS) and Constant-Murley score (Constant score)were used to evaluate the function of the shoulder joint. Paired t test was used for data comparison.

Results

Fourteen patients were followed up for an average of (15±4) months and one patient was excluded because of paralysis caused by other reasons. The ASES score, VAS score and Constant score were (33.0±11.8), (5.1±1.4), (37.4±8.8) respectively before the operation, and (88.7±6.4), (0.9±0.7), (82.3±8.2) respectively at the last follow-up; the differences were statistically significant (t=17.341, 12.902, 13.270, all P<0.001).

Conclusions

Shoulder dislocation in the middle aged and elderly is often complicated with rotator cuff injury, Bankart injury or bony Bankart injury, Hill-sachs injury and other injuries. Timely and comprehensive surgical repair should be performed to reconstruct the stability of the shoulder joint, relieve pain and restore the function of the shoulder joint.

Key words: Middle aged, Shoulder dislocation, Rotator cuff injuries

表1 14例肩关节脱位患者术前及末次随访评分比较[n＝14，(±s)]

时间	ASES评分	Constant评分	VAS评分
术前	33.0±11.8	37.4±8.8	5.1±1.4
末次随访	88.7±6.4	82.3±8.2	0.9±0.7
t值	17.341	12.902	13.270
P值	<0.001	<0.001	<0.001

表1 14例肩关节脱位患者术前及末次随访评分比较[n＝14，(±s)]

时间	ASES评分	Constant评分	VAS评分
术前	33.0±11.8	37.4±8.8	5.1±1.4
末次随访	88.7±6.4	82.3±8.2	0.9±0.7
t值	17.341	12.902	13.270
P值	<0.001	<0.001	<0.001

图1 右肩关节前脱位术前影像。图A为术前正位X线片，示肱骨头盂下脱位；图B为术前右肩关节CT及三维重建，示肩关节脱位伴肱骨头骨折；图C为右肩关节MRI斜冠状位示巨大肩袖(冈上肌)撕裂；图D为肩关节MRI横切位，示肱骨头脱位

图2 右肩关节前脱位合并多种损伤关节镜下所见。图A为肱骨头后上压缩骨折Hill-Sachs损伤；图B为Hill-Sachs损伤置入两枚锚钉，关节镜下过线；图C为两枚锚钉穿过关节囊和冈下肌腱的缝线打结，完成软组织填塞；图D为Bankart损伤；图E为Bankart损伤松解，骨床准备及置入盂唇锚钉；图F为Bankart损伤修补术后；图G为术中探查见冈上肌腱为主的大型L型撕裂；图H为大L型撕裂后方冈下肌腱小L型撕裂，形成不规则复合撕裂；图I为Chinese-Way二头肌腱加强肩袖缝线桥修补

图3 术后1年右肩关节MRI检查。图A为MRI冠状位，示冈上肌肌腱连续、愈合良好，锚钉固定在位；图B为MRI横切位示后方填塞冈下肌肌腱与前方修补的盂唇愈合良好

图4 术前及术后1年右肩关节功能对比。图A为术前，患者右肩关节前屈－外展－外旋－内旋功能均受限；图B为术后1年，患者右肩关节前屈－外展－外旋－内旋功能明显改善

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Treatment of shoulder instability with related rotator cuff tears in middle-aged and elderly patients

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Treatment of shoulder instability with related rotator cuff tears in middle-aged and elderly patients