改良加强减张无结缝线桥技术治疗肩袖撕裂合并冻结肩

doi:10.3877/cma.j.issn.1674-134X.2023.03.019

目的

比较关节镜下松解联合改良加强减张无结缝线桥技术或传统无结缝线桥技术治疗肩袖撕裂合并冻结肩的疗效。

方法

回顾性分析2017年6月至2020年6月，徐州医科大学附属医院关节外科采用关节镜下松解联合改良加强减张无结缝线桥技术(改良组30例)和传统无结缝线桥技术(传统组33例)治疗肩袖撕裂合并冻结肩的患者63例。采用t检验比较两组患者术前和末次随访时的疼痛视觉模拟评分(VAS)，美国加州大学肩关节评分(UCLA)、美国肩肘外科医师学会评分(ASES)和肩关节活动度。根据肩关节MRI影像学Sugaya分型标准评估肩袖愈合情况，比较两组术后肩袖再撕裂发生率。

结果

患者术后随访(21±8)个月。两组患者在一般资料方面差异均无统计学意义(均为P>0. 05)。两组患者术前肩关节活动度差异无统计学意义(均为P>0. 05)。末次随访时，改良组的前屈、外展、体侧外旋优于传统组(t＝3.750、3.244、2.554、均为P<0. 05)。两组患者术前VAS、UCLA和ASES评分差异均无统计学意义(均为P>0. 05)。末次随访时，改良组VAS、UCLA、ASES评分均优于传统组(t＝2.405、3.884、3.899，均为P<0. 05)；改良组再撕裂为0，传统组再撕裂率为21.2%(χ²＝5.172，P＝0.023)。

结论

对于肩袖撕裂合并冻结肩的患者，关节镜下松解联合改良加强减张无结缝线桥技术较传统无结缝线桥技术能获得更好的肩关节活动度和功能，疼痛减轻更明显，肩袖再撕裂发生率更低。

关键词: 关节镜, 肩关节, 滑囊炎, 缝合技术

Objective

To compare the efficacy of arthroscopic release combined with modified load sharing rip-stop and knotless suture bridge technique and traditional knotless suture bridge technique for rotator cuff tear repair in frozen shoulder.

Methods

A retrospective analysis was conducted on 63 patients with rotator cuff tear and frozen shoulder treated by arthroscopic release combined with modified load sharing rip-stop and knotless suture bridge technique (modified group, 30 cases) or traditional knotless suture bridge technique (traditional group, 33 cases) in the Joint Surgery Department of Xuzhou Medical University Affiliated Hospital from June 2017 to June 2020. Visual analogue scale (VAS), the University of California shoulder joint score (UCLA), the American Society of Shoulder and Elbow Surgeons (ASES) score, and range of motion of shoulder joint in the two groups were compared using t tests before surgery and at the last follow-up. The healing of the rotator cuff was evaluated by the Sugaya classification for shoulder joint MRI imaging, and the re-tearing incidence of rotator cuff after surgery was also compared.

Results

The patients were followed up for (21 ±8) months. There was no statistically significant difference in general information between the two groups (all P>0.05). No statistically significant difference was found in the range of motion of shoulder joint between the two groups before operation (all P>0.05). At the last follow-up, the modified group had better flexion, abduction, and lateral rotation than the traditional group (t=3.750, 3.244, 2.554, all P<0.05). There was no statistically significant difference in preoperative VAS, UCLA, nor ASES scores between the two groups (all P>0 05). At the last follow-up, the VAS, UCLA, and ASES scores of the modified group were better than those of the traditional group (t=2.405, 3.884, 3.899, all P<0.05). No re-tearing occurred in modified group, while the re-tearing rate of traditional group was 21.2% (χ²=5.172, P=0.023).

Conclusion

For patients of rotator cuff tear combined with frozen shoulder, arthroscopic release combined with modified load sharing rip-stop and knotless suture bridge technique can achieve better shoulder joint mobility and function compared to traditional knotless suture bridge technique, with more effective pain relief and lower incidence of re-tearing of rotator cuff.

Key words: Arthroscope, Shoulder joint, Bursitis, Suture techniques

图1 传统无结缝线桥技术示意图。图A示置入两枚内排锚钉，4根线尾均匀地缝过肩袖；图B示4根线尾穿入1枚外排锚钉，拉紧缝线后置入外排锚钉；图C示4根线尾分别穿入2枚外排锚钉并拉紧后置入外排锚钉

Figure 1 Schematic diagram of traditional knotless suture bridge technique. A shows insert two medial row anchors are inserted, the remaining four sutures are evenly sewed over the rotator cuff; B shows four sutures are set into one lateral anchor and fastened; C shows four sutures are set into two lateral anchors and fastened

图2 改良加强减张无结缝线桥技术示意图。图A置入2枚内排锚钉，4根蓝色缝线均匀地缝过肩袖，2根绿色缝线分别在蓝色缝线区域两侧各缝一针；图B~C示绿色缝线打结固定，减张缩小撕裂口，蓝色缝线的线尾穿入1枚或2枚外排锚钉并拉紧后置入外排锚钉

Figure 2 Schematic diagram of modified load sharing rip-stop and knotless suture bridge technique. A shows two medial anchors are placed, and four blue sutures are evenly sewed over the rotator cuff, the remaining two green sutures are sewed on each side of the blue sutures; B and C show that the green sutures are tied and fastened to optimize the load sharing and narrow the tear, then the four blue sutures are set into one or two lateral anchors and fastened

表1 两组患者一般资料比较

Table 1 Comparison of general information between two groups

分组Groups	例数Number of cases	年龄[岁，(±s)]Age	性别(男/女)Gender (male/female)	侧别(左/右)Affected side (left/right)	撕裂大小(例)Size of tear
分组Groups	例数Number of cases	年龄[岁，(±s)]Age	性别(男/女)Gender (male/female)	侧别(左/右)Affected side (left/right)	小small	中medium	大large
改良组Modified group	30	57±11	13/17	11/19	12	10	8
传统组Traditional group	33	58±10	11/22	16/17	14	9	10
统计值		t＝0.410	χ²＝0.666	χ²＝0.896	χ²＝0.286
P值		>0.05	>0.05	>0.05	>0.05
分组Groups	例数Number of cases	外伤史(有/无)History of trauma (yes/ no)	吸烟史(有/无)Smoking (yes/ no)	注射类固醇激素(有/无)Steroid injections (yes/ no)	病程Course of disease[个月，(±s)]	随访时间Follow-up time[个月，(±s)]
改良组Modified group	30	16/14	4/26	2/28	10±5	20±7
传统组Traditional group	33	20/13	3/30	4/29	11±6	22±8
统计值		χ²＝0.339	χ²＝0.286	χ²＝0.543	t＝0.680	t＝0.941
P值		>0.05	>0.05	>0.05	>0.05	>0.05

表1 两组患者一般资料比较

Table 1 Comparison of general information between two groups

分组Groups	例数Number of cases	年龄[岁，(±s)]Age	性别(男/女)Gender (male/female)	侧别(左/右)Affected side (left/right)	撕裂大小(例)Size of tear
分组Groups	例数Number of cases	年龄[岁，(±s)]Age	性别(男/女)Gender (male/female)	侧别(左/右)Affected side (left/right)	小small	中medium	大large
改良组Modified group	30	57±11	13/17	11/19	12	10	8
传统组Traditional group	33	58±10	11/22	16/17	14	9	10
统计值		t＝0.410	χ²＝0.666	χ²＝0.896	χ²＝0.286
P值		>0.05	>0.05	>0.05	>0.05
分组Groups	例数Number of cases	外伤史(有/无)History of trauma (yes/ no)	吸烟史(有/无)Smoking (yes/ no)	注射类固醇激素(有/无)Steroid injections (yes/ no)	病程Course of disease[个月，(±s)]	随访时间Follow-up time[个月，(±s)]
改良组Modified group	30	16/14	4/26	2/28	10±5	20±7
传统组Traditional group	33	20/13	3/30	4/29	11±6	22±8
统计值		χ²＝0.339	χ²＝0.286	χ²＝0.543	t＝0.680	t＝0.941
P值		>0.05	>0.05	>0.05	>0.05	>0.05

表2 两组患者肩关节活动度[°，(±s)]

Table 2 Range of motion of shoulder joint in two groups

分组Groups	例数Number of cases	前屈Flexion		外展Abduction		体侧位外旋External rotation at side
分组Groups	例数Number of cases	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up
改良组Modified group	30	115±18	159±12	103±17	148±11	21±11	53±13
传统组Traditional group	33	116±18	148±13	106±17	138±13	21±12	45±11
t值		0.303	3.750	0.629	3.244	0.234	2.554
P值		>0.05	<0.001	>0.05	0.002	>0.05	0.013

表2 两组患者肩关节活动度[°，(±s)]

Table 2 Range of motion of shoulder joint in two groups

分组Groups	例数Number of cases	前屈Flexion		外展Abduction		体侧位外旋External rotation at side
分组Groups	例数Number of cases	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up
改良组Modified group	30	115±18	159±12	103±17	148±11	21±11	53±13
传统组Traditional group	33	116±18	148±13	106±17	138±13	21±12	45±11
t值		0.303	3.750	0.629	3.244	0.234	2.554
P值		>0.05	<0.001	>0.05	0.002	>0.05	0.013

表3 两组患者VAS、UCLA、ASES评分及肩袖再撕裂情况

Table 3 VAS, UCLA, ASES scores and rotator cuff retearing rate in two groups

分组Groups	例数Number of cases	VAS(±s)		UCLA(±s)		ASES(±s)		肩袖再撕裂(愈合/再撕裂)Rotator cuff retear (healed/retear)
分组Groups	例数Number of cases	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	肩袖再撕裂(愈合/再撕裂)Rotator cuff retear (healed/retear)
改良组Modified group	30	7.0±1.6	1.3±0.8	14.9±2.9	31.0±3.2	39.4±6.5	88.1±9.5	30/0
传统组Traditional group	33	6.8±1.5	1.8±0.8	15.3±3.1	27.6±3.9	41.2±7.2	79.2±8.6	26/7
统计值		t ＝0.699	t＝2.405	t＝0.619	t ＝3.884	t＝1.027	t ＝3.899	χ²＝5.172
P值		>0.05	0.019	>0.05	<0.001	>0.05	<0.001	0.023

表3 两组患者VAS、UCLA、ASES评分及肩袖再撕裂情况

Table 3 VAS, UCLA, ASES scores and rotator cuff retearing rate in two groups

分组Groups	例数Number of cases	VAS(±s)		UCLA(±s)		ASES(±s)		肩袖再撕裂(愈合/再撕裂)Rotator cuff retear (healed/retear)
分组Groups	例数Number of cases	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	术前Before surgery	末次随访Final follow-up	肩袖再撕裂(愈合/再撕裂)Rotator cuff retear (healed/retear)
改良组Modified group	30	7.0±1.6	1.3±0.8	14.9±2.9	31.0±3.2	39.4±6.5	88.1±9.5	30/0
传统组Traditional group	33	6.8±1.5	1.8±0.8	15.3±3.1	27.6±3.9	41.2±7.2	79.2±8.6	26/7
统计值		t ＝0.699	t＝2.405	t＝0.619	t ＝3.884	t＝1.027	t ＝3.899	χ²＝5.172
P值		>0.05	0.019	>0.05	<0.001	>0.05	<0.001	0.023

图3 右肩袖撕裂合并冻结肩，行关节镜下松解联合改良加强减张无结缝线桥技术修复肩袖。图A为术前右肩关节MRI，示冈上肌腱撕裂；图B为术中关节镜下示肩袖撕裂；图C示置入两枚内排锚钉；图D示缝线减张缝合裂口并打结固定；图E示4根缝线尾分别穿入2枚外排锚钉后拉紧固定；图F为术后12个月MRI，示肩袖愈合为Sugaya分型Ⅰ型

Figure 3 Rotator cuff tear in right shoulder with frozen shoulder, that was repaired by arthroscopy release combined with modified load sharing rip-stop and knotless suture bridge technique.A is MRI of right shoulder joint before operation, showing supraspinatus tendon tear; B is intraoperative arthroscopic image, showing rotator cuff tear; C shows that two medial anchors were inserted; D shows that the tear of rotator cuff was sutured by load sharing rip-stop method and the sutures were tied fixed; E shows that the four sutures were set into two lateral anchors, fastened and fixed; F is MRI at 12 months after surgery, showing the rotator cuff healed as Sugaya's classification type I

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Modified load sharing rip-stop and knotless suture bridge technique for rotator cuff tear repair in frozen shoulder

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Modified load sharing rip-stop and knotless suture bridge technique for rotator cuff tear repair in frozen shoulder