侧侧缝合联合无结缝线桥技术治疗大型L型肩袖撕裂

doi:10.3877/cma.j.issn.1674-134X.2024.03.001

目的

探讨关节镜下侧侧缝合联合无结缝线桥技术治疗大型L型肩袖撕裂的临床疗效。

方法

回顾性分析2017年9月至2022年9月期间在徐州医科大学附属医院行关节镜治疗的大型L型肩袖撕裂患者，纳入撕裂大小为3~5 cm，且撕裂形态为“L”型或反“L”型的患者，排除合并其他损伤（如：盂唇损伤、神经损伤）的患者，共纳入78例，其中采用单排技术修复患者40例（单排组），采用侧侧缝合联合无结缝线桥技术修复患者38例（缝线桥组）。采用t 检验比较两组患者术前和末次随访时的肩关节活动度、疼痛视觉模拟评分（VAS）、Constant评分、美国加州大学肩关节评分（UCLA）、美国肩肘外科医师评分（ASES）。采用Sugaya分型标准评估肩袖愈合情况，采用卡方检验比较两组患者的再撕裂率。

结果

所有患者均获得1年以上随访，术后平均随访（18.2±5.0）个月。两组患者的一般资料比较差异无统计学意义（均为P>0.05）。术前两组患者的肩关节活动度、VAS、Constant、UCLA和ASES评分比较，差异均无统计学意义（均为P>0.05）。末次随访时，缝线桥组的肩关节前屈、外展、体侧外旋活动度优于单排组（t=3.268、2.623、3.395，均为P<0.05）。缝线桥组VAS、Constant、UCLA、ASES评分均优于单排组（t=2.862、2.773、4.235、3.848，均为P<0.05）。单排组出现9例再撕裂，再撕裂率为22.5%（9/40），缝线桥组出现1例再撕裂，再撕裂率为2.6%（1/38），两组再撕裂率比较，差异有统计学意义（χ²=5.220，P=0.022）。

结论

关节镜下采用侧侧缝合联合无结缝线桥技术修复大型L型肩袖撕裂，比单排修复的临床疗效更好，术后肩袖再撕裂率更低，是一种值得推荐的手术方法。

关键词: 肩关节, 缝合技术, 关节镜, 回旋套

Objective

To explore the clinical efficacy of arthroscopic lateral suture combined with knot free suture bridge technique in the treatment of large L-shaped rotator cuff tears.

Methods

A total of 78 patients with large L-shaped rotator cuff tears who underwent arthroscopic treatment in the Affiliated Hospital of Xuzhou Medical University from September 2017 to September 2022 were included, including patients with a tear size of 3-5 cm and a tear shape of "L" or anti "L", excluding patients with other injuries (such as glenolabial injury and nerve injury). Among them, 40 patients were treated with single row technique (single row group), and 38 patients were treated with lateral suture combined with knotless suture bridge technique (suture bridge group). The shoulder range of motion, visual analogue score (VAS), Constant score, University of California at Los Angeles Shoulder Scores (UCLA), American Shoulder and Elbow Surgeons (ASES) were compared with t test between the two groups before operation and at the last follow-up. Sugaya classification standard was used to evaluate the rotator cuff healing, and chi square test was used to compare the retear rate of the two groups.

Results

All the patients were followed up for more than one year, with an average follow-up of (18.2±5.0) months. There was no statistically significant difference in general information between the two groups (both P>0 05). There was no statistically significant difference in shoulder joint range of motion, VAS, Constant, UCLA, and ASES scores between the two groups before surgery (both P>0 05). At the last follow-up, the shoulder flexion, abduction, and lateral rotation range of motion in the suture bridge group were better than those in the single row group (t=3.268, 2.623, 3.395, all P<0.05). The VAS, Constant, UCLA, and ASES scores of the suture bridge group were better than those of the single row group (t=2.862, 2.773, 4.235, 3.848, all P<0.05). There were nine cases of retearing in the single row group, with a retearing rate of 22.5% (9/40), and one cases of retearing in the suture bridge group, with a retearing rate of 2.6%（1/38）. The difference in retearing rates between the two groups was statistically significant（χ²=5.220, P=0.022).

Conclusion

Arthroscopic repair of large L-shaped rotator cuff tears using lateral suture combined with knot free suture bridge technique has better clinical efficacy than single row repair, lower postoperative rate of rotator cuff retear, and is a recommended surgical method.

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

图1 侧侧缝合联合无结缝线桥技术修复右肩L型肩袖撕裂。图A为术前右肩MRI，示肩袖撕裂、断端回缩；图B~C示术中探查肩袖撕裂为L型；图D~E示采用侧侧缝合修复纵行撕裂；图F~H示采用无结缝线桥技术关闭撕裂口；图I为术后1年复查MRI，示肩袖愈合良好，Sugaya分型I型

Figure 1 Lateral suture combined with knotless suture bridge technique for the treatment of L-shaped rotator cuff tears of the right shoulder. A is preoperative MRI of right shoulder showing rotator cuff tear and retraction; B and C is intraoperative observation showing L-shaped rotator cuff tear; D and E showed that longitudinal tear was repaired by lateral suture; F and H showed that the tear was closed by knotless suture bridge; I is MRI of the right shoulder one year after surgery, showing that the rotator cuff healed well as Sugaya type I

表1 两组患者的一般资料比较

Table 1 Comparison of general information between two groups

组别 Groups	例数 Number of cases	年龄［岁，（）］ Age（year）	性别（男/女） Gender(male/female)	侧别（左／右） Affected side(left/right)	外伤史（有/无） Trauma history (yes/no)
单排组 Single row group	40	60±9	17/23	16/24	12/28
缝线桥组 Suture bridge group	38	59±10	14/24	18/20	13/25
统计值 Statistical value		t=0.574	χ²=0.260	χ²=0.430	χ²=0.159
P值		>0.05	>0.05	>0.05	>0.05
组别 Groups	例数 Number of cases	吸烟史（有/ 无） Smoking(yes/no)	撕裂形态(L型/反L型) Tear type(L/reverse L)	病程［个月，（）］ Course of disease(month)	随访时间［个月，（）］ Follow-up time(month)
单排组 Single row group	40	6/34	24/16	24±11	18±5
缝线桥组 Suture bridge group	38	7/31	20/18	25±12	19±5
统计值 Statistical value		χ²=0.164	χ²=0.430	t=0.715	t=0.547
P值		>0.05	>0.05	>0.05	>0.05

表1 两组患者的一般资料比较

Table 1 Comparison of general information between two groups

组别 Groups	例数 Number of cases	年龄［岁，（）］ Age（year）	性别（男/女） Gender(male/female)	侧别（左／右） Affected side(left/right)	外伤史（有/无） Trauma history (yes/no)
单排组 Single row group	40	60±9	17/23	16/24	12/28
缝线桥组 Suture bridge group	38	59±10	14/24	18/20	13/25
统计值 Statistical value		t=0.574	χ²=0.260	χ²=0.430	χ²=0.159
P值		>0.05	>0.05	>0.05	>0.05
组别 Groups	例数 Number of cases	吸烟史（有/ 无） Smoking(yes/no)	撕裂形态(L型/反L型) Tear type(L/reverse L)	病程［个月，（）］ Course of disease(month)	随访时间［个月，（）］ Follow-up time(month)
单排组 Single row group	40	6/34	24/16	24±11	18±5
缝线桥组 Suture bridge group	38	7/31	20/18	25±12	19±5
统计值 Statistical value		χ²=0.164	χ²=0.430	t=0.715	t=0.547
P值		>0.05	>0.05	>0.05	>0.05

表2 两组患者肩关节活动度［°，（

）］

Table 2 Range of motion of shoulder joint in two groups

组别 Groups	例数 Number of cases	前屈 Forward flexion		外展 Abduction		体侧外旋 External rotation at side
组别 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
单排组 Single row group	40	106±17	151±13	93±17	143±14	26±8	44±10
缝线桥组 Suture bridge group	38	104±19	161±14	91±17	151±15	25±8	51±10
t值		0.504	3.268	0.615	2.623	0.448	3.395
P值		>0.05	0.002	>0.05	0.011	>0.05	0.001

表2 两组患者肩关节活动度［°，（

）］

Table 2 Range of motion of shoulder joint in two groups

组别 Groups	例数 Number of cases	前屈 Forward flexion		外展 Abduction		体侧外旋 External rotation at side
组别 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
单排组 Single row group	40	106±17	151±13	93±17	143±14	26±8	44±10
缝线桥组 Suture bridge group	38	104±19	161±14	91±17	151±15	25±8	51±10
t值		0.504	3.268	0.615	2.623	0.448	3.395
P值		>0.05	0.002	>0.05	0.011	>0.05	0.001

表3 两组患者的VAS、Constant、UCLA、ASES评分(

)

Table 3 VAS, Constant ,UCLA, ASES scores in two groups

组别 Groups	例数 Number of cases	VAS评分		Constant评分
组别 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
单排组 Single row group	40	6.9±1.6	1.9±0.8	47.3±9.7	80.1±9.4
缝线桥组 Suture bridge group	38	7.3±1.6	1.4±0.6	46.4±9.2	85.7±8.3
t值		1.205	2.862	0.373	2.773
P值		>0.05	0.005	>0.05	0.007
组别 Groups	例数 Cases	UCLA评分		ASES评分
组别 Groups	例数 Cases	术前 Before surgery	末次随访 Final follow-up	术前 Before surgery	末次随访 Final follow-up
单排组 Single row group	40	14.9±3.5	26.2±4.6	41.1±9.9	79.8±10.7
缝线桥组 Suture bridge group	38	14.2±3.7	30.2±3.5	42.1±10.7	88.3±8.8
t值		0.900	4.235	0.430	3.848
P值		>0.05	<0.001	>0.05	<0.001

表3 两组患者的VAS、Constant、UCLA、ASES评分(

)

Table 3 VAS, Constant ,UCLA, ASES scores in two groups

组别 Groups	例数 Number of cases	VAS评分		Constant评分
组别 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
单排组 Single row group	40	6.9±1.6	1.9±0.8	47.3±9.7	80.1±9.4
缝线桥组 Suture bridge group	38	7.3±1.6	1.4±0.6	46.4±9.2	85.7±8.3
t值		1.205	2.862	0.373	2.773
P值		>0.05	0.005	>0.05	0.007
组别 Groups	例数 Cases	UCLA评分		ASES评分
组别 Groups	例数 Cases	术前 Before surgery	末次随访 Final follow-up	术前 Before surgery	末次随访 Final follow-up
单排组 Single row group	40	14.9±3.5	26.2±4.6	41.1±9.9	79.8±10.7
缝线桥组 Suture bridge group	38	14.2±3.7	30.2±3.5	42.1±10.7	88.3±8.8
t值		0.900	4.235	0.430	3.848
P值		>0.05	<0.001	>0.05	<0.001

［1］	Feng S，Li H，Zhong Y，et al. Functional and structural outcomes after arthroscopic rotator cuff repair with or without preoperative corticosteroid injections［J］. Am J Sports Med，2023,51(3): 733-742.
［2］	Godshaw BM，Hughes JD，Boden SA，et al. Comparison of functional outcomes after arthroscopic rotator cuff repair between patients with traumatic and atraumatic tears［J/OL］. Orthop J Sports Med，2022,10(10): 23259671221126551. DOI: 10.1177/23259671221126551.
［3］	Davidson J，Burkhart SS. The geometric classification of rotator cuff tears: a system linking tear pattern to treatment and prognosis［J］. Arthroscopy，2010,26(3): 417-424.
［4］	McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder. The exposure and treatment of tears with retraction［J］. Clin Orthop Relat Res，1994,(304): 3-9.
［5］	Millett PJ，Warth RJ. Posterosuperior rotator cuff tears: classification，pattern recognition，and treatment［J］. J Am Acad Orthop Surg，2014,22(8): 521-534.
［6］	Sallay PI，Hunker PJ，Lim JK. Frequency of various tear patterns in full-thickness tears of the rotator cuff［J］. Arthroscopy，2007,23(10): 1052-1059.
［7］	Jung SW，Kim DH，Kang SH，et al. Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears［J］. Knee Surg Sports Traumatol Arthrosc，2017,25(7): 2129-2137.
［8］	Jeon YS，Lee J，Kim RG，et al. Does additional biceps augmentation improve rotator cuff healing and clinical outcomes in anterior L-shaped rotator cuff tears？Clinical comparisons with arthroscopic partial repair［J］. Am J Sports Med，2017,45(13): 2982-2988.
［9］	Haleem A，Gohal C，Leroux T，et al. Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re-tear［J］. Knee Surg Sports Traumatol Arthrosc，2021,29(7): 2134-2142.
［10］	Yang H，Lee S，Shin SJ. Satisfactory functional and structural outcomes of anterior cable reconstruction using the proximal biceps tendon for large retracted rotator cuff tears［J］. Knee Surg Sports Traumatol Arthrosc，2023,31(5): 1910-1918.
［11］	Curtis AS，Burbank KM，Tierney JJ，et al. The insertional footprint of the rotator cuff: an anatomic study［J/OL］. Arthroscopy，2006,22(6): 609.e1. DOI: 10.1016/j.arthro.2006.04.001.
［12］	Sano H，Hatta T，Yamamoto N，et al. Stress distribution within rotator cuff tendons with a crescent-shaped and an L-shaped tear［J］. Am J Sports Med，2013,41(10): 2262-2269.
［13］	Li C，Zhang H，Bo X，et al. Arthroscopic release combined with single-row fixation or double-row suture bridge fixation in patients with traumatic supraspinatus tear and adhesive capsulitis non-responsive to conservative management: a prospective randomized trial［J/OL］. Orthop Traumatol Surg Res，2021,107(4): 102828. DOI: 10.1016/j.otsr.2021.102828.
［14］	Park JY，Jung SW，Jeon SH，et al. Arthroscopic repair of large U-shaped rotator cuff tears without margin convergence versus repair of crescent- or L-shaped tears［J］. Am J Sports Med，2014,42(1): 103-111.
［15］	Jeong JH，Yoon EJ，Kim BS，et al. Biceps-incorporating rotator cuff repair with footprint medialization in large-to-massive rotator cuff tears［J］. Knee Surg Sports Traumatol Arthrosc，2022,30(6): 2113-2122.
［16］	Lee GW，Kim JY，Lee HW，et al. Clinical and anatomical outcomes of arthroscopic repair of large rotator cuff tears with allograft patch augmentation: a prospective，single-blinded，randomized controlled trial with a long-term follow-up［J］. Clin Orthop Surg，2022,14(2): 263-271.
［17］	Burkhart SS，Athanasiou KA，Wirth MA. Margin convergence: a method of reducing strain in massive rotator cuff tears［J］. Arthroscopy，1996,12(3): 335-338.
［18］	Takeda Y，Fujii K，Suzue N，et al. Repair tension during arthroscopic rotator cuff repair is correlated with preoperative tendon retraction and postoperative rotator cuff integrity［J］. Arthroscopy，2021,37(9): 2735-2742.
［19］	Uno T，Mura N，Yuki I，et al. Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment［J/OL］. J Shoulder Elbow Surg，2022,31(5): e213-e222. DOI: 10.1016/j.jse.2021.10.004.
［20］	Yamakado K. A prospective randomized trial comparing suture bridge and medially based single-row rotator cuff repair in medium-sized supraspinatus tears［J］. Arthroscopy，2019,35(10): 2803-2813.

[1]	纪小孟, 刘璠, 唐晓波, 卞为伟, 董佩龙, 刘振鲁. 两种手术方式治疗肩袖撕裂合并粘连性肩关节囊炎[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 561-567.
[2]	苏介茂, 齐岩松, 王永祥, 魏宝刚, 马秉贤, 张鹏飞, 魏兴华, 徐永胜. 关节镜手术在早中期膝骨关节炎治疗的应用进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 646-652.
[3]	王典, 刘双赫, 曾峥. 肩关节镜术后肌肉功能改变对颈椎形态及矢状面参数影响的自身前后对照队列研究[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(05): 371-378.
[4]	薛昶, 王翔, 冯利, 金鑫, 王治伟. 生物补片盆底修补术和直接缝合术在低位直肠癌患者盆底重建中的应用研究[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(03): 327-329.
[5]	曲洋, 蒋浩然, 邢博涵, 张蒙, 张培训. 肩袖损伤的治疗进展[J/OL]. 中华肩肘外科电子杂志, 2024, 12(04): 289-291.
[6]	冯亚飞, 唐诗添, 唐福宽, 周亮. 关节镜下mLSRS 技术及双排缝线桥技术治疗大型肩袖撕裂的疗效及预后分析[J/OL]. 中华肩肘外科电子杂志, 2024, 12(04): 295-301.
[7]	王友健, 陶然, 陆跃, 马洪冬. 退行性中、小型肩袖撕裂两种临床治疗效果对比[J/OL]. 中华肩肘外科电子杂志, 2024, 12(04): 302-308.
[8]	陈天鑫, 杨胜平, 朱瑜琪, 高云, 张帅. 多种手术方式治疗肩关节前向不稳定伴关节盂骨缺损的网状Meta分析[J/OL]. 中华肩肘外科电子杂志, 2024, 12(04): 344-352.
[9]	张琛朋, 王靖, 曾塬杰, 高鹏, 陈昕彤. 反式全肩关节置换术的研究进展[J/OL]. 中华肩肘外科电子杂志, 2024, 12(04): 373-376.
[10]	单磊, 周君琳. 同期修复肩袖撕裂结合锁定钢板治疗老年肱骨近端骨折的特点及疗效分析[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 211-215.
[11]	赵静磊, 陈晓婷, 夏莹, 黄维佳, 周菊, 刘芳. 锁骨骨折切开复位内固定术后患者肩关节功能恢复的风险因素研究[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 216-222.
[12]	郁凯, 曾保起, 杨剑, 杨杰, 张殿英, 孙凤. 全关节镜与切开手术治疗肩袖撕裂疗效比较的系统综述与Meta分析[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 238-245.
[13]	王涵宇, 王蕾. Bankart损伤的关节镜下修复进展[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 262-270.
[14]	白正林, 高明, 孟增东. 肩关节置换术后假体周围感染的研究进展[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 271-276.
[15]	马明太, 居家宝, 张一翀, 丁镇涛, 张殿英, 付中国, 陈建海. 肱骨大结节骨折的治疗进展[J/OL]. 中华肩肘外科电子杂志, 2024, 12(03): 277-280.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Lateral suture combined with knotless suture bridge technique for treatment of large L-shaped rotator cuff tears

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Lateral suture combined with knotless suture bridge technique for treatment of large L-shaped rotator cuff tears