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中华肩肘外科电子杂志

中华肩肘外科电子杂志 ›› 2021, Vol. 09 ›› Issue (01) : 30 -37. doi: 10.3877/cma.j.issn.2095-5790.2021.01.005

所属专题： 文献；

论著

肩袖间隙滑移修补结合渐进式康复治疗巨大肩袖损伤
杨泽政1, 许苑晶2, 柳毅浩3, 李涛3, 刘至原3, 江川4, 王金武3,†(), 戴尅戎3   
  1. 1. 200240　复旦大学附属上海市第五人民医院骨科
    2. 200030　上海交通大学生物医学工程学院生物医学工程专业
    3. 200011　上海交通大学医学院附属第九人民医院骨科
    4. 510120　广州，中山大学孙逸仙纪念医院骨科
  • 收稿日期:2020-09-23 出版日期:2021-02-05
  • 通信作者: 王金武
  • 基金资助:
    国家科技部重点研发计划项目(2018YFB1105600); 国家自然科学基金(81572156、81772326); 上海申康第一轮促进市级医院临床技能与临床创新三年行动计划(16CR3088B); 上海市卫生系统重要薄弱学科建设(2015ZB04904); 上海交通大学医学院高峰高原计划研究型医师项目(20152224); 上海交通大学医学院转化医学创新基金资助(TM201613)

Repair of massive rotator cuff tears using interval slide technique and progressive rehabilitation exercises

Zezheng Yang1, Yuanjing Xu2, Yihao Liu3, Tao Li3, Zhiyuan Liu3, Chuan Jiang4, Jinwu Wang3,†(), Kerong Dai3   

  1. 1. Department of Orthopedics, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai 200240, China
    2. Biomedical Engineering Major, Shanghai JiaoTong University School of Biomedical Engineering, Shanghai 200030, China
    3. Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China
    4. Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
  • Received:2020-09-23 Published:2021-02-05
  • Corresponding author: Jinwu Wang
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引用本文：

杨泽政, 许苑晶, 柳毅浩, 李涛, 刘至原, 江川, 王金武, 戴尅戎. 肩袖间隙滑移修补结合渐进式康复治疗巨大肩袖损伤[J]. 中华肩肘外科电子杂志, 2021, 09(01): 30-37.

Zezheng Yang, Yuanjing Xu, Yihao Liu, Tao Li, Zhiyuan Liu, Chuan Jiang, Jinwu Wang, Kerong Dai. Repair of massive rotator cuff tears using interval slide technique and progressive rehabilitation exercises[J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2021, 09(01): 30-37.

目的

探讨肩袖间隙滑移调整最佳肩袖张力下缝合结合术后渐进式康复锻炼力学刺激治疗巨大肩袖损伤的疗效。

方法

回顾性分析2012年1月至2016年10月上海交通大学医学院附属第九人民医院骨科收治的24例巨大肩袖损伤患者，其中男17例、女7例；年龄43~69岁，平均57.9岁。在肩峰成形、肩袖间隙松解滑移术后，于肩外展位行调整最佳肩袖张力下缝合肩袖，术后在可调式肩关节外展架保护下进行渐进式康复锻炼。术后6个月和24个月记录肩关节活动范围、Constant评分、美国肩肘外科协会评分（American shoulder and elbow surgeons,ASES）、术后僵硬和再撕裂情况。建立肩关节几何模型并进行力学分析。

结果

术前肩关节前举、外展、外旋分别是85~160°、75~130°、25~55°，Constant评分、ASES评分分别为25~72分、26~65分。术后6个月肩关节前举、外展、外旋分别是125~170°、105~180°、35~80°，Constant评分、ASES评分分别为50~88分、59~91分。术后24个月肩关节前举、外展、外旋分别是130~180°、110~180°、45~80°，Constant评分、ASES评分分别为65~94分、63~93分。以上指标术前、术后6个月和术后12个月比较差异有统计学意义（P<0.05）。以上指标术后6个月较术前明显改善，术后24个月较术后6个月进一步改善，差异均有统计学意义（P<0.05）。末次随访时3例患者肩袖发生再撕裂，再撕裂率12.5%；1例患者术后发生肩关节僵硬。根据肩关节模型得出外展角度与肩袖牵拉延长量之间的负相关性公式。

结论

采用肩袖间隙滑移调整最佳肩袖张力下缝合结合术后渐进式康复锻炼力学刺激治疗巨大肩袖损伤，能够有效提高患者肩关节的活动范围、改善肩关节功能、减轻患侧疼痛，且术后再撕裂和僵硬发生率保持在较低水平，患者满意度高。符合基于几何模型的力学分析结果，是巨大肩袖损伤的一种有效的治疗方法。

关键词: 肩关节, 巨大肩袖损伤, 肩撞击综合征, 康复
Background

Rotator cuff injury is a common disease of sports medicine, affecting the quality of work and life, and the incidence increases with age. Many factors impact the treatment of massive rotator cuff tears, including huge damage range, shortening of rotator cuffs, degeneration and adhesion of surrounding tissues. Although there are lots of rotator cuff surgical procedures and postoperative rehabilitation methods, few studies reported on slide repair and systematic rehabilitation exercises. Objective To investigate the curative effect of interval slide technique under the optimal rotator cuff tension and adjustable abduction brace assisted postoperative progressive rehabilitation with mechanical stimulation in the treatment of massive rotator cuff injury.

Methods

From January 2012 to October 2016, 24 patients (17 males and 7 females) with massive rotator cuff injuries were admitted into our hospital. The ages ranged from 43 to 69 years, with an average age of 57.9 years. After acromioplasty, rotator interval release and slide, the rotator cuff were repaired in the abduction position under the optimal tension. The progressive rehabilitation exercises were conducted under the protection of the adjustable abduction brace. The range of motion, shoulder function scores (Constant score, ASES score) , retear and stiffness were evaluated in the 6th and 24th month. The mechanics analysis was performed based on the geometric model of the shoulder joint.

Results

Compared with the preoperative range of motion (120.4°±23.6° of forward elevation, 102.5°±14.9° of abduction, and 35.6°±9.1°of external rotation) , Constant-Murley score [ (48.9±13.3) points] , and ASES score [ (47.5±10.8) points] , the postoperative range of motion (150.6°±12.1° of forward elevation, 151.7°±19.9° of abduction, and 55.6°±10.8° of external rotation) , Constant-Murley score [ (72.7±9.1) points] and ASES score [ (75.7±11.0) points ] were significantly improved in the 6th months, and the pain was less severe than before surgery (P<0.001) . In the 24th month, the above indexes (ROM: 157.3°±13.6° of forward elevation, 155.4°±20.5° of abduction and 62.1°±9.0° of external rotation; Constant-Murley score: (80.6±8.5) points; ASES score: (82.0±8.8) points were further improved compared with those in the 6th month postoperatively (P<0.01) . At the last follow-up, 3 patients were found rotator cuff retear (retear rate 12.5%) , and 1 patient suffered from shoulder stiffness. A negative correlation formula between the abduction angle and the extended length of rotator cuff was derived from the shoulder joint model.

Conclusion

Optimal tension repair of massive rotator cuff tears using interval slide technique and adjustable brace assisted postoperative progressive rehabilitation exercises with mechanical stimulation significantly improved the range of motion, shoulder function, pain relief, and kept lower stiffness rate and retear rate with high patient satisfaction, which was consistent with the results of mechanics analysis based on shoulder joint geometric model.

Key words: Shoulder joint, Massive rotator cuff tear, Shoulder impingement syndrome, Rehabilitation
图1 手术过程：肩关节镜下肩峰下清理（图A），肩关节镜下肩袖间隙松解（图B），小切口术中肩袖修补可见撕裂、短缩的肩袖（图C），肩袖间隙的松解滑移后，牵拉肩袖复位至足迹（图D）
图2 患者男，61岁，摔伤致左侧巨大肩袖损伤，术前MRI提示巨大肩袖撕裂（图A），术前体格检查表现（图B），术后佩戴可调节式肩关节外展支具（图C），并在支具保护下行肩关节被动上举康复锻炼（图D），术后6个月患者肩关节功能恢复良好（图E）
图3 肩关节几何模型：肩关节处于术后初始外展角度α0（90~110°）时，肩关节的解剖特点和冈上肌腱的应力状况（图A）；肩关节处于术后外展角度α1时，肩关节的解剖特点和冈上肌腱的应力状况（图B）
表1 术前和术后肩关节运动范围和功能评分（±s）
时间 前举（°） 外展（°） 外旋（°） Constant评分（分） ASES评分（分）
术前 120.4±23.6 102.5±14.9 35.6±9.1 48.9±13.3 47.5±10.8
术后6个月 150.6±12.1a 151.7±19.9a 55.6±10.8a 72.7±9.1a 75.7±11.0a
术后24个月 157.3±13.6b 155.4±20.5b 62.1±9.0b 80.6±8.5b 82.0±8.8b
F值 -6.905 -10.170 -10.398 -12.556 -14.288
P值 <0.001 <0.001 <0.001 <0.001 <0.001
表2 术前和术后肩关节Constant评分（分，±s）
时间 疼痛 日常活动 主动活动 肌力
术前 5.2±5.2 11.2±5.0 18.2±3.1 14.4±5.8
术后6个月 11.3±4.0a 12.2±5.2a 28.1±2.7a 19.2±4.1a
术后24个月 11.5±4.3 14.6±4.7 32.7±2.7b 21.9±3.2
F值 -4.861 -3.000 -16.663 -5.874
P值 <0.001 <0.01 <0.001 <0.001
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