关节镜下肱二头肌长头肌腱桥接补片联合背阔肌转位治疗不可修复性巨大肩袖撕裂的早期临床疗效

doi:10.3877/cma.j.issn.2095-5790.2021.04.010

目的

观察关节镜下肱二头肌长头肌腱桥接补片联合背阔肌转位治疗不可修复性巨大肩袖撕裂的早期临床疗效并初步探讨该手术方法的作用机制。

方法

回顾性研究本院2018年3月至2020年6月收治的15例不可修复性巨大肩袖撕裂患者，其中男6例、女9例。年龄56~68岁，平均（61.5±3.1）岁。术前症状平均持续时间（11.7±3.5）个月。随访评估患者术前、术后肩关节主动活动度（前屈上举、体侧外旋和外展外旋）、肩关节X线片和MRI，并采用视觉模拟评分（visual analogue scale，VAS）、美国加州大学洛杉矶分校（University of California Los Angeles，UCLA）评分、Constant-Murley评分进行肩关节疼痛和功能评价。

结果

术后无一例再撕裂、鼓眼畸形、严重关节粘连、感染等并发症。所有患者均获得随访，随访时间7~16个月，平均（11.5± 4.3）个月。术前和末次随访时，患者术前及术后肩关节主动活动度分别为前屈上举（85.9±27.4）°和（149.8±29.7）°、体侧外旋（21.5± 8.9）°和（38.3± 12.4）°、外展外旋（52.7 ± 14.2）°和（73.6± 12.8）°、VAS评分（6.2 ± 1.1）分和（1.4 ± 0.5）分、UCLA评分（15.4 ± 3.8）分和（35.1 ± 2.7）分、Constant-Murley评分（42.8 ± 7.6）分和（91. 2 ± 7.3）分、肩峰肱骨头距离（5.2± 1.6）mm和（8.7± 1.3）mm。末次随访时患者肩关节主动活动度、VAS评分、UCLA评分及Constant-Murley评分均较术前明显改善（P<0.001）。末次随访时UCLA评分优6例、良8例、一般1例、优良率93.3%（14/15）。

结论

采用关节镜下肱二头肌长头肌腱桥接补片联合背阔肌腱转位治疗不可修复性巨大肩袖撕裂，可明显缓解疼痛，恢复活动度，改善功能。

关键词: 背阔肌转位, 巨大肩袖撕裂, 肩袖修补

Background

Irreparable massive rotator cuff tear (IMRCT) is the hotspot and difficulty in sports medicine. Because of the severe retraction, poor quality, serious muscle fat infiltration, and decreased acromiohumeral distance caused by high position in IMRCT, patients usually present with severe dysfunction of upper limb and shoulder joint and remarkable pain. IMRACT usually requires surgery due to the poor outcome of conservative treatment.

Objective

To observe the early clinical efficacy of arthroscopic bridge patch of the long head of biceps tendon combined with latissimus dorsi transposition to treat irreparable massive rotator cuff tear and explore the mechanism of this surgical method.

Methods

From March 2018 to June 2020, we retrospectively analyzed the clinical data of 15 patients (6 males and 9 females) with IMRCT. Their ages ranged from 56 to 68 years, with an average age of (61.5±3.1) years. The mean preoperative duration of symptoms was (11.7±3.5) months. Preoperative and postoperative shoulder ranges of active motion (upward flexion, lateral external rotation, abduction and external rotation) , shoulder joint radiographs, and MRI were assessed. The visual analog scale (VAS) , University of California Los Angeles (UCLA) score, and Constant-Murley score were used to evaluate shoulder pain and function.

Results

There were no postoperative complications such as retear, bulbous deformity, severe joint adhesion, or infection. All patients were followed up for 7 to 16 months with an average time of (11.5±4.3) months. At preoperative and final follow-ups, the ranges of active motion of the shoulder joint were (85.9±27.4) ° and (149.8±29.7) ° of upward flexion, (21.5±8.9) ° and (38.3±12.4) ° of lateral external rotation, and (52.7±14.2) ° and (73.6±12.8) ° of abduction and external rotation, respectively. The VAS scores were (6.2±1.1 ) scores and (1.4±0.5) scores, respectively. The UCLA scores were (15.4±3.8) scores and (35.1±2.7) scores, respectively. The Constant-Murley scores were (42.8±7.6) scores and (91.2±7.3) scores, respectively. The acromion humeral head distances were (5.2± 1.6) mm and (8.7± 1.3) mm, respectively. The ranges of active shoulder motion, VAS score, UCLA score, and Constant-Murley score were significantly improved than those before surgery (P<0. 001) . At the last follow-up, 6 cases were excellent, 8 cases were good, and 1 was moderate. The excellent and good rate was 93.3% (14/15) .

Conclusion

Arthroscopic bridge patch of the long head of biceps tendon combined with latissimus dorsi transposition in the treatment of irreparable massive rotator cuff tear can significantly relieve pain, restore ranges of motion and improve function.

Key words: Latissimus dorsi transposition, Irreparable massive rotator cuff tear, Rotator cuff repair

图1 不可修复性巨大肩袖撕裂示意图（图A）；关节镜下背阔肌转位联合肱二头肌长头肌腱桥接补片示意图（图B）

图2 肩关节正位X线片和MRI示肩峰肱骨头距离，术前2.7 mm（图A），术后9.3 mm（图B），背阔肌腱转位后的走行和位置（图C-D）

表1 术前和末次随访时各评价指标比较（±s）

时间	例数	VAS评分（分）	体侧外旋（°）	外展外旋（°）	前屈上举（°）	Constant评分（分）	UCLA评分（分）	肩峰肱骨头距离（mm）
术前	15	6.2±1.1	21.5±8.9	52.7±14.2	85.9±27.4	42.8±7.6	15.4±3.8	5.2±1.6
末次随访	15	1.4±0.5	38.3±12.4	73.6±12.8	149.8±29.7	91.2±7.3	35.1±2.7	8.7±1.3
t值		9.31	6.34	4.52	5.23	13.21	7.16	4.78
P值		<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表1 术前和末次随访时各评价指标比较（±s）

时间	例数	VAS评分（分）	体侧外旋（°）	外展外旋（°）	前屈上举（°）	Constant评分（分）	UCLA评分（分）	肩峰肱骨头距离（mm）
术前	15	6.2±1.1	21.5±8.9	52.7±14.2	85.9±27.4	42.8±7.6	15.4±3.8	5.2±1.6
末次随访	15	1.4±0.5	38.3±12.4	73.6±12.8	149.8±29.7	91.2±7.3	35.1±2.7	8.7±1.3
t值		9.31	6.34	4.52	5.23	13.21	7.16	4.78
P值		<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

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Early clinical efficacy of arthroscopic bridge patch of the long head of biceps tendon combined with latissimus dorsi transposition for treatment of irreparable massive rotator cuff tear

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Early clinical efficacy of arthroscopic bridge patch of the long head of biceps tendon combined with latissimus dorsi transposition for treatment of irreparable massive rotator cuff tear