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中华肩肘外科电子杂志

中华肩肘外科电子杂志 ›› 2025, Vol. 13 ›› Issue (01) : 16 -25. doi: 10.3877/cma.j.issn.2095-5790.2025.01.003

论著

不同肱二头肌长头腱术式联合肩袖修补治疗Ellmann Ⅰ型冈上肌腱合并长头腱损伤的临床疗效比较
门小茜1, 耿悦2, 刘雨2, 田野2, 郑丽2, 龙玉斌3, 张壮岱2, 董江涛2,†()   
  1. 1. 050051 河北医科大学第三医院超声诊断科
    2. 050051 河北医科大学第三医院关节外科
    3. 071030 保定市第一中心医院关节外科
  • 收稿日期:2025-01-03 出版日期:2025-02-05
  • 通信作者: 董江涛

Comparison of clinical efficacy of different biceps long tendon operations combined with rotator cuff repair in the treatment of Ellmann Type I supraspinatus tendon combined with long tendon injury

Xiaoqian Men1, Yue Geng2, Yu Liu2, Ye Tian2, Li Zheng2, Yubin Long3, Zhuangdai Zhang2, Jiangtao Dong2,†()   

  1. 1. Department of Ultrasound Diagnosis， Hebei Medical University Third Hospital， Shijiazhuang 050051， China
    2. Department of Orthopedic Surgery， Hebei Medical University Third Hospital， Shijiazhuang 050051， China
    3. Department of Orthopedic Surgery， Baoding First Central Hospital， Baoding 071030， China
  • Received:2025-01-03 Published:2025-02-05
  • Corresponding author: Jiangtao Dong
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门小茜, 耿悦, 刘雨, 田野, 郑丽, 龙玉斌, 张壮岱, 董江涛. 不同肱二头肌长头腱术式联合肩袖修补治疗Ellmann Ⅰ型冈上肌腱合并长头腱损伤的临床疗效比较[J/OL]. 中华肩肘外科电子杂志, 2025, 13(01): 16-25.

Xiaoqian Men, Yue Geng, Yu Liu, Ye Tian, Li Zheng, Yubin Long, Zhuangdai Zhang, Jiangtao Dong. Comparison of clinical efficacy of different biceps long tendon operations combined with rotator cuff repair in the treatment of Ellmann Type I supraspinatus tendon combined with long tendon injury[J/OL]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2025, 13(01): 16-25.

目的

比较分析关节镜下单纯前间隙清理，结节间沟近端固定和胸大肌上缘固定联合肩袖修补治疗Ellmann Ⅰ型冈上肌腱撕裂合并长头腱损伤的初期临床疗效。

方法

回顾性分析36 例Ellmann Ⅰ型冈上肌腱撕裂合并长头腱损伤导致肩前痛患者的临床资料。根据长头腱术式不同分为前间隙清理+肩袖修补组（AR 组，n=15），结节间沟近端固定+肩袖修补组（IR 组，n=10），胸大肌上缘固定+肩袖修补组（SR 组，n=11）。比较术前、术后至少3～6 个月的视觉模拟评分（visual analogue scale， VAS）、美国肩肘外科评分 （American shoulder and elbow surgeons， ASES）、Constant-Murley肩关节功能评分（Constant-Murley score，CMS）、加州大学洛杉矶分校肩关节评分系统（University of California， Los Angeles，UCLA）、简明肩关节评分（simple shoulder test，SST）、结节间沟压痛发生率以及肩关节主动/被动活动度的改善。术后3 个月、6 个月的MRI，超声和体格检查，统计并发症发生和肩袖愈合情况。

结果

36 例患者均获得了至少3～6 个月的观察和随访。MRI 和肌骨超声图像显示所有患者肩袖愈合良好，均未发生大力水手畸形等并发症；三组患者术后肩关节评分较术前均有明显提升，AR 组术后ASES 评分较术前显著提高（P ＜0.01），IR 组和SR 组术前UCLA 评分较术前显著提高（P ＜0.01），但SR 组术后VAS、SST 评分较术前降低（P=0.02，P=0.04）；IR 组术后主动前屈活动度较术前显著改善（P=0.01），IR 组主动前屈、被动前屈、被动外展活动度显著大于AR 组（P=0.01，P ＜0.01，P=0.05）；三组术后结节间沟压痛阳性率较术前均显著降低（P=0.01，P=0.03，P ＜0.01），IR 和SR 两组显著优于AR 组（P=0.02，P=0.04）。

结论

三种术式联合肩袖修补治疗Ellmann Ⅰ型冈上肌腱退变撕裂合并长头腱损伤术后3～6 个月即可有效缓解肩关节疼痛和改善肩关节功能，胸大肌上缘固定术后疼痛改善更明显，结节间沟近端固定术后具有更好的活动度。

关键词: 肩关节前方疼痛, 肩袖修补, 肱二头长头腱固定术

Background

Anterior shoulder pain （anterior shoulder pain） is the most common form around the shoulder， occurring in up to 30% of patients and lasting for a year or more in 40%.Causes of pain include rotator cuff injury， shoulder impingement syndrome， glenolabial injury， and injury of the biceps long tendon（long head tendon）.As a receptor of shoulder joint pain and pressure， the long head tendon is an important cause of shoulder joint motor dysfunction， manifesting as inflammation， edema， dislocation， tear， etc.The injury can occur alone and is often accompanied by other structural injuries， such as supraspinatus and subscapular tendon injuries.Previous literature has confirmed a high correlation between biceps long tendon injury and rotator cuffinjury.Singaraju et al.showed that the correlation between supraspinatus tendon tear and biceps long tendon injury was as high as 78.5%， and with every 1 cm increase in supraspinatus tendon injury， the incidence of biceps long tendon lesions increased by 1.7 times.Tendinopathy combined with rotator cuff repair is the most commonly used technique for treating anterior shoulder pain caused by rotator cuff injury combined with a long head tendon injury.Tendinopathy can be performed using various surgical techniques， and tendon fixation locations are often selected according to the doctor's surgical preference， the patient's age， and functional requirements.Proximal fixation of intertubercular sulcus has the advantages of being a simple technique， having fast speed and few incisions， but the postoperative pain relief may be incomplete due to residual pathological tendon tissue.Some studies have suggested no significant difference in functional outcome between the intertubercular sulcus's proximal fixation and the pectoralis major's upper margin.However， researchers who support the fixation of the upper margin of the pectoralis major believe that the slide of the long head tendon in the sheath formed by the transverse humeral ligament is the primary source of pain.Hence， the removal of this lesion is particularly important， but this method of fixation is complicated and carries the risk of humeral fracture and neurovascular damage.In recent years， a large number of studies have compared tenodesis.However，due to confounding factors such as the difference between endoscopic and open surgery， long head tendon injury combined with different follow-ups， there is no consensus on the optimal fixation position for long head tendon surgery.Therefore， this study only included patients with typical clinical injuries of long head tendon combined with rotator cuff injury to make the study closer to clinical practice and give full play to the clinical guiding role of the study.At the same time， the type of rotator cuff injury was limited to Ellmann type I supraspinatus tendon degenerative tear to reduce the impact of accompanying injury and its severity on pain and mobility in the study results.Reduce potential bias from other subtypes.

Objective

To compare and analyze the initial clinical efficacy of arthroscopic anterior clearance， proximal intertubercular sulcus fixation， and upper margin pectoralis major fixation combined with rotator cuff repair in the treatment of Ellmann Type I supraspinatus tendon tear complicated with longhead tendon injury.

Methods

The clinical data of 36 patients with Ellmann type I supraspinatus tendon tear and long head tendon injury resulting in anterior shoulder pain were retrospectively analyzed.They were divided into anterior clearance + rotator cuffrepair group （AR group， n=15）， proximal intertubercular sulcus fixation + rotator cuff repair group （IR group， n=10）， fixed upper border of pectoralis major + rotator cuff repair group （SR group， n=11）.VAS，ASES， CMS， UCLA， and SST scores， the incidence of intertubercular sulci tenderness， and the improvement of shoulder active/passive motion were compared before and at least 3 to 6 months after surgery.MRI and physical examination measured the incidence of complications and rotator cuff healing at 3 and 6 months after surgery.

Results

All 36 patients were observed and followed up for at least 3 - 6 months.MRI showed that the rotator cuff healed well in all patients， and no complications such as Popeye deformity occurred.Postoperative shoulder joint scores of patients in the three groups were significantly improved compared with those before surgery； postoperative ASES scores in the AR group were significantly increased compared with those before surgery （P＜0.01）； preoperative UCLA scores in the IR and SR groups were significantly increased compared with those before surgery （P＜ 0.01）； postoperative VAS and SST scores in the SR group were significantly decreased compared with those before surgery （P=0.02， P=0.04）； The active forward flexion activity of IR group was significantly improved after operation （P=0.01）， and the active forward flexion， passive forward flexion and passive abduction activity of IR group were significantly greater than those of AR group （P=0.01， P＜0.01， P=0.05）； The positive rate of internodal groove tenderness after operation was significantly lower than that before operation （P=0.01， P=0.03， P＜ 0.01）， IR and SR groups were significantly better than AR group （P=0.02，P=0.04）.

Conclusion

The three operations combined with rotator cuff repair for Ellmann Type I supraspinatus tendon degeneration tear combined with long head tendon injury can effectively relieve shoulder pain and improve shoulder joint function 3 to 6 months after surgery.The pain improvement is more evident after the upper margin of pectoralis major muscle fixation， and the mobility is better after the proximal intertubercular sulci fixation.

Key words: Anterior shoulder pain, Rotator cuff repair, Biceps humerus long head tendinopathy
图1 患者女性，51 岁，右肩关节前方疼痛不适伴活动受限1 年，术前查体提示肩袖损伤
图2 术前MRI 提示Ellmann Ⅰ型冈上肌腱撕裂和肱二头肌长头腱炎症
图3 术前肌骨超声图像提示Ellmann Ⅰ型冈上肌腱撕裂
图4 术中镜下肩袖修补后
表1 三组患者术前一般资料比较
组别 例数 年龄（岁，xˉ± s ） 性别（例，男/ 女） 侧别（例，左/ 右） 病程（月，xˉ± s ） 糖尿病（例，是/ 否） 吸烟（例，是/ 否）
AR 组 15 50.4±9.8 5/10 5/10 6.0±3.6 2/13 7/8
IR 组 10 54.8±9.1 3/7 3/7 6.8±10.9 0/10 2/8
SR 组 11 50.2±8.3 1/10 4/7 9.2±11.2 2/9 8/3
检验值 H=1.96 χ 2=0.95 χ 2=0.00 H=1.71 χ 2=0.13 χ 2=0.00
P值 0.35 0.28 0.64 0.43 0.56 0.61
图5 术中在结节间沟近端固定长头腱
图6 结节间沟近端固定后切除的肱二头肌长头腱长度：1.1 cm
图7 术中在胸大肌上缘固定长头腱
图8 胸大肌上缘固定后切除的肱二头肌长头腱长度：4.0 cm
图9 切除的肱二头肌长头腱进行长度测量
表2 三组患者围手术期资料比较（）
组别 例数 手术时间（min） 切除长头腱的长度（cm） 锚钉个数（个）
AR 组 15 109.5±26.7 0a 1.9±0.7
IR 组 10 111.2±31.5 0.5±0.4b 2.7±1.2
SR 组 11 115.8±23.5 3.3±0.9c 2.1±1.0
H值 1.19 31.30 3.28
P值 0.87 ＜ 0.01 0.19
表3 三组患者随访评分比较（分，）
组别 例数 VAS 评分 UCLA 评分
术前 术后3 个月 P值 术前 术后3 个月 P值
AR 组 15 5.1±3.0 4.0±3.0 0.23 18.4±5.2 21.6±4.8 0.11
IR 组 10 5.0±2.2 3.0±2.2 0.10 18.1±4.6 24.4±4.5 0.01
SR 组 11 6.4±2.9 4.0±3.0 0.02 14.0±4.6 20.1±6.2 ＜ 0.01
检验值 H=1.91 H=0.95 F=2.99 F=1.84
P值 0.37 0.62 0.06 0.18
组别 例数 ASES 评分 CMS 评分 SST 评分
术前 术后3 个月 P值 术前 术后3 个月 P值 术前 术后3 个月 P值
AR 组 15 11.5±6.8 13.5±5.6 ＜ 0.01 54.7±15.0 58.5±8.9 0.46 4.9±3.2 4.7±1.8 0.89
IR 组 10 14.9±6.3 14.7±5.3 0.92 56.6±16.2b 57.2±16.6 0.91 5.3±3.3 5.3±2.4 1.00
SR 组 11 18.0±10.1 19.3±5.6 0.85 46.4±26.8c 56.7±15.4 0.13 8.3±10.3 3.4±2.9 0.04
检验值 F=5.75 F=4.30 F=4.32 F=2.70 F=1.03 H=2.99
P值 0.06 0.08 0.06 0.08 0.97 0.16
表4 三组患者肩关节活动度比较（°，）
组别 例数 主动前屈 主动外展 被动前屈 被动外展
术前 术后3 个月 P值 术前 术后3 个月 P值 术前 术后3 个月 P值 术前 术后3 个月 P值
AR 组 15 109.0±49.0 108.7±43.9 0.99 108.0±54.1 104.0±49.3 0.84 130.0±38.7 138.7±42.4 0.56 130.7±51.9 132.7±46.8 0.92
IR 组 10 88.0±26.6 130.0±34.6a 0.01 78.0±31.6 114.0±42.0 0.08 139.0±44.1 162.0±29.0b 0.25 117.0±55.2 147.0±35.9c 0.14
SR 组 11 100.9±48.9 90.9±24.7 0.54 95.9±51.9 80.9±35.3 0.36 131.2±5.3 117.3±28.3 0.35 130.9±44.6 103.6±33.2 0.13
检验值 F=0.69 F=3.01 F=1.15 F=1.64 H=0.26 H=8.37 H=0.56 H=6.39
P值 0.49 0.05 0.27 0.21 0.88 0.02 0.76 0.04
表5 三组患者肩关节体格检查比较（例，阳性/阴性）
组别 例数 结节间沟压痛 Speed 试验 Yergasons 试验 Jobe 试验
术前 术后3 个月 P值 术前 术后3 个月 P值 术前 术后3 个月 P值 术前 术后3 个月 P值
AR 组 15 6/9a 1/14b 0.01 10/5 7/8 0.32 4/11 4/11 1.0 15/0 8/7 ＜ 0.01
IR 组 10 9/1 5/5 0.03 7/3 4/6 0.08 3/7 0/10 0.08 7/3 4/6 0.08
SR 组 11 10/1c 5/6d ＜ 0.01 10/1 7/4 0.08 4/7 4/7 1.00 8/3 9/2 0.32
χ 2值 16.8 9.94 2.17 1.29 0.28 4.30 5.17 4.03
P值 ＜ 0.01 0.01 0.348 0.535 0.871 0.124 0.081 0.141
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