三角肌转位治疗巨大不可修复性肩袖撕裂的研究进展

Advance of massive tear of the rotator cuff treated with a deltoid flap

巨大肩袖撕裂常破坏肩关节正常的力偶平衡,进而引发肩关节疼痛及功能丧失。目前关于巨大肩袖损伤的最佳治疗策略存在较大争议,但事实证明手术效果优于保守治疗。修复肩袖可减少肩关节力量的损失,降低继发性盂肱关节炎发生率,但是由于撕裂肩袖的肌腱残端挛缩、脂肪浸润及撕裂面积过大,往往无法直接进行腱骨缝合修复。因此,以肌-腱单位转移为主要手段的肌瓣转移为巨大肩袖撕裂修复提供了选择。与背阔肌肌腱移位术相比,三角肌瓣的优势在于其能够与冈上、下肌协同收缩,对肱骨头具有潜在下压功能,同时还可以保留肌瓣的血管和神经支配。开放手术下进行三角肌瓣与挛缩的冈上肌或冈下肌肌腱残端连接,可重建肩袖连续性,覆盖肱骨头,形成新的"肩袖",在肱骨头与肩峰之间充当肌肉垫子,减轻肱骨头与肩峰之间的撞击,从而缓解疼痛,改善肩关节功能。然而,关于三角肌转位术后是否能够减轻肩关节力量丢失,恢复正常力偶关系,防止盂肱关节炎及肌腱再撕裂仍存在较多争议。因此,对三角肌瓣转位治疗慢性巨大不可修复性肩袖撕裂进展做一系统综述。

Massive rotator cuff tears often destroy equilibrium of couples of the shoulder joints, whichlead toshoulder pain and functional incapacitation. At present, there is a great controversy about the best treatment strategy for the massive rotator cuff tear, nevertheless surgery has been proved to have more satisfactory results than non-operative treatment. It has been confirmed by numerous studies that cuff repair could prevent loss of shoulder strength and glenohumeral osteoarthritis. However, it is impossible to suture tendon to bone directly due to retraction of tendon stump, fat infiltration of rotator cuff and prominent tear size in massive rotator cuff tear. Muscular flap transfer procedures have played important roles in the treatment of massive rotator cuff tears. Compared with other tendon transposition procedures, such as latissimus dorsi transfer, the deltoid muscular flap may be an optimal method as it works synergistically with the infraspinatus and supraspinatus muscle, and presses down the humeral head potentially. Cuff repair in open operation with tendon stump re-attachment to the deltoid muscle flap, aims to reconstruct the cuff continuity and cover the humeral head toform a new cuff. The deltoid muscle flap, also acting as a muscle cushion, is expected to reduce impingement between the humeral head and the acromion and get better results of pain relief and improvement of shoulder function. However, it is still controversial about the efficacy of deltoid muscle flap transfer in reconstructing a new balance of couple with better shoulder strength, alleviating glenohumeral arthritis and preventing tendon retears. This article reviews the advances in the treatment of chronic massive rotator cuff tears with deltoid flap transfer.