巨大肩袖损伤并发肩关节假性瘫痪的危险因素分析

Risk factors for pseudoparalysis in patients with massive rotator cuff tear

目的研究慢性巨大肩袖损伤类型与肩关节活动范围受限的相关性,调查假性瘫痪的危险因素。方法自2011年3月至2015年3月青岛解放军第401医院经影像学检查确诊2个以上慢性巨大肩袖肌腱损伤,脂肪浸润3级以上且无骨关节炎的门诊患者78例并分为五个类型。分析VAS评分与损伤分型的相关性;分析主动前屈上举、体侧外旋、外展外旋和内旋与损伤分型的相关性,确定假性瘫痪的分布规律和危险因素,为临床治疗慢性巨大肩袖损伤提供指导。结果慢性巨大肩袖损伤可分为上前、上后和上前后三大类五个亚型,累及三个肩袖肌腱的损伤类型发生假性瘫痪的危险性显著增大,这其中肩胛下肌腱完全损伤导致假性瘫痪的危险性尤其明显。结论治疗慢性巨大肩袖损伤应该重视肩胛下肌腱的修复,没有条件完全修复者可通过部分修复逆转假性瘫痪恢复肩关节活动范围和功能。

Background Massive rotator cuff tear is a common clinical disorder of the shoulder, which mainly manifests as shoulder joint pain and limited range of motion （ROM）.Cofield proposed the definition of massive rotator cuff tear as massive rotator cuff tears 〉 5 cm;on the other hand, Gerber et al.defined rotator cuff tears involving 2 or more rotator cuff tendons as massive rotator cuff tears.Patients with chronic massive rotator cuff tears and severe muscle degeneration had unique and varying clinical manifestations.Some patients showed only mild to moderate pain while shoulder range of motion limitation was not obvious especially that active flexion and abduction activities were not affected;some other patients had moderate to severe shoulder joint pain accompanied by pseudoparalysis of the shoulder joint,i.e.,active flexion was 〈90° while passive ROM was not limited,seriously affecting daily life of the patients.This brings difficulties and a lot of uncertainties for clinical assessment and treatment of these patients.This study attempts to analyze the correlation between massive rotator cuff tears involving different tendons and the extent of active ROM limitation,in order to determine risk factors for pseudoparalysis in patients with chronic rotator cuff tears and provide guidance on clinical treatment options.Methods From March 2011 to March 2015, we analyzed 78 patients who met the inclusion and exclusion criteria of this study.All patients were unilateral involvement,38 cases of male,40 cases of female,with an average age of 65.2 years old （58-77 years old）,and a dominant side involvement rate of 70.5% （55/78）.Inclusion criteria：（1） medical history, physical examination, shoulder MR imaging and fat suppression T2-weighted sequences confirmed the diagnosis of chronic rotator cuff tears involving two or more tendons.This included：positive Jobe′s test by physical examination,and weak muscle force with corresponding MR 〈br〉 imaging findings supporting the diagnosis of supraspinatus tendon inj ury;weak muscle force at shoulder external rotation position （0° abduction）or positive lag sign with appropriate MR imaging findings to support the diagnosis of infraspinatus tendon inj ury;weak muscle force at shoulder abduction and external rotation position （90° abduction）or positive lag sign,positive hornblower′s sign and appropriate diagnostic MR imaging findings of teres minor tendon damage;weak muscle force by improved Lafosse′s belly press test or positive lag sign accompanied with appropriate diagnostic MR imaging findings of subscapularis muscle injury.（2）T1-weighted MR imaging of shoulder joint showed fatty infiltration Goutallier grades of 3 and 4 in rotator cuff muscles. （3 ）shoulder anteroposterior X-ray examination determined glenohumeral osteoarthritis with Hamada grades of 0-2. Exclusion criteria：（1）passive ROM limitation of the shoulder joint;（2）shoulder MR examination revealed that degeneration of rotator cuff muscles was less than the Goutallier grade 3;（3）shoulder anteroposterior X-ray examination determined glenohumeral osteoarthritis with Hamada grades of 3 or more;（4）patients with incomplete clinical data records;（5）past history of surgeries around the shoulder joint.Shoulder zoning：According to Lafosse′s shoulder zoning methods, assign the supraspinatus muscle into the upper rotator cuff unit,infraspinatus and teres minor muscle into the posterior rotator cuff unit,upper 2/3 tendon and lower 1/3 muscle of subscapularis into the anterior rotator cuff unit,the rotator cuff tear units of all patients who met our inclusion criteria were categorized based on the above 5 structural units,and results of physical examination and MR imaging of all patients were recorded.Measurements：active shoulder ROM：for all patients, record the shoulder active flexion and abduction range,0°abduction and external rotation range and 90°abduction and external rotation range,analyze the correlation between active shoulder ROM limitation and the type of rotator cuff tears.Shoulder pain：use VAS score （0-10 points）to record subjective pain scale of the patients,analyze the correlation with the type of rotator cuff tears,and analyze the distribution of pseudoparalysis and hornblower′s sign and their correlation with the type of rotator cuff tears. Statistical analysis：SPSS 14.0 software was used for statistical analysis.Difference in the shoulder pain scores of all five types of rotator cuff tears was compared by pairwise analysis of variance. Significant level was set at 0.05.Difference in active ROM of all five types of rotator cuff tears （flexion and traction,external rotation,abduction and medial rotation）was compared by pairwise analysis of variance.Significant level was set at 0.05.Results Correlation between types of rotator cuff tears and VAS scores：for the distribution of types of inj uries,all patients had supraspinatus tendon involvement combined with anterior,posterior or anteroposterior rotator cuff tears at the same time.Supraspinatus tendon inj ury combined with anterior subscapularis muscle inj ury was named the superior-anterior type （SA）,accounting for 25 cases,among which supraspinatus injury with upper 2/3 subscapularis tendon inj ury was named the SA-1 type,accounting for 1 5 cases,and supraspinatus combined with whole subscapularis muscle injury was named the SA-2 type,accounting for 10 cases. Supraspinatus tendon inj ury combined with posterior infraspinatus tendon and teres minor tendon injuries was named the superior-posterior type （SP）,accounting for 39 cases.Supraspinatus tendon injury combined with infraspinatus tendon injuries were named as the SP-1 type,accounting for 27 cases.Supraspinatus tendon inj ury combined infraspinatus tendon and teres minor inj ury was named the SP-2 type,accounting for 1 2 cases.Supraspinatus tendon inj ury combined with anterior upper 2/3 subscapularis tendon inj ury and posterior infraspinatus tendon inj ury was named the superior-anterior-posterior （SAP）,accounting for 14 cases.There was no statistically significant difference in shoulder pain VAS scores based on pairwise comparison among different types of rotator cuff tears.The correlation between types of shoulder rotator cuff tears and active shoulder ROM：shoulder anterior elevation ROM limitation among this group of patients was most obvious in the SA-2 type involving the entire subscapularis muscle,as their active anterior elevation range （75°± 27°）had significant difference as compared with the SA-1 type （162°±21°）and SP-1-type （156°±26°）（P 〈0.01）as well as the SP-2 type （133°±48°）（P 〈0.05）.In addition,the active anterior elevation range of motion （111°± 41°）in SAP type involving supraspinatus muscle,upper 2/3 subscapularis and 3 〈br〉 tendons of infraspinatus was significantly different from that of the SP-1 and SP-2 types （P〈0.01）. Among this group of patients,shoulder external rotation limitation was most serious in SP-2 type （2°±2°）,SP-1 type （25°±11°）and SAP type （29°±14°）involving posterior rotator cuff tendons, which had significant difference as compared to the SA-2 type （50°±17°）and SA-1 type （61°±12°） that involved anterior rotator cuff tendons （P 〈0.01）.Abduction and external rotation limitation was seen mostly in the SP-2 type （1 9°±4°）involving posterior rotator cuff tendons and the SA-1 type （90°±17°）involving anterior rotator cuff tendons.The differences with other types were statistically significant （P〈0.01）.Internal rotation limitation in this group of patients was most severe in the SAP type （L3）and SA-2 type （L2）involving anterior rotator cuff tendons while internal rotation was not obviously limited in the SP-1 type （T1 1 ）and SP-2 type （T1 2 ）involving posterior rotator cuff tendons.Types of rotator cuff tears and distribution of pseudoparalysis：in term of pseudo-paralysis distribution,SA-2 type involving the entire subscapularis had the highest ratio of pseudoparalysis that reached 80%,followed by the SAP type involving supraspinatus muscle,upper 2/3 of subscapularis and infraspinatus muscle tendons,reaching 48%.Conclusions Treatment of chronic massive rotator cuff tears should pay attention to repair the subscapularis muscles.In patients that complete repair is not possible,partial repair may be resorted to reverse pseudoparalysis and restore the ROM and function of the shoulder joint.