一期与二期手术治疗肩袖损伤合并肩关节僵硬的疗效对比

Comparison of One-stage Versus Two-stage Procedure for Management of Patients with Rotator Cuff Tear and Concomitant Stiffness

目的：比较一期与二期手术治疗肩袖损伤合并肩关节僵硬的临床疗效。方法：2010年12月至2013年6月接受一期或二期手术治疗的肩袖损伤合并肩关节僵硬且随访时间2年以上的连续病例共42例,其中22例患者接受一期手术同时行关节镜下肩袖修补术及关节囊松解术,另20例患者先接受自主功能锻炼再二期行肩袖修补术。患者于治疗前与术后3、6、12、24个月及末次随访时均接受肩关节活动度检查与临床功能评分。肩关节活动度检查包括前屈上举、体侧外旋及内旋活动。临床功能评分采用VAS评分、ASES（American shoulder and elbow surgeons）评分以及Constant-Murley评分系统。结果：随访时间24~33个月,平均26.3个月。两组患者术前一般资料差异无统计学意义（P〉0.05）。二期组患者经3个月自主锻炼后,前屈上举及内旋活动均有显著提高（t=10.103,P〈0.001;t=3.02,P=0.01）,且1例患者因症状缓解而最终未行手术治疗。两组患者术后肩关节活动度与临床评分较术前均显著改善（P〈0.05）。术后3个月时,一期组患者前屈上举与内旋活动显著低于二期组患者（t=4.025,P=0.001;t=2.14,P=0.038）,体侧外旋差异无统计学意义（P〉0.05）。术后6、12、24个月及末次随访时,两组患者肩关节前屈上举、体侧外旋及内旋活动差异均无统计学意义（P〉0.05）。末次随访时,两组患者临床功能评分及术后满意率（分别为90.0%和68.2%）差异无统计学意义（P〉0.05）。结论：二期组患者经自主锻炼后,19/20（95%）的患者需行二期手术治疗。采用一期手术治疗肩袖损伤合并肩关节僵硬,患者术后肩关节活动恢复至正常较二期组需更长时间,但末次随访时两组患者肩关节活动、临床评分无显著性差异。

Objective To compare the clinical outcomes of one-stage and two-stage procedure for treating patients with rotator cuff tear and concomitant shoulder stiffness. Methods Forty-two patients with rotator cuff tear and concomitant stiffness admitted between December 2010 and June 2013 were recruited and randomly divided into group A of 22 and group B of 20. Group A underwent one-stage procedure including arthroscopic capsule release and concomitant rotator cuff repair within 2 weeks after being diagnosed,while for group B,two-stage procedure was conducted： before the surgery,patients were required to undergo voluntary training to recover the range of motion（ROM）. Before and 3,6,12 and 24 months after the surgery,and at the end of the follow-up,all patients were assessed the range of motion（ROM）and clinical functions using the visual analogue scale（VAS）,American shoulder and elbow surgeons（ASES）and Constant-Murley scores. All patients＇ satisfaction was also evaluated. Results The mean follow-up period was 26.3 months（ranging from24 to 33 months）. There were no significant differences in all the measurements between the groups before the intervention（P〉0.05）. For patients in group B,after 3 months＇ rehabilitation training,there were significant improvements in their forward flexion and internal rotation（P〈0.001 and P=0.01 respectively）and 1 patient recovered without surgery in the end. After the surgery,there was significant improvement in ROM and functional scores in both groups（P〈0.05）. At 3 months after the surgery,forward flexion and internal rotation of patients in group B improved significantly compared with group A（P =0.001 and P =0.038 respectively）.There was no significant difference in ROM between the 2 groups at any other time points（P〉0.05）.Moreover,no significant difference was found in functional scores and satisfaction rate between the 2 groups at the final follow-up（P〉0.05）. Conclusion After rehabilitation training,not all patients（95%）with rotator cuff tear and concomitant shoulder stiffness need surgery. For such patients undergoing surgery,they recovered more quickly than those who undergo surgery directly. However,at the final follow-up visit,no significant differences were found in their ROM and function.