关节镜肩峰下间隙减压术治疗肩峰下撞击综合征临床疗效分析

Clinical outcome of arthroscopic subacromial decompression(ASD)for treatment of subacromial impingement syndrome

目的：评价关节镜肩峰下间隙减压术（arthroscopic subacromial decompression,ASD）治疗肩峰下撞击综合征的方法及效果。方法回顾性分析2013年6月至2015年1月应用 ASD 治疗肩峰下撞击综合征患者32例,其中男14例,女18例；年龄31~76岁,平均51.3岁；左肩11例,右肩21例；术前常规拍摄肩关节前后位、冈上肌出口位和腋位 X 线片。19例行 MRI 检查。Ⅰ型肩峰5例,Ⅱ型肩峰12例,Ⅲ型肩峰15例。应用 ASD,32例均行前肩峰成形术,17例同时行关节镜下肩袖缝合术。采用 UCLA 评分标准评价疗效。结果随访时间12~24个月,平均16.4个月。UCLA 评分术前为（16.8±4.1）分,术后（32.4±1.5）分,两者差异有统计学意义（t =-14.107,P〈0.01）。优11例,良18例,可3例,差0例,优良率为90.6%。结论 ASD 治疗肩峰下撞击综合征能达到减压要求,效果满意,且可同时处理关节内其他病变,创伤小,恢复快,应作为治疗肩峰下撞击综合征的首选。

Background The concept of subacromial impingement syndrome was proposed by Neer through autopsy and clinical research in 1 972,and it is a common cause of pain and dysfunction of the shoulder joint.With the continuous improvement of arthroscopic techniques,the gradual application of shoulder arthroscopy in the treatment of shoulder disorders has been widely approved. This paper aims to retrospectively observe and evaluate the treatment of subacromial impingement syndrome with arthroscopic subacromial decompression （ASD）and its clinical outcome.Methods （1） General information.32 cases were selected in the group from June 2013 to January 201 5.The course of disease ranged from 6 to 48 months and the mean time was 22 months;there were 8 cases with trauma history.All the patients underwent conservative treatment for 3 to 6 months before operation, including rest,physical therapy,oral anti-inflammatory drug therapy and enhanced muscle strength exercises, and the conservative treatment was failed.Imaging examinations X-ray films of anteroposterior view,supraspinatus outlet view and axillary view were performed on routine before operation.According to the acromial classification criteria of Bigliani,5 cases were type I,12 cases were type II and 1 5 cases were type III.Upward migration of humeral head occurred in 9 cases.1 9 cases were examined with MRI and observed the effusion signal below the anterolateral acromion.9 cases showed inhomogeneous signal of rotator cuff,3 cases had partial tear of bursa side and 3 cases＆amp;nbsp;had full-thickness rotator cuff tear.（2 ）Operative method.After general anesthesia,the patient was placed in the beach chair position.After the inspection of glenohumeral joint through posterior portal, intra-articular inflammatory synovial proliferation,articular cartilage stripping and tendon calcification and abrasion were observed and managed with joint debridement and chondroplasty under arthroscopy respectively.Then the subacromial space was examined to find out inflammatory adhesion hyperplasia of bursa and coracoacromial ligament abrasion.The degrees of rotator cuff injury：3 cases were normal,12 cases had surface roughness of rotator cuff in the bursa side,10 cases were partial tear of bursa side and 7 cases had full-thickness rotator cuff tear.Subacromial space decompression was conducted after arthroscopic exploration,and the subacromial superficial osteophyte was removed by motorized bur for 5-8 mm.The purpose was to make the subacromial surface flat by removing enough osteophyte beneath acromion.First,the lateral plane was identified for resection and the grinding was conducted inward towards acromioclavicular joint to remove the acromial osteophyte from the anterior edge to the mid-point.The osteophyte in the anterior angle of acromion must be removed adequately as the pressure there was maximum.The cristae should be avoided in the middle of acromion between the resected and not resected areas.Then the “feather like”resection was continued gradually and the coracoacromial ligament was cut off via radiofrequency ablation.Debridement was performed in 12 cases with surface roughness of rotator cuff in the bursa side,and arthroscopic suturing with anchor was applied for 10 cases of partial tear and 7 cases of full-thickness rotator cuff tear.The joint cavity was irrigated adequately and the bleeding was stopped with radiofrequency ablation.After the drainage tube was placed,the wound was covered with aseptic dressing.The analgesia infusion pump could be a selection postoperatively.Postoperative rehabilitation the affected limb was in a scarf bandage after surgery.Passive anteflexion was conducted after the drainage tube was removed on postoperative day 1.With gradual increase of the angle,the passive movement reached 90＆#176;within 2 weeks.The active movement was initiated 2 weeks after surgery and the strength exercise begin after 6 weeks.Normal life was restored within 3 to 4 months.Curative effect evaluation the University of California Los Angeles shoulder rating scale （UCLA）was adopted for the evaluation of curative effect.The total score of UCLA is 35 points,including 10 points of pain,10 points of function,5 points of joint flexion,5 points of anteflexion strength and 5 points of patient satisfaction.34 to 35 points are excellent,28 to 33 points are good,21 to 27 points are moderate and 0 to 20 points are considered poor.Statistical analysis the SPSS 1 7.0 statistical software was used for data analysis and processing. The measurement data was presented as （x-±s ）and compared using t test.Measurement data used t test.The difference was considered statistically significant with P〈0.05.Results The mean follow-up time ranged from 12-24 months with an average of 1 6.4 months.The UCLA score was （1 6.8 ± 4.1）before operation and （32.4 ± 1.5 ）points after operation.The difference between the two has statistical significance （t =-14.107,P〈0.01）.1 1 cases were excellent,18 cases were good,3 cases were fair and 0 case were poor.The fine rate was 90.6%.Conclusions Acromion impingement syndrome is referred to the repeated impact between the humeral greater tuberosity and the coracoacromial arch during the motion of abduction and anteflexion due to the stricture of subacromial space caused by various reasons, resulting in inflammatory reaction of subacromial bursa, degenerative change of rotator cuff,or even rotator cuff tear,which leads to a series of symptoms such as pain and dysfunction of the shoulder joint.This study had 1 1 excellent cases and 18 good cases.The fine rate was 90.6%,much higher than those reported in the literatures.The curative effect of subacromial impingement syndrome treated with ASD is reliable.Compared with open surgery,ASD has the merits of little trauma,fast postoperative recovery and timely detection and management of structural injuries such as glenoid labrum,joint capsule,biceps tendon,etc.It does slight harm to the deltoid muscle and allows early postoperative functional rehabilitation exercise with good outcomes.Thus,ASD should be the prior choice in the treatment of subacromial impingement syndrome.